Guidelines on the standards for the training of specialised health professionals dealing with breast cancer.

According to EUSOMA position paper 'The requirements of a specialist breast unit', each breast unit should have a core team made up of health professionals who have undergone specialist training in breast cancer. In this paper, on behalf of EUSOMA, authors have identified the standards of training in breast cancer, to harmonise and foster breast care training in Europe. The aim of this paper is to contribute to the increase in the level of care in a breast unit, as the input of qualified health professionals increases the quality of breast cancer patient care.

Axillary dissection in breast cancer revisited.

The pathological status of the axillary nodes remains the single most determining factor for survival, local recurrence and disease-free interval in operable breast cancer. Radical axillary dissection results in better local control with or without systemic disease in all operable cases. In pathologically negative cases, radical axillary dissection decreases local recurrence rates and perhaps prolongs disease-free survival. In pathologically positive cases, radical axillary dissection improves local control only. Radical axillary dissection avoids axillary irradiation and so decreases the risk and the importance of lymphoedema. Perfect axillary dissection does not show a decisive advantage over less complete axillary dissection when the 'quality' of surgery is measured by lymphoscintigraphy, but it should be kept in mind that only total control of the local situation can ensure a patient free of distal spread at the time of first therapy.

Local postoperative morbidity following pre-operative irradiation in locally advanced breast cancer.

The authors have reviewed the medical files of 100 patients with locally advanced breast cancer (Stage III), who were treated in the Department of Surgery at the Institut Jules Bordet between 1974 and 1988. All patients received pre-operative radiotherapy (average total dose 45 Gy), which was associated with chemotherapy in 74% of patients. All patients were subsequently subjected to surgery, using a modified mastectomy in 92% of cases. Our data reveal an incidence of 25% local wound infection, 34% delayed wound healing, 63% seroma formation and 22% lymphoedema of the upper limb. It seems that local postoperative morbidity is increased in patients pre-operatively irradiated. This indicates that pre-operative chemotherapy may be preferable in these patients to minimize the local postoperative morbidity and its impact on the quality of life.

Locoregional recurrences after 649 modified radical mastectomies: incidence and significance.

A continuous series of 649 patients, treated by modified radical mastectomy for primary breast carcinoma, is analyzed after a median follow-up of 92 months. 'True isolated' locoregional recurrences (LR), defined as LR not preceded or followed by distant metastases within 6 weeks, appeared with a cumulative actuarial incidence rate of 6%, 14% and 19% after 1, 5 and 7 years respectively, whereas the respective figures for distant metastases (M1) were 10%, 37% and 48%. The main initial parameters, predicting both the LR-free and the M1-free interval, are presented by statistical analyses in the following order of importance: number of invaded lymph nodes in the axilla, tumor size (T) and histological grading of differentiation. The same factors also predicted the imminence of M1 once LR had occurred, as well as survival after LR. A higher incidence of M1 after LR was also correlated with estrogen-receptor negative tumors and with those LR occurring within one year after mastectomy. LR occurred at the chest wall (65%), in the sub-clavicular fossa (16%) and the axilla (6%); the remaining 13% occurred in two of the sites. There was a trend towards longer survival after chest wall recurrence than after LR recurrence at another site. Axillothoracic irradiations postmastectomy gave a lower rate of LR in 227 patients than did a regimen of 12 months adjuvant chemotherapy with irradiation restricted to the internal mammary lymph nodes in 120 subsequent patients: 17 vs 25% at 5 years (P = 0.03 when adjusted by initial nodal involvement and T-size). Total excision of LR (repeated if new LR occurred) gave better rates of local ultimate control and survival than other kinds of treatments, with or without adjuvant local or systemic therapy. LR is not always a sign of imminent generalized disease. Actuarial 5-year survival after LR is 26.2% overall whereas, if only 'true isolated' LR are considered, the survival is 37%.

In vitro influence of estradiol or progesterone on the thymidine labeling indices of human benign breast tumors.

Using an in vitro tritiated thymidine (3H-dThd) nuclear labeling followed by autoradiography, the effects of 17-beta-estradiol (E2) or progesterone (Pg) on cell proliferation were studied in 22 human benign breast tumors, i.e. 7 fibroadenomas 8 fibrocystic dysplasias 4 gynecomastias and 3 phyllodas. Small tumor fragments were incubated in a chemically-defined medium without serum and were hormonally stimulated in vitro. The procedure used allowed discrimination between weak labeling, suggestive of DNA repair mechanism, and strong labelling, suggesting a true DNA synthesis (S phase). Taking this into account, our results have shown that both estradiol and progesterone can induce in vitro cell replication of both ER+PgR+ and ER-PgR- human breast fibroadenoma, without affecting those of fibrocystic dysplasia, gynecomastia and phylloda. Progesterone, but not estradiol, might significantly decrease DNA repair mechanism in fibrocystic dysplasia, according to the Pg-induced decrease of nuclear incorporation of small amounts of 3H-dThd. We have thus characterized a dynamic test of hormone dependence which permits in vitro study of the hormonal sensitivity of human benign breast tumors, as well as that of any other human neoplasm. This test could be of great value to help clinicians to diagnose and treat hormone-dependent neoplasms properly. Its clinical relevance is now under study.

[Development of a therapeutic strategy and role of surgery in breast cancer]. / Evolution de la stratégie thérapeutique et rôle de la chirurgie dans le cancer du sein.

The evolution of therapeutic strategy and the role of surgery in breast cancer. Loco-regional control of breast cancer is achieved with lesser surgical mutilation. Quality of results is however dependent of the stage of the disease more than of therapeutic modalities.

Modern trends in the treatment of breast cancer.

Good cosmetic results after treatment of localized breast cancer can be achieved by breast conservative techniques for small tumors. These techniques are still in the experimental stage for tumors of 2 cm or more and in the presence of axillary nodes. Modified radical mastectomy is widely accepted as first choice surgical procedure: it is radical enough for cure and conservative enough for good functional and cosmetic results. It permits excellent secondary breast reconstruction, even after adjuvant radio- or chemotherapy.

Implications of surgical techniques.

Modified radical mastectomy, with preservation of both pectoralis muscles, is the treatment of choice in most cases of breast cancer. The technique of this procedure is explained and important details to facilitate later reconstruction are stressed.

[Modified radical mastectomy. Experience of the Institut J. Bordet (author's transl)]. / Mastectomie radicale modifiée. Expérience de l'Institut Bordet.

The authors report the results of a homogeneous series of 319 modified radical mastectomies where both pectoralis muscles are respected, in the treatment of breast cancer. Operative mortality is nill and morbidity is low. Persistant lymphedema of the arm is not marked. The frequency of axillary nodes is 64%. Local recurrences occur in 12% of cases. Total 5 year survival was 50.1%. It was 89% for stage I, 57.3% for stage II and 43.7% for stage 222. It was 61.5% if there were no involved nodes, 63.9% when 1 to 3 nodes were involved and 32% when 4 or more nodes were involved. The authors recommend this type of operation of tumors of state II and III as the 5 year survival is identical to that of other techniques, as morbidity and mortality are low and distant sequellae are unimportant.

Breast reconstruction at the tumor center of the University of Brussels. A three year report.

In 80 cases, breast reconstruction was performed as a secondary procedure at least one year after mastectomy for cancer. The prerequisite was absence of local recurrence and distant metastasis, good general condition and careful information on the result to be expected. In the majority of the cases reconstruction was accomplished in two stages: volume replacement with a prosthetic implant was followed after 3 months, by nipple-areolar reconstruction-usually from the opposite side. Capsulotomy or replacement of the prosthesis in case of asymmetry could be performed at this time. If necessary, skin replacement was done as a first procedure by means of a thoraco-epigastric or a latissimus dorsi myocutaneous flap. Aesthetic results are improving with experience and the positive psychological response of the patients is an encouragement to proceed in helping also patients with a rather poor prognosis.

[Lymphedema after modified radical mastectomy as performed at the Bordet Institute. A report of 60 cases (author's transl)]. / Le lymphoedème du bras après mastectomie radicale modifiée, expérience de l'Institut Bordet. A propos de 60 cas observés.

Three hundred and fifteen patients who underwent a radical mastectomy between 1969 and 1976 were studied. Nineteen percent developed lymphedema of the upper limb. Ten percent were resistant to all forms of therapy while the pathology gradually subsided in 9%. The causes of lymphedema as well as the preventive and curative methods were statistically studied and compared with those in the literature. Several preventive measures are proposed, in particular, the modified radical mastectomy.

[The so-called minimal cancers of the breast (author's transl)]. / Les cancers du sein dits "minimaux".

In situ lobular carcinoma, intraductal carcinoma and papilliferous non-invasive carcinoma are three non-invading cancers that present clinically as the other malignant tumors of the breast. Between January 1, 1973 and August 31, 1976, ten patients were operated at the institut Bordet for such tumors. Surgical treatment varied between radical mastectomy according to Madden and partial mammectomy. Follow-up reveals no recurrence over periods extending from zero to three years. The choice of treatment depends on the histology and the probability of evolution of the actual cancer.

[Morbidity of surgical treatment for advanced cancer of the breast after irradiation]. / Morbidité du traitement chirurgical du cancer due sein avancé après irradiation.

The authors reviewed the medical files of 100 patients with locally advanced breast cancer (stage III), treated in the department of surgery of the Institut Jules-Bordet between 1974 and 1988. All patients received preoperative radiotherapy (average total dose of 45 Grays). This preoperative irradiation was associated with chemotherapy in 74% of patients. All patients subsequently underwent surgery and a modified radical mastectomy was performed in 92% of cases. Our data analysis reveals an incidence of 25% of local wound infections, 34% of delayed wound healing, 63% of seroma formation and 22% of lymphoedema of the upper limb. The local postoperative morbidity appears to be increased in patients preoperatively irradiated. This indicates that preoperative chemotherapy may be preferable in these patients to minimise the local postoperative morbidity and its impact on the quality of life.

[Hormonal receptors of malignant breast tumors]. / Les récepteurs hormonaux des tumeurs malignes du sein

Tissue samples from 166 primary and 136 metastatic breast cancers were analysed for the presence of estrogen receptors. It was found by measuring the affinity of the cytoplasmic fraction of these samples for 3H-estradiol-17 beta that receptors were present in 72 p. 100 and 54 p. 100 of primary and metastatic cancers respectively. Receptor concentration varied among sample in an apparently continuous distribution from zero to 2,080 femtomoles per mg tissue protein. This suggests that mammary tumors are different from one another more in a quantitative than in a qualitative way. Detectable amounts of receptors were found in samples from mammary dysplasia, fibroadenomas as well as from one papilloma; none was detected in samples from non-tumorous mammary gland, nipple areola or skin. At mastectomy, no correlation was found between presence or absence of receptors in the primary tumors, and presence or absence of metastatic axillary nodes. On the other hand both the primary and its axillary metastases almost always displayed the same characteristic as far as presence or absence of receptors was concerned. Analysis of clinical studies reported seems to indicate that women with advanced breast cancer respond in a fair proportion of cases to various endocrine treatments when tumor tissue biopsies contain estrogen receptors whereas the probability of a response is very low in their absence.

[Breast-preserving treatment of breast cancer and peroperative curietherapy]. / Traitement conservateur du cancer du sein et curiethérapie peropératoire.

From May 1988 to December 1990, 35 patients benefitted from a breast-conserving treatment (tumor resection with at least 1 cm of free margin, axillary dissection and peroperative brachytherapy). The iridium sources were introduced 24 h later, delivering between 15 to 17.5 Gy. Three weeks later an additional course of external radiation delivered a dose of 50 Gy in 5 weeks to the whole breast. In this series, only very early breast lesions were included and no patient received additional chemotherapy. Due to the short period of observation, we only report on the acute side effects even if until now we have not seen any case of tumor relapse. We did not observe any major complications after this combined approach: only three patients developed a local infection requiring antibiotics. Esthetic evaluation is quite encouraging with all women showing good and excellent results from the physician's and patient's points of view. This approach seems to be quite interesting cosmetically as it allows to correct the breast shape while preserving an adequate position of the implant and so preserving a good oncological approach.