Local recurrence risk after skin-sparing and conventional mastectomy: a 6-year follow-up

In this study, the records of all patients at the University of Texas M. D. Anderson Cancer Center with T1 or T2 breast cancer who were treated between March of 1986 and November of 1990 with mastectomy followed by immediate breast reconstruction were reviewed for the presence of recurrent disease. Patients with in situ disease were not included. Patients were included in the study if a local recurrence occurred (regardless of the length of follow-up) or if a follow-up of 6 years or longer could be obtained. Patients were grouped according to the use or nonuse of skin-sparing mastectomy, by tumor stage, and by nuclear grade of the tumor. The series included 154 patients, of whom 114 had skin-sparing mastectomies and 40 had nonskin-sparing mastectomies. The local recurrence rate in the skin-sparing mastectomy group was 7.0 percent, whereas in the nonskin-sparing mastectomy group it was 7.5 percent. The sample size in the nonskin-sparing mastectomy group was too small for meaningful statistical analysis, but the data suggest that there is no clinically important difference in recurrence rates between the two groups. We conclude that the use of skin-sparing technique for early breast cancer patients does not significantly increase the risk of tumor recurrence after mastectomy.     

Breast cancer after augmentation mammaplasty: treatment by skin-sparing mastectomy and immediate reconstruction

Breast conservation has been associated with poor cosmetic outcome when used to treat breast cancer in patients who have undergone prior augmentation mammaplasty. Radiation therapy of the augmented breast can increase breast fibrosis and capsular contraction. Skin-sparing mastectomy and immediate reconstruction are examined as an alternative treatment.Six patients with prior breast augmentation were treated for breast cancer by skin-sparing mastectomy and immediate reconstruction. One patient underwent a contralateral prophylactic skin-sparing mastectomy. Silicone gel implants had been placed in the submuscular location in five patients and in the subglandular position in one patient a mean of 10.2 years (range, 6 to 20 years) before breast cancer diagnosis. The mean patient age was 41.3 years (range, 33 to 56 years). Four independent judges reviewed postoperative photographs to grade the aesthetic results in comparison with the opposite native or reconstructed breast.The American Joint Committee on Cancer staging was stage 0 in one patient, stage I for four patients, and stage II for one patient. Five of the six patients presented with a palpable breast mass. Latissimus dorsi flap reconstruction was performed in four patients (bilaterally in one) and a transverse rectus abdominis muscle (TRAM) flap was used in two patients. Three patients were treated by skin-sparing mastectomy with preservation of the breast implant (two patients with latissimus flaps, and one patient with a TRAM flap). The tumor location necessitated the removal of implants in two patients (one patient with a latissimus flap and one with a TRAM. A saline implant was placed under the latissimus flap after gel implant removal. The patient who underwent bilateral skin-sparing mastectomies desired explantation and placement of saline implants. No remedial surgery was performed on the opposite breast to achieve symmetry. Complications occurred in two patients at the latissimus dorsi donor site (seroma in one patient, and seroma and infection in one). Five patients underwent complete nipple reconstructions. The mean duration of follow-up was 33.6 months (range, 15.5 to 70.3 months), and there were no recurrences of breast cancer. The aesthetic results were judged to be good to excellent in all cases.Skin-sparing mastectomy and immediate reconstruction can be used in patients with prior breast augmentation, with good to excellent cosmetic results. Depending on the tumor and implant location, the implant may be preserved without compromising local control.     

The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction

The transverse myocutaneous gracilis free flap with a transverse orientation of the skin paddle in the proximal third of the medial thigh region allows the taking, in selected patients, of a moderate amount of tissue for autologous breast reconstruction. The donor-site morbidity is similar to that of a classic medial thigh lift. The indication for this flap in autologous breast reconstruction and the surgical technique will be discussed in this article. From August of 2002 to March of 2003, 10 patients underwent autologous breast reconstruction with 12 transverse myocutaneous gracilis free flaps. The patients' ages ranged from 26 to 48 years (median, 40 years). Of those, two BRCA-positive women received bilateral breast reconstructions after prophylactic skin-sparing mastectomy, and eight patients received immediate breast reconstruction after skin-sparing mastectomy in early-stage breast cancer. Mean follow-up of the 10 patients was 5 months (range, 1 to 9 months). We had no free-flap failure. Four patients had small areas of ischemic skin necrosis related to very thin preparation of the skin envelope after skin-sparing mastectomy without altering the final aesthetic results. Cosmetic evaluation of the reconstructed breasts and thigh donor site by two plastic surgeons showed good results in nine patients and fair results in one patient. There was no functional donor-site morbidity caused by harvesting the gracilis flap. The transverse myocutaneous gracilis flap is a valuable alternative for immediate autologous breast reconstruction after skin-sparing mastectomy in patients with small and medium-sized breasts and inadequate soft-tissue bulk at the lower abdomen and gluteal region.     

Recurrence following treatment of ductal carcinoma in situ with skin-sparing mastectomy and immediate breast reconstruction

Skin-sparing mastectomy with immediate breast reconstruction can provide an excellent cosmetic result. Despite its increasing popularity, few studies have assessed the risk of recurrence when the procedure is used for the treatment of ductal carcinoma in situ. To evaluate the oncologic safety of skin-sparing mastectomy used for the treatment of ductal carcinoma in situ, the recurrence rate was analyzed. Patients with ductal carcinoma in situ or invasive carcinoma or both who underwent skin-sparing mastectomy with immediate breast reconstruction between 1985 and 1994 and had a follow-up period of at least 6 years were included in this retrospective analysis. The recurrence rates were determined for invasive carcinoma (with or without foci of ductal carcinoma in situ) and ductal carcinoma in situ alone. A total of 221 patients were included, 177 patients with invasive carcinoma and 44 patients with ductal carcinoma in situ alone. The immediate breast reconstructions were performed with transverse rectus abdominis muscle (TRAM) flaps in 62 percent of patients, implants in 34 percent of patients, and latissimus dorsi myocutaneous flaps (with or without implants) in 4 percent of patients. The local recurrence rate was zero of 44 for patients with ductal carcinoma in situ and 5.6 percent (10 of 177) for patients with invasive carcinoma during a mean follow-up period of 9.8 years. There was a 6.8 percent (12 of 177) metastatic recurrence rate in the invasive carcinoma group. All recurrences were invasive ductal carcinoma. Of the patients with ductal carcinoma in situ alone, none developed metastatic disease. The combined metastatic and local recurrence rates for the invasive carcinoma group (n = 177) with each type of reconstruction were 13 percent (14 of 110), 12 percent (seven of 60), and 14 percent (one of seven) for TRAM flaps, implants, and latissimus dorsi flaps, respectively. The risk of recurrence following skin-sparing mastectomy and immediate breast reconstruction for ductal carcinoma in situ is low during this follow-up period. Therefore, skin-sparing mastectomy with immediate breast reconstruction seems to be a safe oncologic treatment option for ductal carcinoma in situ; however, a longer follow-up period is important to determine the long-term risk of recurrence.     

Skin-sparing mastectomy and immediate autologous tissue reconstruction after whole-breast irradiation

Traditional breast conservation therapy consists of lumpectomy and whole-breast irradiation. Local recurrence after breast conservation is usually managed with salvage mastectomy. Skin-sparing mastectomy and immediate autologous tissue reconstruction is an accepted method of managing primary breast malignancies with exceptional aesthetic results. The purpose of this study was to evaluate this technique in the previously irradiated breast. This study is a retrospective review of all patients undergoing skin-sparing mastectomy and immediate reconstruction with autologous tissue after failed breast conservation therapy between 1995 and 1999. There were 11 patients with a mean age of 45 years (range, 34 to 58 years). Initial lumpectomy was performed for ductal carcinoma in situ in six patients and infiltrating carcinoma (ductal or lobular) in five patients. The interval from lumpectomy to salvage mastectomy ranged from 12 to 169 months (mean, 44 months). Reconstructive techniques included unipedicled transverse rectus abdominis musculocutaneous (TRAM) flap (n = 4), free TRAM flap (n = 4), and latissimus flap with immediate placement of a saline implant (n = 3). Flap survival was 100 percent, and there were no early flap complications. One patient developed partial-thickness mastectomy flap loss (3 x 3 cm), which was managed conservatively. There were no instances of full-thickness mastectomy skin loss. Late complications included capsular contracture (n = 2), fat necrosis (n = 1), and ventral hernia (n = 1). There was one late death from metastatic disease; the remaining patients were without evidence of disease at a mean of 48 months (range, 30 to 75 months). Aesthetic results were judged as excellent (n = 4), good (n = 5), fair (n = 1), and poor (n = 1). These results demonstrate that skin-sparing mastectomy and immediate autologous tissue reconstruction can be safely performed in patients with previous whole-breast irradiation. Clearly, patient selection is paramount with attention to the quality of the irradiated breast skin and the anatomic location of the recurrent disease. In this experience, the best results were seen after TRAM (pedicled or free) flap reconstruction.     

Comparison of mastectomy with tamoxifen for treating elderly patients with operable breast cancer.

STUDY OBJECTIVE--Comparison of tamoxifen and mastectomy in treatment of breast cancer in elderly patients. DESIGN--Randomised trial of treatment of operable breast cancer by wedge mastectomy or tamoxifen, with median follow up 24 and 25 months respectively (range 1-63). SETTING--University hospital; most patients from primary catchment area. PATIENTS--135 consecutive patients with breast cancer aged over 70 with operable tumours (less than 5 cm maximum diameter); 68 were allocated to tamoxifen group and 67 to mastectomy group. Histological diagnosis by biopsy. Two incorrect randomisations in each group. Patient characteristics similar in the two groups and all under care of one surgical team. INTERVENTIONS--Mastectomy group received wedge mastectomy plus excision of symptomatic axillary lymph nodes. Tamoxifen group received continuous treatment with tamoxifen 20 mg twice daily. Patients in tamoxifen group received wedge mastectomy if there was sign of local progression. Those in mastectomy group received further excision or radiotherapy for locoregional recurrence and when local treatments had been exhausted or metastatic disease diagnosed they received tamoxifen. END POINT--Treatment efficacy was assessed by local control of disease and by survival. MAIN RESULTS--Mortality from metastatic cancer in tamoxifen group was 7 (10.6%) and in mastectomy group 10 (15.3%) (NS). There was no difference in survival between the two groups. In mastectomy group 70% remained alive and free of local recurrence at 24 months; in tamoxifen group only 47% remained alive and free of local progression. In mastectomy group locoregional recurrence occurred in 16 patients and metastatic disease in 13; in tamoxifen group locoregional progression occurred in 29 patients and metastatic disease in seven. CONCLUSIONS--As a high proportion of patients treated with tamoxifen eventually required surgery treatment of elderly patients with breast cancer should include mastectomy. Optimum treatment may include both mastectomy and tamoxifen.     

Natural history and prognosis of recurrent breast cancer.

Patterns of recurrent disease were analysed in 603 patients with breast cancer. The time of onset, frequency of recurrence, and survival after recurrence were not influenced by age or menopausal state. While survival after local recurrence was longer than survival after distant metastasis, the time to onset of local and distant disease followed an identical pattern, indicating that local recurrence should be regarded as a manifestation of systemic disease. Postoperative radiotherapy did not affect the time of onset of local recurrence. We suggest that patients with local recurrence should receive both systemic and local treatment and that controlled trials of chemotherapeutic agents in these patients might be valuable in finding the most effective drug combinations to be used as adjuvant treatment after mastectomy.     

不同切口下乳腺癌根治术的临床疗效对比分析

目的:探讨不同切口下乳腺癌根治术的临床效果。方法:将140例乳腺癌患者根据治疗方法的不同分为对照组60例和治疗组80例,两组都行乳腺癌改良根治术,对照组采用Halsted-Meyer纵切口,治疗组采用Stewart横切口。比较两组手术并发症的发生情况、术后局部复发与远处转移的情况以及生存质量的改变情况。结果:所有患者都顺利完成手术,与对照组相比,治疗组术后皮瓣下积液、皮瓣坏死、上肢淋巴水肿的并发症发生率均明显降低(P0.05),术后躯体、心理、社会支持、精神评分均明显升高(P0.05),术后6个月的局部复发率与远处转移率均明显降低(P0.05)。结论:横切口下实施乳腺癌改良根治术能减少术后并发症,提高患者的术后生存质量,改善患者的远期预后。     

Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning.

Skin-sparing mastectomy by definition describes the procedure of mastectomy, either simple or modified radical, with a minimum amount of skin excision. The surgical skin excision must: (1) include the nipple-areola complex, (2) include the biopsy site, and (3) allow for access to the axilla for possible dissection. In 27 mastectomies, the senior author has had direct input in the preoperative skin planning. All patients underwent immediate breast reconstruction. In large-breasted women, the mastectomy was performed to a Wise-type pattern. In small-breasted women, the mastectomy involved minimal skin excision followed by reconstruction. Non-continuous incisions were frequently used in small-breasted women, thereby minimizing breast scarring. When appropriately applied, skin-sparing mastectomy can greatly improve the final aesthetic result of the breast.     

Treatment of Early Breast Cancer: A Report after Ten Years of a Clinical Trial

A controlled clinical trial has been carried out to compare radical mastectomy with wide excision (extended tylectomy) in the treatment of early breast cancer. Only patients aged 50 and over were included and 370 entered the trial during a period of 10 years. Postoperative radiotherapy was given in each case. In patients with clinically involved axillary nodes there was a significantly higher incidence of local and distant recurrence in those having a wide excision, and the survival of these patients was significantly less than those who had a radical mastectomy. In patients with clinically uninvolved nodes, although there was a significantly higher incidence of local recurrence in those having a wide excision, there was no increased incidence of distant recurrence and the survival rate was similar to those having a radical mastectomy.     

Trends in unilateral breast reconstruction and management of the contralateral breast: the Emory experience

Recent trends in breast reconstruction have transitioned toward the skin-sparing type of mastectomy and immediate reconstruction using autologous tissue. This study was designed to document trends in the management of patients with unilateral breast cancer and to determine how they influence management of the contralateral breast.All patients who underwent unilateral breast reconstruction at Emory University Hospitals from January of 1975 to December of 1999 were reviewed. The cohort was stratified by timing of reconstruction (immediate versus delayed), method of reconstruction, and mastectomy type (skin-sparing versus non-skin-sparing). The methods of reconstruction included implant, latissimus dorsi flap, and transverse rectus abdominis musculocutaneous (TRAM) flap. Contralateral procedures to achieve symmetry included augmentation, mastopexy, augmentation/mastopexy, and reduction. A total of 1394 patients were evaluated, including 689 delayed and 705 immediate reconstructions. Sixty-seven percent of delayed-reconstruction patients (462 of 689) had a symmetry procedure performed on the opposite breast, compared with 22 percent for the immediate-reconstruction patients (155 of 705) (p 相似文献   

Immediate breast reconstruction with saline-filled implants: no interference with the oncologic outcome?

The possible adverse effects on cancer control due to immediate breast reconstruction have been addressed recently for both silicone-filled implants and flap reconstruction. To evaluate those possible effects after immediate breast reconstruction with saline-filled implants, 49 patients reconstructed with saline-filled breast implants at the Jules Bordet Cancer Institute were studied. Selection was only based on the possibility to find a matched patient. These patients were matched with a control group of 49 matched women with breast cancer treated in the same center by mastectomy without any type of breast reconstruction. The two groups were comparable according to age at diagnosis (within 3 years), year of diagnosis (same year), stage of the tumor, histology, and nodal status. The only difference between the two groups was that radiation therapy was applied to some of the patients who were not reconstructed (due to tumor location). The results show, in terms of local recurrences, distant metastasis, and deaths, no significant difference between the two groups, even for the irradiated patients, within a mean follow-up period of 72 months (range, 24 to 108) months.     

Single-stage, autologous breast restoration

The skin-sparing mastectomy, when performed with immediate reconstruction, is a major advance in breast reconstruction. Traditionally, reconstruction of the nipple-areola complex is performed as a subsequent procedure. In this study, 17 patients (mean age, 43 years; range, 35 to 53 years) underwent one-stage breast and nipple-areola reconstruction over a 21-month period. In all cases of breast reconstruction, a buried transverse rectus abdominis musculocutaneous (TRAM) flap was used, and all patients had a simultaneous nipple-areola complex reconstruction performed. Nine patients had a Wise keyhole pattern used and contralateral reduction performed. Four patients retained all their breast skin, and a TRAM skin island was used in another four. It has recently been shown that patients with early-stage breast cancer and peripherally sited tumors have a very low risk of nipple-areola involvement. In 10 patients with early disease and peripheral tumors, the areola was retained (as a thin full-thickness graft), but more recently, in three patients with early-stage disease, the entire nipple-areola complex was used as a thin full-thickness graft. The thin full-thickness skin graft is removed from the breast in an apple-coring fashion, so that most of the ducts are retained as part of the mastectomy specimen. (There was histological confirmation of absence of tumor in the nipples of these patients.)One-stage autologous reconstruction should be considered for all patients undergoing immediate breast reconstruction. In patients with early-stage disease and peripheral tumors, the nipple-areola complex may be retained through the use of a thin full-thickness graft that is applied to a deepithelialized CV flap on the TRAM flap. This allows the best method of nipple-areola complex reconstruction: by retaining the original breast envelope, the color match and texture in the reconstruction are ideal. Patient satisfaction in this study was high. Necrosis of the mastectomy flaps impaired the cosmetic results in some patients. A large multicenter study is required to confirm the effectiveness of this procedure.     

Hazard-Rate Analysis and Patterns of Recurrence in Early Stage Melanoma: Moving towards a Rationally Designed Surveillance Strategy

Background

While curable at early stages, few treatment options exist for advanced melanoma. Currently, no consensus exists regarding the optimal surveillance strategy for patients after resection. The objectives of this study were to identify patterns of metastatic recurrence, to determine the influence of metastatic site on survival, and to identify high-risk periods for recurrence.

Methods

A retrospective review of the Duke Melanoma Database from 1970 to 2004 was conducted that focused on patients who were initially diagnosed without metastatic disease. The time to first recurrence was computed from the date of diagnosis, and the associated hazard function was examined to determine the peak risk period of recurrence. Metastatic sites were coded by the American Joint Committee on Cancer (AJCC) system including local skin, distant skin and nodes (M1a), lung (M1b), and other distant (M1c).

Results

Of 11,615 patients initially diagnosed without metastatic disease, 4616 (40%) had at least one recurrence. Overall the risk of initial recurrence peaked at 12 months. The risk of initial recurrence at the local skin, distant skin, and nodes peaked at 8 months, and the risk at lung and other distant sites peaked at 24 months. Patients with a cutaneous or nodal recurrence had improved survival compared to other recurrence types.

Conclusions

The risk of developing recurrent melanoma peaked at one year, and the site of first recurrence had a significant impact on survival. Defining the timing and expected patterns of recurrence will be important in creating an optimized surveillance strategy for this patient population.     

Breast cancer recurrence after immediate reconstruction: patterns and significance

Local recurrence of cancer after mastectomy and immediate breast reconstruction is generally regarded as a poor prognostic indicator. This study was conducted to identify specific patterns of local recurrence following reconstruction and to determine their biological significance. The records of all patients who had undergone immediate breast reconstruction at The University of Texas M. D. Anderson Cancer Center between June 1, 1988, and December 31, 1998, were reviewed. The records of patients who had local tumor recurrence were then carefully analyzed. During this 10-year period, a local recurrence of cancer was found to have developed in 39 of 1694 patients (2.3 percent). Most recurrences were in the skin or subcutaneous tissue (n = 28; 72 percent), and the remainder were in the "chest wall" (n = 11; 28 percent), as defined by skeletal or muscular involvement. Transverse rectus abdominis myocutaneous flaps were used most often in both groups, but latissimus dorsi myocutaneous flaps and implant techniques were also used in some patients. Patients with subcutaneous tissue recurrence had an overall survival rate of 61 percent at follow-up of 80.8 months, compared with patients with chest wall recurrence, whose survival rate was 45 percent at similar follow-up. Metastases were less likely to develop in patients with subcutaneous tissue recurrence than in those with chest wall recurrence (57 percent versus 91 percent; p = 0.044); the former group also had a greater chance of remaining disease-free after treatment of the recurrence (39 percent versus 9 percent), respectively. Metastasis-free survival was higher in patients with subcutaneous tissue recurrence than with chest wall recurrence (2-year and 5-year survival: 52 and 42 percent versus 24 and 24 percent; p = 0.04). In both groups, the time to detection of the recurrence was similar (subcutaneous tissue recurrence, 27.1 months, versus chest wall recurrence, 29.5 months). Distant disease did not develop in one patient only in the chest wall recurrence group; this patient remained disease-free at 70 months. From these results, it was concluded that (1) not all local recurrences are the same: patients with subcutaneous tissue recurrence have better survival rates, a decreased incidence of metastases, and a greater chance of remaining disease-free than do those with chest wall recurrence; (2) immediate breast reconstruction (although potentially, it can conceal chest wall recurrence) does not seem to delay the detection of chest wall recurrence; and (3) even if a chest wall recurrence develops, it is highly associated with metastatic disease, and the survival rate is not likely to have been influenced by earlier detection. These data support the continued use of immediate breast reconstruction without fear of concealing a recurrence or influencing the oncologic outcome.     

Patterns of post-operative irradiation in breast cancer patients submitted to neoadjuvant chemotherapy

Background/AimPost-operative radiation therapy (PORT) is associated with improvement in loco-regional control and survival rates in early breast cancer. However, the evidence of benefit in patients after treatment with neoadjuvant chemotherapy (NAC) is poor. We aimed to assess the impact of the type of surgery in the PORT plan and the role of the PORT fields in clinical outcomes in breast cancer patients who had undergone NAC followed by surgery.Materials and methodsWe performed a retrospective analysis of all non-metastatic breast cancer patients treated between 2008 and 2014 at our institution who had received NAC and PORT.ResultsA total of 528 women were included of whom 396 were submitted to mastectomy or nipple-sparing/skin-sparing mastectomy. Most (92.8%) of the patients had locally advanced disease (clinical stage IIB to IIIC). All patients underwent irradiation for breast or chest wall. Most patients received PORT to the supraclavicular and axillary (levels II and III) nodes (87.1% and 86.4% for breast-conserving surgery and 95.1% and 93.8% for mastectomy and nipple-sparing/skin-sparing mastectomy, respectively). Irradiation of level I axillary and internal mammary nodes was uncommon. The disease-free survival and overall survival rates at 3 years were 72% and 85%, respectively. There were no statistically significant differences in clinical outcomes according to the use of nodal irradiation.ConclusionsAfter NAC, most patients received irradiation of the breast/chest wall and axillary and supraclavicular nodes. In this setting, PORT to breast/chest wall with or without regional nodal irradiation was safe and effective, with acceptable disease-free and overall survival rates reported in this high-risk population.     

Current Trends in and Indications for Endoscopy-Assisted Breast Surgery for Breast Cancer: Results from a Six-Year Study Conducted by the Taiwan Endoscopic Breast Surgery Cooperative Group

Background

Endoscopy-assisted breast surgery (EABS) performed through minimal axillary and/or periareolar incisions is a possible alternative to open surgery for certain patients with breast cancer. In this study, we report the early results of an EABS program in Taiwan.

Methods

The medical records of patients who underwent EABS for breast cancer during the period May 2009 to December 2014 were collected from the Taiwan Endoscopic Breast Surgery Cooperative Group database. Data on clinicopathologic characteristics, type of surgery, method of breast reconstruction, complications and recurrence were analyzed to determine the effectiveness and oncologic safety of EABS in Taiwan.

Results

A total of 315 EABS procedures were performed in 292 patients with breast cancer, including 23 (7.8%) patients with bilateral disease. The number of breast cancer patients who underwent EABS increased initially from 2009 to 2012 and then stabilized during the period 2012–2014. The most commonly performed EABS was endoscopy-assisted total mastectomy (EATM) (85.4%) followed by endoscopy-assisted partial mastectomy (EAPM) (14.6%). Approximately 74% of the EATM procedures involved breast reconstruction, with the most common types of reconstruction being implant insertion and autologous pedicled TRAM flap surgery. During the six-year study period, there was an increasing trend in the performance of EABS for the management of breast cancer when total mastectomy was indicated. The positive surgical margin rate was 1.9%. Overall, the rate of complications associated with EABS was 15.2% and all were minor and wound-related. During a median follow-up of 26.8 (3.3–68.6) months, there were 3 (1%) cases of local recurrence, 1 (0.3%) case of distant metastasis and 1 (0.3%) death.

Conclusion

The preliminary results from the EABS program in Taiwan show that EABS is a safe procedure and results in acceptable cosmetic outcome. These findings could help to promote this under-used surgical technique in the field of breast cancer.     

Metastatic disease to the breast: the Washington University experience

Background

The cost effective treatment of cancer in developing countries remains challenging. In the elderly with possible limited life expectancy, the health expenditure associated with standard treatment regimes should be carefully considered. We present the results of conservative management of breast cancer in the aged in a resource-limited environment.

Methods

Patients aged 70 or older with early breast cancer were treated with tumour excision or simple mastectomy and adjuvant tamoxifen. The records of patients presenting to the Breast Unit between January 1990 and December 2004 were retrieved and demographic, clinical, pathological and oncological data were reviewed. Survival statistics were calculated using the life table method.

Results

A total of 483 patients above 70 years of age were identified. One hundred and eighty eight patients were managed according to the conservative protocol. Forty-one had a simple mastectomy and 147 tumour excision. Their mean age was 77.3 years. The mean follow-up is 62 months. Thirty-one patients (16.4%) were not compliant with tamoxifen use. TNM staging was 0 in 4 patients, I in 42 patients, II in 116 patients and III in 26 patients. There was no 30-day mortality. The cumulative incidence of local recurrence was 3.3% at 5 and 10 years. The cumulative incidence of regional recurrence was 3.3% at 5 years and 4.5% at 10 years. The cumulative incidence of distant recurrence was 6.2% at 5 years and 12.2% at 10 years. The cumulative overall, disease specific and disease free survival at 10 years was 59%, 88% and 81% respectively.

Conclusion

Limited surgery and tamoxifen provide excellent control of breast cancer in the elderly in a resource restricted environment. Radiotherapy and axillary dissection and can be safely omitted thereby reducing health care resource utilization.     

Management of first trimester breast enlargement with necrosis.

We describe our management of two patients who had massive breast enlargement with necrosis in the first trimester. First, a therapeutic abortion was done to stop the breast growth, then we skin grafted the large ulcerated areas on the breasts, and finally we did a simple mastectomy with silicone gel implants for reconstruction. The latter procedure was to prevent almost certain recurrence of the problem during any succeeding pregnancy.     

Primary squamous cell carcinoma of the breast: A rare case report

BackgroundSquamous cells are normally not found inside the breast. Therefore, a primary squamous cell carcinoma of the breast is an exceptional phenomenon and the management of this type of disease is still debated.AimClinical outcome assessment of a patient with squamous cell carcinoma of the breast.Materials and methodsWe report a case of primary squamous cell carcinoma of the breast (T1cN0M0) in a 51-years-old woman who underwent breast conserving surgery plus adjuvant chemotherapy and radiation therapy (RT).ResultsWith a follow up of 43 months, the patient is alive with no evidence of local or distant recurrence. The patient had Grade 2 acute skin toxicity. No late skin or respiratory toxicity was observed.ConclusionsPure primary squamous cell carcinoma of the breast is a rare and aggressive disease, often treatment-refractory. Our case shows that the addition of RT after breast conserving surgery, allows to achieve a high local control without adding severe toxicity. A multidisciplinary approach seems to be the optimal management for early stages in this rare disease.