Survival in breast cancer patients with a delayed DIEP flap breast reconstruction after adjustment for socioeconomic status and comorbidity

Purpose

Overall survival in breast cancer patients receiving a delayed deep inferior epigastric perforator (DIEP) flap breast reconstruction is better than in those without delayed breast reconstruction. This study aimed at determining the impact of socioeconomic status (SES) and comorbidity on these observations.

Materials and methods

This matched cohort study included all consecutive women undergoing a delayed DIEP flap reconstruction at Karolinska University Hospital, Sweden, between 1999 and 2013. Controls had not received any delayed breast reconstruction and were relapse-free after a corresponding follow-up interval. Matching was by year of and age at mastectomy, tumour stage and lymph node status. Charlson Comorbidity Index (CCI) and socioeconomic data were obtained from national registers. Associations with breast cancer-specific (BCSS) and overall survival (OS) were investigated by Kaplan-Meier survival estimates and Cox proportional hazard regression analysis.

Results

Women in the DIEP group (N = 254) more often continued education after primary school (88.6% versus 82.6%, P = 0.026), belonged to the high-income group (76.0% versus 63.1%, P < 0.001), were in a partnership (57.1% versus 55.7%, P = 0.024) and healthier (median CCI 1.00 (range 0–13) versus 2.00 (range 0–16), P = 0.021) than the control group (N = 729). After adjustment for tumour and treatment factors, SES and comorbidity, OS remained significantly better for the DIEP group than the control group (HR 2.27, 95% CI 1.44–3.55).

Conclusion

Women with a delayed DIEP flap reconstruction are a subgroup of higher socioeconomic status and better health. Higher survival estimates for the DIEP group persisted after adjusting for those differences, suggesting the presence of further unmeasured covariates.

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Women with a delayed DIEP flap reconstruction have a higher socioeconomic status.

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They also have less comorbidity than women with no delayed reconstruction.

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Superior survival in DIEP patients is not eliminated by adjustments for such differences.

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Unmeasured selection to the reconstructive process may explain observed survival differences.

Long-term prognosis in breast cancer is associated with residual disease after neoadjuvant systemic therapy but not with initial nodal status

BACKGROUND

This follow-up analysis of a Swedish prospective multicentre trial had the primary aim to determine invasive disease-free (IDFS), breast cancer-specific (BCSS) and overall survival (OS) rates, and their association with axillary staging results before and after neoadjuvant systemic therapy for breast cancer.

METHODS

Women who underwent neoadjuvant systemic therapy for clinically node-positive (cN+) or -negative (cN0) primary breast cancer between 2010 and 2015 were included. Patients had a sentinel lymph node biopsy before and/or after neoadjuvant systemic therapy, and all underwent completion axillary lymph node dissection. Follow-up was until February 2019. The main outcome measures were IDFS, BCSS and OS. Univariable and multivariable Cox regression analyses were used to identify independent factors associated with survival.

RESULTS

The study included a total of 417 women. Median follow-up was 48 (range 7-114) months. Nodal status after neoadjuvant systemic therapy, but not before, was significantly associated with crude survival: residual nodal disease (ypN+) resulted in a significantly shorter 5-year OS compared with a complete nodal response (ypN0) (83·3 versus 91·0 per cent; P = 0·017). The agreement between breast (ypT) and nodal (ypN) status after neoadjuvant systemic therapy was high, and more so in patients with cN0 tumours (64 of 66, 97 per cent) than those with cN+ disease (49 of 60, 82 per cent) (P = 0·005). In multivariable analysis, ypN0 (hazard ratio 0·41, 95 per cent c.i. 0·22 to 0·74; P = 0·003) and local radiotherapy (hazard ratio 0·23, 0·08 to 0·64; P = 0·005) were associated with improved IDFS, and triple-negative molecular subtype with worse IDFS.

CONCLUSION

The present findings underline the prognostic significance of nodal status after neoadjuvant systemic therapy. This confirms the clinical value of surgical axillary staging after neoadjuvant systemic therapy.

Omitting completion axillary lymph node dissection after detection of sentinel node micrometastases in breast cancer: first results from the prospective SENOMIC trial

BACKGROUND

Completion axillary lymph node dissection has been abandoned widely among patients with breast cancer and sentinel lymph node micrometastases, based on evidence from prospective RCTs. Inclusion in these trials has been subject to selection bias, with patients undergoing mastectomy being under-represented. The aim of the SENOMIC (omission of axillary lymph node dissection in SENtinel NOde MICrometases) trial was to confirm the safety of omission of axillary lymph node dissection in patients with breast cancer and sentinel lymph node micrometastases, and including patients undergoing mastectomy.

METHODS

The prospective SENOMIC multicentre cohort trial enrolled patients with breast cancer and sentinel lymph node micrometastases who had breast-conserving surgery or mastectomy at one of 23 Swedish hospitals between October 2013 and March 2017. No completion axillary lymph node dissection was performed. The primary endpoint was event-free survival, with a trial accrual target of 452 patients. Survival proportions were based on Kaplan-Meier survival estimates.

RESULTS

The trial included 566 patients. Median follow-up was 38 (range 7-67) months. The 3-year event-free survival rate was 96.2 per cent, based on 26 reported breast cancer recurrences, including five isolated axillary recurrences. The unadjusted 3-year event-free survival rate was higher than anticipated, but differed between patients who had mastectomy and those who underwent breast-conserving surgery (93.8 versus 97.8 per cent respectively; P = 0.011). Patients who underwent mastectomy had significantly worse tumour characteristics. On univariable Cox proportional hazards regression analysis, patients who had mastectomy without adjuvant radiotherapy had a significantly higher risk of recurrence than those who underwent breast-conserving surgery (hazard ratio 2.91, 95 per cent c.i. 1.25 to 6.75).

CONCLUSION

After 3 years, event-free survival was excellent in patients with breast cancer and sentinel node micrometastases despite omission of axillary lymph node dissection. Long-term follow-up and continued enrolment of patients having mastectomy, especially those not receiving adjuvant radiotherapy, are of utmost importance.

Carbon tattooing for targeted lymph node biopsy after primary systemic therapy in breast cancer: prospective multicentre TATTOO trial

Background

Several techniques for targeted lymph node biopsy in patients with node-positive breast cancer receiving primary systemic therapy are in use, each with their inherent advantages and disadvantages. The aim of the TATTOO trial was to evaluate the feasibility and accuracy of carbon tattooing of positive lymph nodes as a method for targeted lymph node biopsy avoiding radiation exposure, high costs, and preoperative localization procedures.

Methods

Patients with initially cT1–4c cN1–3 cM0 invasive breast cancer were included in this prospective multicentre trial. Before initiation of primary systemic therapy, a carbon suspension was injected into the most suspicious axillary lymph node. Targeted lymph node biopsy was performed in all patients after completion of primary systemic therapy. Additional sentinel lymph node biopsy was done in those with axillary downstaging, and completion axillary lymph node dissection in patients still presenting with suspicious lymph nodes.

Results

A total of 118 patients were included and 110 were eligible for data analysis. The detection rate for the targeted lymph node was 93.6 per cent (103 of 110), and the sentinel lymph node was identical to the targeted lymph node in 60 per cent. The false-negative rate for the combination of targeted and sentinel node lymph node biopsy (targeted axillary dissection) was 9 per cent.

Conclusion

Targeted axillary dissection after carbon tattooing is associated with a high detection rate, an acceptable false-negative rate, and appears feasible for clinical use even in healthcare settings with limited resources.

Quality of life and patient satisfaction after implant-based breast reconstruction with or without acellular dermal matrix: randomized clinical trial

Background

Acellular dermal matrix (ADM) in implant‐based breast reconstructions (IBBRs) aims to improve cosmetic outcomes. Six‐month data are presented from a randomized trial evaluating whether IBBR with ADM provides higher health‐related quality of life (HRQoL) and patient‐reported cosmetic outcomes compared with conventional IBBR without ADM.

Methods

In this multicentre open‐label RCT, women with breast cancer planned for mastectomy with immediate IBBR in four centres in Sweden and one in the UK were allocated randomly (1 : 1) to IBBR with or without ADM. HRQoL, a secondary endpoint, was measured as patient‐reported outcome measures (PROMs) using three validated instruments (EORTC‐QLQC30, QLQ‐BR23, QLQ‐BRR26) at baseline and 6 months.

Results

Between 24 April 2014 and 10 May 2017, 135 women were enrolled, of whom 64 with and 65 without ADM were included in the final analysis. At 6 months after surgery, patient‐reported HRQoL, measured with generic QLQ‐C30 or breast cancer‐specific QLQ‐BR23, was similar between the groups. For patient‐reported cosmetic outcomes, two subscale items, cosmetic outcome (8·66, 95 per cent c.i. 0·46 to 16·86; P = 0·041) and problems finding a well‐fitting bra (−13·21, −25·54 to −0·89; P = 0·038), yielded higher scores in favour of ADM, corresponding to a small to moderate clinical difference. None of the other 27 domains measured showed any significant differences between the groups.

Conclusion

IBBR with ADM was not superior in terms of higher levels of HRQoL compared with IBBR without ADM. Although two subscale items of patient‐reported cosmetic outcomes favoured ADM, the majority of cosmetic items showed no significant difference between treatments at 6 months. Registration number: NCT02061527 ( www.clinicaltrials.gov).

Do clinical trials truly mirror their target population? An external validity analysis of national register versus trial data from the Swedish prospective SENOMIC trial on sentinel node micrometastases in breast cancer

Purpose

Increasing evidence suggests that completion axillary lymph node dissection (ALND) may be omitted in breast cancer patients with limited axillary nodal metastases. However, the representativeness of trial participants for the original clinical practice population, and thus, the generalizability of published trials have been questioned. We propose the use of background data from national registers as a means to assess whether trial participants mirror their target population and to strengthen the generalizability and implementation of trial outcomes.

Methods

The Swedish prospective SENOMIC trial, omitting a completion ALND in breast cancer patients with sentinel lymph node micrometastases, reached full target accrual in 2017. To assess the generalizability of trial results for the target population, a comparative analysis of trial participants versus cases reported to the Swedish National Breast Cancer Register (NKBC) was performed.

Results

Comparing 548 trial participants and 1070 NKBC cases, there were no significant differences in age, tumor characteristics, breast surgery, or adjuvant treatment. Only the mean number of sentinel lymph nodes with micrometastasis per individual was lower in trial participants than in register cases (1.06 vs. 1.09, p = 0.037).

Conclusions

Patients included in the SENOMIC trial are acceptably representative of the Swedish breast cancer target population. There were some minor divergences between trial participants and the NKBC population, but taking these into consideration, upcoming trial outcomes should be generalizable to breast cancer patients with micrometastases in their sentinel lymph node biopsy.

Breast-conserving surgery followed by whole-breast irradiation offers survival benefits over mastectomy without irradiation

Background

The prognostic equivalence between mastectomy and breast‐conserving surgery (BCS) followed by radiotherapy was shown in pivotal trials conducted decades ago. Since then, detection and treatment of breast cancer have improved substantially and recent retrospective analyses point towards a survival benefit for less extensive breast surgery. Evidence for the association of such survival data with locoregional recurrence rates is largely lacking.

Methods

The Swedish Multicentre Cohort Study prospectively included clinically node‐negative patients with breast cancer who had planned sentinel node biopsy between 2000 and 2004. Axillary lymph node dissection was undertaken only in patients with sentinel node metastases. For the present investigation, adjusted survival analyses were used to compare patients who underwent BCS and postoperative radiotherapy with those who received mastectomy without radiotherapy.

Results

Of 3518 patients in the Swedish Multicentre Cohort Study, 2767 were included in the present analysis; 2338 had BCS with postoperative radiotherapy and 429 had mastectomy without radiotherapy. Median follow‐up was 156 months. BCS followed by whole‐breast irradiation was superior to mastectomy without irradiation in terms of both overall survival (79·5 versus 64·3 per cent respectively at 13 years; P < 0·001) and breast cancer‐specific survival (90·5 versus 84·0 per cent at 13 years; P < 0·001). The local recurrence rate did not differ between the two groups. The axillary recurrence‐free survival rate at 13 years was significantly lower after mastectomy without irradiation (98·3 versus 96·2 per cent; P < 0·001).

Conclusion

The present data support the superiority of BCS with postoperative radiotherapy over mastectomy without radiotherapy. The axillary recurrence rate differed significantly, and could be one contributing factor in a complex explanatory model.

Radiotherapy to lower axilla key?

Risk of recurrence and death in patients with breast cancer after delayed deep inferior epigastric perforator flap reconstruction

Background

Postmastectomy reconstruction using a deep inferior epigastric perforator (DIEP) flap is increasingly being performed in patients with breast cancer. The procedure induces extensive tissue trauma, and it has been hypothesized that the release of growth factors, angiogenic agonists and immunomodulating factors may reactivate dormant micrometastasis. The aim of the present study was to estimate the risk of breast cancer recurrence in patients undergoing DIEP flap reconstruction compared with that in patients treated with mastectomy alone.

Methods

Each patient who underwent delayed DIEP flap reconstruction at Karolinska University Hospital, Sweden, between 1999 and 2013, was compared with up to four controls with breast cancer who did not receive a DIEP flap. The control patients were selected using incidence density matching with respect to age, tumour and nodal status, neoadjuvant therapy and year of mastectomy. The primary endpoint was breast cancer‐specific survival. Survival analysis was carried out using Kaplan–Meier survival estimates and Cox proportional hazard regression analysis.

Results

The analysis included 250 patients who had 254 DIEP flap reconstructions and 729 control patients. Median follow‐up was 89 and 75 months respectively (P = 0·053). Breast cancer recurrence developed in 50 patients (19·7 per cent) in the DIEP group and 174 (23·9 per cent) in the control group (P = 0·171). The 5‐year breast cancer‐specific survival rate was 92·0 per cent for patients with a DIEP flap and 87·9 per cent in controls (P = 0·032). Corresponding values for 5‐year overall survival were 91·6 and 84·7 per cent (P < 0·001). After adjustment for tumour and patient characteristics and treatment, patients without DIEP flap reconstruction had significantly lower overall but not breast cancer‐specific survival.

Conclusion

The present findings do not support the hypothesis that patients with breast cancer undergoing DIEP flap reconstruction have a higher rate of breast cancer recurrence than those who have mastectomy alone.

Deep inferior epigastric perforator is safe

Abstract P4-13-14: Risk of recurrence and death in breast cancer patients after delayed deep inferior epigastric perforator flap reconstruction

PURPOSE

Post-mastectomy reconstruction using the deep inferior epigastric perforator (DIEP) flap is increasingly performed in breast cancer patients. The procedure induces large tissue trauma and it has been hypothesized that the release of growth factors, angiogenic agonists and immunomodulating factors may reactivate dormant micrometastasis. The aim of our study was to contrast the risk of breast cancer recurrence in patients undergoing DIEP reconstruction to patients treated with mastectomy alone.

PATIENTS AND METHODS

We conducted a retrospective nested case-control study. Cases were defined as breast cancer patients operated with delayed DIEP reconstruction at Karolinska University Hospital, Sweden, between 1999-2013. Three controls, defined as breast cancer patients operated with conventional mastectomy without delayed reconstruction, were matched to each case based on age, tumour stage and year of mastectomy. The primary endpoint was breast cancer-specific survival. Survival analysis was carried out by Kaplan–Meier survival estimates and Cox proportional hazard regression analysis.

RESULTS

In all, 254 cases and 729 controls were included and had a median follow up of 134 and 122 months, respectively (p=0.004). Breast cancer recurrence occurred in 50 (19.7%) cases and 174 (23.9%) controls, respectively (p=0.171). Ten-year breast cancer-specific survival was 90.7% for cases and 85.2% in controls (p=0.067). The corresponding figures for 10-year overall survival was 89.6% and 80.0%, respectively (p&lt;0.001). Higher tumor stage and positive axillary lymph nodes, but not DIEP reconstruction, were independent risk factors for death due to breast cancer.

CONCLUSION

Our findings did not support the hypothesis that breast cancer patients undergoing DIEP reconstruction would have a higher rate of breast cancer recurrence than patients undergoing mastectomy alone.

Citation Format: Adam H, Docherty Skogh A-C, Edsander Nord Å, Schultz I, Gahm J, Hall P, Frisell J, Halle M, de Boniface J. Risk of recurrence and death in breast cancer patients after delayed deep inferior epigastric perforator flap reconstruction [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-13-14.

Abstract P2-03-03: Molecular differences between screen-detected and interval breast cancers are largely explained by PAM50 subtypes

Purpose:Interval breast cancer is of clinical interest as it exhibits an aggressive phenotype and evades detection by screening mammography. A comprehensive picture of somatic changes that drive tumors to become symptomatic in the screening interval can improve understanding of the biology underlying these aggressive tumors.

Experimental design:Initiated in April 2013, Clinical Sequencing of Cancer in Sweden (Clinseq) is a scientific and clinical platform for the genomic profiling of cancer. The breast cancer pilot study consisted of women diagnosed with breast cancer between 2001-2012 in the Stockholm/Gotland regions. A subset of 318 breast tumors were sequenced, of which 113 were screen-detected and were 60 interval cancers.We applied targeted deep-sequencing of cancer-related genes, low-pass whole-genome sequencing and RNA-sequencing technology to characterize somatic differences in the genomic and transcriptomic architecture by interval cancer status. Mammographic density and PAM50 molecular subtypes were considered.

Results:In the crude analyses, TP53, PPP1R3A, and KMT2B were significantly more frequently mutated in interval cancers than in screen-detected cancers. Acquired somatic copy number aberrations with a frequency difference of at least 15% between the two groups included gains in 17q23-q25.3 and losses in 16q24.2. Gene expression analysis identified 447 significantly differentially expressed genes, of which 120 were replicated in an independent microarray dataset. After adjusting for PAM50, most differences were no longer significant.

Conclusions: Molecular differences by interval cancer status were observed, but they were largely explained by PAM50 subtypes. This work offer new insights into the biological differences between the two tumor groups.

Translational relevance: Although screen-detected cancers are biologically distinct from interval cancers in terms of somatic mutations, copy number aberrations and gene expression, most of the differences are no longer significant after adjusting for breast cancer intrinsic subtypes (PAM50). We also show that the molecular differences appear to form a spectrum from less aggressive (screen-detected) to more aggressive (interval) manifestations of the disease, which can be characterized by PAM50 subtypes, namely, luminal A, luminal B, HER2-enriched and basal-like, in that order. This work clarifies the picture on what type of breast cancer we are likely to identify through population-based screening, and what type of cancer we are likely to miss. Current knowledge of PAM50 subtype-specific risk factors need to be expanded as our findings might influence how we screen women with a higher risk of basal-like breast cancer for example, beyond known risk groups BRCA1 mutation carriers and women of African-American descent.

Citation Format: Czene K, Ivansson E, Klevebring D, Tobin NP, Lindström LS, Holm J, Prochazka G, Hilliges C, Palmgren J, Törnberg S, Humphreys K, Hartman J, Frisell J, Rantalainen M, Lindberg J, Hall P, Bergh J, Grönberg H, Li J. Molecular differences between screen-detected and interval breast cancers are largely explained by PAM50 subtypes [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-03-03.

Ten-year report on axillary recurrence after negative sentinel node biopsy for breast cancer from the Swedish Multicentre Cohort Study

BACKGROUND

The omission of axillary lymph node dissection (ALND) in patients with breast cancer with a negative finding on sentinel node biopsy (SNB) has reduced arm morbidity substantially. Early follow-up reports have shown the rate of axillary recurrence to be significantly lower than expected, with a median false-negative rate of 7 per cent for SNB. Long-term follow-up is needed as recurrences may develop late.

METHODS

The Swedish Multicentre Cohort Study included 3518 women with breast cancer and a clinically negative axilla, in whom SNB was planned. ALND was performed only in patients with sentinel node metastasis. Twenty-six centres contributed to enrolment between September 2000 and January 2004. The primary endpoint was the axillary recurrence rate and the secondary endpoint was breast cancer-specific survival, calculated using Kaplan-Meier survival estimates.

RESULTS

Some 2216 sentinel node-negative patients with 2237 breast cancers were analysed. The median follow-up time was 126 (range 0-174) months. Isolated axillary recurrence was found in 35 patients (1·6 per cent). High histological grade and multifocal tumours were risk factors for axillary recurrence, whereas the removal of more than two sentinel nodes decreased the risk. Fourteen (40 per cent) of 35 patients died as a consequence of axillary recurrence.

CONCLUSION

The risk of axillary recurrence remains lower than expected after a negative finding on SNB at 10-year follow-up. Axillary recurrences may occur long after primary surgery, and lead to a significant risk of breast cancer death.

Complementary use of scintimammography with 99m-Tc-MIBI to triple diagnostic procedure in palpable and non-palpable breast lesions

Purpose: The aim of this study was to determine the clinical value of scintimammography with 99m-Tc-MIBI ( Sc) as a complementary method to the triple diagnostic procedure in the diagnosis of breast lesions.

Material and Methods: Ninety-six consecutive patients with 65 palpable and 54 non-palpable breast lesions were included in a prospective study. All lesions were evaluated by clinical examination, mammography and fine-needle-aspiration cytology (FNAC), called triple diagnostic procedure ( TD). Prone planar scintimammography with 99m-Tc-MIBI was performed in all patients. Five groups were defined for diagnosis: 1 = normal; 2 = benign; 3 = probably benign; 4 = highly suspect of malignancy; and 5 = malignant. In the calculations, groups 1–3 were considered benign, and 4–5 malignant. All lesions were excised and examined histologically. The additional value of Sc +  TD procedure was studied separately for palpable and non-palpable lesions.

Results: Histologically, 83 malignant and 36 benign lesions were found in the 119 breast lesions. Sensitivity for malignancy in palpable lesions of TD alone and of the combination TD +  Sc were 95.6% and 100%, respectively. Sensitivity for malignancy in non-palpable lesions of TD and TD +  Sc was 89.1% and 97.2%, respectively.

Conclusion: Adding scintimammography to the triple diagnostic procedure increased the sensitivity for the detection of both palpable and non-palpable breast cancers, but decreased the specificity.

Population-based analysis of colorectal cancer risk after oophorectomy

BACKGROUND

The development of colorectal cancer is influenced by hormonal factors. Oophorectomy alters endogenous levels of sex hormones, but the effect on colorectal cancer risk is unclear. The aim of this cohort study was to examine colorectal cancer risk after oophorectomy for benign indications.

METHODS

Women who had undergone oophorectomy between 1965 and 2011 were identified from the Swedish Patient Registry. Standard incidence ratios (SIRs) and 95 per cent confidence intervals for colorectal cancer risk were calculated compared with those in the general population. Stratification was carried out for unilateral and bilateral oophorectomy, and hysterectomy without specification of whether the ovaries were removed or not. Associations between the three oophorectomy options and colorectal cancer risk in different locations were assessed by means of hazard ratios (HRs) and 95 per cent confidence intervals calculated by Cox proportional hazards regression modelling.

RESULTS

Of 195 973 women who had undergone oophorectomy, 3150 (1·6 per cent) were diagnosed with colorectal cancer at a later date (median follow-up 18 years). Colorectal cancer risk was increased after oophorectomy compared with that in the general population (SIR 1·30, 95 per cent c.i. 1·26 to 1·35). The risk was lower for younger age at oophorectomy (15-39 years: SIR 1·10, 0·97 to 1·23; 40-49 years: SIR 1·26, 1·19 to 1·33; P for trend < 0·001). The risk was highest 1-4 years after oophorectomy (SIR 1·66, 1·51 to 1·81; P < 0·001). In the multivariable analysis, women who underwent bilateral oophorectomy had a higher risk of rectal cancer than those who had only unilateral oophorectomy (HR 2·28, 95 per cent c.i. 1·33 to 3·91).

CONCLUSION

Colorectal cancer risk is increased after oophorectomy for benign indications.

Self-perceived, but not objective lymphoedema is associated with decreased long-term health-related quality of life after breast cancer surgery

BACKGROUND

The primary aim was to compare long-term health-related quality of life (HRQoL) in patients undergoing sentinel lymph node biopsy (SLNB) alone versus axillary lymph node dissection (ALND), with or without axillary metastases. Secondary aims were to a) investigate agreement between objectively measured and self-reported lymphoedema and b) compare, with respect to HRQoL, women with objective arm lymphoedema without subjective ratings and those with no objective but subjective ratings of arm lymphoedema.

METHODS

The three study groups were defined by axillary surgery: 1) SLNB alone (N = 140), 2) ALND in patients without axillary metastases (N = 125) and 3) ALND in patients with axillary metastases (N = 155). Preoperatively, one and three years postoperatively arm volume was measured and questionnaires regarding self-perceived symptoms of arm lymphoedema and HRQoL were completed (The Swedish Short Form-36 Health Survey, SF-36).

RESULTS

Out of the original 516 who had axillary surgery, 420 (81%) completed the study. There were no statistically significant differences in HRQoL between the three study groups. No statistically significant agreement was found between self-perceived and objectively measured arm lymphoedema. Women without self-perceived arm lymphoedema, regardless of objective arm lymphoedema or not, scored higher on all eight SF-36 domains than those who reported self-perceived arm lymphoedema.

CONCLUSION

Women reporting self-perceived arm lymphoedema, regardless of objective lymphoedema or not, have a decreased long-term health-related quality of life. This indicates that more attention should be given to the subjective reports of symptom in order to better help these women.

Arm lymphoedema after axillary surgery in women with invasive breast cancer

BACKGROUND

The primary aim was to compare arm lymphoedema after sentinel lymph node biopsy (SLNB) alone versus axillary lymph node dissection (ALND) in women with node-negative and node-positive breast cancer. The secondary aim was to examine the potential association between self-reported and objectively measured arm lymphoedema.

METHODS

Women who had surgery during 1999-2004 for invasive breast cancer in four centres in Sweden were included. The study groups were defined by the axillary procedure performed and the presence of axillary metastases: SLNB alone, ALND without axillary metastases, and ALND with axillary metastases. Before surgery, and 1, 2 and 3 years after operation, arm volume was measured and a questionnaire regarding symptoms of arm lymphoedema was completed. A mixed model was used to determine the adjusted mean difference in arm volume between the study groups, and generalized estimating equations were employed to determine differences in self-reported arm lymphoedema.

RESULTS

One hundred and forty women had SLNB alone, 125 had node-negative ALND and 155 node-positive ALND. Women who underwent SLNB had no increase in postoperative arm volume over time, whereas both ALND groups showed a significant increase. The risk of self-reported arm lymphoedema 1, 2 and 3 years after surgery was significantly lower in the SLNB group compared with that in both ALND groups. Three years after surgery there was a significant association between increased arm volume and self-reported symptoms of arm lymphoedema.

CONCLUSION

SLNB is associated with a minimal risk of increased arm volume and few symptoms of arm lymphoedema, significantly less than after ALND, regardless of lymph node status.

Causes of false-negative sentinel node biopsy in patients with breast cancer

Background

Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection as the routine staging procedure in clinically node-negative breast cancer. False-negative SLN biopsy results in misclassification and may cause undertreatment of the disease. The aim of this study was to investigate whether serial sectioning of SLNs reveals metastases more frequently in patients with false-negative SLNs than in patients with true-negative SLNs.

Methods

This was a case–control study. Tissue blocks from patients with false-negative SLNs, defined as tumour-positive lymph nodes excised at completion axillary dissection or a subsequent axillary tumour recurrence, were reassessed by serial sectioning and immunohistochemical staining. For each false-negative node, two true-negative SLN biopsies were analysed. Tumour and node characteristics in patients with false-negative SLNs were compared with those in patients with a positive SLN by univariable and multivariable regression analysis.

Results

Undiagnosed SLN metastases were discovered in nine (18 per cent) of 50 patients in the false-negative group and in 12 (11.2 per cent) of 107 patients in the true-negative group (P = 0.245). The metastases were represented by isolated tumour cells in 14 of these 21 patients. The risk of a false-negative SLN was higher in patients with hormone receptor-negative (odds ratio (OR) 2.50, 95 per cent confidence interval 1.17 to 5.33) or multifocal tumours (OR 3.39, 1.71 to 6.71), or if only one SLN was identified (OR 3.57, 1.98 to 6.45).

Conclusion

SLN serial sectioning contributes to a higher rate of detection of SLN metastasis. The rate of upstaging of the tumour is similar in false- and true-negative groups of patients.

Abstract P3-07-03: The impact of Carcinoma in situ of the breast and family history on risk of subsequent breast cancer events and mortality - a population based study from Sweden

Purpose: To evaluate the long-term risk of subsequent breast cancer and mortality among women diagnosed with carcinoma in situ of the breast.

Patients and Methods: Using the population-based Swedish Multi-Generation and Cancer Registers we selected 8,111 women diagnosed with in situ breast cancer between 1980 and 2004. We estimated the relative risks of subsequent ipsi- and contralateral invasive breast cancer or a contalateral in situ expressed as standardized incidence ratios (SIRs), in relation to age, year, time since diagnosis and family history (1st degree relative) for breast cancer. The relative risk of death was expressed as standardized mortality ratio, (SMR).

Results: Of 8,111 women identified with first in situ, 859 had a family history for breast cancer. The overall risk of a subsequent invasive breast cancer is over four fold and the risk for contralateral in situ breasts cancer was almost seven fold, compared with the risk in healthy women.

Prediction of non-sentinel lymph node status in breast cancer patients with sentinel lymph node metastases: evaluation of the tenon score

INTRODUCTION

Current guidelines recommend completion axillary lymph node dissection (cALND) in case of a sentinel lymph node (SLN) metastasis larger than 0.2 mm. However, in 50%-65% of these patients, the non-SLNs contain no further metastases and cALND provides no benefit. Several nomograms and scoring systems have been suggested to predict the risk of metastases in non-SLNs. We have evaluated the Tenon score.

PATIENTS AND METHODS

In a retrospective review of the Swedish Sentinel Node Multicentre Cohort Study, risk factors for additional metastases were analysed in 869 SLN-positive patients who underwent cALND, using uni- and multivariate logistic regression models. A receiver operating characteristic (ROC) curve was drawn on the basis of the sensitivity and specificity of the Tenon score, and the area under the curve (AUC) was calculated.

RESULTS

Non-SLN metastases were identified in 270/869 (31.1%) patients. Tumour size and grade, SLN status and ratio between number of positive SLNs and total number of SLNs were significantly associated with non-SLN status in multivariate analyses. The area under the curve for the Tenon score was 0.65 (95% CI 0.61-0.69). In 102 patients with a primary tumour <2 cm, Elston grade 1-2 and SLN metastases ≤2 mm, the risk of non SLN metastasis was less than 10%.

CONCLUSION

The Tenon score performed inadequately in our material and we could, based on tumour and SLN characteristics, only define a very small group of patients in which negative non-sentinel nodes could be predicted.

Axillary recurrence rate 5 years after negative sentinel node biopsy for breast cancer

BACKGROUND

Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) as the standard axillary staging procedure in breast cancer. Follow-up studies in SLN-negative women treated without ALND report low rates of axillary recurrence, but most studies have short follow-up, and few are multicentre studies.

METHODS

Between September 2000 and January 2004, patients who were SLN-negative and did not have ALND were included in a prospective cohort. Kaplan-Meier estimates were used to analyse the rates of axillary recurrence and survival. The risk of axillary recurrence was also compared in centres with high and low experience with the SLN biopsy (SLNB) technique.

RESULTS

A total of 2195 patients with 2216 breast tumours were followed for a median of 65 months. Isolated axillary recurrence was diagnosed in 1·0 per cent of patients. The event-free 5-year survival rate was 88·8 per cent and the overall 5-year survival rate 93·1 per cent. There was no difference in recurrence rates between centres contributing fewer than 150 SLNB procedures to the cohort and centres contributing 150 or more procedures.

CONCLUSION

This study confirmed the low risk of axillary recurrence 5 years after SLNB for breast cancer without ALND.

Differences in Endpoints between the Swedish W-E (Two County) Trial of Mammographic Screening and the Swedish Overview: Methodological Consequences

Objectives

To characterize and quantify the differences in the number of cases and breast cancer deaths in the Swedish W-E Trial compared with the Swedish Overview Committee (OVC) summaries and to study methodological issues related to trials in secondary prevention.

Setting

The study population of the W-E Trial of mammography screening was included in the first (W and E county) and the second (E-county) OVC summary of all Swedish randomized mammography screening trials. The OVC and the W-E Trial used different criteria for case definition and causes of death determination.

Method

A Review Committee compared the original data files from Wand E county and the first and second OVC. The reason for a discrepancy was determined individually for all non-concordant cases or breast cancer deaths.

Results

Of the 2615 cases included by the W-E Trial or the OVC, there were 478 (18%) disagreements. Of the disagreements 82% were due to inclusion/exclusion criteria, and 18% to disagreement with respect to cause of death or vital status at ascertainment. For E-County, the OVC inclusion rules and register based determination of cause of death (second OVC) rather than individual case review (W-E Trial and 1st OVC) resulted in a reduction of the estimate of the effect of screening, but for W-County the difference between the original trial and the OVC was modest.

Conclusions

The conclusion that invitation to mammography screening reduces breast cancer mortality remains robust. Disagreements were mainly due to study design issues, while disagreements about cause of death were a minority. When secondary research does not adhere to the protocols of the primary research projects, the consequences of such design differences should be investigated and reported. Register linkage of trials can add follow-up information. The precision of trials with modest size is enhanced by individual monitoring of case status and outcome status such as determination of cause of death.

Compression of the inferior caval vein--a rare complication of a large non-parasitic liver cyst

A patient with massive edema of the legs and scrotum is presented in whom non-parasitic cysts of the liver were found. Surgical evacuation of one large lobulated liver cyst completely relieved the patient of his edema. It is concluded that in this patient the peripheral edema was caused solely by cystic obstruction of the inferior caval vein.

Lymph drainage studied by lymphoscintigraphy in the arms after sentinel node biopsy compared with axillary lymph node dissection following conservative breast cancer surgery

PURPOSE

To investigate lymphatic drainage as measured by lymphoscintigraphy in the arms of patients undergoing either sentinel lymph node biopsy (SNB) or axillary lymph node dissection (ALND).

MATERIAL AND METHODS

From January 2001 to December 2002, 30 patients with unilateral invasive breast carcinoma underwent breast-conserving surgery with SNB and 30 patients with ALND. All patients received radiotherapy to the breast. Lymphoscintigraphy was performed, and skin circulation, skin temperature, and arm volume were measured 2-3 years after radiotherapy.

RESULTS

None of the 30 patients who underwent SNB showed any clinical manifestation of lymphedema. Of the 30 patients undergoing ALND, six (20%) had clinical lymphedema, with an arm volume that was >10% larger on the operated than on the non-operated side (P<0.01). Scintigraphically, visual analysis revealed lymphatic dysfunction in three patients, manifested as forearm dermal back flow. Two of these patients also had an increased arm volume. Quantitative analysis showed no differences between the groups, apart from a smaller amount of isotope in the axilla in the ALND group. There was no difference in skin circulation or skin temperature.

CONCLUSION

Our study shows that lymph drainage in the operated arm compared with the non-operated arm was less affected by SNB than by ALND, and that morbidity associated with SNB was lower than with ALND. However, the results do not confirm our hypothesis that lymphoscintigraphy can reveal differences in lymph circulation that are not evident clinically in the form of manifest lymphedema. The most sensitive clinical method of assessing lymph drainage seems to be measurement of arm volume.

Sentinel node biopsy for breast cancer larger than 3 cm in diameter

Background

Sentinel node biopsy (SNB) is a standard staging procedure in early breast cancer. Its suitability for larger tumours has been questioned. This study evaluated the reliability of SNB in women with invasive breast cancer larger than 3 cm in diameter who were clinically axillary node negative.

Methods

Some 109 women with a tumour larger than 3 cm on pathological analysis were identified from the Swedish prospective SNB database. They were included if a completion axillary clearance was planned, regardless of SNB results.

Results

The sentinel node detection rate was 103 (94·5 per cent) of 109. The overall false-negative rate was eight (13 per cent) of 64. Although a preoperative diagnosis of multifocal tumour was an exclusion criterion, 16 such cases were revealed on postoperative pathological examination. The false-negative rate in this subgroup was higher than that in women with a unifocal tumour (four (31 per cent) of 13 versus four (8 per cent) of 51; P = 0·012). No other significant predictors of a false-negative sentinel node biopsy were identified.

Conclusion

SNB is feasible in patients with unifocal breast tumours larger than 3 cm. When large tumour size coincides with multifocality, however, the false-negative rate seems to be increased and a completion axillary clearance should be considered even if the SNB is negative.

Sentinel node biopsy in non-palpable breast cancer and in patients with a previous diagnostic excision

AIM

As a means of staging the axilla with minimal surgical trauma, sentinel lymph node biopsy (SNB) has dramatically altered the management of early-stage breast cancer. The aim of this prospective multicentre study was to assess the safety of the method in cases of non-palpable tumours and in cases with an open biopsy prior to SNB.

METHOD

In the period 1999-2001, 57 non-palpable breast cancers and 75 patients with diagnostic biopsy were collected prospectively to the first part of the study. In the second part, 745 patients with non-palpable breast cancers and 86 cases with prior open surgery diagnosed between 2000 and 2005 were followed up till the end of 2005. All patients in the first part of the study had an axillary clearance irrespective of sentinel node status, whereas in the second part axillary clearance was done only if the sentinel node was metastatic.

RESULTS

The detection rate was 95% in the group of non-palpable breast cancers, with a false negative rate of 5.6% (1/18), and the corresponding figures for the group with prior intervention were 96% and 10% (2/20). Two axillary recurrences, after a negative SNB at primary surgery, were found in the non-palpable group after 16 and 17 months, respectively. No axillary recurrence has been observed in the group of cancers with a prior open biopsy. Four women in the non-palpable group and two women with a diagnostic operation experienced distant metastases.

CONCLUSION

We conclude that SNB is a safe procedure for women with non-palpable breast cancer, as well as after previous open diagnostic excision.

Intraoperative sentinel lymph node examination by frozen section, immunohistochemistry and imprint cytology during breast surgery – A prospective study

The aim of this study was to compare the sensitivity of intraoperative frozen section with hematoxyllin-eosin (H&E) staining, immunohistochemistry (IHC) or imprint cytology (IC) in the analysis of sentinel node (SN) in breast cancer. Towards this end, a prospective study of 102 patients undergoing mastectomy or sector resection with SN biopsy was conducted. Frozen sections of SN with H&E, IHC staining and IC had sensitivities of 73.5%, 75.5% and 51.0%, respectively. The combination of H&E and IHC raised the overall sensitivity to 83.7%. Macrometastases (>2 mm) were detected in 100% of the cases with H&E, 92.6% with IHC and 81.5% with IC; and micrometastases (2 mm) in 35.0%, 45.0% and 5.0%, respectively. The combination of H&E and IHC staining raised the sensitivity to 55.0%. Frozen-section analysis with H&E staining showed high sensitivity in detecting macrometastases but not micrometastases. The sensitivity for detection of micrometastases was not substantially increased by the use of intraoperative IHC. Imprint cytology did not provide any additional information.

Multicentre validation study of sentinel node biopsy for staging in breast cancer

BACKGROUND

The aim of this study was to validate sentinel node biopsy for axillary staging after the initial learning phase, and to analyse factors associated with false-negative biopsies.

METHODS

Some 675 patients, who had standard sentinel node biopsy followed by level I and II axillary clearance in one of 20 hospitals in Sweden and were operated on by 36 different surgeons, were recruited prospectively.

RESULTS

The overall detection rate was 94.5 per cent. It varied between surgeons but was not influenced by the number of operations per surgeon. Moreover, it was lower among older patients. The overall false-negative rate was 7.7 per cent. This rate was not affected by patient age, tumour histological type or Elston grade, but was increased in patients with multifocal tumours. Some 21 per cent of patients with a multifocal tumour diagnosed on postoperative histopathological analysis had a false-negative biopsy compared with 5.6 per cent of those with unifocal tumours (P = 0.004).

CONCLUSION

Sentinel node biopsy was shown to be a reliable method for axillary staging of unifocal breast tumours.

A randomised study of axillary drainage and pectoral fascia preservation after mastectomy for breast cancer

BACKGROUND

To reduce the risk of seroma after modified radical mastectomy in breast cancer patients, the use of suction axillary drainage is a standard procedure. The optimal time to remove the drain is not established. Whether the removal or preservation of the pectoral fascia influences the risk of seroma formation or loco-regional recurrence rate remains unclear.

METHOD

The trial included 247 patients with breast cancer who underwent modified radical mastectomy in five Swedish hospitals 1993-1997. The median follow-up time was 6 years. One hundred and twenty-two and 125 patients, respectively, were randomised between removal versus preservation of the pectoral fascia. Of these 247 patients a total of 198 patients were also randomised to have the drain removed 24 h postoperatively or to keep the drain in until discharge had decreased to less than 40 ml/24 h.

RESULTS

Early removal of the axillary drain was associated with significantly more seromas and a shorter average postoperative hospital stay. There were no differences between the two groups regarding the rate of wound infections and/or hematoma formation. Removal or preservation of the pectoral fascia did not influence the formation of seroma or the amount of peroperative bleeding. A trend towards an increased risk for chest wall recurrence was observed in patients with preserved pectoral fascia (16/125 compared with 8/122; hazard ratio=2.0, 95% confidence interval=0.9-4.7).

CONCLUSION

Early removal of axillary drain shortened the duration of hospital stay without any increase in wound complications. However, it yielded a significantly higher incidence of seroma. Seroma formation and the chest wall recurrence rate was not significantly influenced by the preservation of the pectoral fascia or not.

Risk factors for local recurrence after breast-conserving surgery

BACKGROUND

It is not clear whether risk factors for local recurrence after breast-conserving surgery differ in women having surgery for in situ or invasive cancer. Furthermore, the Nottingham Prognostic Index (NPI) and Nottingham Histological Grade (NHG) have been little studied as determinants of local recurrence risk.

METHOD

In a case-control study (491 cases and 1098 controls) nested within a cohort of 7502 women who had surgery for in situ or invasive cancer of the breast, patient characteristics, tumour characteristics and treatment-related variables were evaluated as risk factors for local recurrence.

RESULTS

Multivariate conditional logistic regression analyses showed that age below 40 years, tumour multicentricity and an unclear or unknown surgical margin were significant risk factors for local recurrence. Radiotherapy to the breast and adjuvant hormone therapy were protective. Cancer in situ was not associated with a higher risk of local recurrence than invasive cancer (odds ratio 1.0, 95 per cent confidence interval 0.8 to 1.3). NHG and NPI were not helpful in determining risk of local recurrence.

CONCLUSION

Margin status, age, tumour multicentricity, and use of radiotherapy and adjuvant hormone therapy were important determinants of risk of local recurrence. With the exception of surgical margin, variables related to the quality of surgical management did not predict risk of local recurrence.

Body site of cutaneous malignant melanoma--a study on patients with hereditary and multiple sporadic tumours

Individuals with an increased risk of developing cutaneous malignant melanoma (CMM) include members of kindreds with hereditary cutaneous malignant melanoma (HCMM) and patients who have already been treated for a CMM. Some of these patients develop multiple primary cutaneous malignant melanomas (MCMMs). Ultraviolet radiation is the main instigator of CMM. There are indications that patients in these high-risk groups react differently to sunlight than patients who develop a single sporadic CMM. The objectives of this study were to analyse tumour site in patients with HCMM and sporadic MCMM. Data on 2517 patients with 2608 CMMs from a population-based regional cancer registry were used. The new computer program EssDoll was used for the analyses of primary tumour sites. This software is able to analyse any chosen body area(s) with reference to the number of tumours arising there. When the site of the first and second tumours in patients with sporadic MCMM were analysed in a skin 'field division', there was a significant concordance with respect to site (P < 0.0001). In patients with MCMM, the second primary tumour was significantly thinner than the first (P = 0.001). Primary tumour sites in patients with HCMM were compared with those in patients with a single sporadic CMM. In HCMM we found significantly fewer tumours in the head and neck area and more on the trunk. These differences remained significant in two different body area models, even when stratified for age (P < 0.05). In conclusion, a site-concordance was noted for sporadic MCMM. This may be the result of a 'field effect'. Our results indicate that intermittent ultraviolet exposure may be of relatively greater importance than chronic exposure in HCMM.

Complementary use of scintimammography with 99m-Tc-MIBI to triple diagnostic procedure in palpable and non-palpable breast lesions

PURPOSE

The aim of this study was to determine the clinical value of scintimammography with 99m-Tc-MIBI (Sc) as a complementary method to the triple diagnostic procedure in the diagnosis of breast lesions.

MATERIAL AND METHODS

Ninety-six consecutive patients with 65 palpable and 54 non-palpable breast lesions were included in a prospective study. All lesions were evaluated by clinical examination, mammography and fine-needle-aspiration cytology (FNAC), called triple diagnostic procedure (TD). Prone planar scintimammography with 99m-Tc-MIBI was performed in all patients. Five groups were defined for diagnosis: 1 = normal; 2 = benign; 3 = probably benign; 4 = highly suspect of malignancy; and 5 = malignant. In the calculations, groups 1-3 were considered benign, and 4-5 malignant. All lesions were excised and examined histologically. The additional value of Sc + TD procedure was studied separately for palpable and non-palpable lesions.

RESULTS

Histologically, 83 malignant and 36 benign lesions were found in the 119 breast lesions. Sensitivity for malignancy in palpable lesions of TD alone and of the combination TD + Sc were 95.6% and 100%, respectively. Sensitivity for malignancy in non-palpable lesions of TD and TD + Sc was 89.1% and 97.2%, respectively.

CONCLUSION

Adding scintimammography to the triple diagnostic procedure increased the sensitivity for the detection of both palpable and non-palpable breast cancers, but decreased the specificity.

Local recurrence in the breast after conservative surgery--a study of prognosis and prognostic factors in 391 women

In a population-based cohort of 6613 women with invasive breast cancer, who had breast-conserving surgery between 1981 and 1990, 391 recurrences in the operated breast were identified. The main aim of this study was to examine the prognosis and prognostic factors in different subgroups of local recurrences, characterised by the time to recurrence, location of recurrence and previously given radiotherapy. The median follow-up for women who had a local recurrence was 7.9 years. The life-table estimates for breast cancer-specific survival in women with local recurrences were 84.5% (standard error (S.E.) 1.8) at 5 years and 70.9% (S.E. 2.7) at 10 years. The risk of breast cancer death was highest among women who had an early (<or=2 years) recurrence in the same quadrant as the primary tumour, with a breast cancer-specific survival of 67.9% (S.E. 4.8) at 5 years and 56.0% (S.E. 5.9) at 10 years. There was a statistically significant difference in the probability of breast cancer-specific survival, as measured from the recurrence, between women who initially did or did not receive radiotherapy (P=0.0123). However, when measured from primary treatment, there was no significant difference, indicating that the difference in prognosis could be due to a lead-time bias. Independent prognostic factors for breast cancer-specific survival in women with local recurrences were time to local recurrence and the Nottingham Prognostic Index (NPI).

Consequences of axillary recurrence after conservative breast surgery

BACKGROUND

The aim was to study the incidence, time course and prognosis of patients who developed axillary recurrence after breast-conserving surgery, and to evaluate possible risk factors for axillary recurrence and prognostic factors after axillary recurrence.

METHODS

In a population-based cohort of 6613 women with invasive breast cancer who had breast-conserving surgery between 1981 and 1990, 92 recurrences in the ipsilateral axilla were identified. Risk factors for axillary recurrence were studied in a case-control study nested in the cohort, and late survival was documented in the women with axillary recurrence.

RESULTS

The overall risk of axillary recurrence was 1.0 per cent at 5 years and 1.7 per cent at 10 years. The risk of axillary recurrence increased with tumour size (P = 0.033) and was highest in younger women (odds ratio (OR) 3.9 for women aged less than 40 years compared with those aged 50-59 years). Radiotherapy to the breast reduced the risk of axillary recurrence (OR 0.1 (95 per cent confidence interval 0.1 to 0.4)). The breast cancer-specific survival rate after axillary recurrence, as measured from primary treatment, was 78.0 per cent at 5 years and 52.3 per cent at 10 years. Tumour size and node status had a statistically significant effect on death from breast cancer.

CONCLUSION

Axillary recurrence is rare, although more common in younger women with large tumours. Radiotherapy to the breast was protective. Tumour size and node status were the most important prognostic factors in women with axillary recurrence.

A new computerized methodology to analyse tumour site in relation to phenotypic traits and epidemiological characteristics of cutaneous malignant melanoma

BACKGROUND

While sunlight is important in the aetiology of cutaneous malignant melanoma (CMM), the relationship between skin areas receiving intermittent or chronic sun exposure and the development of CMM has not been fully explored. There is a requirement for an improved method for more detailed site mapping and for analysis of tumour density in different areas of the skin in relation to the type of sun exposure, phenotypic traits and prognosis of patients with CMM.

OBJECTIVES

To describe and demonstrate the use of EssDoll, a new computerized method to map and analyse tumour sites.

METHODS

We have used the new software to analyse data on 2517 patients with 2608 primary CMMs.

RESULTS

The results obtained were consistent with previous data on the distribution of CMM in men and women. The distribution of CMM on the back was uneven, with the density on the upper back being twice that on the lower back.

CONCLUSIONS

The new methodology allows a more accurate mapping and analysis of skin tumour site, including determination of tumour density. This improves the possibility of analysing tumour site in relation to aetiological, phenotypic and prognostic parameters.

Multicentre study of detection and false-negative rates in sentinel node biopsy for breast cancer

BACKGROUND

Sentinel node biopsy has recently evolved as a means of staging the axilla in breast cancer with minimal surgical trauma. The aim of this prospective multicentre study was to identify factors that influenced the detection and false-negative rates during the learning phase.

METHODS

Data on all 498 sentinel node biopsies performed between August 1997 and December 1999 in Sweden were collected.

RESULTS

A sentinel node was found in 450 patients (90 per cent). Preoperative scintigraphy visualized 83 per cent of all sentinel nodes. The detection rate was higher with same-day injection of tracer than with injection the day before (96 versus 86 per cent; P < 0.01). Dye injected less than 5 min or more than 30 min before the start of the operation lowered the detection rate (less than 60 per cent versus more than 65 per cent; P = 0.02). The detection rate varied from 61 to 100 per cent between surgeons. The false-negative rate was 11 per cent. The presence of multiple tumour foci and a high S-phase fraction increased the risk of a false-negative sentinel node, whereas the number of operations performed by each surgeon was less important.

CONCLUSION

Training of the individual surgeon influenced the detection rate, as did timing of tracer and dye injection. The false-negative rate seemed to be related to biological factors.

Time trends in the results of breast conservation in 4694 women

In a population-based cohort of 4694 women with invasive breast cancer, operated upon with breast conserving surgery (BCS) in 1981--1990 and followed through to 1997, we studied how this technique had been adopted into clinical practice, especially with reference to the use of radiotherapy (RT). Our main aim was to see whether there was a drift in the risk of local recurrence and breast cancer death over time. During the 30,151 person-years of observation in the cohort, there were 582 local recurrences, 456 breast cancer deaths and 438 deaths due to other causes. Postoperative RT was given to 70.2%, but usage increased over the period. The women not receiving RT were mostly elderly, but also in women <70 years, 20.4% did not receive RT. The risk for local recurrence after RT were 7.6 and 17.8% at 5 and 10 years, respectively. Without RT, more than 30% had a local recurrence at 10 years. Thus, the choice not to irradiate failed to target women at a low risk. In a multivariate Cox analysis taking tumour size, nodal status, age at operation and RT into account, there was a trend for a higher risk of local recurrence in the later time period, relative hazard 1.5 (95% confidence interval (CI) 1.0--2.1). Corrected survival was 93.3 and 85.2% at 5 and 10 years, respectively.

Sentinel node in breast cancer--a Swedish pilot study of 75 patients

OBJECTIVE

To find out if the sentinel node can be detected in sufficient numbers of women with breast cancer to be useful as a prognostic sign, whether it reflects that state of the entire axilla, and whether it detects micrometastases that would otherwise be missed.

DESIGN

Prospective study.

SETTING

3 teaching hospitals, Sweden.

SUBJECTS

75 patients with breast cancer who were listed to have axillary dissection as well as resection of their tumour.

INTERVENTIONS

Injection of 99Tc nanocolloid 0.4 ml and patent blue dye 1 ml around the tumour or under the skin above the tumour, followed by preoperative lymphoscintigraphy and then identification of the sentinel node during operation either because it had turned blue or with a gamma probe. Removal of the sentinel node and complete axillary dissection.

MAIN OUTCOME MEASURES

Identification of the sentinel node and presence of metastatic nodes in the axilla.

RESULTS

The sentinel node was identified in 69/75 (92%). It correctly predicted the state of the axilla in 66/69 (96%), and detected metastases in 24 of the 27 with invaded nodes in the axilla (89%). The false negative rate was 11%. In 14/27 with axillary metastases (52%) the sentinel node was the only involved node. In 3/24, metastases were detected by immunohistochemistry alone.

CONCLUSION

Biopsy of the sentinel node predicted the presence or absence of axillary metastases with acceptable accuracy. However, before axillary node dissection is rejected in favour of sentinel node biopsy alone, large multicentre studies are needed to establish the true false negative rate.

A prospective population-based study of cutaneous malignant melanoma of the head and neck

OBJECTIVES/HYPOTHESIS For cutaneous malignant melanoma (CMM) of the head and neck, neither prognostic factors in population-based groups, nor outcome with respect to surgical resection margins is clear. Therefore, we analyzed data in a regional registry to align treatment results for CMM of the head and neck with prognosis and survival times.

STUDY DESIGN

Patient material collected prospectively for an 18-year period in a Swedish cancer registry underwent statistical analyses to establish the most reliable prognostic factors and the influence of surgical treatment on the survival of patients with CMM of the head and neck.

METHODS

Data originated from the CMM database of the Stockholm-Gotland area of Sweden. Tumor thickness or invasiveness (Breslow or Clark's levels), extent of surgical margin, sex, histogenetic type, anatomic site, and ulceration were compared statistically for 469 patients.

RESULTS

Male patients with head and neck CMM had a 68% 10-year survival rate; the 10-year survival rate for female patients was 87%. The corresponding figures for CMM at other sites were 83% and 90%, respectively. Tumor thickness (or Clark level of invasion) was the only statistically significant prognostic factor in a multivariate analysis (P < .001). The surgical resection margin seemed to be of no importance to outcome.

CONCLUSIONS

Long-term survival after treatment for CMM of the head and neck is better than reported in most earlier publications, presumably because our evaluation used population-based materials, an important factor in accurate reporting of this kind. Tumor thickness is the main prognostic factor in estimating outcome.

Epidemiological characteristics of cutaneous malignant melanoma of the head and neck--a population-based study

Since cutaneous malignant melanoma (CMM) and melanoma in situ (MIS) of the head and neck have only partially been differentiated from CMM of other anatomic sites, these lesions are classified in detail in this study. Data from 756 patients derived from the population-based register of the Stockholm-Gotland area were analyzed and the findings showed that the incidence of CMM was 3.4 times higher in the face compared to the skin outside the head-neck area and that lentigo maligna melanoma was 74 times and nodular melanoma 2.3 times more common in the face. Mean age at diagnosis was significantly higher for patients with CMM of the head and neck irrespective of histogenetic type. Tumor site within the head and neck related to age at diagnosis. CMM of the head and neck differs from CMM of other locations. Epidemiological data are in agreement with the hypothesis that UV radiation (chronic or intermittent) may give rise to melanomas with various phenotypic traits.

The Stockholm Mammographic Screening Trial: Risks and benefits in age group 40-49 years

This article presents updated data on breast cancer mortality for women under age 50 from the Stockholm Mammographic Screening Trial, as well as a review of some side effects associated with screening in this age group. Approximately 40,000 women aged 40-64 (14,842 aged 40-49 years) were randomized to a trial of breast cancer screening by single-view mammography alone; 20,000 women (7,103 aged 10-49) were randomized to a control group. In the 40-49 age group, 24 and 12 breast cancer deaths were found in the study and control groups, respectively, after 11.4 years of follow-up. The relative risk of breast cancer death in screened to nonscreened women was 1.08 (95% confidence interval: 0.54-2.17). The rates of benign surgical biopsies, false positives, and follow-up costs were higher among women under age 50. Large overview studies are needed, however, to determine whether mammography screening consistently reduces mortality in women 40-49 years of age. Side effects such as costs and public aspects of mammography screening in this age group also warrant further study.

Updated overview of the Swedish Randomized Trials on Breast Cancer Screening with Mammography: age group 40-49 at randomization

The purpose of this overview is to estimate more precisely the long-term effect of mammography screening by adding four more years of follow-up to women aged 40-49 years in the four Swedish trials on mammography screening. Data from the four, trials were merged and linked to the Swedish Cancer and Cause of Death Register for 1958-1993 and 1951-1993 respectively to identify date of breast cancer diagnosis and cause and date of death. The invited and control groups comprised 48,569 and 40,247 women respectively. At the December 1993 follow-up, 602 and 482 breast cancer cases were identified in the two groups respectively, of which 104 and 111 had breast cancer as the underlying cause of death. This corresponds to a relative risk (RR) of 0.77 (95% CI: 0.59-1.01) for the two groups. In the 40-44 age group at randomization, 94% of breast cancer patients in the study and 89% in the control group were diagnosed before the age of 50; however, among breast cancer deaths in this age group, only two in the invited and five in the control group died after age 50. At follow-up of women 40-44 years at randomization 208 women in the invited and 184 in the control group were reported to the Cancer registry with breast cancer. Out of these 195 (94%) and 163 (89%) respectively were reported before the age of 50. Further, the relative risk for the age group 40-44 years at randomization by age at follow-up was 1.11, 0.51 and 0.46 for the age groups 45-49, 50-54, and 55-59 at follow-up. This study shows a 23% reduction in the breast cancer mortality in women 40-49 years at randomization achieved from a median trial time of 7.0 years, a median follow-up time of 12.8 years, and a screening interval of 18-24 months. Almost all of the effect in the 40-44 year age group at randomization was due to screening before the age of 50.