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Biomedical subjects

A Recht

Publications and source records attributed to A Recht.

At least 109 records · Page 6Linked to original sources
PubMed1990

Early breast cancer: predictors of breast recurrence for patients treated with conservative surgery and radiation therapy.

The identification of factors associated with breast recurrence following conservative surgery (CS) and radiation therapy (RT) is of potential use in refining patient selection criteria and treatment technique. In an attempt to define such factors we examined the relationship between various clinical, pathologic and treatment characteristics and the likelihood of breast recurrence in 783 patients with clinical stage I or II breast cancer treated between July 1968 and December 1982. Treatment consisted of complete gross excision of the primary tumor and RT to a total dose of at least 60 Gy to the primary site. During this period, pre-treatment mammograms and detailed histologic assessment of the margins of resection were not routinely performed. Median follow-up for surviving patients was 80 months. Thirteen patients (1.6%) were lost to follow-up. Ninety-one patients (12%) have developed a breast recurrence, corresponding to 5- and 10-year actuarial rates of 10 and 18%, respectively. The major feature associated with breast recurrence was the presence of an "extensive intraductal component" (EIC+). An EIC+ tumor was seen in 28% of evaluable cases with infiltrating ductal carcinoma and accounted for 60% of breast recurrences. Forty-three of 166 patients (26%) with EIC+ tumors developed a breast recurrence compared with 29 of 418 patients (7%) without an EIC (EIC-) (p = 0.0001). The 5-year actuarial rates of breast relapse were 24 and 6%, respectively (p = 0.0001). Very young age (defined as 34 years of age or younger) was also a significant factor associated with the risk of breast recurrence. Very young patients comprised 8% of the patient population and accounted for 16% of breast recurrences. Fifteen of 61 very young patients (25%) developed a breast recurrence compared with 76 of 722 older patients (11%) (p = 0.001). The corresponding 5-year actuarial rates of breast recurrence were 21 and 9% (p = 0.005). None of the other clinical or pathological factors examined by univariate analysis were significantly correlated with recurrence in the breast. A multivariate model of site of first failure (polychotomous logistic regression) also showed that EIC+ tumors and very young age were the main factors associated with a high relative risk of breast recurrence. We conclude that EIC+ tumors and very young age are associated with a high risk of breast recurrence for patients treated with limited excision prior to RT.

Actuarial Analysis↗
PubMed1990

Clinical problems in follow-up of patients after conservative surgery and radiotherapy.

Patients treated with conservative surgery and radiotherapy for early-stage breast carcinoma are at risk of developing an ipsilateral breast recurrence for a long period. Fortunately, few such patients present with an inoperable recurrence or simultaneous distant metastases. Salvage rates are high and may be improved by early detection. Although usually unambiguous, physical examination of the treated breast may reveal changes attributable to surgery and radiotherapy that can mimic a recurrent cancer. There also is substantial overlap in radiologic appearance between benign and malignant lesions. It may be necessary to perform a biopsy when there is a question of recurrence. Careful life-long follow-up of patients thus is a critical part of their care.

Breast Neoplasms↗
PubMed1990

Selection of patients with early-stage breast cancer for conservative surgery and radiation.

The great majority of patients with an early-stage breast cancer can be successfully treated with conservative surgery and radiotherapy (CS + RT). Careful clinical, radiologic, and pathologic assessment of the tumor's extent and characteristics is the key to appropriate patient selection. While disagreements remain, some guidelines for who should not be so treated have emerged. Patients with multiple palpable or radiologically detected lesions or widespread microcalcifications of the breast ordinarily should undergo mastectomy. Patients who present with a nipple discharge or subareolar mass are not suitable candidates for CS + RT unless nipple-areolar resection is acceptable to the patient. The role of pathologic margins in treatment selection remains controversial. The authors believe that margins have clinical meaning only when interpreted in relation to the histology of the primary tumor and that "negative" margins are not always needed to achieve a high rate of local tumor control.

Age Factors↗
PubMed1989

Influence of infiltrating lobular histology on local tumor control in breast cancer patients treated with conservative surgery and radiotherapy.

To determine the influence of infiltrating lobular histology on local tumor control, the authors studied 49 patients with Stages I and II infiltrating lobular breast carcinoma treated by limited excision of the tumor and radiotherapy between 1968 and 1981 (median follow-up, 75 months). Results were compared with those in 561 cases of infiltrating ductal carcinoma similarly treated during the same period. The 5-year actuarial risk of local recurrence was similar for patients with infiltrating lobular or ductal carcinoma when the latter was evaluated as a single group (12% versus 11%). However, the 12% 5-year actuarial local recurrence risk for patients with infiltrating lobular carcinoma was intermediate between that for patients with infiltrating ductal carcinomas with an extensive intraductal component (23%) and those without an extensive intraductal component (5%). The pattern of recurrence in the breast was similar in the infiltrating lobular and ductal groups. All recurrences in patients with infiltrating lobular carcinoma and 80% of recurrences in the infiltrating ductal group occurred in the vicinity of the primary tumor (P = not significant). None of the clinical or morphologic features examined significantly influenced the risk of local recurrence in patients with infiltrating lobular carcinoma. The authors conclude that combined conservative surgery and radiotherapy appear to be a reasonable treatment option for patients with infiltrating lobular carcinoma, but further follow-up will be required to confirm these results.

Adult↗
PubMed1989

Selection criteria for local excision with or without adjuvant radiation therapy for rectal cancer.

As an alternative to radical surgery, local excision with or without adjuvant pelvic radiation therapy has been used in selected patients with rectal cancer. To determine which clinical and pathologic features can predict the presence of positive lymph nodes (LN+), a retrospective review of 168 patients who underwent potentially curative surgery for rectosigmoid and rectal cancer was performed. By univariate analysis, tumor penetration, grade, and histology were significant predictive features. This was confirmed by logistic regression analysis. The incidence of LN+ increased with increasing tumor penetration (T1, 0%; T2, 28%; T3, 36%; T4, 53%; P = 0.04), grade of adenocarcinoma (well-differentiated, 0%; moderately differentiated, 30%; poorly differentiated, 50%; P = 0.07, [borderline significance]), and the presence of any colloid histology (pure adenocarcinoma, 30%; total colloid, 52%; P = 0.04). Using 2 X 2 contingency tables, the presence of blood vessel invasion (BVI), lymphatic vessel invasion (LVI), vascular invasion (VI), total colloid histology, and high grade further increased the incidence of LN+ with increasing tumor penetration. Regardless of tumor size, grade, histology, BVI, LVI, or VI, none of the nine patients with Stage T1 tumors or the seven with well-differentiated adenocarcinomas had LN+. For this group, local excision alone is recommended. The incidence of LN+ was greater than or equal to 19% in all other categories. For this group of patients, if there is no evidence of gross tumor in the pelvis, then a local excision plus adjuvant pelvic radiation may be an alternative to radical surgery.

Adenocarcinoma↗
PubMed1989

Conservative surgery and radiation therapy for early breast cancer. Long-term cosmetic results.

To evaluate the cosmetic outcome of conservative surgery (CS) and radiation therapy (RT) for early-stage breast cancer and its stability over time, we reviewed the records of 593 patients treated from 1968 to 1981. The breast appearance was scored as "excellent," "good," "fair," or "poor". Median follow-up was 76 months (range, 37 to 186 months). Cosmetic results were generally excellent or good. The percents of excellent, good, fair, and poor results at three years were 65%, 25%, 7%, and 3%, respectively. Patients not receiving adjuvant chemotherapy were more likely than those receiving chemotherapy to have excellent scores at five years (71% vs 40%). Tumor size also influenced cosmetic outcome: 73% of patients with T1 tumors vs 55% with T2 tumors had excellent scores at five years. Our results were stable over time: of 36 patients assessable at seven years whose cosmetic scores were good or excellent at three years, 34 (94%) continued to have good or excellent scores, and only two (5%) deteriorated to fair. We conclude that the cosmetic results achieved with CS and RT are good to excellent in approximately 90% of patients and that these results remain stable for at least seven years.

Adult↗
PubMed1989

Prognosis following local or regional recurrence after conservative surgery and radiotherapy for early stage breast carcinoma.

Factors which influence patient prognosis following a breast recurrence or regional nodal recurrence after initial treatment of early-stage invasive breast carcinoma with conservative surgery and radiotherapy are not well known. Ninety patients treated at the Joint Center for Radiation Therapy treated from 1968-1981 had a recurrence in the treated breast before (84) or simultaneous with (6) distant metastases. Sixty-five patients had salvage mastectomy (median subsequent follow-up in patients without further disease, 32 months; range, 1-123 months). The five-year rate of further recurrence in this group was 37%. The most important variable associated with subsequent outcome was the histology of the recurrent tumor. There were no further recurrences among 10 patients with purely non-invasive cancer or 10 patients with predominantly non-invasive disease and only focal areas of invasion. In contrast, 17/45 patients (38%) with predominantly infiltrating tumors suffered further local-regional recurrences (6) or distant metastases (11) following mastectomy (5-year actuarial rate, 55%) (p less than 0.05). Ten patients developed regional nodal failures without evidence of simultaneous breast recurrence (1 internal mammary, 3 supraclavicular, 1 both supraclavicular and axillary, and 5 axillary). Only 3 of these 10 (all with axillary node failures) did not have simultaneous distant metastases; they remain alive without evidence of further distant or local-regional recurrence following salvage treatment 1, 59, and 87 months after recurrence. We conclude that the great majority of the patients (88% in this series) who have a breast recurrence following initial conservative surgery and radiation therapy for early stage breast carcinoma will have disease limited to the breast clinically and tumors amenable to salvage mastectomy. Salvage mastectomy appears to be effective treatment for patients with an isolated breast recurrence, especially if the recurrence is predominantly or wholly non-invasive.

Adult↗
PubMed1989

Results of conservative surgery and radiation therapy for multiple synchronous cancers of one breast.

A small number of patients with early stage breast cancer are found on presentation to have two or more separate carcinomas within the breast. To assess the effectiveness of conservative surgery and radiation therapy in these patients we compared treatment outcome among 10 patients with multiple lesions (21 cancers) and 707 patients with single lesions, treated at the Joint Center for Radiation Therapy between 1968-1981. Median follow-up was 64 months and 75 months for the multiple and single lesion groups, respectively. In each patient with multiple lesions, both (or all 3) lesions had similar histologic features. Eight of these ten patients (80%) had an infiltrating ductal carcinoma (IDC) compared to 72% of patients with single lesions. Six of these 8 patients with IDC had at least 1 lesion with an extensive intraductal component (EIC), compared to a 33% incidence of an EIC in solitary lesions. All lesions were grossly excised. Radiotherapy was given to the entire breast in all patients, with the majority also receiving a boost dose to the tumor bed site. Four of the 10 patients with multiple lesions recurred in the treated breast (40%) compared to 77 of the 707 patients (11%) with single lesions (p = 0.019, Fisher exact test). In the six patients with multiple lesions who had an EIC, three developed a local failure. In comparison, 43 of 167 patients (26%) with a single lesion with EIC developed a local failure. In patients with multiple lesions, 0 of 2 with IDC without an EIC, and 1 of 2 with histologies other than IDC had recurrence in the treated breast compared to 19 of the 342 (6%) and 15 of the 198 (8%) patients with single lesions with similar histologic features, respectively (p = NS). These results suggest that the presence of 2 or more separate primary tumors in the breast is associated with a high likelihood of local recurrence after treatment with conservative surgery and radiation therapy, even when all identified tumors are grossly resected. This may reflect the common finding of an EIC in these tumors. We conclude that the use of conservative surgery and radiation therapy for patients with more than one primary cancer in the breast should be considered with caution.

Adult↗
PubMed1989

Premenopausal breast cancer patients treated with conservative surgery, radiotherapy and adjuvant chemotherapy have a low risk of local failure.

The use of adjuvant chemotherapy in premenopausal breast cancer patients with positive nodes is now routine, but the optimal local treatment of these patients is uncertain. To determine the effect of adjuvant chemotherapy on the likelihood of local recurrence as the first site of failure in premenopausal patients treated with conservative surgery (CS) and radiotherapy (RT), we examined the outcome of 74 patients treated with CS, RT, and adjuvant chemotherapy and compared it to the outcome in 192 patients treated with CS and RT alone. Adjuvant chemotherapy consisted of four or more cycles of either a doxorubicin-containing regimen or cyclophosphamide, methotrexate, and 5-fluorouracil. All patients were less than 50 years old, had UICC-AJCC Stage I or II breast cancer treated between 1968 and 1981, had gross excision of the primary tumor, and had a total radiation dose to the primary tumor bed of greater than or equal to 6000 cGy. Factors predicting for local recurrence, such as extensive intraductal carcinoma and age less than 35, were equivalent in the two groups. Women treated with adjuvant chemotherapy had significantly worse T- and N-stages than women treated with conservative surgery and radiotherapy alone: 61% versus 36% had T2 tumors (p = 0.0003), 34% versus 6% had clinically positive nodes (p less than 0.0001), and 97% versus 4% had pathologically positive nodes (p less than 0.0001). Despite the poorer prognosis of patients treated with adjuvant chemotherapy, within 5 years of diagnosis, 4% of patients who received adjuvant chemotherapy had their initial relapse in the breast and 24% had initial failure elsewhere, compared with 15% local failure first and 14% failure elsewhere first for those treated without chemotherapy (p = 0.01). We conclude that premenopausal patients with positive nodes treated with combined modality therapy (conservative surgery, radiation therapy, and adjuvant chemotherapy) have a low risk of local recurrence as a first site of failure. These results suggest a possible interaction between radiation therapy and chemotherapy in their effects on local tumor control.

Adult↗
PubMed1989

Late cosmetic outcome after conservative surgery and radiotherapy: analysis of causes of cosmetic failure.

Although the majority of patients with early breast cancer treated with conservative surgery and radiotherapy have acceptable cosmetic outcomes, the specific causes of a less-than-acceptable result are not well known. To assess the technical factors associated with late cosmetic failure, we reviewed the records of 593 patients treated with conservative surgery and radiotherapy at the Joint Center for Radiation Therapy, Boston, between 1968 and 1981. Median follow-up was 76 months with a range of 37-186 months. Using a 4-point scoring system (excellent, good, fair, poor) patients were noted to have cosmetic "failure" if scored as either fair or poor. Cosmetic results were similar at 3, 5, and 7 years with excellent or good scores seen in 88%, 90%, and 78% of patients, respectively. Three technical factors were associated with a significant worsening of the cosmetic results. The resection of 70 cm3 or more of breast tissue was more common among the failed patients than among matched patients with good or excellent results (p = 0.03). Eighty-nine percent of patients treated with a tangent pair technique had excellent results at 5 years compared to 69% of patients treated with a three-field technique (p = 0.004). The use of a larger volume implant was associated with a greater risk of a fair or poor cosmetic result compared to the use of a smaller volume implant. We conclude that overall cosmesis has been acceptable in this series, but there are technical (surgery and radiotherapy) factors which can be modified to optimize the cosmetic result without compromising local tumor control.

Breast Neoplasms↗
PubMed1989

The predictors of distant relapse following conservative surgery and radiotherapy for early breast cancer are similar to those following mastectomy.

Although previous studies have indicated that the predictors of local recurrence following conservative surgery (CS) and radiotherapy (RT) are not the same as those following mastectomy, it remains unclear whether the predictors of distant relapse differ by local treatment modality. Clinical and pathologic features predictive of distant relapse for patients treated with mastectomy have been well established and include lymph node involvement, histologic grade, and peritumoral lymphatic vessel invasion (LVI). To study the influence of these and other factors on the rate of distant relapse in patients treated with CS and RT, we have identified a group of 438 patients treated between 1968 and 1981 who met the following criteria: primary tumor size less than or equal to 5 cm, excision of the primary tumor, infiltrating ductal carcinoma as the most aggressive histologic subtype, histology evaluable for the presence of an extensive intraductal component, and a dose to the primary site greater than or equal to 60 Gy. Estrogen receptor status was available in 58% of cases, 76% had an axillary dissection, and 23% were treated with adjuvant chemotherapy. With a median follow-up of 89 months, 107 patients (24%) developed a distant relapse. The 5-year actuarial freedom from distant relapse (FDR) was 80%. Stepdown Cox proportional hazards regression analysis identified several factors associated with a significantly (p less than 0.01) increased risk for distant relapse: positive lymph nodes, histologic grade, necrosis, and lymphatic vessel invasion. The magnitude of each effect was then examined with a lifetable calculation. Five-year freedom from distant relapse was 86% for the node-negative subgroup, 78% for patients with one to three positive nodes, and 45% for patients with four or more positive nodes. For histologic grades I, II, and III, 5-year freedom from distant relapse was 96%, 97%, and 75%, respectively. For necrosis scored as absent, scant, moderate, or marked, 5-year freedom from distant relapse was 90%, 78%, 77%, and 66%, respectively. For lymphatic vessel invasion scored as absent or present, 5-year freedom from distant relapse was 85% and 63%, respectively. We conclude that the clinico-pathologic predictors for distant relapse following conservative surgery and radiotherapy appear to be the same as those following mastectomy. This observation is consistent with the notion that distant relapse is caused by the presence of micrometastases at the time of initial patient sentation and is not greatly influenced by selection of local treatment.

Breast Neoplasms↗
PubMed1989

Lymphatic vessel invasion is an independent prognostic factor for survival in colorectal cancer.

To assess whether lymphatic vessel invasion (LVI) is an independent prognostic factor in colorectal cancer, we retrospectively reviewed the records of 462 patients who underwent potentially curative surgery for carcinoma of the colon and rectosigmoid/rectum (rs/rectum) at the New England Deaconess Hospital from 1965-1978. Sixty-one patients were identified as having tumors with lymphatic vessel invasion (LVI+), and they were compared with the remaining group of 401 patients who had tumors without lymphatic vessel invasion (LVI-). The incidence of lymphatic vessel invasion was significantly increased in tumors with blood vessel invasion (24% vs. 5%, p = 0.000001). Patients with LVI+ tumors also had a significantly increased incidence of positive nodes (59% vs. 25%, p = 0.0004), the average number of positive nodes (4.8 vs. 2.2, p = 0.0003), and a lower 5-year survival rate (colon: 57% vs. 84%, p = 0.0001; rs/rectum: 38% vs. 71%, p = 0.004). There was a significant (p less than or equal to 0.05) increase in local (16% vs. 7%), abdominal (33% vs. 9%), and distant (13% vs. 4%) failure as a component of component of failure in patients with LVI+ colon cancer and a significant increase in abdominal (33% vs. 11%) and distant (13% vs. 8%) failure as a component of failure in patients with LVI+ rectosigmoid/rectal cancer. Proportional hazards analysis demonstrated that lymphatic vessel invasion was an independent prognostic factor for survival.

Adenocarcinoma↗
PubMed1989

In situ carcinoma of the breast.

In situ carcinoma of the breast is a proliferation of potentially malignant cells within the lumen of the ductal-lobular system and is classified as ductal or lobular in type. It has become an increasingly frequent clinical management problem, primarily because of its enhanced detection by screening mammography. In this paper, we discuss the problems in histologic diagnosis, the natural history, presentation, and options for management of these two forms of in situ carcinoma.

Breast Neoplasms↗
PubMed1989

Therapy of in situ cancer.

In situ carcinoma of the breast is divided into ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS). These two entities have different morphologic appearances and natural histories. The traditional treatment of DCIS has been mastectomy, which has been shown to yield a very high cure rate. Other options include excision with or without radiotherapy. Preliminary evidence suggests that these techniques can be successful in the great majority of patients, with most treatment failures being manageable by salvage mastectomy. Careful observation of these patients appears associated with a low risk of breast cancer mortality and is generally the recommended policy.

Axilla↗
PubMed1988

Resectable adenocarcinoma of the rectosigmoid and rectum. I. Patterns of failure and survival.

In an effort to determine the patterns of failure and survival of rectosigmoid and rectal cancer, a retrospective review of 168 patients who underwent potentially curative surgery at the New England Deaconess Hospital was performed. The 5-year actuarial survival for the entire group was 67%. Survival rates decreased with increasing penetration of the bowel wall by tumor and the presence of lymph node metastasis, but only the latter reached statistical significance. Those patients who underwent an abdominoperineal resection also experienced a significant decrease in survival compared to a low anterior resection. Patterns of failure, expressed as the actuarial incidence of first failure at 5 years, were examined by stage. With the exception of stages B3 and C3, there was a trend towards increased abdominal, distant, and total failure with increasing bowel wall penetration by tumor. A similar trend was seen in local failure in those patients with positive nodes. Knowledge of these data may help identify those patients who may benefit most from adjuvant therapy.

Adenocarcinoma↗
PubMed1988

Resectable adenocarcinoma of the rectosigmoid and rectum. II. The influence of blood vessel invasion.

Several series have examined the influence of blood vessel invasion (BVI) by tumor on survival of patients with colorectal cancer; however, little data are available regarding its influence on patterns of failure. In an effort to determine the influence of BVI on the patterns of failure and survival in rectosigmoid and rectal cancer, a retrospective review of 168 patients who underwent potentially curative surgery at the New England Deaconess Hospital was performed. In patients who had tumors with extramural BVI, there was a significant decrease in five-year actuarial survival compared with patients who had tumors with intramural BVI or were BVI-negative (BVI-). When the intramural and extramural types of BVI were combined, no significant impact was noted on the patterns of failure or survival in patients with BVI+ versus those with BVI- tumors. In contrast, the presence of lymphatic vessel invasion was found to significantly decrease survival. By using a proportional hazards analysis, it was found that BVI was not an independent prognostic variable. Therefore, the use of BVI alone is not recommended for selecting patients with rectosigmoid and rectal cancer who may benefit from adjuvant therapy.

Adenocarcinoma↗
PubMed1988

The effect of young age on tumor recurrence in the treated breast after conservative surgery and radiotherapy.

Prognostic factors for local recurrence following conservative surgery and radiation therapy for patients with early breast cancer have not been fully established. To evaluate the importance of young age as a prognostic factor for local recurrence, we reviewed the results of treatment of 597 patients with 607 UICC-AJCC Stage I or II breast cancers, 47 of which were diagnosed when the patient was less than 35 years old. All were treated with excisional biopsy and a total dose to the site of the primary tumor of 60 Gy or more. The median follow-up in survivors was 63 months. Patient age and the presence of an extensive intraductal component (EIC) were both highly associated with the likelihood of tumor recurrence in the treated breast. Patients under 35 had an actuarial 5-year recurrence rate of 26%, compared to 10% for older patients (p = 0.002). Patients with an EIC had a breast recurrence rate of 25%, compared to 5% when EIC was absent (p less than 0.0001). Although the incidence of an EIC was higher in the younger subgroup (44% vs. 31%), this alone did not account for the difference in in breast recurrence rates, since younger patients had a higher recurrence rate than older patients even when an EIC was absent (22% vs. 3%, p = 0.0003). We conclude that the age of the patient is an important prognostic factor for local recurrence following conservative surgery and radiation therapy. This finding is in part attributed to the observation that younger women are more likely to have tumors with an EIC than older women, but even when an EIC is absent, they may be at an increased risk of local recurrence. However, caution is required in interpreting these findings with regard to selecting among treatment options until further data are available comparing the results of conservative surgery and radiation therapy to those of mastectomy in younger patients.

Adult↗