Controversies in primary breast cancer management

doi:10.1016/S0002-9610(05)81144-4

The American Journal of Surgery

Volume 166, Issue 5, November 1993, Pages 502-508

https://doi.org/10.1016/S0002-9610(05)81144-4 Get rights and content

Adequate locoregional treatment of patients with primary operable breast cancer involves the control of multicentric disease in the breast and axillary dissection to stage the disease and control it in the axilla, when present. Two options, having equal survival rates in prospective, randomized studies, are breast preservation and mastectomy. In breast preservation, adequate tumor excision with clear histologic margins and axillary dissection is followed by breast irradiation. The mastectomy option involves no radiotherapy and can be followed by reconstruction. Careful selection of patients and a detailed description of the pros and cons of each approach should be undertaken on an individual basis.

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Cited by (35)

Surgery for Breast Cancer
2005, Breast Cancer
Why remove four by chance when one will suffice?
2001, European Journal of Cancer
The breast cancer patient with multiple sentinel nodes: When to stop?
2001, Journal of the American College of Surgeons
BACKGROUND:
During sentinel lymph node (SLN) biopsy for breast cancer, most authors report identifying a mean of 1 to 3 SLNs, but a range of 1 to 8 (or more) SLNs per patient. A significant minority of patients have 4 or more SLNs. Here we seek to determine the significance for the breast cancer patient of finding multiple SLNs, and whether there is an optimal threshold number of SLNs that should be removed.
STUDY DESIGN:
1,561 patients who underwent successful SLN biopsy using blue dye and radioisotope in combination. Each SLN site was categorized prospectively by the operating surgeon as a dye success, an isotope success, or both. All SLNs containing counts at least four times greater than the postexcision axillary background were considered to be isotope successes.
RESULTS:
Fifteen percent of patients (241) had multiple (> 3) SLNs. Ninety-eight percent of node-positive patients (440 of 449) were identified within the first three SLN sites examined. In 2% of all SLN positive patients (9 of 449) or 4% of patients with multiple SLN (9 of 241), a positive SLN was detected at site four or more. In eight patients the first positive SLN was found at sites four or more. Blue dye and isotope were equally effective in identifying metastases in patients with multiple SLNs.
CONCLUSIONS:
Fifteen percent of patients having SLN biopsy for breast cancer have multiple SLNs. Although 98% of positive SLNs were identified within the first three sites sampled, a small number of patients had their first positive SLN at sites 4 to 8. These data suggest that there is no absolute upper threshold for the number of SLNs that should be removed. Sampling a few additional SLNs probably adds little morbidity to the procedure, yet may significantly alter the treatment of some individuals. SLN biopsy should be continued until all blue and hot nodes are removed.
Estimating the overlap between sentinel lymph nodes and axillary node samples in breast cancer
1999, Pathology and Oncology Research
Management of the axilla in breast cancer patients is a controversial issue. Axillary sampling and sentinel lymphadenectomy are both conservative surgical approaches which aim to stage the disease. These procedures target selective treatment of node-positive patients and seem to allow the omission of axillary clearance in node-negative ones. In this way, they reduce the rate of complications in an otherwise overtreated subset of patients. Forty consecutive patients with palpable T1 and T2 breast carcinoma underwent sentinel lymphadenectomy following mapping with Patent blue dye, with subsequent axillary clearance and excision of the tumor or mastectomy. Then the largest/firmest 3, 4, 5 and 6 nodes were selected from all the lymph nodes in order to model an axillary sample. It was suggested that these are the nodes that are the most likely to be included in the specimen during sampling, because of their size and consistency. The probability of the sentinel lymph nodes falling into the sample of the 3–6 largest/firmest nodes was calculated. The sentinel nodes predicted the axillary nodal status in 95%, while the samples of the largest 3, 4, 5 and 6 nodes were predictive in 95, 96, 98 and 98%, respectively. The two methods of evaluation displayed a considerable overlap, as the sentinel node would have been included in the 3—6 largest/firmest nodes in 79—92% of the cases, depending on the number of largest nodes evaluated. The overlap was greater after fine needle aspiration of the primary tumor. Although the two alternative staging procedures of 3, 4, 5 or 6 node sampling and sentinel lymphadenectomy with the vital blue dye technique cannot be simultaneously done without one influencing the other, and the first method was only modeled, the results suggest that there is a considerable overlap between the two; axillary sampling may often remove the sentinel lymph nodes. Copyright 1999 W.B. Saunders Company Ltd on behalf of the Arányi Lajos Foundation
Patterns of clinical metastasis in breast cancer: an analysis of 100 patients
1995, European Journal of Surgical Oncology
Many patients diagnosed with breast cancer will develop metastases and these have diverse presentations. We have reviewed 100 consecutive patients who have died with metastatic breast cancer, to determine the frequency, sites and mode of presentation of recurrent disease. The commonest site of failure was loco-regional (n = 61), this usually presented with a mass, but a minority of patients also complained of pain. Bone metastases developed in 60 patients and produced bone pain, pathological fracture (n = 6) or cord compression (n = 5). Pulmonary metastases producing shortness of breath were diagnosed in 34 patients and were asymptomatic in a further 10. Intra-abdominal metastases were found at some time in 23 patients, most commonly in the liver (n = 20) and the majority complained of epigastric pain (n = 17). Brain metastases occurred in 23 patients and produced a wide range of symptoms including those of a space-occupying lesion (n = 10), cranial nerve palsy (n = 7), diabetes insipidus (n = 3), focal limb weakness (n = 2) and meningitis (n = 1). Three patients had choroid metastases producing reduced visual acuity. Recurrent breast carcinoma can present in a variety of ways, therefore any new symptom or sign should be considered to represent recurrence until proved otherwise.
The sentinel node biopsy is not contraindicated in multifocal breast carcinoma
2011, European Journal of Oncology

View all citing articles on Scopus

¹: From the Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York.

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Controversies in primary breast cancer management

Lancet

Eur J Cancer Clin Oncol

The concept and implications of multicentricity in breast carcinoma

Residual mammary carcinoma following simulated partial mastectomy

Cancer

Multicentricity of nonpalpable breast cancer

Cancer

The clinical significance of preinvasive breast carcinoma

Cancer

Segmental mastectomy without radiotherapy

Cancer

Histologic multifocality of Tis, T1-2 breast carcinomas

Cancer

Diseases of the breast

The 1982 survey of carcinoma of the breast in the United States by the American College of Surgeons

Surg Gynecol Obstet

Discontinuous or “skip” metastases in breast carcinoma. Analysis of 1228 axillary dissections

Ann Surg

The accuracy of clinical nodal staging and of limited axillary dissection as a determinant of histologic nodal status in carcinoma of the breast

Surg Gynecol Obstet

Patterns of axillary nodal involvement in breast cancer. Predictability of level one dissection

Ann Surg

Assessment of axillary lymph node status

Ann Surg

Significance of occult metastases—a study of breast cancer

Cancer

Occult axillary lymph node metastases in invasive breast carcinoma. Characteristics of the primary tumor and significance of the metastases

Pathol Annu

Distribution of axillary node metastases by level of invasion: an analysis of 539 cases

Cancer

Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation

N Engl J Med