To determine the incidence of, and risk factors for, regional nodal failure (RNF) and to evaluate the effectiveness of, and indications for, regional nodal irradiation (RNI) in patients with Stage ...I–II breast cancer treated with breast-conserving therapy.
A total of 1500 cases of Stage I–II breast cancer were treated with breast-conserving therapy between February 1980 and December 2000. All patients underwent excisional biopsy, and 925 (62%) underwent re-excision. Level I–II axillary lymph node dissection was done in 94% of patients. The lymph nodes were pathologically involved in 335 patients (22%); 255 with 1–3 nodes and 80 with ≥4 nodes involved. All patients received whole breast irradiation to a median dose of 45 Gy, and 97% received a tumor bed boost to a median dose of 61 Gy. Treatment included the breast only in 1309 patients (87%), and the breast and regional lymphatics in 191 (13%).
With a median follow-up of 8.1 years, 35 patients had failure within the regional nodes: 12 patients (6%) who received RNI and 23 patients (2%) who did not. The 5- and 10-year rate for any RNF was 1.9% and 2.8%, respectively. The 5 and 10-year rates of axillary failure and supraclavicular failure were 0.6% and 1.0% and 0.9% and 1.6%, respectively. In patients with ≥4 positive lymph nodes, RNI reduced the 10-year rate of any RNF from 11% to 2% (
p = 0.024), the rate of axillary failure from 5% to 0% (
p = 0.019), and the rate of supraclavicular failure from 11% to 2% (
p = 0.114). RNI did not affect the rate of axillary failure or supraclavicular failure in patients with 1–3 positive nodes. In node-negative patients, the rate of RNF was significantly greater if <6 nodes were removed at the time of axillary dissection. Multiple clinical, pathologic, and treatment-related factors were analyzed for association with RNF. On univariate analysis, RNF was associated with the number of nodes excised, number of positive nodes, percentage of positive nodes, size of nodal metastasis, presence of angiolymphatic invasion, estrogen receptor status, age, systemic chemotherapy, and RNI. Three subsets of patients had unusually high rates of RNF, those with ≥67% nodes positive (16%), nodal metastasis ≥2.0 cm (44%), or age ≤35 years (14%). On multivariate analysis, the only significant predictor of RNF was the maximal size of the nodal metastasis. RNI did not improve the overall survival for any subset of patients. The number of lymph nodes excised had an impact on overall survival, with a 10-year survival rate of 33%, 65%, and 69% in patients with <6, 6–10, and >10 nodes excised, respectively (
p = 0.05)
Failure within the regional lymph nodes as an isolated site of first relapse is uncommon in patients with Stage I–II breast cancer treated with breast-conserving therapy. RNI can significantly reduce the rate of RNF (axillary failure) in patients with ≥4 positive lymph nodes. The maximal size of the lymph node metastasis was found to be the only significant independent predictor of RNF, with nodal metastases ≥2.0 cm associated with extremely high regional failure rates. Despite this, young age and the extent of axillary dissection (particularly as related to the number of positive nodes) also appear to be important and should be considered when evaluating patients for RNI. Inadequate axillary dissection was not only associated with increased regional failure, but also reduced survival.
Many studies have analyzed the metastatic patterns of breast carcinoma. However, very few studies have analyzed the differences in metastatic patterns of lobular versus ductal carcinoma.
By use of ...our tumor registry, the metastatic sites of all invasive lobular and invasive ductal breast carcinoma cases during an 18-year period (January 1973 to December 1990) were analyzed.
There were 2605 cases of invasive lobular and invasive ductal breast carcinoma. Lobular carcinoma accounted for 359 (14%) and ductal carcinoma for 2246 (86%) of the cases. The percentage of patients with regional lymph node metastasis at diagnosis was not significantly different between the two groups. The rates of metastasis to all lymph nodes, liver, and central nervous system were not significantly different. However, the rates of metastasis to the gastrointestinal system (4.5% vs 0.2%), gynecologic organs (4.5% vs 0.8%), peritoneum-retroperitoneum (3.1% vs 0.6%), adrenal glands (0.6% vs 0%), bone-marrow (21.2% vs 14.4%), and lung-pleura (2.5% vs 10.2%) were significantly different (p < 0.05).
The metastatic patterns of lobular and ductal carcinoma of the breast are different, with gastrointestinal system, gynecologic organ, and peritoneum-retroperitoneum metastases markedly more prevalent in lobular carcinoma. Physicians should be aware of these different metastatic patterns of lobular and ductal carcinoma of the breast.
Purpose
: We present the preliminary findings of our in-house protocol treating the tumor bed alone after lumpectomy with low-dose rate (LDR) interstitial brachytherapy in selected patients with ...early-stage breast cancer treated with breast-conserving therapy (BCT).
Methods and Materials
: Since March 1, 1993, 60 women with early-stage breast cancer were entered into a protocol of tumor bed irradiation only using an interstial LDR implant with iodine-125. Patients were eligible if the tumor was ≤3 cm, margins were ≥2 mm, there was no extensive intraductal component, the axilla was template either at the time of reexcision or shortly after lumpectomy. A total of 50 Gy was delivered at 0.52 Gy/h over a period of 96 h to the lumpectomy bed plus a 2-cm margin. Perioperative complications, cosmetic outcome, and local control were assessed.
Results
: The median follow-up for all patients is 20 months. Three patients experienced minimal perioperative pain that required temporary nonnarcotic analgesics. There have been four postoperative inections which resolved with oral antibiotics. No significant skin reactions related to the implant were noted and no patients experienced impaired would healing. Early cosmetic results reveal minimal changes consisting of transient hyperpigmentation of the skin at the puncture sites and temporary induration in the tumor bed. Good to excellent cosmetic results were noted in all 19 patients followed up a minimum of 24 mounts posttherapy. To date, 51 women have obtained 6–12-month follow-up mammograms and no recurrences have been noted. All patients currently have no physical signs of recurrence, and no patient has failed regionally or distantly.
Conclusion
: Treatment of the tumor bed alone with LDR interstitial brachytherapy appears to be well tolerated, and early results are promising. Long-term follow-up of these pateints is necessary to establish the equivalence of this treatment approach compared to standard BCT, however.
We reviewed our institution's experience treating predominantly mammographically detected ductal carcinoma in situ (DCIS) with breast-conserving therapy (BCT) to determine if any clinical, ...pathologic, or treatment-related factors affected outcome.
From January 2, 1980 to January 6, 1992, 107 breasts in 105 patients were treated with BCT at William Beaumont Hospital, Royal Oak, MI. All patients underwent at least an excisional biopsy and 70 patients (65%) were reexcised. All patients received whole-breast irradiation to a median dose of 50.4 Gy (range 43.1 to 56.0 Gy). Ninety-nine patients (93%) received a supplemental boost to the tumor bed for a median total dose of 60.4 Gy (range 59.1 to 71.8 Gy) using either photons (2 patients), electrons (69 patients), or an interstitial implant (28 patients).
With a median follow-up of 78 months, 10 patients have failed in the treated breast for a 5- and 10-year actuarial local control rate of 91.2 and 89.8%, respectively. Thirteen percent of the population have been followed for 10 years or more. Three recurrences were pure DCIS, and seven were invasive. All patients were salvaged with mastectomy. Nine patients remain without evidence of disease a median of 30.6 months after surgery. One patient failed distantly 36 months after local recurrence for an ultimate cause specific survival of 99%. Potential clinical (age, mammographic findings, method of detection, etc.), pathologic (nuclear grade, margins, etc.), and treatment-related factors (dose, boost technique, reexcision status, etc.) affecting outcome were analyzed. No variable was found to be associated with an ipsilateral breast tumor recurrence. However, when only recurrences that occurred within or immediately adjacent to the lumpectomy cavity were analyzed, both margin status and the extent of cancerization of lobules (COL) near the surgical margin were associated with the development of a local recurrence.
Patients treated with BCT for predominantly mammographically detected DCIS achieve excellent rates of local control and overall survival. Both margin status and the extent of COL near the surgical margin appear to be associated with recurrences within or immediately adjacent to the lumpectomy cavity. These data suggest that careful attention to the completeness of surgical resection of DCIS is an important determinant of outcome.
We performed a retrospective review to determine the need for reexcision after excisional biopsy in patients with breast cancer who were treated with breast-conserving therapy.
Eighty-seven patients ...with infiltrating ductal carcinoma of the breast underwent excisional biopsy followed by reexcision of the tumor site. Reexcision specimens were evaluated for residual disease and correlated with initial mammographic and pathologic findings.
Tumors with an extensive intraductal component (EIC) were more likely to have residual disease at reexcision than those without an EIC (65% versus 6%, p < .01). Initially positive margins did not predict residual disease at reexcision significantly better than did initially negative margins (29% versus 13%, p = .08). Suspicious mammographic calcifications, absence of a discernible mass detected mammographically, or both were associated with a significantly increased risk of residual disease at reexcision. By combining all features (EIC, margin status, and mammography), we found that subsets of patients had significantly different risks of residual disease, which ranged from 6% to 83% (p < .01).
Mammographic and pathologic findings are useful in predicting the adequacy of breast resection before radiation therapy in patients treated with breast-conserving therapy. An EIC is the most useful predictor of residual disease at reexcision. When combined, EIC, margin status, and mammographic findings form a powerful tool to judge the need for reexcision before radiation therapy.
Purpose
: We have retrospectively reviewed our institution's experience treating a predominantly mammographically detected population of ductal carcinoma
in situ (DCIS) patients with conservative ...surgery and radiation therapy (CSRT) to determine outcome and prognostic factors for local recurrence.
Methods and Materials
: Between January 1, 1982 and December 31, 1988, 52 consecutive cases of DCIS of the breast were treated with CSRT at William Beaumont Hospital. Forty-six (88%) were mammographically detected nonpalpable lesions. All patients underwent at least an excisional biopsy and 28 (54%) were reexcised. The axilla was surgically staged in 41 (79%) and all were N0. The entire breast was irradiated to 45–50 Gy over 5–6 weeks. The tumor bed was boosted in 49 (94%) so that the minimum dose was 60 Gy. The three patients not boosted received a minimum dose of 50 Gy to the entire breast. Pathologic materials were reviewed by one of the authors.
Results
: The predominant DCIS pattern was comedo in 40%, cribriform in 28%, solid in 17%, and micropapillary in 15%. The predominant nuclear grade was Grade I in 51%, Grade II in 49%, and Grade III in 0%. The median follow-up is 68 months. There have been three recurrences in the treated breast at a median time to failure of 30 months. The 5- and 8-year actuarial local recurrence rate is 6%. One patient recurred with invasive ductal cancer at 28 months, and the other two recurrences were DCIS at 30 and 50 months. All three patients were treated with salvage mastectomy. The patient who recurred locally with an invasive cancer developed metastasis and died at 64 months. The 5- and 8-year actuarial cause-specific survival rates are 100% and 97%, respectively.
The following pathologic factors were analyzed for an association with local recurrence: predominant DCIS histology, predominant nuclear grade, and highest nuclear grade. Of these, the predominant nuclear grade was the best predictor of local recurrence (
p = 0.070). No clinical or treatment related factor analyzed was associated with local recurrence.
Conclusion
: Our results indicate that excellent local control (94%) at 8 years is obtainable after CSRT in a mammographically detected population of patients with DCIS. The predominant nuclear grade was the only factor found that may be associated with local recurrence.
Background. The authors have reviewed their institution's experience with conservative surgery and radiation therapy for early stage breast cancer with the goal of defining the impact of infiltrating ...lobular histology (ILC) on the local recurrence rate. Also, they have examined the preoperative mammograms of the ILC patients to determine if mammographic features could be used to predict treatment outcome.
Methods.Between January 1, 1980, and December 31, 1987, 402 cases of Stages I and II breast cancer were treated with conservative surgery and radiation therapy (BCT) at William Beaumont Hospital. Each patient had at least an excisional biopsy. Radiation consisted of 45–50 Gy to the entire breast followed by a supplemental boost dose, so that a minimum of 60 Gy was delivered to the tumor bed. Thirty cancers were classified histologically as infiltrating lobular carcinoma (ILC), 346 as infiltrating ductal carcinoma (IDC), and 26 as other. Median followup is 60 months.
Results There was no significant differnce in 5 year actuarial local recurrence rates between ILC and IDC, 3. 3. versus 4. 2%, respectively, (P = not significant). Preoperative mammograms were retrospectively reviewed for 29 of the 30 ILC patients. A spiculated opacity was the most common primary mammographic finding (63%), followed by architectural distortion (17%), poorly defined opacity (7%), and negative (7%). Of the patients who had a preoperative primary mammographic finding of a spiculated opacity, 55% underwent reexcision after the initial excisional biopsy, and residual invasive carcinoma was found in 18% of the reexcision specimens. In contrast, of the patients with a primary mammographic finding of an architectural distortion, poorly defined opacity, or negative, 89% underwent reexcision after an initial excisional biopsy, and residual invasive carcinoma was found in 100% of the reexcision specimens.
Conclusions. Infiltrating lobular carcinoma does not have a worse local recurrence rate compared with IDC when each is treated with breast‐conserving therapy. The primary finding on preoperative mammograms in patients with ILC may prove to be a useful tool for predicting the likelihood of residual carcinoma in the breast after initial excisional biopsy. Cancer 1994; 74: 640‐47
Trends in surgical practice suggest that pathologists will encounter increased numbers of patients with small invasive ductal adenocarcinomas; small, if any, metastatic deposits in axillary lymph ...nodes (ALNs); and possibly fewer ALN specimens to examine. New prognostic histologic features may be needed in this environment. We studied histologic features of primary breast carcinoma and ALN metastasis from 86 patients who had stage T1 ductal carcinomas with only 1 ALN metastasis that was 0.5 cm or less and correlated these features with the development of distant metastases to evaluate their potential usefulness as prognostic indicators. The median follow-up period was 5.3 years. Distant metastases developed in 12 patients. Features significantly associated with 10-year distant metastases-free survival were lymph node hilar tissue invasion (HTI) and ALN metastasis size (stage N1a vs N1b). Tumor grade 1 vs grades 2 or 3 approached significance. The presence of HTI also was related significantly to a decreased 10-year distant metastases-free survival in the stage N1b group. Our study suggests that HTI, along with other well-known parameters, is a useful prognostic feature. In addition, it supports the opinion that ALN dissection may provide limited additional information for patients with grade 1, stage Tla, invasive ductal carcinomas. Additional studies are needed to confirm our findings.
To understand the prevalence of axillary node metastasis and survival of patients with T1a and T1b breast cancers, we reviewed the experience at a large community hospital. All patients in the ...William Beaumont Hospital tumor registry with breast cancer treated between January 1983 and November 1995 were evaluated for tumor size, age, cell type, and the presence or absence of axillary node disease. Long-term survival was evaluated in patients treated between 1983 and 1992. The patients were defined as premenopausal or postmenopausal based on age (49 years or less, premenopausal; 50 years or greater, postmenopausal). Of the 4590 patients treated for breast cancer from 1983 to 1995, 915 had tumors 1.0 cm or less in size. Of 181 patients who had T1a cancer, 27 were premenopausal, and 154 were postmenopausal. Twenty-three premenopausal patients had axillary lymph nodes examined, two (8.7%) had histologically positive lymph nodes. Of 118 postmenopausal patients who had axillary nodes examined, six (5.1%) had positive lymph nodes. In those with T1b tumors, 130 patients were premenopausal; 604 patients were postmenopausal. Of these, 119 premenopausal patients had axillary nodes examined, and 29 (24.4%) had positive lymph nodes. Of 464 postmenopausal patients who had axillary nodes examined, 66 (14.2%) had positive nodes. The overall, disease-free, and tumor-specific survival rates for patients with T1a tumors were 93.8, 87.5, and 93.8 per cent (premenopausal) and 86.2, 95.4, and 95.4 per cent (postmenopausal), respectively. These survival rates for patients with T1b tumors were 87.8, 87.8, and 91.1 per cent (premenopausal) and 82.9, 88.5, and 92.9 per cent (postmenopausal), respectively. Premenopausal T1b patients had a higher rate of nodal involvement than postmenopausal T1b patients (P = 0.011). Postmenopausal T1b patients had a higher nodal metastasis rate than postmenopausal T1a patients (P = 0.01). T1b patients had a higher rate of axillary involvement than did T1a patients (P = 0.0018). Based on the rate of axillary lymph node metastasis and survival statistics, there may be a role for axillary node dissection in select patients with tumors less than 1.0 cm. in size.
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