Pathologic Characteristics of Breast Cancer that Predict for Local Recurrence After Lumpectomy Alone

Outcome Analysis of Patients with Early Infiltrating Breast Carcinoma Treated by Surgery with Intraoperative Evaluation of Surgical Margins

Aim

The purpose of this study was to determine the effect of intraoperative evaluation of surgical margins (IESM) on the local recurrence rate, the occurrence of distant metastases and survival in invasive breast carcinoma (T1-2).

Methods

Two groups of patients were compared: a control group of 149 patients treated by classical quadrantectomy without IESM, and an IESM study group of 102 patients submitted to surgical treatment guided by this procedure. In the IESM group 64 quandrantectomies, 33 enlarged quadrantectomies and five mastectomies were performed.

Results

In the control group 17 local recurrences (11.4%), 49 distant metastases (39.2%) and 43 deaths (31.5%) occurred; in the IESM group there were no local recurrences, nine distant metastases occurred (8.8%) and three patients died (2%). Adjuvant treatment was the same in both groups. The survival curves were estimated by the Kaplan-Meier method and compared with the log-rank test. The curves were censored at 99 months of follow-up for adequate comparison because the follow-up period was different in the two groups. Significant differences in local recurrence-free survival and distant metastasis-free survival curves (P = 0.001) in favor of the study group were observed. The overall survival curve of the IESM group was also superior, but statistical analysis revealed only a strong tendency without significance (P = 0.06).

Conclusion

Treatment of early infiltrating breast carcinoma guided by IESM results in a better prognosis.

Histopathological Study on Conservatively Operated Breast Carcinomas

In this histopathological study we looked at 303 cases of breast carcinomas, managed though conservative breast surgery and later analysed with the help of a classical histopathological technique, paraffin embedding. The carcinomas were assessed in terms of tumor size, lymph node status, histological type, correlation between invasive tumors and an situ carcinoma component, resection margins, grading and patients age. Following assessment, we looked at associations between above morphological and clinical parameters and ipsilateral local recurrences. We concluded that more than half of our cases were carcinomas, measuring between 2 cm and 5 cm, with no associated lymph node involvement, in keeping with pTNM criteria for stage II. By far, in our study, the most frequent histopathological type was type NOS (63.37%) followed by invasive lobular carcinoma (10.56%) and mixed ducto-lobular invasive carcinoma (6.27%). Other types of invasive carcinoma were rarer, each representing less than 4% of cases. In regards to in situ carcinomas we noted the most common histological types to be both cribriform intraductal carcinoma and comedocarcinoma, each identified in 1.65% of cases. Amongst invasive breast carcinomas, infiltrating ductal carcinoma not otherwise specified (NOS) was found to be most commonly associated with in situ ductal carcinoma lesions. This was seen in 34.9% of cases, and was the only type associated with an extensive in situ component. Analysing the grading of mammary carcinomas in our study showed that the vast majority of cases (63.04%) were grade 3 tumors. In regards to surgical resection margins, ¾ of cases were noted to have negative margins. Tumor recurrences were noted in 12 cases. These cases were most commonly noted to reoccur following initial poorly differentiated, infiltrating ductal carcinomas, not otherwise specified (NOS), with positive resection margins, measuring less than 2 cm. Patiens tended to be under the age of 40 and had positive lymph nodes. The emergence of local recurrences after conservative surgery for early breast cancer is singnificantly linked to poorly differentiated primary tumors (p <0.05) but not correlated with histological type, presence of extensive intraductal carcinoma component, size of primary breast tumor or lymph node status ( p> 0.05). In terms of increasing the risk of ipsilateral recurrence the most important aspect highlighted in our sudy was the status of the resection margins. Patients with positive resection margins had a significantly high risk to develop recurrences after the conservative surgery, compared to those with negative margins (p <0.001).

Validation of a Web-Based Tool to Predict the Ipsilateral Breast Tumor Recurrence (IBTR! 2.0) after Breast-Conserving Therapy for Korean Patients

Purpose

IBTR! 2.0 is a web-based nomogram that predicts the 10-year ipsilateral breast tumor recurrence (IBTR) rate after breast-conserving therapy. We validated this nomogram in Korean patients.

Methods

The nomogram was tested for 520 Korean patients, who underwent breast-conserving surgery followed by radiation therapy. Predicted and observed 10-year outcomes were compared for the entire cohort and for each group, predefined by nomogram-predicted risks: group 1, <3%; group 2, 3% to 5%; group 3, 5% to 10%; group 4, >10%.

Results

In overall patients, the overall 10 year predicted and observed estimates of IBTR were 5.22% and 5.70% (p=0.68). In group 1, (n=124), the predicted and observed estimates were 2.25% and 1.80% (p=0.73), in group 2 (n=177), 3.95% and 3.90% (p=0.97), in group 3 (n=181), 7.14% and 8.80% (p=0.42), and in group 4 (n=38), 11.66% and 14.90% (p=0.73), respectively.

Conclusion

In a previous validation of this nomogram based on American patients, nomogram-predicted IBTR rates were overestimated in the high-risk subgroup. However, our results based on Korean patients showed that the observed IBTR was higher than the predicted estimates in groups 3 and 4. This difference may arise from ethnic differences, as well as from the methods used to detect IBTR and the healthcare environment. IBTR! 2.0 may be considered as an acceptable nomogram in Korean patients with low- to moderate-risk of in-breast recurrence. Before widespread use of this nomogram, the IBTR! 2.0 needs a larger validation study and continuous modification.

Audit of local recurrence following breast conservation surgery with 5-mm target margin and hypofractionated 40-Gray breast radiotherapy for invasive breast cancer

INTRODUCTION

The risk of ipsilateral breast tumour recurrence (IBTR) following breast conservation surgery (BCS) for invasive breast cancer (IBC) and radiotherapy is dependent on patient-, tumour- and treatment-related variables. In the Cambridge Breast Unit, breast conserving surgery has been performed with a target radial margin of 5 mm for IBC, in combination with 40-Gy hypofractionated (15 fractions) breast radiotherapy, since 1999.

PATIENTS AND METHODS

An audit was performed of cases treated between 1999 and 2004. A total of 563 patients underwent BCS for invasive breast cancer with 90.4% receiving radiotherapy (RT) and 60.4% of patients receiving boost RT (3 fractions of 3-Gy).

RESULTS

After a median follow-up of 58 months, five of the 563 (0.9%) patients developed IBTR. The 5-year actuarial IBTR rate was 1.1%. In terms of distant disease recurrence (DDR), 29 of the 563 (5.2%) had DDR during follow-up, giving a 5-year actuarial DDR rate of 5.4%. The 5-year breast cancer specific survival was 95%, with the poorer NPI groups having worse breast cancer specific survival (Log-rank, P<0.0001). More importantly, patients with IBTR had a shorter breast cancer-specific survival than those who were IBTR-free (Log-rank, P<0.0001).

CONCLUSIONS

Our treatment regimen, combining BCS with a 5-mm target margin and hypofractionated 40-Gy RT, results in an extremely low rate of IBTR, and compares favourably with the target IBTR rate of <5% defined by the Association of Breast Surgeons (ABS) at BASO guidelines.

Breast surgery: minimally invasive diagnosis and treatment

The increasingly large proportion of elderly women in the United States population carries a disproportionate burden of breast cancer. The advent of minimally invasive surgical techniques applicable to breast disease has brought new opportunities to diagnose and treat breast cancer in the older population. This article reviews issues important to the evolving field of breast cancer management in older women: cancer risk and screening considerations, diagnosis and biopsy approaches, and surgical treatment options based on current studies and recommendations.

Ascertaining prognosis for breast cancer in node-negative patients with innovative survival analysis

Clinical decisions to administer adjuvant systemic therapy to women with early breast cancer require knowledge about baseline prognosis, which is only assessable in the absence of such adjuvant treatment, which most patients currently do receive. The Cox model is the standard tool for assessing the effect of prognostic factors; however, there may be substantive differences in the estimated prognosis obtained by the Cox model rather than a log-normal model. For more than 50 years, clinical breast cancer data for cohorts of patients have supported the choice of a log-normal model. The prognostic impact of model type is examined here for a cohort of breast cancer patients, only 7% of whom received adjuvant systemic therapy. We quantitated prognosis utilizing Kaplan-Meier, Cox, and log-normal survival analyses for 415 consecutive T1-T3, M0, histologically node-negative patients who were operated on for primary breast cancer at Women's College Hospital between 1977 and 1986. Recurrence outside the breast for disease-free interval (DFI) and breast cancer death for disease-specific survival (DSS) were the events of interest. The patient follow-up for these investigations was 96% complete: a median 8 years for those surviving. Factors used in these investigations were age, weight, tumor size, histology, tumor grade, nuclear grade, lymphovascular invasion, estrogen receptor (ER), progesterone receptor (PR), combined ER/PR receptor, overexpression of neu oncoprotein, DNA ploidy, S-phase, and adjuvant therapy. In our study we found evidence against the Cox assumption of proportional hazards, which is not an assumption for the log-normal approach. We identified patients with greater than 96% and others with less than 40% DSS at 10 years. The difference in prognosis determined by using the Cox versus the log-normal model ranged for DFI from 1.2% to 8.1%, and for DSS from 0.4% to 6.2%; interestingly, the difference was more substantial for patients with a high risk of recurrence or death from breast cancer. Estimated prognoses may differ substantially by survival analysis model type, by amounts that might affect patient management, and we think that the log-normal model has a major advantage over the Cox model for survival analysis.

[Non-metastatic breast cancer]

Seen before as a secondary branch in the field of surgery, the surgery of breast cancer is now a fully stand-alone specialty. A number of factors explain this trend: a dramatic increase of incidence, which practically doubled during the past twenty years, an evolution of the surgical practices leading to a "therapeutic coming-down" and, above all, a complexification of indications and elements of classification. The surgeon still remains the first actor of the treatment, often seing the patient in first place, and having by his surgical treatment a key action on the prognosis and the patient's quality of life. Nevertheless, the surgeon is not anymore the only master of the situation, as he once could have been. Breast cancer is now the archetypal disease where a multidisciplinary approach is mandatory at every stage. The aim of this article is to overview the reality of breast cancer at present, trying to clarify the numerous elements of classification, otherwise confusing.

Prognostic factors affecting the natural history of node-negative breast cancer

PURPOSE

We undertook a natural history investigation of a broad selection of prognostic factors in a cohort of women with node-negative breast cancer.

PATIENTS AND METHODS

The cohort consisted of 415 consecutive histologic node-negative (T1-3, M0) patients, operated on for primary breast cancer at Women's College Hospital, Toronto, Canada, between 1977 and 1986. Only 7% of these patients were given adjuvant systemic therapy; further, for the 48% of women who underwent lumpectomy, only 29% received adjuvant radiotherapy to the breast. Paraffin-embedded tumour tissue was available for the majority of patients. The following factors were examined for their univariate and multivariate effects on time to recurrence outside the breast (DFI) and survival from breast cancer (DSS): age, weight, tumour size, estrogen receptor, progesterone receptor, histologic type, tumour grade, nuclear grade, lymphovascular invasion, overexpression of neu oncoprotein, DNA ploidy, % cells in S-phase, and adjuvant therapy. Multivariate analyses utilized a Cox model with a step-wise factor selection for the 260 patients with complete information.

RESULTS

A worse prognosis was indicated when there was lymphovascular invasion (for DFI, p < 0.001; for DSS, p = 0.0046), high %S-phase (for DFI, p = 0.08; for DSS, p = 0.02), high tumour grade (for DFI, p = 0.02; for DSS, p = 0.03), and overexpression of neu oncoprotein (for DSS, p = 0.07).

CONCLUSIONS

In our natural history investigation, two factors, lymphovascular invasion and tumour grade, are of particular interest since they may be readily incorporated into clinical practice. Overexpression of neu oncoprotein may also play a role in determining prognosis for women administered adjuvant systemic therapy.

Breast cancer in the elderly: the role of adjuvant radiation therapy

PURPOSE

To evaluate available data on breast conserving surgery (BCS) with or without radiation therapy (RT), and alternative options (e.g. Tamoxifen alone) (Tam), focusing specifically on the older patients.

METHODS AND MATERIALS

The MEDLINE was searched for the terms elderly, BCS, adjuvant/postoperative RT, Tamoxifen, and randomized trials from 1992 to 2002.

RESULTS

Authors reviewed papers of general interest on the elderly and breast cancer (BC), meta-analysis, randomized trials on BCS+/-RT and Tam+/-surgery without RT, retrospective non-randomized trials, and reported on prognostic factors for local recurrence in BCS alone, including biomarkers, attempts made to define a low-risk group, and methods of modification of the current, protracted standard adjuvant RT course.

CONCLUSIONS

Postoperative RT after BCS has a firm rationale; in current clinical practice, if the BCS+RT is medically appropriate and the patient shares the choice, after a full information of the available options and their implications, it is clinically sound to propose this approach. However, there is controversy whether a subgroup of elderly patients could be safely spared: in this setting a randomized trial is clearly warranted.

Factors associated with local breast cancer recurrence after lumpectomy alone: postmenopausal patients

BACKGROUND

We have been following a cohort of patients who underwent a lumpectomy without receiving adjuvant radiotherapy or adjuvant systemic therapy. We now report the experience of a postmenopausal subgroup.

METHODS

The postmenopausal subgroup included 244 patients accrued between 1977 and 1986 and followed up. The end point was ipsilateral local breast cancer recurrence. The factors studied were the patient's age in years; tumor size (in mm); nodal status (N-, Nx, N+); estrogen and progesterone receptor status (< 10, - 10 fmol/mg protein); presence or absence of lymphovascular/perineural invasion; presence or absence, and type, of DCIS (none, non-comedo, comedo); percentage of DCIS; histological grade (1,2,3); and nuclear grade (1,2,3). Univariate analyses consisted of Kaplan-Meier plots and the Wilcoxon (Peto-Prentice) test statistic; the multivariate analyses were step-wise Cox and log-normal regressions.

RESULTS

The median follow-up of those patients still alive was 9.1 years, and the overall relapse rate was 24% (59/244). The univariate results indicated that the characteristics of smaller tumor size, negative nodes, positive ER status, and no lymphovascular or perineural invasion were associated with significantly (P <.05) lower relapse. From the multivariate analyses, the factors lymphovascular or perineural invasion, age, and amount of DCIS were all significantly associated with local relapse with both Cox and log-normal regressions. Additionally, there was weak evidence of an association between ER (P = .08 in the Cox regression and in the log-normal) and nodal status (P = .09 in the log-normal regression) with local relapse. We also are able to define a low-risk subgroup (N-, age -65, no comedo, ER positive, no emboli) with a crude 10-year local recurrence rate of 9%.

CONCLUSION

With longer follow-up, and for postmenopausal patients, there continues to be support for the theory that local relapse is affected by the factors lymphovascular or perineural invasion, age, amount of DCIS, ER, and nodal status. A low risk subgroup has been identified.