Surgical margins and risk of locoregional recurrence in invasive breast cancer: an analysis of 10-year data from the Breast Cancer Treatment Quality Assurance Project.

AIM: There is debate as to what constitutes an adequate excision margin to reduce the risk of locoregional recurrence (LRR) after breast cancer surgery. We have investigated the relationship between surgical margin distance and LRR in women with invasive breast cancer (IBC). METHODS: Tumour free margin distances were extracted from histopathology reports for women with IBC, treated by either breast conserving surgery or mastectomy, enrolled in the Breast Cancer Treatment Group Quality Assurance Project from July 1997 to June 2007. Cox proportional hazards regression analyses were conducted to compare the risk of LRR for involved margins compared with negative margins, measured in increments rounded to the nearest mm. RESULTS: 88 of 2300 patients (3.8%) experienced an LRR after a mean follow-up of 7.9 years. An involved margin, or a margin of 1 mm was associated with an increased risk of LRR (HR 2.72, 95% CI 1.30-5.69), whilst margin distances of 2 mm or greater were not. Risk of LRR with margin distances <2 mm was particularly high amongst those not receiving radiotherapy (RT). CONCLUSION: Based on our findings, we recommend that a tumour free margin distance of 2 mm be adopted as an adequate margin of excision for IBC, in the setting of patients receiving standard adjuvant RT and adjuvant drug therapies as dictated by the current clinical treatment paradigms.

Variation in the management of early breast cancer in rural and metropolitan centres: implications for the organisation of rural cancer services.

The study examines the management and outcomes of women with early invasive breast cancer treated in rural and metropolitan centres over a nine-year observation period. A prospective audit of the treatment and outcomes of 2081 women with early breast cancer who underwent potentially curative surgery between 1997 and 2006 in metropolitan Canberra or in the surrounding rural region was completed. Overall, there was good agreement between published guidelines and the treatment received by the women in the study. However, women treated in rural centres were less likely to receive postoperative radiotherapy after breast-conserving surgery, or to undergo axillary lymph node surgery or sentinel lymph node biopsy compared with women treated in metropolitan centres. Surgery in a rural centre was associated with increased breast cancer recurrence (HR = 1.54, p < 0.001) and increased breast cancer mortality (HR = 1.84, p < 0.001), after adjustment for age and tumour characteristics. Non-cancer related mortality was increased in women treated in rural centres compared with women travelling to a metropolitan centre for surgery (HR = 2.08; p = 0.005). There were differences in both the care provided and treatment outcomes between women treated in rural centres and women treated in metropolitan centres. However, the increased non-cancer related mortality in women treated in rural centres suggests an increased medical comorbidity in this group. Initiatives supporting rural-based surgeons to adopt new procedures such as sentinel node biopsy may help to optimise rural breast cancer treatment.

Sentinel node biopsy in larger or multifocal breast cancers: to do or not to do.

BACKGROUND: The use of sentinel node biopsy (SNB) in breast cancer patients with large and/or multifocal tumours is controversial. METHODS: A review of clinical records was undertaken for 213 consecutive patients undergoing SNB for invasive breast cancer from September 2000 to February 2006. The results of SNB and axillary dissection were compared for patients with unifocal or multifocal tumours less than 3 cm and 3 cm or larger. Patient outcomes were also assessed. RESULTS: The mean number of sentinel nodes removed per patient increased from 2.33 in 2000 to 4.17 in 2006. For patients with unifocal tumours less than 3 cm, 47 of 147 (32.0%) were sentinel node positive compared with 15 of 30 (50%) for multifocal tumours less than 3 cm (P = 0.04), 19 of 28 (67.9%) for unifocal tumours 3 cm or larger (P < 0.001) and 7 of 8 (87.5%) for multifocal tumours 3 cm or larger (P = 0.003). Following axillary dissection, 20 of 48 (41.7%) patients with sentinel node macrometastases were found to have positive non-sentinel nodes, compared with 4 of 20 (20.0%) and 1 of 8 (12.5%) for patients with sentinel node micrometastases and isolated tumour cells. The mean total number of positive nodes was 1.74 compared with 4.21 for unifocal tumours less than or greater than 3 cm, respectively (P = 0.004). No axillary recurrences were detected during the follow-up period. CONCLUSION: Although patients with large and/or multifocal tumours were more likely to have a positive sentinel node, the findings provide some indication that SNB may be reliable for staging the axilla in these patients.

Surgical management of invasive breast cancer: a 5-year prospective study of treatment in the Australian Capital Territory and South-Eastern New South Wales.

BACKGROUND: Breast cancer is a major health problem in Australia. The aim of the present report is to evaluate the surgical management of invasive breast cancers in our region. METHODOLOGY: As part of a multidisciplinary quality assurance project, data were collected for the majority of breast cancers treated in our region between July 1997 and June 2002. Participants included surgeons, medical and radiation oncologists, pathologists and general practitioners. RESULTS: Over the 5-year period, 1069 invasive breast cancers were treated. Mastectomy (52%) was more common than breast conservation. For cancers less than 2 cm in diameter (61%), breast conservation was achieved in 62%. High nuclear grade cancers (27%) resulted in mastectomy in 60%. This treatment pattern was the same for patients living in urban and rural areas and in all age groups. Those patients requiring two or more operations (30%) to achieve surgical clearance still had a 33% rate of breast conservation. Over the last 5 years there has been an increase in sentinel node biopsies (16 sentinel node biopsies during 1998-1999; 64 during 2001-2002) and axillary dissections started to decrease. A small group has had no axillary node biopsy or dissection, mainly patients over 70 years of age. Multimodality treatments increased over the 5-year period of our study with the use of postoperative radiotherapy increasing from 60% to 65% and chemotherapy from 36% to 55%. CONCLUSIONS: The project has mapped treatment trends for breast cancer in our region and documented the implementation of new treatment methods as well as the increasing use of multidisciplinary management, multimodality treatment and the implementation of best practice guidelines.

Methotrexate in the management of granulomatous mastitis.

Granulomatous mastitis is a rare benign inflammatory breast disease that often clinically simulates carcinoma. Surgical resection of the entire lesion has been the main method of treatment but recurrence, infection, sinus formation and delayed wound healing can occur relatively commonly. Corticosteroids are also effective in recurrent or resistant cases but are associated with side-effects and relapse of disease after steroid withdrawal. A low weekly oral dose of methotrexate was used in five resistant cases after surgery plus corticosteroid. All cases achieved remission, withdrawal of corticosteroid without relapse and no methotrexate side-effect.

The clinical significance of cytokeratin-positive cells in lymph nodes at the time of mastectomy from patients with ductal carcinoma-in-situ.

BACKGROUND: We determined the presence or absence of and clinical significance of cytokeratin-positive cells in the lymph nodes of patients who had had mastectomies for ductal carcinoma-in-situ. METHODS: Two pathologists independently assessed the axillary lymph nodes found. All patients had either a core or open biopsy performed before the time of mastectomy. The lymph nodes were assessed with hematoxylin and eosin stain and immunohistochemistry for cytokeratin marker AE1/AE3. The slides were assessed for the presence or absence of epithelial cells. As a control, axillary lymph nodes found in prophylactic mastectomies were assessed. None of these had had a previous biopsy performed. RESULTS: Lymph nodes from all patients demonstrated no obvious epithelial cells on hematoxylin and eosin stain. Peripheral sinuses of lymph nodes from six patients (23%) who had mastectomies for ductal carcinoma-in-situ contained a few cytokeratin-positive cells on immunohistochemistry. The lymph nodes of the control group demonstrated no cytokeratin-positive cells. The mean follow-up of patients was 5 years, and all patients were alive without recurrence at the time of the study. CONCLUSIONS: Epithelial cells may be present in the lymph nodes draining a site of recent breast biopsy in the absence of invasive carcinoma, indicating that these are an artifact of recent surgery and not of micrometastatic disease.