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Abdallah A, Abdelwahab K, Awny S, Zuhdy M, Hamdy O, Atallah K, Elfeky A, Hegazy MAF, Metwally IH. Fungating and Ulcerating Breast Cancer: Wound Closure Algorithm, Complications, and Survival Trends. Indian J Surg Oncol 2023; 14:93-105. [PMID: 36891440 PMCID: PMC9986193 DOI: 10.1007/s13193-022-01602-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/19/2022] [Indexed: 11/30/2022] Open
Abstract
Fungating breast cancer severely affects patients' daily lives, and patient management poses major oncology challenges. To present 10-year outcomes of unique tumor presentation, suggesting a focused algorithm for surgical management and providing deep analysis for factors affecting survival and surgical outcomes. Eighty-two patients with fungating breast cancer were enrolled in the period from January 2010 to February 2020 in the Mansoura University Oncology Center database. Epidemiological and pathological characteristics, risk factors, different surgical treatment techniques, and surgical and oncological outcomes were reviewed. Preoperative systemic therapy was used in 41 patients, with the majority (77.8%) showing progressive response. Mastectomy was performed in 81 (98.8%) patients, with primary wound closure in 71 (86.6%), and wide local excision in a single patient (1.2%). Different reconstructive techniques in non-primary closure operations were used. Complications were reported in 33 (40.7%) patients, of which 16 (48.5%) were of Clavien-Dindo grade II category. Loco-regional recurrence occurred in 20.7% of patients. The mortality rate during follow-up was 31.7% (n = 26). Estimated mean overall survival (with 95% CI) was 55.96 (41.98-69.9) months; estimated mean loco-regional recurrence-free survival (with 95% CI) was 38.01 (24.6-51.4) months. Surgery is a cornerstone fungating breast cancer treatment option, but at the expense of high morbidity. Sophisticated reconstructive procedures may be indicated for wound closure. A suggested algorithm based on the center's experience of wound management in difficult mastectomy cases is displayed.
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Affiliation(s)
- Ahmed Abdallah
- Surgical Oncology Department, Oncology Center, Mansoura University (OCMU), Mansoura, 35516 Egypt
| | - Khaled Abdelwahab
- Surgical Oncology Department, Oncology Center, Mansoura University (OCMU), Mansoura, 35516 Egypt
| | - Shadi Awny
- Surgical Oncology Department, Oncology Center, Mansoura University (OCMU), Mansoura, 35516 Egypt
| | - Mohammad Zuhdy
- Surgical Oncology Department, Oncology Center, Mansoura University (OCMU), Mansoura, 35516 Egypt
| | - Omar Hamdy
- Surgical Oncology Department, Oncology Center, Mansoura University (OCMU), Mansoura, 35516 Egypt
| | - Khalid Atallah
- Surgical Oncology Department, Oncology Center, Mansoura University (OCMU), Mansoura, 35516 Egypt
| | - Abeer Elfeky
- Surgical Oncology Department, Oncology Center, Mansoura University (OCMU), Mansoura, 35516 Egypt
| | - Mohammed A. F. Hegazy
- Surgical Oncology Department, Oncology Center, Mansoura University (OCMU), Mansoura, 35516 Egypt
| | - Islam H. Metwally
- Surgical Oncology Department, Oncology Center, Mansoura University (OCMU), Mansoura, 35516 Egypt
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Fahradyan A, Liu A, Taylor L, Jones V, Li WY. Short Stay Management of Locally Advanced Breast Cancer Using Immediate Local Thoracoabdominal Advancement Flap and Enhanced Recovery After Surgery Protocol. Ann Plast Surg 2022; 88:S366-S373. [PMID: 37740470 DOI: 10.1097/sap.0000000000003140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
BACKGROUND Patients with locally advanced invasive breast cancer (LABC) are often considered inoperable, because of the anticipated chest wall defect and need for complex reconstruction. We present a series of patients who underwent mastectomy with extensive skin resection and immediate chest wall reconstruction using a local thoracoabdominal advancement flap (TAAF). All patients were managed after surgery with an ERAS (Enhanced Recovery After Surgery) protocol, to decrease length of stay in hospital. We also present 1 patient who subsequently had satisfactory bilateral delayed breast reconstruction with pedicled latissimus dorsi myocutaneous flaps with prepectoral silicone implants. METHODS This is a single-surgeon, single-institution retrospective chart review of patients with LABC who underwent mastectomy with skin resection and local TAAF from May 2017 to October 2019, with minimum 3-month follow-up. RESULTS Thirteen patients met inclusion criteria. Twelve of 13 patients presented with stage III or IV invasive breast cancer, with skin involvement. The mean chest wall defect measured 248.7 cm2 (140-336 cm2; SD, 63.2 cm2), and all were successfully reconstructed with immediate local TAAF. There were no intraoperative complications, but 1 patient developed a postop hematoma. The mean hospital stay was 1.3 nights, with 9 patients (69.2%) staying less than 23 hours and 4 patients (30.8%) staying 2 nights. Nine patients (69.2%) underwent adjuvant therapy, beginning on average 32 days (13-55 days; SD, 13.1 days) after surgery. The mean follow-up time was 13.8 months (4.5-31.6 months; SD, 9.2 months). One patient underwent successful delayed bilateral breast reconstruction with pedicled latissimus dorsi myocutaneous flaps and silicone implant placement. CONCLUSIONS Our study demonstrates that reconstruction with local TAAF is an outpatient procedure that reliably provides durable, immediate chest wall coverage, after mastectomy in patients with LABC. This technique has a short operative time, low blood loss, and low complication rate, allowing timely adjuvant therapy. Using an ERAS postop protocol we were able to reduce mean hospital stay to 1.3 days. Compared with other described techniques of reconstruction, the additional scars and donor site morbidity are minimal, allowing for delayed breast reconstruction. We also present survival outcomes data on these surgically managed patients.
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Affiliation(s)
| | - Alice Liu
- Keck School of Medicine, University of Southern California, Los Angeles
| | | | | | - Wai-Yee Li
- Plastic and Reconstructive Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA
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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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Song J, Han Y, Liu J, Cheng K, Gao Q, Wang X, Yang ZL. Using KISS Flaps in a Chest Wall Reconstruction After Mastectomy for Locally Advanced Breast Cancer: A New Technique. Surg Innov 2019; 27:5-10. [PMID: 31631789 DOI: 10.1177/1553350619877299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study described a technique for the reconstruction of large lateral thoracic defects after local advanced breast cancer resection that allows for complete cover of the defect and primary closure of the donor site. The authors performed reconstruction using the newly designed KISS flap in 2 women for coverage of their large skin defect (15 × 13 cm each) following mastectomies with extensive tissue resection. The KISS flap consisting of 2 skin islands (marked Flap A and Flap B; 15 × 6 cm each) was designed and transferred to the thoracic defect through the subcutaneous tunnel, and based on the same vessel. The flap covered properly without causing excessive tension and allowed primary closure of chest wound and donor defect. The security it brings is comparable with that of classical radical mastectomy, and its success rate is similar to that of single skin flap transplantation. Compared with the conventional pedicled latissimus-dorsi-musculocutaneous flap, we believe that the donor zone tension decreases, wherein the KISS flaps can reduce the incidence of incision dehiscence and nonhealing complications to some extent. The study reported good results from this technique and discussed the techniques that referenced previous reports.
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Affiliation(s)
- Jia Song
- Binzhou Medical University Hospital, Binzhou, Shandong, People's Republic of China
| | - Yong Han
- Binzhou Medical University Hospital, Binzhou, Shandong, People's Republic of China
| | - Jian Liu
- Binzhou Medical University Hospital, Binzhou, Shandong, People's Republic of China
| | - Kai Cheng
- Binzhou Medical University Hospital, Binzhou, Shandong, People's Republic of China
| | - Qiang Gao
- Binzhou Medical University Hospital, Binzhou, Shandong, People's Republic of China
| | - Xiaohong Wang
- Binzhou Medical University Hospital, Binzhou, Shandong, People's Republic of China
| | - Zhen-Lin Yang
- Binzhou Medical University Hospital, Binzhou, Shandong, People's Republic of China
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Mateo AM, Mazor AM, DeMora L, Sigurdson ER, Handorf EA, Daly JM, Aggon AA, Obeid E, Hayes SB, Bleicher RJ. Patterns of Care and Efficacy of Chemotherapy and Radiotherapy in Skin-Involved Breast Cancers of All Sizes. Clin Breast Cancer 2019; 19:292-303. [PMID: 30871966 DOI: 10.1016/j.clbc.2019.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/22/2018] [Accepted: 02/09/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The management of small skin-involved (SI) invasive breast cancers is controversial because although they are considered unresectable, their prognosis is far better than their stage III classification. This study was undertaken to determine how SI lesions are treated in the United States and to discern the benefit of systemic therapy. PATIENTS AND METHODS Data of patients diagnosed with stage I-III breast cancer in the National Cancer Data Base between 2004 and 2011 were reviewed. Treatment patterns were examined and overall survival assessed. RESULTS A total of 3485 patients had SI and 456,287 patients had non-SI breast cancers. Chemotherapy was administered to 68.5% of SI and 45.9% of non-SI tumors (P < .001), including 77.2% of SI and 33% of non-SI tumors < 2 cm (P < .001). After adjusting for patient and tumor characteristics, SI patients were 19.4% more likely to receive chemotherapy than non-SI patients. Radiotherapy was provided to 61.1% of SI and 64.3% of non-SI tumors (P < .001), including 65.5% of SI and 66.5% non-SI tumors < 2 cm (P = .711). After adjusting for patient and tumor characteristics, SI patients were 76.6% more likely to receive radiotherapy than non-SI patients. Chemotherapy and radiotherapy provided an overall survival benefit for stage II and III SI and non-SI tumors. CONCLUSION Despite controversy regarding staging and prognosis of SI tumors, the majority of patients are provided systemic therapy and radiotherapy. Varied patterns of chemotherapy administration for SI tumors suggests that further treatment guidance and standardization are required, especially because chemotherapy and radiotherapy are equally efficacious in SI and non-SI tumors alike.
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Affiliation(s)
- Alina M Mateo
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Anna M Mazor
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Lyudmila DeMora
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, PA
| | - Elin R Sigurdson
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | | | - John M Daly
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Allison A Aggon
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Elias Obeid
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Richard J Bleicher
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA.
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Tirada N, Aujero M, Khorjekar G, Richards S, Chopra J, Dromi S, Ioffe O. Breast Cancer Tissue Markers, Genomic Profiling, and Other Prognostic Factors: A Primer for Radiologists. Radiographics 2018; 38:1902-1920. [PMID: 30312139 DOI: 10.1148/rg.2018180047] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
An understanding of prognostic factors in breast cancer is imperative for guiding patient care. Increased tumor size and more advanced nodal status are established independent prognostic factors of poor outcomes and are incorporated into the American Joint Committee on Cancer (AJCC) TNM (primary tumor, regional lymph node, distant metastasis) staging system. However, other factors including imaging findings, histologic evaluation results, and molecular findings can have a direct effect on a patient's prognosis, including risk of recurrence and relative survival. Several microarray panels for gene profiling of tumors are approved by the U.S. Food and Drug Administration and endorsed by the American Society of Clinical Oncology. This article highlights prognostic factors currently in use for individualizing and guiding breast cancer therapy and is divided into four sections. The first section addresses patient considerations, in which modifiable and nonmodifiable prognostic factors including age, race and ethnicity, and lifestyle factors are discussed. The second part is focused on imaging considerations such as multicentric and/or multifocal disease, an extensive intraductal component, and skin or chest wall involvement and their effect on treatment and prognosis. The third section is about histopathologic findings such as the grade and presence of lymphovascular invasion. Last, tumor biomarkers and tumor biology are discussed, namely hormone receptors, proliferative markers, and categorization of tumors into four recognized molecular subtypes including luminal A, luminal B, human epidermal growth factor receptor 2-enriched, and triple-negative tumors. By understanding the clinical effect of these prognostic factors, radiologists, along with a multidisciplinary team, can use these tools to achieve individualized patient care and to improve patient outcomes. ©RSNA, 2018.
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Affiliation(s)
- Nikki Tirada
- From the Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201
| | - Mireille Aujero
- From the Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201
| | - Gauri Khorjekar
- From the Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201
| | - Stephanie Richards
- From the Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201
| | - Jasleen Chopra
- From the Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201
| | - Sergio Dromi
- From the Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201
| | - Olga Ioffe
- From the Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201
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Khoury T, Gaudioso C, Fang YV, Sanati S, Opyrchal M, Desouki MM, Karabakhtsian RG, Li Z, Wang D, Yan L, Jacobson R. The role of skin ulceration in breast carcinoma staging and outcome. Breast J 2018; 24:41-50. [PMID: 28597587 PMCID: PMC5722717 DOI: 10.1111/tbj.12830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/14/2016] [Accepted: 10/13/2016] [Indexed: 11/30/2022]
Abstract
Breast carcinoma with skin ulceration (SU) is considered a locally advanced disease. The purpose of the study is to investigate if SU is an independent adverse factor. Breast carcinoma patients with SU (n=111) were included in the study. A subset (n=38, study cohort) was matched with cases that had no SU (n=38, matched cohort); the survival analyses were compared between these groups. Then, cases (n=80) were staged independent from SU into stage I, II or III. Disease free survival (DFS) and overall survival (OS) were analyzed. Patients with larger tumors tended to present with distant metastases more often than patients with smaller tumors (P=.004). In the matched cases, the 5-year DFS probability was 53% for the study cohort and 58% for the matched cohort; and for OS 75% for the study cohort and 84% for the matched cohort with no statistical significant difference. However, there was a trend towards worse DFS for the patients whose tumors had SU. When the cases were staged based on tumor size and node status (I, II or III), the OS was statistically significant (P=.047) but not the DFS (P=.195). Relatively small tumors with SU had an extent of disease similar to that observed in patients with early stages disease. The survival analysis suggests that SU may not be an adverse factor. However, more cases are needed to further examine this finding.
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Affiliation(s)
- Thaer Khoury
- Department of Pathology, Roswell Park Cancer Institute, Buffalo, NY
| | - Carmelo Gaudioso
- Department of Pathology, Roswell Park Cancer Institute, Buffalo, NY
| | - Yisheng V Fang
- Department of Pathology, University of Texas Southwestern Medical Center at Dallas, Dallas TX
| | - Souzan Sanati
- Department of Pathology, Washington University, Saint Louis, MO
| | - Mateusz Opyrchal
- Department of Medical Oncology, Roswell Park Cancer Institute, Buffalo, NY
| | | | - Rouzan G Karabakhtsian
- Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Zaibo Li
- Department of Pathology, Ohio State University, Columbus, OH
| | - Dan Wang
- Department of Biostatistics, Roswell Park Cancer Institute; Roswell Park Cancer Institute, Buffalo, NY
| | - Li Yan
- Department of Biostatistics, Roswell Park Cancer Institute; Roswell Park Cancer Institute, Buffalo, NY
| | - Rebecca Jacobson
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
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Lee EJ, Han SH, Kang BJ, Kim SH. Imaging and Pathologic Characterization of the Skin Thickening or Enhancement under the Breast MRI. ACTA ACUST UNITED AC 2016. [DOI: 10.13104/imri.2016.20.1.9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Eun Jae Lee
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Hee Han
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bong Joo Kang
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Hun Kim
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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9
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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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10
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Silverman D, Ruth K, Sigurdson ER, Egleston BL, Goldstein LJ, Wong YN, Boraas M, Bleicher RJ. Skin involvement and breast cancer: are T4b lesions of all sizes created equal? J Am Coll Surg 2014; 219:534-44. [PMID: 25026875 PMCID: PMC4143438 DOI: 10.1016/j.jamcollsurg.2014.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 03/15/2014] [Accepted: 04/14/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Nonmetastatic, noninflammatory, invasive breast cancers with skin involvement (SI) are classified as T4b, regardless of size. This study evaluated disease-specific survival (DSS) to determine whether size should be considered for these lesions rather than grouping them all into stage III. STUDY DESIGN Surveillance, Epidemiology, and End Results data linked to Medicare claims were reviewed. Skin involved and non-SI tumors were reclassified using the American Joint Committee on Cancer, 7(th) edition groupings using tumor size and nodal involvement alone without considering SI (neostage). Disease-specific survival was adjusted for demographics, histology, and treatment using competing risk methods with propensity score-based weighting and bootstrap standard errors. RESULTS Among 924 SI patients diagnosed between 1992 and 2005, tumors were 0.1 to 2.0 cm, 2.1 to 5.0 cm, and >5.0 cm in 11.6%, 51.1%, and 37.3% of patients, respectively. There were no nodal metastases in 22.3%, 1 to 3 positive nodes in 31.7%, 4 to 9 positive in 28.6%, and ≥10 positive in 17.4% of patients. For SI patients, adjusted 5-year DSS was 95.8% (95% CI, 95.6-96.0) for neostage I, declining progressively to 36.4% (95% CI, 33.8-39.2) for neostage IIIC patients. Adjusted 5-year DSS for SI and non-SI tumors (n = 66,185) was similar for neostage I, IIA, and IIB, and markedly lower for IIIA and IIIC. Adjusted DSS for SI IIIA was similar to non-SI IIIC. CONCLUSIONS Noninflammatory SI breast cancers have widely varied DSS that differs by tumor size and nodal involvement and therefore should not all be stage III. Skin involvement should be subordinate to T and N groupings to classify SI with non-SI lesions having similar prognoses.
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Affiliation(s)
- Diana Silverman
- Department of Surgery, Saint Francis Hospital and Health Center, Poughkeepsie, NY
| | - Karen Ruth
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, PA
| | - Elin R Sigurdson
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Brian L Egleston
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, PA
| | - Lori J Goldstein
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Yu-Ning Wong
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Marcia Boraas
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Richard J Bleicher
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA.
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Sinn HP, Helmchen B, Wittekind CH. [TNM classification of breast cancer: changes and comments on the 7th edition]. DER PATHOLOGE 2011; 31:361-6. [PMID: 20711589 DOI: 10.1007/s00292-010-1307-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The 7th edition of the TNM classification includes only minor changes in the main TNM categories for breast cancer. Only ductal and lobular carcinoma in situ (DCIS, LCIS), and isolated Paget's disease of the nipple are classified as pTis, but not precursor lesions such as atypical ductal or lobular hyperplasia (ADH, ALH). AJCC emphasizes that microscopic measurement is the most accurate and preferred method to determine pT in small invasive cancers and stresses the importance of strict adherence to criteria for T4 cancers. For better distinction from micrometastases in regional lymph nodes, small clusters of cells not greater than 0.2 mm, or nonconfluent or nearly confluent clusters of cells not exceeding 200 cells in a single histologic lymph node cross section are classified as isolated tumour cells (pN0(i+)). The pN classification has otherwise remained unchanged. In the setting of patients having received neoadjuvant therapy, ypT1-ypT3 is based on the total extent of viable tumour cells, irrespective of tumour regression. Stage I breast tumours have been subdivided into Stage IA and Stage IB; Stage IB includes small tumours (TI) with lymph node micrometastases (N1mi). These changes and clarifications will contribute to maintaining the clinical and prognostic relevance of TNM in breast cancer.
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Affiliation(s)
- H-P Sinn
- Pathologisches Institut der Universität, Im Neuenheimer Feld 220, 69120, Heidelberg, Deutschland
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12
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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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Harms K, Wittekind C. Prognosis of women with pT4b breast cancer: the significance of this category in the TNM system. Eur J Surg Oncol 2008; 35:38-42. [PMID: 18215492 DOI: 10.1016/j.ejso.2007.11.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Accepted: 11/28/2007] [Indexed: 11/24/2022] Open
Abstract
AIMS The T4b/pT4b category of the TNM System for breast cancer is discussed controversially. For a more detailed analysis, we explored the prognosis of patients with breast cancer strictly fulfilling the criteria for T4b/pT4b tumors according to the TNM System. METHODS Retrospectively analysed data from patients with pT4b breast tumors diagnosed between January 1994 and December 2004 were collected. Reclassification was undertaken according to the TNM System criteria establishing a study group including only "correctly" classified T4b/pT4b tumors. A control group with pT1-3 carcinomas was used for analysing the prognostic value of criteria for T4b/pT4b tumors. RESULTS Eighty-six patients with pT4b carcinomas were found. After reclassification, 65 remained as pT4b fulfilling the strict criteria. The study group showed a 60% three-year Disease Specific Survival (DSS). Age (p<0.01) and regional lymph node status (p<0.01) were significantly related to prognosis. Compared to the control group, the DSS in the study group of patients with a tumor size >2 cm to 5 cm was significantly worse (three-year survival: 82% vs. 51%, p<0.01). For tumors >5 cm, the DSS was not significantly different between both groups (three-year survival: 68% vs. 72%, p=0.7). CONCLUSIONS The criteria for T4b/pT4b breast cancer are associated with a poorer prognosis in patients with a tumor size >2 cm to 5 cm. For tumors >5 cm, prognosis is independent of T4b/pT4b criteria. These findings do not justify the demanded deletion of the T4b/pT4b category. The missing uniformity in applying the correct criteria of T4b/pT4b tumors queries the practicability of this category.
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Affiliation(s)
- K Harms
- Institute of Pathology, University Hospital of Leipzig, Leipzig, Germany
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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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Ahern V, Boyages J, Gebski V, Moon D, Wilcken N. Selective Mastectomy in the Management of Locally Advanced Breast Cancer. Int J Radiat Oncol Biol Phys 2007; 68:1010-7. [PMID: 17398030 DOI: 10.1016/j.ijrobp.2007.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2006] [Revised: 01/10/2007] [Accepted: 01/11/2007] [Indexed: 11/23/2022]
Abstract
PURPOSE To evaluate local control for patients with locally advanced noninflammatory breast cancer (LABC) managed by selective mastectomy. METHODS AND MATERIALS Between 1979 and 1996, 176 patients with LABC were prospectively managed by chemotherapy (CT)-irradiation (RT)-CT without routine mastectomy. All surviving patients were followed for a minimum of 5 years. RESULTS A total of 132 patients (75%) had a T4 tumor and 22 (12.5%) supraclavicular nodal disease. The clinical complete response rate was 91% (160/176), which included 13 patients who underwent mastectomy and 2 an iridium wire implant. The first site of failure was local for 43 patients (breast +/- axilla for 38); 27 of these patients underwent salvage mastectomy and 11 did not for an overall mastectomy rate of 23% (40/176). If all 176 patients had undergone routine mastectomy (136 extra mastectomies), 11 additional patients may have avoided an unsalvageable first local relapse. The others would have either have not had a local relapse or would have suffered local relapse after distant disease. No tumor or treatment related factor was found to predict local disease at death. Median disease-free and overall survival for all patients was 26 and 52 months, respectively. CONCLUSIONS Selective mastectomy in LABC may not jeopardize local control or survival.
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Affiliation(s)
- Verity Ahern
- Department of Radiation Oncology, Westmead Hospital, NSW 2145, Sydney, Australia.
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Conklin C, Huntsman D, Yorida E, Makretsov N, Turbin D, Bechberger JF, Sin WC, Naus CC. Tissue microarray analysis of connexin expression and its prognostic significance in human breast cancer. Cancer Lett 2007; 255:284-94. [PMID: 17583422 DOI: 10.1016/j.canlet.2007.05.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Revised: 04/30/2007] [Accepted: 05/02/2007] [Indexed: 10/23/2022]
Abstract
Breast cancer accounts for approximately 15% of all cancer deaths. Currently, axillary nodal status is the most reliable prognostic indicator for breast cancer. Tumor size and histological grade are used to stage breast cancer. Estrogen receptor/progesterone receptor (ER/PR) and HER-2/neu status are useful in predicting patient survival and relapse. Ki67, an indicator of proliferative activity, also correlates well with prognosis. Connexin proteins form gap junction channels, permitting intercellular exchange of ions and small molecules. Reduced connexin protein levels and impaired gap junctional intercellular communication are associated with tumor phenotypes. This study investigated the prognostic value of connexin proteins as breast cancer markers. Tissue microarrays, containing 438 cases of invasive breast carcinoma, were stained with Cx26, Cx32, and Cx43 antibodies. The degree of connexin immunoreactivity was determined and then correlated with patient outcome, tumor grade, tumor size, lymph node status, and immunohistochemical markers, such as p53, ER/PR status, Ki67 and c-erbB-2 expression. Cx26, Cx32, or Cx43 did not correlate well with tumor grade, tumor size, p53 or c-erbB-2 status. There was an inverse correlation between Cx32 and lymph node status (P <0.05) and a positive correlation between Cx43 and PR status (P <0.01). Cx32 and Cx43 correlated positively with ER status (P <0.01). Cx43 correlated negatively with Ki67 expression (P <0.01). Cx26, Cx32, and Cx43 did not correlate with patient outcome. Based on our observations in this study, connexin proteins do not appear to be reliable indicators of breast cancer prognosis.
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Affiliation(s)
- Chris Conklin
- Department of Cellular & Physiological Sciences, The University of British Columbia, BC, Canada V6T 1Z3
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Gueth U, Wight E, Schoetzau A, Langer I, Dieterich H, Rochlitz C, Herberich L, Holzgreve W, Singer G. Non-inflammatory skin involvement in breast cancer, histologically proven but without the clinical and histological T4 category features. J Surg Oncol 2007; 95:291-7. [PMID: 17326124 DOI: 10.1002/jso.20660] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The study evaluates characteristics and prognostic significance of breast cancer with histologically proven non-inflammatory skin involvement but without the clinical and histological features that are mandatory for inclusion in the T4 category. METHODS We compared retrospectively the clinical course of 55 patients with this clinico-pathologic entity to the outcome of a control group of 309 consecutive patients with tumors of the same size but without skin involvement. The median follow-up time was 6.6 years in the study and 8.4 years in the control group. Two subsets were analyzed: (A) 1.1-2.0 cm (T1c); (B) 2.1-5.0 cm (T2). RESULTS The distribution of TNM stages within Study Group A was: Stage I: 28.6%, Stage II: 61.9%, Stage III: 9.5%. The distribution within Study Group B was: Stage II: 67.7%, Stage III: 23.5%, and Stage IV: 8.8%. Differences in disease-specific survival (DSS) between study and control groups were not significant. In multivariate analysis, skin involvement was not a significant variable, while lymph node involvement was found to be significant for worse outcome (Group A: HR=3.99 [1.33-12.05], P=0.014; Group B: HR=2.37 [1.37-4.08], P=0.002). CONCLUSION Breast carcinomas with histologically proven skin involvement without the clinical and histological correlate are a heterogeneous group of cases, but the majority of the patients have Stage I/II disease. While lymph node involvement had a most significant effect on DSS, skin involvement was not a significant prognostic factor. Physicians must be aware of this clinico-pathologic entity in order not to misclassify these cases as T4 and consider them falsely as being locally advanced breast cancer.
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Affiliation(s)
- Uwe Gueth
- Department of Gynecology and Obstetrics, University Hospital Basel (UHB), Spitalstrasse, Basel, Switzerland.
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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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