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Duct carcinoma-in-situ of the breast: Does conservation surgery and radiotherapy provide acceptable local control?
Radiation Oncology, Biology, Physics
132
October 1990, Volume 19, Supplement
1
17 THE ASSOCIATION
BE’IWXEN VERY YOUNG THERRPY
~UR~~ERY (cs) AND RADIATION
AGE AND RE. CUE'RFNCEIN THE BREAST IN PTS TREATED WITH CONSERVATIVE (RT)
Frank Vicini MD, Abram Recht MD, Anthony Abner I,2D, Barbara Silver [email protected] Jay R. Harris ND Joint Center for Radiation Therapy, and Dept. of Radiation Therapy, Harvard Nedical School, Boston Pl?. The association between very young age and breast recurrence after conservative surgery and radiation therapy is not fully established. To examine this effect, we reviewed the records of 1625 pts treated between 1968 and 1985. Of these, 1382 had total gross excision of the tumor and received > 60 Gy and these constituted the study population. The population was divided into an "old cohort" of 783 pts treated from 1968-82 (median followuo. 100 months) and a "new cohort" of 599 uts treated from 1983-85 (median followup, 60 months) to reflect changes in treatment policy. Pts in the new cohort more frequently had pre- and post-operative film-screen mammograms, careful attention to the evaluation of specimen margins and reexcision in cases with an extensive intraductal component or uncertain initial margins. Pts with prominent residual disease on reexcisionwere recommended for mastectomy. The 5-year actuarial rates of local recurrence were as follows: Age Group
Old Cohort (1968-1982) # Pts % Recurrence 62 335 240 146 783
<34 35-50 51-64 _>65 Total
All Patients # Pts % Recurrence
New Cohort (1983-1985) % Recurrence # Pts 45 237 177 140 --_ 599
20 12 8 3 10
12 11 3 7 -_ 8
107 572 417 286
17 12 6 5
1382
9
When the total group of pts treated from 1968-85 was examined, the incidence of breast recurrencewas significantly higher in pts < 34 than in pts 1 35 (17% vs 8%, p=O.O05). This effect was less pronounced in the new cohort (12% vs 7%; p=NS) than in the old one (20% vs 9%, p=O.O08). Differences between the old and new cohorts were not statistically significant but suggested an overall trend of improved results using the new policy. We also examined the effect of reexcision on breast recurrence in very young pts. Twenty-one percent of young pts in the old cohort and 70% in the new cohort had a reexcision. When the two cohorts were combined, the five- and ten-year actuarial local failure rates in 46 pts who underwent reexcision were 10% and 10% compared to 23% and 39% in 58 pts who did not have a reexcision (p=O.O8). Our results indicate that there is an association between very young age and the likelihood of breast recurrence. However, they also suggest that this effect can be reduced by improved patient selection and careful attention to treatment techniques.
18 DUCT CARCINOMA-IN-SITU OF THE ACCEPTABLE LOCAL CONTROL? Beryl
McCormick,
M.D.,
Paul
BREAST:
P. Rosen,
DOES
M.D.,
CONSERVATION
David
SURGERY
AND
M.D.,
Louise
Kinne,
RADIOTHERAPY
Cox,
R.N.,
PROVIDE
Joachim
Yahalom, M.D. Memorial Sloan-Kettering
Cancer Center, New York, New York
Duct carcinoma-in-situ (DCIS) has been diagnosed with increasing frequency at our center. Between 1977 and 1988, 54 patients including one with bilateral DCIS, opted for breast conserving surgery and radiation therapy. The median follow-up was 3 years (range 2-13 years). During this period, 10 patients have recurred in the breast; the local failure probability was 18% at 6 years (Kaplan-Meier). All patients had pre-biopsy mammograms, and in 67% of them, this was the presenting abnormality. The mammographic findings were: 60% exhibited microcalcifications only, 13% mass only, 6% both and 20% normal. Thirty-three lesions (60%) required needle localization. Size, as determined by mammogram or pathology, was 2 cm or less in 60%, 4 cm. in 2%, and could not be measured in the remainder due to the lack of distinct borders with this histology. In the patients who locally recurred (LR), close or involved margins were noted in 30%; 50% of the LR patients had re-excision after their initial biopsy. The breasts which maintained local control (LC) had only 4% involved margins (P = O-01), and re-excision was performed in only 20% (P = 0.05) of the LC group. It is of interest that 40% of the LR group had family history of breast cancer in a first degree relative, compared to only 13% (p = Radiation doses were similar in both groups, ranging from 4600 to 0.05) in the LC group. 5200 cGy to the entire breast with tangential fields, followed by a boost dose in 73% of patients. In the LR group, post-operative mammograms were negative for signs of malignancy in 7; in 3, a few scattered microcalcifications remained but these patients refused further surgery at that time. Histological classification of the recurrences revealed DCIS in 7, including all three with residual microcalcifications after initial surgery. The remaining 3 patients had invasive carcinoma, including 2 with skin involvement. The local failure rate (probability) of 18% in DCIS patients is significantly higher than the LR rate of 3% in preliminary analysis of patients treated for invasive breast cancer (p=0.000). While no patient in the study has developed distant metastasis or died from DCIS to date, the LR rate is of concern and has alerted our group to re-examine its treatment policy in DCIS patients with evidence of margin involvement. We continue to consider residual The microcalcifications after surgery to be a contraindication for breast conservation. significance of family history as a factor in local control should be further explored.
132
October 1990, Volume 19, Supplement
1
17 THE ASSOCIATION
BE’IWXEN VERY YOUNG THERRPY
~UR~~ERY (cs) AND RADIATION
AGE AND RE. CUE'RFNCEIN THE BREAST IN PTS TREATED WITH CONSERVATIVE (RT)
Frank Vicini MD, Abram Recht MD, Anthony Abner I,2D, Barbara Silver [email protected] Jay R. Harris ND Joint Center for Radiation Therapy, and Dept. of Radiation Therapy, Harvard Nedical School, Boston Pl?. The association between very young age and breast recurrence after conservative surgery and radiation therapy is not fully established. To examine this effect, we reviewed the records of 1625 pts treated between 1968 and 1985. Of these, 1382 had total gross excision of the tumor and received > 60 Gy and these constituted the study population. The population was divided into an "old cohort" of 783 pts treated from 1968-82 (median followuo. 100 months) and a "new cohort" of 599 uts treated from 1983-85 (median followup, 60 months) to reflect changes in treatment policy. Pts in the new cohort more frequently had pre- and post-operative film-screen mammograms, careful attention to the evaluation of specimen margins and reexcision in cases with an extensive intraductal component or uncertain initial margins. Pts with prominent residual disease on reexcisionwere recommended for mastectomy. The 5-year actuarial rates of local recurrence were as follows: Age Group
Old Cohort (1968-1982) # Pts % Recurrence 62 335 240 146 783
<34 35-50 51-64 _>65 Total
All Patients # Pts % Recurrence
New Cohort (1983-1985) % Recurrence # Pts 45 237 177 140 --_ 599
20 12 8 3 10
12 11 3 7 -_ 8
107 572 417 286
17 12 6 5
1382
9
When the total group of pts treated from 1968-85 was examined, the incidence of breast recurrencewas significantly higher in pts < 34 than in pts 1 35 (17% vs 8%, p=O.O05). This effect was less pronounced in the new cohort (12% vs 7%; p=NS) than in the old one (20% vs 9%, p=O.O08). Differences between the old and new cohorts were not statistically significant but suggested an overall trend of improved results using the new policy. We also examined the effect of reexcision on breast recurrence in very young pts. Twenty-one percent of young pts in the old cohort and 70% in the new cohort had a reexcision. When the two cohorts were combined, the five- and ten-year actuarial local failure rates in 46 pts who underwent reexcision were 10% and 10% compared to 23% and 39% in 58 pts who did not have a reexcision (p=O.O8). Our results indicate that there is an association between very young age and the likelihood of breast recurrence. However, they also suggest that this effect can be reduced by improved patient selection and careful attention to treatment techniques.
18 DUCT CARCINOMA-IN-SITU OF THE ACCEPTABLE LOCAL CONTROL? Beryl
McCormick,
M.D.,
Paul
BREAST:
P. Rosen,
DOES
M.D.,
CONSERVATION
David
SURGERY
AND
M.D.,
Louise
Kinne,
RADIOTHERAPY
Cox,
R.N.,
PROVIDE
Joachim
Yahalom, M.D. Memorial Sloan-Kettering
Cancer Center, New York, New York
Duct carcinoma-in-situ (DCIS) has been diagnosed with increasing frequency at our center. Between 1977 and 1988, 54 patients including one with bilateral DCIS, opted for breast conserving surgery and radiation therapy. The median follow-up was 3 years (range 2-13 years). During this period, 10 patients have recurred in the breast; the local failure probability was 18% at 6 years (Kaplan-Meier). All patients had pre-biopsy mammograms, and in 67% of them, this was the presenting abnormality. The mammographic findings were: 60% exhibited microcalcifications only, 13% mass only, 6% both and 20% normal. Thirty-three lesions (60%) required needle localization. Size, as determined by mammogram or pathology, was 2 cm or less in 60%, 4 cm. in 2%, and could not be measured in the remainder due to the lack of distinct borders with this histology. In the patients who locally recurred (LR), close or involved margins were noted in 30%; 50% of the LR patients had re-excision after their initial biopsy. The breasts which maintained local control (LC) had only 4% involved margins (P = O-01), and re-excision was performed in only 20% (P = 0.05) of the LC group. It is of interest that 40% of the LR group had family history of breast cancer in a first degree relative, compared to only 13% (p = Radiation doses were similar in both groups, ranging from 4600 to 0.05) in the LC group. 5200 cGy to the entire breast with tangential fields, followed by a boost dose in 73% of patients. In the LR group, post-operative mammograms were negative for signs of malignancy in 7; in 3, a few scattered microcalcifications remained but these patients refused further surgery at that time. Histological classification of the recurrences revealed DCIS in 7, including all three with residual microcalcifications after initial surgery. The remaining 3 patients had invasive carcinoma, including 2 with skin involvement. The local failure rate (probability) of 18% in DCIS patients is significantly higher than the LR rate of 3% in preliminary analysis of patients treated for invasive breast cancer (p=0.000). While no patient in the study has developed distant metastasis or died from DCIS to date, the LR rate is of concern and has alerted our group to re-examine its treatment policy in DCIS patients with evidence of margin involvement. We continue to consider residual The microcalcifications after surgery to be a contraindication for breast conservation. significance of family history as a factor in local control should be further explored.