Histological Typing of Breast Tumors

Randomized trial of breast self-examination in Shanghai: final results

BACKGROUND

Among women who practice breast self-examination (BSE), breast cancers may be detected when they are at an earlier stage and are smaller than in women who do not practice BSE. However, the efficacy of breast self-examination for decreasing breast cancer mortality is unproven. This study was conducted to determine whether an intensive program of BSE instruction will reduce the number of women dying of breast cancer.

METHODS

From October 1989 through October 1991, 266,064 women associated with 519 factories in Shanghai were randomly assigned to a BSE instruction group (132,979 women) or a control group (133,085 women). Initial instruction in BSE was followed by reinforcement sessions 1 and 3 years later, by BSE practice under medical supervision at least every 6 months for 5 years, and by ongoing reminders to practice BSE monthly. The women were followed through December 2000 for mortality from breast cancer. Cumulative risk ratios of dying from breast cancer were estimated using Cox proportional hazards models. All statistical tests were two-sided.

RESULTS

There were 135 (0.10%) breast cancer deaths in the instruction group and 131 (0.10%) in the control group. The cumulative breast cancer mortality rates through 10 to 11 years of follow-up were similar (cumulative risk ratio for women in the instruction group relative to that in the control group = 1.04, 95% confidence interval = 0.82 to 1.33; P =.72). However, more benign breast lesions were diagnosed in the instruction group than in the control group.

CONCLUSIONS

Intensive instruction in BSE did not reduce mortality from breast cancer. Programs to encourage BSE in the absence of mammography would be unlikely to reduce mortality from breast cancer. Women who choose to practice BSE should be informed that its efficacy is unproven and that it may increase their chances of having a benign breast biopsy.

Outcome and predictive factors of local recurrence and distant metastases following primary surgical treatment of high-grade malignant phyllodes tumours of the breast

AIM

High-grade malignant phyllodes tumour (MPT) is a rare but aggressive breast malignancy and forms approximately 25% of all phyllodes tumours. The aim of the study was to determine parameters that influence outcome in high-grade MPT.

METHODS

This study consisted of 48 women diagnosed with high-grade MPT. All patients were treated primarily with surgery by local excision (LE, margins <1 cm), wide local excision (WLE, margins > or =1 cm) or mastectomy. Cox's regression was used for multivariate analysis of the data.

RESULTS

The mean patient age was 47 (range 21-85) years and the average tumour size was 7.8 (range 1.5-20) cm. Ten patients were treated with LE, 14 with WLE and 24 with mastectomy. The median follow-up was 9 years (range 5 months-28 years). Local recurrence (LR) occurred in 19 patients (40%) at mean time of 28 (range 5-84) months after primary treatment. Distant metastasis (DM) occurred in 13 (27%) patients at average time of 25.6 (range 6-120) months. LR, subsequent metastatic spread and survival following treatment of MPT were related to tumour size and excision margins, but not to other clinical or histopathological characteristics.

CONCLUSION

Tumour size and surgical margins were found to be the principal determinants of LR and DM. Complete surgical excision, by mastectomy if necessary, is important in the primary surgical treatment of high-grade MPT.

CD34, CD117, and actin expression in phyllodes tumor of the breast

BACKGROUND

This study investigated the immunophenotypic patterns of CD34, CD117 (a product of the c-kit proto-oncogene), and actin (HHF35) in benign and malignant phyllodes tumors (PTs). We correlated the expression of CD34, CD117, and actin with histopathological grade.

MATERIALS AND RESULTS

We analyzed 19 cases (7 benign and 12 malignant cases) of PTs using immunohistochemical analysis. Six of 7 benign PT stromal lesions stained positively for CD34, while only 3 of 12 cases of malignant PT were focally CD34 positive (P = 0.0106). Only 1 of the 7 benign PTs stromal lesions expressed CD117. Nine of the malignant PTs were composed CD117-positive fibroblasts. This result demonstrated that CD117 expression is associated with the malignant potential of PTs (P = 0. 0106). Actin (HHF-35) expression was found in 8 of 12 cases of malignant PTs (P = 0.027), but in only 1 of 7 cases of benign PTs. Actin expression was significantly (P = 0.04) correlated to frequent mitotic activity (>5 mitoses per 10 high-power fields). The immunophenotypic markers were not related to tumor size. Additionally, we sequenced part of the juxtamembrane region of the c-kit proto-oncogene and found point mutations in two malignant PTs.

CONCLUSION

Our results demonstrated that expression of CD34 was associated with benign PTs, while CD117 and actin were preferentially expressed in malignant PTs. Our results implied that these immunohistological markers might be used for the histopathological grading of PTs.

Sonographic and pathologic findings in typical and atypical medullary carcinomas of the breast

PURPOSE

We investigated whether there was a relationship between the sonographic and histologic appearances of medullary carcinomas of the breast to determine whether sonography is helpful in the differentiation of typical and atypical medullary carcinomas.

METHODS

We retrospectively reviewed the histologic slides and sonograms of 20 patients who had been diagnosed with medullary carcinoma of the breast. We then classified the carcinomas as typical or atypical based on strict histologic criteria. We also evaluated the relationship between sonographic findings and the histologic reclassification.

RESULTS

Eight (40%) of the 20 medullary carcinomas were classified as typical, and 12 (60%) were classified as atypical. On sonography, a smooth outline was visualized in 6 (75%) of the 8 typical medullary carcinomas but in none of the 12 atypical carcinomas. A jagged margin was sonographically visualized in 10 (83%) of the 12 atypical carcinomas, and a focal irregularity in the margin was visualized in 2 (17%) of the 12 atypical carcinomas. Four of the typical medullary carcinomas had posterior enhancement, and 9 of the atypical medullary carcinomas showed retrotumoral shadowing. The difference in tumor-margin regularity between typical and atypical medullary carcinomas was found to be statistically significant (p < 0.001) using the 2-tailed Fisher's exact test.

CONCLUSIONS

To prevent overdiagnosis of medullary carcinoma, a thorough pathologic review of the entire tumor is recommended if sonography shows a jagged margin or a margin with focal irregularity.

Elevated steroid sulfatase expression in breast cancers

In situ estrogen synthesis makes an important contribution to the high estrogen concentration found in breast cancer tissues. Steroid sulfatase which hydrolyzes several sulfated steroids such as estrone sulfate, dehydroepiandrosterone sulfate, and cholesterol sulfate may be involved. In the present study, we therefore, assessed steroid sulfatase mRNA levels in breast malignancies and background tissues from 38 patients by reverse transcription and polymerase chain reaction. The levels in breast cancer tissues were significantly increased at 1458.4+/-2119.7 attomoles/mg RNA (mean +/- SD) as compared with 535.6+/-663.4 attomoles/mg RNA for non-malignant tissues (P<0.001). Thus, increased steroid sulfatase expression may be partly responsible for local overproduction of estrogen and provide a growth advantage for tumor cells.

A comparison of cell cycle markers in well-differentiated lobular and ductal carcinomas

Infiltrating lobular carcinoma (ILC) and infiltrating ductal carcinoma (IDC) are similar in many respects and their histologic features occasionally overlap. Despite the many similarities, some clinical follow-up data and the patterns of metastasis suggest that ILC and IDC are biologically distinct. Unfortunately, most breast cancer research has focused almost exclusively on the ductal subtype or has not stressed the biologic or molecular genetic distinctions between breast carcinoma subtypes. Several reports have suggested the possibility that ILCs and IDCs differ with respect to expression of antigens involved in proliferation and cell cycle regulation. Therefore, we undertook an immunohistochemical evaluation of cell cycle related antigens in ILCs, including histologic variants thought to represent aggressive neoplasms, and IDCs matched for histologic grade (Modified Bloom-Richardson Grade I). We believe that different antigen expression profiles could elucidate the biological distinctiveness of breast carcinoma subtypes and possibly provide diagnostically relevant information. We studied the expression of the following antigens in 28 archived, formalin-fixed ILCs and 34 well-differentiated IDCs: estrogen receptor (ER), progesterone receptor (PR), Her 2-neu, mib-1, cyclin D1, p27, p53, mdm-2 and bcl-2. 94% of ILCs and 100% of IDCs expressed ER; 75% of ILCs and 76% of IDCs expressed PR; 4% of ILCs and 13% of IDCs expressed c cerb B-2; ILCs and IDCs both expressed mib-1 in approximately 10% of lesional cells; 82% of ILCs and 54% of IDCs expressed cyclin D1; 90% of ILCs and 83% IDCs expressed p27 strongly; 4% of ILCs and 4% of IDCs expressed p53, 25% of ILCs and 33% of IDCs expressed mdm-2; 96% of ILCs and 100% of IDCs expressed bcl-2. None of the apparent differences were statistically significant. The ILC variants demonstrated immunophenotypes that were essentially similar to ILCs of the usual type. We conclude that ILCs and well-differentiated IDCs show similar proliferation and cell cycle control antigen profiles. Despite their unusual histologic features, most ILC variants appear to maintain a characteristic ILC immunophenotype.

FDG PET evaluation of mucinous neoplasms: correlation of FDG uptake with histopathologic features

OBJECTIVE

Our goal was to assess the sensitivity of positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) for the detection of mucinous carcinoma and to determine the histologic features of these tumors that may affect lesion detectability.

MATERIALS AND METHODS

A retrospective review of all patients with mucinous carcinoma who had undergone FDG PET at our institution from 1995 through 1998 identified 25 patients with new or recurrent mucinous carcinoma at the time of PET. In 22 of these patients, tissue specimens available from either core biopsy or surgical resection allowed detailed histologic analysis.

RESULTS

FDG PET revealed mucinous carcinoma in only 13 (59%) of 22 patients, resulting in an unusually high percentage (41%) of false-negative results. Two histologic features were found to be predictive of FDG PET results: tumor cellularity (p = 0.011) and the amount of mucin within the tumor mass (p = 0.009). There was a positive correlation between tumor FDG uptake and cellularity but a negative correlation with the amount of mucin.

CONCLUSION

FDG PET is limited in the evaluation of mucinous tumors, particularly in hypocellular lesions with abundant mucin.

Phyllodes Tumors of the Breast: A Review of 32 Cases

Most general surgeons involved in breast cancer care have limited experience with phyllodes tumors. We analyzed a comprehensive database incorporating 8567 breast cancer cases treated surgically in the Tulsa, Oklahoma, region between 1969 and 1993. This yielded 32 cases of phyllodes tumors (0.37%) in 31 patients. The median age was 57 years (range, 18–91). There were 9 low-grade (28%), 2 intermediate-grade (6%), and 21 high-grade (66%) lesions. Size distribution consisted of 23 (72%) lesions 5 cm or less and 9 (28%) greater than 5 cm (mean, 3; range, 1.2–17.5 cm). Of 137 resected nodes in 13 patients, none were positive for metastatic disease. Surgical management consisted of wide excision or mastectomy. No patients received adjuvant chemoradiation therapy. The disease-free, locoregional disease-free, and overall mean survival rates were 80, 81, and 97 months, respectively. Ten-year disease-free survival (DFS), locoregional disease-free survival (LRDFS), and overall survival (OS) rates were 66, 72, and 55 per cent, respectively. Although there was a tendency toward a higher rate of locoregional recurrences and metastases with high-grade lesions, this was not statistically significant and did not affect DFS, LRDFS, or OS rates. Similarly, size of lesion did not affect DFS, LRDFS, or OS rates. Three patients (9.6%) had metastatic disease at presentation, and a further two (6.4%) developed metastases during follow-up. Overall, nine (28.1%) recurrences developed in eight patients, seven locoregional and two distant. Four patients (12.9%) died with evidence of disease. These findings indicate prolonged survival in this patient population with cystosarcoma phyllodes. Wide local excision of primary and recurrent lesions remains the mainstay of therapy. Neither regional lymph node dissection nor adjuvant chemoradiation adds significant benefit.

Mucinous carcinoma of the breast: a multifaceted study with special reference to histogenesis and neuroendocrine differentiation

Although mucinous carcinoma (MC) of the breast is considered to originate from ductal carcinoma, it is not known whether mucinous growth begins in the intraductal carcinoma or later in the invasive carcinoma. In this study, 33 MC (16 pure without any ductal components, 10 mixed Type I with an intraductal component, seven mixed Type II with a common invasive ductal carcinoma (IDC) component)) were examined to clarify the time when mucinous growth begins. Histochemical and immunohistochemical examinations of mucin revealed that mucinous growth can begin in the intraductal carcinoma and in the common IDC. Histological transition and clonality analysis using microsatellite markers supported that some MC originate from common IDC. The pure type of MC probably originates from the intraductal carcinoma, showing a micropapillary feature. Neuroendocrine differentiation, known to be associated with MC, seemed to create the main progress in the typical MC. Moreover, we analyzed the factors of a worse prognosis of mixed MC Type II, which was strongly suggested by the lymph node status. However, no explainable differences on the cell proliferating ability, or c-erbB-2 and p53 protein overexpression were found.

A Case of Phyllodes Tumor with Bloody Nipple Discharge in Juvenile Patient

We report a rare case of phyllodes tumor of the breast in a juvenile patient with bloody nipple discharge. An 11-year-old girl had a chief complaint of a palpable 5 cm well-circumscribed tumor with nipple discharge in the left breast. The histopathological diagnosis of the resected specimen was benign phyllodes tumor showing extensive areas of hemorrhagic necrosis. The bloody nipple discharge was caused by spontaneous infarction of the tumor. Preoperative ultrasonography and galactography were helpful in evaluating the mechanism of nipple dicharge from the tumor. Although phyllodes tumor must be differentiated from fibroadenoma, the present case was histopathologically identical to phyllodes tumor.

Loss of laminin-5 in the epithelium-stroma interface: an immunohistochemical marker of malignancy in epithelial lesions of the breast

AIMS

To demonstrate immunohistochemically the alpha3 and gamma2 chain of laminin-5 in benign epithelial and malignant lesions of the human breast.

METHODS AND RESULTS

The alpha3 chain was identified by the monoclonal antibody BM165 and the gamma2 chain by GB3 in shock frozen samples using APAAP (alkaline phosphatase monoclonal anti-alkaline phosphatase) technique. The pre-existing breast epithelium, the 12 benign ductal and lobular proliferations and the three fibroadenomas showed a continuous immunostaining in the basement membrane region. In contrast to benign epithelial lesions, the 44 cases of invasive breast carcinoma showed a loss of the laminin-5 chains in more than 50% of the carcinoma stroma interface. Twenty-four out of the 44 invasive carcinomas revealed a complete loss of laminin-5 immunostaining. Focal defects of the laminin-5 immunostaining were also found in ductal carcinoma in situ in its pure form.

CONCLUSIONS

As recently described, the malignant transformation of breast epithelium with expression of an invasive phenotype is associated with a decrease of hemidesmosomes. The reduced immunostaining of laminin-5 is in line with this finding because laminin-5 represents the major component of the anchoring filaments attaching hemidesmosomes to the basement membrane. We feel that immunohistochemical demonstration of laminin-5 may serve as a marker of benignity in epithelial breast lesions. While other carcinoma types exhibit an increased laminin-5 deposition, which has been suggested as an invasion promoting factor, the loss of laminin-5 in breast cancer supports the view that breast carcinomas do not utilize laminin-5 for invasion.

Factors leading to local recurrence or death after surgical resection of phyllodes tumours of the breast

BACKGROUND

Local recurrence and death from metastases are occasional, but consistent, themes in reports of patients with phyllodes tumours. Factors that might contribute to these outcomes were sought.

METHODS

Data from 38 patients with a phyllodes breast tumour were reviewed retrospectively, reclassifying the pathological material using the Pietruszka and Barnes criteria.

RESULTS

At a median of 12 months, nine patients had developed a local recurrence and four had died from metastases. Following local excision in 24 patients (for diagnosis in 13, for 'fibroadenoma' in nine and for phyllodes tumour in two patients), 13 had no further surgery and five had local recurrence (three of eight benign tumours, two of two malignant tumours). Wide local excision or mastectomy in 18 patients was followed by four recurrences (one of eight borderline tumours, three of ten malignant tumours). All patients with recurrence had margin involvement on histological examination, but not all patients with margin involvement developed recurrence. Lack of statistical correlation between local recurrence and age, delay, size, grade or type of surgery was confounded by selection bias for more extensive surgery for malignant tumours. Death correlated with size (P = 0.05) and grade (P = 0.03) of tumour.

CONCLUSION

Inadequate preoperative diagnosis ('fibroadenoma' or failure of triple assessment) frequently led to local excision with positive margins. Without revision this often resulted in local recurrence. Local recurrence of any grade was usually followed by further recurrence. Death was related to tumour size and histological grade, confirming these as prognostic factors.

Cyclin-dependent kinase inhibitor p27Kip1 expression and interaction with other cell cycle-associated proteins in mammary carcinoma

p27, cyclin D1, and retinoblastoma (Rb) protein have been demonstrated using immunohistochemistry in 189 cases of primary breast carcinoma with long-term follow-up. There was a statistically significant association between the expression of p27 and both cyclin D1 and the retinoblastoma gene product (pRb), corresponding to their close interactions in regulating the G1/S transition in the cell cycle. Low levels of p27 were seen in high-grade, rapidly proliferating, oestrogen receptor-negative tumours. In univariate analysis, low p27 expression was associated with a reduced relapse-free and overall survival. In multivariate analysis, p27 was not an independent predictor of survival when either histological grade or proliferative activity (S-phase fraction) was included in the model. When the combined expression of p27 and cyclin D1 was related to survival, patients with high levels of p27, regardless of their cyclin D1 status, did well, whilst those with low p27 had a poor outcome. The only exception, in the latter group, was patients with tumours expressing high levels of cyclin D1, who did as well as the high p27 group. We have shown that in clinical material p27 expression is associated with proliferative activity and while univariate analysis shows it to be a significant indicator of prognosis, this significance is lost in multivariate analysis when traditional prognostic factors are included in the model. The interest in p27 expression in mammary carcinoma lies in its behaviour when examined in combination with other G1 cell cycle regulators.

Psychological profile related to malignant tumours of different histopathology

In a previous preoperative study of patients with gliomas, we made the original observation that patients with high grade as opposed to those with low-grade gliomas have a psychological profile marked by extreme emotional reactivity. In this postoperative study of the psychological profiles of patients with breast cancer, the main funding was unexpectedly analogous with the findings in the brain tumour study. The patients with poorly differentiated ductal carcinomas showed a specific and, compared to the patients with well differentiated carcinomas, outstanding psychological profile marked by extreme emotional reactivity as well as by genuine creativity. Some of the present patients with well differentiated carcinomas showed personality profiles marked by compulsive inhibition, also described earlier in the literature of patients with breast cancer. The psychobiological relations between emotional reactivity and aggressiveness of tumour growth are discussed.

Pure mucinous carcinoma of the breast: a clinicopathologic correlation study

BACKGROUND

Pure mucinous carcinoma (PMC) of the breast has a better prognosis than does invasive ductal carcinoma not otherwise specified and is more prevalent in older patients. We investigated the correlation between prognostic indices and clinical outcome in this histologic subset.

METHODS

A retrospective review was done of patients with PMC treated between 1989 and 1996. Demographic data, pathologic indices of prognosis, axillary nodal status, and outcome were assessed.

RESULTS

Out of 6083 cases of breast carcinoma, 30 were PMC. Only 3 of 25 (12%) axillary dissections were positive. The average age of the group with positive nodes was 57 years, as compared to 69.5 years (95% CI; 63.24-75.76) in the group with negative nodes. All the tumors with positive nodes were aneuploid and had a high nuclear grade, compared to a 31.25% aneuploidy rate in the group without nodal disease (P = .058). Negative ER receptors were found in only 2 of 20 (10%) of the patients tested. Both had axillary disease (P = .016). Tumor size did not correlate with axillary metastasis. Two of the 29 patients died from unrelated diseases. The other 27 patients are alive with no evidence of disease.

CONCLUSIONS

Axillary nodal disease is rare in PMC and correlates with a younger age, aneuploidy, high nuclear grade, or a negative ER receptor status. Sentinel lymph node biopsy may help identify the need for axillary dissection.

Phyllodes Tumor of the Breast with a Grossly Malignant Appearance: A Case Report

A huge phyllodes tumor of the breast that appeared grossly malignant in a 43-year-old woman is described. The patient suffered from a large breast tumor thatsuddenly increased in size over 5 months to occupy the entire breast. The tumorwas hard, ulcerated and 20 cm in greatest diameter. Diagnostic imaging(US, CT and MRI)demonstrated a circumscribed mass with a large cystic cavity. She underwent total mastectomy under a diagnosis of malignant breast tumor. Grossly, the cut surface of the tumor showed a large cystic cavity surrounding a fleshy, hemorrhagic and necrotic mass with a lobulared or trabeculared appearance. Unexpectedly, benign phyllodes tumor(PT)without any stromal overgrowth was diagnosed histologically. She has been doing well since total mastectomy. In our case and in many other reported cases, PT does not show any distinctive correlation between pathologic findings and tumor behavior. Thus wide local excision is the preferred initial treatment for PT.

The extent of surgery and prognosis of patients with phyllodes tumor of the breast

In an attempt to clarify the controversial issues related to prognosis and therapeutic aspects of phyllodes tumors (PT), we retrospectively reviewed all cases of PT treated in our hospital during the last fifteen years. Re-examining the pathology material we found 84 cases, while thirteen more cases which had been initially classified as fibroadenomas with areas of phyllodes tumor were rejected from the analysis because they were classified as fibroadenomas. Based on the criteria proposed by Azzopardi and Salvadori and adopted by WHO, we found 55 benign PT (65.14%), 14 borderline PT (16.6%), and 15 malignant PT (17.8%). The median age of the patients with benign PT was 34 years, compared to 46.5 years for those with borderline tumors and 52 years for those with malignant. The median size of benign tumors was 3 cm, 9.5 cm for borderline, and 7.25 cm for malignant. Out of 55 patients with benign PTs, 37 underwent wide local excision and the remaining 18, with small tumors, underwent enucleation. In this group of patients, there was no recurrence after a median interval of 6.65 years. Eleven patients with borderline PT underwent wide local excision and three mastectomy; one immediately after an incomplete PT excision and the remaining two 8 months and 2 years later due to a locally recurrent PT (the last one proven histologically in the permanent biopsy of the recurrence to be malignant). Twelve patients with malignant PT underwent mastectomy, either during the same operation or following the results of the permanent section biopsy. Three more patients with malignant PT underwent wide local excision. The size of the tumor in these patients was relatively small and the pathology report indicated clear margins with normal breast tissue surrounding the tumor. One patient with 8 cm diameter malignant PT, who underwent mastectomy, passed away sixteen months later from widely spread metastases. Applying the criteria of Azzopardi and Salvadori, each case of PT can be managed successfully avoiding unnecessary mastectomies.

Cyclin gene amplification and overexpression in breast and ovarian cancers: evidence for the selection of cyclin D1 in breast and cyclin E in ovarian tumors

Evidence of the involvement of cyclin genes in genetic alterations in human cancer is growing. In the present study, we investigated the amplification, in human breast and ovarian cancer, of 5 cyclin genes; cyclin A, cyclin D1, cyclin D2, cyclin D3 and cyclin E. For this purpose, a series of 1,171 breast and 237 ovarian tumors tested for DNA amplification by Southern blotting and a subset of 132 breast and 22 ovarian cancers were analyzed for RNA expression levels by slot-blot and Northern blotting. In breast tumors, only cyclin D1 was found to be activated in a sizeable fraction of the tumors (amplification 12.6%, overexpression 19%). Cyclin A, D2, D3, and E genes never, or only on rare occasions, showed increased DNA copy numbers and were never found overexpressed at the RNA level. Amplification of cyclin D1 correlated with ER+ breast cancer and the presence of lymph-node metastasis. Interestingly, we were also able to determine an association with invasive lobular carcinoma. Our data suggest that cyclin D1 activation determines the evolution of a particular subset of estrogen-responsive tumors. Data obtained in ovarian tumors contrasted with observations in breast cancer. Cyclin D1 DNA amplification was much less frequent in ovarian than in breast tumors (3.3% vs. 12.6%), whereas cyclin E amplification and overexpression were observed in a significant number of cases (12.5% and 18.0% respectively). Cyclin A, cyclin D2 and D3 rarely showed anomalies at the DNA level and were never overexpressed. No clear correlation could be observed between amplification of the cyclin E gene and tumor type, stage or grade in ovarian cancer. Data presented here suggest distinct pathways of cyclin activation in human breast and ovarian cancer.

The treatment and prognosis of patients with phyllodes tumor of the breast: an analysis of 170 cases

BACKGROUND

The study addresses the controversial prognostic and therapeutic aspects of phyllodes tumor of the breast.

METHODS

Records of 170 women with phyllodes tumor of the breast were reviewed. On the basis of the criteria proposed by Azzopardi and Salvadori et al., including estimation of tumor margin, growth of the connective tissue component, mitoses, and cellular atypia, the entire series was divided into three histotypes of phyllodes tumor, i.e., benign (92 cases, 54.1%), borderline (19 cases, 11.2%), and malignant (59 cases, 34.7%). Ninety-eight patients (57.6%) were treated by wide local excision (79 benign, 15 borderline, and 4 malignant), 43 (25.3%) by simple mastectomy (13 benign, 4 borderline, and 26 malignant), and 29 (17.1%) by radical mastectomy (all malignant).

RESULTS

Of the 170 treated patients, 141 (82.9%) survived 5 years without evidence of disease. In the Cox multivariate analysis the histotype of the tumor was the only independent prognostic factor: 5-year NED survival was observed in 95.7% of the patients with benign phyllodes tumor, 73.7% with borderline phyllodes tumor, and 66.1% with malignant phyllodes tumor. After a wide local excision 98.7% of the patients with benign tumor, and 80% with borderline tumor, were cured. Local recurrence was found in 14 patients (8.2%) (4 benign, 3 borderline, and 7 malignant); 10 of these underwent reoperation (7 wide local excision, 3 radical mastectomy) and survived 5 years NED.

CONCLUSIONS

The histotype of phyllodes tumor (benign, borderline, and malignant), assessed on the basis of the criteria proposed by Azzopardi and Salvadori et al., was the only prognostic factor in our group of patients. Based on the data from literature and our own observations, we observed that a wide local excision, with an adequate margin of normal breast tissue, is the preferred initial therapy for phyllodes tumor of the breast.

Interpretation of the risk associated with the unexpected finding of lobular carcinoma in situ

BACKGROUND

The risk of developing invasive breast cancer after finding lobular carcinoma in situ (LCIS) is controversially reported in the literature. The surgeon who finds LCIS unexpectedly may be tempted to remove the breast, or even remove both breasts.

METHODS

From 1976 to 1991, 157 consecutive women with palpable or mammographically detected breast lesions underwent surgery to resolve doubt as to the presence of invasive cancer. We report on the women in whom LCIS was found after diagnostic breast surgery and analyze the incidence of breast cancer after a mean 5 years of follow-up in comparison with that in the normal reference population.

RESULTS

Eight patients developed infiltrating breast carcinoma (four ipsilateral, four contralateral as first events), equal to a homolateral rate of 0.00625. The expected rate in the normal reference population is 0.00152; ratio 4.11 (95% confidence interval 1.1-10.5). For a contralateral event the rate ratio is 3.0 (95% confidence interval 0.8-7.6).

CONCLUSION

LCIS is one of many markers for later infiltrating cancer, so patients should be carefully followed. Ablative surgery is not justified.

Allelic imbalance study of 16q in human primary breast carcinomas using microsatellite markers

The high incidence of allelic imbalance on the long arm of chromosome 16 in breast cancer suggests its involvement in the development and progression of the tumor. Several loss of heterozygosity (LOH) studies have led to the assignment of commonly deleted regions on 16q where tumor suppressor genes may be located. The most recurrent LOH regions have been 16q22.1 and 16q22.4-qter. The aim of this study was to gain further insight into the occurrence of one or multiple "smallest regions of overlap" on 16q in a new series of breast carcinomas. Hence, a detailed allelic imbalance map was constructed for 46 sporadic breast carcinomas, using 11 polymorphic microsatellite markers located on chromosome 16. Allelic imbalance of one or more markers on 16q was shown by 30 of the 46 tumors (65%). Among these 30 carcinomas, LOH on the long arm of chromosome 16 was detected at all informative loci in 19 (41%); 13 of them showed allelic imbalance on the long but not on the short arm, with the occurrence of variable "breakpoints" in the pericentromeric region. The partial allelic imbalance in 11 tumors involved either the 16q22.1-qter LOH region or interstitial LOH regions. A commonly deleted region was found between D16S421 and D16S289 on 16q22.1 in 29 of the 30 tumors. The present data argue in favor of an important involvement of a tumor suppressor gene mapping to 16q22.1 in the genesis or progression of breast cancer.

p53 protein expression in fine-needle aspirates of breast cancer: an immunocytochemical assay for identifying high-grade ductal carcinomas

The expression of the p53 gene product was investigated immunocytochemically in a series of 51 fine-needle aspiration (FNA) samples of breast carcinomas. Results were compared with those obtained by immunocytochemically on paraffin embedded tissue sections of the corresponding surgical specimens. Cytological samples showed a variable degree of p53 immunoreactivity in 14 tumors (27.6%), all of ductal type, while p53 immunoreactive tumor cells were present in tissue sections from 15 carcinomas (29.4%). The only discordant case was a signet-ring cell carcinoma. Abnormal p53 expression was significantly associated with high nuclear grade in ductal carcinomas. No association was seen with tumor size, lymph node status, and age of the patient. Detection of p53 altered expression in FNA samples of breast carcinoma may play a role in the assessment of tumoral grading and is predictive of p53 immunoreactivity in histological specimens.

A Malignant Phyllodes Tumor of the Breast in a 6-Year Old Girl

We recently encountered a 6-year-old girl with a malignant phyllodes tumor of the breast. The patient's mother noticed a tumor on the right breast of her first doughter at 8 months after from her birth. The baby was brought to the Second Depertment of Surgery, University of Tokushima, at age 20 months. We recommended removal of the 3.5 x 2.9 cm tumor in the right breast, but it was not done. Next, she visited our department at 6 years of age because the tumor had gradually enlarged, reaching a size of 4.3 &timus; 4.0 cm. She underwent excisional resection of the tumor, and the tumor was diagnosed as a malignant phyllodes tumor of the breast coexisting with a borderline phyllodes tumor. To our knowledge, this is the youngest reported case of a malignant phyllodes tumor of the breast. Moreover, the malignant lesion was positive for estrogen receptor (ER) and showed strong proliferating cell nuclear antigen (PCNA) staining. On the other hand, the borderline part was negative for ER and showed weak PCNA staining. Thus, in the present case, the expression of ER, the exposure to estrogen (for example, the mother's estrogen during gestation) and increase in the proliferation rate may have played important roles in the mechanism of the transformation of the phyllodes tumor.

Prognostic factors for survival after breast conserving therapy for stage I and II breast cancer. The role of local recurrence

Risk factors for local recurrence (LR) in a univariate analysis had a significant correlation with survival. Local and distant failure could not be regarded as independent events. We undertook a multivariate survival analysis to study the relation between LR and survival. In a retrospective study of 1026 patients treated with tumorectomy, axillary dissection and radiotherapy, factors associated with disease-specific survival (DSS) were analysed. Actuarial estimates for DSS are 91% at 5 years and 86% at 10 years. The multivariate analysis revealed five factors: clinical stage, number of affected axillary nodes, histological grade, degree of tubule formation and left-sided primary tumour. Controlling for these factors, LR appeared to be significantly correlated with DSS. The hazard rate of DSS was estimated to increase by a factor 8.8 (95% confidence interval 4.6-16.8) upon occurrence of a LR. Local recurrence per se, apart from the identified prognostic factors, is a risk factor for DSS. The exact mechanism by which LR has an influence on survival cannot be clarified from these data.

Non-palpable lesions of the breast detected by mammography--review of 1182 consecutive histologically confirmed cases

We report on 1182 consecutive histologically confirmed non-palpable breast lesions detected by mammography (infiltrating carcinoma 427, in situ carcinoma 121, benign 634). The proportion of cancer cases varied according to age (< 50 years = 33%; 50-59 years = 46%; > 59 years = 63%), mammographic pattern (regular opacities = 8%, parenchymal distortions = 20%, isolated calcifications = 42%, irregular opacities = 62%, stellate opacities = 73%), and calendar period (1970-1985 = 29%, 1986-1989 = 56%; 1990-1992 = 69%). A sharp decrease of the benign/malignant biopsy ratio was evident after routine fine-needle aspiration cytology (sonography-guided or stereotaxic) was introduced in 1986. The independent significant association of cancer frequency to age, calendar period and mammographic pattern was confirmed by multivariate analysis. A significant trend over time in favour of conservative surgery was also observed for cancer cases (1970-1979 = 6%, 1980-1985 = 41%, 1986-1992 = 83%). Among invasive cancers, node involvement was observed in 11.5% of cases, being associated with tumour size (pT1a = 0%, pT1b = 7%, pT1c = 13%, pT2a = 33%). Five-, ten- and fifteen-year overall survivals of invasive cancers were 98.1, 95.7 and 87.3%, respectively.

Mucinous breast carcinoma. Single cutaneous metastasis

BACKGROUND

Mucinous or colloid carcinoma is an uncommon breast neoplasm which is generally associated with a good prognosis. Metastases tend to occur late in the disease and are found principally in lymph nodes, lungs, and bones. The longest latency period reported for development of a distant metastasis is 30 years after primary resection of the tumor.

OBJECTIVE

To describe a case of cutaneous metastasis from a mucinous breast carcinoma occurring 22 years after initial resection and review the literature.

RESULTS

Comparison of the primary tumor with the metastatic lesion showed identical histology. Review of the literature revealed this case represents the second longest latency for a distant metastasis from mucinous breast carcinoma and the unusual involvement of the skin.

CONCLUSION

This represents the second longest reported latency period for the development of a distant metastasis from mucinous breast carcinoma and its rare occurrence in the skin.

FGFRI and PLAT genes and DNA amplification at 8p12 in breast and ovarian cancers

Several chromosomal regions are found to be consistently amplified in human breast cancers. For two of these regions, 8p12 and 10q26, we previously reported the amplification of genes encoding FGF receptors, FGFRI/FLG and FGFR2/BEK, in about 12% of breast tumors. The PLAT gene, encoding the tissue-type plasminogen activator, is also located close to or within the 8p12 region. In the present study, we show that both FGFRI and PLAT can be amplified in breast as well as ovarian carcinomas. FGFRI amplification was detected in 14.5% of breast and 7.8% of ovarian tumors, whereas PLAT was found to be amplified in 15.6% and 19.4% of the tumors, respectively. Each gene could be amplified independently of the other. These data raised the question of which gene is selected for amplification at 8p12. In most cases, the levels of expression of FGFRI and PLAT in breast tumors were comparable to their level of expression in normal mammary tissue. However, FGFRI was expressed above the normal level in a certain number of cases. This gene could be a good candidate as "driver" of the 8p12 amplification, but it cannot account for all complex molecular events taking place in this region.

TGF alpha and TGF beta expression in mammary carcinoma

TGF alpha and beta expression was examined using rabbit polyclonal antibodies and immunohistochemistry on a series of 195 breast carcinomas. TGF alpha immunoreactivity was observed in all but nine of the tumours, with over 50 per cent staining strongly. The polyclonal TGF alpha antibody (CIM1), when compared with a commercially available mouse monoclonal TGF alpha antibody used on the same sections, gave a good correlation (r = 0.52, P < 0.001). Both TGF alpha antibodies produced a granular cytoplasmic staining pattern, that with CIM1 being coarser, suggestive of binding to an aggregated protein or organelle. Eighty-one per cent of tumours stained with the TGF beta antibody, 35 per cent strongly. There was significant co-expression of TGF alpha and TGF beta (P < 0.001). However, they were not found to be useful prognostic indicators, lacking any significant correlation with histological classification, tumour size, nodal status, oestrogen receptor status, S-phase fraction, or overall survival over a 9-12 year period. The expression of these growth factors in most breast carcinomas suggests that they have important biological roles, but the exact nature of these roles remains unclear at the moment.

Breast cancer is associated with loss of the c-kit oncogene product

The proto-oncogene c-kit encodes a tyrosine kinase receptor related to the PDGF/CSF-1 receptors. Mutations of this gene result in impairment of hematopoiesis, melanogenesis and gametogenesis. Using monoclonal antibodies to the c-kit gene product, we have analyzed its expression in normal and transformed human tissues. Unexpectedly, the receptor was found to be expressed in normal mammary epithelium. While in benign breast lesions, the c-kit gene product was detected at variable levels in 82% of the instances, in primary tumors, no product could be identified in 87% of the cases. This phenotype is maintained in metastatic foci. These findings were confirmed by paired Northern blot analysis of RNA preparations from normal and tumor tissues. These results demonstrate that the c-kit receptor may also be involved in the growth control of mammary epithelium and that this function may be impaired following malignant transformation and de-differentiation.

KiS1--a novel monoclonal antibody which recognizes proliferating cells: evaluation of its relationship to prognosis in mammary carcinoma

Immunohistochemical staining with a novel monoclonal antibody, KiS1, which recognizes a cell cycle-associated antigen, was investigated in 142 cases of stage I and II invasive breast carcinoma. KiS1 staining indices were compared with disease-free interval, overall survival, and post-relapse survival. Using a semi-quantitative method of assessment, we found that tumours with a high level of staining (34/142, 24 per cent) had a significantly worse prognosis than those with a low level of staining (108/142, 76 per cent). Significant correlations were found between KiS1 staining and disease-free interval (P < 0.001), overall survival (P < 0.001), and post-relapse survival (P = 0.008). A more time-consuming, quantitative method of assessment gave similar results. Cox multivariate analysis showed these results to be independent of nodal status, histological type, and grade of tumour (P = 0.01). We conclude that KiS1 is a valuable new antibody which affords useful prognostic information in breast carcinoma. As it can be used in formalin-fixed, paraffin-embedded material, it may be of particular use in the study of small lesions such as those identified in the Breast Cancer Screening Programme.

Breast cyst fluid concentrations of beta-endorphin, steroids and gonadotrophins in premenopausal women with gross cystic disease

Breast cyst fluid (BCF) and plasma levels of beta-endorphin (beta-EP), oestradiol (E2), progesterone (P), luteinizing hormone (LH), follicle-stimulating hormone (FSH), thyroid-stimulating hormone (TSH), prolactin (PRL) and cortisol were assayed radiochemically in a group of 10 premenopausal women aged 45-50 years suffering from gross cystic breast disease. The concentration of beta-EP (fmol/ml) in BCF (17.6 +/- 4.6 S.E.) was over four times higher than that in plasma (4.2 +/- 0.5 S.E.). The level of E2 was 41 times higher (1738.2 +/- 350.5 S.E. pg/ml) and that of P was 47 times higher (65.47 +/- 8.25 S.E. ng/ml) in BCF than in plasma. The significantly increased values of beta-EP, E2 and P in BCF and the identification of beta-EP in the cyst-lining epithelium indicated that local synthesis occurs. Growth factor-like properties of beta-EP and E2 are responsible for the propagation of cystic changes. The autonomous formation and activity of beta-EP, E2 and P in cystic formations were not correlated with LH, FSH, TSH and cortisol levels, which were significantly higher in plasma than in BCF. The concentration of PRL in BCF was not significantly higher than that in plasma. Moreover, the plasma concentrations of testosterone, androstenedione, thyroxine, triiodothyronine, thyroxine-binding globulin and sex-hormone-binding globulin were within the normal ranges. In this study we demonstrated synergism between beta-EP and steroid hormones which encourages the development of gross cystic disease in premenopausal women.

Point mutation at codon 12 of the Ki-ras gene in a primary breast carcinoma and the MDA-MB-134 human mammary carcinoma cell line

We found an activated Kirsten (Ki)-ras gene in the MDA-MB-134 breast carcinoma cell line by transfection of NIH3T3 cells. Oligonucleotide hybridization demonstrated that this cell line carries a single G to C point mutation at position 12 leading to a glycine-arginine substitution. However, only a fraction of the cell population seems to contain this Ki-ras mutation. Since mutations can occur in cell lines during in vitro culture, we searched in breast carcinoma samples for the presence of single mutations at codon 12, but also for the presence of the double mutation previously found in the H-466B breast carcinoma cell line. Using polymerase chain reaction (PCR), we detected one primary tumour carrying a single mutation at codon 12. No double mutation was found in any of the tumours. These results show that Ki-ras gene mutation could be involved in breast carcinogenesis, albeit at a low frequency.

Use of monoclonal antibodies to human breast-tumor-associated antigens in the diagnosis of fine-needle aspirates of breast nodules: results of a multicenter study

Fine-needle aspiration (FNA) cytology is being increasingly employed in conjunction with physical examination and mammography in the pre-surgical diagnosis of breast nodules. In the present study, we have submitted to multicenter validation an immunocytochemical test which employs monoclonal antibodies (MAbs) to breast-tumor-associated antigens (BTAA) for the diagnosis of breast cancer. The results of this analysis, which has evaluated 846 FNAs, show that the immunological test has a sensitivity of 88.62%, a specificity of 97.9% and an accuracy of 92.4%. The predictive value of a positive and a negative finding were 98.4% and 85.57% respectively. Comparison between the cytological and immunocytochemical diagnosis displayed a higher sensitivity, accuracy and predictive value of a negative result with the latter method (p less than 0.01). Our findings clearly indicate that immunocytochemical methods can complement and improve the diagnostic accuracy of FNA cytology of breast nodules.

Surgical treatment of phyllodes tumors of the breast

Eighty-one female patients with phyllodes tumors of the breast, surgically treated from 1974 to 1983, were studied. Their age ranged from 9 to 88 years. According to histology, the series was divided into three groups, of 28 (34.5%) benign tumors, 32 (39.5%) border-line tumors, and 21 (25.9%) malignant tumors. Because ten patients were lost to follow-up, only 71 women could be evaluated. All the patients had received surgical treatment: 51 women had been treated conservatively (11 enucleations, 40 wide resections), and 20 had undergone radical operations (13 underwent total and five underwent subcutaneous mastectomies, whereas one underwent modified and one underwent radical mastectomy). The mean follow-up, for the three groups, was 106 months for benign, 84 months for borderline, and 82 months for malignant tumors; in no case was radical surgery followed by local recurrence: of 51 women conservatively treated, 14 experienced local relapse, i.e., one of 24 women with benign, ten of 22 with borderline, and three of 8 with malignant lesions. Only two of 47 patients (4.2%) with borderline or malignant tumors developed distant metastasis and died from disease. No relationship between tumor size and risk of local recurrence could be demonstrated, and no difference could be identified between borderline and malignant lesions, in terms both of local and distant relapse. Local recurrences do not appear to affect survival: as a consequence, wide resection should be the primary treatment. Enucleation is to be proscribed. Total mastectomy has been indicated for very large tumors and for local recurrences of borderline and malignant lesions. Axillary dissection is not worthwhile.

CEA and HMFG in hyperplastic and malignant lesions of the breast

In order to evaluate a possible transition from proliferative lesions of the breast to ductal carcinoma in situ (DCIS), an immunohistochemical retrospective analysis was carried out. Twelve patients with hyperplasia without atypia, 11 patients with hyperplastic lesions with atypia, 21 patients with DCIS and 24 patients with invasive carcinoma were studied. The expression of carcino-embryonic antigen (CEA), a dedifferentiation marker, was investigated, applying one monoclonal antibody (Amersham). The expression of human milk fat globulin (HMFG), a differentiation marker, was studied by means of three monoclonal antibodies. The results reveal that no CEA activity can be demonstrated in normal and hyperplastic breast tissue, either with or without atypia. The monoclonal antibody was positive in 48% of DCIS and 50% of the invasive carcinomas. We failed to observe a correlation between the presence of CEA and the differentiation of the tumor. The application of this antiserum adds no substantial information about the phenotypic alterations during the progression from atypical hyperplasia to DCIS. HMFG was present in benign as well as in malignant breast lesions. Therefore, we conclude that HMFG is not useful for the evaluation of the phenotypic change from atypical hyperplasia to malignancy. However, as pointed out by others, it can be used in a diagnostic panel of different antibodies in the distinction between epithelial and non-epithelial lesions.

Clonogenic in vitro growth and histologic grading of primary human breast tumors

We determined the relationship of clonogenic in vitro growth and histopathologic features of 31 primary human breast tumors. Well-differentiated primary tumors formed fewer colonies than poorly differentiated tumors, and the clonogenic in vitro growth of tumors correlated inversely with patient survival. The potential of the clonogenic assay to serve as a predictor of disease course should be explored further.

Heterogeneous distribution of actin, myosin, fibronectin and basement membrane antigens in primary and metastatic human breast cancer

The distribution of actin, myosin, fibronectin and basement membrane antigens has been studied by indirect immunofluorescence in benign and malignant human breast lesions. While benign tumors showed only minor differences from normal mammary tissue, tumors of different histological types displayed a heterogeneous distribution of the antigens studied. Heterogeneity was observed within the same tumor, among different neoplasms and between primary tumors and autologous metastases. As a common characteristic, most of the tumors did not stain for actin and myosin, the pattern being similar to that found in myoepithelial cell distribution. In transformed epithelia there was often a lack of detectable actin with a myosin-positive fluorescence. Staining for both proteins was diffused to most of the cell cytoplasm. Staining for fibronectin was seen in only a minority of the cases, with medullary tumors being the most positive. Basement membrane stain was either absent or decreased and fragmented, except in rare ductal, i.e. papillary, carcinomas. Medullary tumors displayed an almost continuous, though fragmented basement membrane in approximately 70% of cases.