Owen Ung

Effect of margins on ipsilateral breast tumor recurrence after breast conservation therapy for lymph node-negative breast carcinoma.

Breast conservative surgery (CS) with radiotherapy (RT) is the most commonly used treatment for early‐stage breast carcinoma. However, there is controversy regarding the importance of the pathologic margin status on the risk of ipsilateral breast tumor recurrence (IBTR). The current study evaluated the effect of the pathologic margin status on IBTR rates in a cohort of women with lymph node‐negative breast carcinoma treated with CS and RT.

Frequency and predictors of axillary lymph node metastases in invasive breast cancer

Background:  The objectives of the present study were to evaluate the incidence and predictors of axillary lymph node metastases (ALNM) in patients with breast cancer, and to identify if axillary surgery could be safely omitted in selected patients.

Treatment implications of a positive sentinel lymph node biopsy for patients with early-stage breast carcinoma.

Sentinel lymph node (SLN) mapping and biopsy is emerging as an alternative to axillary lymph node dissection (ALND) in determining the lymph node status of patients with early‐stage breast carcinoma. The hypothesis of the technique is that the SLN is the first lymph node in the regional lymphatic basin that drains the primary tumor. Non‐SLN (NSLN) metastasis in the axilla is unlikely if the axillary SLN shows no tumor involvement, and, thus, further axillary interference may be avoided. However, the optimal treatment of the axilla in which an SLN metastasis is found requires ongoing evaluation. The objectives of this study were to evaluate the predictors for NSLN metastasis in the presence of a tumor‐involved axillary SLN and to examine the treatment implications for patients with early‐stage breast carcinoma.

Combined chemotherapy and radiotherapy for patients with breast cancer and extensive nodal involvement.

PURPOSE This retrospective review examines local control, freedom from distant failure, and survival for patients with nonmetastatic breast cancer with extensive nodal disease (> 10 nodes, 45 patients; or > or = 70% involved nodes, if < 10 nodes found, 19 patients). All patients received chemotherapy and radiotherapy following mastectomy. PATIENTS AND METHODS Sixty-four patients were treated between January 1980 and December 1988 at Westmead Hospital, Westmead, NSW Australia. The median follow-up duration for surviving patients was 91.5 months (range, 56 to 121). The median age was 51 years, and the median number of positive nodes was 11. Four successive protocols evolved, each with three phases, as follows: induction chemotherapy (doxorubicin or mitoxantrone, plus cyclophosphamide; three cycles), radiotherapy (50 Gy in 25 fractions to chest wall and regional nodes), then chemotherapy (cyclophosphamide, methotrexate, and fluorouracil [CMF]) of progressively shorter duration. Radiotherapy and chemotherapy were concurrent in the fourth regimen. RESULTS One patient (1.5%) developed local recurrence before distant relapse, and seven patients (11%) developed local and/or regional recurrence simultaneously or after distant relapse. The 5-year actuarial freedom from distant relapse and overall survival rates were 45% and 65%, respectively. Overall survival did not vary significantly by menopausal status, nodal subgroup, or dose-intensity. There were no treatment-related deaths. CONCLUSION Combined chemotherapy and radiotherapy in standard dosage is an acceptable approach following mastectomy for patients with extensive nodal involvement at high risk for local recurrence and distant relapse. This approach should be considered standard best therapy for any randomized trials that examine high-dose chemotherapy or bone marrow transplantation for this subgroup of patients.

Review of complex breast cysts : Implications for cancer detection and clinical practice

The use of ultrasound in breast diagnosis has resulted in the increasing identification of incidental benign‐appearing lesions, of which complex (or atypical) breast cysts are frequently reported. Complex breast cysts were estimated to be reported in approximately 5% of breast ultrasound examinations. A systematic review of the literature on sonographically detected complex breast cysts was carried out. The quality of primary studies and extracted data on cancer detection was assessed. Very few studies have examined complex breast cysts and quantified the associated cancer detection rate. In most of these studies, subjects have been selected on the basis of progress to intervention, which would overestimate the likelihood of malignancy. The only study to examine complex cysts from all consecutive ultrasounds reported one case of non‐invasive cancer from 308 lesions − 0.3% (95% confidence interval, 0.01−1.84). Ultrasound features associated with a higher risk of the lesion being a cancer are: thickened walls, thick internal septations, a mix of cystic and solid components, and an imaging classification of indeterminate. Using the information from the present review, complex breast cysts were categorized on the basis of associated risk of malignancy, and an approach to the management of these lesions to assist clinical decision‐making was suggested. Provided adequate information is given to the patient, complex breast cysts with a very low risk of malignancy do not always require image‐guided biopsy.

A risk index for early node-negative breast cancer

This study compared the application of the St Gallen 2001 classification with a risk index developed at the New South Wales Breast Cancer Institute (BCI Index) for women with node‐negative breast cancer treated without adjuvant systemic therapy.

Is there a role for fine‐needle aspiration in radial scar/complex sclerosing lesions of the breast?

The fine‐needle aspiration cytology (FNA) from 12 mammographically detected, histologically confirmed radial scar/complex sclerosing lesions (RS/CSL) and their corresponding mammography were reviewed. Six aspirates were obtained by palpation, four by ultrasound guidance, and two by stereotactic guidance. Of the eight lesions with sufficient material, five (62.5%) were reported as benign, two (25%) as atypical, and one (12.5%) as suspicious. It is proposed that FNA for RS/CSL should not be performed, and lesions require excision for histologic assessment. Diagn. Cytopathol. 16:537–542, 1997.

Phytoestrogens and indicators of breast cancer prognosis

Abstract: Breast cancer incidence is lower and survival is longer in Asian women residing in Japan, China, or the Philippines than Caucasian women residing in the United States. Phytoestrogen intake has been examined as a possible reason for the disparity in breast cancer incidence and survival. This study examined the association between phytoestrogen intake prior to diagnosis of breast cancer and indicators of breast cancer prognosis (tumor size, estrogen and progesterone receptor status, histological grade, lymphovascular invasion, nodal spread, and stage) in 128 women, aged 40–79 yr, newly diagnosed with invasive breast cancer. After controlling for significant confounding factors, higher intakes of phytoestrogens were associated with favorable indicators of breast cancer. In women with higher intakes of phytoestrogens, there was a 32% reduction in the odds of being diagnosed with any stage of cancer other than stage 1 (95% confidence interval, CI = 0.49–0.93; P = 0.02), a 38% reduction in odds of being diagnosed with positive lymphovascular invasion (95% CI = 0.40–0.95; P = 0.03), and a 66% increase in the odds of being diagnosed with a positive progesterone receptor (95% CI = 1.06–2.58; P = 0.03). We conclude that phytoestrogen intake prior to diagnosis may improve prognosis of breast cancer.

Complex sclerosing lesion: the lesion is complex, the management is straightforward.

Background: Complex sclerosing lesion (CSL) and its smaller counterpart, the radial scar (RS), are frequently seen pathological entities. They are clinically asymptomatic and, prior to the implementation of mammographic screening, were most commonly found incidentally during pathological examination of other biopsied lesions. Complex sclerosing lesions are being detected regularly on mammograms due to widespread screening; many of their features resemble those of malignancy. Management varies and has been controversial.

COMPLETE AXILLARY DISSECTION: A TECHNIQUE THAT STILL HAS RELEVANCE IN CONTEMPORARY MANAGEMENT OF BREAST CANCER

Axillary lymph node status is an important prognostic indicator for women with breast cancer and axillary dissection provides accurate information regarding nodal status. In addition, local control of axillary disease and allocation of adjuvant systemic therapy are dependent on appropriate axillary surgery. The survival benefit of an axillary dissection remains controversial. We describe a technique of complete axillary clearance that includes levels I, II and III. In our experience this technique is associated with no additional morbidity to patients and incurs minimal prolongation of operative time compared with a level II dissection. Other operative descriptions of axillary surgery generally do not adequately describe a method that clearly and consistently identifies the boundaries, anatomical landmarks and neurovascular structures that traverse the axilla. This technique, with relative ease, allows the identification and preservation of these structures in their original anatomical planes and avoids the division of the pectoralis minor muscle. The assumption that routine level III axillary clearance, as opposed to level I or level II dissection, is associated with greater morbidity warrants further evaluation. No well‐conducted randomized trials have addressed this issue.