Barbara Fowble

Microinvasive breast carcinoma

Microinvasive breast carcinoma (MIC) has a good prognosis but specific definitions have varied in the past, making the clinical significance of MIC a subject of debate.

USE OF THE PRONE POSITION IN RADIATION TREATMENT FOR WOMEN WITH EARLY STAGE BREAST CANCER

PURPOSE The prone position has been advocated for women with large pendulous breasts undergoing breast-conserving treatment with radiation therapy. However, there is no information in the literature regarding the coverage of the target volume with this technique. The purpose of this study was to evaluate the effectiveness of the prone treatment position in including at least the biopsy cavity with a 2-cm margin. METHODS AND MATERIALS Eleven consecutive patients who underwent CT simulation in the prone position were included in this study. Patients underwent CT simulation in the prone position using a flat platform containing an aperture for the breast to hang through in a dependent fashion. CT slices were 5-mm thick taken at 3-mm intervals. The biopsy cavity was localized and outlined on sequential CT images using the surgical clips (when present) as well as the residual seroma. A 2-cm margin was included around the biopsy cavity to define the minimal target volume (mTV). Lateral fields were used for treatment planning. The beam arrangements were considered adequate if the mTV was totally included in the lateral fields. RESULTS Median age of the patient population was 55 years. Bra sizes ranged from 36A-44DD. The majority of patients had mammographically detected T1 lesions. Median volume of the biopsy cavity was 48 cm3. Five of 11 (45%) patients underwent reexcision of the biopsy cavity, and 6 of 11 (55%) had surgical clips placed in the biopsy cavity. Overall, 8 of 11 (73%) patients did not have the entire mTV included in the lateral opposed tangential fields in the prone position. This was especially true in patients whose biopsy cavity extended down to the chest wall. There were no other clinical factors that could predict for the adequacy of coverage in the prone position. CONCLUSION Special attention must be paid to the location of the surgical clips to determine the proximity of the biopsy cavity to the chest wall, or CT simulation should be performed to determine the exact location of the biopsy cavity prior to selecting patients with large pendulous breasts for treatment in the prone position.

Family History Status as a Prognostic Factor for Breast Cancer Patients Treated with Conservative Surgery and Irradiation

From 1977 to 1986, 264 women with stage I or II breast cancer and positive breast cancer family histories were treated with conservative surgery, axillary dissection, and irradiation. The records of these cases were reviewed and compared to those of 517 women with stage I or II breast cancer and negative breast cancer family histories who were treated similarly during the same time period. Patients with a negative family history were more likely to present with positive axillary lymph nodes than patients whose history was positive (33% vs. 26.5%, p = 0.054). There were no statistically significant differences found between the family history positive and family history negative women in terms of 5 and 10 year actuarial overall survival (5 yr: 91% vs. 90%, 10 yr: 86% vs. 82%) or relapse‐free survival (5 yr: 76% vs. 76%, 10 yr: 64% vs. 61 %). Breast recurrence rates were likewise not significantly different for the two groups of patients (5 yr: 6% vs. 9%, 10 yr: 17% vs. 18%). A separate analysis restricted to lymph node‐positive patients revealed no significant differences in survival between the family history positive and family history negative groups. It thus appears that women with early stage breast cancer who have a family history of the disease can be treated with breast‐conserving surgery and definitive irradiation with the same excellent results as seen in women without such a family history.

Is There a Subset of Patients with Early Stage Invasive Breast Cancer for Whom Irradiation May Not Be Indicated After Conservative Surgery Alone

Abstract: Irradiation is accepted as standard treatment following an excisional biopsy for stages I and II breast cancer and its equivalence to mastectomy has been demonstrated by a number of prospective randomized trials. However, the role of treatment directed to less than the entire breast for small invasive cancers has been questioned. This review has identified elderly women with primary tumors less than 2 cm and low histologic grade without an extensive intraductal component or lymphatic or vascular invasion, negative axillary nodes, and negative margins of resection as having a 15–20% risk of residual microscopic disease following an excision with a 2–3 cm margin of normal tissue. Breast recurrence rates in these patients range from 10–20% with conservative surgery alone and 5–10% with conservative surgery and irradiation This improvement in local control with irradiation has the potential for a 2–3% survival benefit. Therefore, even in this carefully selected group of patients irradiation decreases the risk of a breast recurrence. The role of wide excision and tamoxifen requires further investigation.

The Integration of Conservative Surgery and Radiation for Stage I-II Breast Cancer with Adjuvant Systemic Therapy

Abstract: The timing of radiation with adjuvant systemic therapy in patients with stage I‐II breast cancer treated with breast‐conservation therapy may impact on ipsilateral breast recurrence rates, cosmesis, and complications. Delays to the initiation of radiation of more than 4 months result in breast recurrence rates of 20‐25% at 5 years in patients with close or positive margins of resection. Patients with negative margins of resection do not have an increased risk of breast recurrence with delays to the initiation of radiation of 4‐6 months. The concurrent use of tamoxifen and radiation has not resulted in an increased risk of breast recurrence; however, patients treated in this manner may experience more acute reactions during radiation, including breast edema and erythema. Symptomatic pneumonitis is more frequent in patients receiving concurrent chemotherapy with methotrexate and radiation to the breast and regional nodes. A higher incidence of arm edema, rib fractures, and cardiac events has been reported in patients receiving radiation and chemotherapy. Cosmesis may be adversely affected by the concurrent use of chemotherapy with methotrexate or tamoxifen during radiation. The optimal sequencing of radiation and adjuvant systemic therapy requires further study.

The Role of Radiotherapy in the Treatment of Ductal Carcinoma In Situ—The Challenge of the 1990s

uctal carcinoma in situ (DClS) represents 10-15% D of all breast cancer and 20-30% of those detected solely by mammography. Treatment has traditionally been mastectomy. Winchester et a1 (1) reported that 55% of the 6,225 cases of DClS submitted to the National Cancer Data Base in 1991 had a mastectomy, 20% had conservative surgery alone, and 15% conservative surgery and radiation. The use of conservative surgery and radiation for the treatment of DCIS has followed the published reports from individual institutions as well as prospective randomized trials demonstrating the equivalence of this modality to mastectomy for the treatment of invasive breast cancer. As the role of radiation following conservative surgery for early stage invasive breast cancer was questioned in prospective randomized trials, its role in localized DCIS was also challenged by a number of prospective randomized trials and individual investigators. The treatment of DClS remains controversial. The controversy reflects our limited knowledge regarding the natural history of DCIS in the conserved breast as well as its heterogeneity in terms of clinical presentation, mammographic appearance, distribution in the breast, pathology, and biologic markers. These issues are least relevant in patients undergoing mastectomy.

The Identification of a Subset of Patients with Axillary Node‐Negative Minimally Invasive Breast Cancer Who May Benefit from Adjuvant Systemic Therapy

Abstract: It is generally accepted that women with axillary node‐negative minimally invasive breast cancers (≤1 cm) are not candidates for systemic therapy because of their low risk for distant metastases and excellent overall prognosis. However, recent studies have suggested that a subset of these patients may have a significant risk of failure. In this study, 188 women with axillary node‐negative minimally invasive breast cancer (≤1 cm) were treated with conservative surgery and radiation. Their median age was 56 years. The median followup was 6.2 years. The following factors were analyzed for their ability to predict for freedom from distant metastases, distant disease‐free survival, and cause‐specific survival: patient age, method of detection of the primary, tumor size, estrogen and progesterone receptor status, and lymphatic invasion.

The Results of Conservative Surgery and Radiation for Mammographically Detected Ductal Carcinoma In Situ

Abstract: Approximately 85% of all ductal carcinoma in situ (DCIS) are now detected by mammographic screening. For the most part, the literature that reported the results of conservative surgery and radiation for DCIS reflected outcomes in a heterogeneous patient population that frequently included patients with clinically evident DCIS (palpable mass or bloody nipple discharge). There are limited data regarding outcome in patients with mammographically detected DCIS treated with conservative surgery and radiation. The 10‐year breast recurrence rate ranges from 4% to 7% for patients with negative margins of resection with a 10‐year cause‐specific survival of 96–100%. Factors that have been associated with an increased risk of breast recurrence include the failure to remove all malignant appearing calcifications prior to radiation and positive margins of resection. The influence of young age and positive family history on breast recurrence rates requires further study. To date there has been little correlation with the pathologic features of DCIS (architectural pattern, necrosis, nuclear grade) and breast recurrence rates in patients receiving radiation. Comedo or high nuclear grade DCIS tends to recur at a shorter median interval than noncomedo or low nuclear grade DCIS. Approximately 50% of the recurrences are invasive and salvage mastectomy has resulted in long‐term control in 100% of the noninvasive recurrences and approximately 80% of the invasive recurrences.

Conservative Surgery and Radiation for Stage I and II Breast Cancer: Identification of a Subset of Patients with Early Stage Breast Cancer for Whom Breast-Conserving Therapy May Be Contraindicated

onservative surgery and radiation has been estabC lished as an alternative equal to mastectomy for stages I and I1 breast cancer by six prospective randomized trials (1-6). In five (1, 2, 4-6) of the six trials, the risk of recurrence in the breast following radiation was not signficantly different from the risk of a recurrence in the chest wall after mastectomy. At 5 years, the risk for either type of local recurrence was 5-10% (1, 2, 4-6). However, data from retrospective series have identified several factors that may predispose certain patients with early stage breast cancer to a substantially higher risk of recurrence in the breast (30-40%) when treated with excision and radiation. While there is no consensus as to the magnitude of the risk that would result in a recommendation for mastectomy, some of these factors have been included in the guidelines established by the Patterns of Care study (7) , and the report from the American College of Radiology, the American College of Surgeons, College of American Pathologists, and Society of Surgical Oncology (8) as relative or absolute contraindications to conservative surgery and radiation. The com-