Consenso sobre la biopsia selectiva del ganglio centinela en el cáncer de mama. Revisión 2013 de la Sociedad Española de Senología y Patología Mamaria / Consensus on sentinel lymph node biopsy in breast cancer. Review of the Spanish Society of Senology and Breast Pathology 2013

La biopsia selectiva del ganglio centinela es una técnica diagnóstica aceptada como el procedimiento de elección para la estadificación axilar del cáncer de mama. En este documento, correspondiente a la última Reunión de Consenso celebrada en Valencia y organizada por la Sociedad Española de Senología y Patología Mamaria, se actualizan los consensos previos y se reflejan las conclusiones acerca de las últimas propuestas en el manejo del ganglio centinela en el cáncer de mama (AU)

Sentinel lymph node biopsy is currently a widely accepted diagnostic technique and is the procedure of choice for axillary staging of breast cancer. In this article, following the latest Consensus Meeting held in Valencia organized by the Spanish Society of Senology and Breast Pathology, previous consensus are updated. Also discussed are conclusions related to the latest trends in the management of the sentinel node in breast cancer (AU)

Consenso sobre la biopsia selectiva del ganglio centinela en el cáncer de mama. Revisión 2013 de la Sociedad Española de Senología y Patología Mamaria / Consensus on sentinel lymph node biopsy in breast cancer. Review of the Spanish Society of Senology and Breast Pathology 2013

La biopsia selectiva del ganglio centinela es una técnica diagnóstica aceptada como el procedimiento de elección para la estadificación axilar del cáncer de mama. En este documento, correspondiente a la última Reunión de Consenso celebrada en Valencia y organizada por la Sociedad Española de Senología y Patología Mamaria, se actualizan los consensos previos y se reflejan las conclusiones acerca de las últimas propuestas en el manejo del ganglio centinela en el cáncer de mama

Sentinel lymph node biopsy is currently a widely accepted diagnostic technique and is the procedure of choice for axillary staging of breast cancer. In this article, following the latest Consensus Meeting held in Valencia organized by the Spanish Society of Senology and Breast Pathology, previous consensus are updated. Also discussed are conclusions related to the latest trends in the management of the sentinel node in breast cancer

Factors associated with health-related quality of life in a cohort of Spanish breast cancer patients.

BACKGROUND: Several factors can modify health-related quality of life (HRQOL) of breast cancer survivors. The objective of the current study was to analyse the associations between HRQOL scores 1 year after breast cancer surgery and sociodemographic and clinical factors. METHODS: This was an observational, multicentre and prospective study of a cohort of patients who underwent oncological breast cancer surgery and which was followed up for 1 year. The HRQOL was assessed at 1 year after surgery using three questionnaires: EuroQol-5D, EORTC QLQ-C30 and its breast-specific module BR-23. RESULTS: A total of 364 patients participated in the study. Some factors were associated with better HRQOL 1 year after surgery: age between 60 and 69 years and under 50 years, being single or a housewife, stage I-II, invasive papillary carcinoma, breast-conserving surgery (BCS) or lack of axillary dissection. However, only the following were independent predictive factors: being single or a housewife, BCS, invasive papillary carcinoma, coming from an outpatient clinic or not receiving radiotherapy. Further, some factors were independent predictors of a worse HRQOL: age over 70 years, being married, separated or widowed, stage III or not receiving adjuvant chemotherapy. CONCLUSIONS: Demographic and clinical factors can influence HRQOL, some of them independently.

¿Mejora la cirugía mamaria la supervivencia del cáncer oculto de mama? / Does surgery improve survival in occult breast cancer?

Introducción. El cáncer oculto de mama (COM), con una incidencia del 0,3-1%, aún plantea retos diagnósticos y terapéuticos. El objetivo del trabajo fue determinar las características patológicas de nuestra serie de COM, evaluar los resultados de las técnicas diagnósticas y terapéuticas empleadas (cirugía mamaria con linfadenectomía axilar o solo linfadenectomía axilar) y la supervivencia global. Pacientes y métodos. Análisis retrospectivo de 21 pacientes con metástasis ganglionares de cáncer mamario con mamografía y ecografía mamaria negativas. Desde 2003 se incluyó la resonancia magnética nuclear (RMN) en el protocolo de estudio. Se valoró la supervivencia en 2 grupos; grupo A: pacientes con COM tratadas con cirugía mamaria (15 casos), bien mastectomía radical (10 pacientes) bien cirugía conservadora (5 casos), y grupo B: 4 pacientes tratadas quirúrgicamente con linfadenectomía axilar niveles i y ii de Berg. Se asoció radioterapia sobre la mama tras cirugía conservadora (50 Gy) y sobre la axila si > 3 adenopatías axilares tumorales. Resultados. En 9 pacientes (7 de las mastectomías y 2 de las cirugías conservadoras) se identificó histológicamente un carcinoma de mama, de tipo ductal infiltrante en 8 casos y un carcinoma medular. La RMN (6 casos) demostró en 2 pacientes tumor mamario con confirmación histológica de carcinoma. Con una mediana de seguimiento de 87 meses, la supervivencia global fue de 101,2 meses (rango: 12-235 meses) con una supervivencia a 5 años del 69%. La supervivencia media en el grupo A fue de 120 meses, superior a los 41 meses del grupo B (p = 0,05). Conclusiones. En nuestra serie el tratamiento quirúrgico sobre la mama mejora la supervivencia global respecto al grupo tratado solo con linfadenectomía axilar. La RMN ha sido útil para evidenciar nódulos tumorales ante un supuesto COM y permite seleccionar a pacientes para realizar cirugía conservadora de la mama(AU)

Introduction. Occult breast cancer (OBC) has an incidence of 0.3-1% but nevertheless represents a diagnostic and therapeutic challenge. The aim of our study was to determine the pathologic characteristics of patients in our OBC series, compare the results of the different diagnostic and therapeutic techniques available (breast surgery with axillary lymphadenectomy or axillary lymphadenectomy alone), and overall survival. Patients and methods. A retrospective analysis was carried out in 21 patients with axillary lymph node metastases and negative mammography and breast ultrasonography. From 2003 onward, our group included magnetic resonance imaging (MRI) in the study protocol of OBC. Overall survival was determined and 2 groups were compared: Group A consisted of patients with OBC treated with breast surgery (n = 15), either with radical breast mastectomy (n = 10) or breast-conserving surgery (n = 5); and group B consisted of patients (n = 4) treated surgically with Berg level i or ii axillary lymphadenectomy. We added breast radiotherapy (50 Gy) in patients treated with breast-conserving therapy and axillary radiotherapy when there were more than 3 metastatic axillary nodes. Results. In 9 patients (7 mastectomies, 2 breast-conserving interventions), one breast carcinoma, 8 infiltrating ductal carcinomas and one medullar carcinoma were identified by histology. Two breast carcinomas were detected by MRI in 6 patients, which were later confirmed by histologic study. The median follow-up was 87 months, with an overall survival of 101.2 months (range: 12-235 months) and a 5-year survival of 69%. The mean survival was 120 months in group A and 41 months in group B (P = .05). Conclusions. In our series, surgical treatment of OBC improved overall survival compared with lymphadenectomy alone. MRI was useful in the identification of malignant tumors in suspected OBC and allowed patient selection for breast-conserving surgery(AU)

Evolution of Health-Related Quality of Life in Breast Cancer Patients during the First Year of Follow-Up.

PURPOSE: The objective of this study was to describe the evolution of health-related quality of life (HRQOL) in a cohort of breast cancer patients over 1 year after surgery and to analyse the predictive ability of HRQOL measurement instruments. METHODS: Observational, multicenter and prospective study of a cohort of breast cancer patients, assessing HRQOL at 1, 6, and 12 months after surgery using three questionnaires: EuroQol-5D-3L, EORTC QLQ-C30, and EORTC QLQ-BR23. RESULTS: A total of 364 women participated in the study. Visual Analogue Scale (VAS) scores from the EuroQol improved (1 month vs. 1 year: 70 vs. 80; p<0.0001); however, the EuroQol score showed no significant change (0.81 vs. 0.83; p=0.1323). In contrast, Global Health Status on the EORTC QLQ-C30 improved (66.67 vs. 100.00; p<0.0001), as did all of this instrument's scales and most of its independent items. The EORTC QLQ-BR23 dimensions showed improvement, except for sexual functioning (100.00 vs. 86.67; p=0.0030) and future perspective (33.33 vs. 66.67; p<0.0001). Patients with good HRQOL outcomes at 1 month showed improved levels of HRQOL at 1 year; HRQOL measured at 1 month was predictive of HRQOL at 1 year. CONCLUSION: HRQOL improved during the follow-up period. Likewise, HRQOL measurement instruments can predict early HRQOL.

Cáncer de mama y embarazo. Análisis de una serie de 27 pacientes / Breast cancer and pregnancy. Analysis of a series of 27 patients

Objetivo: Realizar un análisis descriptivo de la serie de pacientes con cáncer de mama (CM) y embarazo diagnosticadas en nuestro centro en relación con los métodos terapéuticos empleados y supervivencia global de la serie. Pacientes y métodos: Entre 1982 y 2009, de 5.906 pacientes diagnosticadas de CM, se trató a 27 pacientes con CM y embarazo (0,46%). Analizamos las características clínicas y anatomopatológicas, el diagnóstico, los tratamientos y la evolución de estas pacientes en nuestro centro. Resultados: La edad media al diagnóstico fue de 35 años. Durante la gestación se diagnosticó a 21 pacientes y en el posparto, a 6. El retraso medio diagnóstico desde el inicio de los síntomas fue de 4 meses. Respecto al perfil inmunohistoquímico determinado en 19 pacientes, 5 (26%) eran receptor 2 de factor de crecimiento epidérmico humano (HER2) positivo; otros 5 (26%), triple negativo; 3, luminal A, y en las 6 restantes, luminal B. Al diagnóstico, se clasificó a 5, 9, 11 y 2 pacientes en estadio I, II, III y IV, respectivamente. Histológicamente, 21 (78%) eran carcinomas ductales infiltrantes; 11 (41%), de alto grado histológico, y 4 casos (15%) presentaron características de carcinoma tipo inflamatorio al diagnóstico. Se pautó quimioterapia neoadyuvante en 16 pacientes (59%), sin que se detectaran complicaciones fetales. Se operó a todas las pacientes, y se realizó mastectomía radical modificada en 24 (89%), así como cirugía conservadora en 3. Con un tiempo medio de seguimiento de 60 meses, la supervivencia global fue del 70%. Cuatro pacientes (15%) presentaron recaída local y 13 (48%), recaída sistémica. Conclusiones: El carcinoma de mama durante el embarazo se asocia con un retraso diagnóstico, estadios avanzados y grados histológicos altos. El tratamiento quirúrgico conlleva un alto porcentaje de mastectomías radicales. La quimioterapia no produjo efectos adversos en el feto tras el primer trimestre de gestación. El pronóstico de CM durante el embarazo es similar al de las pacientes no gestantes de la misma edad y estadio tumoral (AU)

Objective: To perform a descriptive analysis of patients with breast cancer (BC) and pregnancy diagnosed in our centre, as regards the therapeutic methods used and the overall survival of the series. Patients and methods: Between 1982-2009, 5906 patients were diagnosed with BC, of whom 27 (0.46%) were treated for pregnancy-associated BC. We analysed the characteristics, diagnosis, treatments and outcome of these patients in our centre. Results: The mean age at diagnosis was 35 years. Twenty-one patients were diagnosed during pregnancy and six of them in the post-partum period. The mean diagnostic delay from the onset of symptoms was four months. In the immunohistochemical profile performed in 19 patients, 5 (26%) were HER2, 5 (26%) were triple-negative, luminal A in three patients, and luminal B in the other 6 cases. At diagnosis, 5, 9, 11 and 2 patients were classified into stages I, II, III and IV, respectively. Histologically, 21 (78%) were infiltrating ductal carcinomas, 11 (41%) were high grade carcinomas and 4 (15%) were inflammatory carcinomas at diagnosis. Neoadjuvant chemotherapy was prescribed in 16 patients (59%), with no foetal complications detected. All patients underwent surgery; 24 (89%) had modified radical mastectomy while three had conservative surgery. The mean follow-up time was 60 months, in which the overall survival was 70%. Four patients (15%) had local recurrence and 13 (48%) had systemic recurrence. Conclusions: Breast carcinoma during pregnancy is associated with diagnostic delay, advanced stages and high histological grades. Surgical treatment involves a high percentage of radical mastectomies. Chemotherapy did not produce adverse effects in the foetus after the first trimester. The prognosis for BC during pregnancy is similar to that of non-pregnant patients of the same age and tumour stage(AU)

Removal of primary tumor improves survival in metastatic breast cancer. Does timing of surgery influence outcomes?

BACKGROUND: Resection of intact primary tumor is controversial in metastatic breast cancer patients. The aim of this study is to review the impact of surgical resection of primary tumor on overall survival and to assess the role of timing of surgery on survival rates. METHODS: 208 patients with metastatic breast cancer diagnosed between 1982 and 2005 in the Hospital Clinico of Valencia (Spain) were analysed. Exclusion criteria were age >80, PS 3-4, Charlson score 3 or follow-up < 90 days. 123 of these underwent surgery and 85 did not. In order to assess the role of timing, the "surgery" cohort was divided into two sub-groups: "before" (n = 78) or "after" (n = 45) diagnosis of disseminated disease. RESULTS: In the surgery group, patients underwent mastectomy with axillary dissection (82.9%), without axillary dissection (8.9%) and conservative surgery (8.1%). After a median follow-up of 29.68 months, median OS in the "surgery" and the "non-surgery" groups were, 40.4 and 24.3 months. Removal of the primary tumor therefore had a significant positive impact on survival rates (p < 0.001). Benefits of surgery were observed mainly in patients with visceral disease (p = 0.005); no statistical differences were found in those with bone disease (p = 0.79). Univariate analysis for overall survival (OS) identified surgery, performance status, clinical T stage, hormone receptors and number and type of metastases as variables that impacted on survival. In the multivariate test, only resection of primary tumor and estrogen receptors maintained statistical significance, surgery having a protective effect with an HR 0.52 (95% CI 0.35-0.77). No differences in survival were found between the two sub-groups according to the timing of surgery: "before" vs "after"(p = 0.996). CONCLUSIONS: Resection of primary tumor should be considered not only as a palliative or preventive strategy but also as an approach that possibly contributes to the control of the disease in selected patients.

Phase III trial evaluating the addition of paclitaxel to doxorubicin followed by cyclophosphamide, methotrexate, and fluorouracil, as adjuvant or primary systemic therapy: European Cooperative Trial in Operable Breast Cancer.

PURPOSE: To evaluate the addition of paclitaxel to an anthracycline-based adjuvant regimen and to compare this combination with the same regimen given as primary systemic (neoadjuvant) therapy. PATIENTS AND METHODS: A total of 1,355 women with operable breast cancer were randomly assigned to one of three treatments: surgery followed by adjuvant doxorubicin (75 mg/m(2)) followed by cyclophosphamide, methotrexate, and fluorouracil (CMF; arm A); surgery followed by adjuvant paclitaxel (200 mg/m(2)) plus doxorubicin (60 mg/m(2)), followed by CMF (arm B); or paclitaxel (200 mg/m(2)) plus doxorubicin (60 mg/m(2)) followed by CMF followed by surgery (arm C). The two coprimary objectives were to assess the effects on relapse-free survival (RFS) of the addition of paclitaxel to postoperative chemotherapy (arm B v arm A) and primary chemotherapy versus adjuvant chemotherapy (arm B v arm C). RESULTS: Doxorubicin plus paclitaxel followed by CMF was well-tolerated as adjuvant or as primary chemotherapy. The addition of paclitaxel to adjuvant doxorubicin followed by CMF significantly improved RFS compared with adjuvant doxorubicin alone followed by CMF (hazard ratio [HR], 0.73; P = .03). Distant RFS was similarly improved (HR, 0.70; P = .027). There was no significant difference in RFS when the paclitaxel/doxorubicin/CMF chemotherapy was given before surgery compared with the same regimen given after surgery (HR, 1.21; P = .18). However, the rate of breast-conserving surgery was significantly higher with preoperative chemotherapy (63% v 34%; P < .001). CONCLUSION: Incorporating paclitaxel into anthracycline-based adjuvant therapy resulted in a significant improvement in RFS and distant RFS. When given as primary systemic therapy, the paclitaxel-containing regimen allowed breast-sparing surgery in a significant percentage of patients.

Feasibility and tolerability of sequential doxorubicin/paclitaxel followed by cyclophosphamide, methotrexate, and fluorouracil and its effects on tumor response as preoperative therapy.

PURPOSE: The European Cooperative Trial in Operable breast cancer (ECTO) randomly tested whether efficacy of adjuvant doxorubicin followed by i.v. cyclophosphamide, methotrexate, and fluorouracil (CMF; doxorubicin-->CMF, arm A) could be improved by adding paclitaxel (doxorubicin/paclitaxel-->CMF) as adjuvant (arm B) or primary systemic therapy (PST, arm C). We report here feasibility, tolerability, locoregional antitumor activity, and breast conservation rate. METHODS: A total of 1,355 women entered the study. Feasibility and safety were compared in arm A versus arms B plus C. Surgical findings were compared in arms A plus B versus arm C. RESULTS: Grade 3 or 4 National Cancer Institute toxicities were low (<5%) in all arms. Neuropathy was more frequent in the paclitaxel-containing arms (grade 2, 20.5% versus 5.0%; grade 3, 1.3% versus 0.2%). At 31 months of follow-up, asymptomatic drop of left ventricular ejection fraction was similar in all arms, whereas symptomatic cardiotoxicity was recorded in three patients (0.5%) in A and in three patients (0.3%) in B plus C. PST induced clinical complete plus partial remission in 78%, with an in-breast pathologic complete response rate of 23% and an in-breast plus axilla pathologic complete response rate of 20%. In the multivariate analysis, only estrogen receptor (ER) status was significantly associated with pathologic complete response (odds ratio for ER negative, 5.77; 95% confidence interval, 3.49-9.52; P<0.0001). PTS induced a significant axillary downstaging (P<0.001), and breast sparing surgery was feasible in 65% versus 34% (P<0.001). CONCLUSIONS: Doxorubicin/paclitaxel-->CMF is feasible, safe, and well tolerated. Given as PST, it is markedly active, allowing for breast-sparing surgery in a large fraction of patients.