Plasmacytoma of the breast. A report of two cases diagnosed by aspiration biopsy

BACKGROUND

Extramedullary plasmacytoma of the breast is an uncommon neoplasm, occurring either as a solitary tumor or as evidence of disseminated multiple myeloma.

CASE

Two cases of plasmacytoma of the breast were diagnosed by fine needle aspiration cytology. Aspiration smears showed a dispersed population of plasmacytoid cells with eccentric nuclei, abundant cytoplasm and the characteristic paranuclear hof.

CONCLUSION

The clinical, cytologic and immunophenotypic features of plasmacytoma are characteristic, and the importance of distinguishing these neoplasms from primary mammary tumors is important to avoid unnecessary surgery.

Fine-needle aspiration cytology of spindle cell lesions of the breast

BACKGROUND

Fine-needle aspiration biopsy (FNA) has been successful in diagnosing epithelial lesions of the breast. Its role in the evaluation of spindle cell and mesenchymal lesions of the breast, which include a variety of benign and malignant conditions, is less clear. This article discusses the cytologic features and differential diagnosis of these lesions, as well as the potential diagnostic pitfalls associated with them.

METHODS

FNAs of the breast, in which a spindle cell or mesenchymal component was a key or dominant feature, were retrieved. Fibroadenomas without cellular stroma and typical lipomas were excluded.

RESULTS

Forty-six aspirates (0.87%) in a series of 5306 breast FNAs contained a significant spindle cell or mesenchymal component. The aspirates were classified into 4 categories: 1) reactive conditions, including 2 diabetic mastopathies, 3 granulation tissue specimens, and 7 granulomatous lesions; 2) benign neoplastic conditions, including 1 mammary hamartoma, 1 dermatofibroma, 1 fibromatosis, 2 granular cell tumors, 2 angiolipomas, and 7 cellular fibroadenomas; 3) low grade malignant neoplastic lesions, including 10 low grade phyllodes tumors; and 4) high grade malignant neoplastic lesions, including 1 metaplastic carcinoma with chondroid stroma, 1 pleomorphic liposarcoma, 2 malignant fibrous histiocytomas, 2 osteosarcomas, and 4 metastatic melanomas. A specific diagnosis was rendered in 38 cases (82.6%). The mammary hamartoma was diagnosed as fibrocystic changes; the dermatofibroma as benign spindle cell lesion, not otherwise specified (NOS); and the primary osteosarcoma as an atypical spindle cell proliferation, NOS. The reactive ductal epithelial cells in one of the granulomatous mastitis specimens, as well as the hyperplastic ductal epithelial cells in one of the phyllodes tumors, were interpreted as atypical ductal proliferation. The marked cytologic atypia displayed by one granular cell tumor was interpreted as low grade adenocarcinoma and the primary liposarcoma as poorly differentiated carcinoma.

CONCLUSIONS

Breast lesions with a significant spindle cell or mesenchymal component are rarely encountered in FNA and constitute a heterogeneous group that may pose a diagnostic dilemma. FNA should be the initial diagnostic procedure for investigating these lesions, as a specific diagnosis was rendered in the majority of cases. Cancer (Cancer Cytopathol)

Fine-needle aspiration cytology of renal-cell adenocarcinoma metastatic to the breast: A report of three cases

Metastases to the breast from extramammary primary malignancies, including renal adenocarcinoma, are rare. Fine-needle aspiration biopsy (FNA) is a useful, noninvasive, and rapid procedure to evaluate these mammary lesions. This study describes the cytomorphology of 3 cases of renal-cell adenocarcinoma metastatic to the breast. All patients had a prior history of renal-cell adenocarcinoma treated with radical nephrectomy, and they presented with a solitary mammary mass. The cytologic findings showed irregular clusters and dispersed single cells with eccentric nuclei and abundant, vacuolated cytoplasm in a hemorrhagic background. The nuclei were round to oval, with fine granular chromatin and a single, prominent nucleolus. All aspirates were interpreted initially and correctly as consistent with metastatic renal-cell adenocarcinoma. In summary, a cytologic diagnosis of renal-cell adenocarcinoma metastatic to the breast can be made by correlating clinical and cytologic findings. The distinction between metastatic extramammary malignancies to the breast and primary mammary carcinoma is critical to avoid unnecessary surgery and to ensure appropriate chemotherapy or radiation therapy.

Fine-needle aspiration cytology of Rosai-Dorfman disease of the breast: A case report

We report the cytologic findings of a case of Rosai-Dorfman disease of the breast in a 52-year-old diabetic woman, initially sampled by fine-needle aspiration biopsy (FNA). The patient presented with a 2-week history of a 3 x 2 cm nodule in the mid-upper area of the left breast. A mammogram taken 6 months prior was negative. FNA smears demonstrated lymphocytes, plasma cells, and large pale cells, with enlarged irregular nuclei, admixed with fragments of fibrous tissue and calcific debris. Lymphophagocytosis (emperipolesis) was scarce. Our diagnosis was atypical lymphohistiocytic proliferation. Flow cytometry was negative, but in the face of a strong clinical suspicion of a lymphoid malignancy, excision was performed. The final diagnosis was Rosai-Dorfman disease (RDD). The differential diagnosis of FNA of breast inflammatory lesions with atypical cytology is discussed, with a review of the literature. The early recognition on FNA of the hallmarks of this rare disease should prevent unnecessary radical surgery. Diagn. Cytopathol. 1999;21:287-291.

Fine-needle aspiration cytology of hemangiopericytoma: A report of five cases

BACKGROUND

Hemangiopericytoma (HPC) is a relatively rare neoplasm, accounting for approximately 2.5% of all soft tissue tumors. Its histopathology has been well documented but to the authors' knowledge reports regarding its fine-needle aspiration (FNA) cytology rarely are encountered. In the current study the authors report the cytologic findings in FNA specimens from nine confirmed cases of HPC and attempt to correlate the cytologic features with the biologic outcomes.

METHODS

FNA was performed with or without radiologic guidance. Corresponding sections of tissue were reviewed in conjunction with the cytologic preparations.

RESULTS

Nine FNAs were performed in 5 patients (3 men and 2 women) with an age range of 38-77 years (mean, 56 years). Two lesions were primary soft tissue lesions arising in the lower extremities; seven were recurrent or metastatic lesions from bone (one lesion), kidney (one lesion), pelvic fossa (one lesion), lower extremities (two lesions), trunk (one lesion), and breast (one lesion). All aspirates were cellular and were comprised of single and tightly packed clusters of oval to spindle-shaped cells aggregated around branched capillaries. Basement membrane material was observed in 6 cases (67%). The nuclei were uniform and oval, with finely granular chromatin and inconspicuous nucleoli in all cases except one. No mitotic figures or areas of necrosis were identified. A correct diagnosis of HPC was made on one primary lesion and all recurrent or metastatic lesions.

CONCLUSIONS

HPCs show a spindle cell pattern in cytologic preparations and must be distinguished from more common spindle cell lesions. The presence of branched capillaries and abundant basement membrane material supports a diagnosis of HPC. Immunohistochemistry and electron microscopy performed on FNA samples may be helpful in the differential diagnosis. FNA is a useful and accurate tool with which to confirm recurrent or metastatic HPC; however, prediction of the biologic behavior of HPC based on cytologic features is not feasible. Cancer (Cancer Cytopathol)

The influence of margin width on local control of ductal carcinoma in situ of the breast

BACKGROUND

Ductal carcinoma in situ is a non-invasive carcinoma that is unlikely to recur if completely excised. Margin width, the distance between the boundary of the lesion and the edge of the excised specimen, may be an important determinant of local recurrence.

METHODS

Margin widths, determined by direct measurement or ocular micrometry, and standardized evaluation of the tumor for nuclear grade, comedonecrosis, and size were performed on 469 specimens of ductal carcinoma in situ from patients who had been treated with breast-conserving surgery with or without postoperative radiation therapy, according to the choice of the patient or her physician. We analyzed the results in relation to margin width and whether the patient received postoperative radiation therapy.

RESULTS

The mean (+/-SE) estimated probability of recurrence at eight years was 0.04+/-0.02 among 133 patients whose excised lesions had margin widths of 10 mm or more in every direction. Among these patients there was no benefit from postoperative radiation therapy. There was also no statistically significant benefit from postoperative radiation therapy among patients with margin widths of 1 to <10 mm. In contrast, there was a statistically significant benefit from radiation among patients in whom margin widths were less than 1 mm.

CONCLUSIONS

Postoperative radiation therapy did not lower the recurrence rate among patients with ductal carcinoma in situ that was excised with margins of 10 mm or more. Patients in whom the margin width is less than 1 mm can benefit from postoperative radiation therapy.

A prospective comparison of stereotaxic fine-needle aspiration versus stereotaxic core needle biopsy for the diagnosis of mammographic abnormalities

BACKGROUND

Confidence in a negative stereotaxic breast biopsy result allows for safe clinical and mammographic follow-up, whereas a positive or equivocal diagnosis leads to excision. Direct comparison of stereotaxic core needle biopsy (SCBX) and fine-needle aspiration (SFNA) is needed, and should be based on the use of appropriate current methods of practice, and address the indication of each for different types of mammographic lesions.

METHODS

The diagnostic accuracy of SFNA, SCBX, and combined SFNA with SCBX performed at a community radiology practice were assessed for different mammographic lesions and levels of radiologic suspicion. Negative predictive values (NPVs) measured the confidence that a negative diagnosis (failure to identify atypia or malignancy) was benign and therefore suitable for follow-up. A benign outcome was accepted only after surgical excision or > or =24 months' follow-up of the lesion. Positive predictive values (PPVs) [final diagnoses at least atypical (A) or carcinoma (CA)] also were calculated.

RESULTS

SFNA was performed for 495 lesions and was combined with SCBX for 252 of these. Nondiagnostic (SFNA, 2%; SCBX, 8%) and atypical (SFNA, 7%; SCBX, 3%) rates were low. The authors obtained 94% follow-up (81% > or = 24 months). NPVs were all SFNAs, 99%; SCBXs, 95% (corresponding SFNAs, 98%); and SFNA with SCBX, 99%. NPVs were 100% for masses, ill-defined densities, and architectural distortions. NPVs for microcalcifications (for low, moderate, and high suspicion) were all SFNAs, 97% (100, 95, and 75); SCBXs, 93% (94, 93, and 67), corresponding SFNAs, 96% (100, 94, 75); and SFNA with SCBX, 98% (100, 97, 75). All false-negative lesions were microcalcifications. Calcium was recognized in 98% of SFNA specimens and in 89% of SCBX specimens from microcalcifications. No calcium was identified in the histologic sections in 63% (5 of 8) SCBX false-negative specimens. PPVs(A) were atypical (SFNA, 46%; SCBX, 88%) and suspicious (SFNA, 93%). PPVs(CA) were SFNA carcinoma, 100%; SCBX in situ, 89%; and SCBX invasive, 100%.

CONCLUSIONS

SFNA identified benign lesions more reliably for follow-up, particularly microcalcifications. Based on these results, the authors suggest 1) added SCBX if on-site SFNA assessment is nondiagnostic, atypical, or positive (and needs preoperative confirmation of invasion); 2) either SCBX or SFNA for masses, architectural distortions, and ill-defined densities; 3) SFNA for microcalcifications, with SCBX added for moderately and highly suspicious lesions; and 4) surgical excision for all highly suspicious microcalcifications.

Radical prostatectomy specimens among Medicare patients in New York State: a review of pathologists' reports

CONTEXT

Gross and microscopic pathologic examinations of radical prostatectomy specimens should result in reports that contain comprehensive information. Such information is important for facilitating adjuvant therapy decisions, assessing treatment interventions, providing patients and their families with estimates of prognosis, and in analyzing clinical outcomes. An important element of the information in radical prostatectomy specimen reports is the tumor status of margins, which is essential for staging.

OBJECTIVES

The purposes of this study were to analyze the gross and microscopic examinations documented in a sample of radical prostatectomy reports and, by doing so, to determine the comprehensiveness of these reports.

METHODS

The pathology reports from 414 charts of male Medicare patients aged 70 years and older who underwent radical prostatectomy in the 3-year period between 1991 and 1993 in New York State were examined. This group included all patients 75 years and older and a random sample of the 1266 patients aged 70 to 74 years who had undergone the procedure during the 3-year time frame. A protocol was used for recording general information from each pathology report as well as data relevant to gross and microscopic examinations.

RESULTS

The results of this study demonstrated an absence of uniformity in reporting protocols, as well as documentation problems in those protocols used. Important information concerning both the gross and microscopic examinations was frequently absent. An important finding of the study was the high level (94.9%) of reporting on the microscopic status of prostate gland margins, which permitted an accurate assessment of margin positivity. Among those cases for which margin status was reported, 54% were found to be tumor positive. This is a significant finding in that it has implications for TNM staging. Such patients have an increased risk of disease progression and have been shown to have the same 5-year mortality rate as patients who have not been treated surgically.

CONCLUSIONS

The study demonstrated a lack of uniformity in the pathology protocols used to describe radical prostatectomy specimens and the frequent absence of important gross and microscopic information. The results of this study also demonstrated a high rate (54%) of margin positivity among elderly men undergoing radical prostatectomy. Based on the results of this study, there is a need for closer attention to the issue of margin positivity. There is also a need for considering the usefulness of standardized reporting that includes elements with proven, putative, or prognostic value.

Stereotaxic aspiration biopsy in the evaluation of mammographically detected clustered microcalcification

BACKGROUND

Stereotaxic fine-needle aspiration biopsy (SFNA) of mammographically detected nonpalpable lesions of the breast provides accurate diagnosis and may eliminate many unnecessary excisional biopsies of areas of microcalcification.

METHODS

SFNA of microcalcification of indeterminate radiologic significance was performed on 125 patients (1991-1994), yielding 130 specimens (2 sites in 2 patients and bilateral aspirations in 3 patients). Stereotaxic localization was performed, and samples from within the area of microcalcification were obtained using 22-gauge needles. Smears stained with a Giemsa-type stain were prepared and studied by a cytopathologist during the procedure to determine the adequacy of each specimen.

RESULTS

Of 130 specimens, 104 (80%) were cytologically benign, 13 (10%) were atypical, 6 (4.6%) were suspicious, and 7 (5.3%) were malignant. All malignant diagnoses were confirmed by subsequent operative biopsy. Follow-up was available in 74 of 104 benign cases (71%): surgical excisions (all benign) in 8 cases and follow-up mammograms at 6 months to 5.8 years in 66 cases (no radiologic change in 64 cases and 2 [1.9%] cases with new radiologic findings [SFNAs of the new radiographic abnormality revealed adenocarcinoma in both]).

CONCLUSIONS

SFNA is a reliable and cost-effective method of evaluating indeterminate microcalcification; however, mammographic follow-up is indicated because of the possibility of subsequent and independent cancers.

Malignant melanoma metastatic to the breast: a report of seven cases diagnosed by fine-needle aspiration cytology

BACKGROUND

Metastases to the breast from extramammary primary tumors are uncommon. Malignant melanoma is one of the most common neoplasms to secondarily involve the mammary parenchyma.

METHODS

Seven cases of malignant melanoma metastatic to the breast diagnosed by fine-needle aspiration biopsy are presented.

RESULTS

The cytologic findings of malignant melanoma metastatic to the breast usually are straightforward on aspiration cytology. However, knowledge of a prior history of melanoma is crucial to make an accurate diagnosis.

CONCLUSIONS

Malignant melanoma metastatic to the breast can be diagnosed reliably by fine-needle aspiration cytology, thus avoiding radical and unnecessary surgery.

Compact cell blocks. Use for body fluids, fine needle aspirations and endometrial brush biopsies

OBJECTIVE

To obtain an ideal cell block wherein the maximal number of cells are displayed within the smallest area on the block surface.

STUDY DESIGN

Cyto-Rich Red (AutoCyte, Inc., Elon College, North Carolina, U.S.A.) is added to fresh cellular sediment in a centrifuge tube at a ratio of 1:1. After two minutes, three to four drops of plasma and topical thrombin (5,000 U/10 mL) is added. The tube is then gently agitated for two minutes, until a gelatinous clot is obtained. The clot is then slid onto a lens tissue on top of paper towels. The lens tissue is folded once over the clot. By gently squeezing the excess fluid from it through the lens tissue into the paper towels, the clot is transformed into a flat, compact, densely cellular aggregate, which is painted with mercurochrome prior to fixation in formaldehyde.

RESULTS

From each of the 495 cases, including 250 body cavity fluids, 170 fine needle aspirates and 75 endometrial brush biopsies, processed with the above protocol, there was a compact cell block containing packed cells or tissue fragments in a clean background devoid of red blood cells.

CONCLUSION

The compact cell block is about 10-20% the size of a conventional cell block, yet more cells are on display, thus reducing the need for deeper cuts and screening time while increasing the efficiency of cytodiagnosis. The compact cell block technique is particularly helpful for endometrial brush biopsies.

Outcome after invasive local recurrence in patients with ductal carcinoma in situ of the breast

PURPOSE

To detail the outcome, in terms of local recurrence, local invasive recurrence, distant recurrence, and breast cancer mortality for patients previously treated for ductal carcinoma in situ (DCIS).

PATIENTS AND METHODS

Clinical, pathologic, and outcome data were collected prospectively for 707 patients with DCIS accrued from 1972 through June 1997.

RESULTS

There were 74 local recurrences; 39 were noninvasive (DCIS) and 35 were invasive. Fifty-one percent of patients with invasive recurrences presented with stage 1 disease; the remainder presented with more advanced disease. Invasive local recurrence after mastectomy was a rare event that occurred in 0.8% of patients. Invasive recurrence after breast preservation was more common and occurred in 7.4% of patients. The 8-year probability of breast cancer mortality after breast preservation was 2.1%, a number that is likely to increase with longer follow-up. The 8-year breast cancer-specific mortality and distant-disease probability for the subgroup of 74 patients with locally recurrent disease was 8.8% and 20.8%, respectively. If only the 35 invasive recurrences are considered as events, the 8-year breast cancer-specific mortality and distant-disease probability was 14.4% and 27.1%, respectively.

CONCLUSION

Invasive local recurrence after breast-preservation treatment for patients with DCIS is a serious event that converts patients with previous stage 0 disease to patients with disease that ranges from stage I to stage IV. These results, however, indicate that most DCIS patients with local recurrence can be salvaged.

Aspiration cytology of signet-ring cell lymphoma. A case report

BACKGROUND

Signet-ring cell lymphoma is a rare subtype of non-Hodgkin's lymphoma, composed of vacuolated cells with a signet-ring cell appearance. We found only two cases that had been reported as diagnosed by fine needle aspiration biopsy.

CASE

A 61-year-old female had signet-ring cell lymphoma diagnosed by computed tomography-guided aspiration biopsy. Smears of aspirates from her retroperitoneal mass contained a population of small to medium-sized, angular lymphoid cells; lymphoglandular bodies; and an abundance of signet-ring cells. The signet-ring cells were negative for cytokeratin and positive for leukocyte common antigen and CD20, a B-cell marker. Monoclonality for lambda light chain determinant was noted, and a diagnosis of signet-ring cell lymphoma of the B-cell type was made. A core biopsy specimen confirmed the diagnosis.

CONCLUSION

Signet-ring cell lymphoma should always be considered in the differential diagnosis of tumors composed of signet-ring cells.

A prognostic index for ductal carcinoma in situ of the breast

BACKGROUND

There is controversy and confusion regarding therapy for patients with ductal carcinoma in situ (DCIS) of the breast. The Van Nuys Prognostic Index (VNPI) was developed to aid in the complex treatment selection process.

METHODS

The VNPI combines three significant predictors of local recurrence: tumor size, margin width, and pathologic classification. Scores of 1 (best) to 3 (worst) were assigned for each of the 3 predictors and then totaled to give an overall VNPI score ranging from 3 to 9. Three hundred thirty-three patients with pure DCIS treated with breast preservation (195 by excision only and 138 by excision plus radiation therapy) were studied with detection of local recurrence as the end point.

RESULTS

There was no statistical difference in the 8 year local recurrence free survival in patients with VNPI scores of 3 or 4, regardless of whether or not radiation therapy was used (100% vs. 97%; P = not significant). Patients with VNPI scores of 5, 6, or 7 received a statistically significant 17% local recurrence free survival benefit when treated with radiation therapy (85% vs. 68%; P = 0.017). Patients with scores of 8 or 9, although showing the greatest relative benefit from radiation therapy, experienced local recurrence rates in excess of 60% at 8 years.

CONCLUSIONS

DCIS patients with VNPI scores of 3 or 4 can be considered for treatment with excision only. Patients with intermediate scores (5, 6, or 7) show a 17% decrease in local recurrence rates with radiation therapy. Patients with VNPI scores of 8 or 9 exhibit extremely high local recurrence rates, regardless of irradiation, and should be considered for mastectomy.

A prognostic index for ductal carcinoma in situ of the breast

BACKGROUND

There is controversy and confusion regarding therapy for patients with ductal carcinoma in situ (DCIS) of the breast. The Van Nuys Prognostic Index (VNPI) was developed to aid in the complex treatment selection process.

METHODS

The VNPI combines three significant predictors of local recurrence: tumor size, margin width, and pathologic classification. Scores of 1 (best) to 3 (worst) were assigned for each of the 3 predictors and then totaled to give an overall VNPI score ranging from 3 to 9. Three hundred thirty-three patients with pure DCIS treated with breast preservation (195 by excision only and 138 by excision plus radiation therapy) were studied with detection of local recurrence as the end point.

RESULTS

There was no statistical difference in the 8 year local recurrence free survival in patients with VNPI scores of 3 or 4, regardless of whether or not radiation therapy was used (100% vs. 97%; P = not significant). Patients with VNPI scores of 5, 6, or 7 received a statistically significant 17% local recurrence free survival benefit when treated with radiation therapy (85% vs. 68%; P = 0.017). Patients with scores of 8 or 9, although showing the greatest relative benefit from radiation therapy, experienced local recurrence rates in excess of 60% at 8 years.

CONCLUSIONS

DCIS patients with VNPI scores of 3 or 4 can be considered for treatment with excision only. Patients with intermediate scores (5, 6, or 7) show a 17% decrease in local recurrence rates with radiation therapy. Patients with VNPI scores of 8 or 9 exhibit extremely high local recurrence rates, regardless of irradiation, and should be considered for mastectomy.

Small renal parenchymal neoplasms: further observations on growth

PURPOSE

To determine the growTH rate and behavior of small (< or = 3.5-cm diameter) incidentally detected renal parenchymal neoplasms.

MATERIALS AND METHODS

Forty renal parenchymal tumors in 37 adult patients (mean age, 65.5 years) were observed with computed tomography (CT) and ultrasound for 1.75-8.5 years (mean, 3.25 years). Surgical removal was performed of 26 tumors proved and graded at pathologic examination. Fourteen tumors with CT criteria of neoplasm are being followed up.

RESULTS

The overall growth rate of neoplasms was 0-1.1 cm/y (mean, 0.36 cm/y). Thirty tumors grew 0.5 cm/y or less and 19 grew very slowly (< or = 0.35 cm/y). No patient developed metastatic disease. Nine (24%) had multiple neoplasms.

CONCLUSION

Most small, incidentally discovered, well-marginated renal parenchymal neoplasms grow slowly and are not an immediate threat to a patient's life. Watchful waiting might be appropriate instead of surgical removal, especially in patients who are elderly or may not survive surgery.

The fate of breast implants: a critical analysis of complications and outcomes

Complications and outcomes were monitored following the implantation of 1655 breast implants over a 15-year period. Smooth, polyurethane, and textured implants were used in a variety of clinical settings. The time course of capsular contracture was analyzed by the Kaplan-Meier method. Regardless of implant type or indication for surgery, the probability of contracture increased with time. Polyurethane-covered implants were associated with a significant reduction in the risk of contracture for at least 7 years following implantation. Smooth and textured silicone implants had contracture rates similar to each other, and the particular type of surface texturing (Biocel versus Siltex) was of no consequence. Contracture was more common following breast reconstruction and implant replacement than after augmentation mammaplasty and was not affected by filler material or implant size. Implant position did not alter the risk of contracture after augmentation; tissue expansion did not affect the risk of contracture after breast reconstruction. Infections were unusual but most common after reconstruction and unrelated to surface texture or filler material. Skin wrinkling was more frequent with saline implants and in the presence of surface texturing. Implant rupture was rare, with an incidence of 1 per 760 implant-years. Implant-associated connective-tissue disease was noted in only one individual, an incidence of 1 per 3801 implant-years.

Extended skin island delay of the unipedicle TRAM flap: experience in 35 patients

A technique to surgically delay a single-pedicle TRAM flap is described. This extended skin island delay essentially divides the unipedicle TRAM flap into two stages separated by 1 week. Experience with this flap in 35 patients is reported. On the basis of this experience, we believe that the extended skin island delayed TRAM flap should be considered a safe and reliable alternative to double muscle pedicle and free tissue transfer in high-risk patients.

Ten-year results comparing mastectomy to excision and radiation therapy for ductal carcinoma in situ of the breast

The 10-year results of 300 patients with ductal carcinoma in situ (DCIS) without microinvasion are reported; 167 treated with mastectomy and 133 treated with excision and radiation therapy. There was a significant difference in disease-free survival at 10 years, in favour of those treated with mastectomy, 98% versus 81% (P = 0.0004). Multivariate analysis confirmed nuclear grade as the only significant predictor of local recurrence (P = 0.02) or invasive local recurrence (P = 0.03) in patients with DCIS treated with excision and radiation therapy. There was no difference in breast cancer-specific survival or overall survival between the two treatment groups.

Predicting axillary node positivity in patients with invasive carcinoma of the breast by using a combination of T category and palpability

BACKGROUND

In spite of the development of numerous new tumor markers, axillary lymph node status continues to be the single most important prognostic variable regarding survival of patients with carcinoma of the breast. This study was undertaken to determine whether or not the combination of T category (TNM staging system) and palpability would be a better predictor of nodal positivity than T category alone.

STUDY DESIGN

Clinical and pathologic data were analyzed for 1,554 patients who underwent axillary lymph node dissection as part of their treatment for invasive carcinoma of the breast. Data were analyzed by the primary lesion's T category and whether or not the lesion was palpable.

RESULTS

Five hundred fifty-one (35 percent) of 1,554 axillary node dissections contained metastases. The probability of nodal involvement was significantly higher and the average tumor diameter was slightly, but significantly, larger for palpable T1b, T1c, and T2 lesions when compared with nonpalpable lesions within the same T category (all p values less than or equal to 0.003). The probability of lymphatic tumor emboli or vascular invasion was generally higher for palpable lesions compared with nonpalpable lesions and increased as lesions got larger. The percentage of patients with low nuclear grade and favorable histology was generally lower for patients with palpable lesions compared with those having nonpalpable lesions and decreased as lesions got larger.

CONCLUSIONS

Nodal positivity was significantly higher for palpable T1b, T1c, and T2 carcinoma of the breast when compared with nonpalpable carcinoma of the breast within the same T category. The combination of T category and palpability was a more accurate predictor of nodal positivity than T category alone.

Prognostic classification of breast ductal carcinoma-in-situ

We present a new prognostic classification designated the Van Nuys classification for ductal carcinoma-in-situ (DCIS). The classification combines high nuclear grade and comedo-type necrosis to predict clinical recurrence. Three groups of DCIS patients were defined by the presence or absence of high nuclear grade and comedo-type necrosis: 1--non-high-grade DCIS without comedo-type necrosis, 2--non-high-grade DCIS with comedo-type necrosis, 3--high-grade DCIS with or without comedo-type necrosis. There were 31 local recurrences in 238 patients after breast-conservation surgery 3.8% (3/80) in group 1, 11.1% (10/90) in group 2, and 26.5% (18/68) in group 3. The 8-year actuarial disease-free survivals were 93%, 84%, and 61%, respectively (all p < or = 0.05). The Van Nuys classification defines three distinct and easily recognisable groups, each of which has a different likelihood of local recurrence if treated with breast conservation.

Fine needle aspiration biopsy of proliferative breast disease

Proliferative breast disease (PBD) is a well-recognized histologic entity that has received increasing attention in the cytologic literature. We have attempted to prospectively identify and subclassify PBD by fine needle aspiration biopsy since 1987 using criteria we developed through our experience. Over 2800 breast FNABs were performed on breast lesions from 1987 to mid-1992; 257 were cytologically diagnosed as PBD with or without atypia. Eighty-four were significantly worrisome clinically to warrant surgical excision. Forty of these were designated PBD without atypia by cytology; 23 (58%) were in agreement with histology; three (8%) were PBD with atypia by histology; five (13%) were cancers; and nine (22%) were nonproliferative. Forty-four cases were designated PBD with atypia; 24 (55%) were in agreement with the histologic diagnosis; 12 (27%) proved to be PBD without atypia; six (13%) were carcinoma; and two (5%) were nonproliferative. After 1991 we employed stricter criteria for PBD, improving on the results from 1991-1992. During this period, there were 53 diagnoses of PBD with or without atypia and 34 were excised. Nine of the 10 (90%) aspirates designated as PBD without atypia were in agreement with histologic findings. The other case was nonproliferative. Fifteen of the 24 cases diagnosed as PBD with atypia were in concordance with histologic findings (63%), one was nonproliferative, seven were PBD without atypia (29%), and one (4%) proved to be carcinoma.(ABSTRACT TRUNCATED AT 250 WORDS)