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S Eva Singletary

Publications and source records attributed to S Eva Singletary.

At least 37 records · Page 2Linked to original sources
PubMed2005

Predictors of systemic recurrence and disease-specific survival after ipsilateral breast tumor recurrence.

BACKGROUND: In patients with breast carcinoma, ipsilateral breast tumor recurrence (IBTR) after breast-conserving therapy (BCT) is an independent predictor of systemic recurrence and disease-specific survival (DSS). However, only a subgroup of patients with IBTR develop systemic recurrences. Therefore, the management of isolated IBTR remains controversial. The objective of the current study was to identify determinants of systemic recurrence and DSS after IBTR. METHODS: The medical records of 120 women who underwent BCT for Stage 0-III breast carcinoma between 1971 and 1996 and who subsequently developed isolated IBTR were reviewed. Clinicopathologic factors were studied using univariate and multivariate analyses for their association with DSS and the development of systemic recurrence after IBTR. RESULTS: The median time to IBTR was 59 months. At a median follow-up of 80 months after IBTR, 45 patients (37.5%) had a systemic recurrence. Initial lymph node status was the strongest predictor of systemic recurrence according to the a univariate analysis (P = 0.001). Other significant factors included lymphovascular invasion (LVI) in the primary tumor, time to IBTR < or = 48 months, clinical and pathologic IBTR tumor size > 1 cm, LVI in the recurrent tumor, and skin involvement at IBTR. In a multivariate logistic regression analysis, initially positive lymph node status (relative risk [RR], 5.3; 95% confidence interval [95% CI], 1.4-20.1; P = 0.015) and skin involvement at IBTR (RR, 15.1; 95% CI, 1.5-153.8; P = 0.022) remained independent predictors of systemic recurrence. The 5-year and 10-year DSS rates after IBTR were 78% and 68%, respectively. In a multivariate Cox proportional hazards model analysis, only LVI in the recurrent tumor was found to be an independent predictor of DSS (RR, 4.6; 95% CI, 1.5-14.1; P = 0.008). CONCLUSIONS: Patients who initially had lymph node-positive disease or skin involvement or LVI at IBTR represented especially high-risk groups that warranted consideration for aggressive, systemic treatment and novel, targeted therapies after IBTR. Determinants of prognosis after IBTR should be taken into account when evaluating the need for further systemic therapy and designing risk-stratified clinical trials.

Adult↗
PubMed2005

Improving local control with breast-conserving therapy: a 27-year single-institution experience.

BACKGROUND: The risk of ipsilateral breast tumor recurrence (IBTR) after breast-conserving therapy (BCT) is associated with treatment and tumor-related variables, such as surgical margin status and the use of systemic therapy, and these variables have changed over time. Correspondingly, the authors of the current study hypothesized that the contemporary multidisciplinary management of breast carcinoma would lead to an improvement in IBTR rates after BCT. METHODS: Between 1970 and 1996, 1355 patients with pathologic Stage I-II invasive breast carcinoma underwent BCT (breast-conserving surgery and adjuvant radiation therapy) at The University of Texas M. D. Anderson Cancer Center. Contemporary methods of analyzing surgical margins were in routine use by 1994. To analyze the effect of this variable and others, patient and tumor characteristics and IBTR rates in patients treated during 1994-1996 were compared with those in patients treated from 1970 to 1993. RESULTS: Characteristics were similar in patients treated during 1994-1996 (n = 381) and those treated before 1994 (n = 974) except for patients aged >50 years (63.3% vs. 51.7%, P < 0.001), and patients who had a family history of breast carcinoma (37.9% vs. 30.8%, P = 0.017). Patients treated after 1994 were less likely to have positive or unknown margins (2.9 % vs. 24.1 %, P = 0.0001), more likely to receive chemotherapy (40.5% vs. 26%, P < 0.001), and more likely to receive hormonal therapy (33.3% vs. 19.4%, P < 0.001), but less likely to receive radiation boosts to the primary tumor bed (59.8% vs. 89%, P < 0.001). The 5-year cumulative IBTR rate was significantly lower among patients treated in 1994-1996 than among patients treated before 1994 (1.3% vs. 5.7%, P = 0.001) largely because of the drop in IBTR rates among patients aged < or = 50 years (1.4 % vs. 9.1 %, P = 0.0001). On multivariate analysis, age > 50 (hazards ratio [HR] = 0.401; P = 0.0001), presence of negative surgical margins (HR = 0.574; P = 0.017), and use of adjuvant hormonal therapy (HR = 0.402; P = 0.05) were independent predictors of improved 5-year IBTR-free survival. On subgroup analysis, use of chemotherapy was associated with increased IBTR-free survival among women aged < or = 50 years (HR = 0.383; P = 0.001). Although 5-year cumulative IBTR rates were lower among women aged > 50 years than among younger women before 1994 (2.6 % vs. 9.1%, P < 0.0001), no such difference was found in the group treated in 1994-1996 (1.2 % for age > 50 yrs vs. 1.4 % for < or = 50 yrs, P = 0.999). CONCLUSIONS: The IBTR rate after BCT appears to be declining, especially among patients < 50 years of age. However, long-term follow-up is necessary to confirm this finding. This finding may reflect changes in surgical approaches and pathologic evaluation as well as an increased use of systemic therapy. The current low incidence of IBTR with multidisciplinary management of breast carcinoma may result in more patients choosing BCT over mastectomy.

Age Factors↗
PubMed2005

Clinical outcome of patients with lymph node-negative breast carcinoma who have sentinel lymph node micrometastases detected by immunohistochemistry.

BACKGROUND: The ideal pathologic assessment of sentinel lymph nodes (SLNs) in patients with breast carcinoma remains controversial. The authors evaluated how detailed assessment of SLNs using immunohistochemistry (IHC) and serial sectioning would affect treatment decisions and outcomes in patients with breast carcinoma who had negative SLNs on standard hematoxylin and eosin staining. METHODS: The SLNs from patients who were treated between June 1998 and June, 1999 and who had negative lymph node status determined by hematoxylin and eosin staining (n = 84 patients) were evaluated further with serial sectioning and cytokeratin IHC. Patients were offered adjuvant therapy based on primary tumor factors. RESULTS: The median patient age was 57 years, and the median tumor size was 1.2 cm. At a median follow-up of 40.2 months, 81 patients (96%) were alive with no evidence of disease, 1 patient was alive with disease, 1 patient had died of disease, and 1 patient had died of other causes. Fifteen patients (18%) had micrometastases identified on IHC. Of the total 84 patients, information regarding adjuvant therapy was not available for 5 patients. Of the remaining 79 patients, 10 patients (13%) were not offered adjuvant chemotherapy but had positive SLN status determined by IHC. SLN status based on IHC evaluation did not correlate with age (P = 0.077), tumor size (P = 0.717), grade (P = 0.148), estrogen receptor status (P = 1.000), or lymphovascular invasion (P = 0.274). Furthermore, IHC-detected positive SLN status did not correlate with distant metastasis (P = 0.372) or overall or distant metastasis-free survival (P = 0.543 and P = 0.540, respectively). CONCLUSIONS: Although the finding of SLN micrometastases by IHC may change management in > 12% of patients, preliminary results suggested that such micrometastases do not affect outcomes significantly.

Adult↗
PubMed2005

Lower and central tumor location correlates with lymphoscintigraphy drainage to the internal mammary lymph nodes in breast carcinoma.

BACKGROUND: Radiation to the internal mammary chain (IMC) may be indicated for breast carcinoma patients with positive axillary sentinel lymph nodes (SLNs) and lymphoscintigraphic evidence of drainage to the IMC. The purpose of this study was to identify predictors of IMC drainage in patients with positive axillary SLNs. METHODS: The records of 297 breast carcinoma patients with positive axillary SLNs and preoperative lymphoscintigraphy were reviewed between 1995 and 2002. Radiolabeled colloid was injected peritumorally with lymphoscintigraphy performed 30-60 minutes later. Drainage to the regional nodes of 279 patients was seen on lymphoscintigraphy. Associations among patient and tumor-related factors and drainage to the IMC were examined. RESULTS: Drainage to the IMC on lymphoscintigraphy was seen in 63 patients (21%). IMC drainage only occurred in 4 patients, and 59 patients had both axillary and IMC drainage. The only variable that correlated with IMC drainage was tumor location (P = 0.017). Rates of drainage to the IMC were 14.1% for upper outer quadrant (n = 128), 16.7% for upper inner quadrant (n = 30), 31.6% for lower outer quadrant (n = 19), 42.9% for lower inner quadrant (n = 14), and 28.4% for central tumors (n = 88). IMC drainage rates differed significantly between upper and lower tumors (lower 36.4% vs. central 28.4% vs. upper 14.6%, P = 0.003) but not between medial and lateral tumors (medial 25.0% vs. central 28.4% vs. lateral 16.3%, P = 0.077). CONCLUSIONS: Patients with tumors in the lower or central breast and positive axillary SLNs have increased incidence of drainage to the IMC. Preoperative lymphoscintigraphy can help to define the nodal basins at risk for harboring disease.

Adult↗
PubMed2005

Paget's disease of the breast: there is a role for breast-conserving therapy.

BACKGROUND: The optimal surgical management of Paget's disease of the breast remains to be defined. Mastectomy has been the standard of care, but several institutions have recently advocated breast-conserving surgery, particularly for patients with minimal disease. In an effort to develop rational treatment guidelines, we examined our institutional experience with Paget's disease of the breast. METHODS: Patients with Paget's disease of the breast who had surgical therapy at our institution between 1949 and 1993 were reviewed. In addition to patient and tumor characteristics, charts were reviewed for treatment modalities, locoregional recurrence patterns, and survival. Subgroups were compared for differences in survival in both univariate and multivariate analyses. RESULTS: A total of 104 patients met the study criteria. The most common presenting symptoms were nipple discharge and eczematous changes of the nipple/areola complex. Ninety-seven patients (93.2%) had an underlying invasive or noninvasive cancer associated with Paget's disease. Ninety-two patients (88.5%) underwent mastectomy, and 12 (11.5%) had a breast-conserving procedure. On univariate analysis, patients with age <60 years at diagnosis, stage II disease, positive lymph nodes, invasive disease, or a palpable mass had significantly lower 10-year disease-specific and recurrence-free survival. There were four locoregional recurrences (three after mastectomy and one after breast conservation). There were no significant differences in overall, disease-specific, or recurrence-free survival according to the type of surgery. CONCLUSIONS: Paget's disease of the breast is almost always associated with an underlying breast cancer. Breast-conserving approaches result in local control and survival rates similar to those achieved with mastectomy.

Adult↗
PubMed2005

Breast conservation after neoadjuvant chemotherapy.

BACKGROUND: The appropriate selection criteria for breast-conserving therapy (BCT) after neoadjuvant chemotherapy are poorly defined. The purpose of the current report was to develop a prognostic index to help refine selection criteria and to serve as a general framework for clinical decision-making for patients treated by this multimodality approach. METHODS: From a group of 340 patients treated with BCT after neoadjuvant chemotherapy, the authors previously determined 4 statistically significant predictors of ipsilateral breast tumor recurrence (IBTR) and locoregional recurrence (LRR): clinical N2 or N3 disease, residual pathologic tumor size > than 2 cm, a multifocal pattern of residual disease, and lymphovascular space invasion in the specimen. The M. D. Anderson Prognostic Index (MDAPI) was developed by assigning scores of 0 (favorable) or 1 (unfavorable) for each of these 4 variables and using the total to give an overall MDAPI score of 0-4. RESULTS: The MDAPI stratified the 340 patients into 3 subsets with statistically different levels of risk for IBTR and LRR after neoadjuvant chemotherapy and BCT. Actuarial 5-year IBTR-free survival rates were 97%, 88%, and 82% for patients in the low (MDAPI overall score 0 or 1, n=276), intermediate (MDAPI score 2, n=43), and high (MDAPI score 3 or 4, n=12) risk groups, respectively (P<0.001). Corresponding actuarial 5-year LRR-free survival rates were 94%, 83%, and 58%, respectively (P<0.001). CONCLUSIONS: Patients with an MDAPI score of 0 or 1, which made up 81% of the study population, had very low rates of IBTR and LRR. The MDAPI enabled the identification of a small group (4%) of patients who are at high risk for IBTR and LRR and who may benefit from alternative locoregional treatment strategies.

Adult↗
PubMed2005

Determinants of mastectomy in breast conservation therapy candidates.

BACKGROUND: Although underused, breast conservation therapy (BCT) is an accepted method for treatment of noninvasive and early breast cancer. The purpose of this analysis was to identify factors associated with receiving mastectomy when eligible for BCT. METHODS: From a recent experience, 397 patients at the University of Texas M. D. Anderson Cancer Center presented with clinical stage 0, I, or II breast cancer. Demographics and tumor characteristics of patients who underwent BCT versus mastectomy were compared. RESULTS: Of 293 BCT candidates, 203 patients (69%) underwent BCT and 90 patients (31%) received a mastectomy. Of those 90 patients, 66 patients (73%) had documented concerns about receiving BCT. Multivariate analyses showed that widow status was a factor associated with receiving mastectomy at presentation (P = .04). CONCLUSIONS: The majority of BCT candidates with early stage breast cancer undergo BCT. In our study, widow status was a predictive factor of mastectomy in BCT candidates.

Breast Neoplasms↗
PubMed2005

Predictors of invasive breast cancer in patients with an initial diagnosis of ductal carcinoma in situ: a guide to selective use of sentinel lymph node biopsy in management of ductal carcinoma in situ.

BACKGROUND: The role of sentinel lymph node biopsy (SLNB) in patients with an initial diagnosis of ductal carcinoma in situ (DCIS) has not been well defined. The purpose of our study was to determine when the risk of finding invasive disease on final pathology in patients with an initial diagnosis of DCIS was sufficiently high to justify use of SLNB. STUDY DESIGN: The records of 398 consecutive patients from our prospective database with an initial diagnosis of DCIS, treated between July 1999 and December 2002, were analyzed. Associations between clinical and pathologic factors and patient selection for SLNB and outcomes were analyzed for significance using univariate and multivariate analyses. RESULTS: Of the 398 patients, 80 (20%) were found to have invasive disease on final pathology. Multivariate analysis revealed 4 independent predictors of invasive cancer on final pathology: 55 years of age or younger (odds ratio [OR], 2.19; p = 0.024), diagnosis by core-needle biopsy (OR, 3.76; p = 0.006), mammographic DCIS size of at least 4 cm (OR, 2.92; p = 0.001), and high-grade DCIS (OR, 3.06; p = 0.002). A total of 141 patients (35%) underwent SLNB as a component of their initial operation. Multivariate analysis revealed that the presence of comedonecrosis (OR, 2.69; p = 0.007) and larger mammographic DCIS size (OR, 1.18; p = 0.0002) were independent predictors of patients' undergoing SLNB. Of these 141 patients, 103 (73%) were diagnosed by core-needle biopsy, 42 (30%) had invasive disease on final pathology, and 14 (10%) had a positive sentinel lymph node: 12 (86%) by hematoxylin and eosin staining and 2 by immunohistochemistry. The only independent predictor of a positive SLN was the presence of a palpable tumor (OR, 4.28, p = 0.042). Of these 14 patients with a positive sentinel node, only 11 (79%) had invasive cancer on final pathology. CONCLUSIONS: SLNB should not be performed routinely for all patients with an initial diagnosis of DCIS. Risks and benefits of SLNB should be discussed with patients who are younger, are diagnosed by core-needle biopsy, or have large or high-grade DCIS.

Adult↗
PubMed2005

Treatment trends in early-stage invasive lobular carcinoma: a report from the National Cancer Data Base.

OBJECTIVE: To examine treatment trends in invasive lobular carcinoma (ILC) over the last 15 years and, in particular, to compare rates of recurrence and disease-free survival associated with breast conservation therapy compared with mastectomy. SUMMARY BACKGROUND DATA: The biologic characteristics of ILC make it difficult to estimate the extent of the disease by either clinical examination or mammography, and can also make it difficult to detect axillary lymph node metastases. Because of this, there has been a bias toward treating ILC with aggressive therapy. METHODS: Patients with ILC were selected from the National Cancer Data Base (1989-2001) using an extensive set of inclusion and exclusion criteria. A total of 21,596 patients were selected, including 8108 who received breast conservation therapy and 13,488 who received mastectomy. Analysis included demographic characteristics, trends in usage of sentinel lymph node biopsy, rates of local and distant recurrence, and 5-year disease-free survival rates. RESULTS: The use of breast conversation therapy increased almost threefold during the study period. From 1998 to 2001, the use of sentinel node biopsy increased more than twofold in the breast conservation group (an average of 23% in 1998 versus 57% in 2001), compared with limited usage in the mastectomy group (an average of 10% in 1998 versus 23% in 2001). Local recurrence rates were very low and disease-free survival rates were correspondingly high in both treatment groups for all diagnosis years and across all pathologic tumor size/lymph node status designations. CONCLUSIONS: Less invasive treatment options are becoming widely used for invasive lobular carcinoma, yielding outcomes equivalent to those seen with more aggressive treatment.

Breast Neoplasms↗
PubMed2005

Effect of dietary intake of phytoestrogens on estrogen receptor status in premenopausal women with breast cancer.

Although many dietary studies have focused on breast cancer risk, few have examined dietary influence on tumor characteristics such as estrogen receptor (ER) status. Because phytoestrogens may modulate hormone levels and ER expression, we analyzed ER status and phytoestrogen intake in a case-case study of 124 premenopausal breast cancer patients. We assessed intake with a food-frequency questionnaire and obtained ER status from medical records. Rather than focusing on risk, we evaluated whether low intakes were more strongly associated with ER-negative tumors than with ER-positive disease. In logistic regression adjusting for potential confounders, threefold greater risks of ER-negative tumors relative to ER-positive tumors were associated with low intake of the isoflavones genistein (odds ratio, OR=3.50; 95% confidence interval, CI=1.43-8.58) and daidzein (OR=3.10; 95% CI=1.31-7.30). Low intake of the flavonoid kaempferol (OR=0.36; 95% CI=0.16-0.83), the trace element boron (OR=0.33; 95% CI=0.13-0.83), and the phytosterol beta-sitosterol (OR=0.42; 95% CI=0.18-0.98) were associated with decreased risk of ER-negative tumors relative to ER-positive disease. Other phytoestrogens were not significantly associated with ER status. Thus, in premenopausal patients, some phytoestrogens may affect breast carcinogenesis by influencing ER status. Such findings suggest new directions for mechanistic research on dietary factors in breast carcinogenesis that may have relevance for prevention and clinical treatment.

Adult↗
PubMed2004

Contralateral prophylactic mastectomy. Predictors of significant histologic findings.

BACKGROUND: Women with unilateral breast carcinoma are at increased risk for developing contralateral breast carcinoma (CBC). The authors sought to identify predictors of malignant or moderate to high-risk histologic findings in contralateral prophylactic mastectomy (CPM) specimens, and to determine the efficacy of CPM. METHODS: The authors performed a retrospective review of 239 patients with unilateral early-stage breast carcinoma who underwent CPM. The number of CBCs expected if the contralateral breast had been left intact was calculated based on CBC rates observed in the Surveillance, Epidemiology, and End Results (SEER) database and on life-table analysis by family history. RESULTS: In the current study, 11 patients (4.6%) had occult contralateral malignancies (4 invasive carcinomas and 7 ductal carcinomas in situ) and 44 (18.4%) patients had moderate to high-risk pathology (8 lobular carcinoma in situ, 11 atypical lobular hyperplasia, 25 atypical ductal hyperplasia). At 1846 patient-years of follow-up, only 1 patient (0.4%) developed a new CBC compared with 11 expected cancers based on SEER data. One CBC was observed among 140 patients with a family history of breast carcinoma, compared with 16 expected cancers based on life-table analysis adjusted for adjuvant therapy. The determinants of significant findings at CPM were invasive lobular histology, estrogen and progesterone receptor positivity, additional ipsilateral moderate to high-risk pathology, and age > 40 years at cancer diagnosis. CONCLUSIONS: CPM was associated with a low risk of subsequent development of breast carcinoma. Evaluation of histologic findings in the ipsilateral breast may help to predict the likelihood of significant disease in the contralateral breast and assist in risk stratification.

Adult↗
PubMed2004

Feasibility and utility of using chromosomal aneusomy to further define the cytologic categories in nipple aspirate fluid specimens: a preliminary study.

BACKGROUND: There is renewed interest in using the cytologic changes in the epithelial cells obtained from specimens such as nipple aspiration fluid (NAF) and ductal lavage for risk stratification of women at increased risk for developing breast carcinoma. METHODS: Molecular tests such as fluorescence in situ hybridization (FISH) have the potential to be used as adjuncts to conventional cytology for more accurately categorizing cells in these types of specimens. The current study investigated the feasibility and utility of FISH analysis of aneusomy in chromosomes 1, 8, 11 and 17 as an adjunct to conventional cytology in the classification of NAF specimens. RESULTS: The authors found chromosomal aneusomy for at least one chromosome in all three malignant and both markedly atypical cases. Of the five cases classified as being mildy atypical on cytology, four were disomic, and only one showed aneusomy in chromosomes 8 and 11. CONCLUSIONS: The current study established the possibilities, limitations, and feasibility of using FISH in conjunction with routine cytology for a more accurate classification of ductal epithelial cells in NAF specimens. FISH-based detection of chromosomal aneusomy helped to define mild atypia, thereby aiding in the selection of the truly atypical cases for appropriate therapeutic intervention. In addition, FISH-based detection of chromosomal aneusomy can also be a valuable adjunct to conventional cytology in selected cases for confirming a benign, suspicious, or malignant diagnosis.

Biopsy, Needle↗
PubMed2004

The effect of ethnicity on immediate reconstruction rates after mastectomy for breast cancer.

BACKGROUND: Multiple factors may influence whether patients undergo immediate breast reconstruction along with mastectomy for breast cancer. The authors investigated whether ethnicity was an independent predictor of immediate breast reconstruction. METHODS: The authors identified 1004 patients who underwent mastectomy for breast cancer during the period 2001-2002. The rates of immediate reconstruction among different ethnicities were evaluated using the chi-square test. Logistic regression was used to adjust for covariates, including age and disease stage. Medical records were analyzed to identify factors that influenced each patient's decision for or against immediate breast reconstruction. RESULTS: Three hundred seventy-six women (37.5%) underwent immediate breast reconstruction: This included 20.2% of African-American women, compared with 40.0% of white women, 42.0% of Hispanic women, 42.2% of Asian women, and 10.0% of Middle Eastern women (P < 0.001). The unadjusted odds ratio (OR) for immediate reconstruction for African-Americans versus whites was 0.38 (95% confidence interval [95% CI], 0.23-0.63; P < 0.001). After multivariate analysis, this disparity persisted, with an adjusted OR of 0.34 (95% CI, 0.18-0.62; P = 0.001). Asian women had lower rates of immediate reconstruction compared with white women (adjusted OR, 0.50; 95% CI, 0.24-1.04; P = 0.06). Hispanic women did not have immediate reconstruction rates that differed significantly from white women. Middle Eastern women had lower rates of immediate reconstruction compared with white women (adjusted OR, 0.08; 95% CI, 0.02-0.38; P = 0.002), but they had a corresponding increase in the rate of delayed reconstruction. In a stepwise analysis of the decision pathway to immediate reconstruction, it was found that African-American women were less likely to be offered referrals for reconstruction, were less likely to accept offered referrals, were less likely to be offered reconstruction, and were less likely to elect reconstruction if it was offered. CONCLUSIONS: African-American women underwent immediate breast reconstruction at significantly lower rates compared with white women, Hispanic women, and Asian women. After adjusting for covariates, including age and disease stage, African-American women and Asian women had lower rates of reconstruction compared with white women. The factors that contribute to these differences warrant further study.

Black or African American↗
PubMed2004

Intramammary lymph node metastases are an independent predictor of poor outcome in patients with breast carcinoma.

BACKGROUND: Breast carcinoma with intramammary lymph node (intraMLN) metastases is considered to be Stage II disease, even in the absence of axillary lymph node involvement. Nonetheless, little is known regarding the clinical significance of intraMLN metastases. The goals of the current retrospective analysis were to elucidate the clinical relevance of intraMLN metastases and to assess the relation between such metastases and outcome in patients with breast carcinoma. METHODS: One hundred ninety-six intraMLN specimens obtained between 1983 and 2003 were identified in the pathology database at The University of Texas M. D. Anderson Cancer Center (Houston, TX); 130 of these specimens were obtained in association with a primary breast malignancy. Data on the clinical and pathologic features of these specimens were collected and evaluated on univariate and multivariate analysis for potential correlations with 5-year rates of disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS). The median follow-up duration was 36 months (range, 12-180 months). RESULTS: The median age of the 130 patients in the current study was 53 years (range, 27-84 years). Twenty-four patients (18%) had intraMLNs that were identified preoperatively by either mammographic or sonographic methods; in the remaining 106 cases, intraMLNs were detected on pathologic examination of surgical breast specimens. IntraMLN metastases were found in 28% of all cases (n = 36). Most patients who had intraMLN metastases (81%) also had axillary metastases; however, isolated intraMLN metastases were documented in 6 patients (5%). Univariate analysis revealed that patients with intraMLN metastases (compared with all other patients) had poorer 5-year rates of DFS (54% vs. 89%; P = 0.001), DSS (66% vs. 90%; P = 0.001), and OS (64% vs. 88%; P = 0.004). Furthermore, multivariate analysis indicated that intraMLN involvement was an independent predictor of reduced DFS (hazard ratio, 2.33; P = 0.03), DSS (hazard ratio, 5.32; P = 0.002), and OS (hazard ratio, 3.22; P = 0.006). CONCLUSIONS: The current retrospective analysis demonstrated that the presence of intraMLN metastases is an independent predictor of poor outcome in patients with breast carcinoma. Identification of an intraMLN on preoperative imaging should prompt further histopathologic assessment. Identification of malignant intraMLNs by lymphatic mapping may help to identify high-risk patients for whom further evaluation of the axillary lymph nodes is warranted despite otherwise clinically negative findings in the axilla.

Adult↗
PubMed2004

Effective local control and long-term survival in patients with T4 locally advanced breast cancer treated with breast conservation therapy.

BACKGROUND: The presence of skin involvement has been accepted as a relative contraindication to breast preservation because it is believed to be associated with an increased local failure rate. This study was conducted to assess the outcome of a carefully selected group of patients who presented with breast cancer involving the skin and who had breast conservation therapy (BCT) following neoadjuvant chemotherapy. METHODS: Between 1987 and 1999, 33 patients with stage IIIB or IIIC breast cancer completed treatment consisting of four cycles of neoadjuvant chemotherapy, lumpectomy, radiation therapy, and consolidative chemotherapy. Clinicopathologic factors were analyzed and patients were followed for locoregional and distant recurrence. RESULTS: Initial median tumor size was 7 cm. All patients had skin involvement, defined as erythema, skin edema, direct skin invasion, ulceration, or peau d'orange. Following chemotherapy, median pathologic tumor size was 2 cm. Complete resolution of skin changes occurred in 29 patients (88%). At median follow-up time of 91 months in surviving patients, 26 patients (79%) were alive without evidence of disease. The 5-year, disease-free survival rate was 70%, and the 5-year overall survival rate was 78%. The actuarial ipsilateral breast cancer recurrence rate was 6% at 5 years. CONCLUSIONS: Patients who present with T4 breast cancer who experience tumor shrinkage and resolution of skin changes with neoadjuvant chemotherapy represent a select group of patients who can have BCT. These patients have favorable rates of long-term local control and survival. Mastectomy is not mandatory for all patients with breast cancer who present with skin involvement.

Adult↗
PubMed2004

Feasibility of breast-conserving surgery for patients with breast carcinoma associated with nipple discharge.

BACKGROUND: Few studies in the literature address the surgical management of patients with breast carcinoma who present with associated nipple discharge. The purpose of the current study was to determine the feasibility of breast-conserving surgery (BCS) for these patients. METHODS: The medical records of patients who presented with pathologic nipple discharge and underwent diagnostic or curative surgery between January 1990 and December 2002 were retrospectively reviewed. RESULTS: A total of 188 patients presented with nipple discharge during the study period. Of those, 47 had breast carcinoma. One patient had metachronous bilateral nipple discharge associated with malignant disease. Therefore, medical records associated with a total of 48 cases were reviewed. The median patient age was 52 years (range, 29-87 years), and the median follow-up duration was 45 months (range, 6-109 months). Twenty-nine patients had ductal carcinoma in situ (DCIS), 14 had Stage I disease, 3 had Stage II disease, and 2 had Stage III disease. Twenty-four patients were ultimately treated with mastectomy. For 16 of these patients, mastectomy was required because extensive disease was found in reexcisional segmental mastectomy specimens. Among patients with Stage 0 or I disease, the incidence of occult nipple-areola complex (NAC) involvement was 16% (3 of 19 patients). Twenty-four patients were ultimately treated with BCS with (n = 13) or without (n = 11) adjuvant radiotherapy. Local disease recurrence was noted at 14, 28, and 40 months, respectively, in 3 patients who declined adjuvant radiotherapy after BCS for DCIS. Among patients treated with BCS, comedonecrosis, multifocality, and the absence of adjuvant radiotherapy were associated with decreased local recurrence-free survival (P = 0.0005, P = 0.045, and P = 0.013, respectively). However, disease-free survival (mean +/- standard error) was similar for patients who underwent mastectomy and patients who underwent BCS (90 +/- 6 months; 95% confidence interval [CI], 78-101 months vs. 82 +/- 6 months; 95% CI, 69-94 months; P = 0.528). One patient with Stage I disease died of distant metastases at 99 months. CONCLUSIONS: Patients with breast carcinoma accompanied by nipple discharge presented primarily with early-stage breast carcinoma associated with DCIS. Occult NAC involvement was not an uncommon finding in patients with early-stage breast carcinoma. Nonetheless, BCS can be performed safely if negative margins are achieved and if appropriate adjuvant radiotherapy or systemic therapy is administered.

Adult↗
PubMed2004

The use of alternate, non-cross-resistant adjuvant chemotherapy on the basis of pathologic response to a neoadjuvant doxorubicin-based regimen in women with operable breast cancer: long-term results from a prospective randomized trial.

PURPOSE: To evaluate the use of an alternate, non-cross-resistant adjuvant chemotherapy regimen in women with a poor pathologic response to a preoperative doxorubicin-based regimen. PATIENTS AND METHODS: Patients with locally advanced breast cancer received three cycles of vincristine, doxorubicin, cyclophosphamide, and prednisone (VACP) every 21 days followed by surgery. Patients with less than 1 cm(3) residual tumor at mastectomy received an additional five cycles of VACP. Those with more than 1 cm(3) residual tumor were randomly assigned to receive an additional five cycles of VACP or five cycles of vinblastine, methotrexate with calcium leucovorin rescue, and fluorouracil (VbMF). RESULTS: One hundred ninety-three patients were evaluable. Overall clinical response was seen in 83.4% after three cycles of VACP, whereas the pathologic complete response was 12.2%. One hundred six patients were randomly assigned to VACP or VbMF. Those receiving VbMF achieved higher relapse-free survival (RFS) and overall survival (OS) than those who received additional VACP, although the differences did not reach statistical significance. Initial stage of tumor, clinical complete response, and pathologic complete response were all associated with statistically superior survival rates. CONCLUSION: Clinical and pathologic response to preoperative doxorubicin-based chemotherapy predicted for improved survival in women with operable breast cancer. For those with a poor response to initial neoadjuvant chemotherapy, treatment with VbMF was associated with a trend toward improved RFS and OS compared with those continuing with the doxorubicin regimen.

Adolescent↗