Bernard S. Lewinsky

The Influence of Margin Width on Local Control of Ductal Carcinoma in Situ of the Breast

BACKGROUND Ductal carcinoma in situ is a non-invasive carcinoma that is unlikely to recur if completely excised. Margin width, the distance between the boundary of the lesion and the edge of the excised specimen, may be an important determinant of local recurrence. METHODS Margin widths, determined by direct measurement or ocular micrometry, and standardized evaluation of the tumor for nuclear grade, comedonecrosis, and size were performed on 469 specimens of ductal carcinoma in situ from patients who had been treated with breast-conserving surgery with or without postoperative radiation therapy, according to the choice of the patient or her physician. We analyzed the results in relation to margin width and whether the patient received postoperative radiation therapy. RESULTS The mean (+/-SE) estimated probability of recurrence at eight years was 0.04+/-0.02 among 133 patients whose excised lesions had margin widths of 10 mm or more in every direction. Among these patients there was no benefit from postoperative radiation therapy. There was also no statistically significant benefit from postoperative radiation therapy among patients with margin widths of 1 to <10 mm. In contrast, there was a statistically significant benefit from radiation among patients in whom margin widths were less than 1 mm. CONCLUSIONS Postoperative radiation therapy did not lower the recurrence rate among patients with ductal carcinoma in situ that was excised with margins of 10 mm or more. Patients in whom the margin width is less than 1 mm can benefit from postoperative radiation therapy.

Prognostic classification of breast ductal carcinoma-in-situ

We present a new prognostic classification designated the Van Nuys classification for ductal carcinoma-in-situ (DCIS). The classification combines high nuclear grade and comedo-type necrosis to predict clinical recurrence. Three groups of DCIS patients were defined by the presence or absence of high nuclear grade and comedo-type necrosis: 1--non-high-grade DCIS without comedo-type necrosis, 2--non-high-grade DCIS with comedo-type necrosis, 3--high-grade DCIS with or without comedo-type necrosis. There were 31 local recurrences in 238 patients after breast-conservation surgery 3.8% (3/80) in group 1, 11.1% (10/90) in group 2, and 26.5% (18/68) in group 3. The 8-year actuarial disease-free survivals were 93%, 84%, and 61%, respectively (all p < or = 0.05). The Van Nuys classification defines three distinct and easily recognisable groups, each of which has a different likelihood of local recurrence if treated with breast conservation.

A Prognostic Index for Ductal Carcinoma In Situ of the Breast

There is controversy and confusion regarding therapy for patients with ductal carcinoma in situ (DCIS) of the breast. The Van Nuys Prognostic Index (VNPI) was developed to aid in the complex treatment selection process.

Outcome after invasive local recurrence in patients with ductal carcinoma in situ of the breast.

PURPOSE To detail the outcome, in terms of local recurrence, local invasive recurrence, distant recurrence, and breast cancer mortality for patients previously treated for ductal carcinoma in situ (DCIS). PATIENTS AND METHODS Clinical, pathologic, and outcome data were collected prospectively for 707 patients with DCIS accrued from 1972 through June 1997. RESULTS There were 74 local recurrences; 39 were noninvasive (DCIS) and 35 were invasive. Fifty-one percent of patients with invasive recurrences presented with stage 1 disease; the remainder presented with more advanced disease. Invasive local recurrence after mastectomy was a rare event that occurred in 0.8% of patients. Invasive recurrence after breast preservation was more common and occurred in 7.4% of patients. The 8-year probability of breast cancer mortality after breast preservation was 2.1%, a number that is likely to increase with longer follow-up. The 8-year breast cancer-specific mortality and distant-disease probability for the subgroup of 74 patients with locally recurrent disease was 8.8% and 20.8%, respectively. If only the 35 invasive recurrences are considered as events, the 8-year breast cancer-specific mortality and distant-disease probability was 14.4% and 27.1%, respectively. CONCLUSION Invasive local recurrence after breast-preservation treatment for patients with DCIS is a serious event that converts patients with previous stage 0 disease to patients with disease that ranges from stage I to stage IV. These results, however, indicate that most DCIS patients with local recurrence can be salvaged.

Duct carcinoma in situ: 227 cases without microinvasion

From 1979 to 1990, 227 patients with intraductal carcinomas (DCIS) without microinvasion were selectively treated; the least favourable (large lesions with involved biopsy margins) with mastectomy, the most favourable (small lesions with clear margins) with breast preservation. The preservation group was further subdivided into those who received radiation therapy (excision and radiation) and those who did not (excision alone). In the mastectomy group, there were 98 patients (43%) with an average lesional size of 3.3 cm; 41% had multifocal lesions, 15% had multicentric lesions. There has been one local invasive recurrence and no deaths. The 7-year actuarial disease-free survival is 98% with mastectomy. In the excision and radiation group, there were 103 patients (45%) with an average lesional size of 1.4 cm. 10 patients have had local recurrences (5 invasive and 5 noninvasive) one of whom has died. The 7-year actuarial disease-free survival is 84%, a statistically significant difference when excision and radiation is compared with mastectomy (P = 0.038). In the excision alone group, there were 26 patients (11%) with an average lesional size of 1.0 cm. There have been two local recurrences (8%), one of which was invasive and no deaths. The 7-year actuarial disease-free survival is 67%, but only 3 patients have been followed for more than 4 years. A total of 163 axillary node dissections were done; all were negative. Since DCIS without microinvasion rarely metastasizes to axillary lymph nodes, routine dissection should not be performed. Patients in this series with intraductal carcinoma treated with excision and radiation recurred locally at a statistically higher rate than those treated with mastectomy, in spite of the fact that those chosen for excision and radiation had clinically more favourable lesions. 6 of 12 (50%) local recurrences in conservatively treated patients were invasive. There was, however, no significant difference in overall survival in any subgroup regardless of treatment.

Hooked‐wire‐directed breast biopsy and overpenetrated mammography

Six hundred fifty‐three biopsies were performed for clinically occult, mammographically detected breast abnormalities. One hundred forty‐seven cancers (22.5%) were found. Eighty‐nine of those cancers (60.5%) were noninvasive. None of the in situ lesions had involved axillary lymph nodes. Of the 58 invasive cancers, only six (10.3%) had metastases to axillary nodes. Fifty‐four patients (36.7%) were treated by mastectomy while 93 patients (63.3%) were treated conservatively, 20 by biopsy only, and 73 by lumpectomy, axillary node dissection, and radiation therapy. Only four patients (0.7%) had significant complications. Cancer 59:715‐722, 1987.

Conservation therapy for invasive lobular carcinoma of the breast

Earlier literature suggests a high incidence of multicentricity and bilaterality, with an overall poor prognosis, in patients with invasive lobular carcinoma of the breast. Consequently, there is considerable disagreement regarding appropriate local management of this disease. To determine the influence of invasive lobular histologic findings on local tumor control, disease‐free survival, and overall survival, the authors reviewed 60 patients with Stage I and II invasive lobular breast carcinoma treated with local tumor excision and radiation therapy between 1981 and 1987 (mean follow‐up, 5.5 years; range, 2.5 to 10 years). The 5‐year actuarial risk of locoregional recurrence was 5%, with two of three failures occurring in the regional lymphatics. The mean time to locoregional failure was 28 months. The 5‐year actuarial disease‐free survival (84%) and overall survival (91%) were comparable to those seen in several large series of similarly treated patients with invasive ductal carcinoma. Contralateral breast cancer occurred at a rate of approximately 0.6% per year. This study and a review of the literature suggest that breast conservation, with local resection and radiation therapy, is appropriate therapy for invasive lobular breast cancer.

Breast conservation therapy after augmentation mammaplasty : Is it appropriate ?

&NA; Breast conservation therapy, consisting of lumpectomy, axillary node dissection, whole‐breast irradiation, and a boost to the tumor bed, is an increasingly popular option for the treatment of breast cancer. Among patients with stage I and stage II disease, breast conservation therapy yields survival rates equivalent to those for mastectomy. The cosmetic results of radiotherapy are usually good, and this approach preseryes an intact, sensate breast. Most studies on breast conservation therapy, however, have been performed in nonaugmented patients. Relatively little has been published regarding breast conservation therapy in the presence of silicone implants. Between 1981 and 1994, we treated 33 augmented patients with breast conservation therapy. Among 26 individuals for whom complete follow‐up data were available, 17 (65 percent) developed significant capsular contracture on the irradiated side. Thus far 8 patients with radiation‐induced contracture have undergone corrective surgery. In our experience, augmented breast cancer patients treated with breast conservation therapy have less satisfactory cosmetic results than nonaugmented women. In addition, mammographic follow‐up, critical for identifying local recurrence, may be impaired by the presence of an implant and capsular contracture. On the basis of these considerations, breast conservation therapy may be less than optimal in augmented cancer patients unless explantation is performed before treatment.

Breast-conserving therapy for ductal carcinoma in situ: a 20-year experience with excision plus radiation therapy

BACKGROUND Breast conservation therapy is a practical alternative to mastectomy for the treatment of ductal carcinoma in situ (DCIS). The role of radiation therapy after excision for DCIS has been debated, however, its value in reducing recurrence has been proven by multiple prospective randomized trials and is well accepted. METHODS We examined a prospective database of 260 patients treated for DCIS with excision and radiation from 1979 to 2002. Two different treatment regimens were examined for local recurrence-free survival. Patients treated with radiation therapy 4 days per week were compared with patients treated 5 days per week. The total doses were similar for both groups; boost types differed. Local recurrence as a function of other factors, including nuclear grade, comedonecrosis, and margin width was evaluated. RESULTS The median time to local recurrence was 61 months for patients treated 4 days per week compared with 52 months for patients treated 5 days per week (P = not significant). There was no statistical difference in the Kaplan-Meier detailing the probability of local recurrence-free survival for patients treated 4 days per week versus patients treated 5 days per week. Overall, cosmetic results between the two groups were equivalent. CONCLUSIONS The comparison of two different radiation treatment regimens shows no difference in local disease-free survival or cosmetic result.

Conservation therapy for breast cancer following augmentation mammaplasty

Breast conservation therapy (wide local excision, axillary lymph node dissection, and whole-breast irradiation) is an increasingly popular alternative to mastectomy for breast cancer patients. A sizable (and growing) number of breast cancers occur in women with prior augmentation mammaplasty. Augmented breast cancer patients are currently being treated with conservation therapy, but no study has investigated complications and cosmetic results of radiation therapy specifically in this group of women. Between 1981 and 1988, we used conservation therapy in 17 augmented breast cancer patients. Fifteen patients were available for follow-up. In 10 (67 percent), significant capsular contracture occurred in the irradiated breast an average of 12 weeks following completion of treatment. Four patients have undergone revisionary surgery to correct symptoms arising from contracture. This poor outcome contradicts the results reported in previously published studies. We conclude that irradiation of the breast for cancer in augmented women results in a high incidence of scar-tissue contracture and poor cosmetic results.