Conservative surgery in patients with multifocal/multicentric breast cancer.
Conservative surgery in patients with multifocal/multicentric breast cancer
Gentilini O, Botteri E, Rotmensz N et al.
Breast Cancer Res Treat, 2009, 113, 577-583
This study from the Institute of Oncology, Milan reports a retrospective series of patients who had breast conservation surgery between 1997 and 2002. For the study, 476 patients were identified who had multifocal (separate tumours within the same quadrant) or multicentric (separate tumours in different quadrants) breast cancer. Multifocality and multicentricity were diagnosed on pathological criteria when interpositioning tissue was free of in situ or infiltrating neoplasia. In current practice, tumour multifocality and multicentricity are often cited as reasons to recommend mastectomy rather than breast conservation surgery. Multifocality can usually be resected within the same segment but multicentricity often requires either an extremely wide en bloc resection or, in effect what amounts to, multiple lumpectomies.
The median patient age in this study was 53 years (range 23-86). Median follow-up was 73 months (range 11-118) and 421 patients had multifocality and 55 had multicentric disease. Invasive lobular carcinoma was reported in 88 patients. The study cohort appeared to have a high node-positive rate of 55%.
The 5-year cumulative incidence of local recurrence was 5.1%. On multivariate analysis, overexpression of HER2, oestrogen and progesterone receptor-negativity were associated with higher ipsilateral breast cancer recurrence rates [hazard ratio (HR): 3.2 and 2.7; 95% confidence interval (CI): 1.0-10.0 and 1.06-7.7, respectively]. Node positivity of four or more lymph nodes and lack of oestrogen and progesterone receptors were associated with a worse overall survival (HR: 2.7 and 4.7; 95% CI: 1.06-6.7 and 2.1-10.4, respectively). All patients received institutional multidisciplinary recommendations for chemotherapy, radiotherapy and endocrine therapy.
Although a retrospective analysis, this study provides food for thought on the dogma that multifocality and, in particular, multicentricity needs to be managed by mastectomy. The local recurrence rates achieved in this study are within very acceptable limits. It is not clear in this study whether all of these tumours were resected en bloc, hence removing interpositioning tumour, or whether multiple lumpectomies were done with the risk of leaving disease in between the various tumour foci. The diagnosis of multicentricity or multifocality can be established preoperatively, but may sometimes only come to light when the surgical pathology is assessed. The findings of this study justify reconsideration of a conservative surgical approach to multifocality and multicentricity if clear margins are adequately achieved. Patient choice may also be an essential factor in considering breast conservation given the low rate of local recurrence. Careful patient selection and informed decision-making remains the fundamental basis on which patients can be best advised on individual clinical circumstances.
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|Publication:||Advances in Breast Cancer|
|Date:||Mar 1, 2009|
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