ORLANDOA series of clinical studies presented at the 52nd
Annual Cancer Symposium of the Society of Surgical Oncology (SSO)
addressed various aspects of breast cancer diagnosis, staging, and treatment.
MRI in Occult Breast Cancer
Modified radical mastectomy is the accepted treatment in occult
breast cancer, based on the assumption that isolated axillary
metastases must reflect the presence of a primary tumor somewhere.
However, in one-third of women with occult breast cancer, no tumor is
found in mastectomy specimens. John A. Olson, Jr., MD, of Memorial
Sloan-Kettering Cancer Center, reported that modified magnetic
resonance imaging (MRI) can prevent many of those unnecessary mastectomies.
Dr. Olson and his colleagues reviewed records of 40 women with
biopsy-proven metastatic axillary lymph nodes, occult primary cancer,
and negative physical examination and mammography. Results of MRI
with and without gadolinium were compared with pathologic findings in
Tumors were identified in 95% of specimens from patients who were MRI
positive but in only 1 of 5 patients who were MRI negative. Dr. Olson
noted that there is room for improvement, since one of the five
MRI-negative patients actually had a tumor, but he concluded that
MRI identifies most occult breast cancer and facilitates breast conservation.
Preop Chest X-Rays Add Little
Routine chest x-rays add little to preoperative staging in clinical
stage I or stage II breast cancer and should be used only in patients
in whom metastasis is suspected, Gregory A. Carlson, MD, reported.
Dr. Carlson and his colleagues at the Baystate Medical Center,
Springfield, Massachusetts, found that preoperative chest x-rays had
changed management in only one of 1,571 such patients treated at that institution.
These procedures represent an unnecessary cost and should be
reserved for patients with other indications of underlying
disease, Dr. Carlson concluded. He estimated that dropping
these routine x-rays could save $18 million annually nationwide.
Skin-sparing mastectomies facilitate immediate breast reconstruction,
give better cosmetic results (see Figure),
and are well accepted by patients. Rache Simmons, MD, reported that
they are also as safe as other approaches.
Dr. Simmons and her colleagues at Cornell Medical Center, New York,
compared outcomes in 77 patients who had skin-sparing mastectomies
with those of 154 patients who had non-skin-sparing mastectomies.
There were no significant differences in local recurrence rates,
distant recurrence rates, local recurrence-free survival at 5 years,
or distant recurrence-free survival at 5 years.
However, Dr. Simmons pointed out two possible study biases: Patients
referred for skin-sparing mastectomy tended to be younger, and median
follow-up for the newer technique was 15.6 months vs 32.4 months for
patients treated with other types of mastectomy surgery.
There has been concern that immediate breast reconstruction might
jeopardize outcomes for patients with locally advanced breast cancer
by delaying subsequent chemotherapy. Lisa Newman, MD, reported that
immediate breast reconstruction can be done with low morbidity in
patients with locally advanced disease and does not increase local or
distant relapse rates.
Dr. Newman and her colleagues at the University of Texas M.D.
Anderson Cancer Center compared postoperative management and outcomes
in 50 patients with locally advanced breast cancer who had modified
radical mastectomies and immediate reconstruction with those of 72
patients undergoing mastectomy without immediate reconstruction.
The median interval between surgery and postoperative chemotherapy
was 35 days for those having immediate breast reconstruction vs 21
days for those who did not. Dr. Newman described this difference as
(P = .05). It did not appear to be clinically important, since there
were no significant differences in local or distant relapse rates.
However, 7 of the 15 patients receiving immediate reconstruction with
implants (47%) required subsequent implant extractions because of
contractures or infections. Thus, Dr. Newman stressed that immediate
reconstruction in this setting should be performed with autogenous tissue.
Patients who have had carcinoma in one breast have an elevated risk
of cancer in the contralateral breast and may consider contralateral
prophylactic mastectomy as a preventive measure. Leslie Montgomery,
MD, of Memorial Sloan-Kettering Cancer Center, reported results of a
study incorporating data from the National Prophylactic Mastectomy
Registry, developed at Memorial Sloan-Kettering. At the time of the
report, the registry included 817 women who had undergone
prophylactic (unilateral or bilateral) mastectomy.
The results show that most women undergoing unilateral prophylactic
mastectomy have no regrets. Only 18 of 296 patients (6%) who had
undergone contralateral prophylactic mastectomy reported that they
regretted having had the procedure.
To minimize the risk of regrets in women who are contemplating
contralateral prophylactic mastectomy, it is imperative that these
women be counseled regarding an estimation of the risk of
contralateral breast cancer, the possible alternatives to
contralateral prophylactic mastectomy, and the efficacy of
prophylactic mastectomy, Dr. Montgomery advised.