Therapeutic Judith
R. Samuels,
MD
#{149} Bruce
MD
G. Haifty,
Breast Conservation with Mammographically Breast Cancer’ The authors reviewed their experience with 542 patients with breast cancer who were treated with conservative surgery and radiation therapy (CSRT) and analyzed the outcome in those patients whose tumors could not be detected with mammography. Fifty-five of the patients (10.1%) had a palpable, pathologically confirmed breast carcinoma and a negative preoperative mammogram. Routine follow-up included annual mammography and physical examination. The local recurrence, 5-year actuarial survival, and 5-year disease-free survival rates for these 55 patients did not differ significantly from those for patients with positive mammograms. There were six cases of local breast recurrence in this subgroup. Four of five cases were visible on mammograms (one patient did not undergo mammography at the time of recurrence); two of the cases were detected with mammography alone following physical examination with negative results. The authors conclude that patients with palpable but mammographically occult early-stage breast cancer are suitable candidates for CSRT and that mammography is a mandatory
part
servatively
treated
of follow-up
of con-
patients.
Carol
#{149}
H. Lee,
MD
Diana
#{149}
Radiology
B. Fischer,
PhD
Therapy in Patients Undetected
C
surgery and radiation therapy (CSRT) is well estabbished as effective treatment for early-stage invasive breast cancer (1). Both survival and disease-free survival are equivalent in patients
other
treated
tangential Gy, with
ONSERVATIVE
with
mastectomy
treated with jority of the breast, with Careful
and
those
CSRT, while the vast mabatter group retain the good cosmetic results (2).
follow-up
is a critical
at diagnosis.
of invasive
carcinoma
radiation
employed
accelerator.
The
breast
was
treated
median
dose
dose were
of 46 Gy.
therapy or hormonal 31% of the patients.
included
and
An attempt
original
by
negative
nately,
we
to review
unable
Unfortuto retrieve
Radiology
1992;
185:425-427
Between
AND
January
METHODS
1962
and
December
542 patients were treated at YNHH. To ensure adequate 1985,
with CSRT follow-up,
the review was limited to patients treated before 1986; the majority of these patients had their cancer diagnosed and treated between
I From the Departments of Therapeutic Radiology (J.R.S., B.G.H., D.B.F.) and Diagnostic Radiology (C.H.L.), Yale University School of Medicme, 333 Cedar St, New Haven, CT 06510. Received February 3, 1992; revision requested March 3; revision received June 22; accepted June 24. Address reprint requests to B.G.H. C RSNA, 1992
1983 and
1985.
The
charts
reference apy record original
was made and/or
in the hospital
diagnostic
negative.
Twelve
mograms
were
remainder
mammogram acquired
ing community
mammographic detail. Fibrocystic
noted
have
contributed
and affiliated original
original
majority
ductal
of them
carcinoma,
negative
mamoutside
reports were reviewed in changes or dense breasts
in a majority to the
report.
while
at surround-
of the
32 of the
been
mam-
at YNHH,
hospitals
were
had
acquired
Sixteen and
therthat the
of the 55 original were
institutions. mograms
radiation record
of cases negative
Although
prebiopsy
we
were
and may mammounable
material, the of negative with the literareference to a
mammogram
in all 55
cases.
RESULTS
were
reviewed carefully to determine the initial methods of tumor detection (Table 1). Fifty-five of the 542 patients (10.1%) had a palpable, pathologically confirmed breast carcinoma and a negative preoperative mammogram. All of these patients underwent excisional biopsy of the palpable mass. The filtrating
the
mammograms of all of these paHowever, in all 55 cases, specific
to review all of the original 10.1 % rate (55 of 542 patients) mammograms is consistent ture and there was a specific
MATERIALS
the
55 patients
mammograms.
graphic
Breast
and
oncologists.
made
Index terms:
Breast neoplasms, postoperative, neoplasms, surgery, 00.45 neoplasms, therapeutic radiology, 00.47
in
referring
of the
were
was
was used follow-up the
radiation
was
mammograms
with
axilla
mammography
examinations
physicians
The
who had underAdjuvant chemo-
therapy Routine
annual
physical
of 64 Gy. The treated to a
00.32
#{149} Breast
with
fields to a median dose of 46 an electron boost to the tumor
not treated in patients gone axiblary dissection.
the
axibbary group
therapy techniques 4- or 6-MeV linear
on a
bed to a total median regional lymph nodes
original tients.
(Table
(64%) underwent and one-third of this lymph nodes.
Standard
were
total
compo-
nent of CSRT and includes both frequent physical examination and mammography. Together, these two methods can allow detection of early local recurrence, which can be treated effectively with mastectomy without compromising survival (3). At the time of diagnosis, 10% of patients with pathologically confirmed breast cancer have negative mammograms (4,5). Physicians may be rebuctant to refer these patients for CSRT because of the fear that, after conservative treatment, recurrence may be once again undetectable at mammography, making effective follow-up difficult. To evaluate this problem, we reviewed our experience at Yale-New Haven Hospital (YNHH) with patients who received CSRT and analyzed the outcome in the subgroup of patients with false-negative mammograms
types
2). Thirty-five dissection, had involved
(80%)
had
in-
while
20% had
As of September
patients follow-up
Abbreviations: and radiation yen Hospital.
1990,
this
group
of
had a minimum assessable of nearly 5 years and a me-
CSRT therapy,
= conservative surgery YNHH = Yale-New Ha-
425
dian follow-up of 7 years. Forty-one of the 55 patients with negative mammograms
were
alive
without
(Table tuarial
3). This gives a 79% disease-free survival,
5-year
disease-free
developed distant metastases at the time of or shortly after the local recurrence. Nine patients with negative mammograms had recurrence only distantly, and two had only regional nodal recurrence (Table 3). Four of the cases of local recurrence were discovered at physical examination, and two of these cases were confirmed at mammography. Two cases of local recurrence were detected with mammography alone following physical examination with negative results (Table 5). Of the six patients with negative mammograms who had a local recurrence, four underwent modified radical mastectomy. Three of these patients remain alive without evidence of disease; one developed metastases and died 5 years after mastectomy, without having another local recurrence. One case of local recurrence was treated with excision only, as the patient had developed concurrent liver metastases. The remaining patient received no salvage surgery for recurrence in the skin; she was alive and was being treated with hormonal therapy. Of the three patients who had only local recurrence and under-
disease
5-year acthe same
survival
seen
in
the 219 patients with positive mammograms treated at YNHH from 1962 through 1985. The overall survival of the negative mammogram group was slightly
better
than
that
of the
posi-
tive mammogram group (94% vs 84% at 5 years) (Fig 1). As shown in Table 4, there was no significant difference between the two groups with respect to stage, nodal status, or adjuvant therapy. The only significant difference between the two groups was in age. The median age of the negative mammogram group was 48 years versus
57 years
for
the
positive
mammo-
gram group. There were six cases of local breast recurrence among the 55 patients with negative mammograms (10.9%). This
frequency
of local
recurrence
was comparable with that seen in the positive mammogram group (23 of 219 or 10.5%) (Fig 2). Of the six patients with negative mammograms who had a local recurrence, two also
went salvage mastectomy, all are alive without evidence of disease. DISCUSSION It has been demonstrated that patients undergoing CSRT for invasive breast cancer will have local recurrence at a rate of 1%-2% per year and that mastectomy provides effective salvage (6,7). Therefore, providing effective follow-up care for these patients is imperative. The question of adequate follow-up of patients whose tumors were palpable but could not be visualized at mammography is raised frequently by both referring physicians
and
patients
Clinical
Patients
stage
I II
43(78) 12(22)
Histologic type Infiltrating ductal infiltrating lobular Tubular
Treated
Patients
Positive Positive Positive Negative =
PE results, PE results, PE results, PE results,
physical
Table 3 Results of Follow-up with Breast Cancer
Group
Patients 202(37.3) 219(40.4) 55(10.1) 66(12.2)
no mammogram positive mammogram negative mammogram positive mammogram
examination.
Numbers
in parentheses
Adjuvant
of Patients
Note-Numbers
with
Negative
of dis41 (75)
with disease no evidence with disease of treatment recurrence and distant
Distant Nodal
recurrence recurrence
426
#{149} Radiology
and Patients
with Positive
Positive Mammogram Group (%)
P Va!ue*
stage
78
66
22
34
45 55
68 32
50y
7(13) of dis-
only
Mammograms
Negative Mammogram Group (%)
Parameter Clinical
no evidence
55(100)
48(87)
4
Comparison Mammograms
No. of Patients
Result
hormonal
ages. Median (range, 30-84
are percentages.
Table in 55 Patients and Negative
20(36) 23(42) 12(22)
therapy
Mammograms
Status Alive, ease Alive, Dead, ease Dead, Patterns Breast Breast
carcinoma
dissection
Positive results Treatment Breast irradiation Nodal irradiation Adjuvant systemic
CSRT
with
No. of Detection
Note.-PE
44(80) 5(9) 4(7) 2(4)
Not done Negative results
in 542
not
No. of Feature
Other invasive
Detection
has
Table 2 Features of 55 Patients with Breast Cancer and Negative Mammograms
Axillary
Table 1 Means of Tumor
and
*
P value
chemotherapy
hormonal
for comparison
therapy
of overall
results
13
ii
87
89
between
the two groups.
NS
=
NS not significant.
November
1992
is difficult
-
-
-
.-.
Pyc
p5ys,c
.-.
0
2
Ev
P03
Pos
E*m
-
Ma?.m,hy Mm.gap4y
(-
55)
Pos (‘-2t9)
8
4
YEARS
Nig
8
0
P5yc
E.am
Pos
.-.
P5ysc
Ew
Ps
0
2
L
.
May
1.g
Mammog,aphy
Po).219)
4
FOLLOW-UP
6
(.
why
the
re-
live negative time ofof a recurrence.
mammogram
at the
55)
8
CONCLUSIONS
10
YEARS FOLLOW-UP
1. Figures breast standard
.-.
to understand
current lesion was visible at mammography when the original primary lesion was mammographically occult. Decreasing density in the breast as the patient aged, however, is one possibbe contributing factor to this phenomenon. Although the total number of patients in our study was small, it appears that a negative mammogram at the time of diagnosis is not predic-
2. 1, 2. Plots of (1) actuarial survival according to method of detection and (2) actuarial recurrence-free rate according to method of detection. Points are actuarial estimate error at 5 and 10 years. Exam = examination, Neg = negative, Pos = positive.
±
On cover
the basis a median
years,
we
of these data, which follow-up period of 7
conclude
that
patients
with
mammographically occult early-stage breast cancer are acceptable candidates for CSRT. Our data suggest that these patients will experience a local recurrence rate and a survival rate similar to those of patients with positive mammograms. Furthermore, early local recurrence can be effectiveby treated with mastectomy without compromise of survival. For this group, as for all patients who undergo conservative treatment for breast cancer, regular follow-up mammography
early
remains
diagnosis
a valuable
of recurrence.
tool
for
#{149}
References 1.
been addressed our knowledge.
in the literature, Our retrospective
analysis
demonstrated
clearly
to that
this group of patients, when cornpared with those with mammographically visible tumors, had a similar local recurrence rate (4% vs 8% at 5 years). In addition, the two groups had the same disease-free survival rate (79% at 5 years). The negative mammogram group actually had a slightly higher overall survival rate than the positive mammogram group (94% vs 84%). This survival advantage might be explained by the slight, statisticabby insignificant preponderance of clinical stage I patients in the negative mammogram group (78% vs 66% in the positive mammogram group). The negative mammogram group did not differ significantly from the positive mammogram group with respect to clinical stage, nodal status, or treat-
ment. The only significant difference between the two groups was the younger median age of the negative mammogram group. The fact that younger patients generally have more dense breasts may have contributed to the younger median age of the negative mammogram group. Although studies have shown that young age is a poor prognostic factor for overall survival and breast recurrence rates, the younger negative mammogram group had acceptable survival and breast recurrence rates compared with those of the positive mammogram group. A particularly important finding of this
review
examination
185
#{149} Number
2
that
of the
five
pa-
alone
with
following
negative
3.
4.
5. 6.
7.
tients who underwent mammography at the time of local recurrence, four had mammographically visible recurrence. In fact, two cases of local recurrence were detected with mammography
Volume
was
2.
Mate TP, Carter D, Fischer DB, et a!. A clinical and histopathologic analysis of the results of conservation surgery and radiation therapy in stage I and II breast carcinoma. Cancer 1986; 58:1995-2002. Fisher B, Redmond C, Poisson R, et a!. Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Eng! J Med 1989; 320:822-828. Recht A, Schnitt SJ, Connolly JL, et a!. Prognosis following local or regional recurrence after conservative surgery and radiotherapy for early stage breast carcinoma. Int J Radiat Oncol Biol Phys 1989; 16:3-9. de Paredes ES. Atlas of film-screen mammography. Baltimore: Urban & Schwarzenberg, 1989. Langer TG, de Paredes ES. Pitfalls in mammography. AppI Radio! 1990; 19:13-24. Haffty BG, Goldberg NB, Fischer D, et a!. Conservative surgery and radiation therapy in breast carcinoma: local recurrence and prognostic implication. IntJ Radiat Oncol Biol Phys 1989; 17:727-732. Fourquet A, Campana F, Zafrani B, et Prognostic factors of breast recurrence in the conservative management of early breast cancer: a 25-year follow-up. Int J Radiat Onco! Biol Phys 1989; 17:719-725.
physical
results.
It
Radioloev
427
#{149}
R. Samuels,
MD
#{149} Bruce
MD
G. Haifty,
Breast Conservation with Mammographically Breast Cancer’ The authors reviewed their experience with 542 patients with breast cancer who were treated with conservative surgery and radiation therapy (CSRT) and analyzed the outcome in those patients whose tumors could not be detected with mammography. Fifty-five of the patients (10.1%) had a palpable, pathologically confirmed breast carcinoma and a negative preoperative mammogram. Routine follow-up included annual mammography and physical examination. The local recurrence, 5-year actuarial survival, and 5-year disease-free survival rates for these 55 patients did not differ significantly from those for patients with positive mammograms. There were six cases of local breast recurrence in this subgroup. Four of five cases were visible on mammograms (one patient did not undergo mammography at the time of recurrence); two of the cases were detected with mammography alone following physical examination with negative results. The authors conclude that patients with palpable but mammographically occult early-stage breast cancer are suitable candidates for CSRT and that mammography is a mandatory
part
servatively
treated
of follow-up
of con-
patients.
Carol
#{149}
H. Lee,
MD
Diana
#{149}
Radiology
B. Fischer,
PhD
Therapy in Patients Undetected
C
surgery and radiation therapy (CSRT) is well estabbished as effective treatment for early-stage invasive breast cancer (1). Both survival and disease-free survival are equivalent in patients
other
treated
tangential Gy, with
ONSERVATIVE
with
mastectomy
treated with jority of the breast, with Careful
and
those
CSRT, while the vast mabatter group retain the good cosmetic results (2).
follow-up
is a critical
at diagnosis.
of invasive
carcinoma
radiation
employed
accelerator.
The
breast
was
treated
median
dose
dose were
of 46 Gy.
therapy or hormonal 31% of the patients.
included
and
An attempt
original
by
negative
nately,
we
to review
unable
Unfortuto retrieve
Radiology
1992;
185:425-427
Between
AND
January
METHODS
1962
and
December
542 patients were treated at YNHH. To ensure adequate 1985,
with CSRT follow-up,
the review was limited to patients treated before 1986; the majority of these patients had their cancer diagnosed and treated between
I From the Departments of Therapeutic Radiology (J.R.S., B.G.H., D.B.F.) and Diagnostic Radiology (C.H.L.), Yale University School of Medicme, 333 Cedar St, New Haven, CT 06510. Received February 3, 1992; revision requested March 3; revision received June 22; accepted June 24. Address reprint requests to B.G.H. C RSNA, 1992
1983 and
1985.
The
charts
reference apy record original
was made and/or
in the hospital
diagnostic
negative.
Twelve
mograms
were
remainder
mammogram acquired
ing community
mammographic detail. Fibrocystic
noted
have
contributed
and affiliated original
original
majority
ductal
of them
carcinoma,
negative
mamoutside
reports were reviewed in changes or dense breasts
in a majority to the
report.
while
at surround-
of the
32 of the
been
mam-
at YNHH,
hospitals
were
had
acquired
Sixteen and
therthat the
of the 55 original were
institutions. mograms
radiation record
of cases negative
Although
prebiopsy
we
were
and may mammounable
material, the of negative with the literareference to a
mammogram
in all 55
cases.
RESULTS
were
reviewed carefully to determine the initial methods of tumor detection (Table 1). Fifty-five of the 542 patients (10.1%) had a palpable, pathologically confirmed breast carcinoma and a negative preoperative mammogram. All of these patients underwent excisional biopsy of the palpable mass. The filtrating
the
mammograms of all of these paHowever, in all 55 cases, specific
to review all of the original 10.1 % rate (55 of 542 patients) mammograms is consistent ture and there was a specific
MATERIALS
the
55 patients
mammograms.
graphic
Breast
and
oncologists.
made
Index terms:
Breast neoplasms, postoperative, neoplasms, surgery, 00.45 neoplasms, therapeutic radiology, 00.47
in
referring
of the
were
was
was used follow-up the
radiation
was
mammograms
with
axilla
mammography
examinations
physicians
The
who had underAdjuvant chemo-
therapy Routine
annual
physical
of 64 Gy. The treated to a
00.32
#{149} Breast
with
fields to a median dose of 46 an electron boost to the tumor
not treated in patients gone axiblary dissection.
the
axibbary group
therapy techniques 4- or 6-MeV linear
on a
bed to a total median regional lymph nodes
original tients.
(Table
(64%) underwent and one-third of this lymph nodes.
Standard
were
total
compo-
nent of CSRT and includes both frequent physical examination and mammography. Together, these two methods can allow detection of early local recurrence, which can be treated effectively with mastectomy without compromising survival (3). At the time of diagnosis, 10% of patients with pathologically confirmed breast cancer have negative mammograms (4,5). Physicians may be rebuctant to refer these patients for CSRT because of the fear that, after conservative treatment, recurrence may be once again undetectable at mammography, making effective follow-up difficult. To evaluate this problem, we reviewed our experience at Yale-New Haven Hospital (YNHH) with patients who received CSRT and analyzed the outcome in the subgroup of patients with false-negative mammograms
types
2). Thirty-five dissection, had involved
(80%)
had
in-
while
20% had
As of September
patients follow-up
Abbreviations: and radiation yen Hospital.
1990,
this
group
of
had a minimum assessable of nearly 5 years and a me-
CSRT therapy,
= conservative surgery YNHH = Yale-New Ha-
425
dian follow-up of 7 years. Forty-one of the 55 patients with negative mammograms
were
alive
without
(Table tuarial
3). This gives a 79% disease-free survival,
5-year
disease-free
developed distant metastases at the time of or shortly after the local recurrence. Nine patients with negative mammograms had recurrence only distantly, and two had only regional nodal recurrence (Table 3). Four of the cases of local recurrence were discovered at physical examination, and two of these cases were confirmed at mammography. Two cases of local recurrence were detected with mammography alone following physical examination with negative results (Table 5). Of the six patients with negative mammograms who had a local recurrence, four underwent modified radical mastectomy. Three of these patients remain alive without evidence of disease; one developed metastases and died 5 years after mastectomy, without having another local recurrence. One case of local recurrence was treated with excision only, as the patient had developed concurrent liver metastases. The remaining patient received no salvage surgery for recurrence in the skin; she was alive and was being treated with hormonal therapy. Of the three patients who had only local recurrence and under-
disease
5-year acthe same
survival
seen
in
the 219 patients with positive mammograms treated at YNHH from 1962 through 1985. The overall survival of the negative mammogram group was slightly
better
than
that
of the
posi-
tive mammogram group (94% vs 84% at 5 years) (Fig 1). As shown in Table 4, there was no significant difference between the two groups with respect to stage, nodal status, or adjuvant therapy. The only significant difference between the two groups was in age. The median age of the negative mammogram group was 48 years versus
57 years
for
the
positive
mammo-
gram group. There were six cases of local breast recurrence among the 55 patients with negative mammograms (10.9%). This
frequency
of local
recurrence
was comparable with that seen in the positive mammogram group (23 of 219 or 10.5%) (Fig 2). Of the six patients with negative mammograms who had a local recurrence, two also
went salvage mastectomy, all are alive without evidence of disease. DISCUSSION It has been demonstrated that patients undergoing CSRT for invasive breast cancer will have local recurrence at a rate of 1%-2% per year and that mastectomy provides effective salvage (6,7). Therefore, providing effective follow-up care for these patients is imperative. The question of adequate follow-up of patients whose tumors were palpable but could not be visualized at mammography is raised frequently by both referring physicians
and
patients
Clinical
Patients
stage
I II
43(78) 12(22)
Histologic type Infiltrating ductal infiltrating lobular Tubular
Treated
Patients
Positive Positive Positive Negative =
PE results, PE results, PE results, PE results,
physical
Table 3 Results of Follow-up with Breast Cancer
Group
Patients 202(37.3) 219(40.4) 55(10.1) 66(12.2)
no mammogram positive mammogram negative mammogram positive mammogram
examination.
Numbers
in parentheses
Adjuvant
of Patients
Note-Numbers
with
Negative
of dis41 (75)
with disease no evidence with disease of treatment recurrence and distant
Distant Nodal
recurrence recurrence
426
#{149} Radiology
and Patients
with Positive
Positive Mammogram Group (%)
P Va!ue*
stage
78
66
22
34
45 55
68 32
50y
7(13) of dis-
only
Mammograms
Negative Mammogram Group (%)
Parameter Clinical
no evidence
55(100)
48(87)
4
Comparison Mammograms
No. of Patients
Result
hormonal
ages. Median (range, 30-84
are percentages.
Table in 55 Patients and Negative
20(36) 23(42) 12(22)
therapy
Mammograms
Status Alive, ease Alive, Dead, ease Dead, Patterns Breast Breast
carcinoma
dissection
Positive results Treatment Breast irradiation Nodal irradiation Adjuvant systemic
CSRT
with
No. of Detection
Note.-PE
44(80) 5(9) 4(7) 2(4)
Not done Negative results
in 542
not
No. of Feature
Other invasive
Detection
has
Table 2 Features of 55 Patients with Breast Cancer and Negative Mammograms
Axillary
Table 1 Means of Tumor
and
*
P value
chemotherapy
hormonal
for comparison
therapy
of overall
results
13
ii
87
89
between
the two groups.
NS
=
NS not significant.
November
1992
is difficult
-
-
-
.-.
Pyc
p5ys,c
.-.
0
2
Ev
P03
Pos
E*m
-
Ma?.m,hy Mm.gap4y
(-
55)
Pos (‘-2t9)
8
4
YEARS
Nig
8
0
P5yc
E.am
Pos
.-.
P5ysc
Ew
Ps
0
2
L
.
May
1.g
Mammog,aphy
Po).219)
4
FOLLOW-UP
6
(.
why
the
re-
live negative time ofof a recurrence.
mammogram
at the
55)
8
CONCLUSIONS
10
YEARS FOLLOW-UP
1. Figures breast standard
.-.
to understand
current lesion was visible at mammography when the original primary lesion was mammographically occult. Decreasing density in the breast as the patient aged, however, is one possibbe contributing factor to this phenomenon. Although the total number of patients in our study was small, it appears that a negative mammogram at the time of diagnosis is not predic-
2. 1, 2. Plots of (1) actuarial survival according to method of detection and (2) actuarial recurrence-free rate according to method of detection. Points are actuarial estimate error at 5 and 10 years. Exam = examination, Neg = negative, Pos = positive.
±
On cover
the basis a median
years,
we
of these data, which follow-up period of 7
conclude
that
patients
with
mammographically occult early-stage breast cancer are acceptable candidates for CSRT. Our data suggest that these patients will experience a local recurrence rate and a survival rate similar to those of patients with positive mammograms. Furthermore, early local recurrence can be effectiveby treated with mastectomy without compromise of survival. For this group, as for all patients who undergo conservative treatment for breast cancer, regular follow-up mammography
early
remains
diagnosis
a valuable
of recurrence.
tool
for
#{149}
References 1.
been addressed our knowledge.
in the literature, Our retrospective
analysis
demonstrated
clearly
to that
this group of patients, when cornpared with those with mammographically visible tumors, had a similar local recurrence rate (4% vs 8% at 5 years). In addition, the two groups had the same disease-free survival rate (79% at 5 years). The negative mammogram group actually had a slightly higher overall survival rate than the positive mammogram group (94% vs 84%). This survival advantage might be explained by the slight, statisticabby insignificant preponderance of clinical stage I patients in the negative mammogram group (78% vs 66% in the positive mammogram group). The negative mammogram group did not differ significantly from the positive mammogram group with respect to clinical stage, nodal status, or treat-
ment. The only significant difference between the two groups was the younger median age of the negative mammogram group. The fact that younger patients generally have more dense breasts may have contributed to the younger median age of the negative mammogram group. Although studies have shown that young age is a poor prognostic factor for overall survival and breast recurrence rates, the younger negative mammogram group had acceptable survival and breast recurrence rates compared with those of the positive mammogram group. A particularly important finding of this
review
examination
185
#{149} Number
2
that
of the
five
pa-
alone
with
following
negative
3.
4.
5. 6.
7.
tients who underwent mammography at the time of local recurrence, four had mammographically visible recurrence. In fact, two cases of local recurrence were detected with mammography
Volume
was
2.
Mate TP, Carter D, Fischer DB, et a!. A clinical and histopathologic analysis of the results of conservation surgery and radiation therapy in stage I and II breast carcinoma. Cancer 1986; 58:1995-2002. Fisher B, Redmond C, Poisson R, et a!. Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Eng! J Med 1989; 320:822-828. Recht A, Schnitt SJ, Connolly JL, et a!. Prognosis following local or regional recurrence after conservative surgery and radiotherapy for early stage breast carcinoma. Int J Radiat Oncol Biol Phys 1989; 16:3-9. de Paredes ES. Atlas of film-screen mammography. Baltimore: Urban & Schwarzenberg, 1989. Langer TG, de Paredes ES. Pitfalls in mammography. AppI Radio! 1990; 19:13-24. Haffty BG, Goldberg NB, Fischer D, et a!. Conservative surgery and radiation therapy in breast carcinoma: local recurrence and prognostic implication. IntJ Radiat Oncol Biol Phys 1989; 17:727-732. Fourquet A, Campana F, Zafrani B, et Prognostic factors of breast recurrence in the conservative management of early breast cancer: a 25-year follow-up. Int J Radiat Onco! Biol Phys 1989; 17:719-725.
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#{149}
