Small bowel metastases from primary carcinoma of the lung

Although about half of all patients with carcinoma of the lung have metastases at initial presentation, only nine with metastases to the small bowel have been previously reported. This study was performed to determine the incidence of occult and clinically apparent metastases of lung cancer to the small intestine. Small bowel metastases were present in 46 of 431 patients with primary lung cancer who underwent autopsy during an 11-year period. These patients had an average of 4.8 metastatic sites. Small bowel metastases were present in 12 of 31 (39.0%) patients with large cell carcinoma, 13 of 108 (12.3%) with adenocarcinoma, six of 73 (8.0%) with small cell carcinoma, 15 of 199 (7.5%) with squamous cell carcinoma, and none of 20 with undifferentiated carcinoma. During the same interval, six of 78 patients undergoing small bowel resection for metastatic tumor had lung cancer primaries. Among the nine previously reported clinical cases of small bowel metastases and the six in this series, 14 were operated upon for small bowel perforation and one for obstruction. Nine patients died perioperatively, and no patient survived longer than 16 weeks. These data demonstrate that the incidence of lung cancer metastases to the small bowel is higher than is clinically apparent. Lung cancer metastases to the small bowel often present as intestinal perforation and indicate a poor prognosis; surgery is indicated for palliation.

Small bowel metastases from primary carcinoma of the lung

Although about half of all patients with carcinoma of the lung have metastases at initial presentation, only nine with metastases to the small bowel have been previously reported. This study was performed to determine the incidence of occult and clinically apparent metastases of lung cancer to the small intestine. Small bowel metastases were present in 46 of 431 patients with primary lung cancer who underwent autopsy during an 11-year period. These patients had an average of 4.8 metastatic sites. Small bowel metastases were present in 12 of 31 (39.0%) patients with large cell carcinoma, 13 of 108 (12.3%) with adenocarcinoma, six of 73 (8.0%) with small cell carcinoma, 15 of 199 (7.5%) with squamous cell carcinoma, and none of 20 with undifferentiated carcinoma. During the same interval, six of 78 patients undergoing small bowel resection for metastatic tumor had lung cancer primaries. Among the nine previously reported clinical cases of small bowel metastases and the six in this series, 14 were operated upon for small bowel perforation and one for obstruction. Nine patients died perioperatively, and no patient survived longer than 16 weeks. These data demonstrate that the incidence of lung cancer metastases to the small bowel is higher than is clinically apparent. Lung cancer metastases to the small bowel often present as intestinal perforation and indicate a poor prognosis; surgery is indicated for palliation.

Small bowel metastases from primary carcinoma of the lung

Although about half of all patients with carcinoma of the lung have metastases at initial presentation, only nine with metastases to the small bowel have been previously reported. This study was performed to determine the incidence of occult and clinically apparent metastases of lung cancer to the small intestine. Small bowel metastases were present in 46 of 431 patients with primary lung cancer who underwent autopsy during an 11-year period. These patients had an average of 4.8 metastatic sites. Small bowel metastases were present in 12 of 31 (39.0%) patients with large cell carcinoma, 13 of 108 (12.3%) with adenocarcinoma, six of 73 (8.0%) with small cell carcinoma, 15 of 199 (7.5%) with squamous cell carcinoma, and none of 20 with undifferentiated carcinoma. During the same interval, six of 78 patients undergoing small bowel resection for metastatic tumor had lung cancer primaries. Among the nine previously reported clinical cases of small bowel metastases and the six in this series, 14 were operated upon for small bowel perforation and one for obstruction. Nine patients died perioperatively, and no patient survived longer than 16 weeks. These data demonstrate that the incidence of lung cancer metastases to the small bowel is higher than is clinically apparent. Lung cancer metastases to the small bowel often present as intestinal perforation and indicate a poor prognosis; surgery is indicated for palliation.

Beta-chain human chorionic gonadotropin-producing leiomyosarcoma of the small intestine

A 22-year-old patient with primary leiomyosarcoma of the small bowel presented with symptoms including nausea and vomiting, a symptom complex similar to hyperemesis gravidarum in the pregnant female. She was found to have elevated levels of serum beta-HCG which were localized to the leiomyosarcoma cells utilizing an immunoperoxidase staining technique. Thus, this patient presents evidence that beta-HCG may be produced by sarcoma cells and, therefore, that beta-HCG may be used as a tumor marker in some sarcoma patients.

Experience with the Hickman catheter: unusual complications and suggestions for their prevention

With the expanding clinical use of the Hickman catheter, new complications have emerged. This report describes two such complications: one in an adult with postplacement malposition and a second in a child with a ballooning double-lumen catheter. The risk of postplacement malposition can be reduced by placing the catheter's tunnel as medial as possible; the risk of material malfunction can be reduced by careful quality control and careful surgical technique.

Inhibition of human neuroblastoma by dopamine antagonists

The effects of dopamine agonists and antagonists were investigated in human neuroblastoma (HNB) tissue culture cell lines and correlated with the presence of specific membrane-bound dopamine-binding activity ("receptor"). In four HNB cell lines the dopamine antagonists domperidone, pimozide, and spiroperidol inhibited macromolecular synthesis in vitro as indicated by decreased 3H-TdR and 14C-leu incorporation in a dose-response fashion with at least 50% inhibition noted at 10(-6)M concentration of each drug. Dopamine agonists showed no significant inhibition. Scatchard analysis of competitive dopamine-binding assays in all four HNB cell lines and in five of eight solid tumors obtained at surgery demonstrated high affinity, limited-capacity binding consistent with a single class of receptor sites with receptor concentrations (Rc) ranging from 8.8 to 26.7 pmol/gm wet weight of tissue with dissociation constants (KD) from 0.40 to 6.6 nmol/L, compared with a mean Rc of 28.1 +/- 5.2 pmol/gm wet weight of tissue and KD = 0.38 +/- 0.09 nmol/L in receptor-rich dog caudate nucleus, the normal dopamine-sensitive control. Survival was prolonged after inoculation of the SK-N-AS cell line into nude mice and subsequent domperidone administration by 50% (24 days after drug initiation versus 16 days in control mice). These data demonstrate inhibition of macromolecular synthesis in HNB by dopamine antagonists and suggest that dopamine receptor is associated with this inhibition. The determination of dopamine receptors may prove useful in the selection of dopamine antagonists as specific chemotherapy for patients with neuroblastoma.

Emergency surgical treatment for patients with acute leukemia

A series of 21 emergency operations performed upon 19 patients with acute leukemia was reviewed. The most common procedure performed was laparotomy for intra-abdominal emergency complications which was associated with a high mortality (58 per cent), especially in those patients with leukemia not in remission (78 per cent). Patients who underwent extra-abdominal procedures, even with leukemia not in remission, had a low mortality (14 per cent). All five patients who were operated upon while in remission survived. The most accurate prognostic signs associated with postoperative mortality were abnormal white blood cell counts and development of leukemia not in remission. Early surgical intervention is advised combined with intensive supportive care to improve survival rates of patients with acute leukemia who undergo emergency surgical procedures.

Prognostic features of pediatric soft-tissue sarcomas

Eight hundred ninety-two patients under 20 years of age with soft-tissue sarcomas histologically diagnosed between 1955 and 1971 (before the era of combined modality therapy) were reviewed to delineate important prognostic variables. Differing histologic findings, extent of disease at initial presentation, and site of the primary tumor correlated with prognosis; age, sex, and race did not affect survival significantly. Patients with fibrosarcomas, liposarcomas, and leiomyosarcomas had improved survival rates when compared with adults with the same histologic findings; patients with localized tumors and extremity primary sites had the best prognosis. Patients with rhabdomyosarcomas, disseminated disease, or retroperitoneal primary sites had the worst prognosis. These data suggest that some childhood sarcomas are not as aggressive as adult sarcomas or childhood rhabdomyosarcomas. Therefore they may not require the adjuvant therapy shown to be beneficial in childhood rhabdomyosarcomas.

Prognosis of level V malignant melanoma

Level V melanomas have been reported to have a poor prognosis, but in-depth analyses of prognostic factors and treatment have not been reported. From 1952 through 1982, 41 patients presented with primary Clark's Level V melanomas. There were 23 patients who presented with clinical Stage I disease and 18 with Stage II. Among Stage I patients, 9 were treated by wide excision alone and 13 underwent wide excision plus prophylactic regional lymph node dissection (RLND); 8 of 13 patients had histologically positive nodes. Twelve Stage II patients were treated by wide excision and RLND (including three hemipelvectomies), and four refused surgery. The 5-year survival was 52%. For Stage I patients, survival was 62% and disease-free survival (DFS) 28% at 5 years; 6 of 10 recurrences were local or regional only. Prophylactic RLND reduced the incidence of recurrence but did not appear to influence survival rates. Among 14 evaluable Stage II patients, overall survival was 60% and DFS 42% at 3 years; of 4 patients who subsequently had a recurrence, 3 had distant metastases. All seven patients with distant metastases at the time of first recurrence died of disease within 14 months (median, 4 months) of detection of metastatic disease. Primary melanomas of the foot (11 patients) and trunk (4 patients) appeared to have a worse prognosis than other sites. Ulceration (seen in 21 patients) did not appear to significantly influence outcome. These data suggest that most patients with Level V melanoma present with clinically localized disease. Prophylactic RLND did not significantly affect overall survival. The invasiveness of these deep tumors appears to reduce the influence of other factors, including primary site, sex, race, and ulceration. The prognosis of patients with Level V melanoma, even with clinically or histologically positive lymph nodes, is not hopeless, and these patients should be treated aggressively.

Adjuvant Corynebacterium parvum immunotherapy for squamous cell epitheliomas of the oral cavity, pharynx, and larynx

Patients with primary squamous cell epitheliomas of the oral cavity, pharynx, and larynx were stratified according to stage and site and randomized to receive either intratumoral immunotherapy with Corynebacterium parvum followed 2 weeks later by surgery and postoperative C parvum for 2 years or surgery alone. There were 209 patients entered into the trial and 176 were fully evaluable. All prognostic variables were similar between the two groups. There was no difference in disease-free survival or absolute survival between the two groups of patients. In addition, there was no difference noted for any stage and/or site. The only difference in sequential immunologic testing was that chemokinesis was increased following intratumoral C parvum, but neither this nor any other immunologic test correlated with ultimate recurrence or survival. These data demonstrate that immunotherapy using preoperative, intralesional C parvum and postoperative, subcutaneous C parvum is ineffective when used as an adjuvant to surgery for primary cancers arising in the oral cavity, pharynx, and larynx.

Reconstruction after mediastinal tracheostomy

Mediastinal tracheostomy has been associated with high morbidity and mortality, often due to skin necrosis, with resultant exposure of the great vessels and subsequent hemorrhage. During a 4 year period, 11 patients underwent mediastinal tracheostomy. Reconstruction included the use of a pectoralis major musculocutaneous flap to provide well-vascularized skin for anastomosis to the superior portion of the tracheostoma in nine patients. Whenever possible (eight patients), the trachea was transposed below the innominate artery to allow for slightly more mobility of the trachea and to remove the cartilaginous portion of the trachea from the artery. Among the eight elective operations reported herein, there were no postoperative deaths and only two minor wound-related complications. Among three patients who underwent emergency mediastinal tracheostomy, two patients died, one with an aneurysm of the innominate artery that ruptured several weeks postoperatively and the other with respiratory instability who could not be weaned from the respirator. These results suggest that use of the pectoralis major musculocutaneous flap and tracheal transposition decreases the risk of skin necrosis and resultant major vessel rupture. We advocate this approach in the reconstruction of the patient who requires mediastinal tracheostomy.

Improved survival following complete excision of retroperitoneal sarcomas

Charts and slides of 47 patients with primary retroperitoneal sarcomas (excluding pediatric rhabdomyosarcoma) were reviewed to determine clinical presentation, histologic features, extent of surgical resection, operative morbidity and mortality, use of radiation and/or chemotherapy, and survival data. Most patients presented with pain and a palpable mass. Leiomyosarcomas and liposarcomas were the most common tumors. Eighteen of the 47 patients (38%) had complete tumor excision; 68% required resection of adjacent organs. Operative morbidity was 33% with no mortality. After complete resection, the disease-free 5-year survival was 50% and the overall survival was 70% at 5 years; 10-year disease-free survival was 25% with an overall 58% survival at 10 years. Eleven patients (61%) developed recurrent disease with a median interval of 5 years following complete excision. Six patients received adjuvant radiation and/or chemotherapy with four remaining disease-free from 46 to 61 months. Eighteen patients underwent partial excision of tumor and 11 patients underwent biopsy only; these groups had similar survival curves with only 4% alive at 5 years. Their operative morbidity was 18% and mortality was 7%; median time to clinical evidence of tumor progression was 12 months. Sixty per cent of these patients received therapeutic radiation and/or chemotherapy, but their survival was the same as those undergoing surgery alone. These data emphasize the importance of an aggressive surgical approach in the treatment of retroperitoneal sarcomas. Complete tumor resection and total excision of recurrences will allow many patients long-term survival.

Inhibition of murine neuroblastoma growth by dopamine antagonists

C-1300 murine neuroblastoma ( MNB ) contains the catecholamine biosynthetic pathway. This study investigated manipulation of this pathway for effects on cell growth and survival in tumor-bearing mice, and to correlate these findings with specific membrane-bound dopamine-binding activity. The dopamine antagonists domperidone, pimozide, and spiroperidol inhibited macromolecular synthesis in vitro as demonstrated by decreased [3H]TdR and [14C]leu incorporation in a dose-response fashion; 56, 49, and 43% inhibition was noted at 10(-6) M concentration of each drug, respectively, with no loss of cell viability. Dopamine agonists showed no significant inhibition. Scatchard analysis of dopamine binding was consistent with a single class of receptor sites with a mean concentration of 13.2 +/- 2.0 pmole/g wet weight of tissue and mean dissociation constant (Kd) = 0.69 +/- 0.38 nM, compared to a mean receptor concentration of 28.1 +/- 5.2 pmole/g wet weight of tissue and Kd = 0.38 +/- 0.09 nM in receptor-rich dog caudate nucleus, the normal control. A/J mice injected with 1 X 10(6) tumor cells and treated with daily pimozide or domperidone had a significant increase in disease-free survival when compared to controls (15 versus 8.5 days, P less than 0.001) as well as a significant increase in overall survival (35 versus 25 days, P less than 0.001). These data suggest that dopamine antagonists inhibit macromolecular synthesis in the C-1300 MNB . The inhibition of MNB tumor growth in vivo by dopamine antagonists suggests a specific chemotherapeutic approach to neuroblastoma, possibly mediated by dopamine receptors.

Malignant fibrous histiocytomas in children

The natural history of malignant fibrous histiocytomas in children has not been well delineated. During a 6-year period, we have treated six patients less than 18 years of age. The sites of origin included the retroperitoneum in 2 patients, neck in 2 patients, and extremities in 2 patients. Surgical treatment consisted of wide local excision in 5 patients and amputation in 12; radiation and/or chemotherapy were administered to 2 patients following resection of all tumor. All children remain free of local recurrence or distant metastases with a median follow-up in excess of 4 years. These data suggest that malignant fibrous histiocytomas in children may have a better prognosis than in adults.

Management of locoregional recurrent oropharyngeal carcinoma

Sixty-seven patients with recurrent locoregional squamous cell epithelioma of the oropharynx were reviewed to determine the curative potential of secondary therapy for recurrent carcinoma. Of the 37 patients in whom recurrent carcinoma developed after radical surgery, only 11 percent (4 of 37) had a 2 year disease-free survival following secondary treatment. Recurrence developed in 30 patients after radiation therapy. Surgical resection of the recurrent carcinoma was possible in 13 of the patients, 38 percent (5 of 13) of whom were free of disease for a minimum of 2 years. Though treatment results in patients with recurrent oropharyngeal carcinoma are discouraging, secondary therapy in selected patients can yield 2 year disease survival in over a third of cases. Favorable prognostic factors included the development of recurrent carcinoma following radiation therapy and a tumor initially classified as stage I or II, irrespective of the initial mode of therapy.

The pectoralis major myocutaneous flap in head and neck reconstruction. Analysis of complications

Sixty-seven patients underwent 73 pectoralis major myocutaneous flap procedures for the immediate reconstruction of defects after resection of head and neck cancers. Thirty-six patients experienced a total of 50 complications for an overall complication rate of 54 percent. There were 3 instances of total flap necrosis, 9 of partial flap necrosis, 12 orocutaneous fistulas, 9 suture line separations, 8 neck wound complications, 1 donor site complication, and 8 mandibular replacement complications. Most complications were minor and did not require a second procedure for correction; however, 36 percent did require a second operation. Eight of 10 patients in whom a metal appliance was placed to restore mandibular continuity required the removal of that appliance due to either flap necrosis, fistula formation, or exposure. Based on our experience, we conclude that attention to flap design, operative technique, and post-operative management were useful in reducing the incidence of complications. We also conclude that a metal appliance was an unsatisfactory means of restoring mandibular continuity when utilized beneath a pectoralis major myocutaneous flap. Although the overall incidence of complications was high, the actual incidence of flaps failing to accomplish their intended purpose and requiring secondary repair was acceptable. The pectoralis major myocutaneous flap was reliable in the reconstruction of defects in the head and neck region.

Tubed pectoralis major musculocutaneous flaps for cervical esophageal replacement

Five patients undergoing laryngopharyngectomy and cervical esophagectomy for cancer were reconstructed using a tubed pectoralis major musculocutaneous flap for esophageal replacement. One patient had no complications, 2 had pinpoint fistulas with rapid healing, a fourth died of a myocardial infarction, and the fifth had a partial breakdown requiring secondary flap closure. This flap is safe, reliable, and easy to rotate and tube on itself; use of the tubed pectoralis major musculocutaneous flap obviates the necessity for laparotomy for colon interposition, gastric pull-through, or jejunal free grafts. In addition, microvascular anastomoses are not required. Therefore, it is recommended as an excellent means of replacing the cervical esophagus and should be considered a method of choice in debilitated patients.

Phase II trial of the dopaminergic inhibitor pimozide in previously treated melanoma patients

Pimozide, a potent neuroleptic which inhibits the release of pituitary releasing factors and is an effective dopamine antagonist, was administered to 30 patients with previously treated metastatic melanoma. Six patients were inevaluable because of poor drug tolerance (two), disease progression within 1 week and death within 2 weeks (three), and death from other causes (one). Among the 24 evaluable patients, two had complete response, two had partial response, and two had disease stabilization. Responses were observed in soft tissue, lymph nodes, liver, and lung. Toxic effects consisted of extrapyramidal manifestations in nine patients and malaise in seven. Pimozide has activity in patients with previously treated metastatic melanoma (17% response rate in evaluable patients) and merits consideration of further study in combination regimens.

Computed tomography in the management of soft tissue tumors

Forty-six patients with primary soft tissue sarcomas underwent computed tomographic evaluation. Among 21 patients with retroperitoneal sarcomas, computed tomography was misleading in three patients and accurate and helpful in 18 patients. It was also useful in detecting recurrence by follow-up scanning and determining response to chemotherapy. Among 16 patients with tumors of the extremity, computed tomography demonstrated clinically helpful findings in only two patients and was misleading in two others. Computed tomographic scans were helpful and accurate in evaluating six sarcomas involving the trunk and abdominal wall. Computed tomographic scans were more accurate than ultrasonography or xeroradiography when patients had both imaging modalities. Computed tomographic scans should not supplant clinical examination for tumors of the extremity but are valuable in the preoperative evaluation of sarcomas arising at other sites. They are also valuable in the postoperative follow-up study of patients and may detect a recurrence prior to clinical examination.

Estrogen receptors in primary breast cancer

Estrogen receptor (ER) activity was assayed in 132 patients undergoing mastectomy for primary breast cancer and in 75 patients whose initial treatment for metastatic cancer was endocrine manipulation. Estrogen receptor status correlated with response to endocrine therapy. Among patients whose ER activity was assayed in the primary tumor, ER-positive patients had an improved disease-free survival (independent of stage or nodal or menopausal status) after mastectomy when compared with ER-negative patients (P less than .05). The ER-positive and ER-negative patients receiving adjuvant chemotherapy had similar disease-free survivals. These data confirm that patients with ER-positive primary tumors have a better prognosis than patients with ER-negative primary tumors. Although adjuvant chemotherapy improves the prognosis in patients with histologically positive lymph nodes in both ER-positive and ER-negative patients, the disease-free survivals in ER-negative patients may improve to a greater extent than in ER-positive patients.

Effects of dopamine agonists and antagonists on murine melanoma: correlation with dopamine binding activity

The biosynthetic pathway melanin is present in many melanomas. Previous investigations have suggested that pharmacologic levels of intermediates in this pathway (L-dopa, dopamine, and their analogues) may inhibit macromolecular synthesis in some tissue culture melanoma cell lines and prolong survival in tumor-bearing mice. Recently, a potent antidopamine drug (pimozide) has been developed. This study was designed to investigate the effects of these drugs on murine melanomas and to correlate effects on macromolecular synthesis with competitive dopamine binding activity (receptors) and melanin synthesis. Three murine melanomas (F1, F10, B16) were studied. The amelanotic B16 cell line showed no inhibition by dopa, dopamine, or pimozide when assayed for 14C-leu or 3H-TdR incorporation. Using a competitive binding assay, only low levels of dopamine binding were present. The very melanotic F1 cell line showed no inhibition by dopa or dopamine, but pimozide inhibited 14C-leu and 3H-TdR incorporation in a dose-response fashion; 50% inhibition was noted at 10(-9) M concentration with no loss in cell viability as tested by trypan blue exclusion or cell counting. Competitive dopamine binding was present (19 pmoles per g of wet tissue) with a Kd of 0.2 nM, figures approximating those seen in normal dog caudate nucleus controls. The F10 line, with melanin production between the B16 and F1, was intermediate in terms of inhibition of 14C-leu and 3H-TdR incorporation and dopamine binding. Purified melanin did not bind and, thus, does not appear to explain these binding results. These data suggest that pimozide, a drug which is a potent dopamine antagonist, may inhibit 14C-leu and 3H-TdR incorporation in murine melanoma cells and that competitive dopamine binding (receptor) appears to correlate with this inhibition. This drug and the dopamine binding assay may be useful in the study of human melanoma.

Medical adrenalectomy in patients with advanced breast cancer

Medical adrenalectomy, consisting of aminoglutethimide plus either dexamethasone or hydrocortisone, was administered to 53 women with advanced breast cancer. Sixteen (30%) patients had an objective response, five patients had stabilization of disease, 26 patients demonstrated progression of disease, two patients did not adhere to protocol, and four patients had severe toxicity necessitating discontinuation of the drugs. Medical adrenalectomy accurately predicted response to subsequent surgical adrenalectomy in 23 patients. Estrogen receptor (ER) data accurately predicted response (eight of nine (89%) ER-positive patients responded) or failure (only two of 14 (14%) ER-negative patients responded) to medical adrenalectomy. Thirty (of 51 women adhering to protocol) had no toxicity. Therefore, it appears that medical adrenalectomy is safe, usually well tolerated, and can accurately predict response to surgical adrenalectomy. Its use should be limited to ER-positive patients, and it may totally supplant surgical adrenalectomy in the management of advanced breast cancer.

Pancreatic and periampullary carcinoma. Experience with 200 patients over a 12 year period

The operative management of 200 patients with pancreatic and periampullary cancer was reviewed. Patients with metastatic disease and biliary obstruction are best treated by the nonoperative techniques of biopsy and internal biliary drainage if technically feasible. For patients who undergo exploration and are found to be candidates for a bypass procedure, both biliary and gastroduodenal bypass should be performed. Lymph node involvement and age of the patient were found to be significant variables in determining the candidates suitable for curative resection. A definite incidence of multicentricity was found in patients undergoing total pancreatectomy for ductal carcinoma of the pancreas; however, significant problems with diabetic management arose from this procedure. The primary site of the lesion as well as the intelligence and socioeconomic background of the patient should dictate the type of resection employed. Pancreatoduodenectomy (Whipple procedure) is recommended for periampullary cancers other than pancreatic carcinoma, while total pancreatectomy may be appropriate in selected patients. However, there has been no evidence thus far in this early trial with total pancreatectomy that more complete resection of the pancreas leads to longer survival.

Risk of subsequent contralateral breast carcinoma in a population of patients with in-situ breast carcinoma

One hundred ninety-one cases of unilateral noninvasive breast carcinoma were studied with regard to the development of subsequent cancers in the contralateral breast. The majority of patients were treated by mastectomy and have been followed for an average of nine years. Their overall survival did not differ significantly from that of age-specific population survival figures for U. S. women. Among all cases, 13 or 6.8% subsequently developed contralateral carcinoma; 3.1% of these contralateral tumors were invasive. The authors found only one histological type, namely lobular carcinoma in-situ for which the development of subsequent contralateral carcinomas was statistically significant. Seven of the 68 women with this type developed second breast cancers (10.3%; 4.4% of these were invasive). These data suggest that the occurrence of clinically apparent subsequent cancers developing in the opposite breast following the diagnosis of in-situ carcinoma is relatively small.