RESUMEN
BACKGROUND: Guideline-consistent treatment (GCT) for inflammatory breast cancer (IBC) includes neoadjuvant chemotherapy (NAC), modified radical mastectomy (MRM), and radiation. We hypothesized that younger patients more frequently receive GCT, resulting in survival differences. METHODS: Using the National Cancer Database (2004-2018), female patients with unilateral IBC (by histology code and clinical stage T4d) were stratified by age (< 50, 50-65, > 65 years). Factors associated with NAC, MRM, radiation, and "GCT" (defined as all three treatments) were identified using multivariable logistic regression. Multivariable Cox proportional hazards regression identified predictors of overall survival. RESULTS: Of 3278 IBC patients, 30% were younger than 50 years, 44% were 50-65 years of age, and 26% were older than 65 years. The youngest group comprised the greatest proportion of non-White patients ([35%] vs. [29%] age 50-65 years and [23%] age > 65 years, p < 0.001) and was most often treated at academic facilities ([33%] vs. [28%] age 50-65 years; and [23%] age > 65, p < 0.001). Patients older than 65 years received NAC, MRM, and radiation less frequently, and only 35% underwent GCT (vs. [57%] age 50-65 years and [52%] age < 50 years; p < 0.001). On multivariable logistic regression, age older than 65 years independently predicted omission of NAC (odds ratio [OR], 0.36), MRM (OR, 0.56), and radiation (OR, 0.56) (all p < 0.001), and patients older than 65 years also were less likely to undergo GCT than patients 50-65 years of age (OR, 0.65; p = 0.001). GCT was associated with superior overall survival in all three age groups ([hazard ratio {HR}, 0.61] age < 50 years, [HR, 0.62] age 50-65 years, [HR, 0.53] age > 65 years; all p < 0.001). CONCLUSION: Advanced age alone should not limit receipt of GCT for IBC. Multimodal care should be performed for IBC patients of all ages to improve oncologic outcomes for this aggressive breast cancer subtype.
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Neoplasias de la Mama , Neoplasias Inflamatorias de la Mama , Anciano , Neoplasias de la Mama/tratamiento farmacológico , Quimioterapia Adyuvante , Femenino , Humanos , Neoplasias Inflamatorias de la Mama/patología , Neoplasias Inflamatorias de la Mama/terapia , Mastectomía , Persona de Mediana Edad , Terapia Neoadyuvante , Estudios RetrospectivosRESUMEN
BACKGROUND: Neoadjuvant chemotherapy (NCT) is considered more effective in downstaging hormone receptor-positive (HR+) breast cancer than neoadjuvant endocrine therapy (NET), particularly in node-positive disease. This study compared breast and axillary response and survival after NCT and NET in HR+ breast cancer. METHODS: Based on American College of Surgeons Oncology Group (ACOSOG) Z1031 criteria, women age 50 years or older with cT2-4 HR+ breast cancer who underwent NET or NCT and surgery were identified in the National Cancer Database 2010-2016. Chi-square and logistic regression analysis determined differences between the NCT and NET groups and therapy response, including downstaging and pathologic complete response (pCR, ypT0/is and ypN0). RESULTS: Of 19,829 patients, 14,025 (70.7%) received NCT and 5804 (29.3%) received NET. The NET patients were older (mean age, 68.9 vs. 60.3; P < 0.001) and had greater comorbidity (1+ Charlson-Deyo score, 21% vs. 16%; P < 0.001). Therapy achieved T downstaging (any) for 58% of the patients with NCT versus 40.5% of the patients with NET, and in-breast pCR was achieved for 9.3% of the NCT versus 1.3% of the NET patients (P < 0.001). Approximately half of the mastectomy procedures could have been potentially avoided for the patients with in-breast pCR (53.6% of the NCT and 43.8% of the NET patients). For the cN+ patients, N downstaging (any) was 29% for the NCT patients versus 18.3% for the NET patients (P < 0.001), and nodal pCR was achieved for 20.3% of the NCT versus 13.5% of the NET patients (P < 0.001). Among those with nodal pCR, axillary lymph node dissection (ALND) still was performed for 56% of the patients after NCT and 45% of the patients after NET. CONCLUSIONS: Although the response rates after NCT were higher, NET achieved both T and N downstaging and pCR. Neoadjuvant endocrine therapy can be used to de-escalate surgery for patients who cannot tolerate NCT or when chemotherapy may not be effective based on genomic testing.
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Neoplasias de la Mama , Terapia Neoadyuvante , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias de la Mama/tratamiento farmacológico , Neoplasias de la Mama/cirugía , Quimioterapia Adyuvante , Femenino , Hormonas , Humanos , Mastectomía , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND: Neoadjuvant chemotherapy (NAC) downstages breast cancer and provides prognostic information. Males with breast cancer are known to receive less treatment overall and have poorer outcomes relative to females. We hypothesized that males would be less likely to receive NAC. PATIENTS AND METHODS: Patients with a primary diagnosis of cN1-3 breast cancer were identified in the National Cancer Database (2004-2016). Multivariable logistic regression determined the association between NAC utilization and sex, and the relationship between sex and NAC response, controlling for demographic and tumor factors. Overall survival was analyzed using a multivariable Cox model. RESULTS: In total, 196,027 patients (194,010 females, 2017 males) met inclusion criteria. A significantly greater proportion of males underwent mastectomy (80% vs. 60%, P < 0.001), and axillary lymph node dissection (76% vs. 74%, P = 0.022). Overall fewer men received chemotherapy than women (73% vs. 84%, P < 0.001); men also received NAC at a significantly lower rate (26% men vs. 45% women, P < 0.001). After accounting for demographic and oncologic factors including hormone receptor (HR) subtype, females remained more likely to undergo NAC (OR 1.84, P < 0.001). On multivariable analysis, sex was not associated with pathologic response or overall survival after NAC. CONCLUSIONS: Although oncologic outcomes after NAC were similar, males with node-positive breast cancer received less NAC and more aggressive surgery than females. These data suggest men achieve outcomes comparable to women with cN1-3 disease, and NAC should be used in appropriate male patients to downstage the breast and axilla.
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Neoplasias de la Mama , Axila , Neoplasias de la Mama/tratamiento farmacológico , Neoplasias de la Mama/cirugía , Femenino , Humanos , Ganglios Linfáticos/cirugía , Masculino , Mastectomía , Terapia NeoadyuvanteRESUMEN
BACKGROUND: As an alternative to traditional wire localization, an inducible magnetic seed system can be used to identify and remove nonpalpable breast lesions and axillary lymph nodes intraoperatively. We report the largest single-institution experience of magnetic seed placement for operative localization to date, including feasibility and short-term outcomes. METHODS: Patients who underwent placement of a magnetic seed in the breast or lymph node were identified from July 2017 to March 2019. Imaging findings, core needle biopsy, surgical pathology results, and type of surgery were collected. Outcomes included procedural complications, magnetic seed and biopsy clip retrieval rates, and need for additional surgery. RESULTS: A total of 842 magnetic seeds were placed by nine radiologists in 673 patients and retrieved by six surgeons at six operative locations. The majority of breast lesions were malignant (395/659, 59.9%); 136 seeds were placed for lymph node localization. The overall magnetic seed retrieval rate was 98.6%, whereas the biopsy clip retrieval rate was 90.9%. Only six patients (0.7%) experienced a complication from magnetic seed placement. Reexcision was performed in 15.2% of patients with breast cancer; 9.6% of benign/high risk lesions were upgraded to malignancy at surgical excision. CONCLUSIONS: The magnetic seed technique is safe, effective, and accurate for localization of breast lesions and lymph nodes, and importantly uncouples surgery from the localization procedure. The high magnetic seed retrieval rate and low reexcision rate may reflect the accuracy of magnetic marker placement as a "second chance" localization procedure, especially in cases with biopsy clip migration.
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Neoplasias de la Mama , Ganglios Linfáticos , Axila , Neoplasias de la Mama/diagnóstico por imagen , Neoplasias de la Mama/cirugía , Hospitales , Humanos , Ganglios Linfáticos/diagnóstico por imagen , Ganglios Linfáticos/cirugía , Fenómenos MagnéticosRESUMEN
Breast magnetic resonance imaging (MRI) has been repeatedly shown to have a high false-positive rate for additional findings in the breast resulting in additional breast imaging and biopsies. We hypothesize that breast MRI is also associated with a high rate of false-positive findings outside of the breast requiring additional evaluation, interventions, and delays in treatment. We performed a retrospective review of all breast MRIs performed on breast cancer patients in 2010 at a single institution. MRI reports were analyzed for extra-mammary findings. The timing and yield of the additional procedures was also analyzed. Three hundred and twenty-seven breast cancer patients (average age = 53.53 ± 11.08 years) had a breast MRI. Incidental, extra-mammary findings were reported in 35/327 patients (10.7%) with a total of 38 incidental findings. The extra-mammary findings were located in the liver (n = 21, 60.0%), thoracic cavity (n = 12, 34.3%), kidneys (n = 1, 2.9%), musculoskeletal system (n = 3, 8.6%), and neck (n = 1, 2.9%). Eighteen of the 35 patients (51.4%) received additional radiographic imaging, 3 (8.6%) received additional laboratory testing, 2 (5.7%) received additional physician referrals and 2 (5.7%) received a biopsy of the finding. The average time to additional procedures in these patients was 14.5 days. None of the incidental, extra-mammary findings were associated with breast cancer or other malignancy. Breast MRI was associated with a high rate (10.7%) of extra-mammary findings, which led to costly additional imaging studies, referrals, and tests. These findings were not associated with breast cancer or other malignancies. Extra-mammary findings highlight an unrecognized adverse consequence of breast MRI.
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Neoplasias de la Mama/patología , Hallazgos Incidentales , Imagen por Resonancia Magnética/métodos , Adulto , Reacciones Falso Positivas , Femenino , Humanos , Riñón/diagnóstico por imagen , Riñón/patología , Hígado/diagnóstico por imagen , Hígado/patología , Medicare , Persona de Mediana Edad , Cuello/diagnóstico por imagen , Cuello/patología , Radiografía/economía , Estudios Retrospectivos , Estados UnidosRESUMEN
BACKGROUND: Currently, no standard guidelines exist regarding routine screening imaging in breast cancer patients following autologous reconstruction. Concern over nonpalpable chest wall recurrence has prompted many to pursue screening imaging. We analyzed the pattern of locoregional recurrence (LRR) and yield of screening imaging and exam in these patients. METHODS: We performed a retrospective chart review of all patients who had mastectomy with autologous reconstruction between 2000 and 2009. Presentation of LRR and utility of imaging and breast exam were analyzed. Screening mammography was performed at the discretion of the treating physicians. RESULTS: A total of 615 patients were identified and follow-up data were available for 541. Median follow-up from time of reconstruction was 7 years. Twenty-seven patients developed a LRR (5.0 %). Among patients screened with mammography (n = 397), an abnormality led to 25 biopsies in 25 patients, and 2 were malignant (8 %). Among patients receiving routine clinical exam (n = 537), an abnormality led to 77 biopsies in 66 patients, and 30 were malignant (39 %). The median time from cancer surgery to LRR was 2.6 years. LRR was detected on clinical exam in 24 of 27 patients (88.9 %). Screening mammography detected two recurrences that were palpable on follow-up exam. One patient had an incidental chest wall recurrence found on PET/CT. In summary, 26 of 27 (96.3 %) patients had a clinically detectable LRR. CONCLUSIONS: Diligent surveillance with clinical breast exam is a reliable method of detecting LRR after autologous reconstruction, identifying 96.3 % of recurrences in our study. Our results do not support routine mammographic screening in this population.
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Neoplasias de la Mama/diagnóstico por imagen , Carcinoma Ductal de Mama/diagnóstico por imagen , Carcinoma Intraductal no Infiltrante/diagnóstico por imagen , Carcinoma Lobular/diagnóstico por imagen , Detección Precoz del Cáncer , Mamoplastia , Mamografía , Recurrencia Local de Neoplasia/diagnóstico por imagen , Adulto , Neoplasias de la Mama/patología , Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama/patología , Carcinoma Ductal de Mama/cirugía , Carcinoma Intraductal no Infiltrante/patología , Carcinoma Intraductal no Infiltrante/cirugía , Carcinoma Lobular/patología , Carcinoma Lobular/cirugía , Femenino , Estudios de Seguimiento , Humanos , Mastectomía , Persona de Mediana Edad , Invasividad Neoplásica , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/cirugía , Estadificación de Neoplasias , PronósticoRESUMEN
BACKGROUND: Nodal positivity is correlated with a poorer prognosis in breast cancer. A study was composed to compare nodal positivity in patients with single versus multiple lesions found on magnetic resonance imaging (MRI) and mammogram (MMG). METHODS: A retrospective study of breast cancer patients undergoing MRI and MMG was performed. Nodal positivity was compared in patients with additional invasive lesions found on MRI versus single invasive lesions found on MRI and MMG. RESULTS: A total of 425 patients were included. The overall nodal positivity was 23.8%. Patients with single versus multiple malignant lesions had nodal positivity of 20.9% vs 31.1% (P = .04). MRI detected multiple lesions in 120 patients, 80 of which were not detected by MMG (18.8%). Comparing single lesions with additional malignant lesions detected by MRI only, nodal positivity increased from 20.9% to 51.6% (P = .0002). CONCLUSIONS: Patients with additional invasive lesions on MRI had significantly higher nodal positivity than single invasive lesions. Hence, addition of MRI in early-stage breast cancer may have prognostic value because of detection of potential node-positive patients.