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Bichoo RA, Yadav SK, Mishra A, Lal P, Chand G, Agarwal G, Agarwal A, Mishra SK. Fungating Breast Cancer: Experience in Low and Middle Income Country. Indian J Surg Oncol 2020; 11:281-286. [PMID: 32523276 DOI: 10.1007/s13193-020-01040-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 01/17/2020] [Indexed: 12/24/2022] Open
Abstract
Fungating breast cancer (FBC) is a rare entity in developed nations. But this occurrence is not uncommon in our country. The aim of this study was to review clinico-pathologic profile and outcomes of FBC in a developing country. This retrospective study consisted of patients with FBC managed at our institute (Jan 2005-Dec 2015). Clinico-pathologic profile, management details, and outcomes were analyzed. The Kaplan-Meier method was used to determine overall survival (OS). Log-rank test was performed to compare survival in various subgroups. Seventy-nine patients were detected to have FBC constituting 3.3% of all breast cancers and 24.8% of those having T4b lesions. Mean age of the patients was 55 + 11 years. Ninety-six percent were women and 67% belonged to rural areas. A total of 75% women were postmenopausal. Mean duration of lump was 16 + 11 months. The mean tumor size was 8+ 2 cm. Eighty-seven percent had axillary lymph node involvement and 42% distant metastases. Fifty-eight percent (n = 46) patients had stage III and 42% (n = 33) stage had IV tumors. Hormone receptor (HR) positivity was noted in 44% (n = 35) and HER2/neu overexpression in 39% (n = 31) tumors, whereas 32% (n = 25) were triple negative. Overall, 95% (n = 75) of patients received chemotherapy, 91% (n = 72) patients underwent mastectomy, and 76% (n = 60) loco-regional radiotherapy. Median duration of follow-up was 40 (2-93) months. Median survival was 36 months, and 5-year OS was 40%. Except for stage (53% vs 22%, p = 0.005), no other factor influenced OS. Multimodality therapy in FBS results in good symptom palliation and comparable survival to stage III and IV patients without fungating tumors.
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Affiliation(s)
- Raouef Ahmed Bichoo
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014 India
| | - Sanjay Kumar Yadav
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014 India
| | - Anjali Mishra
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014 India
| | - Punita Lal
- Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Gyan Chand
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014 India
| | - Gaurav Agarwal
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014 India
| | - Amit Agarwal
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014 India
| | - Saroj K Mishra
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014 India
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Grassadonia A, Vici P, Gamucci T, Moscetti L, Pizzuti L, Mentuccia L, Iezzi L, Scognamiglio MT, Zilli M, Giampietro J, Graziano V, Natoli C, Tinari N. Long-term outcome of breast cancer patients with pathologic N3a lymph node stage. Breast 2017; 32:79-86. [DOI: 10.1016/j.breast.2016.12.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 12/22/2016] [Accepted: 12/25/2016] [Indexed: 01/10/2023] Open
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Histopathological characterization of ulcerated breast cancer and comparison to their non-ulcerated counterparts. Tumour Biol 2014; 36:3423-8. [DOI: 10.1007/s13277-014-2977-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 12/11/2014] [Indexed: 10/24/2022] Open
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Factors influencing the outcome of breast cancer patients with 10 or more metastasized axillary lymph nodes. Int J Clin Oncol 2011; 16:473-81. [PMID: 21360123 DOI: 10.1007/s10147-011-0207-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 02/07/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The purpose of this study was to investigate prognostic factors in breast cancer patients with metastasis of ten or more lymph nodes (pathologic N3a). METHODS We conducted a retrospective analysis of the cases of 304 breast cancer patients with pathologic N3a disease who had undergone definitive surgery between 1986 and 2006, and investigated the correlation between clinicopathologic characteristics and treatment outcomes. RESULTS With a median follow-up period of 55 months, the 5-year disease-free survival rate was 42.9% and the overall survival rate was 57.8%. Univariate analysis showed that the factors associated with poor disease-free survival were: age < 35 years (P = 0.001), history of neoadjuvant chemotherapy (P < 0.001), T4 stage (P < 0.001), 20 or more positive lymph nodes (P < 0.001), presence of lymphovascular invasion (P = 0.003), and negative progesterone receptor expression (P = 0.003). Multivariate analysis showed the factors with independent prognostic significance to be: history of neoadjuvant chemotherapy (hazard ratio [HR] 3.163; 95% confidence interval [CI], 2.025-4.941; P < 0.001), 20 or more positive nodes (HR 1.598; 95% CI, 1.063-2.402; P = 0.024), and presence of lymphovascular invasion (HR 1.636; 95% CI, 1.009-2.654; P = 0.046). Factors associated with poor overall survival in univariate analysis were: age < 35 years (P = 0.033), history of neoadjuvant chemotherapy (P < 0.001), T4 stage (P = 0.001), 20 or more positive lymph nodes (P < 0.001), and negative progesterone receptor expression (P = 0.013). Multivariate analysis showed these factors to be: history of neoadjuvant chemotherapy (HR 2.900; 95% CI, 2.011-4.182; P < 0.001), and 20 or more positive nodes (HR 1.956; 95% CI, 1.419-2.696; P < 0.001). CONCLUSION Cases of breast tumors with extensive nodal metastasis were found to be heterogeneous in terms of prognosis. History of previous neoadjuvant chemotherapy and higher numbers of metastatic lymph nodes were found to be the two most important prognostic markers for pathologic N3a disease. New strategies such as biologic therapy and novel combinations should be considered for application in patients with poor prognosis, rather than conventional treatment.
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Mersin H, Yildirim E, Berberoglu U, Gulben K. Triple negative phenotype and N-ratio are important for prognosis in patients with stage IIIB non-inflammatory breast carcinoma. J Surg Oncol 2010; 100:681-7. [PMID: 19798691 DOI: 10.1002/jso.21411] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim is to evaluate novel prognostic factors such as triple negative (TN) phenotype and ratio between positive nodes and total dissected lymph nodes (N-ratio) in stage IIIB breast carcinoma patients. METHODS In this retrospective study, primary endpoints were local recurrence (LR), distant recurrence (DR), and overall survival (OS). Univariate and multivariate prognostic factor analyses were carried out using Cox and Kaplan-Meier methods in the data of 185 patients. RESULTS The median observation time was 36 (range 16-86) months. Pathological tumor size (continuous [cont.], P = 0.002; Hazard ratio [HR], 1.2; 95% confidence interval [CI], 1.1-1.3) and N-ratio (cont., P < 0.0001; HR, 1.02; CI, 1.01-1.03) were strongly associated with LR. Tumor phenotype (triple vs. non-triple, P = 0.002; HR, 2.6; CI, 1.4-4.7), N-ratio (cont., P = 0.01; HR, 1.02; CI, 1.01-1.03) and pathological tumor size (cont., P = 0.003; HR, 1.2; CI, 1.1-1.3) for DR, and also tumor phenotype (triple vs. non-triple, P < 0.0001; HR, 3.7; CI, 1.8-7.5), N-ratio (cont., P = 0.03; HR, 1.02; CI, 1.01-1.03) and pathological tumor size (cont., P = 0.006; HR, 1.3; CI, 1.2-1.4) for OS were the most important prognostic factors. CONCLUSIONS N-Ratio and TN phenotype were the most important prognostic factors for stage IIIB breast carcinoma patients.
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Affiliation(s)
- Hakan Mersin
- Department of Surgery, Ankara Oncology Training and Research Hospital, Ankara, Turkey.
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Güth U, Huang DJ, Schötzau A, Dirnhofer S, Wight E, Singer G. Breast cancer with non-inflammatory skin involvement: current data on an underreported entity and its problematic classification. Breast 2009; 19:59-64. [PMID: 20015652 DOI: 10.1016/j.breast.2009.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 09/17/2009] [Accepted: 11/25/2009] [Indexed: 12/01/2022] Open
Abstract
We evaluated 166 breast cancer cases with non-inflammatory skin involvement (NISI), which were classified in the TNM classification as T4b. The distribution of tumour sizes and stages was: < or =3 cm:24.1%, 3.1-5 cm:21.7%, 5.1-10 cm:33.1%, >10 cm:21.1%; stages:I/II:21.0%, III:43.4%, IV:35.6%. To assess the impact of NISI on axillary lymph node involvement (ALNI), we analyzed a sub-group of 50 patients with tumours < or =5 cm and compared them with a matched control group. NISI was found to be associated with increased ALNI (HR, 2.66; 95%CI, 1.59-4.63; p<0.0001). According to the inherent rules of tumour classification, only tumours with similar morphologic extent and prognostic significance should be combined. Since there is a high grade of heterogeneity, this basic tenet is clearly violated regarding breast cancer with NISI. Our proposal is to eliminate these tumours from the T4 category and to classify them simply by size (T1-3). Due to its prognostic significance, NISI should be indicated by an optional descriptor (e.g. S1).
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Affiliation(s)
- Uwe Güth
- University Hospital Basel, Department of Gynecology and Obstetrics, Spitalstrasse 21, Basel, Switzerland.
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Güth U, Wight E, Schötzau A, Langer I, Dieterich H, Rochlitz C, Herberich L, Holzgreve W, Singer G. A new approach in breast cancer with non-inflammatory skin involvement. Acta Oncol 2009; 45:576-83. [PMID: 16864172 DOI: 10.1080/02841860600602953] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The widely accepted image of breast cancer with non-inflammatory skin involvement (T4b) is determined by the tenet that all these tumors are locally advanced (Stage IIIB). The study addresses the question whether this view is justified. Data from 453 non-metastatic breast cancer patients were collected retrospectively. Eighty-one patients had T4b disease. To assess the malignant potential of tumors independent of the feature skin involvement, a reclassification only considering tumor size was undertaken. We compared the clinical course of three study groups (A: Stage II; B: Stage IIIA; C: Stage IIIC) with control groups of 372 patients without skin involvement. In the study groups, we found a broad distribution among the stages (A:36.2%; B:33.7%; and C:27.7%) with significant differences in disease-specific survival (DSS) (A/B: p = 0.032; B/C: p = 0.048). There were no significant differences in DSS between the study and the corresponding control group. In multivariate analysis, skin involvement was not a significant predictor of DSS. Heterogeneity of the T4b category and a lack of prognostic significance expand the widely accepted image of breast cancer with non-inflammatory skin involvement. The highest T category, or Stage III, is not the appropriate classification for a considerable number of patients having this clinicopathologic entity.
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Affiliation(s)
- Uwe Güth
- Department of Gynecology and Obstetrics, University Hospital Basel, UHB, Spitalstrasse 21, CH-4031, Basel, Switzerland.
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Güth U, Jane Huang D, Holzgreve W, Wight E, Singer G. T4 breast cancer under closer inspection: A case for revision of the TNM classification. Breast 2007; 16:625-36. [PMID: 17604172 DOI: 10.1016/j.breast.2007.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 05/13/2007] [Indexed: 01/27/2023] Open
Abstract
The presence of skin involvement in breast cancer results in the classification of the tumor into the highest tumor category, and accordingly into the highest non-metastatic disease stage (current TNM classification: T4/stage III). This traditional view is no longer justifiable, as tumors that show non-inflammatory skin involvement (T4b) make up a considerably heterogeneous group with a high percentage of small-sized tumors. Classifying all lesions demonstrating this feature together results in the combination of tumors with widely differing prognostic and therapeutic implications into a single group. This violates the basic principle of the TNM concept in that only tumors exhibiting similar extension and prognosis should be grouped into one category/stage. Furthermore, the currently valid definitions of non-inflammatory skin involvement are misconceived for the substantial group of small tumors which often have ambiguous morphologic findings: the clinical classification depends on the subjective perception of the individual observer, and the pathologic staging considers histologic criteria that are not justifiable from a functional-morphological point of view. For these reasons, we strongly feel that there is a need to revise the current T4 category. We recommend that breast carcinomas currently classified as T4a-c should be eliminated from the T4 category and classified simply according to their tumor size (T1-3). The prognostically very unfavorable inflammatory carcinoma (T4d) should be maintained as the only clinicopathologic entity in the T4 category. This proposal, which will also lead to a revision of the stage III group, adheres more closely to the goals and principles of the TNM classification than do the current classification guidelines. Through the revision of the T4 category, the definitions and guidelines of inflammatory breast carcinoma should be adapted to the internationally accepted nomenclature.
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Affiliation(s)
- Uwe Güth
- University Hospital Basel, Department of Gynecology and Obstetrics, Spitalstrasse 21, CH-4031 Basel, Switzerland.
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Keam B, Im SA, Kim HJ, Oh DY, Kim JH, Lee SH, Chie EK, Han W, Kim DW, Moon WK, Kim TY, Park IA, Noh DY, Heo DS, Ha SW, Bang YJ. Prognostic impact of clinicopathologic parameters in stage II/III breast cancer treated with neoadjuvant docetaxel and doxorubicin chemotherapy: paradoxical features of the triple negative breast cancer. BMC Cancer 2007; 7:203. [PMID: 17976237 PMCID: PMC2217558 DOI: 10.1186/1471-2407-7-203] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2007] [Accepted: 11/01/2007] [Indexed: 01/24/2023] Open
Abstract
Background Prognostic factors in locally advanced breast cancer treated with neoadjuvant chemotherapy differ from those of early breast cancer. The purpose of this study was to identify the clinical significance of potential predictive and prognostic factors in breast cancer patients treated by neoadjuvant chemotherapy. Methods A total of 145 stage II and III breast cancer patients received neoadjuvant docetaxel/doxorubicin chemotherapy were enrolled in this study. We examined the clinical and biological factors (ER, PR, p53, c-erbB2, bcl-2, and Ki-67) by immunohistochemistry. We analyzed clinical outcome and their correlation with clinicopathologic parameters. Results Among the clinicopathologic parameters investigated, none of the marker was correlated with response rate (RR) except triple negative phenotype. Patients with triple negative phenotype showed higher RR (83.0% in triple negative vs. 62.2% in non-triple negative, p = 0.012) and pathologic complete RR (17.0% in triple negative vs. 3.1% in non-triple negative, p = 0.005). However, relapse free survival (RFS) and overall survival (OS) were significantly shorter in triple negative breast cancer patients (p < 0.001, p = 0.021, respectively). Low histologic grade, positive hormone receptors, positive bcl-2 and low level of Ki-67 were associated with prolonged RFS. In addition, positive ER and positive bcl-2 were associated with prolonged OS. In our homogeneous patient population, initial clinical stage reflects RFS and OS more precisely than pathologic stage. In multivariate analysis, initial clinical stage was the only significant independent prognostic factor to impact on OS (hazard ratio 3.597, p = 0.044). Conclusion Several molecular markers provided useful predictive and prognostic information in stage II and III breast cancer patients treated with neoadjuvant docetaxel/doxorubicin chemotherapy. Triple negative phenotype was associated with shorter survival, even though it was associated with a higher response rate to neoadjuvant chemotherapy.
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Affiliation(s)
- Bhumsuk Keam
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
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Gülben K, Berberoğlu U, Cengiz A, Altınyollar H. Prognostic Factors Affecting Locoregional Recurrence in Patients with Stage IIIB Noninflammatory Breast Cancer. World J Surg 2007; 31:1724-1730. [PMID: 17629742 DOI: 10.1007/s00268-007-9139-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of the present study was to identify the clinicopathological factors affecting locoregional recurrence (LRR) in patients with clinical stage IIIB noninflammatory breast cancer (NIBC). METHODS The records of 120 stage IIIB NIBC patients treated with neoadjuvant chemotherapy (NAC) and then modified radical mastectomy followed by radiotherapy were evaluated. In this retrospective cohort, the effects of age, menopausal status, clinical tumor size, clinical response to NAC, pathological axillary status, number of positive axillary lymph nodes, pathological response to NAC, grade, lymphovascular invasion, estrogen receptor status, progesterone receptor status, Her-2-neu status, and p53 status on LRR were evaluated by univariate and multivariate analyses. RESULTS The clinical response rate of 120 patients was 79.2% (17.5% complete and 61.7% partial), with a complete pathological response rate of 12.5%. The median follow-up was 28 months (range: 10-74 months). The LRR rate was 13.3%. Based on the univariate analysis, the clinical tumor size, clinical response rate, pathological axillary status, four or more positive axillary lymph nodes, lymphovascular invasion, and estrogen receptor status were factors that significantly affected LRR. In the multivariate analysis, however, only the clinical response rate and the number of positive axillary lymph nodes were found to be statistically significant independent factors. CONCLUSIONS Effective local control of disease can be achieved in patients with stage IIIB NIBC using a combination of NAC, surgery, and radiotherapy. However, a worse clinical response after chemotherapy and four or more positive axillary lymph nodes affect LRR negatively in these patients.
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Affiliation(s)
- Kaptan Gülben
- Department of Surgery, Ankara Oncology Training and Research Hospital, Urankent sitesi, C-9 block, No:33, 06200, Demetevler, 06200, Ankara, Turkey.
| | - Uğur Berberoğlu
- Department of Surgery, Ankara Oncology Training and Research Hospital, Urankent sitesi, C-9 block, No:33, 06200, Demetevler, 06200, Ankara, Turkey
| | - Aziz Cengiz
- Department of Surgery, Ankara Oncology Training and Research Hospital, Urankent sitesi, C-9 block, No:33, 06200, Demetevler, 06200, Ankara, Turkey
| | - Hüseyin Altınyollar
- Department of Surgery, Ankara Oncology Training and Research Hospital, Urankent sitesi, C-9 block, No:33, 06200, Demetevler, 06200, Ankara, Turkey
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Güth U, Wight E, Schötzau A, Langer I, Dieterich H, Rochlitz C, Herberich L, Holzgreve W, Mihatsch MJ, Singer G. Correlation and significance of histopathological and clinical features in breast cancer with skin involvement (T4b). Hum Pathol 2006; 37:264-71. [PMID: 16613321 DOI: 10.1016/j.humpath.2005.11.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A retrospective review was performed to investigate the prognostic significance and validity of the pathological and clinical TNM staging of noninflammatory skin involvement in breast cancer. In 128 tumors with histologically proven skin involvement and a size up to 5 cm (64% of the entire group), we distinguished clearly between group A) cases showing the classical clinical signs (cT4b) and those that do not, and between group B) carcinomas infiltrating the epidermis (pT4b) and those infiltrating only the dermis. We found only moderate concordance (kappa = 0.44) between the pathological and clinical TNM staging system. In the analysis of 80 patients with a tumor size from 2.1 to 5.0 cm, neither the appearance of classical clinical signs nor the histological diagnosis of infiltration of the epidermis was shown to be a relevant factor. In comparison to the control groups, similar clinicopathologic entities without significant differences in long-term outcome were observed. After regrouping of the patients having tumor infiltration of the papillary dermis from the control group into the study group (pT4), the study group showed a significant higher number of involved axillary lymph nodes (P = .014) and a more extensive lymph node involvement (pN3; P = .025). The combination epidermis-papillary dermis seems to be more a functional unit than the epidermis alone that is defined as the crucial and delineating factor in the TNM Classification. Our results challenge the validity of the TNM rules and recommendations concerning T4b breast cancer because it leads, in the majority of cases, to tumors of comparable extent and prognosis being placed in different categories.
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Affiliation(s)
- Uwe Güth
- Department of Gynecology and Obstetrics, University Hospital Basel (UHB), CH-4031 Basel, Switzerland
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Güth U, Singer G, Langer I, Schötzau A, Herberich L, Holzgreve W, Wight E. T4 category revision enhances the accuracy and significance of stage III breast cancer. Cancer 2006; 106:2569-75. [PMID: 16688772 DOI: 10.1002/cncr.21920] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Because of the considerable heterogeneity in breast carcinoma with noninflammatory skin involvement (T4b/Stage IIIB), a revision was proposed of the TNM staging system that would classify these tumors exclusively based on their tumor size and lymph node status. In the current study, the authors evaluated how implementation of this proposal will affect Stage III noninflammatory breast cancer. METHODS Two hundred seven patients who were classified with noninflammatory Stage III breast cancer were treated consecutively between 1990 and 1999 at the University Hospital Basel, Switzerland. To assess the extent of T4b/Stage IIIB tumors independent of the clinicopathologic feature of skin involvement, the reclassification was undertaken. RESULTS Of 68 patients who had nonmetastatic T4b breast cancer, 37 patients (54.4%) had a tumor extent in accordance with Stage I/II and had improved disease-specific survival (DSS) compared with patients who had Stage III breast cancer (P = .008). Excluding those patients from Stage III led to a 17.9% reduction of the number of patients in this group (n = 170 patients). The 10-year DSS declined from 48.5% to 42.9%. CONCLUSIONS Considerable numbers of patients who are classified with noninflammatory Stage IIIB breast cancer show only a limited disease extent. Through a revision of the T4 category, these low-risk patients were excluded from the highest nonmetastatic TNM stage, and overstaging could be avoided. This procedure decreased the degree of heterogeneity of the entire Stage III group and may result in a more precise assessment of this disease entity.
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Affiliation(s)
- Uwe Güth
- Department of Gynecology and Obstetrics, University Hospital Basel, Basel, Switzerland.
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Guth U, Wight E, Schotzau A, Langer I, Dieterich H, Rochlitz C, Herberich L, Holzgreve W, Singer G. Breast carcinoma with noninflammatory skin involvement (T4b). Cancer 2005; 104:1862-70. [PMID: 16130140 DOI: 10.1002/cncr.21394] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In this study, the authors evaluated the clinical presentation of patients with T4b breast carcinoma, analyzed the impact of noninflammatory skin involvement on long-term survival, and addressed the question whether the T4 tumor category still has any justification. METHODS The clinical course of a study group of 119 patients with skin involvement was compared with the outcome of a control group of 299 consecutive patients who had tumors of the same size but without skin involvement. All tumors were stratified into 1 of 4 subsets according to greatest tumor dimension, as follows: Group A, < or = 3.0 cm; Group B, 3.1-5.0 cm; Group C, 5.1-10.0 cm; and Group D, > 10.0 cm. RESULTS The study group distribution of patients within the size subsets were as follows: Group A, 26.1%; Group B, 24.3%; Group C, 26.1%; and Group D, 23.5%. Differences in disease-specific survival between the tumor size subsets were significant (Groups A and B vs. Groups C and D; P < 0.0001). In contrast to large tumors (> 5.0 cm), carcinomas < or = 5.0 cm showed no statistical significant differences in disease-specific survival between study group patients and control group patients (Group A: P = 0.17; Group B: P = 0.31). CONCLUSIONS There is a broad range of clinicopathologic breast carcinoma entities within the T4b category. For > 50% of patients with T4b breast carcinoma, the feature noninflammatory skin involvement had no significant prognostic impact. Approximately 25% of patients had an extent of disease similar to that observed in patients with Stage I-II disease and, thus, falsely were considered to have more advanced disease. Heterogeneity and a lack of prognostic significance suggest that a revision of the T4 category, a relic of historic tumor classifications, is necessary.
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Affiliation(s)
- Uwe Guth
- Department of Gynecology and Obstetrics, University Hospital Basel, Basel, Switzerland.
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Güth U, Singer G, Schötzau A, Langer I, Dieterich H, Rochlitz C, Herberich L, Holzgreve W, Wight E. Scope and significance of non-uniform classification practices in breast cancer with non-inflammatory skin involvement: a clinicopathologic study and an international survey. Ann Oncol 2005; 16:1618-23. [PMID: 16033873 DOI: 10.1093/annonc/mdi319] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The study evaluates the scope of non-uniform classification practices concerning breast carcinomas with non-inflammatory skin involvement. PATIENTS AND METHODS We compared the clinical course of patients with histologically proven non-inflammatory skin involvement: 119 (65.4%) with clinically obvious 'classical' skin changes (Group A) and 63 (34.6%) with no or only discreet changes (Group B). A questionnaire was circulated to pathology departments in 24 countries to assess the practice concerning the placement of skin- involved breast carcinomas in the TNM classification. RESULTS Patients in Group B showed a significantly better disease specific survival (P=0.0002). Eighty-six respondents (70.5%) of the survey preferred the 'histological view' and classified tumors with only histological proven skin involvement as T 4 b/stage IIIB. The opposing classification principle ('clinical view'), which dictates that T 4 b breast cancer is a clinical diagnosis and the classical signs must be present, was supported by 31 respondents (25.4%). CONCLUSIONS A large number of breast cancer patients with non-inflammatory skin involvement are only histologically proven and show, compared with cases exhibiting the classical clinical signs, significant differences in clinical course and prognosis. In general, both subsets were aggregated in one T category/stage (T 4 b/IIIB). This results in a considerable distortion of the reported statistical data.
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Affiliation(s)
- U Güth
- Department of Gynecology and Obstetrics, University Hospital Basel, Switzerland.
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Poole GV, Thigpen JT, Vance RB, Barber WH. Management of Women who Present with T4 Breast Cancer. Am Surg 2004. [DOI: 10.1177/000313480407000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to review the clinical presentation and outcome of women who present with large or locally invasive (T4) breast carcinoma. This retrospective study was conducted at the University of Mississippi Medical Center, a state tertiary care referral institution. One hundred twenty-nine women between the ages of 28 and 85 years (mean, 55 years) presented with T4 breast carcinoma. Follow-up was available for 128 women. Only 23 women have survived (18%), 5 of whom (21.7%) have metastatic disease. Mean survival for those who died was 21.6 months, compared to 76.3 months for survivors. Survival was not influenced by tumor characteristics ( P > 0.5), but was strongly influenced by nodal status ( P < 0.001) and by the presence of metastases at the time of diagnosis ( P < 0.001). Survival was strongly related to mode of therapy ( P < 0.01), but this was principally related to very high mortality rates in women who received no therapy (100%), surgery only (92.3%), or chemotherapy only (95%). The best survival was seen in women who received chemotherapy prior to surgery (40%); their survival was superior to that of women treated initially by surgery, followed by chemotherapy (16.3%, P = 0.04). However, when women who presented with metastatic disease were excluded, survival was not different between these two groups ( P = 0.18). Despite public education efforts and the wide availability of screening programs for breast carcinoma, many women still present with locally advanced disease. Outcome can be favorable in the absence of node involvement or metastatic disease, even in the presence of large, fungating tumors. Multimodality therapy gives the best results, but early surgery may be required for progression of disease during chemotherapy or because of extensive ulceration at initial presentation.
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Affiliation(s)
- Galen V. Poole
- From the Departments of Surgery and Medicine, Division of Oncology, University of Mississippi Medical Center, Jackson, Mississippi
| | - J. Tate Thigpen
- From the Departments of Surgery and Medicine, Division of Oncology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Ralph B. Vance
- From the Departments of Surgery and Medicine, Division of Oncology, University of Mississippi Medical Center, Jackson, Mississippi
| | - W. Henry Barber
- From the Departments of Surgery and Medicine, Division of Oncology, University of Mississippi Medical Center, Jackson, Mississippi
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