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Kuwatsuru Y, Saito AI, Usui K. Radiation Oncologists' Views on Adjuvant Radiotherapy for Early-Stage Breast Cancer in the Elderly: Comparisons between Japan and the United States. Cancer Invest 2024; 42:309-318. [PMID: 38666473 DOI: 10.1080/07357907.2024.2343860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/12/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE To understand perspective on breast cancer using a survey. MATERIALS & METHODS Questionnaire was distributed to 304 Japanese radiation oncologists (RadOncs) (response rate: 64.1%). Result was compared with a similar US survey. RESULTS In a scenario with an 81-year-old patient with comorbidities, while most US RadOncs chose to tell that radiation might not be necessary, 2% of Japanese chose it. In a scenario with a healthy 65-year-old breast cancer patient with lumpectomy, while most US RadOncs chose to discuss omission of radiation, 24.5% of Japanese chose it. CONCLUSIONS Differences were observed on radiotherapy for older early-stage breast cancer.
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Affiliation(s)
- Yoshiki Kuwatsuru
- Department of Radiology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Anneyuko I Saito
- Department of Radiation Oncology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Keisuke Usui
- Department of Radiation Oncology, Juntendo University Faculty of Medicine, Tokyo, Japan
- Department of Radiological Technology, Juntendo University Faculty of Health Science
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2
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Kunkler IH, Williams LJ, Jack WJL, Cameron DA, Dixon JM. Breast-Conserving Surgery with or without Irradiation in Early Breast Cancer. N Engl J Med 2023; 388:585-594. [PMID: 36791159 DOI: 10.1056/nejmoa2207586] [Citation(s) in RCA: 128] [Impact Index Per Article: 128.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND Limited level 1 evidence is available on the omission of radiotherapy after breast-conserving surgery in older women with hormone receptor-positive early breast cancer receiving adjuvant endocrine therapy. METHODS We performed a phase 3 randomized trial of the omission of irradiation; the trial population included women 65 years of age or older who had hormone receptor-positive, node-negative, T1 or T2 primary breast cancer (with tumors ≤3 cm in the largest dimension) treated with breast-conserving surgery with clear excision margins and adjuvant endocrine therapy. Patients were randomly assigned to receive whole-breast irradiation (40 to 50 Gy) or no irradiation. The primary end point was local breast cancer recurrence. Regional recurrence, breast cancer-specific survival, distant recurrence as the first event, and overall survival were also assessed. RESULTS A total of 1326 women were enrolled; 658 were randomly assigned to receive whole-breast irradiation and 668 to receive no irradiation. The median follow-up was 9.1 years. The cumulative incidence of local breast cancer recurrence within 10 years was 9.5% (95% confidence interval [CI], 6.8 to 12.3) in the no-radiotherapy group and 0.9% (95% CI, 0.1 to 1.7) in the radiotherapy group (hazard ratio, 10.4; 95% CI, 4.1 to 26.1; P<0.001). Although local recurrence was more common in the group that did not receive radiotherapy, the 10-year incidence of distant recurrence as the first event was not higher in the no-radiotherapy group than in the radiotherapy group, at 1.6% (95% CI, 0.4 to 2.8) and 3.0% (95% CI, 1.4 to 4.5), respectively. Overall survival at 10 years was almost identical in the two groups, at 80.8% (95% CI, 77.2 to 84.3) with no radiotherapy and 80.7% (95% CI, 76.9 to 84.3) with radiotherapy. The incidence of regional recurrence and breast cancer-specific survival also did not differ substantially between the two groups. CONCLUSIONS Omission of radiotherapy was associated with an increased incidence of local recurrence but had no detrimental effect on distant recurrence as the first event or overall survival among women 65 years of age or older with low-risk, hormone receptor-positive early breast cancer. (Funded by the Chief Scientist Office of the Scottish Government and the Breast Cancer Institute, Western General Hospital, Edinburgh; ISRCTN number, ISRCTN95889329.).
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Affiliation(s)
- Ian H Kunkler
- From the University of Edinburgh (I.H.K., L.J.W., D.A.C., J.M.D.) and Western General Hospital (W.J.L.J.) - both in Edinburgh
| | - Linda J Williams
- From the University of Edinburgh (I.H.K., L.J.W., D.A.C., J.M.D.) and Western General Hospital (W.J.L.J.) - both in Edinburgh
| | - Wilma J L Jack
- From the University of Edinburgh (I.H.K., L.J.W., D.A.C., J.M.D.) and Western General Hospital (W.J.L.J.) - both in Edinburgh
| | - David A Cameron
- From the University of Edinburgh (I.H.K., L.J.W., D.A.C., J.M.D.) and Western General Hospital (W.J.L.J.) - both in Edinburgh
| | - J Michael Dixon
- From the University of Edinburgh (I.H.K., L.J.W., D.A.C., J.M.D.) and Western General Hospital (W.J.L.J.) - both in Edinburgh
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Sabatino V, Pignata A, Valentini M, Fantò C, Leonardi I, Campora M. Assessment and Response to Neoadjuvant Treatments in Breast Cancer: Current Practice, Response Monitoring, Future Approaches and Perspectives. Cancer Treat Res 2023; 188:105-147. [PMID: 38175344 DOI: 10.1007/978-3-031-33602-7_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Neoadjuvant treatments (NAT) for breast cancer (BC) consist in the administration of chemotherapy-more rarely endocrine therapy-before surgery. Firstly, it was introduced 50 years ago to downsize locally advanced (inoperable) BCs. NAT are now widespread and so effective to be used also at the early stage of the disease. NAT are heterogeneous in terms of therapeutic patterns, class of used drugs, dosage, and duration. The poly-chemotherapy regimen and administration schedule are established by a multi-disciplinary team, according to the stage of disease, the tumor subtype and the age, the physical status, and the drug sensitivity of BC patients. Consequently, an accurate monitoring of treatment response can provide significant clinical advantages, such as the treatment de-escalation in case of early recognition of complete response or, on the contrary, the switch to an alternative treatment path in case of early detection of resistance to the ongoing therapy. Future is going toward increasingly personalized therapies and the prediction of individual response to treatment is the key to practice customized care pathways, preserving oncological safety and effectiveness. To gain such goal, the development of an accurate monitoring system, reproducible and reliable alone or as part of more complex diagnostic algorithms, will be promising.
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Affiliation(s)
- Vincenzo Sabatino
- Breast Imaging Department, Santa Chiara Hospital, APSS, Trento, Italy.
| | - Alma Pignata
- Breast Center, Spedali Civili Hospital, ASST, Brescia, Italy
| | - Marvi Valentini
- Breast Imaging Department, Santa Chiara Hospital, APSS, Trento, Italy
| | - Carmen Fantò
- Breast Imaging Department, Santa Chiara Hospital, APSS, Trento, Italy
| | - Irene Leonardi
- Breast Imaging Department, Santa Chiara Hospital, APSS, Trento, Italy
| | - Michela Campora
- Pathology Department, Santa Chiara Hospital, APSS, Trento, Italy
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4
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Eliminating the breast cancer surgery paradigm after neoadjuvant systemic therapy: current evidence and future challenges. Ann Oncol 2021; 31:61-71. [PMID: 31912797 DOI: 10.1016/j.annonc.2019.10.012] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 09/26/2019] [Accepted: 10/17/2019] [Indexed: 12/14/2022] Open
Abstract
In patients with operable early breast cancer, neoadjuvant systemic treatment (NST) is a standard approach. Indications have expanded from downstaging of locally advanced breast cancer to facilitate breast conservation, to in vivo drug-sensitivity testing. The pattern of response to NST is used to tailor systemic and locoregional treatment, that is, to escalate treatment in nonresponders and de-escalate treatment in responders. Here we discuss four questions that guide our current thinking about 'response-adjusted' surgery of the breast after NST. (i) What critical diagnostic outcome measures should be used when analyzing diagnostic tools to identify patients with pathologic complete response (pCR) after NST? (ii) How can we assess response with the least morbidity and best accuracy possible? (iii) What oncological consequences may ensue if we rely on a nonsurgical-generated diagnosis of, for example, minimally invasive biopsy proven pCR, knowing that we may miss minimal residual disease in some cases? (iv) How should we design clinical trials on de-escalation of surgical treatment after NST?
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A comparative study based on deformable image registration of the target volumes for external-beam partial breast irradiation defined using preoperative prone magnetic resonance imaging and postoperative prone computed tomography imaging. Radiat Oncol 2019; 14:38. [PMID: 30836970 PMCID: PMC6402104 DOI: 10.1186/s13014-019-1244-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 02/25/2019] [Indexed: 01/18/2023] Open
Abstract
Background To explore the differences and correlations between the target volumes defined using preoperative prone diagnostic magnetic resonance imaging (MRI) and postoperative prone computed tomography (CT) simulation imaging based on deformable image registration (DIR) for external-beam partial breast irradiation (EB-PBI) after breast-conserving surgery (BCS). Methods Eighteen breast cancer patients suitable for EB-PBI were enrolled. Preoperative prone diagnostic MRI and postoperative prone CT scan sets for all the patients were acquired during free breathing. Target volumes and ipsilateral breast were all contoured by the same radiation oncologist. The gross tumor volume (GTV) delineated on the preoperative MRI images was denoted as the GTVpreMR and the tumor bed (TB) delineated on the postoperative prone CT images was denoted as the GTVpostCT. The MIM software system was used to deformably register the MRI and CT images. Results When based on the coincidence of the compared target centers, there were statistically significant increases in the conformity index (CI) and degree of inclusion (DI) values for GTVpostCT-GTVpreMR, GTVpostCT-CTVpreMR + 10, CTVpostCT + 10-GTVpreMR, and CTVpostCT + 10-CTVpreMR + 10 when compared with those based on the DIR of the thorax (Z = − 3.724, − 3.724, − 2.591, − 3.593, all P < 0.05; Z = -3.724, − 3.724, − 3.201, − 3.724, all P < 0.05, respectively). Conclusions Although based on DIR, there was relatively poor spatial overlap between the preoperative prone diagnostic MRI images and the postoperative prone CT simulation images for either the whole breast or the target volumes. Therefore, it is unreasonable to use preoperative prone diagnostic MRI images to guide postoperative target delineation for EB-PBI.
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Castaneda CA, Rebaza P, Castillo M, Gomez HL, De La Cruz M, Calderon G, Dunstan J, Cotrina JM, Abugattas J, Vidaurre T. Critical review of axillary recurrence in early breast cancer. Crit Rev Oncol Hematol 2018; 129:146-152. [PMID: 30097233 DOI: 10.1016/j.critrevonc.2018.06.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 05/20/2018] [Accepted: 06/18/2018] [Indexed: 01/07/2023] Open
Abstract
Around 2% of early breast cancer cases treated with axillary lymph node dissection (ALND) underwent axillary recurrence (AR) and it has a deleterious effect in prognosis. Different scenarios have incorporated Sentinel Lymph Node (SLN) Biopsy (SLNB) instead of ALND as part of the standard treatment and more effective systemic treatment has also been incorporated in routine management after first curative surgery and after regional recurrence. However, there is concern about the effect of SLNB alone over AR risk and how to predict and treat AR. SLN biopsy (SLNB) has been largely accepted as a valid option for SLN-negative cases, and recent prospective studies have demonstrated that it is also safe for some SLN-positive cases and both scenarios carry low AR rates. Different studies have identified clinicopathological factors related to aggressiveness as well as high-risk molecular signatures can predict the development of locoregional recurrence. Other publications have evaluated factors affecting prognosis after AR and find that time between initial treatment and AR as well as tumor aggressive behavior influence patient survival. Retrospective and prospective studies indicate that treatment of AR should include local and systemic treatment for a limited time.
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Affiliation(s)
- Carlos A Castaneda
- Medical Oncology Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru; Research Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru.
| | - Pamela Rebaza
- Research Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Miluska Castillo
- Research Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Henry L Gomez
- Medical Oncology Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Miguel De La Cruz
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Gabriela Calderon
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Jorge Dunstan
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Jose Manuel Cotrina
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Julio Abugattas
- Breast Cancer Surgery Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Tatiana Vidaurre
- Medical Oncology Department, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
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7
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Kuo LW, Chiu LC, Lin WL, Chen JJ, Dong GC, Chen SF, Chen GS. Development of an MRI-Compatible High-Intensity Focused Ultrasound Phased Array Transducer Dedicated for Breast Tumor Treatment. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2018; 65:1423-1432. [PMID: 29993540 DOI: 10.1109/tuffc.2018.2841418] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
High-intensity focused ultrasound (HIFU) under magnetic resonance imaging (MRI) guidance can achieve a noninvasive and precise ablation of the solid tumor. In the study, an MRI-compatible 1-MHz 16-channel ring-shaped transducer was developed to minimize the burn risk of breast skin and perform volumetric ablation for short treatment time. The measured electroacoustic conversion efficiency of the transducer was 50.90% ± 5. The transducer could produce a point and a quasi-hollow-cylinder lesion in a thermal-sensitive phantom or an ex vivo pork by tuning the phase of each element. It may achieve volumetric ablation of 1.5 cm3 when the point lesion is located inside the hollow lesion. Ex vivo ablation experiments showed that the transducer could cause a coagulative necrosis in the pork from the surrounded subcutaneous fat by 5 mm without fat damage. The temperature and region of the pork ablation were quantified by MRI technique. There was no MRI interference from HIFU and vice versa while both systems operated concurrently.
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8
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Aristei C, Amichetti M, Ciocca M, Nardone L, Bertoni F, Vidali C. Radiotherapy in Italy after Conservative Treatment of Early Breast Cancer. A Survey by the Italian Society of Radiation Oncology (AIRO). TUMORI JOURNAL 2018; 94:333-41. [DOI: 10.1177/030089160809400308] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and Background The aim of surveys on clinical practice is to stimulate discussion and optimize practice. In this paper the current Italian radiotherapy practice after breast-conserving surgery for early breast cancer is described and adherence to national and international guidelines is assessed. Furthermore, results are compared with an earlier survey in northern Italy and international reports. Study Design A multiple-choice questionnaire sent to all 138 Italian radiation oncology centers. Results 48% of centers responded. Most performed breast-conserving surgery when tumor size was ≤3 cm. All centers routinely performed axillary dissection; 45 carried out sentinel node biopsy followed by axillary dissection when the sentinel node was positive. Most centers re-excised when resection margins were positive. The median interval between surgery and radiotherapy, when chemotherapy was not administered, was 60 days. Adjuvant chemotherapy was preferably administered before radiotherapy. Regional lymph nodes were never irradiated in 10 centers; in all others irradiation depended on the number of positive lymph nodes and/or involvement of axillary fat and/or tumor location in medial quadrants. All centers used standard fractionation; hypofractionated schemes were available in 6. Most centers used 4–6 MV photons. In 59 centers the boost dose of 10 Gy could be increased if margins were not negative. All centers ensured patient setup reproducibility. Treatment planning was computerized in 59 centers. The irradiation dose was prescribed at the ICRU point in 56 centers and portal films were made in 54 centers. Intraoperative radiotherapy was used in 4 centers: for partial breast irradiation in 1 and for boost administration in 3 centers. Conclusions Although the quality of radiotherapy delivery has improved in Italy in recent years, approaches that do not conform to international standards persist.
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Affiliation(s)
- Cynthia Aristei
- Department of Radiation Oncology, University of Perugia, Perugia
| | | | - Mario Ciocca
- Medical Physics Unit, European Institute of Oncology, Milan
| | - Luigia Nardone
- Department of Radiotherapy, Sacred Heart Catholic University, Rome
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Riedel F, Hennigs A, Hug S, Schaefgen B, Sohn C, Schuetz F, Golatta M, Heil J. Is Mastectomy Oncologically Safer than Breast-Conserving Treatment in Early Breast Cancer? Breast Care (Basel) 2017; 12:385-390. [PMID: 29456470 PMCID: PMC5803719 DOI: 10.1159/000485737] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AIM To describe and discuss the evidence for oncological safety of different procedures in oncological breast surgery, i.e. breast-conserving treatment versus mastectomy. METHODS Literature review and discussion. RESULTS Oncological safety in breast cancer surgery has many dimensions. Breast-conserving treatment has been established as the standard surgical procedure for primary breast cancer and fits to the preferences of most breast cancer patients concerning oncological safety and aesthetic outcome. CONCLUSIONS Breast-conserving treatment is safe. Nonetheless, the preferences of the individual patients in their consideration of breast conservation versus mastectomy should be integrated into routine treatment decisions.
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Affiliation(s)
| | | | | | | | | | | | | | - Jörg Heil
- Department of Obstetrics and Gynecology, University of Heidelberg, Medical School, Heidelberg, Germany
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10
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Gennaro M, De Santis MC, Mariani L, Lo Vullo S, Cappelletti V, Agresti R, Cortinovis U, Paolini B, Di Cosimo S, Carcangiu ML, Daidone MG, Lozza L. Ten-year results of applying an original scoring system for addressing adjuvant therapy use after breast-conserving surgery for ductal carcinoma in situ of the breast. Breast 2017. [PMID: 28651115 DOI: 10.1016/j.breast.2017.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Although large-scale randomised clinical trials have established that radiotherapy (RT) - alone or combined with hormonal therapy (HT) - is effective in reducing the risk of ipsilateral breast tumour recurrence (IBTR), overall survival does not seem to be improved by adjuvant therapies. We sought to ascertain whether specific criteria can be adopted to avoid RT with an acceptable rate of IBTR after breast-conserving surgery (BCS) achieving tumour-free margins. PATIENTS AND METHODS This non-randomised prospective study concerned the outcome of patients who underwent BCS for ductal carcinoma in situ (DCIS) and were prospectively assessed by means of an established scoring system based on width of free margins in association with age <40, presence of comedonecrosis, high grade, ER negativity and HER2 positivity, to orient the use of any adjuvant therapies. RESULTS From March 2000 to April 2006, a total of 224 patients were enrolled and followed up for this study. No adjuvant treatment was considered for 76 patients, while 53, 39 and 56 patients received HT alone, RT alone, and RT plus HT, respectively. After a median follow-up of 129.6 months, 25 patients developed an IBTR, corresponding to a yearly rate of 1.138% (95% CI: 0.769-1.684). CONCLUSION When the criteria considered in the present study were applied to address the use of adjuvant therapies, no RT was administered to 57.6% of patients, 33.9% received no adjuvant treatments at all, and the rate of IBTR was low. Our findings support the conviction that the risk/benefit of omitting RT may lean on the side of the latter in selected patients.
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Affiliation(s)
- Massimiliano Gennaro
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - Maria Carmen De Santis
- Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Luigi Mariani
- Clinical Epidemiology and Trials Organization Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Salvatore Lo Vullo
- Clinical Epidemiology and Trials Organization Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Vera Cappelletti
- Experimental Oncology and Molecular Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Roberto Agresti
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Umberto Cortinovis
- Plastic and Reconstructive Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Biagio Paolini
- Pathology Service, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Serena Di Cosimo
- Experimental Oncology and Molecular Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Maria Luisa Carcangiu
- Pathology Service, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Maria Grazia Daidone
- Experimental Oncology and Molecular Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Laura Lozza
- Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
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Zhang A, Li J, Wang W, Wang Y, Mu D, Chen Z, Shao Q, Li F. A comparison study between gross tumor volumes defined by preoperative magnetic resonance imaging, postoperative specimens, and tumor bed for radiotherapy after breast-conserving surgery. Medicine (Baltimore) 2017; 96:e5839. [PMID: 28079816 PMCID: PMC5266178 DOI: 10.1097/md.0000000000005839] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The identification and contouring of target volume is important for breast-conserving therapy. The aim of the study was to compare preoperative magnetic resonance imaging (MRI), postoperative pathology, excised specimens' (ES) size, and tumor bed (TB) delineation as methods for determining the gross tumor volume (GTV) for radiotherapy after breast-conserving surgery (BCS). METHODS Thirty-three patients with breast cancer who underwent preoperative MRI and radiotherapy after BCS were enrolled. The GTVs determined by MRI, pathology, and the ES were defined as GTVMRI, GTVPAT, and GTVES, respectively. GTVMRI+1 was defined as a 1.0-cm margin around the GTVMRI. The radiation oncologist delineated GTV of the TB (GTVTB) using planning computed tomography according to ≥5 surgical clips placed in the lumpectomy cavity (LC). RESULTS The median GTVMRI, GTVMRI+1, GTVPAT, GTVES, and GTVTB were 0.97 cm (range, 0.01-6.88), 12.58 cm (range, 3.90-34.13), 0.97 cm (range, 0.01-6.36), 15.46 cm (range, 1.15-70.69), and 19.24 cm (range, 4.72-54.33), respectively. There were no significant differences between GTVMRI and GTVPAT, GTVMRI+1 and GTVES, GTVES and GTVTB (P = 0.188, 0.070, and 0.264, respectively). GTVMRI is positively related with GTVPAT. However, neither GTVES nor GTVTB correlated with GTVMRI (P = 0.071 and 0.378, respectively). Furthermore, neither GTVES nor GTVTB correlated with GTVMRI+1 (P = 0.068 and 0.375, respectively). CONCLUSION When ≥5 surgical clips were placed in the LC for BCS, the volume of TB was consistent with the volume of ES. Neither the volume of TB nor the volume of ES correlated significantly with the volume of tumor defined by preoperative MRI.
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Affiliation(s)
- Aiping Zhang
- Medicine and Life Sciences College of Shandong Academy of Medical Sciences, Jinan University
- Department of Radiation Oncology
| | | | - Wei Wang
- Department of Radiation Oncology
| | | | | | - Zhaoqiu Chen
- Department of Radiology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, Shandong Province, China
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Abstract
PURPOSE OF REVIEW Ductal carcinoma in situ (DCIS) accounts for approximately 20% of mammographically diagnosed breast cancers. Currently, there is a trend to consider DCIS as a lesion for which treatment deescalation is advocated to avoid overtreatment, that is, radiotherapy in addition to breast-conserving surgery or even surgery at all. RECENT FINDINGS The long-term follow-up updates of the four first-generation randomized trials comparing lumpectomy with and without radiation therapy have confirmed that radiation halves the local failure rates. However, radiotherapy is not associated with a survival benefit just as affirmed by the recently published evaluation of the Surveillance, Epidemiology, and End Results registries database, including 108,196 women with DCIS. Nevertheless, the risk of dying of breast cancer increases about factor 18 after experience of an invasive local recurrence. That means at least some DCIS have the potential to progress to a life threatening disease. At the same time, none of the recently updated prospective trials that tested the outcome after excision alone in low-risk DCIS achieved a 10-year local failure rate below 10%. SUMMARY DCIS is not a uniform disease. Its clinical behaviour is heterogeneous, but up to date no citeria are available that allow a precise identification of patients with low or very low progression risk who do not need irradiation. Therefore, excision followed by radiotherapy is still the standard of care in patients undergoing breast conservation. Promising new approaches for risk estimation have to be validated prospectively before their use in daily practice can be recommended.
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Aalders K, van Bommel A, van Dalen T, Sonke G, van Diest P, Boersma L, van der Heiden- van der Loo M. Contemporary risks of local and regional recurrence and contralateral breast cancer in patients treated for primary breast cancer. Eur J Cancer 2016; 63:118-26. [DOI: 10.1016/j.ejca.2016.05.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 03/08/2016] [Accepted: 05/09/2016] [Indexed: 12/17/2022]
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Knuttel FM, van den Bosch MAAJ. Magnetic Resonance-Guided High Intensity Focused Ultrasound Ablation of Breast Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 880:65-81. [PMID: 26486332 DOI: 10.1007/978-3-319-22536-4_4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This chapter describes several aspects of MR-HIFU treatment for breast cancer. The current and future applications, technical developments and clinical results are discussed. MR-HIFU ablation is under investigation for the treatment of breast cancer, but is not yet ready for clinical implementation. Firstly, the efficacy of MR-HIFU ablation should be investigated in large trials. The existing literature shows that results of initial, small studies are moderate, but opportunities for improvement are available. Careful patient selection, taking treatment margins into account and using a dedicated breast system might improve treatment outcomes. MRI-guidance has proven to be beneficial for the accuracy and safety of HIFU treatments because of its usefulness before, during and after treatments. In conclusion, MR-HIFU is promising for the treatment of breast cancer and might lead to a change in breast cancer care in the future.
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Affiliation(s)
- Floortje M Knuttel
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Hughes KS. DCIS does not need treatment… really? Breast Cancer Res Treat 2015; 154:1-4. [DOI: 10.1007/s10549-015-3606-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 10/12/2015] [Indexed: 10/22/2022]
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Unal D, Oguz A, Tasdemir A. Rate of metastasis in examined lymph nodes as a predictor of extracapsular extension in patients with axillary node-positive breast cancer. J NIPPON MED SCH 2015; 81:372-7. [PMID: 25744480 DOI: 10.1272/jnms.81.372] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The status of the axillary lymph nodes is an important factor in the prognosis and treatment of breast cancer. Extracapsular extension (ECE) is the spread of lymphatic tumor cells beyond the capsule of an axillary lymph node. Recent studies have demonstrated that ECE is a strongly unfavorable prognostic factor. OBJECTIVE In the present study, we investigated whether the rate of metastasis among examined lymph nodes can be used to predict ECE in patients with axillary node-positive breast cancer. METHODS The subjects were 95 women with axillary node-positive breast cancer. The numbers of lymph nodes removed (examined) and lymph nodes involved were recorded. The cut-off values, area under the curve, sensitivity, and specificity were calculated with the receiver operating characteristic curve technique for ability of the rate of metastasis to examined lymph nodes to predict ECE. RESULTS The rate of metastasis to examined lymph nodes was significantly greater in patients with ECE than in patients without ECE [0.57 (0.03-1.00) vs. 0.22 (0.04-1.00), respectively, p: 0.001]. Similarly, the presence of vascular infiltration was significantly higher in patients with ECE than in those without ECE [30 (73.2%) vs. 25 (47.2%) respectively, p: 0.010]. On the other hand, other variables did not differ between the groups (p>0.05). When the cut-off value was ≥0.23, the sensitivity and specificity of the rate of metastasis to examined lymph nodes were 80.49% and 55.56%, respectively. The area under the curve was 0.697 (95% confidence interval: 0.594-0.787, p: 0.004). CONCLUSION Our results suggest that rate of metastasis among examined lymph nodes is a predictor of ECE in patients with axillary node-positive breast cancer.
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Affiliation(s)
- Dilek Unal
- Department of Radiation Oncology, Kayseri Education and Research Hospital
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Kümmel A, Kümmel S, Barinoff J, Heitz F, Holtschmidt J, Weikel W, Lorenz-Salehi F, du Bois A, Harter P, Traut A, Blohmer JU, Ataseven B. Prognostic Factors for Local, Loco-regional and Systemic Recurrence in Early-stage Breast Cancer. Geburtshilfe Frauenheilkd 2015; 75:710-718. [PMID: 26257408 DOI: 10.1055/s-0035-1546050] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 12/06/2014] [Accepted: 12/12/2014] [Indexed: 01/13/2023] Open
Abstract
Aim: The risk of recurrence in breast cancer depends on factors such as treatment but also on the intrinsic subtype. We analyzed the risk factors for local, loco-regional and systemic recurrence, evaluated the differences and analyzed the risk of recurrence for different molecular subtypes. Material and Methods: A total of 3054 breast cancer patients who underwent surgery followed by adjuvant treatment at HSK hospital or Essen Mitte Hospital between 1998 and 2011 were analyzed. Based on immunohistochemical parameters, cancers were divided into the following subgroups: luminal A, luminal B (HER2-), luminal B (HER2+), HER2+ and TNBC (triple negative breast cancer). Results: 67 % of tumors were classified as luminal A, 13 % as luminal B (HER2-), 6 % as luminal B (HER2+), 3 % as HER2+ and 11 % as TNBC. After a median follow-up time of 6.6 years there were 100 local (3.3 %), 32 loco-regional (1 %) and 248 distant recurrences (8 %). Five-year recurrence-free survival for the overall patient collective was 92 %. On multivariate analysis, positive nodal status, TNBC subtype and absence of radiation therapy were found to be independent risk factors for all forms of recurrence. Age < 50 years, tumor size, luminal B (HER2-) subtype and breast-conserving therapy were additional risk factors for local recurrence. Compared to the luminal A subtype, the risk of systemic recurrence was higher for all other subtypes; additional risk factors for systemic recurrence were lymphatic invasion, absence of systemic therapy and mastectomy. Conclusion: Overall, the risk of local and loco-regional recurrence was low. In addition to nodal status, subgroup classification was found to be an important factor affecting the risk of recurrence.
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Affiliation(s)
- A Kümmel
- Klinik für Gynäkologie & Gynäkologische Onkologie, Kliniken Essen-Mitte, Essen
| | - S Kümmel
- Klinik für Gynäkologie & Gynäkologische Onkologie, Kliniken Essen-Mitte, Essen
| | - J Barinoff
- Klinik für Gynäkologie & Gynäkologische Onkologie, Kliniken Essen-Mitte, Essen
| | - F Heitz
- Klinik für Gynäkologie & Gynäkologische Onkologie, Kliniken Essen-Mitte, Essen
| | - J Holtschmidt
- Klinik für Gynäkologie & Gynäkologische Onkologie, Kliniken Essen-Mitte, Essen
| | - W Weikel
- Klinik für Gynäkologie & Gynäkologische Onkologie, Kliniken Essen-Mitte, Essen
| | - F Lorenz-Salehi
- Klinik für Gynäkologie & Gynäkologische Onkologie, Kliniken Essen-Mitte, Essen
| | - A du Bois
- Klinik für Gynäkologie & Gynäkologische Onkologie, Kliniken Essen-Mitte, Essen
| | - P Harter
- Klinik für Gynäkologie & Gynäkologische Onkologie, Kliniken Essen-Mitte, Essen
| | - A Traut
- Klinik für Gynäkologie & Gynäkologische Onkologie, Kliniken Essen-Mitte, Essen
| | - J U Blohmer
- Klinik für Gynäkologie & Gynäkologische Onkologie, Kliniken Essen-Mitte, Essen
| | - B Ataseven
- Klinik für Gynäkologie & Gynäkologische Onkologie, Kliniken Essen-Mitte, Essen
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van der Heiden-van der Loo M, Siesling S, Wouters MWJM, van Dalen T, Rutgers EJT, Peeters PHM. The Value of Ipsilateral Breast Tumor Recurrence as a Quality Indicator: Hospital Variation in the Netherlands. Ann Surg Oncol 2015; 22 Suppl 3:S522-8. [DOI: 10.1245/s10434-015-4626-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Indexed: 11/18/2022]
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Gene expression profiling to predict the risk of locoregional recurrence in breast cancer: a pooled analysis. Breast Cancer Res Treat 2014; 148:599-613. [PMID: 25414025 DOI: 10.1007/s10549-014-3188-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 10/29/2014] [Indexed: 12/19/2022]
Abstract
The 70-gene signature (MammaPrint) has been developed to predict the risk of distant metastases in breast cancer and select those patients who may benefit from adjuvant treatment. Given the strong association between locoregional and distant recurrence, we hypothesize that the 70-gene signature will also be able to predict the risk of locoregional recurrence (LRR). 1,053 breast cancer patients primarily treated with breast-conserving treatment or mastectomy at the Netherlands Cancer Institute between 1984 and 2006 were included. Adjuvant treatment consisted of radiotherapy, chemotherapy, and/or endocrine therapy as indicated by guidelines used at the time. All patients were included in various 70-gene signature validation studies. After a median follow-up of 8.96 years with 87 LRRs, patients with a high-risk 70-gene signature (n = 492) had an LRR risk of 12.6% (95% CI 9.7-15.8) at 10 years, compared to 6.1% (95% CI 4.1-8.5) for low-risk patients (n = 561; P < 0.001). Adjusting the 70-gene signature in a competing risk model for the clinicopathological factors such as age, tumour size, grade, hormone receptor status, LVI, axillary lymph node involvement, surgical treatment, endocrine treatment, and chemotherapy resulted in a multivariable HR of 1.73 (95% CI 1.02-2.93; P = 0.042). Adding the signature to the model based on clinicopathological factors improved the discrimination, albeit non-significantly [C-index through 10 years changed from 0.731 (95% CI 0.682-0.782) to 0.741 (95% CI 0.693-0.790)]. Calibration of the prognostic models was excellent. The 70-gene signature is an independent prognostic factor for LRR. A significantly lower local recurrence risk was seen in patients with a low-risk 70-gene signature compared to those with high-risk 70-gene signature.
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Pattern of Ipsilateral Breast Tumor Recurrence After Breast-Conserving Therapy. Int J Radiat Oncol Biol Phys 2014; 89:1006-1014. [DOI: 10.1016/j.ijrobp.2014.04.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 04/16/2014] [Accepted: 04/22/2014] [Indexed: 11/20/2022]
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Schrodi S, Niedostatek A, Werner C, Tillack A, Schubert-Fritschle G, Engel J. Is primary surgery of breast cancer patients consistent with German guidelines? Twelve-year trend of population-based clinical cancer registry data. Eur J Cancer Care (Engl) 2014; 24:242-52. [DOI: 10.1111/ecc.12194] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2014] [Indexed: 02/06/2023]
Affiliation(s)
- S. Schrodi
- Munich Cancer Registry (MCR) of the Munich Cancer Centre (MCC); Department of medical Informatics, Biometry and Epidemiology (IBE); Ludwig-Maximilians-University (LMU), Großhadern Clinic; Munich Germany
| | - A. Niedostatek
- Regional Clinical Cancer Register Dresden (RKKRD); Dresden Germany
| | - C. Werner
- Regional Clinical Cancer Register Dresden (RKKRD); Dresden Germany
| | - A. Tillack
- Cancer Centre Brandenburg; Frankfurt (Oder) Germany
| | - G. Schubert-Fritschle
- Munich Cancer Registry (MCR) of the Munich Cancer Centre (MCC); Department of medical Informatics, Biometry and Epidemiology (IBE); Ludwig-Maximilians-University (LMU), Großhadern Clinic; Munich Germany
| | - J. Engel
- Munich Cancer Registry (MCR) of the Munich Cancer Centre (MCC); Department of medical Informatics, Biometry and Epidemiology (IBE); Ludwig-Maximilians-University (LMU), Großhadern Clinic; Munich Germany
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Baur A, Bahrs SD, Speck S, Wietek BM, Krämer B, Vogel U, Claussen CD, Siegmann-Luz KC. Breast MRI of pure ductal carcinoma in situ: sensitivity of diagnosis and influence of lesion characteristics. Eur J Radiol 2013; 82:1731-7. [PMID: 23743052 DOI: 10.1016/j.ejrad.2013.05.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 04/26/2013] [Accepted: 05/05/2013] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The purpose of the study was to evaluate the sensitivity of breast MRI in the detection of pure DCIS and to analyze the influence of lesion type and nuclear grade. METHODS 58 consecutive patients with pathologically proven pure DCIS and preoperatively performed breast MRI were retrospectively reviewed and analyzed. Sensitivities in the detection of DCIS were calculated for MRI and mammography (Mx). Influence of MRI lesion type and nuclear grading on DCIS diagnosis was evaluated. RESULTS MRI detected pure DCIS with a sensitivity of 79.3%. The sensitivity of Mx was lower (69%), but the difference was not statistically significant (p=0.345). 46.2% of the DCIS presented as enhancing mass and 53.8% as non-mass-like enhancement (NMLE). None of the masses but 21.4% (n=6) of the NMLE were underestimated as probably benign (BI-RADS 3). MRI measured lesion sizes showed a moderate correlation (r=0.74) with histopathologically measured lesion sizes. MRI detection rate of DCIS decreased significantly (p=0.0458) with increasing nuclear grade. Calculated sensitivities were 100% for low-grade DCIS, 84.6% for intermediate-grade DCIS, and 66.7% for high-grade DCIS. CONCLUSIONS In this study MRI could detect pure DCIS more sensitively than Mx. Despite of missing statistically significance preoperative MRI seems to be helpful in patients with DCIS who are eligible for breast conservation. This applies in particular to patients with non-high-grade DCIS because those were significantly more often positive on MRI and significantly more often negative on Mx. Misinterpretation occurs especially in cases of NMLE and high-grade DCIS and therefore a correlation with Mx is also recommended.
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Affiliation(s)
- Astrid Baur
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany.
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Kunkler IH, Kerr GR, Thomas JS, Jack WJ, Bartlett JM, Pedersen HC, Cameron DA, Dixon JM, Chetty U. Impact of Screening and Risk Factors for Local Recurrence and Survival After Conservative Surgery and Radiotherapy for Early Breast Cancer: Results From a Large Series With Long-Term Follow-Up. Int J Radiat Oncol Biol Phys 2012; 83:829-38. [DOI: 10.1016/j.ijrobp.2011.08.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 08/05/2011] [Accepted: 08/30/2011] [Indexed: 10/14/2022]
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Schmitz AC, Pengel KE, Loo CE, van den Bosch MA, Wesseling J, Gertenbach M, Alderliesten T, Mali WP, Rutgers EJT, Bartelink H, Gilhuijs KG. Pre-treatment imaging and pathology characteristics of invasive breast cancers of limited extent: Potential relevance for MRI-guided localized therapy. Radiother Oncol 2012; 104:11-8. [DOI: 10.1016/j.radonc.2012.04.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 04/06/2012] [Accepted: 04/10/2012] [Indexed: 11/17/2022]
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Nava MB, Ottolenghi J, Pennati A, Spano A, Bruno N, Catanuto G, Boliglowa D, Visintini V, Santoro S, Folli S. Skin/nipple sparing mastectomies and implant-based breast reconstruction in patients with large and ptotic breast: Oncological and reconstructive results. Breast 2012; 21:267-71. [DOI: 10.1016/j.breast.2011.01.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 11/08/2010] [Accepted: 01/03/2011] [Indexed: 10/18/2022] Open
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Coskun G, Dogan L, Karaman N, Ozaslan C, Atalay C. Value of sentinel lymph node biopsy in breast cancer patients with previous excisional biopsy. J Breast Cancer 2012; 15:87-90. [PMID: 22493633 PMCID: PMC3318180 DOI: 10.4048/jbc.2012.15.1.87] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2011] [Accepted: 12/02/2011] [Indexed: 11/30/2022] Open
Abstract
Purpose Sentinel lymph node biopsy (SLNB) in breast cancer patients with clinically negative axilla will ensure axillary dissection only for cases with lymph node metastasis and provide information about pathologic staging as accurate as the axillary dissection. It was shown that SLNB could be successfully performed regardless of the type of biopsy. The aim of this study was to investigate the feasibility of SLNB after excisional biopsy. Methods One hundred patients diagnosed with excisional biopsy or guide wire-localization and operated on with SLNB between February 2007 and March 2009 were retrospectively analyzed. SLNB was performed with 10 cc of 1% methylene blue alone or both methylene blue and 1 mCi of Tc-99m nanocolloid combination. Age, tumor localization and size, length of the biopsy incision, size of the biopsy specimen, multifocality, lymphovascular invasion, tumor grade, staining with methylene blue, localization, number and metastatic status of the lymph nodes stained, and success rate with a gamma probe were evaluated. Results Sentinel lymph node (SLN) could not be identified in 9 (16.9%) of patients in the methylene blue group (n=53). In the combination group (n=47), SLN could not be identified in one patient. Of 32 patients with negative SLNB, metastatic involvement was found to be present in 5 patients after axillary lymph node dissection (false negatives). The average numbers of SLNs found in the methylene blue group and combination group were 1.4 and 1.6, respectively. SLN detection and false negative rates in the methylene blue group were 83% and 15.7%, respectively. The rates for the combination group were 98% and 6.4%, respectively. None of the parameters related to patient, tumor or process were found to affect detection rates of SLN. Conclusion Only SLNB using a combination method is a safe and reliable technique for breast cancer patients diagnosed with excisional biopsy.
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Affiliation(s)
- Gokhan Coskun
- Department of General Surgery, Ankara Oncology Training and Research Hospital, Ankara, Turkey
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Güth U, Myrick ME, Viehl CT, Weber WP, Lardi AM, Schmid SM. Increasing rates of contralateral prophylactic mastectomy - a trend made in USA? Eur J Surg Oncol 2012; 38:296-301. [PMID: 22305274 DOI: 10.1016/j.ejso.2011.12.014] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 12/01/2011] [Accepted: 12/13/2011] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Numerous recent studies conducted in the USA reported a considerable rise in the rates of contralateral prophylactic mastectomy (CPM) in early-stage breast cancer (BC). However, this aggressive surgical approach only showed an evidence-based improvement in prognosis for a small subgroup of high-risk BC patients. We present the first European study reporting CPM rates in an unselected cohort of patients with BC. PATIENTS & METHODS The data of 881 patients (≤ 80 years) who underwent surgery for stage I-III BC from 1995 to 2009 at the University of Basel Breast Center was analyzed. RESULTS CPM was performed in 23 of 881 patients (2.6%). Of the entire patient population, 37.5% underwent ipsilateral mastectomy and of those, only 7.0% chose to undergo CPM. Importantly, there was no trend over time in the rate of CPM. Women who chose CPM were significantly younger (54 vs. 60 years, p < 0.001), had more often a positive family history (39.1% vs. 24.4%, p = 0.032) and tumors of lobular histology (30.5% vs. 13.9%, p = 0.035). CONCLUSIONS Our analysis of CPM rates in BC patients, conducted at a European University breast center, does not show the considerably rising CPM rates observed in the USA. We hypothesize that different medico-social and cultural factors, which are highlighted by a different public perception of BC and a different attitude toward plastic surgery, determine the varying CPM rates between the USA and Europe.
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Affiliation(s)
- U Güth
- University Hospital Basel, Department of Gynecology and Obstetrics, Spitalstrasse 21, CH-4031 Basel, Switzerland.
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Outcome of different timings of radiotherapy in implant-based breast reconstructions. Plast Reconstr Surg 2011; 128:353-359. [PMID: 21788827 DOI: 10.1097/prs.0b013e31821e6c10] [Citation(s) in RCA: 169] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The therapeutic role of postmastectomy radiation therapy has been demonstrated both in locally advanced breast cancer and in other high-risk conditions. Implant-based breast reconstruction for irradiated patients can generate higher complication rates. In this study, the authors observed the effects of radiation on temporary expanders and permanent implants. The estimate of the totally failed reconstruction rate was the principal endpoint of this study. Capsular contracture rates and patients' and surgeons' subjective evaluations were the secondary endpoints. METHODS Two hundred fifty-seven patients were consecutively involved in this study. The population was stratified into two groups: group 1, postmastectomy radiation therapy on permanent implants (n = 109 patients); and group 2, postmastectomy radiation therapy on tissue expanders (n = 50 patients). A nonirradiated control group made up of 98 patients was selected randomly. All patients underwent a two-stage immediate breast reconstruction with subpectoral temporary expanders and permanent implants. RESULTS The totally failed reconstruction rate was significantly higher in group 2, with 40 percent of unsuccessful reconstructions compared with 6.4 percent in group 1 and 2.3 percent in the control group (p < 0.0001). The capsular contracture rate was significantly higher for groups 1 and 2 compared with the control group. The shape and symmetry assessment and the patients' opinions demonstrated a higher incidence of good results in group 1 in comparison with group 2. The best scores were always obtained by the control group. CONCLUSION This study demonstrated that radiotherapy during tissue expansion may compromise the outcome of implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Precise correlation between MRI and histopathology - exploring treatment margins for MRI-guided localized breast cancer therapy. Radiother Oncol 2010; 97:225-32. [PMID: 20826026 DOI: 10.1016/j.radonc.2010.07.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 07/04/2010] [Accepted: 07/18/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is more often considered to guide, evaluate or select patients for partial breast irradiation (PBI) or minimally invasive therapy. Safe treatment margins around the MRI-visible lesion (MRI-GTV) are needed to account for surrounding subclinical occult disease. PURPOSE To precisely compare MRI findings with histopathology, and to obtain detailed knowledge about type, rate, quantity and distance of occult disease around the MRI-GTV. METHODS AND MATERIALS Patients undergoing MRI and breast-conserving therapy were prospectively included. The wide local excision specimens were subjected to detailed microscopic examination. The size of the invasive (index) tumor was compared with the MRI-GTV. The gross tumor volume (GTV) was defined as the pre-treatment visible lesion. Subclinical tumor foci were reconstructed at various distances to the MRI-GTV. RESULTS Sixty-two patients (64 breasts) were included. The mean size difference between MRI-GTV and the index tumor was 1.3mm. Subclinical disease occurred in 52% and 25% of the specimens at distances ≥10mm and ≥20mm, respectively, from the MRI-GTV. CONCLUSIONS For MRI-guided minimally invasive therapy, typical treatment margins of 10mm around the MRI-GTV may include occult disease in 52% of patients. When surgery achieves a 10mm tumor-free margin around the MRI-GTV, radiotherapy to the tumor bed may require clinical target volume margins >10mm in up to one-fourth of the patients.
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Alderliesten T, Loo C, Paape A, Muller S, Rutgers E, Peeters MJV, Gilhuijs K. On the feasibility of MRI-guided navigation to demarcate breast cancer for breast-conserving surgery. Med Phys 2010; 37:2617-26. [PMID: 20632573 DOI: 10.1118/1.3429048] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE The aim of this study was to investigate the feasibility of image-guided navigation approaches to demarcate breast cancer on the basis of preacquired magnetic resonance (MR) imaging in supine patient orientation. METHODS Strategies were examined to minimize the uncertainty in the instrument-tip position, based on the hypothesis that the release of instrument pressure returns the breast tissue to its predeformed state. For this purpose, four sources of uncertainty were taken into account: (1) U(ligaments): Uncertainty in the reproducibility of the internal mammary gland geometry during repeat patient setup in supine orientation; (2) U(r_breathing): Residual uncertainty in registration of the breast after compensation for breathing motion using an external marker; (3) U(reconstruction): Uncertainty in the reconstructed location of the tip of the needle using an optical image-navigation system (phantom experiments, n = 50); and (4) U(deformation): Uncertainty in displacement of breast tumors due to needle-induced tissue deformations (patients, n = 21). A Monte Carlo study was performed to establish the 95% confidence interval (CI) of the combined uncertainties. This region of uncertainty was subsequently visualized around the reconstructed needle tip as an additional navigational aid in the preacquired MR images. Validation of the system was performed in five healthy volunteers (localization of skin markers only) and in two patients. In the patients, the navigation system was used to monitor ultrasound-guided radioactive seed localization of breast cancer. Nearest distances between the needle tip and the tumor boundary in the ultrasound images were compared to those in the concurrently reconstructed MR images. RESULTS Both U(reconstruction) and U(deformation) were normally distributed with 0.1 +/- 1.2 mm (mean +/- 1 SD) and 0.1 +/- 0.8 mm, respectively. Taking prior estimates for U(ligaments) (0.0 +/- 1.5 mm) and U(r_breathing) (-0.1 +/- 0.6 mm) into account, the combined impact resulted in 3.9 mm uncertainty in the position of the needle tip (95% CI) after release of pressure. The volunteer study showed a targeting accuracy comparable to that in the phantom experiments: 2.9 +/- 1.3 versus 2.7 +/- 1.1 mm, respectively. In the patient feasibility study, the deviations were within the 3.9 mm CI. CONCLUSIONS Image-guided navigation to demarcate breast cancer on the basis of preacquired MR images in supine orientation appears feasible if patient breathing is tracked during the navigation procedure, positional uncertainty is visualized and pressure on the localization instrument is released prior to verification of its position.
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Affiliation(s)
- Tanja Alderliesten
- Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AVL), P.O. Box 90203, 1006 BE Amsterdam, The Netherlands
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Ess S, Joerger M, Frick H, Probst-Hensch N, Vlastos G, Rageth C, Lütolf U, Savidan A, Thürlimann B. Predictors of state-of-the-art management of early breast cancer in Switzerland. Ann Oncol 2010; 22:618-624. [PMID: 20705910 DOI: 10.1093/annonc/mdq404] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate predictors of state-of-the-art management of early breast cancer in Switzerland. PATIENTS AND METHODS The study included 3499 women aged 25-79 years diagnosed with invasive breast cancer stages I-IIIA in 2003-2005. Patients were identified through population-based cancer registries and treated in all kinds of settings. Concordance with national and international recommendations was assessed for 10 items covering surgery, radiotherapy, systemic adjuvant therapy and histopathology reporting. We used multivariate logistic regression to identify independent predictors of high (10 points) and low (≤7 points) concordance. RESULTS In one-third of the patients, management met guidelines in all items, whereas in about one-fifth, three or more items did not comply. Treatment by a surgeon with caseload in the upper tercile and team involved in clinical research were independent predictors of a high score, whereas treatment by a surgeon with a caseload in the lower tercile was associated with a low score. Socioeconomic characteristics such as income and education were not independent predictors, but patient's place of residence and age independently predicted management according to recommendations. CONCLUSION Specialization and involvement in clinical research seem to be key elements for enhancing the quality of early breast cancer management at population level.
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Affiliation(s)
- S Ess
- Cancer Registry St Gallen-Appenzell, Cancer League St. Gallen-Appenzell, St Gallen.
| | - M Joerger
- Cancer Registry St Gallen-Appenzell, Cancer League St. Gallen-Appenzell, St Gallen; Oncology Department, Cantonal Hospital St Gallen, St Gallen
| | - H Frick
- Cancer Registry Grison-Glarus and Department of Pathology, Cantonal Hospital Graubünden, Chur
| | - N Probst-Hensch
- Cancer Registry Zurich (former); Swiss Tropical and Public Health Institute, University of Basel, Basel
| | - G Vlastos
- Senology Unit, Geneva University Hospitals, Geneva
| | | | - U Lütolf
- Department of Radio-Oncology, Zurich University Hospital, Zurich
| | - A Savidan
- Cancer Registry St Gallen-Appenzell, Cancer League St. Gallen-Appenzell, St Gallen
| | - B Thürlimann
- Breast Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
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A practical approach to manage additional lesions at preoperative breast MRI in patients eligible for breast conserving therapy: results. Breast Cancer Res Treat 2010; 124:707-15. [DOI: 10.1007/s10549-010-1064-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 07/10/2010] [Indexed: 02/03/2023]
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35
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Carcinomes canalaires in situ (CCIS). Caractéristiques histopathologiques et traitement : analyse de 1 289 cas. Bull Cancer 2010; 97:301-10. [DOI: 10.1684/bdc.2010.1048] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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36
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Geographic variation in breast cancer care in Switzerland. Cancer Epidemiol 2010; 34:116-21. [PMID: 20185382 DOI: 10.1016/j.canep.2010.01.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 01/27/2010] [Accepted: 01/28/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE Regional disparities in breast cancer outcomes have been reported in Switzerland. The purpose of this study is to investigate geographic variation in early diagnosis and management of breast cancer. METHODS We used data from a representative sample of 4820 women diagnosed with invasive breast cancer between January 1, 2003 and December 31, 2005 identified by seven Swiss population based cancer registries. We collected retrospectively detailed information on mode of detection, tumor characteristics and treatments. Differences across geographic regions were tested for statistical significance using chi-square tests and uni- and multivariate logistic regression. RESULTS Considerable disparities in early detection and management of early breast cancer were found across regions. In particular, the proportion of early detected cancer varied from 43% in Valais to 27% in St. Gallen-Appenzell. Mastectomy rates varied from 24% in Geneva to 38% in St. Gallen-Appenzell and Grisons-Glarus. Higher reconstruction rates were observed in regions with lower rates of mastectomy. The use of sentinel node procedure in patients with nodal negative disease was high in Geneva and low in Eastern Switzerland. Differences in compliance with recommendations on the use of endocrine therapy and chemotherapy were less pronounced but statistically significant. CONCLUSIONS This analysis shows considerable geographic variation in breast cancer care in a health system characterized by high expenditures, universal access to services and high decentralization. Further study into the causes and effects of this variation on short- and long term patient outcomes is needed.
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Gruber R, Walter E, Helbich TH. Cost comparison between ultrasound-guided 14-g large core breast biopsy and open surgical biopsy: an analysis for Austria. Eur J Radiol 2009; 74:519-24. [PMID: 19427153 DOI: 10.1016/j.ejrad.2009.03.058] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2009] [Revised: 03/22/2009] [Accepted: 03/27/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE To examine the budget impact of ultrasound-guided 14-g large core breast biopsy (US-guided LCBB) by comparing the costs of US-guided LCBB and open surgical biopsy (OSB); to calculate the cost savings attributable to US-guided LCBB; and to assess the frequency with which US-guided LCBB obviates the need for an OSB. MATERIALS AND METHODS In a retrospective study, we reviewed 399 suspicious breast lesions on which US-guided LCBB and OSB or, in cases of benign histology, clinical follow-up, were performed. Cost savings were calculated using nationally allowed flat rates (A-drg) and patient charges. Costs were measured from both, a hospital and a socioeconomic perspective. Deterministic sensitivity analyses were simulated to assess the extent of achievable cost savings. RESULTS Overall cost savings for US-guided LCBB over OSB were euro 977 (euro 2,337/euro 3,314) per case from a hospital perspective, resulting in a total cost decrease of 30% for the diagnosis of suspicious breast lesions. From a socioeconomic perspective, cost savings were euro 1,542 (euro 2,600/euro 4,142) per case, resulting in a 37% reduction in biopsy cost. US-guided LCBB obviated the need for a surgical procedure in 240 (60%) of 399 women. In all four sensitivity analyses, costs of US-guided LCBB remained lower than that of OSB. CONCLUSION From an economic perspective, US-guided LCBB is highly recommended for the diagnosis of suspicious breast lesions, as this procedure reduces the cost of diagnosis substantially. In Austria, annual cost savings would be euro 18.5 million.
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Affiliation(s)
- R Gruber
- Medical University of Vienna, Department of Radiology, Division of Molecular and Gender Imaging, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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Maxwell AJ, Evans AJ, Carpenter R, Dobson HM, Kearins O, Clements K, Lawrence G, Bishop HM. Follow-up for screen-detected ductal carcinoma in situ: results of a survey of UK centres participating in the Sloane project. Eur J Surg Oncol 2009; 35:1055-9. [PMID: 19414235 DOI: 10.1016/j.ejso.2009.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Revised: 03/23/2009] [Accepted: 04/01/2009] [Indexed: 11/30/2022] Open
Abstract
AIMS To investigate the variations in follow-up practice for screen-detected ductal carcinoma in situ (DCIS) in the UK. METHODS A questionnaire enquiring about follow-up practice and the perceived value of clinical follow-up after surgery for screen-detected DCIS was sent to the 74 UK screening centres participating in the Sloane Project. RESULTS Responses were received from 66 hospitals serving 54 screening centres. These demonstrate wide variations in practice. Clinical follow-up duration ranges from 1 year to indefinite, with the frequency of visits from three-monthly to annually. Formal mammographic follow-up duration ranges from none to indefinite. Mammographic frequency ranges from 1 to 2 years. Follow-up varies according to factors such as size and grade of disease and margin status in 23 units and according to whether adjuvant therapy is given in 23. Seven hospitals perform mammography of reconstructed breasts. Thirty-one centres consider clinical follow-up of DCIS to be of value or limited value whereas 28 consider it to be of little or no value. CONCLUSIONS There is no consensus with regard to the duration and frequency of follow-up for screen-detected DCIS, the contribution of predictive and treatment factors, the use of mammography of the reconstructed breast or the perceived value of clinical follow-up. Published guidelines show no consensus. Multidisciplinary teams involved in the care of women with screen-detected non-invasive cancer should contribute to audits such as the Sloane Project in order to determine the most effective and efficient ways to treat and follow up these patients.
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Affiliation(s)
- A J Maxwell
- Bolton Breast Unit, Royal Bolton Hospital, Minerva Road, Bolton BL4 0JR, UK.
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Hoffmann J, Wallwiener D. Classifying breast cancer surgery: a novel, complexity-based system for oncological, oncoplastic and reconstructive procedures, and proof of principle by analysis of 1225 operations in 1166 patients. BMC Cancer 2009; 9:108. [PMID: 19356240 PMCID: PMC2679762 DOI: 10.1186/1471-2407-9-108] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Accepted: 04/08/2009] [Indexed: 11/17/2022] Open
Abstract
Background One of the basic prerequisites for generating evidence-based data is the availability of classification systems. Attempts to date to classify breast cancer operations have focussed on specific problems, e.g. the avoidance of secondary corrective surgery for surgical defects, rather than taking a generic approach. Methods Starting from an existing, simpler empirical scheme based on the complexity of breast surgical procedures, which was used in-house primarily in operative report-writing, a novel classification of ablative and breast-conserving procedures initially needed to be developed and elaborated systematically. To obtain proof of principle, a prospectively planned analysis of patient records for all major breast cancer-related operations performed at our breast centre in 2005 and 2006 was conducted using the new classification. Data were analysed using basic descriptive statistics such as frequency tables. Results A novel two-type, six-tier classification system comprising 12 main categories, 13 subcategories and 39 sub-subcategories of oncological, oncoplastic and reconstructive breast cancer-related surgery was successfully developed. Our system permitted unequivocal classification, without exception, of all 1225 procedures performed in 1166 breast cancer patients in 2005 and 2006. Conclusion Breast cancer-related surgical procedures can be generically classified according to their surgical complexity. Analysis of all major procedures performed at our breast centre during the study period provides proof of principle for this novel classification system. We envisage various applications for this classification, including uses in randomised clinical trials, guideline development, specialist surgical training, continuing professional development as well as quality of care and public health research.
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Affiliation(s)
- Jürgen Hoffmann
- Department of Obstetrics and Gynaecology, University of Tübingen, Tübingen, Germany.
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Leidenius MH, Vironen JH, von Smitten KA, Heikkilä PS, Joensuu H. The outcome of sentinel node biopsy in breast cancer patients with preoperative surgical biopsy. J Surg Oncol 2009; 99:420-3. [DOI: 10.1002/jso.21279] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Risk–benefit analysis of preoperative breast MRI in patients with primary breast cancer. Clin Radiol 2009; 64:403-13. [DOI: 10.1016/j.crad.2008.12.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Revised: 11/27/2008] [Accepted: 12/02/2008] [Indexed: 11/22/2022]
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Cutuli B, Lemanski C, Fourquet A, de Lafontan B, Giard S, Meunier A, Pioud-Martigny R, Campana F, Marsiglia H, Lancrenon S, Mery E, Penault-Llorca F, Fondrinier E, Tunon de Lara C. Breast-conserving surgery with or without radiotherapy vs mastectomy for ductal carcinoma in situ: French Survey experience. Br J Cancer 2009; 100:1048-54. [PMID: 19277037 PMCID: PMC2670007 DOI: 10.1038/sj.bjc.6604968] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
From March 2003 to April 2004, 77 physicians throughout France prospectively recruited 1289 ductal carcinoma in situ (DCIS) patients and collected data on diagnosis, patient and tumour characteristics, and treatments. Median age was 56 years (range, 30–84). Ductal carcinoma in situ was diagnosed by mammography in 87.6% of patients. Mastectomy, conservative surgery alone (CS) and CS with radiotherapy (CS+RT) were performed in 30.5, 7.8 and 61.7% of patients, respectively. Thus, 89% of patients treated by CS received adjuvant RT. Sentinel node biopsy (SNB) and axillary dissection (AD) were performed in 21.3 and 10.4% of patients, respectively. Hormone therapy was administered to 13.4% of the patients (80% tamoxifen). Median tumour size was 14.5 mm (6, 11 and 35 mm for CS, CS+RT and mastectomy, respectively, P<0.0001). Nuclear grade was high in 21% of patients, intermediate in 38.5% and low in 40.5%. Excision was considered complete in 92% (CS) and 88.3% (CS+RT) of patients. Oestrogen receptors were positive in 69.8% of assessed cases (31%). Treatment modalities varied widely according to region: mastectomy rate, 20–37%; adjuvant RT, 84–96%; hormone treatment, 6–34%. Our survey on current DCIS management in France has highlighted correlations between pathological features (tumour size, margin and grade) and treatment options, with several similar variations to those observed in recent UK and US studies.
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Affiliation(s)
- B Cutuli
- Radiation Oncology Department, Polyclinique Courlancy, Reims, France.
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Pengel KE, Loo CE, Teertstra HJ, Muller SH, Wesseling J, Peterse JL, Bartelink H, Rutgers EJ, Gilhuijs KGA. The impact of preoperative MRI on breast-conserving surgery of invasive cancer: a comparative cohort study. Breast Cancer Res Treat 2008; 116:161-9. [DOI: 10.1007/s10549-008-0182-3] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Accepted: 09/02/2008] [Indexed: 12/31/2022]
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Reitsamer R, Menzel C, Glueck S, Hitzl W, Peintinger F. Predictors of Mastectomy in a Certified Breast Center The Surgeon is an Independent Risk Factor. Breast J 2008; 14:324-9. [DOI: 10.1111/j.1524-4741.2008.00592.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Blichert-Toft M, Nielsen M, Düring M, Møller S, Rank F, Overgaard M, Mouridsen HT. Long-term results of breast conserving surgery vs. mastectomy for early stage invasive breast cancer: 20-year follow-up of the Danish randomized DBCG-82TM protocol. Acta Oncol 2008; 47:672-81. [PMID: 18465335 DOI: 10.1080/02841860801971439] [Citation(s) in RCA: 197] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The main objective of the present study aims at comparing the long-term efficacy of breast conserving surgery (BCS) vs. mastectomy (M) based on a randomized design. The Danish Breast Cancer Cooperative Group (DBCG) conducted the trial (DBCG-82TM) from January 1983 to March 1989 recruiting 1154 patients with invasive breast carcinoma. Follow-up time ended 1(st) May 2006 with a median follow-up time of 19.6 years (time span 17.1-23.3 years). Eligibility criteria included a one-sided, unifocal, primary operable breast carcinoma, patient age below 70 years, probability of satisfactory cosmetic outcome with BCS, and no evidence of disseminated disease. The patients accrued were grouped into three subsets: correctly randomized, suspicion of randomization error, and declining randomization. The main analyses focus on the subgroup of 793 correctly randomized patients representing 70% of the complete series. 10-year recurrence free survival (RFS) and 20-year overall survival (OS) based on intent to treat did not reveal significant differences in outcome between breast conserving surgery vs. mastectomy, p=0.95 and p=0.10, respectively. Including the complete series comprising 1133 eligible patients based on treatment in fact given similarly no significant difference between surgical options could be traced in outcome of 10-year RFS and 20-year OS, p=0.94 and p=0.24, respectively. The pattern of recurrences as a first event in breast conservation vs. mastectomy did not differ significantly irrespective of site, p=0.27. Looking into the type of local relapse, viz., new primaries vs. true recurrences, it appeared that new primaries were significantly associated to BCS, while true recurrences dominated among M treated patients (p<0.001). In conclusion, long-term data indicate that BCS in eligible patients proves as effective as mastectomy both regarding local tumour control, RFS and OS. Local failures as a first event consistent with new primaries are strongly associated with BCS, whereas true recurrence predominates after mastectomy.
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de Kok M, van der Weijden T, Kessels A, Dirksen C, van de Velde C, Roukema J, van der Ent F, Bell A, von Meyenfeldt M. Implementation of an Ultra-short-stay Program After Breast Cancer Surgery in Four Hospitals: Perceived Barriers and Facilitators. World J Surg 2008; 32:2541-8. [DOI: 10.1007/s00268-007-9357-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Krämer S, Kümmel S, Camara O, Grosse R, Friedrich M, Blohmer JU. Partial Mastectomy Reconstruction with Local and Distant Tissue Flaps. Breast Care (Basel) 2007. [DOI: 10.1159/000109244] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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48
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de Kok M, Frotscher CNA, van der Weijden T, Kessels AGH, Dirksen CD, van de Velde CJH, Roukema JA, Bell AVRJ, van der Ent FW, von Meyenfeldt MF. Introduction of a breast cancer care programme including ultra short hospital stay in 4 early adopter centres: framework for an implementation study. BMC Cancer 2007; 7:117. [PMID: 17605796 PMCID: PMC1914078 DOI: 10.1186/1471-2407-7-117] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Accepted: 07/02/2007] [Indexed: 12/02/2022] Open
Abstract
Background Whereas ultra-short stay (day care or 24 hour hospitalisation) following breast cancer surgery was introduced in the US and Canada in the 1990s, it is not yet common practice in Europe. This paper describes the design of the MaDO study, which involves the implementation of ultra short stay admission for patients after breast cancer surgery, and evaluates whether the targets of the implementation strategy are reached. The ultra short stay programme and the applied implementation strategy will be evaluated from the economic perspective. Methods/design The MaDO study is a pre-post-controlled multi-centre study, that is performed in four hospitals in the Netherlands. It includes a pre and post measuring period of six months each with six months of implementation in between in at least 40 patients per hospital per measurement period. Primary outcome measure is the percentage of patients treated in ultra short stay. Secondary endpoints are the percentage of patients treated according to protocol, degree of involvement of home care nursing, quality of care from the patient's perspective, cost-effectiveness of the ultra short stay programme and cost-effectiveness of the implementation strategy. Quality of care will be measured by the QUOTE-breast cancer instrument, cost-effectiveness of the ultra short stay programme will be measured by means of the EuroQol (administered at four time-points) and a cost book for patients. Cost-effectiveness analysis will be performed from a societal perspective. Cost-effectiveness of the implementation strategy will be measured by determination of the costs of implementation activities. Discussion This study will reveal barriers and facilitators for implementation of the ultra short stay programme. Moreover, the results of the study will provide information about the cost-effectiveness of the ultra short stay programme and the implementation strategy. Trial registration Current Controlled Trials ISRCTN77253391.
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Affiliation(s)
- Mascha de Kok
- Department of Surgery, University Hospital Maastricht, Maastricht, the Netherlands
| | - Caroline NA Frotscher
- Department of Radiology, University Hospital Maastricht, Maastricht, the Netherlands
| | - Trudy van der Weijden
- Department of General Practice/Centre for Quality of Care Research/Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Alfons GH Kessels
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), University Hospital Maastricht, Maastricht, the Netherlands
| | - Carmen D Dirksen
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), University Hospital Maastricht, Maastricht, the Netherlands
| | | | - Jan A Roukema
- Breast Unit, St. Elisabeth Hospital, Tilburg, the Netherlands
| | - Antoine VRJ Bell
- Department of Surgery, Laurentius Hospital, Roermond, the Netherlands
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Yildirim E, Berberoglu U. Lymph Node Ratio is More Valuable than Level III Involvement for Prediction of Outcome in Node-Positive Breast Carcinoma Patients. World J Surg 2007; 31:276-89. [PMID: 17219275 DOI: 10.1007/s00268-006-0487-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND We examined the relationship between different expressions of positive axillary lymph nodes (PN) and the outcomes of node-positive breast carcinoma patients to determine the best predictor(s) among these expressions and to assess whether anatomic high level involvement is an independent prognostic factor. STUDY DESIGN In this retrospective study, the primary endpoints were distant recurrence (DR), locoregional recurrences (LRR), and disease-free survival (DFS). Univariate and multivariate prognostic factor analyses were carried out using survival and regression methods in the data of 704 patients with PN. RESULTS In multivariate analysis, the number of PN, ratio of PN, log odds of PN, and level III (L-III) involvement, separately, were significant factors for DR in addition to age, tumor size, and lymphovascular invasion (LVI). In the final model including all expressions of nodal involvement, age (continuous P = 0.001; hazard ratio [HR]: 0.98; 95% confidence Interval [95% CI]: 0.96-0.99), tumor size (continuous: P < 0.0001; HR: 1.3; 95% CI, 1.2-1.5), LVI (yes vs. no: P = 0.005; HR: 1.6; 95% CI, 1.2-2.2), and ratio of PN (continuous: P = 0.02; HR: 1.03; 95% CI, 1.01-1.06) were the independent prognostic factors for DR. For LRR, ratio of PN (continuous: P = 0.001; HR: 1.02; 95% CI, 1.01-1.03) was the most important factor in addition to age (continuous: P = 0.02; HR: 0.98; 95% CI, 0.97-0.99) and tumor size (continuous: P = 0.04; HR: 1.3; 95% CI, 1.1-1.6). When patients were stratified by number categories of PN (1-3 vs. 4-9 vs. >/= 10), there was no difference between DFSs of patients with and without L-III involvement. In contrast, when patients were stratified by L-III involvement, DFSs according to the number categories were statistically different. CONCLUSIONS Ratio of PN was more valuable than number of PN for predicting outcome in node-positive breast carcinoma patients. Level III involvement was not an independent prognostic indicator either for locoregional or for distant recurrences.
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Affiliation(s)
- Emin Yildirim
- Ankara Oncology Training and Research Hospital, Ankara, Turkey.
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Nitz U, Grosse R, Thomssen C. Breast Cancer Surgery – Oncological Aspects. Breast Care (Basel) 2006. [DOI: 10.1159/000095125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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