Jashbhai K. Patel

Axillary lymph node metastasis from an occult breast cancer

Twenty‐nine cases were reviewed in which carcinoma manifested first as the enlargement of an axillary node from an occult breast carcinoma. A small hidden breast cancer was identified in 16 patients. In the remaining 13, the breast tumor was never discovered. Regardless of whether the primary tumors were discovered, the metastasis‐free survival rates were comparable to those of patients with breast carcinoma with axillary nodal metastasis. The authors recommend that carcinoma found in an axillary node should be treated as a breast cancer, even in the absence of the breast tumor. Extensive investigative procedures in an attempt to uncover an extramammary primary site were largely unproductive and should either be omitted or performed selectively. Mammography, if positive or suspicious, can lead to the primary tumor in 75% of the patients, but, when negative, it does not necessarily exclude the breast as the source of the carcinoma. A carcinoma of the breast was found by pathologic examination in 44% of the patients with negative mammograms.

Factors affecting recurrence in lumpectomy without irradiation for breast cancer

Between 1980 and 1988, 122 women with operable invasive breast cancers underwent wide excision and axillary dissection without subsequent irradiation. During the follow‐up period of 1 to 8 years (median, 4 years), recurrences were observed in 23 patients (19%), 22 occurring in the breast and one in the axilla. This is a significant rate of recurrence and supports the need for breast irradiation after conservative surgery. The incidence of recurrence in the breast did not appear to be related to the presence or absence of axillary nodal metastasis. No recurrences were noted in 20 patients whose primary tumors were smaller than 1 cm. The incidence of recurrence was directly correlated to the increasing size of the tumor, but it also appeared to decrease with advancing age. In 31 patients over 70 years of age, only one (3%) recurrence was observed. If these early findings are confirmed, it is likely that patients with tumors smaller than 1 cm or patients over 70 years of age may be spared breast irradiation after wide excision.

Metastatic breast cancer in males assessment of endocrine therapy

From June 1958 to June 1982, 22 men with metastatic breast cancer were treated with endocrine therapy. All 22 patients were initially treated by bilateral orchiectomy, and objective response was seen in 11 (50%) patients for 15 months. Bilateral adrenalectomy was performed subsequently in 10 patients, and 8 (80%) patients had a mean duration of objective response of 15 months. Five of seven orchiectomy responders and 3 of 3 orchiectomy nonresponders subsequently responded to bilateral adrenalectomy. Tamoxifen was tried in three patients after relapse following adrenalectomy; all three patients responded with a mean duration of 9 months. One patient was successfully treated with aminoglutethimide for 7 months following orchiectomy failure. In this patient bilateral adrenalectomy was performed on disease relapse and again resulted in objective remission. In this review, a sequential endocrine therapy program provided palliation in men. Further study is required to determine the timing of the various endocrine‐modalities. Cancer 53:1344‐1346, 1984.

Does more intense palliative treatment improve overall survival in metastatic breast cancer patients

A retrospective review of 483 women who had metastatic breast cancer and were treated between 1942 and 1975 was carried out to examine the effects of improving and aggressive palliative modalities on patient survival. There was a steady increase in the proportion of patients treated by chemotherapy and/or hormonal ablative therapy. Additive hormonal therapy, irradiation, and surgery for palliation decreased in frequency during the same period. Survival time from the first recurrence did not appear to increase in these patients over the period of this study. In spite of increasingly sophisticated palliative therapies, the survival time of patients with metastasis did not appear to be significantly prolonged.

Aminoglutethimide in patients with metastatic breast cancer

Aminoglutethimide (AG) was administered as palliative therapy in 112 patients with metastatic breast cancer. In 36 patients, the dose level was 1000 mg/day; 76 patients received a dose level of 500 mg/day. Patients with brain or liver metastasis were excluded, as were patients with tumors determined to be negative for estrogen receptors. Objective regression was observed in 35(31%) patients, with the duration of response ranging from 4 to 36+ months (mean, 12 months; median, 10 months). Response was observed in 11 of 31(35%) patients with soft tissue metastasis; 16/59 (27%) patients with osseous metastasis; and 8 of 22(36%) having visceral metastasis. In 93 patients with positive estrogen receptor (ER), 33 responded (35%), whereas in 19 patients with unknown ER status, two responded (11%). Response to previous treatment with tamoxifen (TAM) had occurred in 31 patients; of these, response to AG was noted in 11 (35%). Of 24 patients failing to respond to prior treatment with tamoxifen, four (17%) responded to subsequent therapy with AG. Thirteen patients had previously received combination chemotherapy, and response to AG was noted in two (15%). The side effects observed in this study included skin rash in ten patients, fever in eight, somnolence in three, weakness and dizziness in one, headache in one, insomnia in one, dyspnea in one, and ataxia in one. Treatment had to be discontinued in eight patients, due to the severity of the side effects. As expected, patients receiving AG at the lower dose level of 500 mg/day experienced fewer and less severe side effects than those treated with the higher dose. The response rate in the 1000 mg/day group was 10/36 (28%) and in the 500 mg/day group, it was 25/76 (33%). The lower dosage was better tolerated without apparent compromise in therapeutic efficacy.

Tamoxifen (nolvadex) versus adrenalectomy in metastatic breast cancer

The relative efficacy of adrenalectomy and tamoxifen (Nolvadex) was evaluated in a randomized study of 51 patients with metastatic breast cancer. In 25 patients undergoing adrenalectomy, there were 13 responders. There were 9 responders of 26 patients receiving tamoxifen. There was no statistically significant difference. In the crossover phase, 15 patients received tamoxifen following adrenalectomy and 3 responded, one of the 6 previous adrenalectomy responders and 2 of the 9 adrenalectomy non‐responders. Nine patients underwent adrenalectomy following tamoxifen, and there were five responders, one of two tamoxifen responders and four of seven tamoxifen nonresponders. Both tamoxifen and adrenalectomy were effective modalities, and appear to retain effectiveness in crossover trials. The frequency of remission was similar in both groups treated by both modalities in different sequences. Response rates to adrenalectomy, considered as both primary and secondary therapy, were significantly higher, since 18 of 34 patients (53%) responded to this therapy, whereas 12 of 41 (29%) responded to tamoxifen as either primary or secondary therapy. Cancer 53:1333‐1335, 1984.