Use of bilateral prophylactic nipple-sparing mastectomy in patients with high risk of breast cancer.

BACKGROUND: Nipple-sparing mastectomy (NSM) is being performed increasingly for risk reduction in high-risk groups. There are limited data regarding complications and oncological outcomes in women undergoing bilateral prophylactic NSM. This study reviewed institutional experience with prophylactic NSM, and examined the indications, rates of postoperative complications, incidence of occult malignant disease and subsequent breast cancer diagnosis. METHODS: Women who had bilateral prophylactic NSM between 2000 and 2016 were identified from a prospectively maintained database. Rates of postoperative complications, incidental breast cancer, recurrence and overall survival were evaluated. RESULTS: A total of 192 women underwent 384 prophylactic NSMs. Indications included BRCA1 or BRCA2 mutations in 117 patients (60·9 per cent), family history of breast cancer in 35 (18·2 per cent), lobular carcinoma in situ in 29 (15·1 per cent) and other reasons in 11 (5·7 per cent). Immediate breast reconstruction was performed in 191 patients. Of 384 NSMs, 116 breasts (30·2 per cent) had some evidence of skin necrosis at follow-up, which resolved spontaneously in most; only 24 breasts (6·3 per cent) required debridement. Overall, there was at least one complication in 129 breasts (33·6 per cent); 3·6 and 1·6 per cent had incidental findings of ductal carcinoma in situ and invasive breast cancer respectively. The nipple-areola complex was preserved entirely in 378 mastectomies. After a median follow-up of 36·8 months, there had been no deaths and no new breast cancer diagnoses. CONCLUSION: These findings support the use of prophylactic NSM in high-risk patients. The nipples could be preserved in the majority of patients, postoperative complication rates were low, and, with limited follow-up, there were no new breast cancers.

ANTECEDENTES: La mastectomía con preservación del pezón (nipple-sparing mastectomy, NSM) se realiza cada vez más para reducir riesgos en los grupos de pacientes de alto riesgo. Se dispone de pocos datos sobre complicaciones y resultados oncológicos en mujeres sometidas a NSM bilateral profiláctica. Este estudio revisó la experiencia institucional de la NSM profiláctica, y analizó las indicaciones, tasas de complicaciones postoperatorias, incidencia de enfermedad maligna oculta y diagnóstico de subsiguiente cáncer de mama. MÉTODOS: Se identificaron mujeres sometidas a NSM bilateral profiláctica durante el periodo 2000-2016 a partir de una base de datos prospectiva. Se evaluaron tasas de complicaciones postoperatorias, cáncer de mama incidental, recidiva y supervivencia global. RESULTADOS: Un total de 192 mujeres fueron sometidas a 384 NSMs profilácticas. Las indicaciones incluyeron mutaciones BRCA1 o BRCA2 en 117 (61%) pacientes, historia familiar de cáncer de mama en 35 (18%), carcinoma lobulillar in situ en 29 (15%) y otros motivos en 11 (5,7%). La reconstrucción mamaria inmediata se realizó en 191 pacientes. De las 384 NSMs, 116 (30%) presentaron alguna evidencia de necrosis de la piel durante el seguimiento y la mayoría se resolvieron de forma espontánea, con solo 24 (6,2%) mamas que requirieron desbridamiento. Globalmente hubo al menos una complicación en 129 (34%) mamas; 3,6% y 1,6% tuvieron hallazgos incidentales de carcinoma ductal in situ o cáncer de mama invasivo, respectivamente. El complejo areola-pezón se preservó completamente en 378 mastectomías. Tras una mediana de seguimiento de 36,8 meses, no hubo fallecimientos ni ningún diagnóstico nuevo de cáncer de mama. CONCLUSIÓN: Estos hallazgos apoyan la utilización de la NSM profiláctica en pacientes de alto riesgo. En la mayoría pacientes fue posible la preservación del pezón, las tasas de complicaciones postoperatorias fueron bajas y, con un seguimiento limitado, no hubo nuevos casos de cáncer de mama.

Breast cancer in young black women.

BACKGROUND: Young age at breast cancer diagnosis is associated with negative prognostic outcomes, and breast cancer in black women often manifests at a young age. This study evaluated the effect of age on breast cancer management and outcomes in black women. METHODS: This was a retrospective cohort study of all black women treated for invasive breast cancer between 2005 and 2010 at a specialized tertiary-care cancer centre. Clinical and treatment characteristics were compared by age. Kaplan-Meier methodology was used to estimate overall survival (OS) and disease-free survival (DFS). RESULTS: A total of 666 black women were identified. Median BMI was 30 (range 17-56) kg/m2 and median tumour size was 16 (1-155) mm. Most tumours were oestrogen receptor-positive (66·4 per cent). Women were stratified by age: less than 40 years (74, 11·1 per cent) versus 40 years or more (592, 88·9 per cent). Younger women were significantly more likely to have a mastectomy, axillary lymph node dissection and to receive chemotherapy, and were more likely to have lymphovascular invasion and positive lymph nodes, than older women. The 5-year OS rate was 88·0 (95 per cent c.i. 86·0 to 91·0) per cent and the 5-year DFS rate was 82·0 (79·0 to 85·0) per cent. There was no statistically significant difference in OS by age (P = 0·236). Although DFS was inferior in younger women on univariable analysis (71 versus 88 per cent; P < 0·001), no association was found with age on multivariable analysis. CONCLUSION: Young black women with breast cancer had more adverse pathological factors, received more aggressive treatment, and had worse DFS on univariable analysis. Young age at diagnosis was, however, not an independent predictor of outcome.

ANTECEDENTES: El diagnóstico de cáncer de mama a una edad joven se asocia con un pronóstico de resultados negativo, y en mujeres de raza negra, el cáncer de mama con frecuencia se manifiesta a edades tempranas. Este estudio analiza el efecto de la edad en el tratamiento y resultados del cáncer de mama en mujeres de raza negra. MÉTODOS: Estudio de cohortes retrospectivo de todas las mujeres de raza negra tratadas por cáncer de mama invasivo entre 2005-2010 en un centro oncológico terciario de alta especialización. Se compararon las características clínicas y del tratamiento en función de la edad. Se estimó la supervivencia global (overall survival, OS) y la supervivencia libre de enfermedad (disease-free survival, DFS) con el método de Kaplan-Meier y se utilizó la prueba de log-rank para las comparaciones entre grupos. RESULTADOS: Se identificaron un total de 666 mujeres de raza negra. La mediana del tamaño del tumor fue de 16 mm (rango 1-155 mm). La mayoría de los tumores fueron positivos para el receptor de estrógenos (66,4%); la mediana del índice de masa corporal (IMC) fue 30 kg/m2 (rango 17,2-56,5). Se estratificaron a las mujeres por su edad: < 40 años (n = 74; 11,1%) frente a ≥ 40 años (n = 592; 88,9%). La probabilidad de recibir una mastectomía, un vaciamiento ganglionar axilar y quimioterapia fue significativamente superior en las pacientes jóvenes y además fueron más propensas a presentar invasión linfovascular y ganglios linfáticos positivos en comparación con las mujeres mayores. Las OS y DFS a los 5 años fueron del 88,0% (i.c. del 95% 86-91%) y del 82% (i.c. del 95% 79-85%), respectivamente. No se observaron diferencias estadísticamente significativas en la OS (P = 0,236) en función de la edad. Aunque en el análisis univariado la DFS fue peor en las mujeres jóvenes (71% versus 88%, log-rank P < 0,001), en el análisis multivariable no se confirmó la asociación con la edad. CONCLUSIÓN: Las mujeres jóvenes de raza negra con cáncer de mama tuvieron más factores patológicos adversos, recibieron un tratamiento más agresivo y tuvieron una DFS peor en el análisis univariado. Sin embargo, la edad temprana en el momento del diagnóstico no fue un factor predictivo independiente del resultado.

The role of sentinel lymph node biopsy in Paget's disease of the breast.

BACKGROUND: Sentinel lymph node (SLN) biopsy has become a standard of care for axillary lymph node staging in breast cancer and appears suitable for virtually all patients with clinically node-negative (cN0) invasive disease. However, its role in Paget's disease of the breast, a condition in which invasion may or may not be present, remains undefined. METHODS: Among 7,083 consecutive SLN biopsy procedures, we retrospectively identified 39 patients with Paget's disease of the breast. Nineteen patients had no associated clinical/radiographic features ("Paget's only"), and 20 patients had associated clinical/radiographic findings ("Paget's with findings"). RESULTS: The mean ages for the Paget's alone and with findings groups were 63.6 and 49.6 years, respectively. The use of breast conservation therapy was 32% in the Paget's alone group and 10% in the Paget's with findings group. Invasive carcinoma was found in 27% of patients in the Paget's alone group and 55% of patients in the Paget's with findings group. The success rate of SLN biopsy was 98%, and the mean number of SLNs removed was 3 in both groups. In the entire cohort of Paget's disease, 28% (11/39) of the patients had positive SLNs (11%, Paget's alone; 45%, Paget's with findings). CONCLUSION: In our "Paget's only" cohort, invasive cancer was found in 27% of cases and positive SLNs in 11%. SLN biopsy should be considered in all patients with Paget's disease of the breast, whether associated clinical/radiographic findings are present.

Radical surgical resection and high-dose intraoperative radiation therapy (HDR-IORT) in patients with recurrent gynecologic cancers.

OBJECTIVE: To determine the outcome for patients with recurrent gynecologic tumors treated with radical resection and combined high-dose intraoperative radiation therapy (HDR-IORT). METHODS AND MATERIALS: Between November 1993 and June 1998, 17 patients with recurrent gynecologic malignancies underwent radical surgical resection and high-dose-rate brachytherapy. The mean age of the study group was 49 years (range 28-72 years). The site of the primary tumor was the cervix in 9 (53%) patients, the uterus in 7 (41%) patients, and the vagina in 1 (6%) patient. The treatment for the primary disease was surgery with or without adjuvant radiation in 14 (82%) patients and definitive radiation in 3 (18%) patients. The current surgery consisted of exenterative surgery in 10 (59%) patients and tumor resection in 7 (41%) patients. Complete gross resection was achieved in 13 (76%) patients. The mean HDR-IORT dose was 14 Gy (range 12-15). Additional radiation in the form of permanent Iodine-125 implant was given to 3 of 4 patients with gross residual disease. The median peripheral dose was 140 Gy. RESULTS: With a median follow-up of 20 months (range 3-65 months), the 3-year actuarial local control (LC) rate was 67%. In patients with complete gross resection, the 3-year LC rate was 83%, compared to 25% in patients with gross residual disease, p < 0.01. The 3-year distant metastasis disease-free and overall survival rates were 54% and 54%, respectively. The complications were as follows: gastrointestinal obstruction, 4 (24%); wound complications, 4 (24%); abscesses, 3 (18%); peripheral neuropathy, 3 (18%); rectovaginal fistula, 2 (12%); and ureteral obstruction, 2 (12%). CONCLUSION: Radical surgical resection and combined IORT for patients with recurrent gynecologic tumors seems to provide a reasonable local-control rate in patients who have failed prior surgery and/or definitive radiation. Patient selection is very important, however, as only those patients with complete gross resection at completion of surgery appear to benefit most from this radical approach in the salvage setting.

Is there a role for selective axillary dissection in breast cancer?

Surgery is the most effective therapeutic intervention available for the treatment of breast cancer. It has been responsible for obtaining local control and long-term disease-free intervals in more patients over the past century than any other treatment modality. Trends toward earlier stage at diagnosis are likely to increase the importance of surgery and to secure its central role in the treatment of this disease. Unfortunately, during the 1990s the value of excellent local control of breast cancer has been minimized as the disease has come to be considered systemic from inception and as the results of adjuvant-therapy trials in patients with early-stage breast cancer have revealed survival advantages in patients receiving systemic therapy. Only rarely is it acknowledged that surgery alone achieves long-term disease-free states in 70% to 80% of all patients. At the core of this paradigmatic controversy is management of the axilla. The status of the axilla remains the most powerful predictor of outcome in patients with invasive carcinoma of the breast, and it is likely that a small but identifiable subset of patients obtains a survival benefit from the removal of disease-containing nodes. It is believed that no benefit is derived from the removal of negative nodes, and indeed there are even patients in whom complete elimination of the exploration of the axilla may be considered-all of which underscores the need to investigate the axilla selectively. Lymphatic mapping and sentinel lymph node (SLN) biopsy represents the most exciting development to date toward this end. The challenge today, as we move closer to a selective approach to the axilla, is to ensure that patients with positive nodes have those nodes identified and removed and patients with negative nodes experience minimal disturbance of their axilla.

Paclitaxel-based chemotherapy in carcinoma of the fallopian tube.

OBJECTIVE: The objective of this study was to determine the clinical outcomes of patients with fallopian tube carcinoma treated with paclitaxel-based combination chemotherapy following primary cytoreductive surgery. METHODS: Twenty-four patients with the diagnosis of primary tubal adenocarcinoma treated between 1993 and 1998 were identified through the gynecology service database and the Memorial Sloan-Kettering Cancer Center tumor registry. Medical records were reviewed for information on age, stage, chemotherapy regimen, surgical intervention, relapse, and survival. All patients had their histologic material initially read or reviewed at Memorial Sloan-Kettering Cancer Center prior to treatment. The original slides were reviewed again by one of the authors (P.E.S.) to confirm the diagnosis of primary fallopian tube cancer. RESULTS: The mean age of the patients was 63 years (range, 44-76). Distribution by stage was as follows: four patients (17%) were Stage I, three patients (12%) were Stage II, 16 patients (67%) were Stage III, one patient (4%) was Stage IV. Four patients had grade 2 tumors, 20 had grade 3. Sixteen patients (67%) had optimal cytoreduction at the time of initial surgery with residual disease less than 1 cm. Eight patients (33%) had suboptimal cytoreduction. Following initial surgery, all patients were treated with paclitaxel-based chemotherapy for a median of five cycles. Twenty-three patients received paclitaxel at the dose of 135-175 mg/m(2) in combination with carboplatin or cisplatin; the majority, 17 of 23 (74%), received carboplatin. One patient received paclitaxel alone. Median follow-up from time of initial surgery was 24 months (range, 1-73 months). Two patients are dead of disease. Overall survival for the entire group was 96% at 12 months by Kaplan-Meier analysis, and 90% at 3 years. The overall median progression-free survival was 27 months (range, 5-57 months) for the entire group. The median disease progression-free survival at 3 years was 67% (95% CI, 45-100) in the optimally debulked group as compared with 45% in the suboptimally debulked group (95% CI, 27-57). Twelve patients (50%) had evidence of recurrence or persistent disease. There were fewer recurrences in the optimally debulked group: 5 of the 16 patients (31%) versus 7 of the 8 patients (88%) with suboptimal cytoreduction. CONCLUSION: Optimally cytoreduced patients with primary fallopian tube carcinoma treated with a paclitaxel-based chemotherapy regimen have an excellent possibility of survival.

Breast cancer during pregnancy: diagnostic and therapeutic dilemmas.

The management of breast cancer associated with pregnancy encompasses many diagnostic and therapeutic dilemmas. The various modalities used for screening, diagnosis, and staging of breast cancer are not always applicable during pregnancy. The risk to the unborn child plays a major role in the decision process. Overall, the prognosis of patients with pregnancy-associated breast cancer is worse because a large proportion of patients are first seen with more advanced disease. However, stage for stage, the prognosis is similar.

Impact of sentinel lymph node mapping on relative charges in patients with early-stage breast cancer.

BACKGROUND: The introduction of SLNB has allowed accurate staging in early-stage breast carcinomas and has minimized the number of unnecessary ALNDs. Intraoperative frozen-section analysis is a fundamental component of the sentinel lymph node biopsy (SLNB) procedure. Some patients have positive nodes on frozen-section analysis and thus undergo a conventional axillary lymph node dissection (ALND) at the time of the SLNB. A few patients have negative nodes on frozen-section analysis but have subsequent evidence of metastases on final pathologic examination. The purpose of our study was 2-fold: to compare the hospital-related charges of patients undergoing staging by SLNB with those of patients undergoing conventional ALND and to assess whether the different outcomes associated with SLNB adversely affect the charges incurred with this procedure. METHODS: Our study group consisted of 100 patients with T1 breast cancer and breast conservation therapy who underwent either SLNB or ALND from July 1, 1997, to June 30, 1998. We identified the first 50 consecutive patients to undergo SLNB during this period. We chose a similar cohort of 50 patients for ALND. Mean hospital-related charges for the SLNB patients were categorized and compared with those for the ALND patients. RESULTS: Results for the two groups were analyzed using a two-sample Wilcoxon rank-sum test. Charges for the OR and hospital stay were less for the SLNB group (P < .05). Frozen-section analysis in the SLNB group contributed to the significant difference in charges for pathologic evaluation. Overall, the two groups showed no significant difference in total hospital-related charges. CONCLUSIONS: When SLNB is used for T1 tumors, a small percentage of patients (10% in our study) will return to the operating room for an ALND. This small percentage does not increase the charges related to SLNB, however, as the reduced stay for most patients offsets this subgroup's contribution to the total hospital-related charges. Thus, in patients with clinical stage I breast cancer, SLNB does not cause significantly higher hospital-related charges compared with conventional ALND.

Breast cancer and pregnancy.

Pregnancy-associated breast cancer has an overall worse prognosis than nonpregnancy-associated breast cancers because a large proportion present with more advanced disease. Stage for stage, however, the prognosis is similar. The various modalities used for screening, diagnosis, and staging of breast cancer are not always applicable during pregnancy. Often, a delay in diagnosis may contribute to a more advanced stage at presentation. The management of pregnant women with breast cancer is also different because it involves assessing the possible risks to the fetus versus the maternal benefits.

Long-term experience in the surgical management of cancer of the uterine cervix.

Cancer of the uterine cervix is the seventh most common malignancy among women and the fifth most common cause of cancer mortality worldwide. In the United States, the use of the Papanicolaou (Pap) smear for screening has meant a significant decline in the incidence and mortality from cervical cancer over the past five decades. However, there are still approximately 12,800 new cases diagnosed per year in the U.S. and 4,800 deaths are estimated in 1999. Both surgery and radiation therapy have long-established roles in management. Surgery has the advantages of shorter treatment time, removal of the primary tumor, more limited tissue injury, and the potential to preserve ovarian function; radiation therapy has the capacity to treat tumor that involves the bladder and/or rectum while preserving their function. Therefore, the role of surgery is more suited to the management of early-stage disease and centrally located recurrences that occur after radiation therapy. Studies from our institution have played an integral role in the development of the modern surgical approach to cervical cancer. Reviews on early-stage disease helped define the role of conization and simple hysterectomy for microinvasive cervical cancer and identified patients who were at high risk for recurrence after radical hysterectomy. The classic work of Brunschwig has given gynecologic surgeons the ability to offer hope and life to select patients who previously could have expected only pain and death. Future investigation into the techniques of intra-operative radiation therapy may increase the pool of patients for whom surgically based salvage therapy may be offered.

Laparoscopic-assisted vaginal hysterectomy for endometrial cancer: clinical outcomes and hospital charges.

OBJECTIVE: Our objective was to compare the clinical outcomes and associated hospital charges between two methods of hysterectomy for patients with early-stage endometrial cancer. METHODS: Retrospective chart review of 320 patients with early-stage endometrial cancer treated by laparoscopic-assisted vaginal hysterectomy (LAVH) or total abdominal hysterectomy (TAH) was performed for the period of July 1, 1991, to September 30, 1996, at Memorial Sloan-Kettering Cancer Center. RESULTS: Sixty-nine patients (22%) were treated by LAVH, and 251 (78%) were treated by TAH. The majority of the patients (80%) had Stage I disease. The mean age was similar for both groups: 60 years for the LAVH vs 61 years for TAH. The mean weight was significantly lower for the LAVH group, 71 kg (range 43-117 kg), than for the TAH group, 82 kg (range 38-200 kg), (P < 0.05). Overall complication rates were lower among patients treated by LAVH. Operating room time was longer for the LAVH group (214 min) than for the TAH group (144 min) (P < 0.05). The median length of stay was significantly shorter for patients treated by LAVH (2.0 days) compared to TAH (6.0 days) (P < 0.05). Room charges were significantly higher for the TAH patients ($6960) compared to the LAVH patients ($3130) (P < 0.05). Overall mean total charges were significantly less for the LAVH group ($11,826) than for the TAH group ($15,189) (P < 0.05). With a median follow-up of 30 months for the TAH group and 18 months for the LAVH group, there was no significant difference in disease recurrence (P = 0.91). CONCLUSION: Patients treated by LAVH for early-stage endometrial cancer had significantly shorter hospitalization and fewer complications, resulting in less overall hospital charges when compared to patients treated by TAH. Long-term outcome was similar. Laparoscopic-assisted vaginal hysterectomy is an attractive alternative for selected patients with early-stage endometrial cancer.

Splenectomy in recurrent epithelial ovarian cancer.

OBJECTIVE: To report a series of patients with recurrent epithelial ovarian cancer who underwent splenectomy for isolated parenchymal metastases. METHODS: We performed a retrospective review of all patients who had a splenectomy for ovarian cancer at our institution during the period 1991 to 1997. RESULTS: Six patients were identified who had a splenectomy performed for recurrent epithelial ovarian cancer confined to the splenic parenchyma. All had initial cytoreductive surgery for Stage III disease followed by platinum-based chemotherapy. Five patients underwent second-look surgery and four of them had pathologically confirmed persistent disease. All five patients who underwent second-look surgery had an intraperitoneal (ip) port placed and received platinum-based ip chemotherapy. Computed tomography (CT) scan performed during the posttreatment surveillance period demonstrated recurrent disease confined to the spleen in all six patients. Splenectomy was performed at a median of 57 months (range 28-88 months) after the initial surgery. The only major complication was a diaphragmatic tear necessitating chest tube placement. With a median follow-up of 25.5 months (range 6-65 months), all six patients are alive and free of disease. CONCLUSION: Splenectomy is a safe and feasible procedure in recurrent epithelial ovarian cancer. Isolated parenchymal splenic metastasis may occur as a late recurrence in epithelial ovarian cancer and splenectomy should be considered a part of the management of this group of patients.