Prognostic Factors in Operable Breast Cancer

A series of 743 consecutive cases of operable breast cancer, admitted and treated at the Istituto Nazionale Tumori of Milan from 1969 to 1970, was analized by a multivariate statistical method to evaluate a) the variables of the host and the primary tumor associated with the frequency of nodal metastases, b) the variables that significantly affect survival, and c) the identification of homogeneous risk groups. As regards the frequency of regional node metastases, they were more frequently observed in young than in old patients with large tumors (P values 10–5 and 3×10–5, respectively). Tumors that originated in the axillary tail, upper, outer and central quadrants were significantly associated with a higher rate of node metastases (P = 0.002). Each of these variables maintained its significant value when adjusted by the other two. Survival was affected at a statistically significant level by the age of the patients (P = 2×10–4), the pathologic diameter of the primary tumor (P < 10–6), and the number of metastatic regional nodes (P < 10 –6). The number of involved nodes appears to be the most relevant factor in the assessment of prognosis of patients with positive nodes, Age of the patients, size of the primary tumor, and number of involved nodes maintain their own statistical significance when each is adjusted by the remaining two. The site of origin of the primary tumor, even if associated with the frequency of regional node metastases, did not affect survival. Three groups with a significantly different risk of death were identified in patients with negative lymph nodes and three groups in patients with positive nodes. It is concluded that age, size of the primary, and number of involved lymph nodes are important pieces of information that clinicians should have at hand following radical surgery, not only to make a prognosis, but also to identify groups of patients with high risk of death on which the role of adjuvant treatment should be evaluated.

Ovarian Function Suppression with the Gonadotrophin-Releasing Hormone (GnRH) Analogue Goserelin in Premenopausal Advanced Breast Cancer

Aims and background

Goserelin is a gonadotrophin-releasing hormone (GnRH) analogue that induces the suppression of gonadal steroidogenesis, and it could therefore be a medical alternative to irreversible surgical castration. We report the clinical and endocrine results from 40 goserelin-treated premenopausal patients with advanced breast cancer.

Methods

A depot formulation of the drug (3.6 mg s.c.) was administered fortnightly for the first 4 doses, and monthly thereafter. Gonadotrophins and estradiol (E2) levels were measured before and at specific times during the treatment.

Results

Objective responses were observed in 17 of the 38 evaluable patients (45%), six of whom achieved complete remission. The best responses were observed on soft tissues (65%). Castration E2 levels were achieved in all of the patients.

Conclusions

Our results confirm that goserelin is as effective as surgical oophorectomy in premenopausal advanced breast cancer.

Surgery for Malignant Mesenchymal Tumors of the Breast: A Series of 31 Cases

Thirty-one cases of malignant mesenchymal tumors of the breast were analyzed with the purpose of identifying the most suitable type of surgery to be recommended. All the cases considered underwent pathologic review. Even young women were affected, and menopausal status did not seem to influence the development of mesenchymal tumors. Mammography was of little use for diagnosis. All cases underwent surgery and 26 had an adequate follow-up. In 8 cases a relapse occurred with a mean free interval of 6 months. Total mastectomy was sufficient to provide local control, whereas axillary dissection turned out to be not worthwhile. Postoperative radiotherapy did not improve distant results. Relapses mainly consisted of lung metastases. Fifteen patients were alive, free of disease, at a time ranging from 9 months to 13 years after surgery.

Current results of pelvic perfusion for non-resectable relapsing of pelvic cancer

Twenty-eight patients affected by non-resectable pelvic recurrence of a primary pelvic malignant neoplasm were treated by isolated pelvic perfusion, at mean hyperthermia, with different drugs, chosen taking into account tumor chemosensitivity. All patients had been previously treated. Four complete and six partial responses were observed; nine patients had stable disease and four other patients were non-responders and died due to progression in a few months. Two patients were lost to follow-up, one patients died for other reasons and two recent patients are not yet assessable.

Locally recurrent breast cancer after 'radical' surgery

Tumor recurrence at the site of radical surgery for mammary carcinoma has been studied in 101 cases. Analysis revealed the proximate causes--tumour size, axillary node metastases--and the more extensive type of surgery have a positive correlation even if the P values do not reach the significant value. The prognosis suggests that clinically this phenomenon, seen in the long term, does not differ from that of distant skin and subcutaneous metastases. A treatment strategy is proposed.

Comparison of long-term survival of 1986 consecutive patients with breast cancer treated at the National Cancer Institute of Milano, Italy (1971 to 1972 and 1977 to 1978)

Long-term survival of 1986 consecutive patients with infiltrating duct carcinoma of the breast treated at the National Cancer Institute of Milano (Italy) in two periods of time (1971 to 1972 and 1977 to 1978) was comparatively evaluated to verify if the evolving concepts in the management of breast cancer had an impact on survival. The authors found that 10-year survival of our patients increased from 59.4% of the first period of time to 65% of the second (P = 0.005). Both node-negative (N-) and node-positive (N+) patients had an improvement of survival rates at 10 years of the same magnitude: 6.8% and 5.9% respectively. Taking into consideration both the maximum diameter of the primary tumor and the status of axillary nodes it was found that in (1) both N- and N+ patients with a primary tumor of no more than 2 cm in greatest diameter, the improvement of survival was not statistically significant; and (2) both N- and N+ patients with a primary greater than 2 cm in maximum diameter had a better chance of survival in the second time period.

Prognosis of breast cancer with axillary node metastases after surgical treatment only

Out of 753 patients with breast cancer treated with radical mastectomy from 1968 to 1970 at the National Cancer Institute of Milan, Italy, 308 had histologically proven positive nodes. The number of positive nodes was not dependent on the location of the primary tumour, its diameter and the patient's age. Extracapsular invasion was related to the number of positive nodes at a statistically significant level: P value 2 X 10(-9). Survival was influenced by the number of positive nodes and extension of metastases beyond their capsule and age. Each of these criteria had an independent impact on survival. Three subgroups with different prognosis were identified in patients older than 40: (a) with a single involved node and 69.9% 10 year survival rate, (b) patients with two or more nodes with metastatic deposit still confined within node capsule and 47.4% 10 year survival rate, (c) patients with two or more involved nodes and extracapsular invasion and 25.3% 10 year survival rate. In patients younger than 40 no subgroup was identified: this group had an intermediate 10 year survival rate (50.9%). The authors conclude that there is a need (a) of re-consideration of the prognosis of patients with positive nodes and (b) to agree on the definition of "high-risk patients".

A reappraisal of oophorectomy in carcinoma of the breast

Bilateral oophorectomy was used to treat 601 patients with disseminated breast carcinoma from 1974-1984. The total response rate was 31.2%. Complete regression occurred in 10.5% of patients and partial regression occurred in 20.8%, whereas 28.3% of patients showed no change and the disease progressed in 36.9% of patients. The patients who had a total regression had good survival rates (60.8% at 5 years and 47.3% at 7 years). No significant differences were found in the various age groups or with different types of dissemination. Patients with syncronous primary carcinoma and distant metastases had a high rate of regression as did patients with slow-growing carcinomas that metastasized many years after primary treatment. Estrogen receptor (ER) rates were good indicators of response only when determined on metastatic tissue at the time of oophorectomy. The value of ER determined on the primary tumor was of limited predictivity of response. A total of 220 patients received chemotherapy before oophorectomy. In this group the response rate was 22.3%, lower than that observed in patients who did not receive chemotherapy (36.6%). No important differences in total response rates were found among patients with amenorrhea and without amenorrhea although total regressions were more frequent in the latter patients than in the former patients.

Regional non-nodal metastases of cutaneous melanoma

The authors studied the prognosis of patients with so called local recurrences, satellites and in-transit metastases from cutaneous melanoma on the basis of 291 patients. These are the 19.3% of the 1503 patients with stage I and II melanoma originally submitted to surgical treatment at the National Cancer Institute of Milano (Italy). The majority of patients were males (M/F = 0.7): 102 had local recurrence, 99 in-transit metastases, 24 satellites and 66 both local and in-transit metastases. Regional non-nodal metastases were not related with the site of origin, and inadequate treatment of primary. These metastases were more frequently observed in patients who were submitted to regional node dissection no matter whether in discontinuity or in continuity with primary tumor. The frequency of regional non-nodal metastases was found to increase with increasing thickness of primary melanoma or, in stage II patients, with the number of involved nodes. Local and in-transit metastases were related with prognostic criteria in the same way. The overall survival was very close between in-transit and local metastases. Similar survival rates were observed comparing regional non-nodes and disseminated cutaneous and subcutaneous metastases. The authors conclude that the distinction between local recurrences, satellites and in-transit metastases is artificial and that these metastatic events are not prognostically dissimilar from metastases in distant skin areas.

Prognosis of breast cancer patients after mastectomy and dissection of internal mammary nodes

The results of the analysis carried out on data on 1119 patients with operable breast cancer treated at the National Cancer Institute of Milan from 1965 to 1979 with enlarged mastectomy are reported. Metastases to internal mammary chain were found to be significantly associated with the maximum diameter of primary (16.1% for tumors less than 2 cm and 24.5% for larger tumors, p = 0.007), the age of the patients (27.6% in patients younger than 40 years, 19.7% in patients between 41-50 years, and 15.6% in patients older than 50 years, p = 0.01). The site of origin of the cancer had no impact on internal mammary node metastases. Patients with positive axillary nodes showed metastases to internal mammary nodes in 29.1% of the cases, while 9.1% of patients with axillary negative nodes had positive retrosternal nodes. Survival was significantly affected by the presence of positive internal mammary nodes: the percentage of 10-year survival varied from 80.4% in patients with axillary and internal mammary negative nodes to 30.0% in patients with both nodal basins involved. Intermediate survival rates (54.6% and 53.0%) were found when one or the other of the nodal stations (axillary and internal mammary) was separately affected. Maximum diameter of the primary significantly affected the survival of each group identified by the status of both axillary and internal mammary nodes. In conclusion, the information on the presence or absence of internal mammary node metastases would be of great importance in formulating the prognosis of breast cancer patients. To obtain this information, a biopsy at the first intercostal space may be reasonable in selected patients (age, maximum diameter, and axillary node involvement being the basis for selection) as long as noninvasive methods of diagnosis are available.

Inclusion cytology by fine needle biopsy in mammary tumors

In an attempt to reach a definite preoperative diagnosis of solitary, solid, breast lesions, data collected in our Institute during the last year was analyzed and confirmed the possibility of obtaining adequate cytologic and histologic specimens with fine-needle aspiration. When this is used in association with conventional cytologic examination the sensitivity of the procedure is increased from 73% to 78%. In 14% of cases, these combined aspiration techniques provided extra information concerning the histotype and infiltration of the tumor which was not obtainable with cytology alone.

Risk of internal mammary lymph node metastases and its relevance on prognosis of breast cancer patients

The risk of internal mammary chain metastases according to some parameters and its prognostic relevance was evaluated on the basis of the experience collected at the National Cancer Institute of Milan where, from January 1965 to December 1980, 1085 patients were submitted to Halsted mastectomy plus internal mammary chain dissection. A multivariate analysis was carried out, resorting to a multiple linear regression with logistic transformation of the dependent variable. The selection of prognostic factors has been performed with a step-down approach. The frequency of metastases to internal mammary chain nodes was evaluated according to four criteria: age, site and size of primary tumor, and presence of axillary metastases. Data of this series indicate that the frequency of internal mammary node metastases is significantly associated with the age of the patients (younger patients have a higher risk) (p = 0.006) with the size of primary tumor (p = 0.006) with the presence of axillary node metastases (p = 10(-9). Patients with both axillary and internal mammary positive nodes have a very poor prognosis (10-year survival 37.3%) while patients with either axillary metastases only or internal mammary metastases only have an intermediate less grave prognosis (59.6% and 62.4%, respectively). As regards the risk of internal mammary nodes involvement, it appears that knowing the age, the size, and the axillary nodes status, it is possible to calculate with good approximation the probability of their invasion.