no evidence of increasd local recurrence or decreased survival assoc w needle biopsy

[Lani]

I remember CLTann referring to what she believed were significant recurrence rates due to tumor seeding (which was thought to occur with all cancers in general YEARS AGO before things were looked at with "evidence based medicine")--so I post this for those trying to decide how to proceed:

ABSTRACT: Preoperative Core Needle Biopsy does not Increase Local Recurrence Rate in Breast Cancer Patients [Breast Cancer Research and Treatment]
Objective: Several case reports and clinical studies in the literature demonstrate needle track seeding after core needle biopsy in patients with breast cancer in up to 50% of cases. The impact of this observation on local recurrence and overall survival rate is, however, not fully investigated.

Patients and design: We retrospectively analysed 719 patients after breast conserving surgery and postoperative radiotherapy for stage I and II breast cancer. We divided this group into patients with (189) and without (530) preoperative core needle biopsy. Demographic data, local recurrence and overall survival rate were compared between these two groups.

Result: Preoperative core needle biopsy did not significantly influence the local free recurrence rate (median follow-up time of 78 and 71 months, respectively). The prognostic factors and the postoperative therapy did not differ significantly between the two groups.

Conclusion: Preoperative core needle biopsy seems to have no detrimental impact on local recurrence and overall survival after breast conserving surgery and postoperative radiotherapy.

[al from Canada]

Lani, isn't there somthing called a "punch biopsy" which does have a significant seeding rate?

Al

[AlaskaAngel]

This is a more complicated issue... And I really hope that it doesn't confuse people who are looking for simple answers...

There is the FNA (fine needle aspiration), the core needle biopsy (which takes out a thicker sample of tissue than an FNA does), and the excisional biopsy.

FNA is known to sometimes miss the cancer because it is, as it says, just a fine needle and may hit a part of the tissue that has not yet been invaded by the irregular shape of cancers. Seeding of cancer by FNA is not addressed by the article above.

Core biopsy also can have misses but is less likely. The article referred only to core needle biopsy, and only in regard to seeding, which does not address the issue of missing the cancer entirely.

Excisional biopsy is least likely to miss the cancer. See next paragraph regarding the question of seeding by virtue of disturbance of tissues.

There is bound to be some remaining question in regard to possible tracking by needle that is operator-dependent. For example, the goofy surgeon who did my biopsy actually attempted to biopsy from the opposite side of the breast from the side where the cancer was. Yes, sometimes it IS hard to get the tool to punch into a dense object in dense tissues, but results in terms of tracking would be different depending on the skill of the surgeon. And I believe that question has been raised in terms of "seeding" through various kinds of biopsies (as well as the question of "seeding" through less skillful lumpectomy, mastectomy, prosthesis surgery, and plastic surgery).

AlaskaAngel

P.S. Punch biopsy is used for skin cancers.

[al from Canada]

AA,

I've never researched skin cancers so the only place I would have heard of a "punch" biopsy is here.
Al

[AlaskaAngel]

You are right, Al, and so am I. Some breast cancers are located on the skin so they don't always have to use a tool that goes deeper. I probably should have listed a punch biopsy in the same way that I listed the other biopsies, but I'm just not sure it would be relevant in terms of seeding.

A.A.

[Tami]

Has anyone ever heard anything regarding when you have your lumpectomy? I seem to recall I had heard it was better to have surgery shortly after your period vs. before it. Is there anything to this? or is a wive's tale? thanks.

[Bev]

Hi Tami,

I saw the timing issue in the Breast Book. My surgeon didn't schedule my surgery that way so I hope they've decided it's not that important. Bev

[Alice]

To be honest with you I'm not sure I'm as concerned with local recurance as I am with systemic recurance. If a needle biopsy rendered a local recurance I would just have another sx, not a big deal in the scheme of things, but if a biopsy released cells into the blood,lymph,or other ways to access body tissues I would be greatly concerend.

Just a thought, Alice

[Alice]

As an after thought, how many have been helped VS hurt thru a biopsy?

TOO many to count!!!
Medacine is not an exact science and we all have to do what we can to help ourselves and be watchfull of thers.

[Lani]

neither local recurrence nor overall survival were adversely impacted in this group of patients.

The only paper I have reviewed which reported a frequent rate of seeding which resulted in local occurrence was out of Argentina and concluded that the surgeon should excise a small circle of tissue around the needle or core
biopsy site in cases of skin sparing mastectomy as there had been some local recurrences when they did not. I assumed this was because the skin sparing mastectomy devascularizes the area which means less immune cells which might complex with the few loose cancer cells and render them harmless can get to the area to "do their thing" That may or may not be a correct assumption.

[al from Canada]

That "wifes tale" about lumpectomies and periods probably stemed from the fact that the majority of breast cancers are fueled by estrogen so it makes sense that if you are going to shake things around a bit, do it when the hormonal cycle is low.

Lani, in terms of seeding and HER2 cancers, which are unique, there has been studies done on seeding as a result of surgery. Not seeding so much as HER2 activation as a result of the surgery. HER2 being a growth factor may be additionally activated by surgical traume and one study actually recommended the continuous infusion of 5FU to compensate for this. The article, which I can find if I have to, made me resolve that if Linda were to have a surgery, I would demand a 5FU infusion during the surgery.

The whole point of this is that we have to treat HER2 cancers as a totally different disease and the gerenal rules do not apply.
Al

[Lani]

Al, her2 + breast cancer does seem to have a distinct way of behaving when stimulated by surgery compared to other cancers--I seem to remember reading it activated various thrombolytic (vs clotting) factors and particularly it is often associated with lots of VEGF. It's genetic profile is very similar to inflammation and wound healing and the recent article I posted recommended NOT having a mastectomy as it might stimulate these angiogenic, pro-metastasis and inflammatory factors. Nevertheless, they have never shown that having an oophorectomy is ill-advised in her2+ patients--in fact a paper by Love (Richard, not Susan) showed a marked survival advantage to doing a luteal phase oophorectomy and mastectomy in her2+ patients (small numbers, IHC 2+ and 3+ included)

Remember my post that Ki67 results do seem to depend on phase of menstrual cycle.
Al, I would appreciate a link to the 5FU recommendation.

I wanted to post this to stir up thinking about the fear generated by CLTann's posts months ago which might have caused a lot of fear in those who did have needle or core biopsies. Like so much, the answer is still not in...

[al from Canada]

Dear Lani,

Here is an exerpt with link at the end.

There is a biological rationale for studying optimal timing of initiation of chemotherapy in relation to the surgical removal of the tumour. Experimental cell kinetic data support the hypothesis that timing of cytotoxics administration as close as possible to the operation may improve treatment outcome [1–4]. In mice bearing both a large primary tumour and a metastatic lesion, the removal of the former increased the proliferative fraction (rate) of the latter as compared with preoperative levels [3]. In this animal model, cyclophosphamide was most effective against metastatic growth when the drug was administered either preoperatively or immediately after tumour removal compared with delayed administration [4]. Other data provide a plausible rationale for initiation of chemotherapy as close as possible to the surgical removal of a tumour. Surgical trauma and removal of the primary tumour is known to enhance biological processes, which stimulate both wound healing [5] and may induce tumour progression [6]. Moreover, the results of a meta-analysis of trials on perioperative chemotherapy (PeCT) showed a reduced risk of relapse by 11% with early initiation of chemotherapy compared with a usual delayed administration, which started after removal of stitches and completion of wound healing [7].
Preoperative chemotherapy (PreCT) has been demonstrated to be beneficial for patients with breast cancer, allowing breast-conserving surgery in some of the patients [8]. One of the most effective regimens used in this setting is the combination of continuous infusion of 5-fluorouracil (5-FU), epirubicin and cisplatin (ECF). Smith et al. reported high complete remission rates in 50 patients with large operable breast cancer treated with this regimen. Ninety-eight per cent of these patients had significant tumour shrinkage, 66% had a complete clinical remission, and 27% a pathological complete response [9]. Surgery was performed after completion of 6 months of chemotherapy. The same investigators recently compared preoperative ECF with adriamycin and cyclophosphamide (AC) in a phase III randomised trial involving 426 patients with invasive operable breast cancer. The interim analysis showed a significant survival benefit for continuous infusional 5-FU-containing chemotherapy over conventional AC [10].

http://annonc.oxfordjournals.org/cgi...ull/14/10/1477