Search

Background: Diagnoses of multiple ipsilateral breast cancer (MIBC) are increasing. Historically, the primary treatment for MIBC has been mastectomy due to concerns about in-breast recurrence risk and poor cosmetic outcome. The Alliance Z11102 study prospectively assessed cosmetic outcomes in women with MIBC treated with breast-conserving therapy (BCT)., Patients and Methods: Z11102 was a multicenter trial enrolling women with two or three separate sites of biopsy-proven malignancy separated by ≥ 2 cm within the same breast. Cosmetic outcome was a planned secondary endpoint. Data were collected with a four-point cosmesis survey (1 = excellent, 4 = poor) and the BREAST-Q (scored 0-100). All patients undergoing successful breast-conserving therapy were treated with whole-breast radiation. Associations were assessed with Chi square or Fisher's exact tests as appropriate., Results: Cosmetic outcome data for 216 eligible women who completed therapy are included in this analysis. Of the 136 patients who completed the survey 2 years postoperatively, 70.6% (N = 96) felt the result was good or excellent, while 3.7% (N = 5) felt the result was poor. We found no significant differences in patient-reported cosmetic outcomes when stratifying by patient age, number of lesions (two or three), number of incisions, number of lumpectomies, or size of largest area of disease. Mean satisfaction score on the BREAST-Q was 77.2 at 6 months following whole-breast radiation and 73.7 at 3 years following surgery., Conclusions: BCT performed for MIBC results in good or excellent cosmesis for the majority of women. From a cosmetic perspective, BCT is a valid surgical approach to women with MIBC., Trial Registration: ClinicalTrials.gov Identifier: NCT01556243.

Background: Locoregional recurrence (LRR) after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) is increased in young women. We examined the impact of age on LRR and distant disease after mastectomy for DCIS ± microinvasion., Methods: We identified consecutive patients with DCIS ± microinvasion treated with mastectomy from 1995 to 2017. LRR was defined as recurrence at the ipsilateral chest wall or regional nodes., Results: Overall, 3121 cases were identified, of which 421 (13.5%) had DCIS + microinvasion. Median age was 49 years and median follow-up was 6.4 years; 821 were followed for 10 or more years. Thirty-four LRRs were observed: 33 (97%) were invasive, and 23 (68%) were in the chest wall alone. Cumulative 10-year LRR incidence was 1.4%. Age < 50 years, high grade, and DCIS + microinvasion were associated with LRR (p ≤ 0.001); however, margin status was not (p = 0.14). Adjusting for grade and DCIS + microinvasion, age < 50 years (hazard ratio [HR] 14.7, 95% confidence interval [CI] 3.5-61.5; p < 0.001) was associated with LRR. Compared with women ≥ 50 years of age, women age < 40 years had the highest risk (HR 27.0, 95% CI 6.0-121), and women age 40-49 years had intermediate risk (HR 11.8, 95% CI 2.8-50.5). The cumulative 10-year LRR incidence was 4.2% for women < 40 years of age, 2.0% for women 40-49 years of age, and 0.2% for women ≥ 50 years of age. Women age < 40 years had a 10-year distant disease rate of 1.6% versus women age 40-49 years (0.7%) and women age ≥ 50 years (0.7%) (log-rank p = 0.051). Grade, DCIS + microinvasion, and margins were unassociated with distant disease., Conclusions: LRR after mastectomy for DCIS ± microinvasion is uncommon, but is more frequent among women < 50 years of age, particularly in those < 40 years of age. The 10-year LRR rate in this youngest group remains low at 4.2%. Young age is an independent risk factor for LRR after BCS or mastectomy.

Background: Malignant/borderline phyllodes tumors (PTs) are rare, and little is known about their long-term prognosis. This study sought to evaluate recurrence rates and identify factors associated with local and distant failure., Methods: From 1957 to 2017, we identified 124 patients with 125 PTs (86 malignant and 39 borderline). Recurrence rates and survival were assessed using the Kaplan-Meier method, and correlated with clinicopathologic factors using the log-rank test., Results: The median age of the patients was 44 years, and the median tumor size was 5 cm. Breast-conserving surgery was performed for 57% of the patients. At a median follow-up of 7.1 years, 14 patients experienced a locoregional recurrence (LRR), with a 10-year cumulative LRR incidence of 12%. On univariable analysis, age younger than 40 years (p = 0.02) and close/positive margins (p = 0.001) were associated with increased risk of LRR. Seven patients developed distant disease, all occurring in malignant PTs. The 10-year distant recurrence-free survival was 94%. Uniformly poor pathologic features consisting of marked stromal cellularity, stromal overgrowth, infiltrative borders, and 10 or more mitoses per 10 high-power fields (hpf) were identified in 25 PTs (20%), and all distant recurrences occurred in this group. For the patients who did not have uniformly poor features, the 10-year disease-specific survival was 100%, and the overall survival was 94% compared with 66% and 57%, respectively, among those with poor features., Conclusion: Malignant/borderline PTs without uniformly poor histologic features have an excellent prognosis after surgical resection, with a 10-year disease-specific survival of 100%. The presence of uniformly poor pathologic features predicts a poor prognosis. Efforts should be directed toward new treatment approaches for these tumors.

Background: Women with ductal carcinoma in situ (DCIS) are increasingly choosing bilateral mastectomy. We sought to quantify rates of contralateral breast cancer (CBC) and ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery (BCS) for DCIS, and to compare risk factors for CBC and IBTR., Methods: From 1978 to 2011, DCIS patients undergoing BCS with a contralateral breast at risk were identified from a prospectively maintained database. The association of clinicopathologic and treatment factors with CBC and IBTR were evaluated using Kaplan-Meier analysis, multivariable Cox regression, and competing risk regression (CRR)., Results: Of 2759 patients identified, 151 developed CBC and 344 developed IBTR. Five- and 10-year Kaplan-Meier CBC rates were 3.2 and 6.4%. Overall, 10-year IBTR rates were 2.5-fold higher than CBC rates, and, without radiation, 4-fold higher. On CRR, 5- and 10-year rates were 2.9 and 5.8% for CBC, and 7.8 and 14.5% for IBTR. CBC risk and invasive CBC risk were not significantly associated with age, family history, presentation, nuclear grade, year of surgery, or radiation. By multivariable Cox regression, endocrine therapy was associated with lower CBC risk (hazard ratio 0.57, p = 0.03). Ten-year risk of subsequent CBC in the subset of patients who developed IBTR was similar to the cohort as a whole (8.1 vs. 6.4%)., Conclusions: CBC rates were low across all groups, including those who experienced IBTR. CBC was not associated with factors that increase IBTR risk. While factors associated with IBTR risk are important in decision making regarding management of the index DCIS, they are not an indication for contralateral prophylactic mastectomy.

Over the past several years, there has been an increasing rate of bilateral prophylactic mastectomy (BPM) and contralateral prophylactic mastectomy (CPM) surgeries. Since publication of the 2007 SSO position statement on the use of risk-reducing mastectomy, there have been significant advances in the understanding of breast cancer biology and treatment. The purpose of this manuscript is to review the current literature as a resource to facilitate a shared and informed decision-making process regarding the use of risk-reducing mastectomy.

Background: Randomized trials of radiation after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) found substantial rates of recurrence, with half of the recurrences being invasive. Decreasing local recurrence rates for invasive breast carcinoma have been observed and are largely attributed to improvements in systemic therapy. In this study, we examine recurrence rates after BCS for DCIS over 3 decades at one institution., Methods: We retrospectively reviewed a prospectively maintained database of DCIS patients undergoing BCS from 1978 to 2010. Cox proportional hazard models were used to investigate the association between the treatment period and recurrence, controlling for other variables., Results: Overall, 363 (12%) recurrences among 2996 cases were observed. Median follow-up for patients without recurrence was 75 months (range 0-30 years); 732 patients were followed for ≥10 years. The 5-year recurrence rate for the period 1978-1998 was 13.6 versus 6.6% for the period 1999-2010 [hazard ratio (HR) 0.62, p < 0.0001]. Controlling for age, family history, presentation, nuclear grade, necrosis, number of excisions, margin status, radiation, and endocrine therapy, treatment period remained significantly associated with recurrence, with later years associated with a lower HR (0.74, p = 0.02) compared to earlier. After stratification by radiation use, association of recurrence with treatment period persisted in those treated without radiation (HR 0.62, p = 0.003)., Conclusions: Recurrence rates for DCIS have fallen over time, with increases in screen detection, negative margins, and use of adjuvant therapies only partially explaining this decrease. The unexplained decline persists in women not receiving radiation, suggesting it is not due to changes in radiation efficacy but may be due to improvements in radiologic detection and pathologic assessment.

Objective: The purpose of this study was to evaluate the effect of the use of preoperative breast MRI on surgical and long-term outcomes among women with early-stage breast cancer undergoing breast conservation therapy., Materials and Methods: A retrospective review yielded the cases of 174 women with stage 0, I, or II breast cancer who underwent preoperative MRI between 2000 and 2004. A control group of 174 patients who did not undergo preoperative MRI before breast conservation therapy was matched by age, histopathologic finding, stage, and surgeon. Features compared included breast density, presence of mammographically occult disease, margin status, lymph node involvement, lymphovascular invasion, extensive intraductal component, hormone receptor status, and use of adjuvant therapy. Outcomes, including rates of reexcision, ipsilateral recurrence, and disease-free survival, were compared by Kaplan-Meier methods and the log-rank test., Results: Patients referred for preoperative breast MRI were more likely to have extremely dense breasts (28% vs 6%, p < 0.0001) and mammographically occult cancer (24% vs 9%, p = 0.0003). The two groups had identical rates of final negative margins, lymph node involvement, lymphovascular invasion, extensive intraductal component status, positive hormone receptor results, and systemic adjuvant therapy. Fewer patients in the preoperative MRI group needed reexcision (29% vs 45%, p = 0.02). The median follow-up period after treatment was 8 years. There was no significant difference in locoregional recurrence (p = 0.33) or disease-free survival (p = 0.73) rates between the two groups., Conclusion: Reexcision rates among patients with early breast cancer undergoing conservation therapy were lower among women who underwent preoperative breast MRI. There was no statistically significant effect of the use of preoperative MRI on rates of locoregional recurrence or disease-free survival.

Background/purpose: To evaluate radiation plans of patients undergoing mastectomy with immediate expander-implant reconstruction followed by postmastectomy radiation therapy (PMRT)., Materials/methods: We identified 41 patients from June 2004 to May 2007 who underwent mastectomy, immediate expander-implant reconstruction, and PMRT with intensity-modulated radiation therapy. We assessed chest wall (CW) coverage and volume of heart and lung irradiated., Results: In 73% of patients, all CW borders were adequately covered, and in 22%, all but 1 border were adequately covered. The total lung V(20) was<20% in 39/41 patients. The mean lung V(20) was 13% (range, 3-23%), and the mean heart D(mean) was 2.81 Gy (range, 0.53-9.60 Gy). In patients with left-sided lesions without internal mammary nodes (IMNs) treatment (n=22), the mean lung V(20) was 12.6% and the mean heart D(mean) was 3.90 Gy, and in the patient with IMN treatment, the lung V(20) was 18% and heart D(mean) was 8.04 Gy. For right-sided lesions without IMN treatment (n=12), the mean lung V(20) was 12.4% and the mean heart D(mean) was 0.90 Gy, and in patients with IMN treatment (n=6), these numbers were 17.8% and 1.76 Gy. At a median follow-up of 29 months, the 30-month actuarial local control was 97%., Conclusions: In women undergoing immediate expander-implant reconstruction, PMRT can achieve excellent local control with acceptable heart and lung doses. These results can be achieved even when the IMN are being treated, although doses to the heart and lungs will be higher., ((c) 2009 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To determine intervals between surgery and adjuvant chemotherapy and radiation in patients treated with mastectomy with immediate expander-implant reconstruction, and to evaluate locoregional and distant control and overall survival in these patients., Methods and Materials: Between May 1996 and March 2004, 104 patients with Stage II-III breast cancer were routinely treated at our institution under the following algorithm: (1) definitive mastectomy with axillary lymph node dissection and immediate tissue expander placement, (2) tissue expansion during chemotherapy, (3) exchange of tissue expander for permanent implant, (4) radiation. Patient, disease, and treatment characteristics and clinical outcomes were retrospectively evaluated., Results: Median age was 45 years. Twenty-six percent of patients were Stage II and 74% Stage III. All received adjuvant chemotherapy. Estrogen receptor staining was positive in 77%, and 78% received hormone therapy. Radiation was delivered to the chest wall with daily 0.5-cm bolus and to the supraclavicular fossa. Median dose was 5,040 cGy. Median interval from surgery to chemotherapy was 5 weeks, from completion of chemotherapy to exchange 4 weeks, and from exchange to radiation 4 weeks. Median interval from completion of chemotherapy to start of radiation was 8 weeks. Median follow-up was 64 months from date of mastectomy. The 5-year rate for locoregional disease control was 100%, for distant metastasis-free survival 90%, and for overall survival 96%., Conclusions: Mastectomy with immediate expander-implant reconstruction, adjuvant chemotherapy, and radiation results in a median interval of 8 weeks from completion of chemotherapy to initiation of radiation and seems to be associated with acceptable 5-year locoregional control, distant metastasis-free survival, and overall survival.

Background: A positive sentinel lymph node (SLN) has been reported in 6% to 13% of patients with ductal carcinoma in situ (DCIS). Although it is well established that nodal status for invasive disease is prognostically important, the clinical relevance of a positive SLN in patients with DCIS remains undetermined., Methods: SLN biopsy was performed on 470 high-risk patients with DCIS (22% of all patients with DCIS) at 3 institutions. Of these, 43 (9%) had SLN metastases. Pathology findings of positive cases were reviewed, and follow-up was obtained. At 2 of the 3 institutions, data were also collected on DCIS patients who had negative findings on SLN biopsy. For these 414 patients, univariate analyses of tumor characteristics were performed to identify factors associated with node positivity., Results: Extensive disease requiring mastectomy (p = 0.02) and the presence of necrosis (p = 0.04) were associated with an increased risk of nodal positivity. Three (7%) of the 43 SLN-positive patients had macrometastases (pN1), 4 (9%) had micrometastases (pN1mi), and 36 (84%) had single tumor cells or small clusters (pN0(i+)). Of the 25 women that underwent completion axillary dissection, one was found to have a macrometastasis. On pathological review of the primary lesion, 2 (5%) of 43 patints were found to have microinvasion, and 2 (5%) lymphovascular invasion. Nine of 43 (21%) high-risk DCIS patients with a positive SLN and 9/470 (2%) of all high-risk DCIS patients were upstaged to AJCC stage I or II as a result of the SLN biopsy. At a median (range) follow-up of 27 (3-88) months, 1 patient had developed hepatic metastases. This patient had immunohistochemistry detected isolated tumor cells in her SLN (N0(i+)), and upon pathologic review, was found to have high-grade DCIS with microinvasion., Conclusion: SLN biopsy for high-risk DCIS patients is a mean of detecting those who may have unrecognized invasive disease and therefore are at risk for distant disease.

Purpose/objectives: To evaluate the prevalence, severity, and level of distress of 18 sensations at baseline (3-15 days) and 24 months after breast cancer surgery and to compare sensations after sentinel lymph node biopsy (SLNB) with those after SLNB plus immediate or delayed axillary lymph node dissection (ALND)., Design: Prospective, descriptive., Setting: Evelyn H. Lauder Ambulatory Breast Center at Memorial Sloan-Kettering Cancer Center in New York, NY., Sample: 294 women with breast cancer; 214 had undergone breast conserving therapy, and 80 had undergone total mastectomy; 197 had had SLNB, and 97 had had SLNB and ALND., Methods: Patients completed the Breast Sensation Assessment Scale (BSAS) at baseline and 3, 6, 12, and 24 months after surgery., Main Research Variables: Prevalence, severity, and level of distress of sensations in patients who had undergone breast cancer surgery., Findings: Sensations were less prevalent, severe, and distressing in patients undergoing SLNB than those undergoing ALND. This difference appeared to be limited to those undergoing breast conserving therapy. Most sensations after SLNB and ALND, even if prevalent, were not very severe or distressing. Some sensations persisted as long as two years. These included tenderness after SLNB and numbness after ALND. Patients often reported phantom sensations after total mastectomy., Conclusions: Overall, prevalence, severity, and level of distress were lower after SLNB compared to ALND, but some morbidity existed after SLNB. Certain sensations remained prevalent in both groups for as long as 24 months., Implications for Nursing: Nurses can use information from this study to provide more accurate education and support to patients.

Background: Patients with a history of carcinoma of one breast have an estimated risk of 0.5% to 0.75% per year of developing a contralateral breast cancer. This risk prompts many women to consider contralateral prophylactic mastectomy (CPM) as a preventive measure. Virtually nothing is known about patient acceptance following CPM. We have developed a National Prophylactic Mastectomy Registry comprised of a volunteer population of 817 women from 43 states who have undergone prophylactic (unilateral or bilateral) mastectomy., Methods: Of the 346 women with CPM who responded to national notices, 296 women returned detailed questionnaires. The information obtained included patient demographics, family history, reproductive history, ipsilateral breast cancer staging and treatment, as well as issues involving the CPM., Results: At median follow-up of 4.9 years, the respondents were primarily married (79%), white (97%) women who had some level of college education or above (81%). These women cited the following reasons for choosing CPM: (1) physician advice regarding the high risk of developing contralateral breast cancer (30%); (2) fear of developing more breast cancer (14%); (3) desire for cosmetic symmetry (10%); (4) family history (7%); (5) fibrocystic breast disease (4%); (6) a combination of all of these reasons (32%); (7) other (2%); and (8) unknown (1%). Eighteen of the 296 women (6%) expressed regrets regarding their decision to undergo CPM. Unlike women with bilateral prophylactic mastectomies, regrets tended to be less common in the women with whom the discussion of CPM had been initiated by their physician (5%) than in the women who had initiated the discussion themselves (8%) (P = ns). Family history and stage of index lesion had no impact on regret status. The reasons for regret included: (1) poor cosmetic result, either of the CPM or of the reconstruction (39%); (2) diminished sense of sexuality (22%); (3) lack of education regarding alternative surveillance methods or CPM efficacy (22%); and (4) other reasons (17%)., Conclusions: To minimize the risk of regrets in women contemplating CPM, it is imperative that these women be counseled regarding an estimation of contralateral breast cancer risk, the alternatives to CPM, and the efficacy of CPM. In addition, these women should have realistic expectations of the cosmetic outcomes of surgery and understand the potential impact on their body image.

Background: The discovery of a cadre of breast cancer susceptibility genes has resulted in an increase in the number of women seeking information about prophylactic breast surgery, but virtually no large-scale prospective databases exist to assist women considering prophylactic mastectomy., Methods: The authors constructed a National Prophylactic Mastectomy Registry comprised of a volunteer population of 817 women from 43 states who have undergone prophylactic mastectomy., Results: In the registry, 370 women had undergone bilateral prophylactic mastectomy. Twenty-one (5%) women expressed regrets about the procedure. The median follow-up was 14.6 years (mean 14.8 years; range 0.2-51 years). Those with regrets were subsetted into those with major (n = 10) or minor (n = 7) regrets. Regrets were more common in those women with whom discussion about prophylactic mastectomy was initiated by a physician (19/255), compared with patients who initiated the discussion themselves (2/108; P < .05)., Conclusions: The overall satisfaction rate of 95% reported here may be explained by the voluntary nature of this registry. The most important factor that predicts an unfavorable outcome following bilateral prophylactic mastectomy is a physician-initiated discussion.