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PubMed1997

Lumpectomy or mastectomy? Is breast conserving surgery too expensive?

In the last decade, breast cancer patients have enjoyed an increase in breast conserving surgery (BCS). At present, modified radical mastectomy (MRM) and BCS offers equal expectations of survival. During the last few years, however, a drop in the frequency of BCS has been reported by several authors. Is this new trend due to economic concerns? To clarify the costs of breast cancer therapy (stage I and II), we review the literature and include a cost-utility and a cost-minimisation analysis comparing MRM and BCS. The treatment cost (per patient) of BCS and MRM in Norway was calculated at $9,564 and $5,596, respectively. Employing a quality of life gain in BCS of 0.03 (0-1 scale) and a 5% discount rate, the cost per QALY in BCS compared to MRM was $20,508. In cost-minimising analysis, BCS and mastectomy followed by reconstructive surgery had a cost of $10,748 and $8,538, respectively. This indicates that BCS remains within reasonable cost and should not be displaced by mastectomy on economic grounds.

Breast Neoplasms↗

PubMedDate not supplied

Surgical treatment of pregnancy associated breast cancer.

As the average age of parity increases amongst American women, the incidence of pregnancy associated breast cancer is also rising. The physiologic changes of the breast in pregnancy must be appreciated and understood in order to accurately and expeditiously diagnose pregnancy associated breast cancer (PABC). Core biopsy provides the safest and most accurate diagnostic tool. Once a diagnosis is made, risks and benefits to both the mother and the fetus must be considered prior to accepting a definitive management strategy. Historically women with PABC were encouraged to undergo modified radical mastectomy and to terminate pregnancy in order to safely proceed with adequate adjuvant therapy. Current care, however, relies upon multimodality therapy directed by multidisciplinary teams. PABC diagnosed early in the first trimester is best managed surgically by modified radical mastectomy followed by adjuvant chemotherapy in the second trimester. Women diagnosed in the late first, or the second or third trimesters may be safely treated with the surgical techniques of their choosing. Neoadjuvant chemotherapy, sentinel node biopsy and breast conservation are now considered safe modalities in properly chosen pregnant patients.

Adult↗

PubMed2001

Low-grade (fibromatosis-like) spindle cell carcinoma of the breast.

Spindle cell carcinoma of the breast, a variant of metaplastic carcinoma, includes a wide spectrum of lesions with histomorphologic and nuclear features ranging from overtly malignant to mildly atypical. Spindle cell carcinomas with mildly atypical features may resemble fasciitis, fibromatosis, or myofibroblastic tumors and therefore are often misinterpreted as such. A recent study has suggested that spindle cell carcinomas with a dominant fibromatosis-like phenotype, unlike spindle cell carcinomas in general, have no propensity for distant metastasis and should be termed "tumors" rather than "carcinomas." To investigate the question of fibromatosis-like spindle cell breast carcinoma (FLSpCCs) metastatic potential, we studied cases of FLSpCC seen at the University of Texas M.D. Anderson Cancer Center between 1987 and 2000. Clinical, pathologic, and immunophenotypic features were reviewed, with emphasis on biologic behavior and predictors of clinical outcome. Our series included 24 women who ranged in age from 55 to 85 years (mean 66 years). Tumor size ranged from 1.0 to 5 cm (mean 2.8 cm). Most tumors were grossly well defined but had microscopic infiltrative borders. Tumors showed a dominant fibromatosis-like or myofibroblastic-like growth pattern with prominent collagenization. Inflammatory infiltrate was noted in the majority of tumors. Cytokeratin-positive cells were seen in all cases and usually appeared as cords or sheets of polygonal cells; isolated cytokeratin-positive cells were rare. In most tumors immunoreactivity for smooth muscle actin (SMA) was confined to the cytokeratin-negative cells. In five cases intense co-expression of cytokeratin and SMA was noted. None of the tumors showed immunoreactivity for smooth muscle heavy chain myosin, estrogen receptors, progesterone receptors, or HER-2/neu. Ki-67 expression was noted in fewer than 5% of tumor cells. Treatment consisted of local excision (seven cases) or modified radical mastectomy (13 cases). Treatment was unknown in four cases. In patients who underwent axillary nodal dissection, no lymph node metastases were found. Two of the six patients who underwent local excision developed local recurrence. Two patients who underwent modified radical mastectomy developed lung metastases within 2 years after the initial diagnosis. The metastatic tumors were histologically similar to the primary tumors. Our findings indicate that FLSpCCs have the potential for local recurrence and distant metastasis and should be treated accordingly. Because FLSpCCs may be underdiagnosed as benign, the use of immunohistochemical studies, especially for cytokeratins and SMA, is essential in the evaluation of any spindle cell proliferations of the breast.

Actins↗

PubMed1997

Surgical management of breast cancer in Australian women in 1993: analysis of Medicare statistics.

OBJECTIVE: To examine patterns of surgical management of breast cancer among Australian women. DESIGN: Retrospective survey of Medicare records (a national dataset of all services rendered on a "fee-for-service" basis for which a Medicare benefit has been paid). PATIENTS: All Australian women (4683) who underwent surgery consistent with being for breast cancer in 1993 and for which Medicare benefits were paid. MAIN OUTCOME MEASURES: Proportions of women undergoing different forms of mastectomy, breast-conserving surgery and axillary surgery by patient age and State and region (urban or rural) of residence. RESULTS: Modified radical mastectomy was the most common surgery, performed in 2097 of the 4683 women (44.8%), while 1868 (39.9%) had breast-conserving surgery. Frequency of breast conservation decreased significantly with age and varied significantly between States and region of residence. It ranged from 34% in Western Australia to 49% in South Australia and the Northern Territory, and from 34% among rural women to 42% among urban women. Axillary surgery was recorded for 83% of all women studied. CONCLUSIONS: There was substantial geographical variation in patterns of surgical management for breast cancer. The tendency for rural women to undergo mastectomy rather than breast-conserving surgery may reflect the relative lack of access to postoperative radiotherapy. We are unable to explain the variation between States.

Adult↗

PubMed1989

Ten-year results of a randomized trial comparing a conservative treatment to mastectomy in early breast cancer.

A randomized trial was conducted at the Institut Gustave-Roussy (IGR) between 1972 and 1980 comparing tumorectomy and breast irradiation with modified radical mastectomy. One hundred and seventy-nine patients with an infiltrating breast carcinoma up to 20 mm in diameter at macroscopic examination were included: 88 had conservative management, and 91 a mastectomy. All patients had a low-axillary dissection with immediate histological examination. For the patients with positive axillary nodes, a complete axillary dissection was undertaken. Overall survival, distant metastasis, contralateral breast cancer and locoregional recurrence rates were not significantly different between the two treatment groups.

Adenocarcinoma↗

PubMed2004

Clinical practice guidelines for the care and treatment of breast cancer: 15. Treatment for women with stage III or locally advanced breast cancer.

OBJECTIVE: To define the optimal treatment for women with stage III or locally advanced breast cancer (LABC). EVIDENCE: Systematic review of English-language literature retrieved from MEDLINE (1984 to June 2002) and CANCERLIT (1983 to June 2002). A nonsystematic review of the literature was continued through December 2003. RECOMMENDATIONS: The management of LABC requires a combined modality treatment approach involving surgery, radiotherapy and systemic therapy. Systemic therapy: chemotherapy. Operable tumours. Patients with operable stage IIIA disease should be offered chemotherapy. They should receive adjuvant chemotherapy following surgery, or primary chemotherapy followed by locoregional management. Chemotherapy should contain an anthracycline. Acceptable regimens are 6 cycles of FAC, CAF, CEF or FEC. Taxanes are under intense investigation. Inoperable tumours. Patients with stage IIIB or IIIC disease, including those with inflammatory breast cancer and those with isolated ipsilateral internal mammary or supraclavicular lymph-node involvement, should be treated with primary anthracycline-based chemotherapy. Acceptable chemotherapy regimens are FAC, CAF, CEF or FEC. Taxanes are under intense investigation. Patients with stage IIIB or IIIC disease who respond to primary chemotherapy should be treated until the response plateaus or to a maximum of 6 cycles (minimum 4 cycles). Patients with stage IIIB disease should then undergo definitive surgery and irradiation. The locoregional management of patients with stage IIIC disease who respond to chemotherapy should be individualized. In patients with stage IIIB or IIIC disease who achieve maximum response with fewer than 6 cycles, further adjuvant chemotherapy can be given following surgery and irradiation. Patients whose tumours do not respond to primary chemotherapy can be treated with taxane chemotherapy or can proceed directly to irradiation followed by modified radical mastectomy, if feasible. Systemic therapy: hormonal therapy. Operable and inoperable tumours. Tamoxifen for 5 years should be recommended to pre- and postmenopausal women whose tumours are hormone responsive. Locoregional management. Operable tumours. Patients with stage IIIA disease should receive both modified radical mastectomy (MRM) and locoregional radiotherapy if feasible. They may be managed with MRM followed by chemotherapy and locoregional radiotherapy, or chemotherapy first followed by MRM and locoregional radiotherapy. Breast-conserving surgery is currently not a standard approach. Locoregional radiotherapy should be delivered to the chest wall and to the supraclavicular and axillary nodes. The role of internal mammary irradiation is unclear. Inoperable tumours. Patients with stage IIIB disease who respond to chemotherapy should receive surgery plus locoregional radiotherapy. The locoregional management of patients with stage IIIC disease who respond to chemotherapy is unclear and should be individualized. Patients whose disease remains inoperable following chemotherapy should receive locoregional radiotherapy with subsequent surgery, if feasible. VALIDATION: The authors' original text was revised by members of the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Subsequently, feedback was provided by 9 oncologists from across Canada. The final document was approved by the steering committee. SPONSOR: The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer was convened by Health Canada. Completion date: December 2003.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1999

The Outcome of Patients with Breast Cancer Who Underwent Breast Conserving Treatment with or without Immediate Volume Replacement with Autogenous Tissue.

BACKGROUND: Breast conserving treatment (BCT) is accepted as an appropriate therapy for most patients with stage I and stage II breast cancer. However, BCT is associated with a relatively high incidence of local recurrence, and aesthetically unacceptable results occur in some patients. A novel method of immediate volume replacement using autogenous tissue has been developed to strike a balance between adequate excision and cosmesis. We determined the oncological outcome inpatients with breast cancer treated with wide excision, immediate volume replacement with autogenous tissue, and axillary dissection followed by radiotherapy. METHODS: One hundred fifty-three patients with TIS, stage I, II, or III breast cancer underwent wide excision and axillary dissection. The surgical margin ofexcised breast tissue was examined histologically during surgery. If involved, the breast tissue adjacent to the primary site was excised. When the margin of re-excision was positive, patients underwent modified radical mastectomy with or without breast reconstruction. After wide excision, immediate volume replacementwith autogenous tissue was perform-ed, unless the deformity was corrected by undermining and conization of the residual breast tissue. Postoperatively, all patients received breast irradiation. RESULTS: Eighteen patients underwent modified radical mastectomy. The surgical margin was negative in 132 of the 135 patients who underwent BCT. The crude local recurrence rate was 0.7% (1/135). Estimated overall and disease-free 5-year survival rates were 96% and 94%, respectively. CONCLUSION: Wide excision with tumor-free margins and axillary dissection followed by breast irradiation provides adequate local control in many patients with breast cancer. Immediate breast volume replacement with autogenous tissue mayavoid some unpleasant cosmetic results associated with extensive local resection. Our technique eliminates the need for mastectomy in selected patients.

Journal Article↗

PubMed1997

[Psychosocial acceptance of surgical interventions of the breast in oncological gynecology].

In a retrospective analysis of 197/600 women (33%) treated for primary breast cancer at the Department of Obstetrics and Gynecology at the University of Münster (1984 to 1994) the psycho-social acceptance of mastectomy vs. breast conservative treatment (BET) was evaluated. Mean age was 59 years (range, 31-87 yrs.). BET was performed in 58% (n = 114), modified radical mastectomy (MRM) in 42% (n = 83). Reconstructive surgery after MRM was performed in 40% (n = 33) either as primary procedure in 39% (n = 14) or as secondary procedure in 61% (n = 20). In addition to somatic patterns, features of pre- and postoperative coping, individual psycho-social burden, cosmetic results, contentment of treatment, social rehabilitation and quality of life were evaluated. Performance status and quality of human relations are discussed. In terms of psycho-social acceptance the results of BET are in general not superior to MRM at a mean follow-up of six years. Coping and postoperative quality of life are almost similar within the two groups. Although the alteration of body image after BET is less compared to MRM, the psychologic burden of postoperative radiotherapy and the fear of local recurrence are experienced worst compared to all other features analyzed after BET.

Adaptation, Psychological↗

PubMed2003

Skin-sparing mastectomy. specialty bias and worldwide lack of consensus.

BACKGROUND: Skin-sparing mastectomy (SSM) is a variation of modified radical mastectomy (MRM) optimized for reconstruction. The authors attempted to determine SSM attitudes and biases within different specialties and countries throughout the world. METHODS: The authors polled 11,485 individuals via e-mail, including members of surgical, medical, and breast oncology societies, about SSM. Respondents were directed to a survey website where data were directly entered into a database. RESULTS: Among 1027 respondents, 19 said their knowledge was insufficient to attempt the survey. Surveys were completed by 1008 respondents (8.8%) from 52 countries, comprising 436 (43.3%) surgeons, 376 (37.3%) medical oncologists, 146 (14.5%) radiation oncologists, and 50 (5.0%) individuals from other fields. Of the respondents, 61.9% stated that SSMs are performed at their institution. However 19.1% of these believed that SSM leaves the nipple and areola intact. This perception was higher outside the U.S. (P < 0.0001). Despite knowledge by 77.8% that SSM does not have a higher local disease recurrence rate than MRM, 25.3% of these individuals did not believe the literature. This was most prevalent among radiation oncologists (48.5%), as was the belief that SSM is contraindicated in patients with ductal carcinoma in situ and invasive breast carcinoma (23.3%). CONCLUSIONS: Despite a developing body of literature, there was variation in opinion among specialties and a lack of understanding of SSM. Many physicians were not familiar with the literature. Among those who were, skepticism was highest among radiation oncologists. Although these results were indicative of only those responding, education about SSM is needed across specialties and in other countries if the procedure is to be widely accepted.

Breast Neoplasms↗

PubMed2004

[Deep inferior epigastric perforator (DIEP) free flap in immediate breast reconstruction].

OBJECTIVE: In order to facilitate psychological rehabilitation of the women who underwent modified radical mastectomy for breast cancer, the DIEP free flap was used for immediate breast reconstruction in a series of patients. We present a review of the surgical outcomes. METHODS: From December 2001 to January 2003, unilateral breast reconstruction was performed in 12 patients using the DIEP free flap at the same time of modified radical mastectomy in our department. The recipient vessels were the thoracodorsal artery and vein or the internal mammary artery and its venae concomitants. RESULTS: Of the 12 DIEP flaps, 1 was vascularized by a single perforator, 3 were vascularized by two perforators, 6 by three perforators, 1 by four an 1 by five perforators. One flap failed totally, likely due to previous multiple lower abdominal operations. The eleven reconstructed breasts achieved almost the same size and shape as the healthy sides. The time of patient getting out of bed ranged from 3 to 7 days and the mean hospital stay was 8.8 days. All patients were satisfied with the outcome. No complications were observed in the abdominal wall, including weakness, abdominal bulge or hernia. CONCLUSION: Immediate breast reconstruction facilitates the psychological rehabilitation and helps to avoid the dressing inconveniences resulted from total mastectomy. Free DIEP flap is a new and reliable technique for immediate breast reconstruction with autologous tissue. This flap offers the patients the same advantages as the TRAM flap and avoids its most important disadvantage of potential abdominal wall weakness, by preserving the continuity of the rectus abdominis muscle. The donor site morbidity is thus reduced and recovery is faster. The more complex nature of this procedure leads to increased operating time and requires more demanding surgical skills.

Adult↗

PubMed1994

[Reconstructive surgery in breast cancer operation].

We reported our experience with immediate breast reconstruction after partial or total mastectomy. In patients who underwent breast conserving surgery (BCT), an immediate transposition of adipose tissue with latissimus dorsi muscle vascular pedicle was carried out with the aim of improving cosmetics after wide excision. In those who received modified radical mastectomy, immediate breast reconstruction (MIBR) using a transverse abdominomyocutaneous flap or latissimus dorsi myocutaneous flap was carried out. Although either BCT or MIBR was performed at the patient's request, reconstructive surgery thus plays an important role in breast cancer operation.

Adult↗

PubMed1996

Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow-up data. Institut Gustave-Roussy Breast Cancer Group.

PURPOSES: A randomized trial was conducted to compare tumorectomy and breast irradiation with modified radical mastectomy. We have analyzed the patterns of failure in each arm of the trial and the prognostic factors that have an independent effect on treatment failures and overall survival. PATIENTS AND METHODS: The trial included 179 patients with breast cancer of up to 20 mm in diameter at macroscopic examination. Eighty-eight patients had conservative management and 91 a mastectomy. All patients had axillary dissection with frozen-section examination. For patients with positive axillary nodes (N+), a second randomization was performed: lymph node irradiation versus no further regional treatment. Patterns of failure were determined by a competing-risk approach and multivariate analysis. A prognostic-score was determined by multivariate analysis. RESULTS: Overall survival, distant metastasis, contralateral breast cancer, new primary malignancy, and locoregional recurrence rates were not significantly different between the two surgical groups, or between lymph node irradiation groups. Most recurrences appeared during the first 10 years. Three distinct prognostic groups were determined taking into account age, tumor size, histologic grading, and number of positive axillary nodes. CONCLUSION: Long-term results support conservative treatment with limited surgery and systematic breast irradiation as a safe procedure for the management of small breast cancers. Four easily obtainable clinical and histologic factors may be combined in a prognostic score that is highly predictive of overall and event-free survival.

Adult↗

PubMedDate not supplied

The study of cytokine dynamics at the operation site after mastectomy.

Twenty-nine patients, who each received modified radical mastectomy, were recruited for this study. Wounds were inspected daily for the presence of flap necrosis, infection, and seroma. Drain fluid (20 ml) was collected at 6 a.m. on postoperative days 1, 2, and 5 and the levels of interleukin (IL)-4, IL-6, tumor necrosis factor-alpha, and interferon-gamma determined. For patients with no wound events, only IL-6 levels were elevated during the initial phase, but in the later phase the IL-6 levels dropped with a corresponding rise in tumor necrosis factor-alpha levels. In patients with flap necrosis, there was a sequential rise of IL-4 on day 1, IL-6 on day 2, and tumor necrosis factor-alpha on day 5, but only IL-4 was found to be a statistically significant factor associated with necrosis. In patients with seroma, the levels of IL-4 and interferon-gamma were persistently low and were both statistically significant. To conclude, IL-6 and tumor necrosis factor-alpha are important in normal postoperative wound healing and IL-4 and interferon-gamma may be associated with postoperative necrosis and seroma.

Adult↗

PubMed1994

Advantages of outpatient breast surgery.

This article outlines surgical, financial, and psychosocial advantages of outpatient, definitive breast cancer surgery. The analysis of 118 patients who underwent outpatient breast cancer surgery between January 1991 and December 1993--20 modified radical mastectomy, 90 lumpectomy and axillary dissection or axillary dissection alone, and 8 partial or simple mastectomy--revealed only three patients with minor complications requiring admission. Same-day discharge was safely accomplished by early morning admission and using recovery room time for postoperative education. Outpatient cost was $1572 compared with an average 3-day inpatient cost of $6282, for a potential savings of $4710, or 75%, per patient for modified radical mastectomy. Outpatient cost was $1080 compared with an average 2-day inpatient cost of $4907, for a potential savings of $3827, or 78%, per patient for lumpectomy with axillary node dissection. Patients have indicated a high level of satisfaction with ambulatory surgery and experienced faster healing and recovery at home within the family milieu.

Ambulatory Care↗

PubMed1989

Factors at presentation influencing the prognosis in breast cancer.

Presentation data on 607 breast cancer patients treated by a variety of modalities at Guy's Hospital, London, have been analysed using the Cox proportional hazards model, to identify factors associated with length of overall survival. When deaths attributable to causes other than breast cancer were treated as censoring events, the significant factors were found to be stage, mode of treatment, menstrual status and tumour size. The analysis was repeated for the subgroup of 326 patients treated by modified radical mastectomy. Four variables: stage, age at menarche, menstrual status and age were found to be significantly associated with both overall survival and length of distant recurrence-free interval. These factors have been combined to create a prognostic index which has been used to define subgroups of patients with different prognosis. The index has been validated on a separate group of 457 modified radical mastectomy patients treated at the same hospital.

Adult↗

PubMed2006

[Clinic applications of primary breast reconstruction with a subpectoral silicone tissue expander].

OBJECTIVE: To investigate the application of breast reconstruction that permits the surgeon to expand and recruit sufficient tissue for modified radical mastectomy, skin-sparing mastectomy and asymmetry deformity. METHODS: Placement of round tissue expander in subpectoral position below. Overexpansion of tissue expander to match over 30% approximately 50% opposite breast. After 3 months, removal of tissue expander and replacement with permanent implant. RESULTS: Postoperative follow-up for 3 months to 2 years demonstrated satisfactory results in all the cases. CONCLUSIONS: The breast reconstruction with a subpectoral silicone tissue expander is an ideal treatment to modified radical mastectomy, skin-sparing mastectomy and asymmetry deformity. The women can obtain a restored breast to approximate a full opposite breast and avoids a major distant surgical intervention and additional scars. Tissue expansion should be cautiously used in cases of patients with irradiated chest skin.

Adolescent↗

PubMed1984

Conservation surgery and radiation therapy in the treatment of operable breast cancer.

The combination of conservation surgery and radiation therapy for favorable breast cancer is gaining acceptance as an alternative to radical mastectomy. Presented here is a review of the local and regional tumor control and survival results of several authors, as well as a comparison of 1073 patients with clinically favorable breast cancer treated at the University of Texas M. D. Anderson Hospital between 1955 and 1980, 345 of whom have been treated with conservation surgery and irradiation and 728 of whom have been treated with radical or modified radical mastectomy alone. The locoregional recurrence in the patients treated with an intact breast is 4.9%, and 5.6% in patients treated with radical or modified radical mastectomy; there is no significant difference in the 10-year disease-free survival rates between the two groups. A detailed analysis of the location and timing of recurrences and the incidence of contralateral breast cancer is presented.

Breast Neoplasms↗

PubMed2005

The pattern of lymphatic metastasis of breast cancer and its influence on the delineation of radiation fields.

PURPOSE: The delineation of radiation fields should cover the clinical target volume (CTV) and minimally irradiate the surrounding normal tissues and organs. This study was designed to explore the pattern of lymphatic metastasis of breast cancer and indications for radiotherapy after radical or modified radical mastectomy and to discuss the rational delineation of radiation fields. METHODS AND MATERIALS: Between September 1980 and December 2003, 78 breast cancer patients receiving extended radical mastectomy in the Margottini model and 61 cases with complete data were analyzed to investigate the internal mammary lymphatic metastatic status. Between March 1988 and December 1988, 46 patients with clinical negative supraclavicular nodes received radical mastectomy plus supraclavicular lymph node dissection. The supraclavicular lymph nodes and axillary lymph nodes were labeled as S and levels I, II, or III, respectively, and examined pathologically. Between January 1996 and April 1999, 412 patients who had radical or modified radical mastectomy underwent the pathologic examination of axillary or levels I, II, or III nodes. RESULTS: The incidence of internal mammary lymph node metastasis was 24.6%. It was 36.7% for the patients with positive axillary lymph nodes and 12.9% for the patients with negative axillary lymph nodes. All the metastatic internal mammary lymph nodes were located at the first, second, and third intercostal spaces. Skipping metastasis of the supraclavicular and axillary lymph nodes was observed in 3.8% and 8.1% of patients, respectively. CONCLUSIONS: According to our data, we suggest that the radiation field for internal mammary lymph nodes should exclude the fourth and fifth intercostal spaces, which may help to reduce the radiation damage to heart. It is unnecessary to irradiate the supraclavicular lymph nodes for the patients with negative axillary level III nodes, even with positive level I and level II nodes.

Adenocarcinoma↗