Using Nodal Ratios to Predict Risk of Regional Recurrences in Patients Treated with Breast Conservation Therapy with 4 or More Positive Lymph Nodes

Purpose. The value of nodal ratios (NRs) as a prognostic variable in breast cancer is continually being demonstrated. The purpose of this study was to use NR in patients with ≥4+ nodes to assess a correlation of NR with regional (lymph node) recurrence. Methods. Inclusion criteria was ≥8 nodes dissected with ≥4+ nodes after breast conservation therapy. Of 1060 patients treated from 1975 to 2003 who had a minimum of 8 nodes dissected, 273 were node+; 56 patients had ≥4+ involved nodes and were the focus of this study. Nodal ratios were calculated for each patient and grouped into 3 categories: high (≥70%), intermediate (40%–69%) and low (<40%). Each nodal ratio was correlated with patterns of local, regional, and distant failures and OS. Results. Outcomes for the entire cohort were BRFS-83%, NRFS-93%, DMFS-61%, and OS 63% at 10 yrs. The OS, DMFS, and NRFS correlated with N2 (4–9 nodes+) versus N3 (≥10+) status but did not correlate with BRFS, as expected. When evaluating NR, 18 pts had high NR (>70%). Only 3 patients experienced nodal recurrences, all within previously radiated supraclavicular fields. All 3 in-field regional failures occurred in the N3 group of patients with NR >70%. All were treated with a single AP field prescribed to a dose of 46 Gy at a standard depth of 3 cm. Conclusions. In this group of N2/N3 patients treated with BCT, we were able to identify patients at high risk for regional failures as those with high NR of >70% and ≥10+ nodes. While these findings need to be reproduced in larger datasets, this group of patients with NR of >70% in 4 or more positive axillary lymph nodes may benefit from meticulous targeting of regional nodes, dose escalation, and/or more intensive systemic therapies

Intraoperative Injection of Technetium-99m Sulfur Colloid for Sentinel Lymph Node Biopsy in Breast Cancer Patients: A Single Institution Experience

Background. Most institutions require a patient undergoing sentinel lymph node biopsy to go through nuclear medicine prior to surgery to be injected with radioisotope. This study describes the long-term results using intraoperative injection of radioisotope. Methods. Since late 2002, all patients undergoing a sentinel lymph node biopsy at the Yale-New Haven Breast Center underwent intraoperative injection of technetium-99m sulfur colloid. Endpoints included number of sentinel and nonsentinel lymph nodes obtained and number of positive sentinel and nonsentinel lymph nodes. Results. At least one sentinel lymph node was obtained in 2,333 out of 2,338 cases of sentinel node biopsy for an identification rate of 99.8%. The median number of sentinel nodes found was 2 and the mean was 2.33 (range: 1-15). There were 512 cases (21.9%) in which a sentinel node was positive for metastatic carcinoma. Of the patients with a positive sentinel lymph node who underwent axillary dissection, there were 242 cases (54.2%) with no additional positive nonsentinel lymph nodes. Advantages of intraoperative injection included increased comfort for the patient and simplification of scheduling. There were no radiation related complications. Conclusion. Intraoperative injection of technetium-99m sulfur colloid is convenient, effective, safe, and comfortable for the patient

Should all breast cancers be diagnosed by needle biopsy?

Background Although much data support the National Quality Forum recommendation that breast cancers should be diagnosed by needle biopsy before surgical resection, the exclusion criteria for those that may not be suitable have yet to be defined. Methods We reviewed all patients treated over the past 3 years at the Yale Breast Center to determine the percentage of patients not diagnosed by needle biopsy, and why. Results Reasons for the 17% of 630 patients who were not diagnosed by needle biopsy were as follows: inability to cooperate (1%); small or superficial lesion less than 1 cm that technically was easier to excise in the office (4%); bloody discharge without clinical or mammographic mass (1%); lesion adjacent to implant (.5%); a mammographic lesion that was too posterior, too superficial, or too faint to be performed stereotactically (5%); or patient preference (5%). Conclusions Needle biopsy is the preferred method of diagnosis in most cases, but there are valid reasons why all breast cancers will not be diagnosed in this fashion

Coming to terms with advanced breast cancer: Black women's narratives from Eastern North Carolina

This paper analyzes in-depth interviews with 26 black women who entered the medical system in rural North Carolina with advanced breast disease. In these narratives, women draw on multiple sources of knowledge in order to come to terms with the diagnosis of breast cancer--a biomedically-defined disease that they often refuse to acknowledge or accept. The analysis demonstrates how women relate the meaning of their individual episodes of illness to one or more of the following sources of knowledge: an indigenous model of health emphasizing balance in the blood, popular American notions about cancer, and particular biomedical conceptions about breast disease and its treatment. These narratives provide an important window into the processes involved when individuals attempt to adapt personal experience to pre-existing cultural models, modify such models in the light of new information, and confront conflicts in their own interpretations of the meaning of a single episode of illness.cancer cultural models illness narratives black Americans