Axillary clearance in operable breast cancer: still a necessity?

Complete axillary dissection, as part of radical mastectomy, was the standard of care for the first three-quarters of this century. Long-term follow-up of these patients showed substantial cure rates for positive-node patients before systemic therapy was available, indicating a therapeutic value to nodal dissection. There was also good control of the axilla; axillary recurrence after removal of positive nodes was quite low. Even today, in patients with positive nodes, complete axillary clearance as part of a modified radical mastectomy or a breast conservation approach with lumpectomy leads to control of the axilla and complete axillary staging, allowing medical oncologists to tailor their systemic treatment to the total number of nodes involved. Today, due to a combination of factors including patient awareness and the ability of mammography to detect smaller lesions, many women present with small cancers that carry a much lower risk of axillary involvement. Whereas a complete dissection is indicated for patients with clinically involved nodes, a level I-II dissection is the standard in most centers for patients with clinically negative nodes. In those patients with very small (T1a, T1b) cancers, the role of sentinel lymphadenectomy is being explored; it may spare these patients the morbidity of complete axillary dissection.

Axillary lymphadenectomy: a diagnostic and therapeutic procedure.

Axillary dissection for primary operable cancer follows the basic tenants of surgical oncology and achieves the stated goals. Local control is excellent with failure rates in the 0-2% range. Long-term and disease-free survival is improved with axillary dissection. It is often stated that axillary dissection is not required for the smallest of lesions, but the 15% risk of axillary disease with the T1A lesion would suggest otherwise. Axillary sampling would not achieve the stated goals because of the high probability of retained, potentially resectable disease in the node positive group. Axillary recurrence is associated with an unacceptably high morbidity and mortality. Although the survival is similar in the three treatment groups of NSABP B-04, the inordinately high systemic failure rate with axillary recurrence would suggest that more aggressive local control could prevent many of these failures. After all, long-term survival free of disease is reported in many series even in patients with multiple involved nodes. Axillary dissection also generates the most accurate prognostic variable upon which further therapeutic interventions are predicated. At present there is no other diagnostic or therapeutic approach that achieves all of these goals. In summary the value of the axillary dissection is to provide accurate prognostic information as well as excellent local control and to improve the survival rate in the node positive group. It is hoped that in the future a diagnostic test such as PET scanning or sentinel node mapping may predict those patients with a clear axilla and therefore not require an axillary dissection. Finally, there has yet to be a primary operable carcinoma that benefits from preservation of potentially fully resectable disease.

Systemic adjuvant therapy of breast cancer.

Systematic adjuvant therapy has improved the outcome for women with operable breast cancer. As a result, a substantial proportion of patients with this disease are candidates for adjuvant treatment. In providing a woman with recommendations for therapy, her risk of developing recurrent breast cancer needs to be assessed in relationship to the degree of benefit she will obtain from treatment. With the range of presently available treatments, an individualized approach is necessary to provide the patient with options appropriate for her own situation. For women with a high risk of recurrence despite current standard adjuvant therapies, innovative approaches with high dose chemotherapy followed by infusion of autologous hematopoietic stem cells and growth factors are being evaluated. Ongoing clinical trials will demonstrate whether or not these newer therapies result in a better outcome.

Breast-conserving treatment: controversies and consensus.

Although breast-conserving therapy (BCT) is an accepted alternative for the treatment of breast cancer, numerous controversies surround the selection criteria and the treatment details. A review of the literature revealed that patient selection is of critical importance. However, there is disagreement over the relative importance of some of the criteria for patient selection. A wide excision is preferable to a less complete excision (tumorectomy) or a more radical excision (quadrantectomy). Accurate assessment of surgical margins is important. The risk of local recurrence may be diminished if a re-excision is performed to obtain tumor-free margins. However, the suitability and practicality of the techniques used to assess the resection margins have been questioned. Radiotherapy is an integral part of BCT. Surgery alone remains an investigational approach. Axillary dissection remains a reliable method of assessing nodal status and treating regional disease.

Breast sarcoma.

Primary sarcoma of the breast is a rare problem and accounts for less than 5% of all soft-tissue sarcomas and less than 1% of all breast malignancies. As experience with breast sarcoma has increased, the perceived differences with other soft-tissue sarcomas has decreased. Outcome is predicated upon histologic type, degree of differentiation, and tumor size. Recurrences are primarily local as an early event and distant to the lung somewhat later in the course of the disease.

Is axillary lymph node dissection necessary in the routine management of breast cancer? Yes.

Axillary dissection for primary operable cancer follows the basic tenets of surgical oncology and achieves the stated goals. Local control is excellent, with failure rates of 0% to 2%. Long-term, disease-free survival is improved with axillary dissection. It is often stated that axillary dissection is not required for the smallest lesions, but the 15% risk of axillary disease with the T1A lesion suggests otherwise. Axillary sampling would not achieve the stated goals because of the high probability of retained, potentially resectable disease in the node-positive group. Axillary recurrence is associated with unacceptably high morbidity and mortality rates. Although the survival is similar in the three treatment groups of NSABP B-04, the inordinately high systemic failure rate with axillary recurrence would suggest that more aggressive local control could prevent many of these failures. After all, long-term survival free of disease is reported in many series, even in patients with multiple involved nodes. Axillary dissection also generates the most accurate prognostic variable on which further therapeutic interventions are predicated. At present, no other diagnostic or therapeutic approach achieves all these goals. The value of the axillary dissection is to provide accurate prognostic information, provide excellent local control, and improve the survival rate in the node-positive group. Perhaps in the future, a diagnostic test such as PET scanning or sentinel node mapping will identify patients with a clear axilla, who therefore do not require an axillary dissection. There has yet to be a primary operable carcinoma that benefits from preservation of potentially fully resectable disease.

The surgical management of primary invasive breast cancer.

The treatment of operable primary breast cancer has evolved dramatically in the past few decades. The standard operative procedure has changed from the radical mastectomy to the modified radical mastectomy, and the use of breast-conserving treatment is increasing. This article reviews trends in treatment of early-stage breast cancer, factors associated with increased risk for local recurrence after breast-conserving treatment, and the use of axillary lymph node dissection.

Hypnotic efficacy and safety of triazolam administered during the postoperative period.

This study examined the hypnotic efficacy and safety of short-term use of triazolam following elective surgery. One hundred women (ages 26-69) who had received 0.125 mg of traizalam the evening before breast cancer surgery were enrolled in a randomized, double-blind study comparing triazolam to placebo. Study medication was begun on the first or second evening following surgery, depending on the patient's level of postoperative alterness, and was administered in the hospital for three consecutive evenings. The starting dose of triazolam was 0.125 mg, with the option of increasing the dose to 0.25 mg on subsequent nights if sleep response was inadequate. Relative to patients in the placebo group, patients in the triazolam group reported significantly (p < 0.05) less difficulty falling asleep, fewer nightime awakenings, better overall sleep quality, and a greater sense of restfulness. No clinically significant adverse reactions were encountered and no adverse reactions occurred more frequently in the triazolam group than in the placebo group. Results indicate that administration of traizalam is a safe and effective method of improving sleep in patients recovering from surgery.

Method of tumor detection influences disease-free survival of women with breast carcinoma.

BACKGROUND: Screening mammography provides the primary means of reducing breast cancer mortality. Clinical breast examination (CBE) and breast self-examination (BSE) may be complementary screening modalities enabling palpation of interval cancers and detection of tumors not visualized by mammography; however, their combined contribution to improving prognosis has not been evaluated adequately. METHODS: Disease-free survival was assessed in relation to method of tumor detection among 729 consecutive patients treated by mastectomy and axillary dissection for primary breast carcinoma between 1976 and 1978. RESULTS: Disease-free survival at 10 years was significantly higher after detection by mammography (77% of 30 patients) or CBE (78% of 101 patients) compared to self-detection (64%). The hazard ratio of recurrence associated with clinical examination or mammography in contrast to self-detection was significantly reduced to 0.55 (95% CI, 0.37-0.81; P = 0.001). In addition, annual CBE, compared to less frequent clinical palpation, reduced the risk of recurrence controlling for detection modality (P = .03). In multivariate analyses, the method of detection and frequency of clinical breast examination remained statistically significant prognostic factors after controlling for number of screening mammograms, history of prior breast surgery, family history of breast cancer, and age at diagnosis. Differences in self-examination frequency were not associated with prognosis. CONCLUSIONS: Among patients diagnosed before widespread mammography screening, tumor detection by CBE was associated with a significant reduction in recurrence compared with detection by self-palpation. Improvement in the frequency and quality of CBE and BSE may enhance the contribution of these modalities to early detection, complementing the role of screening mammography in reducing breast cancer mortality rates.

Menstrual timing of treatment for breast cancer.

Although the hormone dependency of breast cancer has been recognized for nearly a century, the influence on disease progression of cyclical hormonal levels among premenopausal women has not been extensively researched. The findings of recent studies, assessing the effect on prognosis of the hormonal milieu at the time of surgery, have been conflicting. However, several reports have noted improved survival among patients with positive, axillary lymph nodes surgically treated in the later phase of the menstrual cycle when progesterone levels are elevated. Biologic support for the influence of menstrual timing is provided by cyclical patterns of cell division and cell death observed in normal breast tissue as well as potential tumor cell dissemination during surgery among patients with positive axillary nodes. Immune parameters, which also respond to cycling endogenous hormones, may influence the metastatic potential of circulating tumor cells. Comparisons among studies of menstrual timing of surgery have been complicated by differences in cycle divisions, extent of primary surgery, frequency of adjuvant therapy, duration of follow-up, and analytic procedures. Although several clinicians are now scheduling breast surgery of premenopausal women in relation to day of the menstrual cycle, a majority of surgeons have deferred consideration of menstrual timing until additional research is available. While waiting 5-10 years for the results of prospective studies, additional retrospective analyses, using carefully collected data, may provide clinical guidance. With increasing concern for issues related to women's health, multidisciplinary studies will be required to adequately characterize the influence of the menstrual cycle and other aspects of women's reproductive physiology on breast cancer and other medical conditions.

Conservation surgery for breast cancer: selection criteria and technical considerations.

Patients with stage I or II breast cancer are candidates for either modified radical mastectomy or breast preservation therapy involving limited resection of the primary tumor, axillary dissection, and breast irradiation. The overall survival rates of both these approaches are comparable according to retrospective reviews and ongoing clinical trials, and long-term follow-up confirms the earlier findings. Thus, patients should be given the choice between these two options by surgeons, radiation therapists, and other physicians involved in their care. However, not all breast cancer patients will choose breast preservation surgery, and because of tumor-related and other factors not all patients are candidates. The patient selection criteria are discussed herein and the optimal surgical techniques are reviewed.

Patient selection criteria for conservation surgery versus mastectomy: Memorial Hospital breast service experience.

Breast cancer remains the most common noncutaneous malignancy of women. Although the incidence of the disease continues to rise, most women now present with early (stage I or II) disease. Breast conservation has been demonstrated to be equal in efficacy to mastectomy in such patients in six modern-day randomized trials. The utilization of breast conservation has been slow throughout the United States. At Memorial Hospital the utilization of breast conservation almost equals that of modified mastectomy in the treatment of 950+ annual primary operable cancers. Excellent local-regional control can be obtained with a defined surgical approach to the primary tumor and axillary nodes, radiotherapy to the breast with a boost to the primary site, and finally patient selection.

Controversies in primary breast cancer management.

Adequate locoregional treatment of patients with primary operable breast cancer involves the control of multicentric disease in the breast and axillary dissection to stage the disease and control it in the axilla, when present. Two options, having equal survival rates in prospective, randomized studies, are breast preservation and mastectomy. In breast preservation, adequate tumor excision with clear histologic margins and axillary dissection is followed by breast irradiation. The mastectomy option involves no radiotherapy and can be followed by reconstruction. Careful selection of patients and a detailed description of the pros and cons of each approach should be undertaken on an individual basis.

Factors influencing prognosis in node-negative breast carcinoma: analysis of 767 T1N0M0/T2N0M0 patients with long-term follow-up.

PURPOSE: This study was undertaken to define prognostically favorable and unfavorable subgroups of node-negative breast carcinoma patients by employing conventional pathologic data. PATIENTS AND METHODS: Seven hundred sixty-seven women with T1N0M0/T2N0M0 breast carcinoma treated consecutively from 1964 through 1970 by modified or radical mastectomy without systemic adjuvant therapy were analyzed at a median follow-up duration of 18 years. RESULTS: Size and histologic type of the carcinoma were crucial discriminants of prognosis. We defined a prognostically favorable group of 219 patients (29%) with infiltrating duct or lobular carcinoma < or = 1.0 cm in diameter or special tumor types < or = 3.0 cm. This group had a relapse-free survival rate of 91% at 10 years and 87% at 20 years. The less favorable group (548 patients, 71%) with infiltrating duct or lobular carcinoma greater than 1.0 cm and special tumor types greater than 3.0 cm had relapse-free survival rates of 73% and 68% at 10 and 20 years, respectively. The frequency of nonmammary malignant neoplasms (NMMN) was similar to that of contralateral carcinoma. Deaths due to NMMN were seven times more frequent than deaths due to contralateral carcinoma. CONCLUSION: Nearly 30% of these node-negative patients, identified on the basis of tumor size and type, had an extremely favorable prognosis. There is insufficient evidence to warrant the routine use of adjuvant therapy in this group unless new forms of treatment prove to be less toxic and/or more effective in enhancing relapse-free survival. Early detection of NMMN should be an important part of the follow-up of node-negative breast carcinoma patients.

Role of contralateral breast biopsy in infiltrating lobular cancer.

BACKGROUND: Although infiltrating lobular carcinoma (ILC) is known to be associated with higher rates of bilaterality, contralateral breast biopsies are not routinely performed in such patients. METHODS: The pathology reports of all patients with ILC admitted to Memorial Sloan-Kettering Cancer Center between 1970 and 1980 were retrospectively reviewed. The incidence of contralateral biopsies, random and directed, was determined. The findings on contralateral biopsy were evaluated with respect to age of the patient, nodal status of the ipsilateral cancer, and multicentricity of the primary lesion. RESULTS: Of the 275 patients undergoing mastectomy for ILC, 130 (47%) had contralateral biopsies. Twenty-two were directed biopsies and 108 were random biopsies. On random biopsy 11 (10%) patients were found to have infiltrating carcinomas and seven (6%) were found to have intraductal cancer. Multicentric invasive disease in the ipsilateral breast was found to be predictive of a positive contralateral biopsy (p = 0.01). CONCLUSIONS: Despite the current trend toward less extensive surgery for breast cancer, random contralateral breast biopsy is indicated in patients with ILC.