Breast cancer in an intramammary sentinel node.

A palpable 3.2 cm infiltrating ductal carcinoma was removed from a 27-year-old woman. Radiologic evaluation of the breasts with mammography and sonography identified an intramammary node between the carcinoma and the axilla. This was localized and removed at the time of axillary dissection. Isosulfan blue, which had been injected into the walls of the lumpectomy cavity to facilitate identification of the sentinel node in the axilla, stained the intramammary node. It contained several foci of carcinoma. Excision of the intramammary nodes may be indicated in breast cancer patients treated with breast conservation.

The significance of malignancies incidental to microcalcifications in breast spot localization biopsy specimens.

BACKGROUND: Incidental breast cancer is occasionally found in spot localization biopsy specimens adjacent to mirocalcifications in benign breast disease. Because this phenomenon could prove problematic for percutaneous sampling of microcalcifications without excisional biopsy, we studied surgical specimens from patients with cancers incidental to microcalcifications and compared them with specimens with microcalcifications within the malignancy. METHODS: The pathology database at the Mount Sinai Medical Center from January 1993 to July 1998 was reviewed to identify breast cancer patients who underwent spot localization biopsy for microcalcifications. Patients presenting with microcalcifications within malignancy (determinate) were compared with patients with mirocalcifications in benign breast tissue adjacent to malignancy (incidental). RESULTS: Thirty-two (13%) of the 241 specimens had microcalcifications in benign tissue adjacent to malignancy and 209 (87%) had microcalcifications within the malignancy. Fifty-six percent of the incidental cases and 65% of the controls had ductal carcinoma in situ. Infiltrating lobular carcinoma accounted for 25% of the incidental cancers and 2% of the determinate cancers (P <0.001). Fifty-seven percent of the infiltrating carcinomas incidental to mammographic findings were infiltrating lobular carcinoma compared with 7% of the nonincidental infiltrating carcinomas. None of the incidental invasive carcinomas were poorly differentiated (P = 0.002). There were no significant differences with regard to age, tumor size, stage, differentiation, estrogen and progesterone receptors, type of surgery and final margin status. In none of the patients with incidental malignancies did local or distant recurrences develop. CONCLUSIONS: Incidental carcinomas were found in 13% of spot localization biopsy specimens obtained for suspicious mammographic microcalcifications and have a favorable prognosis. Infiltrating lobular carcinomas are more commonly found with incidental microcalcifications than with determinate microcalcifications, and incidental invasive carcinomas are less likely to be poorly differentiated. The majority of malignancies, both determinate and incidental to microcalcifications, are due to ductal carcinoma in situ. Incidental malignancies commonly occur adjacent to fibrocystic changes and their other pathologic characteristics are not significantly different from nonincidental carcinomas. Despite the absence of radiographic findings, these patients can be successfully treated with breast conservation.

The consequence of undertreating breast cancer in the elderly.

BACKGROUND: Recent studies have noted that a large fraction of elderly patients do not receive conventional treatment for breast cancer. The consequences of undertreatment of the elderly have not been adequately assessed. STUDY DESIGN: The senior author's database (PIT) was used to identify women undergoing potentially curative operations for breast cancer between 1978 and 1998. Risk factors, presentation, pathologic findings, treatment, and outcomes of 206 women aged over 70 years were compared with those of 920 younger patients. In addition, conventionally treated and "undertreated" elderly patients were identified, and their characteristics and outcomes were compared. RESULTS: Older patients' cancers were more often visible on mammography, usually as a mass; younger patients' mammograms were less frequently positive, presenting more often with calcifications (p = 0.002). Cancers of the elderly were better differentiated (p < 0.001) and more likely to be estrogen- and progesterone-receptor positive (p < 0.001; p = 0.007). Patients over 70 had fewer mastectomies (19% versus 33%; p < 0.001) and were also less likely to undergo axillary node dissection (71% versus 81%, p = 0.006), postoperative radiation (69% versus 92%, p < 0.001), and chemotherapy (18% versus 48%, p < 0.001). Fifty-seven percent of older patients were treated with tamoxifen compared with 36% of younger patients (p < 0.001). Elderly patients' rates of local and distant recurrence were comparable to those of younger patients after both mastectomy and breast conservation. Ninety-eight patients (54%) over 70 were undertreated by conventional criteria. Undertreated elderly patients were significantly older (78 versus 76 years, p = 0.003), were diagnosed with excisional biopsy more often (69% versus 57%, p = 0.069) and with fine-needle aspiration less frequently (22% versus 38%, p = 0.069), and were more likely to have breast conservation (90% versus 73%, p = 0.004). Local and distant disease-free survival rates of both groups were comparable. Tamoxifen treatment significantly reduced the chance of developing distant metastasis in node-negative elderly patients with invasive tumors (p = 0.028). Omission of chemotherapy had no impact on disease control in the elderly. Axillary node status and estrogen-receptor status were significantly related to local disease-free survival, and axillary node status was significantly related to distant disease-free survival in multivariate analysis in the elderly. CONCLUSIONS: Elderly breast cancer patients are frequently treated with breast conservation, omitting axillary dissection, radiation therapy, and chemotherapy. Despite undertreatment by conventional criteria, the rates of local recurrence and distant metastasis are not increased in comparison with conventionally treated elderly patients. Tamoxifen should be administered to elderly breast cancer patients with invasive tumors because it significantly improves distant control.

Lumpectomy with tamoxifen as primary treatment for elderly women with early-stage breast cancer.

BACKGROUND: Appropriate therapy for women over 70 years of age with breast cancer is currently a highly debated topic. The aim of this study was to determine whether a subset of patients could be identified in which lumpectomy alone, followed by tamoxifen, would offer adequate local, regional, and long-term control of disease. METHODS: A retrospective analysis of 171 women over the age of 70 with stage I or II breast carcinomas treated by the senior authors from 1984 to 1998 was undertaken. One hundred and thirty-five patients who received conventional treatment were compared with 43 patients who received lumpectomy alone followed by tamoxifen. Differences in patient and tumor characteristics and in disease outcome and complications between the two groups were analyzed. RESULTS: The patients treated with lumpectomy and tamoxifen were significantly older (80 versus 76 years) and had significantly smaller tumors (1.4 versus 1.8 cm) than the conventionally treated patients. No significant differences were noted in comorbidities, clinical tumor size, histology, margin status, tumor differentiation, and hormone receptor status. There were no local or regional recurrences and only 1 distant recurrence (2%) in the lumpectomy with tamoxifen patients. In the conventionally treated group, 4 patients (3%) recurred locally, none regionally, and 18 patients (13%) recurred distantly. CONCLUSION: These data indicate that lumpectomy alone followed by tamoxifen results in an acceptable disease outcome in a subset of elderly women with breast cancer. This subset is defined by older patients with small, hormone receptor positive tumors.

Subareolar breast cancers.

BACKGROUND: Despite the high rate of pathologic involvement of the nipple-areola complex (NAC) with subareolar cancers and the suboptimal cosmetic results when lumpectomy removes the NAC, breast conservation surgery has been extended to include these patients. METHODS: Ninety-five patients with subareolar cancers operated on between 1979 and 1998 were identified and the relationships between the pathologic findings, treatment, and outcome were studied. RESULTS: Clinical involvement of the NAC (P = 0.001), clinical presentation (P <0.001, mammographic calcium or Paget's disease), and pathologic tumor size (P = 0.019) were significantly related to pathologic involvement of the NAC in univariate analysis. After consideration for clinical NAC involvement, no other variable was significantly related to pathologic NAC involvement in multivariate analysis. Thirty-three patients underwent mastectomy, and 62 were treated with breast conservation. Radiation therapy (P = 0.005), clinical (P = 0.031), and pathologic (P = 0.037) involvement of the NAC were significantly related to local disease-free survival in breast conservation patients in univariate analysis. After consideration for radiation therapy in multivariate analysis, clinical involvement of the NAC was the only additional variable significantly related to local recurrence in breast conservation patients. Clinical or pathologic involvement of the NAC was not significantly associated with local and distant recurrence after mastectomy. No other variable was significantly related to local outcome in univariate analysis in patients treated with mastectomy. CONCLUSIONS: Subareolar cancers can be successfully treated with breast conservation surgery provided adjuvant radiation therapy is always given. Clinical involvement of the nipple-areola complex is associated with high risk of local failure when treated with breast conservation without radiation therapy.

When not to give radiation therapy after breast conservation surgery for breast cancer.

BACKGROUND AND OBJECTIVES: A significant proportion of breast cancer patients treated with breast conservation surgery do not receive adjuvant radiation therapy because of advanced age, severe intercurrent disease, or their own preference. We studied patients for whom adjuvant radiation was not performed, to determine whether the rate of local recurrence was acceptable in particular clinical circumstances. METHODS: Patients who had undergone breast conservation surgery for breast cancer were identified. The charts of patients who did not receive adjuvant radiation therapy were reviewed to identify the reason for omitting radiation. Local and distant recurrence rates were examined in relation to radiation and reason for omitting radiation. RESULTS: Forty-three (9%, two bilateral) of the 487 patients did not receive radiation; 9 because of advanced age, 8 refused, 7 had severe intercurrent diseases, 6 developed stage IV disease while getting chemotherapy for stage III disease, 5 patients (1 bilateral) had two reasons for omission (3 cases: age + intercurrent disease; 2 cases: age + stage IV disease; and 1 case: age + small focus of ductal carcinoma in situ) and the remainder for miscellaneous reasons. None of the 13 patients with intercurrent disease or progression to stage IV disease developed local recurrence in their life time; 5 (63%) of 8 patients who refused radiation recurred in the breast; 2 (22%) 9 of the elderly patients developed local recurrences and none of the 6 cases with more than one reason for omission developed local recurrences. CONCLUSIONS: Omission of radiation therapy after breast conservation is appropriate for patients with intercurrent diseases, for those who develop metastases while receiving preoperative chemotherapy and for selected elderly patients. Patients who refuse recommended adjuvant radiation therapy have unacceptably high rates of local recurrence. Omission of radiation for advanced age alone is associated with local recurrence rates comparable to those for younger patients.

Stage 0 to stage III breast cancer in young women.

BACKGROUND: Breast cancer survival is improving because mammography is leading to diagnosis at earlier stages of the disease. Because young women with breast cancer rarely undergo mammography before diagnosis, outcomes for breast cancer in young women may not be improving. In addition to advanced stage, young age at diagnosis is associated with biologically more aggressive cancers with higher rates of local and distant recurrence. STUDY DESIGN: Risk factors, clinical presentations, pathologic findings, tumor characteristics, extent of disease, treatment, and outcomes for 101 women under age 36 treated for breast cancer between 1989 and 1997 were compared with 631 patients 36 years and older treated by us during the same interval. Stage IV patients were excluded. RESULTS: Patients younger than 36 years were more likely to present with a palpable mass (87% versus 55%, p < 0.001) and were less likely to undergo spot localization breast biopsy for mammographic findings (40% versus 6%, p < 0.001). Patients younger than 36 years had larger tumors (median 2.0 cm versus 1.5 cm, p < 0.001), more nodal involvement (50% versus 37%, p = 0.022), more nodes involved (median 1.0 versus 0, p = 0.010), and were more likely to be diagnosed with stage II or III cancer (60% versus 43%, overall p < 0.001). Young patients' cancers were more poorly differentiated (80% versus 44%, overall p < 0.001), estrogen receptor-negative (52% versus 31%, p < 0.001), aneuploid (70% versus 49%, p = 0.013), and had higher S-phase fractions (59% versus 29%, p = 0.001). Patients less than 36 years were treated more often with mastectomy (59% versus 22%, p < 0.001) and adjuvant chemotherapy (80% versus 54%, p < 0.001) and less often with tamoxifen (36% versus 58%, p = 0.001). Cumulative 5-year local and distant disease-free survival were significantly worse for patients younger than 36 years (p = 0.011 and p = 0.044, respectively). The higher rate of local recurrence in patients less than 36 years was from an excess number of local recurrences in patients treated with breast conservation. After consideration for nodal involvement, chemotherapy, and tamoxifen using the Cox proportional hazards model, no other variable, including age, was significantly related to local disease-free outcomes. After consideration for tumor size and nodal involvement, no other variable was significantly related to distant disease failure rates. CONCLUSIONS: Patients diagnosed with breast cancer before age 36 differ from older patients in numerous respects. They present more often with a palpable mass rather than a mammographic finding and their cancers are more advanced with features that are more aggressive. Despite aggressive treatment, most commonly with mastectomy and chemotherapy, local and distant failure rates are higher than for patients 36 and older. The higher rate of local recurrence in patients less than 36 years reflects an excess number of local recurrences in patients treated with breast conservation.

Lumpectomy margins, reexcision, and local recurrence of breast cancer.

BACKGROUND: The diagnosis of breast cancer is often made by excisional biopsy without margin assessment for mammographic findings or palpable masses. Many patients treated with breast conservation undergo reexcision to obtain clear margins although the relationship between clear margins and local recurrence remains controversial. METHODS: Patients undergoing breast conservation and adjuvant radiation therapy with complete follow-up over 5 years were studied. Factors associated with obtaining clear histopathologic margins and undergoing reexcision to obtain clear margins were studied in relation to the risk of local recurrence. RESULTS: Clear biopsy margins were associated with diagnosis by fine-needle aspiration cytology (fine-needle aspiration 42%, spot localization 11%, excisional biopsy 10%; P <0.001). Reexcision was significantly related to diagnostic method (spot localization 63%, excisional biopsy 36%, fine-needle aspiration 10%; P <0.001), first margin status (clear 0%, close 11%, positive 46%, unknown 48%; P <0.001), patient age (54 years for reexcised patients and 58 for non-reexcised patients; P <0.001), and tumor size (mean tumor size 1. 4 cm for reexcised patients and 1.7 cm for non-reexcised patients; P = 0.003). Patients undergoing reexcision were significantly more likely to be diagnosed by spot localization, have nonnegative excisional biopsy margins, be younger, and have smaller tumors than patients not undergoing reexcision. Local recurrence was not significantly related to margin status (8% with clear margins, 7% with positive margins, 19% with close margins, and 11% with unknown margins) or reexcision (10% local recurrence rate for patients with negative final margins after reexcision and 12% with positive, close or unknown first margin without reexcision). Estrogen receptor status was the only variable related to local recurrence in Cox proportional hazards model (P = 0.009). Estrogen receptor negative patients with nonnegative margins experienced a 20% rate of local recurrence compared with 10% for estrogen receptor negative patients with negative margins and 7% for estrogen receptor positive patients regardless of margin status (P = 0.021). CONCLUSIONS: Clear excision margins are facilitated by preoperative diagnosis by fine-needle cytology. For patients with nonnegative margins, reexcision was more commonly performed in young patients with small tumors diagnosed by spot localization biopsy. The relationship of local recurrence to margins and reexcision was not statistically significant. Estrogen receptor negative tumors with nonnegative margins had a significantly higher rate of local recurrence than estrogen receptor negative tumors with clear margins and estrogen receptor positive tumors regardless of margin status.

Breast cancer diagnosed during hormone replacement therapy.

OBJECTIVE: Hormone replacement therapy (HRT) is associated with decreased breast cancer mortality despite increased incidence. We studied postmenopausal breast cancer patients to determine whether this paradox results from earlier diagnosis, biologically less aggressive tumors, or cessation of hormonal stimulation. METHODS: Demographic, clinical, pathologic, treatment, and outcome information for 455 postmenopausal breast cancer patients who had not used postmenopausal hormones was compared with that of 47 breast cancer patients who used postmenopausal hormones prior to diagnosis. RESULTS: Hormone users were significantly younger, more often white, and of lower body mass index than nonusers. Hormone users presented significantly more often with nonpalpable mammographic findings, resulting in significantly smaller tumors with less nodal involvement than nonusers. Cancers of hormone users were more commonly invasive lobular or in situ ductal and were more likely to be steroid receptor positive. Hormone users were treated with breast conservation significantly more frequently than nonusers. These differences persisted after matching for age and year of surgery and after controlling for race. At 5 years, none of the hormone users with invasive cancers had local recurrence compared with 8% of nonusers, and 7% of users had distant disease compared with 10% of nonusers. CONCLUSION: These results indicate that favorable breast cancer survival after postmenopausal hormone use might result from earlier detection through mammography. Possible hormonal influence on tumor biology and prognosis was not supported by our data.

Lymphatic invasion, tumor size, and age are independent predictors of axillary lymph node metastases in women with T1 breast cancers.

OBJECTIVE: To identify characteristics of the primary tumor highly associated with lymph node metastases. SUMMARY BACKGROUND DATA: Recent enthusiasm for limiting axillary lymph node dissection (ALND) in women with breast cancer may increase the likelihood that nodal metastases will be missed. Identification of characteristics of primary tumors predictive of lymph node metastases may prompt a more extensive surgical and pathologic search for metastases in patients with negative sentinel lymph nodes or limited ALND. METHODS: The authors studied 850 consecutive patients who underwent ALND for T1 breast cancer. Age, tumor size, histopathologic diagnosis, tumor differentiation, presence of lymphatic invasion, and estrogen and progesterone receptor results were studied prospectively. Stepwise logistic regression was used to identify variables independently associated with axillary lymph node metastases. RESULTS: Lymphatic invasion, tumor size, and age were independently associated with lymph node metastases. Fifty-one percent of the 181 patients with lymphatic invasion had axillary lymph node metastases, compared with 19% of the 669 patients without lymphatic invasion. Thirty-five percent of the 470 patients with tumors >1 cm had nodal involvement compared with 13% of the 380 patients with smaller cancers. Thirty-seven percent of the 63 women younger than age 40 had lymph node involvement compared with 25% of the 787 women older than age 40. Significant correlations were noted between lymphatic invasion and patient age and between lymphatic invasion and tumor size. The proportion of tumors with lymphatic invasion decreased progressively with increasing age and increased with increasing tumor size. CONCLUSIONS: Axillary lymph node metastases are most significantly related to lymphatic invasion in the primary tumor, followed, in order of significance, by tumor size and patient age. Axillary nodal metastases should be suspected in the presence of lymphatic invasion of large tumors in young patients.

Complete removal of nonpalpable breast malignancies with a stereotactic percutaneous vacuum-assisted biopsy instrument.

BACKGROUND: Several devices have been developed for sampling nonpalpable mammographic breast lesions. Complete removal of malignancies with a stereotactic percutaneous directional vacuum-assisted biopsy instrument has been reported. STUDY DESIGN: We reviewed our experience with the percutaneous vacuum-assisted biopsy instrument to identify instances of complete excision of cancers: no residual carcinoma found at surgical excision for malignancies diagnosed by the percutaneous vacuum-assisted biopsy instrument. The radiologic and pathologic characteristics of malignancies completely removed by the percutaneous vacuum-assisted biopsy instrument were compared with those of malignancies with residual carcinoma found at surgical excision. RESULTS: Fifty-two malignancies were diagnosed by the percutaneous vacuum-assisted biopsy instrument: 16 infiltrating ductal carcinomas, 5 infiltrating lobular carcinomas, and 31 ductal carcinomas in situ. No residual carcinoma was found at surgical excision in 9 (17%) of the 52 malignancies. Patients with complete removal of the malignant lesion were younger than patients with incomplete removal (52 versus 58 years; p = 0.069). Completely removed malignancies were smaller on mammography (4 versus 17 mm; p = 0.213), and more specimens were removed (19 versus 15; p = 0.074). All nine completely removed malignancies presented with calcifications without a mass (p = 0.112), and all nine were ductal carcinoma in situ (p = 0.019). CONCLUSIONS: Complete removal of nonpalpable breast malignancies is possible with the stereotactic percutaneous directional vacuum-assisted biopsy device. Complete removal is more likely with removal of a large number of specimens from small areas of mammographic calcifications due to ductal carcinoma in situ.

Delay in diagnosis of breast cancer.

OBJECTIVES: To assess the consequences of physician delay in the diagnosis of breast cancer by comparing stage, treatment, and outcome of patients with and without delay, and to identify patient characteristics that may make diagnosis more difficult. SUMMARY BACKGROUND INFORMATION: Delay in diagnosis of breast cancer is the most common clinical scenario resulting in malpractice litigation. METHODS: The records of 1014 patients were reviewed and the events preceding the diagnosis were reconstructed. Accurate assessment of the physician delay in diagnosis could be made for 606 patients, 51 (8%) with physician delay >3 months. Patients with delay were comparable to patients without delay in terms of age, height, weight, age at menarche, pregnancies, children, proportion in menopause, age at menopause, and family history of breast cancer. RESULTS: Thirty-six percent of patients who had a delay in diagnosis had normal mammograms versus 7% of patients without delay. Cancers in patients with delay were significantly larger on average than in those without delay, but there were no significant differences in pathology, differentiation, nodal status, TNM stage, treatment, or outcome. CONCLUSIONS: Physician delay in the diagnosis of breast cancer is common, and patients with delay are similar to patients without delay, although they are more likely to have normal mammograms. The consequences of physician delay in terms of stage at diagnosis, treatment, and outcome were not statistically significant.

Decreased length of stay for patients with colorectal cancer: implications of DRG use.

Hospital length of stay (LOS) has declined significantly at Mt. Sinai Hospital with the advent of diagnosis-related groups (DRGs). Patients with colorectal cancer who were operated on before and after the implementation of the DRG were compared to determine whether the shorter LOS reflected changes in the patient population or changes in the way patients were being treated. Both preoperative and postoperative LOS declined significantly for DRG patients. The decreased LOS for DRG patients could not be attributed to a decreased severity of disease because DRG patients presented with significantly more advanced tumors. The DRG patients had significantly less operative blood loss; shorter, less extensive procedures; fewer transfusion; shorter specimen lengths; shorter margins of resection; and fewer postoperative complications than the pre-DRG patients. Other measures of disease severity (i.e., admission hematocrit, tumor differentiation, and tumor size) and patient mix (i.e., age and sex) did not change. These results suggest that with the use of DRGs, surgeons may have modified certain aspects of treatment for colorectal cancer in an attempt to shorten LOS.

Frequency and carrier risk associated with common BRCA1 and BRCA2 mutations in Ashkenazi Jewish breast cancer patients.

Based on breast cancer families with multiple and/or early-onset cases, estimates of the lifetime risk of breast cancer in carriers of BRCA1 or BRCA2 mutations may be as high as 85%. The risk for individuals not selected for family history or other risk factors is uncertain. We determined the frequency of the common BRCA1 (185delAG and 5382insC) and BRCA2 (6174delT) mutations in a series of 268 anonymous Ashkenazi Jewish women with breast cancer, regardless of family history or age at onset. DNA was analyzed for the three mutations by allele-specific oligonucleotide hybridization. Eight patients (3.0%, 95% confidence interval [CI] 1.5%-5.8%) were heterozygous for the 185delAG mutation, two (0.75%, 95% CI 0.20-2.7) for the 5382insC mutation, and eight (3.0%, 95% CI 1.5-5.8) for the 6174delT mutation. The lifetime risk for breast cancer in Ashkenazi Jewish carriers of the BRCA1 185delAG or BRCA2 6174delT mutations was calculated to be 36%, approximately three times the overall risk for the general population (relative risk 2.9, 95% CI 1.5-5.8). For the 5382insC mutation, because of the low number of carriers found, further studies are necessary. The results differ markedly from previous estimates based on high-risk breast cancer families and are consistent with lower estimates derived from a recent population-based study in the Baltimore area. Thus, presymptomatic screening and counseling for these common mutations in Ashkenazi Jewish women not selected for family history of breast cancer should be reconsidered until the risk associated with these mutations is firmly established, especially since early diagnostic and preventive-treatment modalities are limited.

The efficacy of neoadjuvant chemotherapy compared to postoperative therapy in the treatment of locally advanced breast cancer.

The current approach to the treatment of locally advanced breast cancer is sequential chemotherapy, surgery and/or radiation, and consolidation chemotherapy. Although significant tumor response is seen with this regimen, there are few studies that compare this approach to postoperative chemotherapy. The purpose of this study was to compare the disease-free and overall survival of patients with locally advanced breast cancer treated with neoadjuvant chemotherapy and surgery to patients treated with surgery followed by adjuvant chemotherapy. Ninety-four patients with stage IIB, IIIA, and IIIB breast cancer were treated with a standardized chemotherapy regimen. The first group, 60 patients who were followed prospectively, was treated with neoadjuvant chemotherapy (NCT) consisting of vincristine, prednisone, cytoxan, methotrexate, and 5-FU (CVFMP) followed by surgery and consolidation chemotherapy with adriamycin. The second group, 34 patients evaluated retrospectively, had surgery followed by postoperative chemotherapy (PCT) with CVFMP followed by adriamycin. Overall median follow-up was 38 months. In the NCT group, 45/60 (75%) patients had a clinical response to induction therapy and the median reduction in tumor size was 50%. The rates of local recurrence, distant recurrence, and death from disease were similar in the two groups. The time to local recurrence was similar for the two groups. However, the median time to distant recurrence was shorter in the NCT group (19 month vs. 31 months, p = NS). Overall median survival among the NCT patients was shorter than for the PCT group (30 vs. 47 months, p = NS). The current study suggests that postoperative therapy is comparable to a neoadjuvant regimen in patients with locally advanced breast cancer with regard to local recurrence, distant recurrence, and overall survival.

Randomized trial comparing packed red cell blood transfusion with and without leukocyte depletion for gastrointestinal surgery.

BACKGROUND: Allogeneic transfusion is associated with postoperative infections that significantly prolong hospital stays and increase costs. Recent studies suggest that filtering leukocytes from blood prior to transfusion reduces the risk of postoperative infection associated with blood transfusion. We compared the incidence of postoperative infections, hospital stays, and hospital charges of gastrointestinal surgery patients transfused with packed red cells or leukocyte-depleted cells. METHODS: Consecutive patients admitted for elective gastrointestinal surgery without previous blood transfusion were randomized to receive routine packed red cells or packed red cells filtered to remove leukocytes if transfusion was required. Multivariate analysis was used to assess the significance of the relationship between leukocyte-depleted blood and postoperative infectious complications, postoperative stay, and hospital charges. RESULTS: Fifty-nine (27%) of the 221 patients were transfused. The most significant variable related to transfusion was intraoperative blood loss (P <0.0001), followed by admission hematocrit (P <0.0001) and age (P = 0.0022). Infections were noted in 16% of the patients: 11% of untransfused patients, 16% of leukocyte-depleted blood recipients, and 44% of patients transfused with packed red cells. Both operative site and nosocomial infections were significantly (P <0.001) more frequent in patients transfused with packed red cells compared with patients transfused with leukocyte-depleted red cells. Postoperative stays averaged 9 days for untransfused patients, 12 days for leukocyte-depleted recipients, and 18 days for recipients of packed red cells. Hospital charges were $19,132, $33,954, and $41,002, respectively. Both transfusion and infection were significantly (P <0.001) related to postoperative stay in multivariate analysis. Hospital charges were significantly related to postoperative stay (P <0.001), blood loss (P <0.001), age (P <0.001), infection (P = 0.007), and randomization to packed red cells (P = 0.032). CONCLUSIONS: Filtering blood of leukocytes prior to transfusion for elective gastrointestinal surgery is associated with lower risk of postoperative infection, shorter postoperative stays, and lower hospital charges.