Tumor heterogeneity and clinically invisible micrometastases in metastatic breast cancer-a call for enhanced surveillance strategies

The biology of metastatic breast cancer (MBC) is understudied, primarily due to the difficulty of procuring multiple samples from patients with oligometastatic breast cancer. We developed a rapid postmortem tissue procurement program that allows the collection and analysis of numerous metastatic lesions, subclinical locations, and potential pre-metastatic niches that fall within this scope. We conducted a rapid postmortem tissue collection study on 9 patients with MBC. Patients and their families consented to donate tissues immediately after death in an IRB-approved study. Various disease subtypes, progression histories, organ involvement, and final causes of death are reported. In patients with hormone receptor-positive (HR+) disease, estrogen receptor (ER), progesterone receptor (PR), HER2, and Ki-67 expression were heterogeneous across metastatic lesions within individual patients. Disease phenotype at the end of life trended toward complete loss of HR expression. Nearly all (n = 7) patients exhibited extensive tumor involvement of additional organs that had not been previously diagnosed clinically and were not retrospectively visible on recent imaging. Of these seven individuals, three included organs uncommonly associated with MBC: kidney, spleen, pancreas, and ovary. Finally, we identified clinically undetectable micrometastases in several organs uncommonly involved in MBC. Our findings raise several clinically relevant questions regarding the mechanisms of metastatic progression. Insights from this study argue for better surveillance strategies for monitoring MBC. We highlight the need to capture more accurate biomarker information in the context of heterogeneous disease and urge the consideration of treatment strategies that combine multiple targeted therapies.

Thrombopoietin Receptor Agonists for Thrombocytopenia Secondary to HER2-Targeted Antibody Drug Conjugates

Trastuzumab emtansine and trastuzumab deruxtecan are widely used in breast cancer and other solid tumor malignancies. Thrombocytopenia is a common adverse event associated with the use of these agents that can lead to a treatment delay, reduction in dose intensity, and discontinuation. The role of thrombopoietin receptor agonists (TPO-RA) remains unknown in this setting. We report a case series of 6 individuals with breast cancer that experienced dose-reductions and therapy delays due to thrombocytopenia secondary to trastuzumab emtansine or trastuzumab deruxtecan therapy and received intervention with TPO-RA. All 6 were able to resume therapy with TPO-RA support.

HER2-targeted antibody-drug conjugates for breast cancer: ancestry and dose adjustment for thrombocytopenia

BACKGROUND

Thrombocytopenia is a common adverse event on HER2-targeted therapies, fam-trastuzumab deruxtecan (T-DXd) and ado-trastuzumab emtansine (T-DM1). A reported association of Asian ancestry with this event merits investigation to rule out potential confounding.

METHODS

Subjects in this retrospective cohort were female patients with HER2 positive breast cancer, of Asian or non-Hispanic White ancestry, who initiated T-DM1 or T-DXd from January 2017 through October 2021. Follow-up closed in January 2022. Primary endpoint was dose adjustment for thrombocytopenia. Competing endpoints were discontinuation of drug for other toxicity, disease progression, or for completion of prescribed cycles. The association between Asian ancestry and thrombocytopenia-related dose adjustment was tested at p < 0.01 in a proportional hazards model for the sub-distributions of 4 (primary and competing) endpoints. Covariates examined as potential confounders were age, metastatic disease, specific HER2-targeted drug, and prior drug switching for toxicity.

RESULTS

Among 181 subjects, 48 reported Asian ancestry. Incidence of dose adjustment for thrombocytopenia was higher in patients with Asian ancestry and among patients switched to T-DXd after experiencing thrombocytopenia on T-DM1. Independent of specific drug and prior drug switching, Asian ancestry was associated with dose adjustment for thrombocytopenia (hazards ratio 2.95, 95% confidence interval 1.41-6.18) but not with competing endpoints. Among participants of Asian ancestry, the ancestral origin was usually China or the Philippines (where Chinese ancestry is common).

CONCLUSIONS

The association between Asian ancestry and thrombocytopenia on HER2-targeted therapy is independent of age, metastatic disease, drug, and history of similar toxicity. This association may have a genetic basis linked to Chinese ancestry.

Immunogenicity and efficacy of pembrolizumab and doxorubicin in a phase I trial for patients with metastatic triple-negative breast cancer

Currently there is a limited understanding for the optimal combination of immune checkpoint inhibitor and chemotherapy for patients with metastatic triple-negative breast cancer (mTNBC). Here we evaluate the safety, efficacy, and immunogenicity of a phase I trial for patients with mTNBC treated with pembrolizumab plus doxorubicin. Patients without prior anthracycline use and 0-2 lines of prior systemic chemotherapies received pembrolizumab and doxorubicin every 3 weeks for 6 cycles followed by pembrolizumab maintenance until disease progression or intolerance. The primary objectives were safety and objective response rate per RECIST 1.1. Best responses included one complete response (CR), five partial responses (PR), two stable disease (SD), and one progression of disease (PD). Overall response rate was 67% (95% CI 13.7%, 78.8%) and clinical benefit rate at 6 months was 56% (95% CI 21.2%, 86.3%). Median PFS was 5.2 months (95% CI 4.7, NA); median OS was 15.6 months (95% CI 13.3, NA). Grade 3-4 AEs per CTCAE 4.0 were neutropenia n = 4/10 (40%), leukopenia n = 2/10 (20%), lymphopenia n = 2/10 (20%), fatigue n = 2/10 (20%), and oral mucositis n = 1/10 (10%). Immune correlates showed increased frequencies of circulating CD3 + T cells (p = 0.03) from pre-treatment to cycle 2 day 1 (C2D1). An expansion of a proliferative exhausted-like PD-1 + CD8 + T cell population was identified in 8/9 patients, and exhausted CD8 + T cells were significantly expanded from pre-treatment to C2D1 in the patient with CR (p = 0.01). In summary, anthracycline-naïve patients with mTNBC treated with the combination of pembrolizumab and doxorubicin showed an encouraging response rate and robust T cell response dynamics.Trial registration: NCT02648477.

Phase 2 prospective open label study of neoadjuvant nab-paclitaxel, trastuzumab, and pertuzumab in patients with HER2-positive primary breast cancer

BACKGROUND

The objective of this study was to evaluate the safety and efficacy of nab-paclitaxel, trastuzumab, and pertuzumab as neoadjuvant therapy (NAT) in patients with human epidermal growth factor receptor 2 HER2+ breast cancer (HER2+ BC) to determine pathologic complete response (pCR), invasive disease-free survival (iDFS), and overall survival.

METHODS

Forty-five patients with HER2+ BC Stages II-III were to be enrolled from 2013 to 2017. Patients were treated with weekly nab-paclitaxel (100 mg/m² intravenously), weekly trastuzumab (4 mg/kg loading dose, then 2 mg/kg), and six cycles of pertuzumab (840 mg loading dose, then 420 mg intravenously day 1 every 21 days).

RESULTS

Median follow-up was 60 months (95% CI, 32.3-55.6) and pCR was 29/45 (64%). The 5-year iDFS for patients who achieved pCR (N = 29) was 96.3% (95% CI, 76.5-99.5) and non-pCR patients (N = 16) was 74.3% (95% CI, 39.1-91.0). The 5-year overall survival (N = 45) was 94.1% (95% CI, 77.6-98.5). Based on hormonal status, the 5-year iDFS for HR+ pCR patients (N = 14) was 92.3% (95% CI, 56.6-98.9) and for HR- (N = 15) was 100% (p = .3).

CONCLUSIONS

This anthracycline/carboplatin-free regimen with nab-paclitaxel achieved a pCR rate of 64% in patients with HER2+ BC. The 5-year iDFS in patients with and without pCR was 96.3% and 74.3%, respectively. The pCR rate is comparable with docetaxel, carboplatin, trastuzumab, and pertuzumab therapy in the NAT setting, but with fewer treatment-associated toxicities. This finding suggests the possibility of safe avoidance of anthracyclines and carboplatin as components of NAT in patients with HER2+ BC.

Abstract 5208: Circulating T cell: B cell: NK cell axis associated with response to pembrolizumab plus doxorubicin in patients with metastatic triple negative breast cancer

Introduction: The use of immune checkpoint inhibitors (ICI) in combination with chemotherapy is now standard of care for patients with programmed death ligand 1-positive (PD-L1+) metastatic triple negative breast cancer (mTNBC). However, the mechanisms of response to ICIs are still poorly understood in patients with mTNBC. Here we investigate immune correlates of response in patients with mTNBC treated with programmed cell death protein 1 (PD-1) receptor-targeting pembrolizumab and doxorubicin (n=9).

Methods: Patients received pembrolizumab and doxorubicin every 3 weeks for a total of 6 cycles followed by pembrolizumab maintenance until disease progression. Objective response rates (ORR per RECIST 1.1) were: N=1 complete response (CR), N=4 partial responses (PR), N=3 stable disease (SD), and N=1 progression of disease (PD). Baseline tumor biopsies were collected for PD-L1 (22C3 antibody) and TILs analysis, and peripheral blood was collected for immune correlatives. Circulating peripheral blood mononuclear cells (PBMCs) were assessed by high parameter flow cytometry with samples collected at timepoints cycle 1 day 1 (C1D1), cycle 2 day 1 (C2D1), and cycle 3 day 1 (C3D1)

Results: No association between response and tumor infiltrating lymphocyte (TIL) scoring or PD-L1 expression were observed. Circulating exhausted CD8+ T cells (PD-1 high CD39+) were identified at baseline in all patients, with the patient with PD having a low frequency of exhausted CD8+ T cells (0.08% in PD vs. 0.3% mean in CR/PR/SD) at baseline. In the patient with PD, the following results were observed relative to other patients: high levels of antibody-secreting B cells (ASC, 15.2% in PD vs. 1.5% mean in CR/PR/SD), CD4+ follicular helper T cells (Tfh, 8.47% PD vs. 2.6% mean in CR/PR/SD), and terminally differentiated NK cells (11.0% PD vs. 6.3% mean CR/PR/SD) at baseline. From baseline to C2D1, the patient who achieved CR demonstrated robust expansion of exhausted CD8+ T cells (4.4-fold change in CR vs. 1.4-fold change in PR/SD/PD).

Conclusion: Our data suggests that both baseline immune profile ‘setpoints’ and dynamic remodeling of immune features, including expansion of exhausted CD8+ T cells, are associated with response to ICIs in patients with mTNBC. Lack of response to ICIs is defined not only by a lack of CD8+ T cell expansion, but also by high levels of circulating ASCs, Tfh, and terminal NK cells at baseline. Additional studies to further explore and validate features of this T cell: B cell: NK cell axis and response to ICIs in patients with mTNBC are ongoing.

Citation Format: Colt A. Egelston, Weihua Guo, Peter P. Lee, Susan E. Yost, James R. Waisman, Yuan Yuan. Circulating T cell: B cell: NK cell axis associated with response to pembrolizumab plus doxorubicin in patients with metastatic triple negative breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5208.

Abstract P1-06-01: Insights from rapid autopsy shed light on mechanisms of cancer dissemination in metastatic breast cancer

Previously we presented our initial findings from a 9-patient rapid autopsy pilot for metastatic breast cancer (MBC). At the time of procurement, one third of subjects exhibited clinically unidentified diseased sites in organs not commonly associated with breast cancer metastases, including ovary, kidney, and pancreas. In two other instances, “resolved” bone specimens (as measured by absence of FTG uptake in PET/CT imaging) were later determined to be &gt;30% tumor positive when assessed by a pathologist. We now expand upon these findings in a more in-depth exploration of the presence of micro-metastases in presumed tumor-negative tissues. A subset of tumor-free tissues were selected from each patient (average of 10 specimens per patient). All selected specimens were negative by clinical imaging, appeared grossly normal at procurement, and were reported to be tumor negative by H&E assessment by a clinical pathologist. We included organs both commonly and uncommonly involved in MBC, including lung, bone, spleen, pancreas, kidney, and non-tumor draining lymph nodes. Tissues were stained for one or more of the markers, pan-cytokeratin, GATA-3, HMFG, MUC1, and ER (if patient was previously ER+), depending on tissue type. Of the 87 total specimens assessed, we identified micro-metastases in 13 specimens from 4 individual patients. Across these 4 patients, micro-metastases were found in lung, bone, pancreas, spleen, and several non-tumor draining lymph nodes. While lung and bone are commonly involved in MBC and these results are not entirely surprising, pancreas and spleen involvement is extraordinarily rare. Further surprising was the identification of micro-metastases in several lymph nodes that were not located anatomically downstream from a disease-involved organ. Image patterns demonstrate tumor cell infiltration into the lymph node within the subcapsular sinus. Presence of micro-metastases in tumor-negative tissue did not correlate with tumor hormone status or cancer type (e.g. lobular vs DCIS). Combined with our previous findings, we now report unexpected and clinically undiagnosed disease involvement in 6/9, or two-thirds, of our patients. Based on these findings, we hypothesize that cancer stem cells and/or micro-metastases are present throughout the body, in all tissue types, and that their ability to grow into tumors is regulated by the local immune microenvironment. Lastly, the differing roles and mechanics of lymphatic vs hematological spread in metastatic disease has long been discussed. Our findings provide strong evidence for cancer dissemination through the lymphatics system. Further study is necessary to better understand the timing of metastatic spread, whether systemic dissemination occurs early or later in disease, and if conducive metastatic or pre-metastatic niches are already present throughout the body at the time of primary diagnosis or if these permissive environments develop slowly overtime.

Citation Format: Eliza R. Bacon, Kena Ihle, Colt Egelston, Weihua Guo, Diana Simons, Dan Schmolze, Christina Wei, Lusine Tumyan, Peter P Lee, James R. Waisman. Insights from rapid autopsy shed light on mechanisms of cancer dissemination in metastatic breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-06-01.

Tumor-infiltrating exhausted CD8+ T cells dictate reduced survival in premenopausal estrogen receptor-positive breast cancer

CD8⁺ tumor-infiltrating lymphocytes (TILs) are associated with improved survival in triple-negative breast cancer (TNBC) yet have no association with survival in estrogen receptor–positive (ER⁺) BC. The basis for these contrasting findings remains elusive. We identified subsets of BC tumors infiltrated by CD8⁺ T cells with characteristic features of exhausted T cells (T_EX). Tumors with abundant CD8⁺ T_EX exhibited a distinct tumor microenvironment marked by amplified interferon-γ signaling–related pathways and higher programmed death ligand 1 expression. Paradoxically, higher levels of tumor-infiltrating CD8⁺ T_EX associated with decreased overall survival of patients with ER⁺ BC but not patients with TNBC. Moreover, high tumor expression of a CD8⁺ T_EX signature identified dramatically reduced survival in premenopausal, but not postmenopausal, patients with ER⁺ BC. Finally, we demonstrated the value of a tumor T_EX signature score in identifying high-risk premenopausal ER⁺ BC patients among those with intermediate Oncotype DX Breast Recurrence Scores. Our data highlight the complex relationship between CD8⁺ TILs, interferon-γ signaling, and ER status in BC patient survival. This work identifies tumor-infiltrating CD8⁺ T_EX as a key feature of reduced survival outcomes in premenopausal patients with early-stage ER⁺ BC.

Abstract P6-16-04: A self-administered geriatric assessment tool for Spanish-speaking older women with breast cancer

Background: Almost a quarter of older adults in the United States will identify themselves as Hispanic/Latino by 2060. Our group has previously developed and validated a self-administered geriatric assessment tool which can be used to identify functional, psychological, social and cognitive impairments among older patients with various types of cancer. Among English-speaking older adults, completing this tool using paper/pencil or a tablet takes a median of 15-21 minutes (min), with &lt; 10% needing assistance to answer it (Hurria, JOP 2016). However, the utilization of this tool among Spanish-speaking older adults has not been tested. We assessed the feasibility of administering a translated and validated Spanish version of our geriatric assessment tool for older Hispanic women with breast cancer, and identified their preferred format (tablet or paper/pencil).

Methods: Spanish-speaking women aged ≥ 65 years with a diagnosis of breast cancer completed the geriatric assessment twice on the same day. Patients were randomized into 3 groups: paper/pencil twice; tablet and paper/pencil in random order; and tablet twice. We assessed the proportion of patients requiring assistance to complete the geriatric assessment, the time needed to complete it, and the proportion of patients who thought the geriatric assessment was difficult/very difficult.

Results: 140 older women with breast cancer completed the geriatric assessment twice and were evaluable. Mean age was 71.6 years (SD 5.8), 53% had ≤ 8th grade education, 43% were married, 45% were retired, 32% were homemakers, and 6% were employed. The participants came from 13 different Spanish-speaking countries, although 70% were born in Mexico. For 90%, Spanish was their primary language, and 75% spoke only in Spanish at home. Regarding computer skills, 64% of the patients said they had none. 39% (n = 54) were unable to complete the geriatric assessment on their own; mean time to complete the geriatric assessment was 29 min (range 8-90); and 28% (n = 39) thought the geriatric assessment was difficult/very difficult. The most common reasons for needing assistance were difficulty understanding questions (39%) and visual problems (31%). Patients with ≤ 8th grade education took longer to complete the geriatric assessment (mean 37.2 vs 29.4 min, p &lt; 0.01), and more often needed help completing the assessment (51% vs 19%, p &lt; 0.01) than those with ≥9th grade education. 53% of the participants preferred using a tablet to answer the geriatric assessment, while 47% preferred paper/pencil.

Conclusions: A substantial proportion of Spanish-speaking older women with breast cancer required assistance to complete our self-administered geriatric assessment tool. This may be a consequence of the low educational level we found among this patient population. Tailoring assessments for diverse populations with particular attention to educational level is needed in multicultural settings.

Citation Format: Soto-Perez-de-Celis E, Vazquez J, Kim H, Sun C-L, Somlo G, Yuan Y, Waisman JR, Mortimer JE, Kruper L, Taylor L, Patel NH, Moreno J, Charles K, Roberts E, Uranga C, Levi A, Katheria V, Paredero-Perez I, Mitani D, Hurria A. A self-administered geriatric assessment tool for Spanish-speaking older women with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-16-04.

Abstract P5-21-08: Tolerability of the combination of lapatinib and trastuzumab in older patients with HER2 positive metastatic breast cancer

Background: Older adults are less likely to be included in clinical trials leading to the approval of novel cancer treatments. The Institute of Medicine and ASCO have identified therapeutic phase II trials as a key research priority to increase the evidence base for older adults with cancer. While targeted therapies may represent a less toxic option for older patients, few trials have studied their tolerability and efficacy in older adults. Here, we present a phase II study (NCT01273610) of the combination of trastuzumab and lapatinib in older patients with HER2+ metastatic breast cancer (MBC), incorporating geriatric oncology principles in the study design.

Methods: Patients age ≥ 60 years with MBC and any number of prior chemotherapy (CT) lines received trastuzumab (either 4mg/kg loading dose followed by 2mg/kg weekly or 8mg/kg followed by 6mg/kg q/3 weeks) plus lapatinib 1000 mg/m2 daily in 21-day cycles. Patients completed a pre-treatment geriatric assessment including measures of function, comorbidity, cognition, nutrition, and psychosocial status. A toxicity risk score developed for older adults receiving cytotoxic CT was calculated for each patient (Hurria et al. JCO 2011 & 2016). Relationships between tolerability (dose reductions and grade (G) ≥ 3 toxicity attributed to treatment) and risk score analyzed using a log2 transformation were assessed using generalized linear models, Student's t tests, and Fisher's exact test. Response rate (RR) and progression free survival (PFS) were evaluated.

Results: 40 patients (mean age 72 [60-92]) were accrued from 04/11 to 05/15. 25% (n = 10) were ≥ 75 years of age. 65% of patients (n = 26) had HR+ tumors and 35% (n = 14) were receiving ≥ 3rd line treatment. Median number of cycles was 4 (0-28). RR was 23% (n = 9, 95% CI 11-38%; 1 complete, 8 partial). 23% (n = 9) achieved stable disease. PFS was 2.7 months (95% CI 2.5-12). Based on the toxicity risk score, 21% (n = 8), 54% (n = 21), and 26% (n = 10) were at low, intermediate, and high risk. 70% (n = 28) of patients had G ≥ 2 toxicities and 20% (n = 8) G ≥ 3 toxicities. G 2 and 3 diarrhea occurred in 28% (n = 11) and 5% (n = 2) respectively. 5% (n = 2) were hospitalized due to treatment-related toxicity. No G ≥ 3 cardiac toxicities were observed. 23% of patients (n = 9) had treatment delays, and 43% (n = 17) required a lapatinib dose reduction. The mean toxicity risk score was higher in patients who required dose reductions (Student's t: p = 0.02). No statistically significant relationship was found between toxicity risk scores and the presence of G ≥ 3 treatment toxicity (logistic regression: OR = 3.08, 95% CI [0.54, 21.2], p = 0.22).

Conclusions: Among older patients with MBC (79% at intermediate or high risk of G ≥ 3 cytotoxic CT toxicity), trastuzumab and lapatinib were well tolerated, with only 20% experiencing G3 toxicities. The toxicity risk score was not found to be significantly related with treatment toxicity, which may be explained by the very low incidence of G3 events. Patients with a low toxicity risk score were not likely to require a lapatinib dose reduction.

Citation Format: O'Connor T, Soto-Perez-de-Celis E, Blanchard S, Chapman A, Kimmick G, Muss H, Luu T, Waisman JR, Li D, Mortimer J, Yuan Y, Somlo G, Stewart D, Katheria V, Levi A, Hurria A. Tolerability of the combination of lapatinib and trastuzumab in older patients with HER2 positive metastatic breast cancer [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 P5-21-08.

Project connect online: randomized trial of an internet-based program to chronicle the cancer experience and facilitate communication

PURPOSE

Evidence suggests that expressing emotions related to cancer and receiving interpersonal support can promote psychological and physical health in women diagnosed with breast cancer. However, adaptive expression of feelings and communication with one's social network can pose challenges for patients with cancer. We report on a randomized controlled trial of an intervention, Project Connect Online, for patients with breast cancer to create personal Web sites to chronicle their experience and communicate with their social network.

PATIENTS AND METHODS

Women (N = 88) diagnosed with breast cancer (any stage, any interval since diagnosis) were randomly assigned to participate in a 3-hour workshop for hands-on creation of personal Web sites with a follow-up call to facilitate Web site use, or to a waiting-list control. Assessed before randomization and 6 months after the intervention, dependent variables included depressive symptoms, positive and negative mood, cancer-related intrusive thoughts, and perceived cancer-related benefits in life appreciation and strengthened relationships.

RESULTS

Relative to control participants, women randomly assigned to Project Connect Online evidenced significant benefit 6 months later on depressive symptoms, positive mood, and life appreciation, but not negative mood, perceived strengthened relationships, or intrusive thoughts. Treatment status moderated the intervention effects, such that women currently undergoing medical treatment for cancer benefitted significantly more from the intervention on depressive symptoms and positive mood than did women not receiving treatment.

CONCLUSION

Findings suggest the promise of an intervention to facilitate the ability of women diagnosed with breast cancer to chronicle their experience and communicate with their social network via the Internet.

Sources of referral to early phase clinical trials: a case for putting all your eggs in one basket

Abstract #3116

Background: Studies suggest that only 2% to 3% of all adult cancer patients and approximately 5% of breast cancer patients enroll in clinical trials. To better understand the factors that contribute to enrollment we collected data from patients on sources that prompted them to contact us.&#x2028; Methods: From Jan 2005 to Apr 2008 we screened nearly 400 patients for 8 Phase I/II clinical trials focused on immunotherapy of breast and ovarian cancer. We queried subjects about informational sources that led them to consider our clinical studies. Patients learned about our trials from sources including: Clinicians, the Internet (advocacy group websites, search engines, government/university sites), Other patients, Family/friends, Media, Community events and Postings seeking research participants. Many patients who cited a clinician as their referral source specifically referenced a private, multi-site breast cancer clinic in Southern California with which our clinical group has formed a partnership, or consortium. To ensure that this was represented in the data and because the clinician category comprised a large percentage of the referral sources we split the category into 2 groups-one being the private practice in California (to be referred to as “consortium”) and the other being all other clinicians.&#x2028; Results: Of the 399 patients screened, 336 (84%) were considered potentially eligible for study. A total of 72 patients, or 18% of those screened have enrolled in one of our trials to date.&#x2028; Among patients screened, most learned about our trials from clinicians outside the consortium (34%), the Internet (27%), and consortium clinicians (15%). Patients most often named her2support.org (35%) and clinicaltrials.gov (23%) as their specific Internet sources. The remaining sources, family/friends, patients, media sources, community events and postings in medical facilities, were each cited by &lt;5% of patients.&#x2028; Although consortium clinicians were responsible for only 15% of referrals, 50% of their referrals enrolled in a study. Only 16% of patients referred by other clinicians and 9% referred via the Internet were enrolled. Though other clinicians and the Internet are the most common referral sources, referrals from our consortium were significantly more likely to enroll than any other source (p&lt;0.001).&#x2028; This may be due to the fact that patients referred by the consortium were more likely to meet eligibility criteria. Relative to 93% of consortium referrals, 87% of other clinician and 79% of Internet referrals were potentially eligible for trial (p&lt;0.05). Patients referred by our consortium were significantly more likely to meet study criteria relative to those referred by other sources.&#x2028; Discussion: Physician referrals often lead to higher accrual to clinical trials relative to other referral sources. Our data reveal that accrual can be further improved by forming a close collaborative relationship with a single select practice of clinicians.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3116.

Bevacizumab and albumin-bound paclitaxel treatment in metastatic breast cancer

BACKGROUND

Miller et al demonstrated that the combination of bevacizumab and paclitaxel has significant activity in metastatic breast cancer (MBC). Because albumin-bound paclitaxel has been shown to have less toxicity, a better tumor delivery, and possibly better response for MBC, we combined it with bevacizumab to treat women with MBC.

PATIENTS AND METHODS

This is a retrospective analysis. Billing records from March 2005 through December 2006 were reviewed to identify all patients treated with a combination of albumin-bound paclitaxel/bevacizumab. A total of 40 women were identified. They received a minimum of 2 courses. Patients with measurable disease were monitored for response using Response Evaluation Criteria in Solid Tumors. Women with bone-only disease were monitored with positron emission tomography (PET)/computed tomography/magnetic resonance imaging and tumor markers. All response data were confirmed by independent review.

RESULTS

Of 33 women with measurable disease, 16 had objective responses to the albumin-bound paclitaxel/bevacizumab regimen (3 complete responses and 13 partial responses) for an overall response rate (ORR) of 48.5%. Median time to progression for responders was 128 days. Another 5 women had stable disease (SD) with a median duration of 135 days. Of 7 patients with bone-only disease, 2 had almost complete resolution of PET activity and 4 had SD (median, 148 days). Toxicity was acceptable with fatigue, neuropathy, pain, and hypertension being the most common complaints.

CONCLUSION

In our limited series of women with advanced, heavily pretreated MBC treated with albumin-bound paclitaxel/bevacizumab, we saw a 48.5% ORR. The regimen was well tolerated. Randomized studies are needed to confirm efficacy and safety of this combination in treating breast cancer.

Lymph node status combined with lymphovascular invasion creates a more powerful tool for predicting outcome in patients with invasive breast cancer

BACKGROUND

Multiple clinical, biologic, and pathologic factors are known to correlate with outcome in patients with invasive breast cancer. The utility of lymphovascular invasion as an additional useful prognostic indicator has been heretofore ill defined. The purpose of the current study was to determine whether the presence or absence of peritumoral lymphovascular invasion (LVI) contribute further significant information in assessing survival.

METHODS

Using a prospective database of 1,258 patients with invasive breast cancer followed up for as long as 12 years, eight factors were evaluated for their impact on patient survival: lymph node status, LVI, age at diagnosis, tumor size, tumor palpability, estrogen and progesterone receptor status, and nuclear grade.

RESULTS

Multivariate analysis revealed that both lymph node status and the presence or absence of LVI were highly significant independent predictors of outcome.

CONCLUSIONS

Knowledge of both lymph node status and the presence or absence of LVI can be used to predict which subset of patients will do extremely well (node negative + LVI absent) or extremely poorly (node positive + LVI present). The combination of the two factors is most meaningful in patients with 1 to 3 positive nodes.

Chemotherapy-induced activation of hemostasis: effect of a low molecular weight heparin (dalteparin sodium) on plasma markers of hemostatic activation

PURPOSE

To evaluate the effect of standard chemotherapeutic regimens on the hemostatic profile of patients with breast and lung carcinoma; and to evaluate the effect of a single dose of a low molecular weight (LMW) heparin, dalteparin sodium, administered prior to the chemotherapy on markers of hemostatic activation.

PATIENTS AND METHODS

11 patients with breast cancer and 10 patients with lung cancer receiving systemic chemotherapy were studied. 10 breast cancer patients and 9 lung cancer patients completed at least 1 cycle of treatment and had all hemostatic studies. Patients had a complete hemostatic and prothrombotic profile performed at study initiation. Markers of hemostatic activation consisting of immunoassays for thrombin-antithrombin (TAT) complex and D-dimer were measured in plasma samples obtained prior to chemotherapy and at 1, 24 and 48 h after treatment. A 2500 U dose of dalteparin was given prior to the 2nd cycle of chemotherapy; 5000 U of dalteparin was given prior to the 4th treatment cycle.

RESULTS

Chemotherapy resulted in statistically significant increases in TAT and D-dimer for the 1, 24 and 48 h plasma samples in both the breast and lung cancer patients for all cycles of chemotherapy given without LMW heparin. There were statistically significant increases in basal thrombin generation over the 4 cycles of treatment which was unrelated to active cancer. Both pretreatment doses of dalteparin effectively prevented increases in the markers of hemostatic activation. However, in the lung cancer patients, who had significantly increased basal thrombin generation, the 5000 U dose dalteparin was more effective.

CONCLUSION

Chemotherapy results in significant hemostatic activation in patients with breast and lung cancer. The effect of treatment appears to be cumulative. A single dose of LMW heparin administered prior to therapy can suppress hemostatic activation.

The influence of margin width on local control of ductal carcinoma in situ of the breast

BACKGROUND

Ductal carcinoma in situ is a non-invasive carcinoma that is unlikely to recur if completely excised. Margin width, the distance between the boundary of the lesion and the edge of the excised specimen, may be an important determinant of local recurrence.

METHODS

Margin widths, determined by direct measurement or ocular micrometry, and standardized evaluation of the tumor for nuclear grade, comedonecrosis, and size were performed on 469 specimens of ductal carcinoma in situ from patients who had been treated with breast-conserving surgery with or without postoperative radiation therapy, according to the choice of the patient or her physician. We analyzed the results in relation to margin width and whether the patient received postoperative radiation therapy.

RESULTS

The mean (+/-SE) estimated probability of recurrence at eight years was 0.04+/-0.02 among 133 patients whose excised lesions had margin widths of 10 mm or more in every direction. Among these patients there was no benefit from postoperative radiation therapy. There was also no statistically significant benefit from postoperative radiation therapy among patients with margin widths of 1 to <10 mm. In contrast, there was a statistically significant benefit from radiation among patients in whom margin widths were less than 1 mm.

CONCLUSIONS

Postoperative radiation therapy did not lower the recurrence rate among patients with ductal carcinoma in situ that was excised with margins of 10 mm or more. Patients in whom the margin width is less than 1 mm can benefit from postoperative radiation therapy.

Outcome after invasive local recurrence in patients with ductal carcinoma in situ of the breast

PURPOSE

To detail the outcome, in terms of local recurrence, local invasive recurrence, distant recurrence, and breast cancer mortality for patients previously treated for ductal carcinoma in situ (DCIS).

PATIENTS AND METHODS

Clinical, pathologic, and outcome data were collected prospectively for 707 patients with DCIS accrued from 1972 through June 1997.

RESULTS

There were 74 local recurrences; 39 were noninvasive (DCIS) and 35 were invasive. Fifty-one percent of patients with invasive recurrences presented with stage 1 disease; the remainder presented with more advanced disease. Invasive local recurrence after mastectomy was a rare event that occurred in 0.8% of patients. Invasive recurrence after breast preservation was more common and occurred in 7.4% of patients. The 8-year probability of breast cancer mortality after breast preservation was 2.1%, a number that is likely to increase with longer follow-up. The 8-year breast cancer-specific mortality and distant-disease probability for the subgroup of 74 patients with locally recurrent disease was 8.8% and 20.8%, respectively. If only the 35 invasive recurrences are considered as events, the 8-year breast cancer-specific mortality and distant-disease probability was 14.4% and 27.1%, respectively.

CONCLUSION

Invasive local recurrence after breast-preservation treatment for patients with DCIS is a serious event that converts patients with previous stage 0 disease to patients with disease that ranges from stage I to stage IV. These results, however, indicate that most DCIS patients with local recurrence can be salvaged.

A prognostic index for ductal carcinoma in situ of the breast

BACKGROUND

There is controversy and confusion regarding therapy for patients with ductal carcinoma in situ (DCIS) of the breast. The Van Nuys Prognostic Index (VNPI) was developed to aid in the complex treatment selection process.

METHODS

The VNPI combines three significant predictors of local recurrence: tumor size, margin width, and pathologic classification. Scores of 1 (best) to 3 (worst) were assigned for each of the 3 predictors and then totaled to give an overall VNPI score ranging from 3 to 9. Three hundred thirty-three patients with pure DCIS treated with breast preservation (195 by excision only and 138 by excision plus radiation therapy) were studied with detection of local recurrence as the end point.

RESULTS

There was no statistical difference in the 8 year local recurrence free survival in patients with VNPI scores of 3 or 4, regardless of whether or not radiation therapy was used (100% vs. 97%; P = not significant). Patients with VNPI scores of 5, 6, or 7 received a statistically significant 17% local recurrence free survival benefit when treated with radiation therapy (85% vs. 68%; P = 0.017). Patients with scores of 8 or 9, although showing the greatest relative benefit from radiation therapy, experienced local recurrence rates in excess of 60% at 8 years.

CONCLUSIONS

DCIS patients with VNPI scores of 3 or 4 can be considered for treatment with excision only. Patients with intermediate scores (5, 6, or 7) show a 17% decrease in local recurrence rates with radiation therapy. Patients with VNPI scores of 8 or 9 exhibit extremely high local recurrence rates, regardless of irradiation, and should be considered for mastectomy.

A prognostic index for ductal carcinoma in situ of the breast

BACKGROUND

There is controversy and confusion regarding therapy for patients with ductal carcinoma in situ (DCIS) of the breast. The Van Nuys Prognostic Index (VNPI) was developed to aid in the complex treatment selection process.

METHODS

The VNPI combines three significant predictors of local recurrence: tumor size, margin width, and pathologic classification. Scores of 1 (best) to 3 (worst) were assigned for each of the 3 predictors and then totaled to give an overall VNPI score ranging from 3 to 9. Three hundred thirty-three patients with pure DCIS treated with breast preservation (195 by excision only and 138 by excision plus radiation therapy) were studied with detection of local recurrence as the end point.

RESULTS

There was no statistical difference in the 8 year local recurrence free survival in patients with VNPI scores of 3 or 4, regardless of whether or not radiation therapy was used (100% vs. 97%; P = not significant). Patients with VNPI scores of 5, 6, or 7 received a statistically significant 17% local recurrence free survival benefit when treated with radiation therapy (85% vs. 68%; P = 0.017). Patients with scores of 8 or 9, although showing the greatest relative benefit from radiation therapy, experienced local recurrence rates in excess of 60% at 8 years.

CONCLUSIONS

DCIS patients with VNPI scores of 3 or 4 can be considered for treatment with excision only. Patients with intermediate scores (5, 6, or 7) show a 17% decrease in local recurrence rates with radiation therapy. Patients with VNPI scores of 8 or 9 exhibit extremely high local recurrence rates, regardless of irradiation, and should be considered for mastectomy.

The fate of breast implants: a critical analysis of complications and outcomes

Complications and outcomes were monitored following the implantation of 1655 breast implants over a 15-year period. Smooth, polyurethane, and textured implants were used in a variety of clinical settings. The time course of capsular contracture was analyzed by the Kaplan-Meier method. Regardless of implant type or indication for surgery, the probability of contracture increased with time. Polyurethane-covered implants were associated with a significant reduction in the risk of contracture for at least 7 years following implantation. Smooth and textured silicone implants had contracture rates similar to each other, and the particular type of surface texturing (Biocel versus Siltex) was of no consequence. Contracture was more common following breast reconstruction and implant replacement than after augmentation mammaplasty and was not affected by filler material or implant size. Implant position did not alter the risk of contracture after augmentation; tissue expansion did not affect the risk of contracture after breast reconstruction. Infections were unusual but most common after reconstruction and unrelated to surface texture or filler material. Skin wrinkling was more frequent with saline implants and in the presence of surface texturing. Implant rupture was rare, with an incidence of 1 per 760 implant-years. Implant-associated connective-tissue disease was noted in only one individual, an incidence of 1 per 3801 implant-years.

Ten-year results comparing mastectomy to excision and radiation therapy for ductal carcinoma in situ of the breast

The 10-year results of 300 patients with ductal carcinoma in situ (DCIS) without microinvasion are reported; 167 treated with mastectomy and 133 treated with excision and radiation therapy. There was a significant difference in disease-free survival at 10 years, in favour of those treated with mastectomy, 98% versus 81% (P = 0.0004). Multivariate analysis confirmed nuclear grade as the only significant predictor of local recurrence (P = 0.02) or invasive local recurrence (P = 0.03) in patients with DCIS treated with excision and radiation therapy. There was no difference in breast cancer-specific survival or overall survival between the two treatment groups.

Predicting axillary node positivity in patients with invasive carcinoma of the breast by using a combination of T category and palpability

BACKGROUND

In spite of the development of numerous new tumor markers, axillary lymph node status continues to be the single most important prognostic variable regarding survival of patients with carcinoma of the breast. This study was undertaken to determine whether or not the combination of T category (TNM staging system) and palpability would be a better predictor of nodal positivity than T category alone.

STUDY DESIGN

Clinical and pathologic data were analyzed for 1,554 patients who underwent axillary lymph node dissection as part of their treatment for invasive carcinoma of the breast. Data were analyzed by the primary lesion's T category and whether or not the lesion was palpable.

RESULTS

Five hundred fifty-one (35 percent) of 1,554 axillary node dissections contained metastases. The probability of nodal involvement was significantly higher and the average tumor diameter was slightly, but significantly, larger for palpable T1b, T1c, and T2 lesions when compared with nonpalpable lesions within the same T category (all p values less than or equal to 0.003). The probability of lymphatic tumor emboli or vascular invasion was generally higher for palpable lesions compared with nonpalpable lesions and increased as lesions got larger. The percentage of patients with low nuclear grade and favorable histology was generally lower for patients with palpable lesions compared with those having nonpalpable lesions and decreased as lesions got larger.

CONCLUSIONS

Nodal positivity was significantly higher for palpable T1b, T1c, and T2 carcinoma of the breast when compared with nonpalpable carcinoma of the breast within the same T category. The combination of T category and palpability was a more accurate predictor of nodal positivity than T category alone.

Prognostic classification of breast ductal carcinoma-in-situ

We present a new prognostic classification designated the Van Nuys classification for ductal carcinoma-in-situ (DCIS). The classification combines high nuclear grade and comedo-type necrosis to predict clinical recurrence. Three groups of DCIS patients were defined by the presence or absence of high nuclear grade and comedo-type necrosis: 1--non-high-grade DCIS without comedo-type necrosis, 2--non-high-grade DCIS with comedo-type necrosis, 3--high-grade DCIS with or without comedo-type necrosis. There were 31 local recurrences in 238 patients after breast-conservation surgery 3.8% (3/80) in group 1, 11.1% (10/90) in group 2, and 26.5% (18/68) in group 3. The 8-year actuarial disease-free survivals were 93%, 84%, and 61%, respectively (all p < or = 0.05). The Van Nuys classification defines three distinct and easily recognisable groups, each of which has a different likelihood of local recurrence if treated with breast conservation.

Can intraductal breast carcinoma be excised completely by local excision? Clinical and pathologic predictors

BACKGROUND

Microscopic evaluation of excised intraductal breast carcinoma (DCIS) specimens using a serial subgross technique reveals that in many patients the lesion is larger than expected, often making complete excision impossible with less than a true quadrantectomy. Data is presented on 181 patients with DCIS in whom the initial biopsy was performed using a more cosmetic wide local excision rather than a true quadrantectomy.

METHODS

Clear margins were defined as no tumor within 1 mm of any inked or dyed margin. All of these patients subsequently underwent mastectomy or reexcision of the initial biopsy site. This allowed pathologic evaluation for residual disease.

RESULTS

At mastectomy or reexcision, 76% of patients with initially involved margins had residual DCIS, as did 43% of patients with initially clear margins (P < 0.0001). Larger tumor size was a statistically significant predictor of initial margin involvement and residual DCIS (P < 0.05). Patients with comedo-DCIS had a greater tendency toward positive initial histologic margins and residual DCIS, but this trend was not statistically significant (P < 0.1).

CONCLUSION

DCIS presents major problems to both surgeons and pathologists. It is difficult to excise completely using a wide local excision. Histologically negative margins do not guarantee that residual DCIS has not been left behind. Inadequate excision of the primary lesions may be the most important cause of local failure after conservative treatment for intraductal breast carcinoma.

Infiltrating lobular carcinoma. Is it different from infiltrating duct carcinoma?

BACKGROUND

Infiltrating lobular carcinomas (ILC) represent approximately 10% of all breast cancers. The literature is mixed regarding their prognosis when compared with infiltrating duct carcinomas (IDC). There are few data regarding the treatment of ILC with radiation therapy.

METHODS

The clinical, pathologic, laboratory, and survival data of 161 patients with ILC were compared with the data of 1138 patients with IDC.

RESULTS

ILCs were larger, more difficult to excise completely, and more difficult to diagnose clinically. All prognostic factors measured were more favorable for ILC. Nodal positivity for ILC was 32%, compared with 37% for IDC (P = 0.22). The 7-year disease-free Kaplan-Meier survival (DFS) was 74% for patients with ILC and 63% for patients with IDC (P < 0.03). The 7-year breast cancer specific survival (BCSS) was 83% for patients with ILC and 77% for patients with IDC (P < 0.04). Selected patients with smaller lesions were treated with excision and radiation therapy. Patients with ILC treated with radiation therapy had a better DFS and BCSS than did patients with IDC treated with radiation therapy.

CONCLUSIONS

ILCs often are homogeneous, small cell tumors of low nuclear grade. Their desmoplastic reaction may be absent or less marked than that of IDC, making them more difficult to palpate and to visualize mammographically. Despite this, they can be treated successfully with either mastectomy or excision and radiation therapy.

Axillary lymph node dissection for T1a breast carcinoma. Is it indicated?

BACKGROUND

Axillary dissection has been a routine part of breast cancer treatment for more than 100 years. Axillary node involvement is the single most important prognostic variable in patients with breast cancer. Recently, routine node dissection has been eliminated for intraductal carcinoma because so few patients had positive nodes. With the availability of numerous histologic prognosticators and the development of new immunochemical prognostic indicators, it is time to consider eliminating routine node dissection for lesions more advanced than duct carcinoma in situ (DCIS) but with extremely low likelihood of axillary involvement.

METHODS

Axillary node positivity, disease-free survival, and breast cancer-specific survival were determined for six breast cancer subgroups by T category: Tis (DCIS), T1a, T1b, T1c, T2, and T3.

RESULTS

Nodal positivity for DCIS was 0%; for T1a lesions, 3%. A large increase in nodal positivity was seen in lesions larger than 5 mm. (T1b, 17%; T1c, 32%; T2, 44%; T3, 60%). The rate of nodal positivity was statistically different as each T category was compared with the next more advanced T category. The disease-free survival and breast cancer-specific survival decreased with every increment in T value.

CONCLUSIONS

Axillary node positivity increases as the size of the invasive component increases and is an excellent predictor of DSF and breast cancer-specific survival. Consideration should be given to eliminating axillary node dissection for T1a lesions because of the low yield of positive nodes. Axillary node dissection should be performed routinely for T1b lesions and larger.

Reduction mammaplasty following radiation therapy for breast cancer

This report describes an unusual case in which reduction mammaplasty was performed following radiation therapy for breast cancer. While healing was significantly prolonged (compared with the nonirradiated contralateral breast), the final result was satisfactory from both the functional and the aesthetic standpoint. Women with prior radiation therapy may be considered candidates for reduction mammaplasty. Patients should be warned of the increased risks of wound complications, the likelihood of delayed healing, and the possibility of pigmentation changes in the grafted nipple-areola complex. We elected to transpose the nipple as a full-thickness graft, but consideration also might be given to use of an inferiorly based pedicle flap.

Duct carcinoma in situ: 227 cases without microinvasion

From 1979 to 1990, 227 patients with intraductal carcinomas (DCIS) without microinvasion were selectively treated; the least favourable (large lesions with involved biopsy margins) with mastectomy, the most favourable (small lesions with clear margins) with breast preservation. The preservation group was further subdivided into those who received radiation therapy (excision and radiation) and those who did not (excision alone). In the mastectomy group, there were 98 patients (43%) with an average lesional size of 3.3 cm; 41% had multifocal lesions, 15% had multicentric lesions. There has been one local invasive recurrence and no deaths. The 7-year actuarial disease-free survival is 98% with mastectomy. In the excision and radiation group, there were 103 patients (45%) with an average lesional size of 1.4 cm. 10 patients have had local recurrences (5 invasive and 5 noninvasive) one of whom has died. The 7-year actuarial disease-free survival is 84%, a statistically significant difference when excision and radiation is compared with mastectomy (P = 0.038). In the excision alone group, there were 26 patients (11%) with an average lesional size of 1.0 cm. There have been two local recurrences (8%), one of which was invasive and no deaths. The 7-year actuarial disease-free survival is 67%, but only 3 patients have been followed for more than 4 years. A total of 163 axillary node dissections were done; all were negative. Since DCIS without microinvasion rarely metastasizes to axillary lymph nodes, routine dissection should not be performed. Patients in this series with intraductal carcinoma treated with excision and radiation recurred locally at a statistically higher rate than those treated with mastectomy, in spite of the fact that those chosen for excision and radiation had clinically more favourable lesions. 6 of 12 (50%) local recurrences in conservatively treated patients were invasive. There was, however, no significant difference in overall survival in any subgroup regardless of treatment.

Radiation therapy for intraductal carcinoma. Is it an equal alternative?

Of 213 consecutive patients with intraductal carcinoma, 109 were selectively treated with mastectomy and 104 with radiation therapy. There were eight local recurrences, seven in patients treated with radiation therapy and one in a patient treated with mastectomy. Histologically, there were 110 comedocarcinomas and 103 noncomedocarcinomas. Seven local recurrences occurred in patients with comedocarcinomas and one in a patient with a noncomedo tumor. Three (38%) of eight local recurrences (all comedo) were invasive. The 5-year actuarial survival for all subgroups was 100%. The median follow-up was 51 months. Intraductal carcinoma is unlikely to metastasize to axillary lymph nodes, and routine dissection is unnecessary. Ductal carcinoma in situ of the comedo variety is more aggressive and more likely to recur than its noncomedo counterpart. We currently view conservative therapy for patients with intraductal comedocarcinoma with caution.

Axillary lymphadenectomy for intraductal carcinoma of the breast

During a ten year period, 175 axillary lymph node dissections were done as part of the treatment for intraductal carcinoma of the breast; 98 patients were treated with modified radical mastectomy and 77 were treated by mammary preservation, consisting of excision of the lesion, axillary dissection and radiation therapy. One of 175 axillary node dissections yielded positive nodes. Axillary dissection for intraductal carcinoma of the breast is unlikely to yield involved nodes and is not indicated for use in most instances. It should be reserved for lesions demonstrating microinvasion.

Reasons why mastectomy patients do not have breast reconstruction

Breast reconstruction after mastectomy is valuable, yet only a small percentage of eligible patients ever have reconstruction. Little has been done to determine why so few patients proceed with reconstructive surgery. A homogeneous population of mastectomy patients, some of whom underwent breast reconstruction while others did not, were surveyed regarding their attitudes about breast reconstruction. A total of 245 women were surveyed. One-hundred and fifty-eight (64 percent) responded, 71 of whom had been reconstructed while 87 had not. Comparison of the responses of the two groups suggests factors that play a role in determining whether the mastectomy patient will accept or decline the option of breast reconstruction. Considerations that made it less likely that a woman would pursue reconstruction included advanced age at the time of mastectomy, concern about complications from further surgery, uncertainty about outcome, and fear about the effect of reconstruction on future problems with breast cancer. Marital status, receiving chemotherapy, or knowing a patient who had a bad result from reconstruction did not affect the decision. An awareness and understanding of these factors may be helpful to physicians in counseling patients and in increasing the number of women who enjoy the benefits of breast reconstruction.

Intraductal carcinoma of the breast (208 cases). Clinical factors influencing treatment choice

Two hundred eight cases of intraductal breast carcinoma (DCIS) were selectively treated; 97 with mastectomy, 96 with radiation therapy, and 15 using excisional biopsy only. Mastectomy patients tended to have larger tumors, involved biopsy margins, palpable and often multifocal tumors. Breast preservation patients tended to have smaller, often occult, tumors with clear surgical margins. Before 1983, mastectomy was more common; during and after 1983, breast preservation was more common. Comedocarcinomas were the most frequent tumors. They were the largest, had the highest percentage of microinvasion (20%), and had the highest recurrence rate (8%). Noncomedo DCIS had a recurrence rate of 1%, one of 103 tumors. The recurrence rate for comedocarcinomas treated with radiation therapy was nearly three times higher than for those treated with mastectomy (11% versus 4%). One of 164 (0.6%) axillary lymph node dissections yielded positive nodes. Nine patients have recurred: two in the mastectomy group and seven in the breast conservation group (P less than 0.1). Eight of nine recurrences were the comedo subtype (P less than 0.05). Three patients developed metastatic disease, two of whom have died. Axillary dissection for intraductal carcinoma of the breast is unlikely to yield involved nodes and is not indicated for most cases. It should be reserved for lesions revealing microinvasion. Conservative therapy for comedocarcinoma must be viewed with caution.

Breast cancer diagnosis and prognosis in women augmented with silicone gel-filled implants

From 1981 through 1988, 35 patients with prior augmentation mammoplasty were treated for breast carcinoma. Thirty-two patients had unilateral infiltrating carcinomas; three had noninvasive (in situ) lesions. Thirty-four of 35 (97%) lesions were palpable. One noninvasive cancer was occult, discovered mammographically in the absence of physical findings. Prebiopsy mammography was performed in 29 patients with palpable masses and failed to reveal an abnormality in 12 patients, a false-negative rate of 41%. Fifteen patients were treated with mastectomy; the remaining 20 with breast preservation. Thirty-two patients underwent axillary node dissection; 15 (47%) patients had lymph node metastases. There have been seven (20%) recurrences: one local and six metastatic. Four (11%) patients have died. The median follow-up time is 48 months. Women, previously augmented with silicone gel-filled implants, who develop breast cancer are similar in terms of nodal positivity and prognosis, to nonaugmented breast cancer patients who present with palpable masses. When compared with nonaugmented women whose cancers were found with screening mammography, augmented patients with breast cancer present with a higher percentage of invasive lesion and involved axillary lymph nodes, resulting in a poorer prognosis.

Nonpalpable breast lesions: diagnosis with slightly overpenetrated screen-film mammography and hook wire-directed biopsy in 1,014 cases

Slightly overpenetrated screen-film mammography and hook wire-directed localization were used in 1,014 breast biopsies performed for nonpalpable, mammographically detected breast abnormalities. One lymphoma and 205 breast cancers (20%) were found; 115 breast cancers (56%) were noninvasive, and 90 (44%) were invasive. Mastectomy was performed in 69 breast cancers (34%); 136 (66%) were treated conservatively, 28 with biopsy only and 108 with lumpectomy, node dissection, and radiation therapy. All patients with noninvasive breast cancers treated with axillary dissection had uninvolved lymph nodes. Of the 90 invasive breast cancers, six (7%) had metastases to axillary nodes, which, to the authors' knowledge, is lower than percentages reported in other studies of wire-directed breast biopsies. The authors believe that the slightly overpenetrated technique is a valuable adjunct to screen-film mammography.

Breast cancer in women after augmentation mammoplasty

More than 1 million American women have undergone augmentation mammoplasty; 100,000 (10%) will develop or already have developed breast cancer. Between March 1981 and August 1986, 20 patients with previous augmentation mammoplasty were treated for breast carcinoma. All patients had unilateral infiltrating carcinomas and presented with a palpable mass. None of the cancers were occult (discovered mammographically). Thirteen patients (65%) had metastases to axillary lymph nodes. During the same period, 733 nonaugmented patients with breast cancer were treated: 207 (28%) had involved axillary nodes, 194 (26%) had in situ lesions, and 154 cancers (21%) were occult. Augmentation mammoplasty with sillicone-gel-filled implants reduces the ability of mammography, our best diagnostic tool, to visualize breast parenchyma. When compared with our own nonaugmented breast cancer population, augmented patients with breast cancer presented with more advanced disease; they had a higher percentage of invasive lesions and positive axillary nodes, resulting in a worsened prognosis.

Axillary lymph node dissection for intraductal breast carcinoma--is it indicated?

One hundred patients with intraductal breast carcinoma (DCIS) were treated with either mastectomy (49 patients) or radiation therapy (51 patients). All patients underwent axillary lymph node dissection (average number of nodes removed, 16) as part of their treatment. No patient had any positive axillary lymph nodes. There has been one recurrence in each treatment group (median follow-up, 27 months) and no deaths. Intraductal breast carcinoma has little potential for metastasis to axillary lymph nodes.

Hooked-wire-directed breast biopsy and overpenetrated mammography

Six hundred fifty-three biopsies were performed for clinically occult, mammographically detected breast abnormalities. One hundred forty-seven cancers (22.5%) were found. Eighty-nine of those cancers (60.5%) were noninvasive. None of the in situ lesions had involved axillary lymph nodes. Of the 58 invasive cancers, only six (10.3%) had metastases to axillary nodes. Fifty-four patients (36.7%) were treated by mastectomy while 93 patients (63.3%) were treated conservatively, 20 by biopsy only, and 73 by lumpectomy, axillary node dissection, and radiation therapy. Only four patients (0.7%) had significant complications.