Impact of adjuvant endocrine therapy in older patients with comorbidities and estrogen receptor-positive, node-negative breast cancer-A National Cancer Database analysis.

BACKGROUND: Data are lacking about the benefit of adjuvant endocrine therapy (ET) in older patients with multiple comorbidities. The authors sought to determine the effect of ET on the survival of older patients who had multiple comorbidities and estrogen receptor (ER)-positive/human epidermal growth factor receptor 2 (HER2)-negative, pathologic node-negative (pN0) breast cancer. METHODS: Women aged ≥70 years in the National Cancer Database (2010-2014) with Charlson/Deyo comorbidity scores of 2 or 3 who had pathologic tumor (pT1)-pT3/pN0, ER-positive/HER2-negative breast cancer were divided into 2 cohorts: adjuvant ET and no ET. Propensity scores were used to match patients based on age, comorbidity score, facility type, pT classification, chemotherapy, surgery, and radiation therapy. A Cox proportional hazards model was used to estimate the effect of ET on overall survival (OS). RESULTS: In the nonmatched cohort (n = 3716), 72.8% of patients received ET (n = 2705), and 27.2% did not (n = 1011). The patients who received ET were younger (mean age, 76 vs 79 years; P < .001) and had higher rates of breast conservation compared with those who did not receive ET (lumpectomy plus radiation: 43.4% vs 23.8%, respectively; P < .001). In the matched cohort (n = 1972), the median OS was higher in the ET group (79.2 vs 67.7 months; P < .0001). In the adjusted analysis, ET was associated with improved survival (hazard ratio, 0.70; 95% CI, 0.59-0.83). CONCLUSIONS: In older patients who have pN0, ER-positive/HER2-negative breast cancer with comorbidities, adjuvant ET was associated with improved OS, which may have been overestimated given the confounders inherent in observational studies. To optimize outcomes in these patients, current standard recommendations should be considered stage-for-stage based on life expectancy and the level of tolerance to treatment.

Evolution in practice patterns of axillary management following mastectomy in patients with 1-2 positive sentinel nodes.

PURPOSE: The optimal management of breast cancer patients with a positive sentinel lymph node (SLN) who undergo mastectomy remains controversial. This study aimed to describe treatment patterns of patients with positive SLNs who undergo mastectomy using a large population-based database. METHODS: The NCDB was queried for cT1-2N0 breast cancer patients treated with mastectomy between 2006 and 2014 who had 1-2 positive SLNs. Patients receiving neoadjuvant chemotherapy were excluded. Axillary management included SLN dissection (SLND) alone, axillary lymph node dissection (ALND), post-mastectomy radiation (PMRT) alone, and ALND + PMRT. Trends of axillary management and patient characteristics were examined. RESULTS: Among 12,190 patients who met study criteria, the use of ALND dropped with a corresponding increase in other approaches. In 2006, 34% of patients had SLND alone, 47% ALND, 8% PMRT and 11% ALND + PMRT. By 2014, 37% had SLND, 23% ALND, 27% PMRT and 13% ALND + PMRT. Patients who underwent SLND alone were older (mean 60.6 years) with more comorbidities (Charlson-Deyo score > 2), smaller primary tumors (mean 2.1 cm), well-differentiated histology, hormone receptor-positive, HER2-negative tumors, without lymphovascular invasion (all P values < 0.01). Treatment with SLND alone was more likely if patients had only one positive SLN (P < 0.001) or micrometastatic disease (P < 0.001), and were treated at community centers compared with academic centers (P < 0.001). CONCLUSIONS: The management of breast cancer patients undergoing mastectomy with positive SLNs has evolved over time with decreased use of ALND and increased use of radiation. Some patient subsets are underrepresented in recent clinical trials, and therefore, future trials should focus on these patients.

Randomized trial of Tibetan yoga in patients with breast cancer undergoing chemotherapy.

BACKGROUND: The current randomized trial examined the effects of a Tibetan yoga program (TYP) versus a stretching program (STP) and usual care (UC) on sleep and fatigue in women with breast cancer who were undergoing chemotherapy. METHODS: Women with stage (American Joint Committee on Cancer (AJCC) TNM) I to III breast cancer who were undergoing chemotherapy were randomized to TYP (74 women), STP (68 women), or UC (85 women). Participants in the TYP and STP groups participated in 4 sessions during chemotherapy, followed by 3 booster sessions over the subsequent 6 months, and were encouraged to practice at home. Self-report measures of sleep disturbances (Pittsburgh Sleep Quality Index), fatigue (Brief Fatigue Inventory), and actigraphy were collected at baseline; 1 week after treatment; and at 3, 6, and 12 months. RESULTS: There were no group differences noted in total sleep disturbances or fatigue levels over time. However, patients in the TYP group reported fewer daily disturbances 1 week after treatment compared with those in the STP (difference, -0.43; 95% confidence interval [95% CI], -0.82 to -0.04 [P = .03]) and UC (difference, -0.41; 95% CI, -0.77 to -0.05 [P = .02]) groups. Group differences at the other time points were maintained for TYP versus STP. Actigraphy data revealed greater minutes awake after sleep onset for patients in the STP group 1 week after treatment versus those in the TYP (difference, 15.36; 95% CI, 7.25-23.48 [P = .0003]) and UC (difference, 14.48; 95% CI, 7.09-21.87 [P = .0002]) groups. Patients in the TYP group who practiced at least 2 times a week during follow-up reported better Pittsburgh Sleep Quality Index and actigraphy outcomes at 3 months and 6 months after treatment compared with those who did not and better outcomes compared with those in the UC group. CONCLUSIONS: Participating in TYP during chemotherapy resulted in modest short-term benefits in sleep quality, with long-term benefits emerging over time for those who practiced TYP at least 2 times a week. Cancer 2018;124:36-45. © 2017 American Cancer Society.

Reconstruction in the Metastatic Breast Cancer Patient: Results from the National Cancer Database.

PURPOSE: Modern treatments are prolonging life for metastatic breast cancer patients. Reconstruction in these patients is controversial. The purpose of this study was to characterize de novo metastatic breast cancer patients who undergo mastectomy and reconstruction and to report complication and survival rates. METHODS: We queried the National Cancer Database for de novo metastatic breast cancer patients, who underwent systemic therapy and mastectomy with reconstruction (R) or without reconstruction (NR) between 2004 and 2013. Patient-tumor characteristics, mortality, and readmissions were compared. Propensity score matched analysis was performed, and survival was calculated using the Kaplan-Meier method. RESULTS: A total of 8554 patients fulfilled study criteria (n = 980/11.5% R vs. n = 7574/88.5% NR). There was a significant increase in reconstruction rates by year: 5.2% in 2004, 14.3% in 2013 (p < 0.0001). Compared with the NR patients, R patients were younger (mean age 49 vs. 58 years, p < 0.0001), more hormone receptor-positive (76.1% vs. 70.5%, p = 0.0004), had lower grade disease (p = 0.0082), and fewer sites of metastases (85.7% had 1 metastasis; 14.3% had ≥ 2 R vs. 79% had 1; 21% had ≥ 2 NR, p = 0.0002). R patients received more hormonal and chemotherapy than NR but equally received radiation. Median overall survival of the total cohort was 45 months, and median overall survivals of R and NR groups by matched analysis were 56.7 and 55.3 months respectively (p = 0.86). Thirty-day mortality (0.2%-R, 0.3%-NR, p = 0.56) and readmissions (5.9%-R, 5.8%-NR, p = 0.81) were similar; 90-day mortality also was similar (1.1%-R vs. 1.6%-NR, p = 0.796). CONCLUSIONS: There is an increasing trend to reconstruct metastatic breast cancer patients with low complication rates, without survival compromise. Impact on quality of life warrants further assessment.

Factors impacting the accuracy of intra-operative evaluation of sentinel lymph nodes in breast cancer.

Sentinel lymph node dissection (SLND) is a standard axillary staging technique in breast cancer and intraoperative sentinel lymph node (SLN) assessment is important for decision-making regarding additional treatment and reconstruction. This study was undertaken to investigate clinicopathologic factors impacting the accuracy of intraoperative SLN evaluation. Records of patients with clinically node-negative, invasive breast cancer who underwent SLND with frozen section intraoperative pathologic evaluation from 2004 to 2007 were reviewed. Intraoperative SLN assessment results were compared to final pathology. Patients with positive SLNs that were initially reported as negative during intraoperative assessment were considered false negative (FN) events. Primary tumor histology, grade, receptor status, size, lymphovascular invasion (LVI), multifocality, neoadjuvant chemotherapy or hormonal therapy, number of SLNs retrieved, and SLN metastasis size were evaluated. The study included 681 patients, of whom 262 (38%) received neoadjuvant therapy. There were 183 (27%) patients who had a positive SLN on final pathology, of whom 60 (33%) had FN events. On univariate analysis, lobular histology, favorable histology, absence of LVI and micrometastasis were associated with a higher FN rate. On multivariate analysis, favorable and lobular histology and micrometastasis were independent predictors of FN events whereas LVI and receipt of neoadjuvant therapy were not statistically significant predictors. The accuracy of intraoperative SLN evaluation for breast cancer is affected by primary tumor histology and size of the SLN metastasis. There was no significant association between neoadjuvant therapy and the FN rate by intraoperative assessment. This information may be helpful in counseling patients about their risk for a FN intraoperative SLN assessment and for planning for immediate breast reconstruction in patients undergoing mastectomy.

Using the National Cancer Data Base for quality evaluation to assess adherence to treatment guidelines for nonmetastatic inflammatory breast cancer.

BACKGROUND: Guidelines for the treatment of nonmetastatic inflammatory breast cancer (IBC) using trimodality therapy (TT) (chemotherapy, surgery, and radiotherapy) have remained largely unchanged since 2000. However, many patients with nonmetastatic IBC do not receive TT. It is unknown how patient-level (PL) and facility-level (FL) factors contribute to TT use. METHODS: Using the National Cancer Data Base, patients with nonmetastatic IBC who underwent locoregional treatment from 2003 through 2011 were identified. The authors correlated PL factors, including demographic and tumor characteristics, with TT use. An observed-to-expected ratio for the number of patients treated with TT was calculated for each hospital by adjusting for significant PL factors. Hierarchical mixed effects models were used to assess the percentage of variation in TT use attributable to PL and FL factors, respectively. RESULTS: Of the 542 hospitals examined, 55 (10.1%) and 24 (4.4%), respectively, were identified as significantly low and high outliers for TT use (P<.05). The percentage of the total variance in the use of TT attributable to the facility (11%) was nearly triple the variance attributable to the measured PL factors (3.4%). The nomogram generated from multivariate logistic regression of PL factors only allows a facility to assess TT use given their PL data. CONCLUSIONS: FL factors rather than PL factors appear to contribute disproportionately to the underuse of TT in patients with nonmetastatic IBC. To improve treatment guideline adherence for patients with nonmetastatic IBC, it is critical to identify the specific FL factors associated with TT underuse. More organized FL intervention is required to train physicians and to build multidisciplinary teams. Cancer 2017;123:2618-25. © 2017 American Cancer Society.

Outcomes of Sentinel Lymph Node-Positive Breast Cancer Patients Treated with Mastectomy Without Axillary Therapy.

PURPOSE: Early-stage breast cancer patients with minimal axillary disease identified by sentinel lymph node dissection (SLND) have low regional recurrence rates when treated with breast-conserving surgery and radiation therapy (XRT) and many avoid a completion axillary lymph node dissection (CLND). As the incidence of total mastectomy (TM) has increased, it has become important to characterize which TM patients with a positive SLN may not benefit from further axillary treatment. METHODS: An institutional database was utilized to identify patients treated with a TM for invasive breast cancer and who had a positive SLN from 1994 to 2010. Clinicopathologic factors were analyzed. Regional recurrence rate, recurrence-free survival (RFS), and overall survival (OS) were determined. RESULTS: A total of 525 patients with invasive breast cancer and a positive SLN were treated with TM, including 58 patients who did not have CLND or XRT and 12 patients who did not have CLND but did receive XRT. Median follow-up was 66 months. The incidence of regional recurrence was not significantly different for patients who received no further axillary treatment compared to those who underwent CLND without XRT or those treated with XRT without CLND (10 years rate: 3.8 vs. 1.6 and 0 % respectively). RFS and OS were not significantly different among patients who received no further axillary treatment compared to those who underwent CLND, XRT, or both. CONCLUSIONS: In select patients with early-stage breast cancer treated with mastectomy with a positive SLN, CLND may be avoided without adversely affecting recurrence or survival.

DCIS and axillary nodal evaluation: compliance with national guidelines.

BACKGROUND: The National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) provide guidelines regarding axillary nodal evaluation in ductal carcinoma in situ (DCIS), but data regarding national compliance with these guidelines remains incomplete. METHODS: We conducted a retrospective review of the National Cancer Data Base (NCDB) analyzing all surgical approaches to axillary evaluation in patients with DCIS. Logistic regression analysis was used to assess the multivariate relationship between patient demographics, clinical characteristics, and probability of axillary evaluation. RESULTS: We identified 88,083 patients diagnosed with DCIS between 1998 and 2011; 31,912 (37%) underwent total mastectomy (TM) and 55,349 (63%) had breast conserving therapy (BCT). Axillary evaluation increased from 44.4% in 1998 to 63.3% in 2011. In TM patients, axillary evaluation increased from 74.3% in 1998 to 93.4% in 2011. This correlated with an increase in sentinel lymph node biopsy (SLNB) from 24.3 to 77.1%, while ALND decreased from 50.0 to 16.3% (p <0.01). In BCT patients, evaluation increased from 20.1 to 43.9%; SLNB increased from 7.2 to 39.4% and ALND decreased from 12.9 to 4.5%. Factors associated with axillary nodal evaluation in BCT patients included practice type and facility location. Among TM patients, use of axillary lymph node dissection (ALND) for axillary staging was associated with earlier year of diagnosis, black race, and older age, as well as community practice setting and practice location in the Southern US. CONCLUSIONS: Compliance with national guidelines regarding axillary evaluation in DCIS remains varied. Practice type and location-based differences suggest opportunities for education regarding the appropriate use of axillary nodal evaluation in patients with DCIS.

A Cost Analysis of Preoperative Breast MRI Use for Patients with Invasive Lobular Cancer.

BACKGROUND: Whereas the impact of magnetic resonance imaging (MRI) of the breast on the surgical management of breast cancer patients is well documented, less is known about its effect on health care costs. This study aimed to evaluate whether MRI use for women with invasive lobular carcinoma (ILC) significantly changes the cost of care. METHODS: Patients with ILC were recruited to a prospective registry study of breast MRI. Women who met the same inclusion criteria but had not undergone breast MRI were retrospectively identified for comparison. A micro-costing analysis using institutional billing records was conducted. Nonparametric bootstrapping was used to compare the unadjusted cost differences between the patients receiving MRI and those receiving no MRI. RESULTS: Of the patients in this study, 51 had preoperative MRI, and 60 did not. Method of diagnostic biopsy, disease stage, oncologic procedure, and rates of contralateral prophylactic mastectomy were similar between the two groups. The patients in the MRI group were younger (median age 55 vs. 64 years; p = 0.01) and more likely to undergo reconstruction (45.1 vs. 25 %; p = 0.03). The median costs of care were significantly higher in the MRI group ($24,781 vs. $18,921; p < 0.01). After adjustment for clinical factors, MRI remained significantly associated with increased cost (p = 0.03). Other factors associated with increased cost included type of oncologic procedure (mastectomy vs. lumpectomy; p < 0.01), number of operations required to achieve negative margins (1 vs. >1; p < 0.01), and use of reconstruction (p < 0.01). CONCLUSION: Preoperative breast MRI increases the median total cost of care per patient. However, the contribution to the overall cost of care is modest compared with the cost of other interventions.

Is Sentinel Lymph Node Dissection Warranted for Patients with a Diagnosis of Ductal Carcinoma In Situ?

BACKGROUND: Positive sentinel lymph node (SLN) findings in ductal carcinoma in situ (DCIS) range from 1 to 22 % but have unknown biologic significance. This study sought to identify predictors of positive SLNs and to assess their clinical significance for patients with an initial diagnosis of DCIS. METHODS: The study identified 1234 patients with an initial diagnosis of DCIS who underwent SLN dissection (SLND) at our institution from 1997 through 2011. Positive SLN findings were categorized as isolated tumor cells (ITCs) (≤0.2 mm), micrometastases (>0.2-2 mm), or macrometastases (>2 mm). Predictors of positive SLNs were analyzed, and survival outcomes were examined. RESULTS: Positive SLN findings were identified in 132 patients (10.7 %): 66 patients with ITCs (5.4 %), 36 patients with micrometastases (2.9 %), and 30 patients with macrometastases (2.4 %). Upstaging to microinvasive (n = 68, 5.5 %) or invasive (n = 259, 21.0 %) cancer occurred for 327 patients (26.5 %). Factors predicting positive SLNs included diagnosis by excisional biopsy (odds ratio [OR] 1.90; P = 0.007), papillary histology (OR 1.77; P = 0.006), DCIS larger than 2 cm (OR 1.55; P = 0.030), more than three interventions before SLND (4 interventions: OR 2.04; P = 0.022; ≥5 interventions: OR 3.87; P < 0.001), and occult invasion (microinvasive: OR 3.44; P = 0.001; invasive: OR 6.21; P < 0.001). The median follow-up period was 61.7 months. Patients who had pure DCIS with and without positive SLNs had equivalent survival rates (100.0 vs 99.7 %; P = 0.679). Patients with occult invasion and positive SLNs had the worst survival rate (91.7 %; P < 0.001). CONCLUSIONS: Occult invasion and more than three total interventions were the strongest predictors of positive SLN findings in patients with an initial diagnosis of DCIS. This supports the theory of benign mechanical transport of breast epithelial cells. Except for patients at high risk for invasive disease, routine use of SLND in DCIS is not warranted.

Primary tumor resection as a component of multimodality treatment may improve local control and survival in patients with stage IV inflammatory breast cancer.

BACKGROUND: To the authors' knowledge, the benefit of primary tumor resection among patients with metastatic inflammatory breast cancer (IBC) is unknown. METHODS: The authors reviewed 172 cases of metastatic IBC. All patients received chemotherapy with or without radiotherapy and/or surgery. Patients were classified as responders or nonresponders to chemotherapy. The 5-year overall survival (OS) and distant progression-free survival (DPFS) and local control at the time of last follow-up were evaluated. RESULTS: A total of 79 patients (46%) underwent surgery. OS and DPFS were better among patients treated with surgery versus no surgery (47% vs 10%, respectively [P<.0001] and 30% vs 3%, respectively [P<.0001]). Surgery plus radiotherapy was associated with better survival compared with treatment with surgery or radiotherapy alone (OS rate: 50% vs 25% vs 14%, respectively; DPFS rate: 32% vs 18% vs 15%, respectively [P<.0001 for both]). Surgery was associated with better survival for both responders (OS rate for surgery vs no surgery: 49% vs 23% [P<.0001] and DPFS rate for surgery vs no surgery: 31% vs 8% [P<.0001]) and nonresponders (OS rate for surgery vs no surgery: 40% vs 6% [P<.0001] and DPFS rate for surgery vs no surgery: 30% vs 0% [P<.0001]). On multivariate analysis, treatment with surgery plus radiotherapy and response to chemotherapy were found to be significant predictors of better OS and DPFS. Local control at the time of last follow-up was 4-fold more likely in patients who underwent surgery with or without radiotherapy compared with patients who received chemotherapy alone (81% vs 18%; P<.0001). Surgery and response to chemotherapy independently predicted local control on multivariate analysis. CONCLUSIONS: The results of the current study demonstrate that for select patients with metastatic IBC, multimodality treatment including primary tumor resection may result in better local control and survival. However, a randomized trial is needed to validate these findings.

Impact of identification of internal mammary sentinel lymph node metastasis in breast cancer patients.

BACKGROUND: Accurate assessment of the internal mammary (IM) nodal basin can impact prognosis and treatment in breast cancer. The goal of this study was to identify characteristics associated with positive IM sentinel lymph nodes (SLNs) and the impact on adjuvant treatment. METHODS: Clinically node-negative breast cancer patients who underwent SLN dissection including removal of IM SLNs were identified and medical records were reviewed. Statistical analysis was performed using Fisher's exact test and rank-sum tests with a significance level of 0.05. RESULTS: IM SLNs were removed in 71 patients, 60 (85 %) had negative IM SLNs, whereas 11 (15 %) had positive IM SLNs. Clinicopathologic characteristics were similar between the groups. The majority of patients in both groups had axillary SLNs removed (95 % in the node-negative group vs. 91 % in the node-positive group). Four patients (36 %) with positive IM SLNs had axillary metastasis; thus, IM nodal metastases were the only nodal metastases in 64 % of patients with positive IM SLNs. The identification of IM metastases altered adjuvant therapy in 5 (45 %) patients with positive IM SLNs. CONCLUSIONS: Patients with positive IM SLNs have clinicopathologic features similar to those of patients with negative IM SLNs limiting the ability to predict IM nodal metastasis preoperatively. The identification of IM nodal metastases significantly impacts treatment decisions, especially when IM nodes are the only site of nodal metastasis. Removal of IM SLNs should be considered when lymphoscintigraphy reveals IM drainage.

Timing of infectious complications following breast-conserving therapy with catheter-based accelerated partial breast irradiation.

BACKGROUND: Accelerated partial breast irradiation (APBI) has been used as an alternative to whole-breast irradiation as part of breast-conserving therapy. Indications and outcomes are topics of ongoing investigation. Previous publications have focused on early postoperative infections and reported low rates of delayed infection. We investigated the pattern of infection after catheter-based APBI at our institution. METHODS: Patients who underwent single-entry catheter-based APBI were identified from an institutional prospective registry including data regarding comorbidities and outcomes. Time of infection was calculated from the date of definitive catheter insertion and classified as early (≤30 days) or delayed. RESULTS: A total of 91 breast cancer patients were treated with APBI and enrolled in the registry from 2009 to 2011. The median follow-up was 484 days. Breast infection occurred in 13 (14.3 %), with 3 (3.3 %) occurring within 30 days of catheter placement and 10 (11.0 %) in a delayed fashion. Four patients required hospital admission, five underwent percutaneous aspiration, and one underwent incision and drainage. Eight were treated as outpatients with oral antibiotics alone. CONCLUSIONS: Consistent with other reports, we found an overall infection rate of 14.3 % with single-entry catheter-based APBI. There were substantially fewer infections in the early postoperative period than reported elsewhere, but there were more delayed infections. The intensive follow-up in our study likely identified late infections that may not have otherwise been recognized. Vigilance for infectious complications must continue beyond the immediate treatment period in patients undergoing catheter-based APBI. These infections can range in severity but typically can be managed in an outpatient setting.

Shortened radiation therapy schedules for early-stage breast cancer: a review of hypofractionated whole-breast irradiation and accelerated partial breast irradiation.

Breast-conserving therapy consisting of segmental mastectomy followed by whole-breast irradiation (WBI) has become widely accepted as an alternative to mastectomy as a treatment for women with early-stage breast cancer. WBI is typically delivered over the course of 5-6 weeks to the whole breast. Hypofractionated whole-breast irradiation and accelerated partial breast irradiation have developed as alternative radiation techniques for select patients with favorable early-stage breast cancer. These radiation regimens allow for greater patient convenience and the potential for decreased health care costs. We review here the scientific rationale behind delivering a shorter course of radiation therapy using these distinct treatment regimens in this setting as well as an overview of the published data and pending trials comparing these alternative treatment regimens to WBI.

Impact of chemotherapy sequencing on local-regional failure risk in breast cancer patients undergoing breast-conserving therapy.

OBJECTIVE: This study was performed to evaluate long-term local-regional control rates after breast-conserving therapy (BCT) for patients undergoing surgery before or after neoadjuvant chemotherapy. METHODS: There were 2983 patients who underwent segmental mastectomy with whole-breast irradiation from 1987 to 2005. Clinicopathological and outcome data were reviewed, and comparisons were made between those undergoing surgery before and those undergoing surgery after neoadjuvant chemotherapy. RESULTS: There were 2331 patients (78%) who underwent surgery first and 652 (22%) received neoadjuvant chemotherapy. Patients receiving neoadjuvant chemotherapy had more advanced disease at baseline and more adverse clinicopathological features. The 5- and 10-year local-regional recurrence (LRR)-free survival rates were 97% [95% confidence interval (CI), 96-98) and 94% (95% CI, 93-95) for surgery first and 93% (95% CI, 91-95) and 90% (95% CI, 87-93) after neoadjuvant chemotherapy (P < 0.001). However, there were no differences in LRR-free survival rates when comparing the presenting clinical stage (P = NS). Of 607 patients presenting with clinical stage II/III disease, chemotherapy downstaged 313 patients (52%) to pathological stage 0/I disease; 294 (48%) had residual stage II/III disease. In multivariate analysis, an age less than 50 years, clinical stage III, grade 3, estrogen receptor (ER)-negative disease, estrogen receptor-positive disease without receipt of endocrine therapy, lymphovascular invasion, multifocal disease on pathology, and close/positive margins were associated with LRR. Use of neoadjuvant chemotherapy was not significant when added to the model. Adjusting for adverse factors, there were no differences in LRR between patients who underwent surgery before and those who underwent neoadjuvant chemotherapy after surgery. CONCLUSIONS: LRR after BCT is driven by tumor biology and disease stage. Appropriately selected patients can achieve high rates of local-regional control with BCT with either upfront surgery or surgery after neoadjuvant chemotherapy.

Primary tumor extirpation in breast cancer patients who present with stage IV disease is associated with improved survival.

PURPOSE: Previous evaluation of our institutional experience with stage IV breast cancer patients with an intact primary tumor (IPT) did not reveal an overall survival (OS) benefit for surgery at 32.1 months median follow-up. We assessed the impact of surgery after 74.2 months median follow-up, and the effect of systemic therapy and local radiotherapy (RT). METHODS: We reviewed the records of all patients presenting from 1997 to 2002 with stage IV disease with an IPT. Cox proportional hazards modeling was used to assess differences in survival between treatment groups. RESULTS: Seventy-four (35.6 %) of 208 patients underwent resection of the IPT. After adjustment for covariates, surgery was associated with improved OS (p = 0.04). Multivariable analysis revealed that estrogen receptor (ER) positivity (p = 0.002) and having only a single focus of metastatic disease (p = 0.05) were also associated with improved OS. Surgery was highly associated with receipt of RT (p = 0.0003). RT was significantly associated with improved survival (p = 0.015) in an exploratory analysis. CONCLUSIONS: Stage IV breast cancer patients with an IPT treated surgically had significantly improved OS. Radiation to the primary was also associated with improved survival, but this was evident only with adjustment for the effect of surgery. These findings may be limited by selection bias. Completion of ongoing prospective randomized trials is needed to conclusively determine whether stage IV patients with an IPT should be offered aggressive locoregional therapy.

Incidence and consequence of close margins in patients with ductal carcinoma-in situ treated with mastectomy: is further therapy warranted?

BACKGROUND: The impact of close margins in patients with ductal carcinoma-in situ (DCIS) treated with mastectomy is unclear; however, this finding may lead to a recommendation for postmastectomy radiotherapy (PMRT). We sought to determine the incidence and consequences of close margins in patients with DCIS treated with mastectomy. METHODS: The records of 810 patients with DCIS treated with mastectomy from 1996 through 2009 were reviewed. Clinical and pathologic factors were analyzed with respect to final margin status. Median follow-up was 6.3 years. RESULTS: Overall, 94 patients (11.7 %) had close margins (positive, n = 5; negative but ≤1 mm, n = 54; 1.1-2.9 mm, n = 35). Independent risk factors for close margins included multicentricity, pathologic lesion size ≥1.5 cm, and necrosis, but not age, use of skin-sparing mastectomy, or immediate reconstruction (p > 0.05). Seven patients received PMRT, and none had a locoregional recurrence (LRR). Among the remaining 803 patients, the 10-year LRR rate was 1 % (5.0 % for margins ≤1 mm, 3.6 % for margins 1.1-2.9 mm, and 0.7 % for margins ≥3 mm [p < 0.001]). The 10-year rate of contralateral breast cancer was 6.4 %. On multivariate analysis, close margins was the only independent predictor of LRR (p = 0.005). CONCLUSIONS: Close margins occur in a minority of patients undergoing mastectomy for DCIS and is the only independent risk factor for LRR. As the LRR rate in patients with close margins is low and less than the rate of contralateral breast cancer, PMRT is not warranted except for patients with multiple close/positive margins that cannot be surgically excised.

Implications of constructed biologic subtype and its relationship to locoregional recurrence following mastectomy.

INTRODUCTION: We examined the prognostic value of biologic subtype on locoregional recurrence (LRR) after mastectomy in a cohort of low risk women who did not receive adjuvant radiation therapy. METHODS: A total of 819 patients with invasive breast cancer underwent mastectomy from January 2000 through December 2005. No patient received preoperative chemotherapy. Estrogen receptor (ER) receptor, progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status were used to construct the following 4 subtypes: i) ER+ or PR+ and HER2- (HR+/HER2-), ii) ER+ or PR+ and HER2+ (HR+/HER2+), iii) ER- and PR- and HER2+ (HR-/HER2+)and iv) ER- and PR- and HER2- (HR-/HER2-). LRR-free survival was estimated by the Kaplan-Meier method. Cox proportional hazard models were used to evaluate the association between time-to-event outcomes and patient prognostic factors. RESULTS: At a median follow-up of 58 months, five-year cumulative incidence of LRR for the entire cohort was 2.5%. Subtype specific LRR rates were 1% for HR+/HER2-, 6.5% in HR+/HER2+, 2% for HR-/HER2+ and 10.9% for HR-/HER2- (P < 0.01). In HER-2+ patients (irrespective of ER/PR status), trastuzumab therapy was not associated with LRR-free survival. On multivariate analysis, one to three positive lymph nodes (HR 4.75 (confidence interval (CI) 1.75 to 12.88, P < 0.01), ≥ 4 positive lymph nodes (HR23.4 (CI 4.64 to 117.94, P < 0.01), HR+/HER2+ (HR 4.26 (CI 1.05 to 17.33), P = 0.04), and HR-/HER2- phenotype (HR 13.87 (CI 4.96 to 38.80), P < 0.01) were associated with shorter LRR-free survival whereas age > 50 at diagnosis (HR 0.31 (CI 0.12 to 0.80), P = 0.02) was associated with improved LRR-free survival. Among the HR-/HER2- subtypes, five-year LRR incidence was 23.4% in patients with positive lymph nodes compared to 7.8% for lymph node negative patients (P = 0.01), although this association did not reach significance when the analysis was limited to HR-/HER2- women with only one to three positive lymph nodes (15.6% versus 7.8%, P = 0.11). CONCLUSIONS: Constructed subtype is a prognostic factor for LRR after mastectomy among low risk women not receiving adjuvant radiation therapy, although rates of LRR remain low across subtypes. Patients with node positive, HR-/HER2- type tumors were more likely to experience LRR following mastectomy alone. Prospective studies to further investigate the potential benefit of adjuvant radiation therapy in these women are warranted.

Impact of internal mammary lymph node drainage identified by preoperative lymphoscintigraphy on outcomes in patients with stage I to III breast cancer.

BACKGROUND: Involvement of internal mammary (IM) lymph nodes is associated with a poor prognosis for patients with breast cancer. This study examined the effect of drainage to IM nodes identified by lymphoscintigraphy on oncologic outcomes. METHODS: A prospectively maintained breast cancer patient database at the University of Texas MD Anderson Cancer Center was used to identify patients with stage I to III breast cancer who underwent preoperative lymphoscintigraphy with peritumoral injection of colloid and intraoperative lymphatic mapping from 1996 to 2005. Medical records were reviewed of 1772 patients who had drainage to any lymph node basin on lymphoscintigraphy but who did not undergo IM nodal biopsy. Patients with IM drainage, with or without axillary drainage, were compared with patients without IM drainage. Local-regional recurrence, distant disease-free survival (DDFS), and overall survival were evaluated. RESULTS: We identified IM drainage in 334 patients (18.8%). Patients with IM drainage were significantly younger, less likely to have upper outer quadrant tumors, and more likely to have smaller and medial tumors than patients without IM drainage. Rates of IM irradiation did not differ between the 2 groups. The median follow-up time was 7.4 years. On multivariate analysis, IM drainage was significantly associated with a worse DDFS (hazard ratio, 1.6; 95% confidence interval, 1.03-2.6; P = .04) but not local-regional recurrence or overall survival. CONCLUSIONS: IM drainage on preoperative lymphoscintigraphy was found to be significantly associated with worse DDFS. Further study is needed to determine the role of lymphoscintigraphy in the personalization of breast cancer staging and therapy.