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  • 1
    ISSN: 1534-4681
    Keywords: Early stage breast cancer ; Immediate breast reconstruction ; Skin-sparing mastectomy
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Background: The local recurrence (LR) rate with skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) has been reported as comparable to the LR rate after conventional mastectomy. However, limited data are available on the prognostic significance and management of LR following SSM. Methods: A prospective database maintained at the University of Texas M. D. Anderson Cancer Center identified 437 SSMs performed for 372 invasive T1/T2 breast cancers between 1986 and 1993. Results: Twenty-three LRs were identified, with a LR rate of 6.2% (23/372). Twenty-two of these (96%) presented as palpable skin-flap masses. The median time to recurrence was 25 months (range, 3 to 98 months). Fourteen patients were treated with a combination of surgery and systemic therapy. Resection of the reconstructed breast was performed in only three patients. Complete local control of the recurrent disease was achieved in 17 patients (74%). Nine patients (39%) developed distant metastatic disease. At a median follow-up of 26 months, 14 of 23 patients (61%) are alive without evidence of disease, and 7 (30%) have died from breast cancer. Conclusions: Because LR rate with SSM is low and likelihood of local control and survival is high, SSM and IBR is an acceptable treatment option for early stage breast cancer.
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  • 2
    ISSN: 1534-4681
    Keywords: Axillary lymph node dissection ; Neoadjuvant chemotherapy ; Axillary ultrasonography ; Locally advanced and large primary breast cancer
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Background: Induction chemotherapy has become the standard of care for patients with locally advanced breast cancer (LABC) and currently is being evaluated in prospective clinical trials in patients with earlier-stage disease. To better gauge the role of axillary lymph node dissection in patients with LABC this study was performed to assess initial axillary status on physical and ultrasound examination, axillary tumor downstaging following induction chemotherapy, and the accuracy of physical examination compared with axillary sonography in predicting which patients will have axillary lymph node metastases found on pathologic examination. Methods: Between 1992 and 1996, 147 consecutive patients with LABC were registered in a prospective trial of induction chemotherapy using 5-fluorouracil, doxorubicin, and cyclophosphamide. Physical and ultrasound examinations of the axilla were performed at diagnosis and after induction chemotherapy. Segmental resection with axillary lymph node dissection or modified radical mastectomy was performed, followed by postoperative chemotherapy and irradiation of the breast or chest wall and regional lymphatics. Results: Following induction chemotherapy, 43 (32%) of the 133 patients with clinically positive lymph nodes on initial examination had axillary tumor downstaging as assessed by physical and ultrasound examination. The sensitivity of axillary sonography in identifying axillary metastases was significantly higher than that of physical examination (62% vs. 45%,P=.012). The specificity of physical examination (84%) was higher than that of sonography (70%), but the difference did not reach statistical significance. Among the 55 patients in whom the findings of both physical and ultrasound examination of the axilla were negative following induction chemotherapy, 29 patients (53%) were found to have axillary lymph node metastases on pathologic examination of the axillary contents. However, 28 (97%) of these patients had either 1 to 3 positive lymph nodes or only micrometastases 2 to 5 mm in diameter. Conclusions: Preoperative clinical assessment of the axilla by physical examination combined with ultrasound examination is not completely accurate in predicting metastases in patients with LABC following tumor downstaging. However, patients with negative findings on both physical and ultrasound examinations of the axilla may be potential candidates for omission of axillary dissection if the axilla will be irradiated because minimal axillary disease remains. Patients who have positive findings on preoperative physical or ultrasound examinations should receive axillary dissection to ensure local control. A prospective randomized trial of axillary dissection versus axillary radiotherapy in patients with a clinically negative axilla following induction chemotherapy is currently underway.
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  • 3
    ISSN: 1534-4681
    Keywords: Locally advanced breast cancer ; Immediate breast reconstruction
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Background: Immediate breast reconstruction (IBR) has been considered contraindicated for patients with locally advanced breast cancer (LABC). Our goal was to determine whether IBR resulted in delayed postoperative chemotherapy, increased postoperative complications, or increased risk of recurrent disease. Methods: A prospective database of 540 modified radical mastectomies performed with IBR between 1990 and 1993 identified 50 patients with LABC. Postoperative management and outcome were compared to that of 72 patients undergoing modified radical mastectomy without IBR treated on a standardized LABC protocol using preoperative chemotherapy, postoperative chemotherapy, and radiotherapy during the same time period. Results: Results were evaluated by χ2 analysis. The median ages for the patients with IBR versus those not undergoing IBR were 44 and 46 years, respectively. The stage distribution for the IBR patients versus patients not undergoing IBR was as follows: IIB, 46% versus 17%; IIIA, 44% versus 39%; and IIIB, 10% versus 44%. The types of IBR were transverse rectus abdominis myocutaneous (TRAM) flap (68%), latissimus dorsi flap (2%), and implants (30%). Chemotherapy was given to all IBR patients: 24% preoperatively and 96% postoperatively. Radiotherapy was used in 40%. Four postoperative complications (8%) necessitated prolongation of hospitalization, including two patients requiring surgical debridement for partial flap loss; there were no complete flap losses. The incidences of major and minor wound complications in the group not undergoing IBR were 7% and 4%, respectively. Of the 15 patients receiving implant reconstruction, 7 (47%) required subsequent implant removal because of contractures or infections. The median interval between surgery and postoperative chemotherapy was 35 days for the IBR patients and 21 days for the patients not undergoing IBR. This difference was marginally significant (P 5.05). With a median follow-up of 58.4 months, no significant differences in local or distant relapse rates were detected. Conclusions: IBR can be performed with low morbidity in patients with LABC. Use of autogenous tissue is preferable because of poor results with implants. IBR is associated with somewhat longer intervals to resumption of postoperative chemotherapy, but this does not appear to be clinically significant—the local and distant relapse rates are similar for LABC patients undergoing modified radical mastectomy with or without IBR.
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  • 4
    ISSN: 1534-4681
    Keywords: Black women ; Breast cancer ; Breast-conservation therapy ; Local recurrence ; Survival
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Background: Black women with breast cancer have significantly worse survival rates and receive diagnoses at relatively younger ages, compared with white patients with breast cancer, in the United States. Young age at diagnosis has been associated with increased risk for local recurrence (LR) after breast-conservation therapy (BCT). The goal of this study was to evaluate the impact of age and BCT on LR and survival rates among black patients with breast cancer. Methods: The records for 363 black women treated for breast cancer (excluding stage IV disease) at a comprehensive cancer center were reviewed. Results: Fifty-eight percent of patients (n = 211) had tumors ≤5 cm in diameter. Forty-two of these patients (19.9%) received BCT; the LR rate for this group was 9.8%. A total of 168 patients (79.6%) underwent mastectomy; the LR rate for this group was 8.9%. Data on the primary operation were unavailable for one patient. Five-year disease-free survival rates were similar for patients treated with BCT and those treated with mastectomy (88% and 73%, respectively). LR was associated with significant decreases in 5-year overall survival rates for both the BCT group (67% vs. 95%, P 〈 .01) and the mastectomy group (43% vs. 76%, P 〈 .01). LR and 5-year diseasespecific survival rates were similar for patients 〈50 years of age and patients ≥50 years of age, regardless of treatment. Conclusions: LR and survival rates are not compromised by the use of BCT among black American patients. LR is associated with an increased risk of breast cancer death, regardless of treatment type. Younger age at diagnosis was not associated with an increased rate of LR after BCT in this series.
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  • 5
    ISSN: 1534-4681
    Keywords: Breast neoplasms ; Ductal carcinoma-in-situ ; Breast-conserving therapy ; Local recurrence ; Survival
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Background: The role of breast-conserving therapy (BCT) in the management of ductal carcinoma-in-situ (DCIS) is controversial because of reported high recurrence rates. We reviewed our experience to determine whether the rate and pattern of locoregional recurrence after BCT were similar in patients with DCIS and patients with early-stage (T1) invasive breast tumors and whether local recurrence affected survival. Methods: Between 1973 and 1994, 87 patients with DCIS alone, 22 patients with DCIS with microinvasion (DCIS-M), and 646 patients with invasive breast cancer 2 cm or smaller in diameter were treated with BCT (wide local excision with radiotherapy) at The University of Texas M. D. Anderson Cancer Center. Survival was calculated by the Kaplan-Meier method. The median follow-up times were 11 years for patients with DCIS alone, 12 years for patients with DCIS-M, and 8 years for patients with invasive breast cancer. Results: Eleven (13%) of 87 patients with DCIS and 5 (23%) of 22 patients with DCIS-M had developed locoregional recurrences at follow-up. Two patients with DCIS with locoregional recurrence died of breast cancer. Of the 646 patients with invasive breast cancer, 56 (9%) had a locoregional recurrence, and 16 (2%) died of breast cancer. The median time to locoregional recurrence was significantly longer in patients with DCIS or DCIS-M (9–10 years) than patients with invasive tumors (5 years). Conclusions: DCIS is a favorable disease with an excellent long-term survival. The locoregional recurrence rate in patients with DCIS treated with BCT is similar to that in patients with early-stage invasive breast cancer treated with BCT, but time to locoregional recurrence is significantly longer in patients with DCIS. In patients with DCIS treated with BCT, intense surveillance for locoregional recurrence needs to be maintained for the patient’s lifetime.
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  • 6
    ISSN: 1534-4681
    Keywords: Prophylactic surgery ; BRCA1 ; BRCA2 ; Breast cancer ; Ovarian cancer ; Health insurance
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Background: The efficacy of prophylactic mastectomy and oophorectomy in reducing breast and ovarian carcinoma has recently been reported in high-risk women. Because cost has become central to medical decision-making, this study was designed to evaluate currently existing coverage policies for these procedures. Methods: A confidential detailed cross-sectional nationwide survey of 481 edical directors from the American Association of Health Plans, Medicare, and Medicaid was conducted. Results: Of the 150 respondents, 65% (n 5 97) had 100,000 or more enrolled members and 35% (n 5 53) had fewer than 100,000 enrolled members. Only 44% of private plans have specific policies for coverage of prophylactic mastectomy for a strong family history of breast cancer and 38% of plans for a BRCA mutation. Only 20% of total responding plans had a policy for coverage of prophylactic oophorectomy under any clinical circumstance. Governmental carriers were significantly less likely to have any policy for prophylactic surgery (range, 2%–12%) compared with nongovernmental plans (range, 24%–44%; P,.001). No significant regional differences for coverage policies were identified (P.05). Conclusions: Significant variations currently exist for health insurance coverage of prophylactic mastectomy and oophorectomy. As genetic testing becomes widespread, more uniform policies should be established to enable appropriate high-risk candidates equal access and coverage for these procedures.
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  • 7
    ISSN: 1524-4741
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
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  • 8
    ISSN: 1524-4741
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: Abstract: Selective sentinel lymphadenectomy dissection has been demonstrated to have high predictive value for axillary staging in breast cancer patients. Preoperative lymphoscintigraphy can localize and facilitate the harvesting of sentinel lymph nodes (SNLs) with a high success rate. The failure rate of selective sentinel lymphodenectomy ranges between 2% and 8%. Details of the failures were seldom addressed. This study analyzes the causes of failure to harvest SLNs in spite of positive preoperative lymphoscintigraphy. From November 1997 through November 2000, 201 female patients with histologically confirmed and operable breast carcinoma underwent selective sentinel lymphadenectomy at the University of California, San Francisco (UCSF) Carol Franc Buck Breast Care Center. Among these patients, 183 (91%) received preoperative lymphoscintigraphy to identify axillary lymph nodes. The causes of failure to harvest the SLNs in this group of patients despite successful preoperative lymphoscintigraphy were analyzed. In our series, the failure rate of SLN identification was 7.0% (14/201). The failure rate for our first year was 11.1% (6/54), second year 9.1% (7/77), and third year 1.4% (1/70). The incidence of failure in spite of positive preoperative lymphoscintigraphy was 3.5% (6/170). The shine-through effect of the primary injection site and failure to visualize a blue lymph node were the main reasons for technical failure. Most of these cases occurred during our learning curve of the procedure. The possibility of failure to get the SLN should be explained to patients before surgery. Axillary lymph node dissection (ALND) should be done if selective SLN dissection is not successful. 
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  • 9
    Electronic Resource
    Electronic Resource
    Boston, MA, USA : Blackwell Science Inc
    The @breast journal 6 (2000), S. 0 
    ISSN: 1524-4741
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: Abstract: Lumpectomy with axillary dissection for breast cancer is usually followed by at least an overnight stay in the hospital for drain management. We eliminated drains and discharged patients following lumpectomy and axillary dissection. A retrospective study of 80 consecutive patients from July 1, 1994, to June 30, 1995, formed the basis for this study. Drains were omitted in 20 consecutive patients discharged to home after undergoing lumpectomy with axillary dissection. This group was compared to the 62 previous patients who had 7 mm closed suction drains until the drainage was less than 25 ml/shift. Seroma formation occurred in 40% of the undrained patients compared to 6% of patients kept overnight in the hospital with a closed-suction drain (p 〈 0.001). Tumors were smaller and the number of nodes examined by the pathologists was fewer in the patients managed without drains. Patients developing seromas were older, heavier, and shorter than those who did not develop seromas. The use of a drain was related significantly to seroma formation in multivariate analysis.
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  • 10
    Electronic Resource
    Electronic Resource
    Oxford, UK : Blackwell Publishing Ltd
    The @breast journal 4 (1998), S. 0 
    ISSN: 1524-4741
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: Abstract: Paget's disease of the nipple represents an extremely uncommon disease in men. This report documents the occurrence of bilateral Paget's disease of the nipple in a 49-year-old male within a nine-month period. There was no family history of breast cancer. Bilateral mastectomy revealed intraductal carcinoma bilaterally and associated tiny foci of invasive carcinoma unilaterally. The clinical presentation, diagnosis, and natural history of this rare disease are emphasized. Appropriate treatment of this lesion must address the underlying malignancy often associated with this disease.
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