- Email: [email protected]
2–35 Comparative Analysis of Sentinel Lymph Node Operation in Male and Female Breast Cancer Patients
only was present in 33%, Paget’s disease + DCIS in 41%, and Paget’s disease + invasive cancer in 26%. The mean invasive tumor size was 1.62 cm in the no-SLNB group and 1.59 cm in the SLNB group (P = .96). For invasive disease, ER/PR status was similar, but Her2 was more likely to be overexpressed in SLNB (P = .04). Surgery choice ranged from “no surgery” to lumpectomy to mastectomy. Axillary staging was performed in 45 of 54 patients, with 11% in both cohorts having nodal disease. A sentinel lymph node was identified in 97% of patients. Five-year overall and disease-free survival was 100% in the no-SLNB group and 88% in the SLNB group (P = .97) and 76% in the no-SLNB group and 84% in the SLNB group (P = .88), respectively. Conclusions.—Paget’s disease remains rare but should be treated similar to other “breast cancer.” SLNB should be performed to evaluate the axilla when invasive disease is identified or a mastectomy is planned.
This brief report, which was prepared at the University of South Florida H. Lee Moffitt Cancer Center and Research Institute and presented at the 2006 Annual Meeting of the Society of Breast Surgeons, is a prospective analysis of retrospective data designed to determine a rational treatment algorithm for breast cancer patients who also have Paget’s disease of the nipple-areola complex (NAC). The report was, by its nature, brief; the conclusions had to be inferred. The study prompts one to question: Why were the invasive cancers identified in addition to Paget’s disease (in either the SLNB or the non-SLNB groups) not identified prior to definitive surgery, as the mean tumor size was at least 1.5 cm? It is also of interest that the types and numbers of patients undergoing breast conservation therapy do not completely add up. Nonetheless, because two thirds of patients with Paget’s disease of the NAC also had
underlying breast cancer, the authors suggest that such patients should be treated similarly to patients without Paget’s disease in terms of the management of the axilla. This management obviously affects staging and other appropriate adjuvant treatment recommendations. The authors have developed a sound treatment algorithm that the astute clinician should use (in addition to experience and judgement) to appropriately counsel patients about the management of the axilla when Paget’s disease of the breast is known to exist. Future directives should include additional imaging and staging modalities in this group of patients, possibly including breast magnetic resonance imaging, positron emission tomography, or computed tomography.
2–35
went SLN operation. Clinical and pathologic data were reviewed and statistical analysis performed. Results.—Men presented at an older age (p = 0.005) and with larger tumors than women (p = 0.04). The SLN was identified in 100% of men and in 98.3% of women (p = NS). The mean number of SLNs harvested was 3.5 in men and 3.0 in women (p = NS). The incidence of positive SLNs was higher in men (37.0% versus 22.3%), although this did not reach statistical significance (p = 0.1). In patients with a positive SLN there were additional non-SLNs positive in 62.5% of men, compared with 20.7% in women (p = 0.01). The median size of the largest lymph node metastasis was 10 mm in men and 3 mm in women (p = 0.03). Conclusions.—SLN operation in clinically node-negative men is feasible and accurate. Male breast cancer patients
present at an older age and with larger tumors than female breast cancer patients. Male patients have higher nodal tumor burden reflected in a larger size of nodal metastasis and increased risk of harboring additional disease in axillary lymph nodes when the SLN is positive. Intraoperative SLN evaluation should be considered in the surgical management of male breast cancer.
Comparative Analysis of Sentinel Lymph Node Operation in Male and Female Breast Cancer Patients Boughey JC, Bedrosian I, Meric-Bernstam F, et al (Univ of Texas M. D. Anderson Cancer Ctr, Houston) J Am Coll Surg 203:475-480, 2006
Background.—Male breast cancer accounts for < 1% of breast cancers. Sentinel lymph node (SLN) operation is commonly used in the evaluation of female breast cancer patients. The purpose of this study was to determine whether SLN operation is as feasible and accurate in male patients compared with female patients. Study Design.—Between 1999 and 2005, 30 men and 2,784 women under-
J. L. Bell, MD
Breast cancer in men has been thought for decades to be more aggressive than it is in women. The higher mortality rate among men may be a result of several factors. As pointed out in this study, men usually present at a later age and with larger tumors than do women. Having larger tumors may reflect a delay in diagnosis because of the infrequency of breast cancer in men and the lack of screening ®
Breast Diseases: A Year Book Quarterly Vol 18 No 2 2007
175 175
mammography for men. After adjustment for age and stage, however, men have a survival rate that is similar to that of women. The presence of large tumors in men accounts for other notable differences between them and women with breast cancer that are revealed in this study: a higher frequency of nodepositive disease (37% vs 22%, respectively), a higher frequency of multinodal involvement (62.5% vs 20.7%, respectively), and larger-size nodal metastases (median, 10 mm vs 3 mm, respectively). Improvements in adjuvant therapy and the more aggressive use of other treatment modalities have helped to lower the risk of recurrence. With a median follow-up duration of 20 months, all 30 men in this study were free of local or regional recurrence. Twelve patients received chemotherapy, 20 received tamoxifen, 3 received chest-wall radiation, and 1 received trastuzumab. A common feature in all studies of breast cancer in men is a high prevalence of estrogen receptor–positive dis-
ease. Thus, antiestrogen therapy is often an option in older patients who may not otherwise be candidates for systemic therapy. As determined in other small series,1,2 SLN biopsy appears to be highly sensitive in men. The intraoperative touch prep results were in agreement with the final lymph node pathologic findings in 88% of patients. SLNs were identified in all men using technetiumlabeled sulfur colloid, with or without the use of isosulfan blue. The lack of regional recurrences in this series suggests that SLN biopsy is a highly accurate procedure in this patient population. Another important aspect of this series is that mastectomy was used in all cases to treat the primary tumor. Without the routine addition of postsurgical radiation therapy, mastectomy is the treatment of choice for men. The authors chose to examine internal mammary chain (IMC) lymph nodes, as identified by lymphoscintigraphy, in 3 patients. Although biopsy of these nodes has been supported in women,3 the ef-
fectiveness of this technique is controversial for both men and women, with most cancer centers declining to biopsy IMC lymph nodes because of a low probability of identifying nodal disease. However, IMC SLN biopsy may be useful in the absence of axillary migration and in the presence of IMC activity on lymphoscintigraphy, as identification of regional disease is important to the determination of subsequent therapy.
2–36
Methods.—Patients undergoing PM at the M. D. Anderson Cancer Center between January 2000 and July 2005 were identified from a prospective database. Clinical, radiographic, and pathologic data were collected. Results.—A total of 409 patients (436 PM cases) were identified; 382 underwent contralateral PM (CPM) and 27 underwent bilateral PM (BPM). Cancer was identified in 22 of 436 PM cases (5%). Of these, 14 patients (64%) had ductal carcinoma in situ (DCIS). Only 8 patients (1.8%) had invasive cancer, with a mean tumor size of 5 mm (range, 2–9 mm). There was no difference in the occult cancer rate between CPM and BPM. No cases of invasive cancer were identified in the 23 patients with BRCA mutations. Significantly increased risk of inva-
sive cancer in the PM breast was seen in postmenopausal patients (3.7%; P = .007), patients age >60 years (7.5%; P = .008), and patients with history of invasive lobular carcinoma (9.7%; P = .0002) or lobular carcinoma in situ (LCIS) (7.7%; P = .008). Conclusions.—The frequency of cancer in PM is very low and the majority represents DCIS. Therefore, routine use of SLN surgery in all patients undergoing PM is not warranted. However, patients at higher risk for whom SLN surgery should be considered include older women and patients with a history of lobular cancer or LCIS.
Selective Use of Sentinel Lymph Node Surgery During Prophylactic Mastectomy Boughey JC, Khakpour N, Meric-Bernstam F, et al (M. D. Anderson Cancer Ctr, Houston) Cancer 107:1440-1447, 2006
Background.—Patients with invasive cancer identified at the time of prophylactic mastectomy (PM) will require axillary lymph node dissection for staging; therefore, many surgeons advocate sentinel lymph node (SLN) surgery at the time of PM. The current study investigates the invasive cancer rate in PM and evaluates factors associated with invasive cancer to guide SLN surgery use.
176 176
®
Breast Diseases: A Year Book Quarterly Vol 18 No 2 2007
D. J. Winchester, MD
References 1. Hill AD, Borgen PI, Cody HS III: Sentinel node biopsy in male breast cancer. Eur J Surg Oncol 25:442-443, 1999. 2. Cimmino VM, Degnim AC, Sabel MS, et al: Efficacy of sentinel lymph node biopsy in male breast cancer. J Surg Oncol 86:74-77, 2004. 3. Galimberti V, Veronesi P, Arnone P, et al: Stage migration after biopsy of internal mammary chain lymph nodes in breast cancer patients. Ann Surg Oncol 9:924-928, 2002.
The surgical and medical oncology investigators at The University of Texas M. D. Anderson Cancer Center
This brief report, which was prepared at the University of South Florida H. Lee Moffitt Cancer Center and Research Institute and presented at the 2006 Annual Meeting of the Society of Breast Surgeons, is a prospective analysis of retrospective data designed to determine a rational treatment algorithm for breast cancer patients who also have Paget’s disease of the nipple-areola complex (NAC). The report was, by its nature, brief; the conclusions had to be inferred. The study prompts one to question: Why were the invasive cancers identified in addition to Paget’s disease (in either the SLNB or the non-SLNB groups) not identified prior to definitive surgery, as the mean tumor size was at least 1.5 cm? It is also of interest that the types and numbers of patients undergoing breast conservation therapy do not completely add up. Nonetheless, because two thirds of patients with Paget’s disease of the NAC also had
underlying breast cancer, the authors suggest that such patients should be treated similarly to patients without Paget’s disease in terms of the management of the axilla. This management obviously affects staging and other appropriate adjuvant treatment recommendations. The authors have developed a sound treatment algorithm that the astute clinician should use (in addition to experience and judgement) to appropriately counsel patients about the management of the axilla when Paget’s disease of the breast is known to exist. Future directives should include additional imaging and staging modalities in this group of patients, possibly including breast magnetic resonance imaging, positron emission tomography, or computed tomography.
2–35
went SLN operation. Clinical and pathologic data were reviewed and statistical analysis performed. Results.—Men presented at an older age (p = 0.005) and with larger tumors than women (p = 0.04). The SLN was identified in 100% of men and in 98.3% of women (p = NS). The mean number of SLNs harvested was 3.5 in men and 3.0 in women (p = NS). The incidence of positive SLNs was higher in men (37.0% versus 22.3%), although this did not reach statistical significance (p = 0.1). In patients with a positive SLN there were additional non-SLNs positive in 62.5% of men, compared with 20.7% in women (p = 0.01). The median size of the largest lymph node metastasis was 10 mm in men and 3 mm in women (p = 0.03). Conclusions.—SLN operation in clinically node-negative men is feasible and accurate. Male breast cancer patients
present at an older age and with larger tumors than female breast cancer patients. Male patients have higher nodal tumor burden reflected in a larger size of nodal metastasis and increased risk of harboring additional disease in axillary lymph nodes when the SLN is positive. Intraoperative SLN evaluation should be considered in the surgical management of male breast cancer.
Comparative Analysis of Sentinel Lymph Node Operation in Male and Female Breast Cancer Patients Boughey JC, Bedrosian I, Meric-Bernstam F, et al (Univ of Texas M. D. Anderson Cancer Ctr, Houston) J Am Coll Surg 203:475-480, 2006
Background.—Male breast cancer accounts for < 1% of breast cancers. Sentinel lymph node (SLN) operation is commonly used in the evaluation of female breast cancer patients. The purpose of this study was to determine whether SLN operation is as feasible and accurate in male patients compared with female patients. Study Design.—Between 1999 and 2005, 30 men and 2,784 women under-
J. L. Bell, MD
Breast cancer in men has been thought for decades to be more aggressive than it is in women. The higher mortality rate among men may be a result of several factors. As pointed out in this study, men usually present at a later age and with larger tumors than do women. Having larger tumors may reflect a delay in diagnosis because of the infrequency of breast cancer in men and the lack of screening ®
Breast Diseases: A Year Book Quarterly Vol 18 No 2 2007
175 175
mammography for men. After adjustment for age and stage, however, men have a survival rate that is similar to that of women. The presence of large tumors in men accounts for other notable differences between them and women with breast cancer that are revealed in this study: a higher frequency of nodepositive disease (37% vs 22%, respectively), a higher frequency of multinodal involvement (62.5% vs 20.7%, respectively), and larger-size nodal metastases (median, 10 mm vs 3 mm, respectively). Improvements in adjuvant therapy and the more aggressive use of other treatment modalities have helped to lower the risk of recurrence. With a median follow-up duration of 20 months, all 30 men in this study were free of local or regional recurrence. Twelve patients received chemotherapy, 20 received tamoxifen, 3 received chest-wall radiation, and 1 received trastuzumab. A common feature in all studies of breast cancer in men is a high prevalence of estrogen receptor–positive dis-
ease. Thus, antiestrogen therapy is often an option in older patients who may not otherwise be candidates for systemic therapy. As determined in other small series,1,2 SLN biopsy appears to be highly sensitive in men. The intraoperative touch prep results were in agreement with the final lymph node pathologic findings in 88% of patients. SLNs were identified in all men using technetiumlabeled sulfur colloid, with or without the use of isosulfan blue. The lack of regional recurrences in this series suggests that SLN biopsy is a highly accurate procedure in this patient population. Another important aspect of this series is that mastectomy was used in all cases to treat the primary tumor. Without the routine addition of postsurgical radiation therapy, mastectomy is the treatment of choice for men. The authors chose to examine internal mammary chain (IMC) lymph nodes, as identified by lymphoscintigraphy, in 3 patients. Although biopsy of these nodes has been supported in women,3 the ef-
fectiveness of this technique is controversial for both men and women, with most cancer centers declining to biopsy IMC lymph nodes because of a low probability of identifying nodal disease. However, IMC SLN biopsy may be useful in the absence of axillary migration and in the presence of IMC activity on lymphoscintigraphy, as identification of regional disease is important to the determination of subsequent therapy.
2–36
Methods.—Patients undergoing PM at the M. D. Anderson Cancer Center between January 2000 and July 2005 were identified from a prospective database. Clinical, radiographic, and pathologic data were collected. Results.—A total of 409 patients (436 PM cases) were identified; 382 underwent contralateral PM (CPM) and 27 underwent bilateral PM (BPM). Cancer was identified in 22 of 436 PM cases (5%). Of these, 14 patients (64%) had ductal carcinoma in situ (DCIS). Only 8 patients (1.8%) had invasive cancer, with a mean tumor size of 5 mm (range, 2–9 mm). There was no difference in the occult cancer rate between CPM and BPM. No cases of invasive cancer were identified in the 23 patients with BRCA mutations. Significantly increased risk of inva-
sive cancer in the PM breast was seen in postmenopausal patients (3.7%; P = .007), patients age >60 years (7.5%; P = .008), and patients with history of invasive lobular carcinoma (9.7%; P = .0002) or lobular carcinoma in situ (LCIS) (7.7%; P = .008). Conclusions.—The frequency of cancer in PM is very low and the majority represents DCIS. Therefore, routine use of SLN surgery in all patients undergoing PM is not warranted. However, patients at higher risk for whom SLN surgery should be considered include older women and patients with a history of lobular cancer or LCIS.
Selective Use of Sentinel Lymph Node Surgery During Prophylactic Mastectomy Boughey JC, Khakpour N, Meric-Bernstam F, et al (M. D. Anderson Cancer Ctr, Houston) Cancer 107:1440-1447, 2006
Background.—Patients with invasive cancer identified at the time of prophylactic mastectomy (PM) will require axillary lymph node dissection for staging; therefore, many surgeons advocate sentinel lymph node (SLN) surgery at the time of PM. The current study investigates the invasive cancer rate in PM and evaluates factors associated with invasive cancer to guide SLN surgery use.
176 176
®
Breast Diseases: A Year Book Quarterly Vol 18 No 2 2007
D. J. Winchester, MD
References 1. Hill AD, Borgen PI, Cody HS III: Sentinel node biopsy in male breast cancer. Eur J Surg Oncol 25:442-443, 1999. 2. Cimmino VM, Degnim AC, Sabel MS, et al: Efficacy of sentinel lymph node biopsy in male breast cancer. J Surg Oncol 86:74-77, 2004. 3. Galimberti V, Veronesi P, Arnone P, et al: Stage migration after biopsy of internal mammary chain lymph nodes in breast cancer patients. Ann Surg Oncol 9:924-928, 2002.
The surgical and medical oncology investigators at The University of Texas M. D. Anderson Cancer Center