Towards optimal management of ductal carcinoma in situ of the breast

Post-operative radiotherapy for ductal carcinoma in situ of the breast

BACKGROUND

The addition of radiotherapy (RT) following breast conserving surgery (BCS) was first shown to reduce the risk of ipsilateral recurrence in the treatment of invasive breast cancer. Ductal carcinoma in situ (DCIS) is a pre-invasive lesion. Recurrence of ipsilateral disease following BCS can be either DCIS or invasive breast cancer. Randomised controlled trials (RCTs) have shown that RT can reduce the risk of recurrence, but assessment of potential long-term complications from addition of RT following BSC for DCIS has not been reported for women participating in RCTs.

OBJECTIVES

To summarise the data from RCTs testing the addition of RT to BCS for treatment of DCIS to determine the balance between the benefits and harms.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group Specialised Register (2 June 2011), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE (2 June 2011), EMBASE (2 June 2011) and the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP; 2 June 2011). Reference lists of articles and handsearching of ASCO (2007), ESMO (2002 to 2007), and St Gallen (2005 to 2007) conferences were performed.

SELECTION CRITERIA

RCTs of breast conserving surgery with and without radiotherapy in women at first diagnosis of pure ductal carcinoma in situ (no invasive disease present).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each potentially eligible trial for inclusion and its quality. Two authors also independently extracted data from published Kaplan-Meier analysis (survival curves) and reported summary statistics. Data were extracted and pooled for four trials. Data for planned subgroups were extracted and pooled for analysis.There were insufficient data to pool for long-term toxicity from radiotherapy.

MAIN RESULTS

Four RCTs involving 3925 women were identified and included in this review. All were high quality with minimal risk of bias. Three trials compared the addition of RT to BCS. One trial was a two by two factorial design comparing the use of RT and tamoxifen, each separately or together, in which participants were randomised in at least one arm. Analysis confirmed a statistically significant benefit from the addition of radiotherapy on all ipsilateral breast events (hazards ratio (HR) 0.49; 95% CI 0.41 to 0.58, P < 0.00001), ipsilateral invasive recurrence (HR 0.50; 95% CI 0.32 to 0.76, p=0.001) and ipsilateral DCIS recurrence (HR 0.61; 95% CI 0.39 to 0.95, P = 0.03). All the subgroups analysed benefited from addition of radiotherapy. No significant long-term toxicity from radiotherapy was found. No information about short-term toxicity from radiotherapy or quality of life data were reported.

AUTHORS' CONCLUSIONS

This review confirms the benefit of adding radiotherapy to breast conserving surgery for the treatment of all women diagnosed with DCIS. No long-term toxicity from use of radiotherapy was identified.

Identification of stage-specific breast markers using quantitative proteomics

Matched healthy and diseased tissues from breast cancer patients were analyzed by quantitative proteomics. By comparing proteomic profiles of fibroadenoma (benign tumors, three patients), DCIS (noninvasive cancer, three patients), and invasive ductal carcinoma (four patients), we identified protein alterations that correlated with breast cancer progression. Three 8-plex iTRAQ experiments generated an average of 826 protein identifications, of which 402 were common. After excluding those originating from blood, 59 proteins were significantly changed in tumor compared with normal tissues, with the majority associated with invasive carcinomas. Bioinformatics analysis identified relationships between proteins in this subset including roles in redox regulation, lipid transport, protein folding, and proteasomal degradation, with a substantial number increased in expression due to Myc oncogene activation. Three target proteins, cofilin-1 and p23 (increased in invasive carcinoma) and membrane copper amine oxidase 3 (decreased in invasive carcinoma), were subjected to further validation. All three were observed in phenotype-specific breast cancer cell lines, normal (nontransformed) breast cell lines, and primary breast epithelial cells by Western blotting, but only cofilin-1 and p23 were detected by multiple reaction monitoring mass spectrometry analysis. All three proteins were detected by both analytical approaches in matched tissue biopsies emulating the response observed with proteomics analysis. Tissue microarray analysis (361 patients) indicated cofilin-1 staining positively correlating with tumor grade and p23 staining with ER positive status; both therefore merit further investigation as potential biomarkers.

Oncologic surveillance of breast cancer patients after lipofilling

BACKGROUND

The regenerative effects of fat injections are based on the same hormones, growth factors, and stem cells that stimulate neoplastic angiogenesis and cancer progression in basic research. Few studies have analyzed the oncologic risk. No report has covered 5 years of oncologic surveillance, and no long-term risk has been estimated. The in vivo relationship between lipofilling and breast cancer remains unclear and controversial. This observational study focused on locoregional recurrence (LR) risk after lipofilling.

METHODS

The study enrolled 60 patients after breast cancer surgery (total mastectomy) from 2000 to 2007 treated by lipofilling (82 single-surgeon procedures with the same fat-decanting technique). The study ended when follow-up observation reached 10 years.

RESULTS

The study included invasive carcinoma (55 cases), in situ carcinoma (five cases), T1 (71.6 %) and T2 (23.3 %) carcinoma, N+ carcinoma (45 %), and stages 1 (43.3 %) and 2 (45 %) carcinoma. The overall 12-year incidence of LR was 5 % (1.6 % before and 3.3 % after lipofilling). The incidence of local relapse per 100 person-years was 0.36 in the first observation period and 0.43 after lipofilling. All LRs were stage 2, and the same rate, limited to stage 2, was 1.04. The crude cumulative incidence after lipofilling was 7.25 % (95 % confidence interval [CI], 0-15.4 %) for LR and 7.6 % (95 % CI, 0.2-15 %) for distant metastases.

DISCUSSION

Clinical data and recurrence incidences were compared with those of prior publications concerning lipofilling oncologic risk and discussed in relation to the inherent cancer literature.

CONCLUSIONS

Lipofilling may be used safely to treat tumor node metastasis stage 1 subjects after mastectomy. The local risk is low. For stage 2 patients, local failure was not significantly higher. Compared with institutional data and prior publications, the risk still is reliable. Breast conservative treatment must be investigated further because of the high risk for local relapse.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Progression of Ductal Carcinoma in Situ from the Pathological Perspective

Ductal carcinoma in situ (DCIS) now represents up to 20% of breast cancer cases, yet its behaviour is still poorly understood. Morphological classifications go some way to predicting prognosis, but more sophisticated approaches are required to better tailor therapy to the individual. A number of biological molecules have been identified that appear to relate to prognosis and, in model systems, promote progression to invasive disease. Some of these, such as COX-2, provide real therapeutic opportunities, whilst other marker combinations are showing promise in categorising women according to risk. Gene expression studies have led to an emerging molecular classification of invasive breast cancer, and it is now evident that at least some of these molecular subtypes can be identified at the pre-invasive stage. The difference in frequency of these subtypes between DCIS and invasive cancer may hold clues as to the biological mechanisms underpinning disease transition. It is increasingly clear that the host microenvironment can have a major impact on disease behaviour, and as well as acting as potential predictive factors, the altered microenvironment phenotype also offers novel therapeutic opportunities.

Oncological outcome and patient satisfaction with skin-sparing mastectomy and immediate breast reconstruction: a prospective observational study

BACKGROUND

The management of early breast cancer (BC) with skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) is not based on level-1 evidence. In this study, the oncological outcome, post-operative morbidity and patients' satisfaction with SSM and IBR using the latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis is evaluated.

METHODS

137 SSMs with IBR (10 bilateral) were undertaken in 127 consecutive women, using the LD flap plus implant (n = 85), LD flap alone (n = 1) or implant alone (n = 51), for early BC (n = 130) or prophylaxis (n = 7). Nipple reconstruction was performed in 69 patients, using the trefoil local flap technique (n = 61), nipple sharing (n = 6), skin graft (n = 1) and Monocryl mesh (n = 1). Thirty patients underwent contra-lateral procedures to enhance symmetry, including 19 augmentations and 11 mastopexy/reduction mammoplasties. A linear visual analogue scale was used to assess patient satisfaction with surgical outcome, ranging from 0 (not satisfied) to 10 (most satisfied).

RESULTS

After a median follow-up of 36 months (range = 6-101 months) there were no local recurrences. Overall breast cancer specific survival was 99.2%, 8 patients developed distant disease and 1 died of metastatic BC. There were no cases of partial or total LD flap loss. Morbidities included infection, requiring implant removal in 2 patients and 1 patient developed marginal ischaemia of the skin envelope. Chemotherapy was delayed in 1 patient due to infection. Significant capsule formation, requiring capsulotomy, was observed in 85% of patients who had either post-mastectomy radiotherapy (PMR) or prior radiotherapy (RT) compared with 13% for those who had not received RT. The outcome questionnaire was completed by 82 (64.6%) of 127 patients with a median satisfaction score of 9 (range = 5-10).

CONCLUSION

SSM with IBR is associated with low morbidity, high levels of patient satisfaction and is oncologically safe for T(is), T1 and T2 tumours without extensive skin involvement.

Post-operative radiotherapy for ductal carcinoma in situ of the breast

BACKGROUND

The addition of radiotherapy (RT) following breast conserving surgery (BCS) was first shown to reduce the risk of ipsilateral recurrence in the treatment of invasive breast cancer. Ductal carcinoma in situ (DCIS) is a pre-invasive lesion. Recurrence of ipsilateral disease following BCS can be either DCIS or invasive breast cancer. Randomised controlled trials (RCTs) have shown that RT can reduce the risk of recurrence, but assessment of potential long-term complications from addition of RT following BSC for DCIS has not been reported for women participating in RCTs.

OBJECTIVES

To summarise the data from RCTs testing the addition of RT to BCS for treatment of DCIS to determine the balance between the benefits and harms.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Specialised Register (January 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE (February 2008), and EMBASE (February 2008). Reference lists of articles and handsearching of ASCO (2007), ESMO (2002 to 2007), and St Gallen (2005 to 2007) conferences were performed.

SELECTION CRITERIA

RCTs of breast conserving surgery with and without radiotherapy in women at first diagnosis of pure ductal carcinoma in situ (no invasive disease present).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each potentially eligible trial for inclusion and its quality. Two authors also independently extracted data from published Kaplan-Meier analysis (survival curves) and reported summary statistics. Data were extracted and pooled for four trials. Data for planned subgroups were extracted and pooled for analysis.There were insufficient data to pool for long-term toxicity from radiotherapy.

MAIN RESULTS

Four RCTs involving 3925 women were identified and included in this review. All were high quality with minimal risk of bias. Three trials compared the addition of RT to BCS. One trial was a two by two factorial design comparing the use of RT and tamoxifen, each separately or together, in which participants were randomised in at least one arm. Analysis confirmed a statistically significant benefit from the addition of radiotherapy on all ipsilateral breast events (hazards ratio (HR) 0.49; 95% CI 0.41 to 0.58, P < 0.00001), ipsilateral invasive recurrence (HR 0.50; 95% CI 0.32 to 0.76, p=0.001) and ipsilateral DCIS recurrence (HR 0.61; 95% CI 0.39 to 0.95, P = 0.03). All the subgroups analysed benefited from addition of radiotherapy. No significant long-term toxicity from radiotherapy was found. No information about short-term toxicity from radiotherapy or quality of life data were reported.

AUTHORS' CONCLUSIONS

This review confirms the benefit of adding radiotherapy to breast conserving surgery for the treatment of all women diagnosed with DCIS. No long-term toxicity from use of radiotherapy was identified.

Post-operative radiotherapy for ductal carcinoma in situ of the breast

BACKGROUND

The addition of radiotherapy (RT) following breast conserving surgery (BCS) was first shown to reduce the risk of ipsilateral recurrence in the treatment of invasive breast cancer. Ductal carcinoma in situ (DCIS) is a pre-invasive lesion. Recurrence of ipsilateral disease following BCS can be either DCIS or invasive breast cancer. Randomised controlled trials (RCTs) have shown that RT can reduce the risk of recurrence, but assessment of potential long-term complications from addition of RT following BSC for DCIS has not been reported for women participating in RCTs.

OBJECTIVES

To summarise the data from RCTs testing the addition of RT to BCS for treatment of DCIS to determine the balance between the benefits and harms.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Specialised Register (January 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE (February 2008), and EMBASE (February 2008). Reference lists of articles and handsearching of ASCO (2007), ESMO (2002 to 2007), and St Gallen (2005 to 2007) conferences were performed.

SELECTION CRITERIA

RCTs of breast conserving surgery with and without radiotherapy in women at first diagnosis of pure ductal carcinoma in situ (no invasive disease present).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each potentially eligible trial for inclusion and its quality. Two authors also independently extracted data from published Kaplan-Meier analysis (survival curves) and reported summary statistics. Data were extracted and pooled for four trials. Data for planned subgroups were extracted and pooled for analysis.There were insufficient data to pool for long-term toxicity from radiotherapy.

MAIN RESULTS

Four RCTs involving 3925 women were identified and included in this review. All were high quality with minimal risk of bias. Three trials compared the addition of RT to BCS. One trial was a two by two factorial design comparing the use of RT and tamoxifen, each separately or together, in which participants were randomised in at least one arm. Analysis confirmed a statistically significant benefit from the addition of radiotherapy on all ipsilateral breast events (hazards ratio (HR) 0.49; 95% CI 0.41 to 0.59, P < 0.00001) and ipsilateral DCIS recurrence (HR 0.64; 95% CI 0.41 to 1.01, P = 0.05). Pooled analysis for invasive recurrence did not reach statistical significance. All the subgroups analysed benefited from addition of radiotherapy. No significant long-term toxicity from radiotherapy was found. No information about short-term toxicity from radiotherapy or quality of life data were reported.

AUTHORS' CONCLUSIONS

This review confirms the benefit of adding radiotherapy to breast conserving surgery for the treatment of all women diagnosed with DCIS. No long-term toxicity from use of radiotherapy was identified.

[Ductal carcinoma in situ of the breast (DCIS) under 40: a specific management?]

Ductal carcinoma in situ of the breast (DCIS) is rare in younger women, accounting for about 4% of all cases of DCIS in France, and tends to be diagnosed by clinical findings or casually, after plastic surgery. After breast conserving treatment, young age ( less than 40) is a predictive factor of relapses in patients with DCIS. Age may serve as one more parameter that should be considered in the complex decision-making process necessary to create a treatment plan for a woman with DCIS. Breast conservative treatment (BCT) could be used if: margins are free and more than 10 mm; if DCIS size is less than 11 mm and DCIS is free of necrosis and comedocarcinoma. Mastectomy ought to be proposed in case of: multifocal DCIS, or DCIS size more than 30 mm; invaded margins after re-excision; radiotherapy contraindicated; small breasts and patient choice. Immediate breast reconstruction should be proposed for patients with all the poor predictive factors. In other cases, treatment procedure will be explained to the patient and the treatment will be chosen by the patient in consultation with the medical team (radiologist, surgeon, pathologist and oncologist). Radiotherapy with boost or hormonotherapy with tamoxifen should not be used routinely but may be proposed individually.

Oncological safety and patient satisfaction with skin-sparing mastectomy and immediate breast reconstruction

INTRODUCTION

The management of early breast cancer with skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) is not based on evidence from randomised controlled trials. The purpose of this study is to evaluate the oncological safety, post-operative morbidity and patients' satisfaction with SSM and IBR using the latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis.

METHODS

Eighty-three consecutive women underwent 93 SSMs with IBR (10 bilateral), using the LD flap plus implant (n=55) or implant alone (n=38), indications included early breast cancer and prophylaxis due to BRCA-1 gene mutation. Nipple reconstruction was performed in 38 patients, using the trefoil local flap technique, nipple sharing or Monocryl mesh. Twenty-three underwent contra-lateral surgery in order to optimise symmetry, including 15 augmentations and eight mastopexy/reduction mammoplasties. Patient satisfaction with the outcome of surgery was assessed on a linear visual analogue scale ranging from 0 (not satisfied) to 10 (most satisfied).

RESULTS

There was no local recurrence (LR) after a median follow-up of 34 months (range=3-79 months). Overall survival was 98.8%, three patients developed distant disease and one patient died of metastatic breast cancer. No case of partial or total LD flap loss was observed. Morbidities included infection, requiring implant removal in two patients and one patient developed marginal ischaemia of the skin envelope. Significant capsule formation, requiring capsulotomy, was observed in 87% of patients who had either PMR or prior RT compared with 13% for those who did not have RT. Sixty-one (73.5%) of 83 patients completed the questionnaire with a median and mean satisfaction scores of 10.0 and 9.3, respectively (range=6-10).

CONCLUSION

SSM with IBR is associated with low morbidity, high levels of patient satisfaction and is oncologically adequate for T(is), T1 and T2 tumours without extensive skin involvement.

Oncological and aesthetic considerations of skin-sparing mastectomy

AIM

To review the oncological safety and aesthetic value of skin-sparing mastectomy (SSM) for invasive breast cancer (IBC) and ductal carcinoma in-situ (DCIS). Controversies including the impact of radiotherapy (RT) on immediate breast reconstruction (IBR), preservation of the nipple-areola complex (NAC) and the role of endoscopic mastectomy are also considered.

METHODS

Literature review facilitated by Medline and PubMed databases.

RESULTS

SSM is an oncologically safe technique in selected cases, including IBC <5 cm, multi-centric tumours, DCIS and prophylactic risk-reduction surgery. The high risk of local recurrence (LR) excludes inflammatory breast cancers and tumours with extensive involvement of the skin. SSM can facilitate IBR and is associated with an excellent aesthetic result. Prior breast irradiation or the need for post-mastectomy radiotherapy (PMR) do not preclude SSM, however the cosmetic outcome may be affected. Nipple/areola preservation is possible for remote tumours, employing a frozen section protocol for the retro-areolar tissue. There is limited data available for endoscopic mastectomy and superiority over conventional SSM has not been established.

CONCLUSION

In appropriately selected cases SSM is oncologically adequate. There are several patient centred advantages over conventional mastectomy, including aesthetic outcome and the avoidance of multiple staged procedures. Despite widespread uptake into surgical practice, validation of these techniques from randomised controlled trials is lacking.

National Breast Cancer Audit: ductal carcinoma in situ management in Australia and New Zealand

BACKGROUND

Ductal carcinoma in situ (DCIS) is a significant issue in Australia and New Zealand with rising incidence because of the implementation of mammographic screening. Current information on its natural history is unable to accurately predict progression to invasive cancer. In 2003, the National Breast Cancer Centre in Australia published recommendations for DCIS. In Australia and New Zealand, the National Breast Cancer Audit collects information on DCIS cases. This article will examine these recommendations and provide information from the audit on current DCIS management.

METHODS

Three thousand six hundred and twenty-nine cases of DCIS were entered by 274 breast surgeons between January 1998 and December 2004. Data items in the National Breast Cancer Audit database that were covered in the National Breast Cancer Centre recommendations were reviewed. Information was available on the following: diagnostic biopsy rates for all cases and mammographically positive cases and rates of breast conserving surgery (BCS), clear margins following BCS, postoperative radiotherapy following BCS for groups at high risk of recurrence as well as axillary procedures and tamoxifen prescription.

RESULTS

Close adherence was found in diagnostic biopsy, BCS and clear margin rates. Some high-risk groups received radiotherapy, although women with 'close' margins did not in 33% of cases. Axillary procedures were conducted in 23% of cases and most (81%) patients were not prescribed tamoxifen.

CONCLUSION

There was predominantly close adherence to recommendations with three possible areas of improvement: fewer axillary procedures, an appraisal of radiotherapy practice following BCS and more investigation into tamoxifen prescription practices for DCIS.

Is there an indication for sentinel node biopsy in patients with ductal carcinoma in situ of the breast? A review

Ductal carcinoma in situ (DCIS) of the breast is defined as a proliferation of malignant epithelial cells within breast ducts without evidence of invasion through the basement membrane. The detection rate of DCIS of the breast has dramatically increased since the mid-1980s as the result of the widespread use of screening mammography. DCIS currently represents about 15-25% of all breast cancers detected in population screening programmes. Although inherently a non-invasive disease, occult invasion with the potential of lymph node metastases may occur. Where performing an axillary lymph node dissection-or-not for DCIS used to be an important dilemma, the same now holds for the sentinel node biopsy. This article reviews the potential role of the sentinel node biopsy (SNB) in patients with DCIS. We conclude that based on the current literature, there is in general no role for a SNB in DCIS. A SNB should only be considered in patients with an excisional biopsy diagnosis of high risk DCIS (grade III with palpable mass or large tumour area by imaging) as well as in patients undergoing mastectomy after a core or excisional biopsy diagnosis of DCIS, although SNB may be contraindicated in many of the latter patients because of lesion size and/or multifocality. Even in these patients the value of a positive SN, containing mostly isolated tumour cells, is questionable.

Oncological considerations of skin-sparing mastectomy

Aim

To review evidence concerning the oncological safety of performing skin-sparing mastectomy (SSM) for invasive breast cancer and ductal carcinoma in situ (DCIS). Furthermore, the evidence concerning RT in relation to SSM and the possibility of nipple preservation was considered.

Methods

Literature review facilitated by Medline and PubMed databases.

Findings

Despite the lack of randomised controlled trials, SSM has become an accepted procedure in women undergoing mastectomy and immediate reconstruction for early breast cancer. Compared to non-skin-sparing mastectomy (NSSM), SSM seems to be oncologically safe in patients undergoing mastectomy for invasive tumours smaller than 5 cm, multicentric tumours, DCIS or risk-reduction. However, the technique should be avoided in patients with inflammatory breast cancer or in those with extensive tumour involvement of the skin in view of the high risk of local recurrence. SSM with nipple areola complex (NAC) preservation appears to be oncologically safe, provided the tumour is not close to the nipple and a frozen section protocol for the retro-areolar tissue is followed. Although radiotherapy (RT) does not represent a contraindication to SSM, the latter should be used with caution if postoperative RT is likely, since it detracts from the final cosmetic outcome.

Initial Outcomes for Patients Treated on the American Society of Breast Surgeons MammoSite Clinical Trial for Ductal Carcinoma-In-Situ of the Breast

BACKGROUND

The MammoSite device was designed as a breast brachytherapy applicator and is currently used to deliver accelerated partial breast irradiation (APBI). We hypothesized that APBI delivered with the MammoSite device would be well tolerated and be associated with a good cosmetic outcome in patients with ductal carcinoma-in-situ (DCIS).

METHODS

From 2002 to 2004, 191 patients with DCIS were enrolled in a registry trial to assess the MammoSite applicator. Fifteen patients were excluded from analysis because of device- or patient-related factors; 7 patients were excluded after receiving a radiotherapy boost, thus leaving 169 patients available for study. Follow-up information was available for 158 patients. The average length of follow-up was 7.35 months. Forty-three patients had at least 1 year of follow-up.

RESULTS

Skin spacing for the MammoSite applicator was as follows: < 5 mm, 3 patients (1.78%); 5 to 7 mm, 18 patients (10.65%); and > or = 7 mm, 148 patients (87.57%). Patients with a device-to-skin distance of > or = 7 mm had the best cosmetic result. Patients with a device-to-skin distance of > or = 7 mm also had a lower incidence of radiation dermatitis. Data on 43 patients who were followed up for at least 1 year confirmed these findings. Additional adverse events were primarily related to skin changes, with breast infections occurring in five patients (3.16%). No patient in the study has experienced a recurrence.

CONCLUSIONS

APBI delivered via MammoSite is well tolerated in patients with DCIS, and the lowest toxicity was obtained in patients with the greatest device-to-skin distance. Long-term follow-up data regarding patient satisfaction, cosmesis, and efficacy are needed and will be determined from a recently opened large randomized study.

Skin-sparing mastectomy and immediate breast reconstruction: patient satisfaction and clinical outcome

BACKGROUND

Skin-sparing mastectomy (SSM) followed by immediate reconstruction has been advocated as an effective treatment option for patients with early-stage breast carcinoma. It minimizes deformity and improves cosmesis through preservation of the natural skin envelope of the breast. The purpose of this study was to evaluate postoperative morbidity, patients' satisfaction, and oncological safety for SSM and immediate breast reconstruction (IBR) with a latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis in patients with operable breast cancer.

METHODS

Twenty-one consecutive patients with operable breast cancer undergoing 25 SSM and immediate reconstruction with an LD flap plus implant (n = 14) or implant alone (n = 11) were retrospectively studied (from 2001 through 2005). The median patients' age was 44 years (range, 30-68). Patient satisfaction with the outcome of surgery was assessed using a detailed questionnaire including a linear visual analogue scale ranging from 0 (not satisfied) to 10 (most satisfied). Eight of 20 (40%) patients required adjuvant chemotherapy, and only 2 patients required post-mastectomy radiation. Reconstruction of the nipple-areola complex was performed in 7 patients (33%) using the trefoil local flap technique. Contralateral procedures to achieve symmetry were performed in 6 (28%) patients (5 augmentations and 1 reduction mammoplasty).

RESULTS

Histological analysis showed pure ductal carcinoma in situ (DCIS) in 4 patients and invasive carcinoma (+/- DCIS) in 20 cases, of which 5 (25%) were node positive. One prophylactic mastectomy in a BRCA-2 carrier was negative for malignancy. Tumor size ranged from 5 to 90 mm. The surgical margins were clear in all cases. There was no delay in time to commencement of adjuvant therapies. After a mean follow-up period of 13.5 months (range, 5-46 months), none of the patients developed locoregional recurrence. Only 1 patient (5%) developed systemic recurrence (bony metastases). Overall survival was 100%. The incidence of flap necrosis/loss, implant loss, wound infection, or hematoma requiring surgical evacuation was 0%, 0%, 0%, and 0%, respectively. Capsule formation requiring capsulotomy was observed in 3 of 21 patients (14%). The median patient satisfaction score was 10 (range, 6-10).

CONCLUSION

SSM and IBR for operable breast cancer is associated with a high level of patient satisfaction and low morbidity. The procedure seems to be oncologically safe, even in patients with high-risk (T3 or node-positive) carcinoma. The latter needs to be confirmed with greater numbers of patients and longer follow-up.

Skin-sparing mastectomy

Background

Skin-sparing mastectomy (SSM) is a new technique being used in a variety of clinical settings. This article reviews the published data on SSM to establish its current role in clinical practice.

Methods

A Medline search was carried out using the key words ‘skin-sparing mastectomy’ to identify English-language articles published between 1990 and 2004 and further material referenced in these publications.

Results

SSM is most commonly used for surgical prophylaxis and to treat in situ and early invasive disease in patients who request immediate breast reconstruction. SSM and non-SSM result in similar surgical and oncological outcomes, but skin flap ischaemia is more common after SSM and is associated with a range of risk factors, including smoking.

Conclusion

SSM has become an established procedure in breast surgery, but there is a lack of prospective data on which to make evidence-based decisions about its use in individual patients.

Ductal carcinoma in situ: Value of sentinel lymph node biopsy

BACKGROUND

Ductal carcinoma in situ (DCIS) represents about 20% of newly diagnosed breast carcinomas. Axillary metastasis is often related to undiagnosed DCIS with microinvasion (DCISM). The aim of this study was to confirm the interest of sentinel lymph node (SLN) biopsy in extensive DCIS.

METHODS

Patients with a diagnosis of DCIS or DCISM and axillary lymph node evaluation were selected. Surgical treatment included SLN biopsy and/or axillary lymph node dissection (ALND). Serial sections were stained with hematoxylin and eosin (H&E) and with an immunohistochemical (IHC) method. When a micrometastasis was found, the breast specimen was revised searching for occult microinvasion.

RESULTS

Hundred and forty patients with initial DCIS were enrolled in the study. Node metastasis was identified in 9 patients (7%) of the 128 patients with DCIS and DCISM. At final histology, 4 (10%) of the 39 patients with pure DCIS and SLN biopsy and 1 (7%) of the 14 patients with DCISM and SLN biopsy had axillary micrometastasis. Four of the 12 patients upstaged to invasive carcinoma had metastatic SLNs.

CONCLUSIONS

Sentinel lymph node biopsy is valuable in patients with diffuse DCIS or DCISM who are scheduled for mastectomy in order to search for axillary micrometastases and occult breast microinvasion.

Compliance with guidelines is related to better local recurrence-free survival in ductal carcinoma in situ

The aim was to study the effect of compliance with guidelines on local recurrence (LR)-free survival in patients treated for ductal carcinoma in situ (DCIS). From January 1992 to December 2003, 251 consecutive patients had been treated for DCIS in two hospitals in the North Netherlands. Every case in this two-hospital sample was reviewed in retrospect for its clinical and pathological parameters. It was determined whether treatment had been carried out according to clinical guidelines, and outcomes in follow-up were assessed. In addition, all patients treated for DCIS in this region (n=1389) were studied regarding clinical parameters, in order to determine whether the two-hospital sample was representative of the entire region. In the two-hospital sample, 31.4% (n=79) of the patients had not been treated according to the guidelines. Positive margins were associated with LR (hazard ratio (HR)=4.790, 95% confidence interval (CI) 1.696–13.531). Breast-conserving surgery and deviation from the guidelines were independent predictors of LR (HR=7.842, 95% CI 2.126–28.926; HR=2.778, 95% CI 0.982–6.781, respectively). Although the guidelines changed over time, time was not a significant factor in predicting LRs (HR=1.254, 95% CI 0.272–5.776 for time period 1992–1995 and HR=1.976, 95% CI 0.526–7.421 for time period 1996–1999). Clinical guidelines for the treatment of patients with DCIS have been developed and updated from existing literature and best evidence. Compliance with the guidelines was an independent predictor of disease-free survival. These findings support the application of guidelines in the treatment of DCIS.

Issues in breast cancer screening

This paper will review the use of screening mammography in the United States, with an emphasis on its limitations as currently practiced. It will then emphasize several areas where breast cancer imaging practice can be improved, namely in reducing overtreatment of potentially nonlethal cancers, in monitoring the effectiveness of nonsurgical therapies, and in guiding noninvasive therapies. Any new modality that is to have an impact on breast cancer mortality must perform comparably to screening mammography to become widely utilized. While mammography is not perfect, it has set a high threshold that other modalities must reach before they will be widely utilized for screening or diagnosis.

Perinucleolar Compartment Prevalence Has an Independent Prognostic Value for Breast Cancer

The perinucleolar compartment (PNC) is a multicomponent nuclear structure enriched with RNAs transcribed by RNA pol III and RNA binding proteins. Studies in cultured cells showed an association between PNC and transformed phenotype. To evaluate the relationship between structure and malignancy in vivo, we examined PNC prevalence (the percentage of cells containing at least one PNC) in normal and cancerous paraffin-embedded breast tissues using immunohistochemistry against a PNC-associated protein. Five hundred nuclei in the most active area of each sample were scored for PNC prevalence. The results show that PNC prevalence significantly correlates with the progression of breast cancer (by the criteria of staging). PNC prevalence in primary tumors, lymph nodes, and distant metastases shows a stepwise increase from a median of 23% in primary tumors to ∼100% in distant metastases. In addition, univariate and multivariate (controlling for tumor size and grade) analyses show that early-stage patients with invasive ductal carcinomas containing a higher PNC prevalence have a significantly poorer prognosis. These findings link PNC prevalence with the progression of breast cancer in vivo and suggest that PNC-containing cells have metastatic advantages. These findings also show the potential of PNC prevalence as a prognostic marker for breast cancer.

Ductal carcinoma in situ presenting as microcalcifications: the effect of stereotactic large-core needle biopsy on surgical therapy

The aim of this investigation was to study the efficacy of surgical therapy in patients with non-palpable ductal carcinoma in situ (DCIS) presenting as microcalcifications diagnosed by means of stereotactic large-core needle biopsy (SCNB). This is a retrospective study with a historical control group within a 12-year period. Two groups of consecutive patients diagnosed with DCIS (1991-2002) by means of needle-localised open breast biopsy (NLBB, n=49) and SCNB (n=51) were studied. Both groups were comparable for clinical, radiological and pathological characteristics. The therapeutic interval (time from presentation to definitive of therapy) was 62-days in the SCNB group versus 32-days in the NLBB group (p<0.001). In the SCNB group fewer surgical procedures were required for completion of surgical therapy (p=0.006) and after local excision the surgical margins were more often tumour free (p=0.002). It is postulated that the need for fewer surgical procedures and the greater frequency of tumour-free margins after local excision may be attributable to SCNB.

Skin-sparing mastectomy

BACKGROUND

Skin-sparing mastectomy represents a new surgical approach that allows a mastectomy while preserving the natural skin envelope of the breast. It facilitates immediate breast reconstruction using an implant or myocutaneous flap, resulting in excellent cosmesis.

DATA SOURCES

A PubMed database literature search was performed.

CONCLUSIONS

Skin-sparing mastectomy is an oncologically safe technique in selected cases; T1/T2, multicentric tumors, ductal carcinoma in situ, and prophylactic mastectomies are particularly suited to this technique. Further research is required to confirm oncologic safety in T3 tumors. In selected cases, the nipple-areola complex can be preserved. A modification of skin-sparing mastectomy includes the removal of the nipple while preserving the areola. The balance of evidence suggests that skin-sparing mastectomy does not increase the risk of locoregional recurrence. Furthermore, it does not delay adjuvant therapies. Contraindications to skin-sparing mastectomy approaches include inflammatory breast cancer and extensive skin involvement by tumor. Preoperative and postoperative radiotherapy are not a contraindication to skin-sparing mastectomy.

Gauging the impact of breast carcinoma screening in terms of tumor size and death rate

BACKGROUND

While the question of whether the trials of breast cancer screening have resulted in a reduction in breast cancer death has been the subject of much scrutiny, there has been less attention to the reduction in tumor size achieved by screening.

METHODS

Size data for invasive breast tumors were assembled from a variety of sources. The health consequences that can be expected from finding tumors of various sizes were determined using a recently developed mathematical method for relating tumor size to death rate.

RESULTS

First, in both the Swedish two-country trial and at the MGH Breast Imaging Division, the sizes of the invasive breast cancers in the screening population (those masses seen at screening together with those found as palpable masses after screening examinations) were sufficiently smaller than the cancers found among women who had not used screening to have lead to considerable reductions in death. Second, the lack of reduction in death rates detected in both Canadian National Breast Screening Studies could be ascribed to the small reductions in tumor size achieved in these studies. Third, radiographic density had a small effect, whereas age had a negligible effect, on the capacity of mammographic screening to find breast carcinomas at smaller, and thus less lethal, sizes.

CONCLUSIONS

Prompt attendance at annual mammographic screening offers the potential to reduce tumor size and, presumably, breast carcinoma death, in women of all ages and density groups.