The pathology of invasive breast cancer. A syllabus derived from findings of the National Surgical Adjuvant Breast Project (protocol no. 4)

Multiple steroid receptors in human breast cancer. III. Relationships between steroid receptors and the state of differentiation and the activity of carcinomas throughout the pathologic features

Histopathologic features (tumor cell density, histological type, and histoprognostic grade) were analyzed in 314 breast cancers investigated for estrogen (E) and progestin (P) receptors (R). The presence of PR is associated with the presence of ER. A relationship was found between the acinoductal differentiation of the lesions and the presence of SR: the more differentiated the carcinoma, the higher the frequency of ER. HPG III carcinomas have the lowest frequency of positive ER and HPG I tumors the opposite: the likelihood of the presence of SRs is inversely correlated with HPG. No statistically significant relationship existed between tumor cell density (TCD) and the presence of ER or ER content. Similar findings were observed for the stromal reaction. The results are discussed with respect to the biological significance of SR and histopathologic features: SR presence could be correlated with (1) a differentiated state of the tumors and (2) a slow rate of cellular replication.

Identification of breast cancer patients with high risk of early recurrence after radical mastectomy. II. Clinical and pathological correlations. A report of the Primary Therapy of Breast Cancer Study Group

A prospective study of factors that might be helpful in predicting recurrence of breast cancer during the 2 years after radical mastectomy has been completed in 381 women by the Cooperative Breast Cancer Group (National Cancer Institute). Identification of clinical factors which might be associated with such recurrence has been achieved. A multivariate analysis of the data was oriented toward the identification of clinical factors other than lymph node status that might be simultaneously used to predict recurrence because of the current trend of cancer therapy toward more limited surgery. Degree of differentiation of the tumor, blood vessel invasion, patient age and tumor size were identified as important predictors of recurrence for premenopausal patients and tumor size was identified as important for postmenopausal patients. The addition of axillary lymph node status to these factors, however, made a significant improvement in the prediction equation for both pre- and postmenopausal patients. Studies of this type are of particular value to understand further the biology of breast cancer which is necessary to develop rational primary and adjuvant treatment strategies.

Correlation of carcinoembryonic antigen in tissue sections with spread of mammary carcinoma

An immunoperoxidase technique for the histological demonstration of Carcinoembryonic Antigen (CEA) was applied to paraffin sections from 74 breast carcinomas and 43 benign breast lesions. Sixty-six per cent of the carcinomas and the only case of granular cell myoblastoma examined were CEA positive. Two examples of mammary dysplasia (7%) showed foci of CEA positive acini. All tumour tissue found in lymphatics and in metastases in lymph nodes was CEA positive, including two cases where the primary tumour was CEA negative, and all the metastases examined from CEA positive tumours. A significant relationship was found between CEA positivity of the primary tumour and the presence of lymph node metastases.

Tubular carcinoma of the breast

Retrospective pathologic review of 636 breast carcinomas from 611 patients revealed twelve tumors which were pure low grade tubular carcinoma (TC) and nineteen tumors with features combining both low grade tubular carcinoma and invasive duct carcinoma (T&D). A control group of 23 cases consisted of invasive duct carcinoma with at least a third of the tumor surface area showing tubular formation, but without the low grade features of tubular carcinoma. Life table analysis at 15 years showed a 100%, 72%, and 33% survival for TC, T&D, and controls, respectively. Eight percent of TC and 21% of T&D had axillary metastases compared to 67% for controls. Axillary metastases had no detrimental effect on TC or T&D survival. There were no recurrences in the TC group. Patients with T&D with tumor diameter 1.0 cm or less with 50% or greater low grade tubular carcinoma component are alive and well. The mean age of T&D was 7 years greater than TC. The combined TC and T&D group showed a significant incidence of multiple cancers in the ipsilateral breast and a significant trend toward bilateral cancers when compared to controls. Tubular carcinoma has an inherently low malignant potential with a histological and biological spectrum.

Detection and significance of occult axillary node metastases in patients with invasive breast cancer

Blocks of axillary lymph nodes from 78 patients with invasive breast cancer, which after "routine" pathological examination were regarded as negative for metastases, were step-sectioned at 20 u intervals. Occult metastases were detected in 24% of the cases. A significant association between such metastases and a lack of or slight degree of an intraductal carcinomatous component of the dominant cancer was noted. There was no relationship between occult metastases and 15 other histopathological and 3 clinical features investigated, including an average 5 year survival rate. Similarly there was no correlation between any of the possible discriminants investigated in the 24% of patients who have died of their diseases or are living with recurrence regardless of the presence of occult metastases. Factors accounting for the lack of universal survival in patients with Stage I (and those with occult metastases that might be designated as stage 11/2) remain enigmatic. It is concluded that attempts to detect occult metastases by extending histopathological methods may be more academic than practical or therapeutically significant.

A status report on the management of solid tumours

Progressive improvements in the management of certain paediatric and haematological malignancies have provided guidelines for the current approaches to the management of the more common solid tumours of adults. These include precise histopathological grading; comprehensive evaluation of extent of disease; staging classifications accurately correlated with prognosis and progressive evaluation of available therapeutic modalities for all stages of disease in an attempt to define the best combination of local and systemic forms of therapy. Breast cancer is reviewed in detail as an example of the more responsive tumours where screening programs; improvements in pathological and clinical staging and the introduction of systemic chemotherapy together with optimal use of other methods of treatment for the various stages of disease gives hope for a significant improvement in long term survival statistics. Lung cancer has also been reviewed as an example of the more resistant types of cancer where screening programmes and current therapy including the use of combination chemotherapy have given minor encouragement but not had a definite influence on long term survival. Some further gains may still be achieved with currently available techniques but major improvements will probably require the development of better therapeutic tools including radiotherapy with high linear energy transfer particles; new chemotherapeutic agents and specific forms of immunotherapy. It is also quite possible that completely different forms of therapy for these resistant tumours will be necessary to reach the desired goal of long term improvements in survival.

Amyloid stroma in a tubular carcinoma of palatal salivary gland: a histochemical and ultrastructural study

Amyloid as defined by positive Congo red green birefringence and STB red birefringence was observed in the stroma of a tubular carcinoma of minor salivary gland origin. The amyloid exhibited additional histochemical characteristics of immunamyloid, viz., positive DMAB-nitrate and DC-reactions and spontaneous autofluorescence. Electron microscopic studies of the epithelial tumor cells displayed large amounts of cytoplasmic microfilaments similar to those present in the extracellular amyloid masses. It is suggested that the amyloid is derived from spontaneous assembly or polymerization of cytoplasmic microfibrils of the dying tumor cells as has been proposed for the amyloid associated with the calcifying epithelial odontogenic tumor (CEOT).

Inflammatory carcinoma of the breast

Fifty-eight patients with clinical inflammatory breast carcinoma and 15 patients with "occult" inflammatory cancer (dermal lymphatic carcinomatosis without clinical inflammation) are grouped and reviewed to determine whether diagnosis is pathologic or clinical. All cases represent a retrospective study of records from the Ellis Fischel State Cancer Hospital, Columbia, Missouri. Lesions of clinically apparent and occult inflammatory carcinoma demonstrate similar gross and microscopic growth patterns, histologic types, axillary involvement and early widespread metastases. Regardless of pathologic evidence of dermal lymphatic tumor, patients with clinical inflammation had rapid deterioration. Cases with only a pathological diagnosis were slightly less fulminant in progression. Either clinical or pathologic criteria justify use of the term "inflammatory breast carcinoma" to indicate short-term prognosis despite available treatment.

Histologic classification of pure primary epithelial breast cancer

Current classifications of breast cancer are based on either morphologic descriptive or histogenetic criteria. The positive features and shortcomings of the most commonly used systems are presented. Our knowledge of breast cancer leads validity to a histogenetic topographic classification, a modification of which is suggested.

Squamous carcinoma of the breast

Two cases of primary squamous carcinoma of the breast are described. One of the tumours appeared to have an origin in an epidermoid cyst and had a pseudosarcomatous stroma. The other tumour arose from metaplastic ductal epithelium. A review of the literature is given.

Comparison of the classification by microscopic level (stage) of malignant melanoma by three independent groups of pathologists

The ability of groups of pathologists to classify and stage malignant melanoma varies with their familiarity with the new nomenclature proposed for that process. Primary lesions of malignant melanoma from 79 patients were independently examined and classified by community pathologists, university pathologists, and a referee pathologist all without access to each others diagnoses. The diagnoses of these groups were compared for agreement in variety of melanoma as well as depth of dermal penetration (stage or level). Greatest success (agreement with the referee) of both the community pathologists and the university pathologists was achieved when assessment of level of invasion (+/- 1) of the referee was compared (community pathologists = 94% +/- 12% agreement, university pathologists = 99% +/- 2% agreement). Our survey demonstrates that only a relatively small number of community pathologists (23%) employ the new nomenclature, but they do so with a facility equal to that of the university pathologists. Based upon this study and our continuing experiences, we recommend the review of all primary lesions of malignant melanoma by a pathologist or group experienced in the diagnosis and microscopic staging of the disease.

Breast metastasis: an unusual manifestation of a malignant carcinoid tumor

A metastasis from a bronchial carcinoid tumor presented as an isolated breast mass in a 58-year-old female. A review of the English literature revealed four cases of metastatic carcinoid to the breast that presented as an isolated breast mass. In each case, radical mastectomy was performed after the lesion had been interpreted clinically and pathologically as a primary carcinoma. When the primary tumor was excised, all cases had either regional lymph node or liver involvement. A mass was the usual presenting sign of the metastatic deposit. No metastasis was reported to be greater than 2 cm in diameter. No axillary lymph nodes were reported to contain tumor. Frozen section preparations may not be adequate to differentiate a primary carcinoma of the breast from a metastatic carcinoid tumor, thereby necessitating permanent sections, special stains, review of previously resected neoplasms, or electron microscopy. The first mammogram of a metastatic carcinoid to the breast is reported with this case.

Low incidence of estrogen receptor in breast carcinomas with rapid rates of cellular replication

The results of assay for estrogen receptor (ER) in the tumor cytosol and thymidine labeling indices (TLI) of 63 primary invasive carcinomas of the breast were analyzed. The ER assay was performed by using dextran-charcoal to adsorb unbound tritiated estradiol-17beta (E2) in cytosol. The TLI was measured as the number per hundred of neoplastic cell nuclei labeled by tritiated thymidine. A significant association between low TLI and presence of ER was found. Wereas all 19 tumors with TLI less than 2.5 contained ER in the primary lesion or in axillary metastases and ER was found in 25 of 30 tumors with TLI between 2.5 and 10, only 4 of 14 tumors with TLI greater 10 contained ER (p less than 0.001). TLI and saturable binding of E2 were significantly negatively correlated (r=-0.436,P. less than 0.001). It is concluded that dedifferentiation in breast carcinomas is associated with both high TLI and absence of ER, and suggested that the carcinomas with the most rapid proliferative rates will include the highest proportion of tumors unresponsive to hormonal therapy.

Tubulolobular invasive breast cancer: a variant of lobular invasive cancer

Attention is directed to an apparently unique form of invasive breast cancer designated as tubulolobular invasive cancer. These neoplasms exhibit small tubules as well as cords of neoplastic cells in a lobular configuration reminiscent of lobular invasive carcinoma. The clinical and pathologic characteristics encountered in 24 examples were statistically compared with those of infiltrating ductal carcinomas without special specific features, pure tubular, and pure lobular invasive cancer. The results of these analyses as well as the morphologic characteristics of these lesions prompt the conclusion that this lesion represents a tubular variant of lobular invasive carcinoma. Short term treatment failure rates in patients with tubulolobular invasive carcinoma are intermediate between those of pure tubular cancer and lobular invasive carcinoma.

Histologic variants of lipid-secreting carcinoma of the breast

Ten new cases of so-called lipid-secreting carcinomas of the breast are presented. Histopathologic analysis suggests three different microscopical patterns which are all characterized by abundant intracytoplasmic neutral fat deposits. Review of the literature yielded only 15 well-documented cases. Diagnostic problems are emphasized, with special regard to the secretory differentiation of normal and neoplastic mammary cells.

The pathology of breast cancer detected by mass population screening

Breast cancer was detected in 156 of 17,526 asymptomatic women, (8.9/1000), aged 45-64 years, screened by mammography, thermography, and physical examination, Twenty-six percent of 149 pathologically reviewed cases metastasized to axillary nodes. Thirty-six percent of tumors were in situ, minimally invasive, or low grade tubular carcinomas, none of which metastasized. Increased rates of detection were shown for intraductal and tubular types. Frankly invasive ductal and lobular carcinomas had a mean diameter of 2.3 cm., 46% of which had axillary lymph node metastases. Seventy-percent of these were to only one to three nodes, however. Multicentricity with intraductal and lobular carcinoma in situ was frequently observed. Metastatic potential was related to tumor size, degree of stromal invasion, lymphatic permeation, and histologic grade. Few histological parameters other than size could be considered favorable. Forty-two percent of tumors were not palpable, the majority being in situ, minimally invasive, and tubular types. Only five nonpalpable invasive carcinomas metastasized. While the initial results of mass screening appear favorable, prolonged follow-up is needed to determine its impact on the population at risk.

The ultrastructure of tubular carcinoma of the breast

The ultrastructure of four tubular carcinomas of the breast is described. The neoplastic tubules are single layered and lack a myo-epithelial component, an important feature in distinguishing tubular carcinoma from sclerosing adenosis. Numerous myo-fibroblasts are present in the stroma of all four tumours and, since cells of this type have been recorded only occasionally in the stroma of other types of breast carcinoma, it is suggested that they may be a characteristic feature of tubular carcinomas.

The mammographic demonstration of malignant spicules

A specimen of breast tissue containing a carcinoma with multiple spiculations was used as a test object and examined by a range of mammographic techniques. The images were compared with a photograph of the cleared specimen. A quantitative method of evaluating the performance of each technique is described and used to compare these images. Xeroradiography clearly excelled other imaging methods.

Breast reconstruction after mastectomy

Reconstruction of the breast contour and areolanipple complex can be undertaken in patients who have had mastectomy for carcinoma of the breast. Although the reconstructed breast is not normal, the restored contour and simulation is gratifying for those patients who have sought this procedure.

Radionuclides in oncology

Radionuclides already have a major role in the daily practice of oncology and will, undoubtedly, be of even greater importance in the future. The variety of current and potential applications is shown in tab. 1. Their major use at this time is, in the broadest sense, for 'tumour scanning', which includes the evaluation of specific organs for the presence of tumour (usually with different radiopharmaceuticals for each organ) and the entire body (generalized tumour searches with radiopharmaceuticals like 67Ga-citrate or 111In-labeled bleomycin). The clinician uses these agents in the initial evaluation of extent of tumour (staging) and in the subsequent management of the patient with cancer to assess response to treatment, to reveal early relapse, and to assist in making decisions concerning treatment. The other potential roles for radionuclides are also briefly considered in this review.

Carcinoma arising in the wall of a breast cyst during pregnancy

A 23-year-old patient developed a carcinoma in the wall of a breast cyst during the second trimester of an otherwise uncomplicated pregnancy. A review of the literature revealed 7 reported cases of carcinoma of the breast arising in a cyst wall. However, none of these these cases has been associated with pregnancy. The relationship of fibrocystic disease and carcinoma of the breast is discussed. The possible influence of pregnancy and age on the prognosis of this patient are also considered.

Survival of patients with carcinoma of breast without lymph node metastases in relation to the tumor types

Carcinoma of breast radical mastectomy specimens were examined. The tumors were classified in accordance with their morphologic appearance. The tumors were also graded on the basis of their cytological makeup and assigned a cytologic malignancy score (CMS). While the classification of tumors was based on the overall pattern of the tumor, the CMS was arrived at by examining the least differentiated portion of the tumor. The following conclusions were suggested by the study: Patients with tumors with high CMS have a poor prognosis, even in the absence of axillary lymph node metastases. It appears reasonable to suggest that patients without overt metastases, but with high CMS, should be considered for treatment with all therapeutic measures available. Such an aggressive approach to patients with low CMS does not appear to be justified.

Histologic specificity of the effect of age at birth of first child on breast cancer risk

Slides of 531 breast cancers from Glamorgan, Wales, were classified according to the presence or absence of each of three histologic characteristics: stromal infiltration by linear strands of tumor cells, areas of intraductal carcinoma, and areas of lobular carcinoma in situ. The proportion of tumors with each of these characteristics was positively associated with age at first child-birth. Increasing age at first birth had a strong positive effect on the incidence risk of tumors with any of these features, but only a small effect on risk of tumors with none. For parous women, the rate of breast cancer with or without linear strands, with or without areas of intraductal cancer, and without areas of lobular carcinoma in situ was lower than for nulliparous women. Parity appeared not to reduce the risk of tumors with areas of lobular carcinoma in situ.

The possible relationship between mammary dysplasia and breast cancer

The literature concerning a possible association between benign mammary dysplasia and breast cancer is reviewed. Prospective studies confirm a higher increase in the incidence of breast cancer in patients with clinically and biopsy proven benign mammary dysplasia than in those in whom it has not shown to be present. A plea is made for active follow-up of these patients.

The role of radionuclides in clinical oncology

The major role of radionuclides in clinical oncology is, in the broadest sense, "tumor scanning". This includes evaluating specific organs for the presence of tumor (usually with different radiopharmaceuticals for each organ) or the entire body (generalized tumor searches with radiopharmaceuticals with 67Ga-citrate or 111Inlabeled bleomycin). The clinician uses these agents in the initial evaluation of the extent of tumor (staging) and in the subsequent management of the patient with cancer to assess response to treatment, to detect early relapse, and to assist in making decisions concerning treatment. The uses and limitations of the agents currently available for tumor scanning are summarized in this review (by major tumor type) from the perspective of the practicing oncologist. Other potential roles for radionuclides, including use as components of combined modality treatment programs, use as labels for antibodies or as drugs for both diagnosis and treatment, and use in the prediction of response to treatment, which are of great interest now and which will become realities for the oncologist in the future, are also considered.

The problem of discrimination in mammography. Arguments for using a biological test object

A specimen of breast tissue containing a carcinoma with multiple calcifications was used as a test object and examined by a range of mammographic techniques. The images were compared with a photograph of the actual specimen which was cleared and stained for calcium salts. A quantitative method of evaluating the discriminating ability of each technique is described and used to compare these images. Xeroradiography and Kodak Crystallex film clearly excelled other imaging methods. The value of using a biological test object is discussed.

Prognostic factors in mammary carcinoma

The simultaneous prognostic influence of multiple clinical and microscopic features of mammary carcinoma was analysed in 581 women with radical mastectomy. The most important of these features were connected with the extent of the disease in the axillary lymph nodes. In substantial groups of patients, however, a favourable outcome could be predicted from microscopic features of the primary tumour, viz. tubule formation, mitotic frequency and elastosis.