Breast cancer: strategies for the 1990's.
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Breast Neoplasms↗
Biomedical subjects
D W Kinne
Publications and source records attributed to D W Kinne.
Primary sarcomas of the breast in women under 20 years of age.
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Adenofibroma↗
Survival and prognostic factors in node-negative breast cancer: results of long-term follow-up studies.
Seven hundred sixty-seven patients treated at the Memorial Sloan-Kettering Cancer Center from 1964 through 1970 by mastectomy and axillary dissection have now been followed for a median of 18 years. This unusual database consists of a consecutive series of women cared for by physicians specialized in the treatment of breast cancer in one institution. The data suggest that patients with T1, N0, M0 tumors of 1 cm or less may be "cured" by mastectomy and axillary dissection, the estimated proportion of "cured" patients being 89%. The data also suggest that node-negative patients can be placed in categories of risk for recurrence on the basis of primary tumor size.
Breast Neoplasms↗
Staging and follow-up of breast cancer patients.
Staging systems for breast cancer, unlike those of neoplasms in distant or recessed sites, allowed for the early development of clinical staging evaluation. It was established that clinical assessment of the breast lesion was often wrong compared with the pathologic examination (benign vs. malignant); clinical measurement of the tumor in centimeters was often larger than histologic size; and clinical assessment of axillary nodes (clear or metastatic) was incorrect in about 30% of cases. Although both clinical and pathologic staging provide effective discriminants for prognosis of treated patients, prognosis is more accurately determined by the pathologic stage. The single most important prognostic indicator is the axillary nodal status, and when positive, the number of positive nodes. The American Joint Committee on Cancer and the Union International Contra Cancer have agreed on a TNM staging for breast carcinoma, and this is the preferable staging system. Follow-up of treated patients is of most value in detecting local recurrence on the chest wall (after mastectomy) or in the irradiated breast (after lumpectomy), and also in early detection of contralateral breast cancer. Physical examination and periodic mammography are most useful. There is a tendency to overinvestigate asymptomatic patients (with bone scans, blood tests, etc.), but this has been correctly criticized in recent years.
Breast Neoplasms↗
Inflammatory breast cancer.
Historically, the prognosis of inflammatory breast cancer has been poor. We conducted a retrospective review to evaluate the recent Memorial Sloan-Kettering Cancer Center experience, to evaluate the role of combination chemotherapy, and to compare the effect of surgery and radiation on local/regional failure. Fifty-six patients with local/regional inflammatory breast cancer diagnosed between 1975 and 1984 were identified. All were treated with combination chemotherapy. Overall 5-year survival was 45% with a 5-year disease-free survival rate of 37%. Twenty-one patients were treated with induction chemotherapy followed by mastectomy and adjuvant chemotherapy. Survival and disease-free survival rates were similar to those achieved in patients treated with mastectomy followed by chemotherapy. Residual cancer was found in all 21 patients treated with induction chemotherapy, with extensive disease present in 18, including six of seven complete responders. The local/regional failure rate was 34%.
Adult↗
Prognosis in T2N0M0 stage I breast carcinoma: a 20-year follow-up study.
In a study of prognosis in node-negative breast carcinoma, we investigated 293 T2N0M0 patients treated by mastectomy and axillary dissection with a median follow-up of 19.8 years. The probability of surviving 20 years considering all causes of death was 41.3% +/- 3.0%. Recurrence-free survival (Kaplan-Meier estimate) was 68.6% +/- 3% at 10 years and 63.2% +/- 3.1% at 20 years. The estimated probability of cure determined by the method of Brinkley and Haybittle was 63% (95% confidence interval [Cl], 55% to 72%). Prognosis was related to primary tumor size with the best separation (P = .06) when tumors from 2.1 to 3.0 cm (33% chance of recurrence at 20 years) and from 3.1 to 5.0 cm (44% chance of recurrence at 20 years) were compared. The histologic tumor type was prognostically important. Recurrence at 20 years was not significantly different for patients with invasive duct (34%) and lobular (42%) carcinoma. Women with special types (medullary, mucinous, papillary, etc) of carcinoma had a 25% chance of recurrence. Subsequent contralateral breast carcinoma was diagnosed in 29 patients, and four of these were fatal, accounting for only 4.6% of breast carcinoma deaths. Thirty-two patients (10.9%) developed a nonmammary malignant neoplasm (NMMN) after the ipsilateral breast carcinoma, and 69% of these lesions were fatal. Although the chances of recurrence at 20 years related to tumor size and type did not differ statistically in the series, there were trends that suggest that T2N0M0 patients can be stratified into recurrence risk groups based on tumor size and histologic type. These factors should be taken into consideration in the design and analysis of clinical adjuvant therapy trials. Measures for the early detection of common NMMNs should be included in the routine follow-up of T2N0M0 breast carcinoma patients.
Adult↗
Management of male breast cancer.
Male breast cancer afflicts about 900 men a year in the U.S., of whom 300 die of their disease. General recommendations for treatment are similar to those for females: All patients with positive nodes and selected node-negative patients considered at high risk for recurrence are advised to have systemic therapy. Tamoxifen is often recommended because the majority of male breast cancers are estrogen and progesterone-receptor positive. No significant experience has been reported with primary radiation therapy to date.
Breast Neoplasms↗
Surgical management of stage I and stage II breast cancer.
Patients with Stage I or II breast cancer are candidates for either modified radical mastectomy or breast preservation, with limited resection of the primary, axillary dissection, and breast irradiation. Overall survival rates with these two approaches are comparable in retrospective reviews and in ongoing clinical trials. Longer follow-up has confirmed earlier findings. Patients should be given these options by surgeons, radiation therapists, and other physicians involved in their care. Not all breast cancer patients will choose breast preservation, and not all are candidates for it due to tumor-related and other factors. Patient selection criteria are discussed, and optimal surgical techniques are reviewed.
Breast↗
Surgical management of stages 0, I, and IIA breast cancer.
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Axilla↗
Primary therapy for limited breast cancer. Surgical techniques.
Surgical techniques for breast cancer patients with early stages of disease are discussed. In situ cancers (LCIS, microscopic DCIS, and gross DCIS) present different risks and natural histories, and thus different treatment options are advised. For Stage I and earlier Stage II patients, either modified radical mastectomy or breast preservation with limited resection, axillary dissection, and subsequent breast irradiation are described. Immediate (or delayed) breast reconstruction offers other options for mastectomy patients.
Breast Neoplasms↗
Occult breast cancer presenting with axillary metastases. Updated management.
An isolated axillary lymph node metastasis in a woman without an obvious clinical primary site most frequently originates from the breast. Mastectomy has been the historical treatment of choice. A retrospective study of 35 patients was undertaken to evaluate the roles of modern mammography, breast preservation, and adjuvant systemic therapy in the management of these patients. Twenty-eight patients underwent a mastectomy, while 7 were managed by a combination of limited resection and/or axillary dissection and radiation therapy. Twenty-two (67%) of the 33 breast specimens contained carcinoma. Comparison of the pathologic results with the preoperative mammograms showed a specificity of 73%, while the sensitivity was only 29%. Actuarial 5-year survival after mastectomy or breast preservation was similar (77% and 65%, respectively). Patients with more than one positive lymph node benefited from adjuvant therapy. Mammography does not locate the majority of occult stage II breast cancers, and both breast preservation and adjuvant therapy may have roles in the management of these patients.
Adenocarcinoma↗
Axillary lymphadenectomy. A prospective, randomized trial of 13 factors influencing drainage, including early or delayed arm mobilization.
Greater amount and duration of postoperative wound drainage after lymphadenectomy impede healing. We evaluated the influence of early vs delayed initiation of shoulder mobilization on postoperative drainage. Fifty-seven women with clinical stage I or II breast cancer were randomized to either early (postoperative day 2) or delayed (postoperative day 5) shoulder motion. Early vs delayed time of exercise initiation had no effect on total amount or duration of drainage, either as an inpatient or outpatient. The two groups were determined to be homogeneous as to age, breast size, weight, height, obesity, previous biopsy, excision of pectoralis minor, excision of thoracodorsal complex, level of axillary dissection, total number of lymph nodes, number of positive lymph nodes, lymphatic vessel invasion (with negative lymph nodes), and whether the dominant hand was on the side operated on. The two factors predicting greater drainage were large numbers of positive lymph nodes and no previous surgical biopsy (as in one-step procedure).
Arm↗
Needle-localized mammographic lesions. Results and evolving treatment strategy.
From January 1981 to December 1987, 932 needle-localization breast biopsies were performed at our institution for mammographically detected abnormalities. We reviewed 531 needle-localization breast biopsy procedures performed during two periods (January 1981 to June 1984, n = 311; and January to August 1987, n = 220) to compare results and treatment patterns, and to determine the prevalence of the missed lesions. Mammographic abnormalities detected on routine screening accounted for a larger proportion of needle-localization breast biopsies in the later series (94 [30%] of 311 vs 94 [43%] of 220). However, the rate at which carcinoma was identified remained constant at 29% as did the percentage of cancers that were invasive (46% vs 51%). Overall, the rate of malignant diagnoses after needle-localization breast biopsy was lowest in asymptomatic women undergoing routine screening mammography (44 [24%] of 188) and significantly higher in women undergoing mammographic follow-up of the contralateral breast after treatment for breast cancer (28 [43%] of 65). There were seven missed lesions in 531 needle-localization breast biopsies, necessitating a second procedure in six and interval mammograms in one.
Biopsy, Needle↗
Breast carcinoma in situ.
A total of 150 patients with in situ breast cancer were treated from 1970 through 1976, with a median follow-up of 11.5 years. There were 42 patients with microinvasion and 25 with bilateral disease, analyzed separately. Eight patients who became unavailable for follow-up within five years (but who had no evidence of disease [NED]) were excluded. Eighty-five patients had ductal carcinoma in situ, 43 had lobular carcinoma in situ, and 22 had a mixed type. Modified radical mastectomy was done in 112 cases. One of 128 patients had positive axillary nodes; axillary dissection is not indicated for in situ breast cancer. Of the 150 patients, one with ductal disease died of disease. Six died of other causes, free of disease. Of 18 treated by excision alone, two underwent mastectomy for recurrence and had NED. Patients with microinvasion had involved nodes in 10%, and 94% had NED. However, all bilateral cases had NED.
Breast Neoplasms↗
Nonmammary malignant neoplasms in patients with stage I (T1N0M0) and stage II (T1N1M0) breast carcinoma. A long-term follow-up study.
We have recently updated the follow-up of 644 women with pathologically determined Stage I (T1N0M0) (474 patients) and Stage II (T1N1M0) (170 patients) breast carcinoma treated by modified or radical mastectomy from 1964 through 1970 at Memorial Sloan-Kettering Cancer Center. Median follow-up was 18.2 years with over 90% of surviving patients followed for 15.7 years. Recurrences occurred in 166 (26%) with 148 (23%) dead of disease and 18 (3%) alive with recurrence when last seen. A nonmammary malignant neoplasm (NMMN) was confirmed in 86 (13%) of the 644 patients. Of these, 55/86 (64%) were diagnosed after and 27 (32%) were diagnosed before the breast carcinoma. Four patients (5%) had a NMMN before and after the breast carcinoma. The most frequent sites of prior carcinoma were the cervix (n = 8), colon-rectum (n = 7), and oropharynx (n = 5), whereas the more common locations of subsequent NMMN were the ovary (n = 11), colon-rectum (n = 10), lung (n = 9), stomach (n = 6), and lymphoma-leukemia (n = 5). There was not a statistically significant difference in the frequency of subsequent NMMN when patients who received adjuvant radiation were compared with those who received adjuvant thiotepa or no adjuvant therapy. There was no excess of lymphoma or of other NMMN in the treated region or of contralateral breast carcinoma among adjuvant radiation treated patients. The overall hazard rate for subsequent NMMN was 7/1.000 women at risk per year. The risk was fairly stable over the first 15 years of follow-up but rose to 12/1,000 in the 15-20-year period. The observed frequency and time distribution of NMMN were very similar to the expected frequency determined by comparison with a population of age-matched women. Most fatal NMMN arose in the ovaries, stomach, women. Most fatal NMMN arose in the ovaries, stomach, pancreas, and lungs. There were 35 deaths due to NMMN detected subsequent to the diagnosis of breast carcinoma (15% of all cancer deaths and 64% of 55 subsequent NMMN). In this series, subsequent NMMN were as frequent as contralateral breast carcinoma, and they were responsible for seven times more deaths. Hence, an important goal of any follow-up program for breast cancer patients should be the early detection and treatment of NMMN.
Breast Neoplasms↗
Ductal carcinoma in situ: mammographic findings and clinical implications.
Mammograms, specimen radiographs, and pathology reports of 51 women with ductal cancer in situ (DCIS) in 54 breasts were retrospectively analyzed. Reason for presentation was known for 44 women, including six with symptoms due to DCIS and 16 who either had been previously treated for or had (contralateral) breast cancer. Mammographic patterns of DCIS were microcalcifications in 37 of 54 (68%) lesions and calcifications within a mass in 16 (30%). Multifocal DCIS, evidenced radiographically by patterns of more than one mass, more than one cluster of microcalcifications, or parallel linear, irregular intraductal calcifications, was seen in 35 of 54 (65%) breasts but only on specimen radiographs in four of these. In 22 (41%) lesions maximum tumor expanse was greater than 2.5 cm, and all were multicentric. Multicentricity of tumor and tumor size greater than 2.5 cm may indicate need for therapies more radical than simple excision. Breast irradiation has been shown to significantly diminish recurrence rates in these patients. Mammography and specimen radiography with magnification may be appropriate in these cases to identify all possible tumor sites in the involved breast.
Adult↗
A long-term follow-up study of survival in stage I (T1N0M0) and stage II (T1N1M0) breast carcinoma.
This study was undertaken to investigate the long-term survival and the probability of "cure" in a group of 644 patients treated by mastectomy for T1 breast carcinoma. After a median follow-up of 18.2 years, 23% were dead of recurrent breast carcinoma, 3% were alive with recurrent disease, and 74% had not experienced a recurrence. The probability of recurrence was directly related to the initial extent of the disease. Overall, 16% of recurrences and 25% of deaths due to disease occurred in the second decade of follow-up. The proportion of recurrences detected in the second decade was inversely related to the stage of the primary tumor at diagnosis. When stratified by tumor size, T1N0M0 patients with tumors 1.0 cm or less in diameter had a significantly better 20-year recurrence-free survival (86%) than did T1N0M0 patients with tumors 1.1 to 2.0 cm (69%). When observed and expected survival curves were compared by the method of Brinkley and Haybittle, it appeared that 80% of T1N0M0 patients with tumors 1 cm or less might be cured at 20 years, whereas for those in the 1.1- to 2-cm group, the proportion cured was indeterminate, but might be as high as 70%. A potentially cured group could not be identified among T1N1M0 patients, but an estimated 52% of these patients did not have a recurrence within the nearly 20-year follow-up period. These data are important when one considers the proper role of adjuvant therapy for stage I disease. Patients with tumors larger than 1 cm and those with axillary lymph node metastases may have an improved recurrence-free survival as a result of systemic adjuvant treatment, while women in the T1N0M0 group with an especially favorable recurrence-free survival, particularly those with tumors 1 cm in diameter or smaller, might be spared adjuvant therapy.
Breast Neoplasms↗
Pathological prognostic factors in stage I (T1N0M0) and stage II (T1N1M0) breast carcinoma: a study of 644 patients with median follow-up of 18 years.
Prognostic factors have been examined in 644 patients with tumor-node-metastasis (TNM) stage T1 breast carcinoma treated by mastectomy and followed for a median of 18.2 years. Overall, 148 patients (23%) died of recurrent breast carcinoma. Eighteen (3%) were alive with recurrent disease and 478 (74%) were alive or died of other causes without recurrence. Unfavorable clinicopathologic features were larger tumor size (1.1 to 2.0 cm v less than or equal to 1 cm), perimenopausal menstrual status, the number of axillary lymph node metastases, poorly differentiated grade, presence of lymphatic tumor emboli (LI) in breast tissue near the primary tumor, blood vessel invasion (BVI), and an intense lymphoplasmacytic reaction around the tumor. Median survival after recurrence for the entire series was 2 years. This was not significantly influenced by tumor size, the number of axillary nodal metastases, the type of treatment for recurrence, or the interval to recurrence. The proportions surviving 5 and 10 years after recurrence were 17% and 5%, respectively. Among T1N0M0 cases, the chance of a local recurrence was 2.8% within 20 years. Median survival of T1N0M0 cases after local recurrence (4.5 years) was significantly longer than after systemic recurrence (1.5 years). A similar trend (3.7 v 2.0 years), not statistically significant, was seen in T1N1M0 patients, who had a 6.5% chance of local recurrence within 20 years. Median survival following systemic recurrence detected 10 or more years after diagnosis in T1N0M0 and in T1N1M0 patients was significantly longer than the median survival for systemic recurrences found in the first decade of follow-up. This difference did not apply following local recurrence in either T1N0M0 or T1N1M0 cases. It is evident that patients with T1 breast carcinoma can be subdivided into differing prognostic groups and this must be taken into account when considering the role of adjuvant chemotherapy for stage I disease. Systemic adjuvant treatment may prove to be beneficial for patients with unfavorable prognostic factors, while women with an especially low risk for recurrence (eg, T1N0M0 tumor 1.0 cm or less) might be spared such treatment.
Breast Neoplasms↗