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

Clonality of lobular carcinoma in situ (LCIS) and metachronous invasive breast cancer

Lobular carcinoma in situ (LCIS) of the breast is generally considered an indicator for a bilaterally increased risk of invasive breast cancer (IBC). However, as recent studies suggested a clonal relationship between a subset of synchronous LCIS and invasive lobular carcinomas (ILC), we aimed to examine a possible precursor role for LCIS and IBC occurring in the same breast at a later time. Out of a consecutive series of 88 LCIS, nine patients developed IBC (5 ILC and 4 invasive ductal carcinomas) between 2 and 10 years after initial biopsy. For each case, mitochondrial DNA heteroplasmy was analyzed in normal mammary gland epithelia, LCIS and IBC by PCR, direct DNA sequencing and phylogenetic tree clustering. Two cases of LCIS and ILC showed identical patterns of heteroplasmy. In one further case, additional mtDNA mutations were present in the ILC following LCIS. The remaining two cases of ILC and all 4 IDC were clonally unrelated to the previously diagnosed LCIS. While the overall risk for the development of invasive breast cancer following LCIS is relatively low and the majority of cases are clonally unrelated, our data clearly show that some LCIS eventually do progress to ILC. Thus, LCIS represents both an indicator lesion for an increased risk of subsequent invasive breast cancer and in some cases a precursor of ILC.

Breast cancer patients with 10 or more involved axillary lymph nodes treated by multimodality therapy: influence of clinical presentation on outcome

PURPOSE

To analyze tumor control and survival for breast cancer patients with 10 or more positive lymph nodes without systemic disease, treated by adjuvant radiation alone or combined-modality therapy.

METHODS AND MATERIALS

We reviewed the records of 309 consecutive patients with these characteristics who received locoregional radiotherapy (RT) at our institution. The majority of patients had clinical Stage II or IIIA-B disease (43% and 48%, respectively). The median number of positive axillary lymph nodes was 15 (range, 10-78). Adjuvant therapy consisted of RT alone, with or without chemotherapy, tamoxifen, and/or ovarian castration.

RESULTS

The overall 5-year and 10-year disease-free survival (DFS) rates were 20% and 7%, respectively. Median DFS was higher for patients with Stage I-II compared with those with Stage IIIABC (28 vs. 19 months; p = 0.006). Median DFS for patients aged <or=35 years was lower than that of older patients (12 vs. 24 months; p < 0.0001). Patients treated with a combination therapy had a higher 5-year DFS rate compared with those treated by RT alone (26% vs. 11%; p = 0.03). In multivariate analysis, clinical stage (III vs. I, II; relative risk = 1.8, p = 0.002) and age (<or=35 vs. others; relative risk = 2.6, p <0.001) were found to be independent variables for DFS.

CONCLUSION

This retrospective data analysis identified young age and advanced clinical stage as pertinent and independent clinical prognostic factors for breast cancer patients with advanced axillary disease (10 or more involved nodes). These factors can be used for further prognostic classification.

Primary Squamous Cell Carcinoma of the Breast: Value of Positron Emission Tomography Scanning in Confirming the Diagnosis

Pure primary squamous cell carcinoma of the breast is rare. Controversy exists as to whether a pure form exists or whether described cases represent extreme squamous metaplasia within an adenocarcinoma. We present a case of pure primary squamous cell carcinoma of the breast confirmed histopathologically with the absence of a distant primary tumor excluded using positron emission tomography. Because of the paucity of guidelines in the literature for this rare tumor, it is difficult to draw firm conclusions regarding the optimal treatment modality or the overall prognosis.

Biologic markers in axillary node-negative breast cancer: differential expression in invasive ductal carcinoma versus invasive lobular carcinoma

PURPOSE

The objective of this study was to compare the differential expression of established histopathologic and biologic markers of proliferation, apoptosis, and angiogenesis in invasive lobular carcinoma (ILC) and invasive ductal carcinoma (IDC) in a group of axillary node-negative breast cancers.

PATIENTS AND METHODS

Two hundred twenty patients with axillary node-negative ILC and IDC who underwent surgery at the University of Texas M. D. Anderson Cancer Center between 1978 and 1995 had tissue available for analysis. Of these, 206 (94%) had IDC and 14 (6%) had ILC. Estrogen receptors, progesterone receptors, tumor and stromal expression of vascular endothelial growth factor receptor 2, CD44, laminin-5, E-cadherin, and topoisomerase-2 were evaluated by immunohistochemical analysis. HER2/neu and alpha6beta4 integrin were evaluated by in situ hybridization. The Fisher exact test was used to calculate significant differences between ILC and IDC. Median age was 59 years.

RESULTS

Invasive lobular carcinoma was more likely to occur in patients aged > 50 years. Invasive lobular carcinoma tended to be > 2 cm (50% vs. 39%), have a nuclear grade of 1/2 (100% vs. 72%), be estrogen receptor positive (93% vs. 70%), HER2/neu negative (92% vs. 68%), have high CD44 expression (31% vs. 16%), low stromal vascular endothelial growth factor receptor 2 expression (36% vs. 47%), no E-cadherin expression (0 vs. 90%), and low laminin-5 expression (15% vs. 25%), compared with IDC.

CONCLUSION

Invasive lobular carcinoma and IDC might be distinct histologic types of breast cancer with different expression of biologic markers. These differences, not all being statistically significant in this small study, might generate hypotheses to develop tailored options for future systemic therapy.

Margin status and the risk of local recurrence after breast-conserving treatment of lobular breast cancer

BACKGROUND

Invasive lobular breast carcinoma is known for its multicentricity and is associated with a higher incidence of incomplete excision after breast-conserving therapy. The aim of the study was to examine the influence of positive surgical margins on the local recurrence rate in patients diagnosed with invasive lobular cancer and treated with breast-conserving therapy.

METHODS

All 416 women diagnosed with invasive lobular breast cancer and undergoing breast-conserving treatment between 1995 and 2002 were selected from the population-based Eindhoven Cancer Registry. Their medical charts were reviewed and detailed information was collected.

RESULTS

The risk of margin involvement was 29% after the first operation and 17% when taking into account the final margin status of the patients undergoing re-excision. During follow-up, 18 patients developed a local recurrence. The 5 year actuarial risk of developing a local recurrence was 3.5% (95% confidence interval 2.5-4.5) and the 8 year risk was 6.4% (95% confidence interval 4.7-8.0). There was no influence of positive surgical margins on the risk of local recurrence, neither in the univariate analysis nor after adjustment for age, tumour size, nodal status and adjuvant systemic treatment.

CONCLUSION

Patients with invasive lobular cancer, treated with breast-conservation, have a low risk of local recurrence, despite their high risk of having a microscopically incomplete excision of the tumour.

Metallothionein as a prognostic biomarker in breast cancer

Breast cancer is the most common cancer in women, with a general upward trend in incidence. Basic and clinical breast cancer research has continued at a rapid pace, in the endeavor to understand the biology of the disease so as to improve management of patients. Besides traditional pathological indicators, expression of molecular markers in breast cancer has also been comprehensively investigated. This paper will focus on the prognostic utility of metallothioneins (MTs), a family of low molecular weight metal binding proteins encoded by at least 10 functional MT genes that are associated with cell proliferation in breast cancer. Evidence that MT is a potential prognostic biomarker for breast cancer is supported by many reports in the literature. Expression of the MT protein has been detected by immunohistochemistry in a significant portion of invasive ductal breast cancers. MT expression has also been well studied in association with traditional clinico-pathological parameters of breast cancers. Generally, higher MT expression in breast cancers is predictive of worse patient outcomes. The relationship of MT isoforms to histological grade, estrogen receptor (ER) status, and prognosis will also be discussed.

Gastro-intestinal symptoms as clinical manifestation of peritoneal and retroperitoneal spread of an invasive lobular breast cancer: report of a case and review of the literature

Background

Distant spread from breast cancer is commonly found in bones, lungs, liver and central nervous system. Metastatic involvement of peritoneum and retroperitoneum is unusual and unexpected.

Case presentation

We report the case of a 67 year-old-woman who presented with gastrointestinal symptoms which revealed to be the clinical manifestations of peritoneal and retroperitoneal metastatic spread of an invasive lobular breast cancer diagnosed 15 years before.

Conclusion

To the best of our knowledge, the case presented is the third one reported in literature showing a wide peritoneal and extraperitoneal diffusion of an invasive lobular breast cancer. The long and complex diagnostic work up which led us to the diagnosis is illustrated, with particular emphasis on the multidisciplinary approach, which is mandatory to obtain such a result in these cases. Awareness of such a condition by clinicians is mandatory in order to make an early diagnosis and start a prompt and correct therapeutic approach.

Association between breast cancer and autoimmune thyroid disorders: no increase of lymphocytic infiltrates in breast malignant tissues

An association between thyroid autoimmunity and breast cancer (BC) has been consistently reported, but the cause of this association is still unknown. The role of lymphocytic infiltration (LI) in breast tumorigenesis is controversial and several data suggest that in BC an increase of lymphoid cell infiltrates or a dysfunctional local immune response may be detected very early during tumor development. Chronic autoimmune thyroiditis is characterized by different degrees of LI in thyroid gland and BC cells share some antigenic properties similar to those detected in thyroid tissue, such as sodium iodide symporter (NIS) and peroxidase activity. The aim of this study was to evaluate the frequency and amount of LI in malignant and in normal peritumoral breast tissues, as expression of autoimmune morphological changes, in a group of BC patients with thyroid autoimmunity. We suppose that an increased LI in breast tissues of this group of patients may help explain the association between BC and thyroid autoimmunity. The study group included 26 BC patients with thyroperoxidase antibodies positivity (TPOAb+), 14 of them (53.8%) with Hashimoto's thyroiditis (HT), and 30 BC patients with no evidence of thyroid autoimmune disorders. Malignant and surrounding normal breast tissues were assessed for LI. The amount of LI was scored as very scanty or scanty (LI S) and moderate or marked (LI M), independently by two expert pathologists. LI S was detected in 19/26 (73.1%) BC tissues from patients with TPOAb positivity and LI M in 7 (26.9%). All BC patients with HT had LI S. LI S was detected in 25/30 (83%) and LI M in 5/30 (17%) of BC tissue from patients with no thyroid autoimmunity. The difference in the amount of LI of BC tissues in patient with or without autoimmune thyroid disorders was not significant. The LI was generally absent or very scanty in remote breast tissue in all cases. In conclusion, in breast malignancies the presence of humoral and/or clinical evidence of thyroid autoimmunity is not associated to autoimmune morphological changes of cancer and peritumoral normal tissue. The LI does not seem to have any role in tumorigenesis in patients with BC and thyroid autoimmunity.

Cytomorphology as a risk predictor: experience with fine needle aspiration biopsy, nipple fluid aspiration, and ductal lavage

Primary prevention of breast cancer requires identification and elimination of cancer-causing agents, which is an incredibly difficult task to follow. Secondary prevention involves screening individuals who are at increased risk for breast cancer in hopes that early intervention will affect survival. In the 1980s, chemoprevention received serious attention. This approach was aimed at reducing cancer risk by administration of natural or synthetic clinical compounds that prevent, reverse, or suppress carcinogenesis in individuals at increased risk for cancer. It was not until 1998, however, when the first report from the National Surgical Adjunct Breast and Bowel Project (Breast Cancer Prevention Trial BCPT; P-1) randomized clinical trial appeared in the literature supporting the hypothesis that breast can-cer can be prevented. This study showed that administration of tamoxifen reduced the risk for invasive and noninvasive breast cancer by almost 50% in all age groups. With the current availability of tamoxifen as a chemopreventive agent and with the increasing emphasis on early breast cancer detection and prevention, more women seek consultation to determine their risk for breast cancer. However, in the absence of any detectable breast lesion, clinically and mammographically, only a few women may volunteer to have their breasts sampled by surgical biopsy for risk assessment. Other non-surgical procedures include fine needle aspiration biopsy (FNAB), nipple aspirate fluid (NAF), and the recently introduced procedure, ductal lavage. These techniques may provide better alternatives. These minimally invasive procedures are capable of recruiting cellular material for cytomorphologic interpretation and biomarker studies.

Reconstruction of the nipple-areola complex: an update

Along with continuing progress in reconstructive surgery of the breast numerous techniques of nipple-areola reconstruction have been developed. With time and experience some methods have been discredited to historical significance only while others have evolved to widely accepted concepts used by surgeons all over the world, which in turn contributed new ideas and modifications. In addition to those favourite techniques others are reserved as second-line alternatives in specific situations. The principle criterion for a pleasing nipple-areola complex is symmetry regarding several parameters: colour, texture, size, and projection. The purpose of this manuscript is to review and discuss the concepts and techniques of nipple-areola reconstruction that have evolved over the past decades. Furthermore, those principles and techniques are pointed out that fulfil best the criteria of an ideal nipple-areola complex with emphasis on different techniques of breast reconstruction and individual conditions of the patient.

Total skin-sparing mastectomy without preservation of the nipple-areola complex

BACKGROUND

We hypothesized that total skin-sparing mastectomy (TSM) including where the skin overlying the nipple and areola is preserved would be oncologically safe and facilitate improved cosmetic reconstruction.

METHODS

A review (May 2003 through January 2005) was completed on all procedures that were performed through an inframammary incision or a previous scar with reconstruction using Botox, AlloDerm, and a subpectoral tissue implant.

RESULTS

Thirty-one patients had 50 TSMs. Twelve percent (6/50) of TSMs had the skin of the nipple and areola resected: 4 (14% of tumors) because of tumor involvement and 2 (4%) because of skin necrosis. Fourteen percent of patients had other complications: 4% (2/50) had infection and/or flap necrosis and 10% (5/50) had superficial epidermolysis requiring no intervention, for a total complication rate of 18%. Average cosmetic score was 8.5 (range 4 to 10). No recurrences are evident after mean follow-up of 7.9 +/- 5.4 months.

CONCLUSION

Our short-term experience suggests that TSM has an acceptable complication rate, is theoretically oncologically safe, and facilitates an improved cosmetic result.

A case of non-metastatic giant mucinous carcinoma of the breast

A surgically resected case of giant mucinous carcinoma of the breast that had remained untreated for 2 years is reported. A 64-year-old postmenopausal woman presented with a large right breast mass (17.4 x 16.5 x 14.5 cm). Although she had noticed a mass in the right breast 2 years previously, she had not sought treatment. Mucinous carcinoma was diagnosed by core needle biopsy and she underwent right modified radical mastectomy with a free skin graft. There were no lymph node metastases or distant metastases. Fourteen months postoperatively, she remains well without evidence of tumor recurrence. Although several reports have suggested that pure mucinous carcinoma of the breast has a favorable prognosis, we need to follow this case until the clinical behavior and the outcome become clear.

Mammary ductoscopy: current status and future prospects

BACKGROUND

Mammary ductoscopy (MD) allows direct visualisation of the mammary ducts using sub-millimetre fiberoptic microendoscopes inserted through the ductal opening onto the nipple surface. The sharp clear magnified images are viewed on a video monitor. Such scopes have working channels that allow irrigation and ductal lavage for cytological analysis. MD can be performed under local anaesthesia in the office setting. This article reviews the evolving role of MD in the diagnosis and treatment of intraductal breast disease.

METHODS

A literature search was carried out from Pubmed for indexed articles published over the last 30 years using the keywords 'mammary ductoscopy' and 'breast ductoscopy'.

RESULTS

The search yielded 27 indexed published articles and reports. Important major reports and studies were reviewed, screened and tracked for other relevant publications. The most important articles were analysed and discussed. The review also includes our published and unpublished original work in the field of MD.

CONCLUSIONS

MD is a useful diagnostic adjunct in patients with pathological nipple discharge (PND). Furthermore, it can reduce the number and extent of duct excision operations for PND. However, its potential use in the early detection of breast cancer, guiding breast conserving surgery (BCS) for cancer, therapeutic ablation of intraductal disease, and guiding risk-reducing strategies among high risk women requires further research and evaluation. Future developments include the development of a biopsy kit, combining MD with molecular diagnostic markers and real-time optical biopsy system for the diagnosis of pre-malignant and early malignant disease and radiofrequency for curative ablation of intraductal lesions.

Invasive Lobular Carcinoma Classic Type: Response to Primary Chemotherapy and Survival Outcomes

Purpose

To investigate the impact of histologic type invasive lobular carcinoma (ILC) versus invasive ductal carcinoma (IDC) on response to primary chemotherapy (PC) and long-term outcome.

Patients and Methods

The study included 1,034 patients with stage II and III breast cancer who participated in six clinical trials of PC at our institution between 1985 and 2002. One hundred twenty-two patients (12%) had ILC and 912 (88%) had IDC. All patients received anthracycline-based PC, and 346 patients (33.5%) also received a taxane as part of PC. Pathologic complete response (pCR) was defined as no evidence of invasive disease in the breast and axillary lymph nodes.

Results

The median patient age was 48 years (range, 18 to 79 years). Patients with ILC tended to be older (median age, 53 years v 47 years for patients with IDC) and have more hormone-receptor–positive tumors (92% v 62%; P < .001), lower nuclear grade (nuclear grade 3, 16% v 56%; P < .001), and higher stage at diagnosis (10% v 0% with stage IIIB or IIIC disease; P < .001). Patients with ILC were less likely to have a pCR (3% v 15%; P < .001) and had a larger number of involved axillary lymph nodes (41% v 26% had > 3 involved nodes; P = .001). At a median follow-up time of 70 months, ILC patients tended to have longer recurrence-free survival (P = .004) and overall survival (P = .001).

Conclusion

ILC is characterized by lower rates of pathologic response to PC but better long-term outcomes compared to IDC. pCR might not be a prognostic indicator for this group of patients.

Tubulolobular Carcinoma of the Breast

Tubulolobular carcinoma (TLC) is a rare subtype of mammary carcinoma that has eluded precise classification, exhibiting features of both ductal and lobular differentiation. The clinicopathologic features of 27 cases of TLC were analyzed by both hematoxylin and eosin and immunohistochemical stains for E-cadherin and 34betaE12 (high molecular weight cytokeratin). Five cases of both pure tubular and classic lobular carcinoma were included as controls. Patients with TLC ranged in age from 43 to 79 years (median, 60 years). Tumor characteristics were as follows: size, 0.5 cm to 2.5 cm (median, 1.4 cm); bilaterality, 1 of 27 (4%); and multifocality, 5 of 27 (19%). Twenty-two of the 27 cases (81%) contained an in situ component: 8 (36%) lobular (LIN); 4 (18%) ductal (DIN); and 10 (46%) mixed. All 27 cases were intensely positive (3+) for E-cadherin, a feature of ductal differentiation, while 25 of 27 (93%) cases showed variable positivity for 34betaE12 (1 to 3+), a feature far more common in tumors with lobular differentiation. Clinical follow-up was available on 25 of 27 (93%) patients. Three of 24 (13%) patients developed axillary lymph node metastases and 1 of 25 (4%) patients developed a local recurrence over a follow-up period of 2 to 91 months (median, 39 months). In conclusion, TLCs are a distinct subtype of mammary carcinoma with overlapping morphologic features that are mirrored by a hybrid immunohistochemical profile. The uniform 3+ expression of E-cadherin in TLC supports the ductal differentiation of these tumors, despite a dominant lobular growth pattern. The prognosis of these tumors appears to be excellent, especially in those cases that are unilateral and less than 2 cm in size.

Breast Conservation Therapy for Invasive Lobular Carcinoma: The Impact of Lobular Carcinoma in Situ in the Surgical Specimen on Local Recurrence and Axillary Node Status

Forty patients undergoing breast-conserving therapy for invasive lobular carcinoma were studied for the volume of lobular carcinoma in situ (LCIS) in the surgical specimen and its relationship to the surgical margins. The pathology of all cases was reviewed for margin status as well as the volume of LCIS in the surgical specimen. Mean follow-up time was 67 months. There were no local recurrences despite the fact that 38 per cent of patients had close or involved margins. There was one cancer-related death. Increasing tumor size and moderate or extensive involvement of the surgical specimen with LCIS were found to be independent predictors of axillary node metastases. The volume of LCIS in the surgical did not appear to have an impact on local recurrence. This paper adds to the growing body of literature suggesting that in patients undergoing breast-conserving therapy, LCIS in the surgical margin does not impact the risk of local recurrence and therefore may not require reexcision for close or involved surgical margins.

Pure mucinous carcinoma of the breast

BACKGROUND

The lack of a standard definition of "pure" mucinous carcinoma of the breast has made it difficult to compare data from different studies. This study used the most stringent criteria to define parameters for truly pure lesions.

METHODS

Sixty-five patients were identified. The database was used to evaluate patients' demographics, tumor characteristics, and outcomes. Survival curves and predictors of survival were analyzed.

RESULTS

The mean age of presentation was 67 years. The majority (96%) of patients presented with early-stage disease. The 5- and 10-year overall survival rates were 93.6% and 72.8%, respectively. The number of involved axillary lymph nodes was the only significant predictor of death (P = 0.02).

CONCLUSIONS

Pure mucinous carcinoma of the breast has a favorable prognosis. Tumor size does not appear to impact survival, perhaps because the volume of mucin overestimates tumor burden. The number of involved axillary lymph nodes was the only significant predictor of death from disease.

Squamous metaplasia of Paget's disease

A patient had triple extramammary Paget's disease of both axillary and genital regions. Right inguinal lymphadenopathy was found 1 year after excision of all the skin lesions. Excisional biopsy of the lymph node demonstrated a mixture of Paget cells and atypical squamoid cells with horn pearls suggestive of keratinization. The squamoid cells were positive for cytokeratin 10, a marker of suprabasal epidermis, and also positive for laminin gamma2 which is often expressed in invasive squamous cell carcinoma. The coexistence of these different cells within the same tumour island suggested that the squamoid cells derived from metaplasia of Paget cells.

The diagnosis of invasive lobular breast carcinoma. Does MRI have a role?

Invasive lobular breast carcinoma accounts for approximately 15% of all breast cancers and is difficult to detect using conventional breast imaging techniques. We report a comparison between clinical, ultrasound scan (USS), mammographic and magnetic resonance imaging (MRI) of 22 patients with invasive lobular breast carcinomas. Actual tumour size was ascertained by histopathology. MRI detected 21 of the 22 invasive lobular cancers whilst mammography and USS detected 16 and 20 respectively. 19 tumours were clinically palpable. MRI was more accurate at assessing tumour size than USS and clinical examination, both of which underestimated tumour size.

Infiltrating lobular carcinoma of the breast: tumor characteristics and clinical outcome

INTRODUCTION

Invasive lobular carcinoma (ILC) comprises approximately 10% of breast cancers and appears to have a distinct biology. Because it is less common than infiltrating ductal carcinoma (IDC), few data have been reported that address the biologic features of ILC in the context of their clinical outcome. In the present study we undertook an extensive comparison of ILC and IDC using a large database to provide a more complete and reliable assessment of their biologic phenotypes and clinical behaviors.

METHODS

The clinical and biological features of 4140 patients with ILC were compared with those of 45,169 patients with IDC (not otherwise specified). The median follow-up period was 87 months.

RESULTS

In comparison with IDC, ILC was significantly more likely to occur in older patients, to be larger in size, to be estrogen and progesterone receptor positive, to have lower S-phase fraction, to be diploid, and to be HER-2, p53, and epidermal growth factor receptor negative. It was more common for ILC than for IDC to metastasize to the gastrointestinal tract and ovary. The incidence of contralateral breast cancer was higher for ILC patients than for IDC patients (20.9% versus 11.2%; P < 0.0001). Breast preservation was modestly less frequent in ILC patients than in IDC patients. The 5-year disease-free survival was 85.7% for ILC and 83.5% for IDC (P = 0.13). The 5-year overall survival was 85.6% for ILC and 84.1% for IDC (P = 0.64).

CONCLUSION

Despite the fact that the biologic phenotype of ILC is quite favorable, these patients do not have better clinical outcomes than do patients with IDC. At present, management decisions should be based on individual patient and tumor biologic characteristics, and not on lobular histology.

Medullary carcinoma, provocative now as then

The recent observation that studies of BRCA1-associated tumors contain a high proportion of medullary carcinomas and ductal carcinomas with medullary features has re-introduced pathologists to an old diagnostic problem. The term "medullary carcinoma" dates to the 19th century, but the modern entity was introduced in 1949 by Moore and Foote, who described a carcinoma with a lymphoid infiltrate, a favorable prognosis, and low frequency of metastasis. Almost three decades later, Ridolfi et al proposed specific criteria for diagnosis, resulting in an entity with an even more favorable prognosis and a lower incidence. The reproducibility and clinical relevance of the diagnosis have been questioned recently, and new criteria have been proposed and compared. The tumors typically express cytokeratin 7, often vimentin and S100-protein, but not cytokeratin 20. The usual ones are positive for p53 and negative for estrogen receptor, Her2/neu, and bcl-2. Medullary carcinomas express e-cadherin and beta-catenin more often than ordinary high-grade ductal carcinomas, and the former have genetic differences from the latter. The lymphoid infiltrate of medullary carcinomas is related to beta-actin fragments exposed by apoptotic cells. The present review discusses historical and recent developments and emphasizes diagnostic criteria.

Correlation of tumor volume and surface area with lymph node status in patients with multifocal/multicentric breast carcinoma

BACKGROUND

Multicentric breast carcinomas have a higher frequency of axillary lymph node metastasis than unifocal tumors of similar stage. It remains unclear whether this merely reflects larger tumor volumes or a different biologic behavior. The authors have shown previously that when aggregate tumor diameter are used for staging, unifocal and multifocal tumors have a similar frequency of axillary lymph node metastasis. However, summing diameter overestimates actual tumor volume because volume is proportional to the third power of the diameter. Therefore, the aim of the current study was to reanalyze the relation between size and axillary lymph node status by correcting for tumor volumes and surface areas.

METHODS

Volumes and surface areas of 122 breast tumor specimens with multiple macroscopic nodules (two foci: n = 95; three foci: n = 22; three foci: n = 5) were calculated by approximating the shape of each tumor nodule to an ellipsoid (for volume) or to a prolate spheroid (for area). For comparison, the authors used an internal control series, comprised of 469 macroscopic unifocal tumors. For all patients, multiple assessments of largest tumor size and combined size of all foci were correlated with the status of axillary lymph nodes. The associations between lymph node status, tumor volume or area, and multifocality were modeled using univariate and multivariate logistic regression.

RESULTS

When either the largest or the aggregate tumor volume was used as a size estimate, tumor specimens with multiple nodules had a higher frequency of lymph node involvement compared with unifocal tumors of a similar volume or area. The odds ratio (OR) for having positive lymph nodes was 2.34 for aggregate volume measurement (P < 0.001). Surface area estimates yielded similar results (OR = 2.2, P < 0.001).

CONCLUSIONS

Breast tumors with multiple macroscopic nodules had a different biology, with a propensity to dissemination at smaller tumor volumes (i.e., there was another factor besides volume alone that accounted for the differences in behavior).

Ductal lavage and its histopathologic basis: A cautionary tale

Ductal lavage has been touted as a possible screening tool for patients with a high risk for the development of breast cancer. This article examines the fundamental concepts underlying the procedure and critically evaluates its possible utility in light of the known molecular and surgical pathologic data. It highlights the fact that risk assessment in breast cancer is far from an exact science, since most women who develop breast cancers are not identified as high-risk by the Gail model. The utility of ductal lavage has as yet not been proven, and even if it were useful, it is likely to benefit only a subset of all breast cancer patients. Further studies, preferably controlled clinical trials, are necessary before routine use of the procedure can be recommended.

Pathologic findings from the National Surgical Adjuvant Breast and Bowel Project

BACKGROUND

The current report represents a 12-year clinicopathologic update of an earlier 5-year analysis of 180 patients with lobular carcinoma in situ (LCIS) who were treated with local excision and subsequent surveillance only.

METHODS

Nineteen pathologic characteristics of LCIS were assessed as potential predictors of invasive and noninvasive ipsilateral breast tumor recurrence (IBTR) and contralateral breast tumor recurrence (CBTR) as well as mortality.

RESULTS

Overall, only 26 IBTRs (14.4%) and 14 CBTRs (7.8%) were observed. Nine IBTRs (5.0% of the total cohort) and 10 CBTRs (5.6% of the total cohort) were invasive carcinomas. Eight of 9 IBTRs (88.9%) and 6 of 8 invasive CBTRs (75%) that had histologic sections available for review were of the lobular invasive type. Ninety-six percent of all IBTRs and 100% of invasive IBTRs occurred within the same site as the index LCIS. The numbers of invasive IBTRs were comparable within and after 5 years (5 invasive IBTRs vs. 4 IBTRs). Recurrences of invasive CBTR occurred later than recurrences of invasive IBTR, with 70% of invasive CBTRs recognized after 5 years compared with 44% of invasive IBTRs. It was found that Grade 2-3 LCIS was significantly predictive for invasive IBTR when combined with the number of recurrences of ductal carcinoma in situ (DCIS) alone or with LCIS. Only 2 patients in the cohort (1.1%) succumbed to breast carcinoma; 1 patient had a prior invasive IBTR, and the other patient had an invasive CBTR. The reasons for the lower frequency of invasive recurrences and the higher proportions of the lobular invasive phenotype than noted by others are discussed along with the impact of the findings on the nomenclature, precursor nature, and treatment of LCIS.

CONCLUSIONS

LCIS is a more indolent form of in situ breast carcinoma than DCIS, with which it shares other features of its natural history, particularly very low mortality rates. There is no compelling reason to surgically treat LCIS other than conservatively. The values of other adjuvant modalities in the management of LCIS are discussed. The authors acknowledge that their findings are based on relatively few events and, even at 12 years, may be regarded as "preliminary". Nonetheless, their findings may reflect the true biologic nature of LCIS.

Solitary Papillary Breast Carcinoma Metastasis to the Large Bowel Presenting as Primary Colon Carcinoma: Case Report and Review of the Literature

Breast carcinoma has the potential for widespread dissemination. Spread to the lower gastrointestinal tract is infrequent, often multifocal, occurs in association with spread to other sites, and most commonly develops from lobular carcinoma. Solitary colorectal metastasis as the first and sole manifestation of spread is a rare occurrence and can be confused with primary intestinal malignancy. We present a case of metastatic papillary breast carcinoma presenting as a perforated primary colon cancer. Identity of the lesion was confirmed by direct histologic comparison of the resected tumor with prior breast specimen, cytokeratin expression, and the presence of estrogen receptors.

Bone marrow micrometastasis in breast cancer

BACKGROUND

Several studies have demonstrated that bone marrow micrometastasis in patients with breast cancer is an independent prognostic factor for systemic recurrence and poorer survival.

METHODS

This review describes the detection and clinical significance of micrometastatic cells in bone marrow, and examines the correlation between such micrometastasis and established clinicopathological prognostic factors. The relevant English language literature on bone marrow micrometastasis in breast cancer was searched via Medline (1975-2002), cross-referencing with key articles on the subject.

RESULTS AND CONCLUSION

The balance of evidence favours the hypothesis that bone marrow micrometastasis impacts on disease-free and overall survival. Further prospective studies are required to examine this in greater detail, with particular reference to early node-negative breast cancer and the value of adjuvant systemic therapy in patients with bone marrow micrometastasis.

Skin involvement in invasive breast carcinoma: safety of skin-sparing mastectomy

BACKGROUND

There is concern about the oncological safety of preserving most of the breast skin in skin-sparing mastectomy (SSM). Most supportive evidence for SSM evaluates the local recurrence rate on clinical follow-up.

METHODS

The skin and 10 mm of the subcutaneous tissue of 30 total mastectomy specimens were studied with a step-serial sectioning technique. The incidence and mode of involvement of the skin and subcutaneous tissue were recorded in detail. This was correlated with other clinical and pathologic parameters.

RESULTS

The incidence of skin involvement outside the nipple-areola complex was 20% (6 of 30). This was significantly related to the clinical T stage, site of the tumor, skin tethering, pathologic tumor size, and perineural infiltration. When the effects of both skin and subcutaneous tissue involvement were considered, the incidence of skin-flap involvement outside the nipple-areola complex was 23% (7 of 30). The significant parameters related to skin-flap involvement were skin tethering (75% vs. 15%; P <.05), pathologic tumor size (P <.03), and perineural infiltration (63% vs. 9%; P <.01).

CONCLUSIONS

It would be oncologically safe to perform SSM in T1 and T2 tumors, because the chance of skin involvement is small. It is safe to preserve the skin overlying the tumor if there is no skin tethering.

Retrospective analysis of breast cancer among young African American females

PURPOSE

To evaluate the patterns of failure, relapse-free survival and overall survival among African American breast cancer patients younger than 40 years.

PATIENTS AND METHODS

We retrospectively reviewed the records of 124 African American breast cancer patients younger than 40 years who were registered with the Howard University Cancer Center Database between 1990 and 1999. One hundred and six patients were found eligible and subsequently included in this analysis. Ninety-eight percent of these patients were pre-menopausal and 30% had a documented family history of breast cancer. Patient distribution per stage is as follows: 19%, stage I; 61%, stage II; 16%, stage III and 4%, stage IV. Surgery was a component of treatment for 98% of the patients. Forty-six percent underwent mastectomy, 47% had breast-conserving surgery and 5% underwent biopsy only. Fifty-nine percent of the patients received adjuvant radiation and 56% were also treated with adjuvant chemotherapy. Median follow-up was 35 months (range of 4-126 months).

RESULTS

Locoregional only first failure rate was 6% while systemic failure occurred in 20% of these patients. Among 17 stage III patients, 50% developed distant metastasis. The 5-year overall survival for these patients was 73%, with relapse-free survival being numerically similar. Patients with early stage disease, stages I and II, were noted to have 5-year overall survival rates of 100 and 78-83%, respectively. Those who presented with stage III or stage IV disease had dismal 5-year overall survival rates of 25-29 and 0%, respectively. Multivariate analysis using the Cox proportional hazard model identified the presence of metastasis as a factor that significantly affects survival in these young African American females.

CONCLUSION

These results show that African American females younger than 40 years with early stage breast cancer have local control and survival rates comparable to that of the general population. In contrast, young African American females in this study, with stages III and IV disease, appear to suffer a worse prognosis despite standard therapy. A larger series of young African American females with breast cancer, followed for a longer period of time, will be required to confirm a negative trend in survival.

Assessment of utility of ductal lavage and ductoscopy in breast cancer-a retrospective analysis of mastectomy specimens

Early detection of breast lesions continues to be an important goal in the management of breast cancer. At present, mammographic imaging in addition to physical examination is the main screening method for the detection of cancer. Fiberoptic ductoscopy and duct lavage are being recently used to evaluate patients at risk for breast cancer. Both techniques examine the nipple and central duct area to identify intraductal lesions. In this study, we examined the frequency of involvement of these structures in mastectomy specimens as a surrogate marker to estimate the utility of these methods in breast cancer patients. The presence and type of involvement of the nipple and central duct area was retrospectively evaluated in 801 mastectomy specimens from a 4-year period that had been performed for infiltrating or in situ carcinoma. Atypical proliferation or cells, when seen in the ducts of this region, was considered as evidence of nipple involvement, even if definite evidence of malignancy was lacking. The review of 801 mastectomies showed nipple and central duct involvement in 179 (22%) cases. Among the 665 cases of infiltrating carcinoma, 17% did not have an intraductal component. The relative rarity of nipple and central duct in mastectomy specimens and the lack of an in situ component in many cases raise questions about the utility of fiberoptic ductoscopy and duct lavage as methods for screening of breast cancer. Additionally, as these methods examine only 1-2 ducts of the 15-20 ducts that open at the nipple, they might fail to detect focal abnormalities.

Histological characteristics of tumors in blood vessels play an important role in tumor progression of invasive ductal carcinoma of the breast

Whether the characteristics of tumor cells in blood vessels play an important role in the tumor progression of invasive ductal carcinoma (IDC) of the breast is not known. The purpose of this study was to investigate the significance of the characteristics of tumor cells in blood vessels in relation to tumor progression in 247 IDC patients with blood vessel invasion, in comparison with well-known histological parameters. Blood vessel tumor embolus dimensions were measured. Nuclear atypia, numbers of mitotic and apoptotic figures, and fibrosis grade of tumor cells in blood vessels were assessed. Cox proportional hazard multivariate analyses showed that >2 mitotic figures in blood vessel tumors significantly increased the hazard rates (HRs) of disease-free survival (P=0.002) and initial distant organ metastasis-free survival (IDOMS) in node-negative IDCs (P=0.005), and the HRs of disease-free survival (DFS, P=0.007) and IDOMS (P=0.015) in node-positive IDCs. Apoptotic figures >2 in blood vessel tumor emboli significantly increased the HR of overall survival (P=0.007) in node-positive IDCs. The present study showed the number of mitotic and apoptotic figures in tumor cells in the blood vessels to play a very important role in the tumor progression of IDCs.

A subset of breast invasive ductal carcinoma with distinctive cytomorphology, aggressive clinical behavior, and unique immunologic profiles

BACKGROUND

Invasive ductal carcinoma of the breast is a heterogeneous collection of divergent types of carcinomas. Some subtypes have been characterized by histologic observations. This study describes a distinctive subset recognized through cytomorphologic examination of breast carcinoma specimens obtained by fine-needle aspiration biopsies (FNAB). Identification of this subset is established further by analyses of its clinical and immunologic characteristics.

METHODS

One hundred patients underwent FNAB and were diagnosed with breast ductal carcinoma. These diagnoses were followed by surgical resections and histologic evaluation of tumors. Immunohistochemical analyses of estrogen receptor, progesterone receptor, Her2/neu, p53 protein, and Ki-67 were performed. Patient's age, race, and family history of breast carcinoma were obtained. The objective of the study is to identify a cytomorphologically distinctive, clinically relevant, subset of breast carcinomas.

RESULTS

A subset carcinoma was recognized by cytomorphologic examination of Pap-stained FNAB slides. This subset consisted of seven patients with a median age of 37 years. At the time of surgical resection, all patients had axillary lymph node metastases. Six of seven patients had distant metastases. Immunohistochemical studies revealed that all tumors are positive for p53 protein and negative for estrogen and progesterone receptors.

CONCLUSION

This study presented a unique subset of breast ductal carcinomas that involved young patients and had aggressive growth behavior. These tumors expressed p53 protein but not estrogen and progesterone receptors.

Long-term prognosis of teenagers with breast cancer

We report 4 new cases of breast carcinoma in teenage girls diagnosed by use of histochemical and immunohistochemical methods. These cases of breast carcinoma in women under 20 years of age were found in the files of our department in the last 24 years (1976-2000). The patients had operable breast carcinomas corresponding to various histologic types (1 invasive ductal carcinoma associated with fibroadenoma, 2 secretory carcinomas, and 1 invasive lobular-type carcinoma). Simple mastectomy with low axillary lymph node dissection was performed in 2 postpubertal patients. Only 1 patient received adjuvant chemotherapy (case 4). After follow-up ranging from 76 to 126 months, 3 patients are alive and disease-free and 1 has disseminated metastatic disease. The correlations with prognosis-related risk factors (stage, age, previous benign lesions, family history, histologic types, hormonal receptors, and pregnancy) were examined.

Clinical significance of glucose transporter 1 (GLUT1) expression in human breast carcinoma

Glucose uptake and glycolytic metabolism are enhanced in cancer cells compared to normal cells and tissues. Increased expression of glucose transporter 1 (GLUT1) has been reported in human malignant cells. The aim of this study is to determine the expression of the facilitative glucose transporter protein GLUT1 in human breast carcinomas and a possible correlation between GLUT1 expression and clinical outcome including disease-free or overall survival. One hundred consecutive formalin-fixed, paraffin-embedded sections of invasive breast carcinomas were evaluated by means of immunohistochemical staining of GLUT1. Forty-seven (47%) of 100 breast carcinomas showed positive staining for GLUT1. Expression of GLUT1 correlated significantly with nuclear grade (P < 0.001), estrogen receptor status (P = 0.002), and progesterone receptor status (P = 0.001). The mean disease-free survival periods of GLUT1-positive and -negative patients were 47 +/- 2.4 months and 54.3 +/- 1.3 months, respectively (P = 0.017). The mean overall survival periods of GLUT1-positive and -negative patients were 48.7 +/- 2.2 and 56.1+/- 1.3 months, respectively (P = 0.043). In the multivariate analysis, disease-free survival correlated significantly with GLUT1, tumor size, and lymph node involvement (P = 0.043, P = 0.014, and P = 0.045, respectively). In analysis of overall survival, however, lymph node involvement, tumor size, and nuclear grade were statistically significant (P = 0.024, P = 0.023, and P = 0.003, respectively). Our data suggest that absence of GLUT1 expression significantly increases disease-free survival. These findings demonstrate that GLUT1 expression in breast carcinoma can be a marker of aggressive biological behavior and identifies a worse prognosis in breast carcinoma patients.

Pathobiology of preoperative chemotherapy: findings from the National Surgical Adjuvant Breast and Bowel (NSABP) protocol B-18

BACKGROUND

Examination was performed on pathologic material from patients enrolled in the National Surgical Adjuvant Breast Project (NSABP) protocol B-18, in which the clinical effects of preoperative (preop) and postoperative (postop) doxorubicin and cyclophosphamide (AC) were compared.

METHODS

Of the total number of 1523 patients, 1234 patients (81%) were in the pathologically evaluable cohort. Six hundred twenty-six patients had been randomized prospectively to receive AC postop and 608 had been randomized to receive AC preop. Preentry diagnosis was made by fine-needle aspiration (FNA) and/or Tru-cut biopsy (TC). AC-induced and other pathologic changes were identified, and their relation to pathologic response and overall survival (OS) and disease-free survival (DFS) was determined. Frequencies of the number of lymph node metastases, their size, stromal reaction, and extracapsular extension (ECE) were compared in the two treatment groups, as was their correlation with OS and DFS. Survival estimates were based on 9 years of follow-up.

RESULTS

Approximately 13% of primary breast carcinoma cases exhibited both a clinical complete response (cCR) and a pathologic complete response (absence of invasive tumor [pCR]) to preop AC. An additional 7% of patients exhibited a pCR in the absence of a cCR. A pCR occurred in 38% of those patients determined to have achieved a cCR. Poor nuclear grade of the tumor cells in the pre-entry FNA and/or TC specimens significantly predicted a pCR. Patients with the latter exhibited a better OS and DFS compared with those with a pathologic partial response (presence of sparse invasive tumor [pPR]) or no pathologic response (pNR). Epithelial alterations considered to be induced in tumors by preop AC were comprised of types 1 and 2 giant cells with meganuclei, apocrine metaplasia, and cytoplasmic vacuolation. They had a high degree of specificity (range, 86-99%) but a low sensitivity (range, 7-38%). All were predictive of a pPR and were found to be related adversely to OS and DFS. A fibrous stromal reaction noted in tumors or their putative sites in the preop group was found to have only modest degrees of specificity (63%) and sensitivity (74%). Moderate/marked sclerosis of basement membranes of the ductal and ductular elements of the terminal ductolobular unit (TDLU) was significantly more frequent in nontumor-bearing areas of breasts from patients in the preop treatment group compared with those in the postop treatment group (67% vs. 48%; P < 0.0001). The degrees of change in the TDLU in patients in the postop treatment group were found to be unrelated to age. Lymphatic tumor extension in the primary tumor, as well as a positive lymph node status, were less frequent in the preop treatment group compared with the postop treatment group. The OS and DFS were nearly identical in both treatment groups, being 69% and 55% and 70% and 53% in the preop and postop treatment groups, respectively, at 9 years. A fibrous stromal response to lymph node metastases was found to be significant for DFS but not OS. ECE was similar in both groups (55% vs. 48%; P = 0.12). Only 1% of ECE was found to be related to axillary failure in both treatment arms combined. There was no significant difference with regard to the parameters of survival for patients in the postop treatment group whose lymph nodes contained micrometastases (< 2.0 mm) or mini micrometastases (< 1.0 mm) (the latter detected immunohistochemically with anticytokeratin), and a true-negative lymph node status (not immunohistochemically converted to positive). Conversely, there was no apparent difference with regard to OS in preop treated patients with lymph node micrometastases, mini micrometastases, and macrometastases (P = 0.19). Those with mini micrometastases had a significantly worse OS compared with those with a true-negative lymph node status (P = 0.0007). DFS remained worse for patients in that treatment group with micrometastases and mini micrometastases compared with those with negative lymph nodes, although it was better than that for patients with macrometastases (P = 0.02).

CONCLUSIONS

Poor nuclear grade of tumor cells in the preentry FNA or TC specimens in the preop group was predictive of a pCR. AC-induced meganuclear giant cells and apocrine changes and nuclear and histologic grades of the primary tumors also were found to be prognostically significant in patients in the preop treatment group, and the latter two variables were found to be significant for those patients in the postop treatment group. No evidence was found to support the need for axillary lymph node radiation for ECE of lymph node metastases. Extended pathologic or immunohistochemical procedures also appear to be unnecessary for the detection of lymph node mini micrometastases, at least when traditional postop chemotherapy is used. The adverse relation between such small metastases and OS and DFS after preop AC appears to be related to the timing of the chemotherapy administration rather than any pathobiologic reasons.

Cytological grading, apoptosis, and Bcl-2 protein expression in breast cancer

A prospective study was conducted on 27 cases of infiltrating duct carcinoma of breast diagnosed by fine-needle aspirate cytology (FNAC), subjected to mastectomy following the FNA diagnosis. Cytological grading, Bcl-2 score, and quantification of apoptotic cell count were done on FNA material. Next, the carcinomas were graded on the corresponding histopathological sections. The overall concordance between cytological and histological gradings was 77.7%, with maximum concordance in Grade I tumors and minimum in Grade II. The mean apoptotic rates were 0.59 +/- 0.722, 2.11 +/- 0.707, and 2.95 +/- 0.854 in Grades I, II, and III, respectively. Similarly Bcl-2 scores were 1.36 +/- 0.82, 0.22 +/- 0.13, and 0.14 +/- 0.116, in Grades I, II, and III lesions, respectively. When the cytological grade was correlated with histological grade alone, and subsequently along with Bcl-2 scores and apoptotic rates, there was a significant improvement from 0.662-0.713 (P value, 0.001).

Calcificações malignas da mama: correlação mamografia-anatomia patológica

Neste trabalho foram realizados 30 estudos de correlação entre os achados da mamografia e da anatomia patológica em 29 pacientes com tumores malignos na mama, cujas mamografias apresentaram calcificações relacionadas com as lesões. Os objetivos principais foram: verificar se as formas das calcificações corresponderam a tipos específicos de tumores e se as formas das calcificações estavam relacionadas aos locais onde eram formadas. Foram estudados dois aspectos objetivos das calcificações identificados nas mamografias: forma e distribuição. Este estudo concluiu que os carcinomas tipo comedo tiveram elevada freqüência de calcificações pleomorfas (95,5%) e padrão de distribuição ductal em 66,5% dos casos. Os carcinomas tipo cribriforme, quando não associados ao tipo comedo, evidenciaram somente calcificações arredondadas em 66,5% dos casos e predominância de distribuição indefinida (78,5%). Os tumores micropapilares, quando não associados ao tipo comedo, mostraram somente calcificações arredondadas em 66,5% dos casos e predominância do padrão de distribuição indefinido (66,5%). Nenhum tumor mostrou padrão de distribuição lobular. Calcificações amorfas na ausência de nódulo tumoral são suspeitas de carcinoma ductal infiltrante. De acordo com o padrão histológico arquitetural dos 30 tumores, 24 (80%) tiveram calcificações com as formas esperadas.

Pathologic analysis of tumor size and lymph node status in multifocal/multicentric breast carcinoma

BACKGROUND

For unifocal invasive breast carcinoma, increasing tumor diameter predictably correlates with a greater frequency of lymph node involvement, thereby facilitating treatment decisions. In invasive breast tumors presenting with multiple nodules, however, it is unclear whether tumor size correlates with lymph node dissemination in a similar manner.

METHODS

The authors analyzed a series of 101 invasive breast carcinomas presenting with multiple macroscopically apparent lesions (2 foci: n = 77; 3: n = 20; 4: n = 4). Two different assessments of the tumor size (diameter of largest focus and combined diameter of all the foci) were then correlated with the status of axillary lymph nodes. For comparison with unifocal tumors, the authors used both external and internal control series (the latter consisting of 469 patients from their institution). The associations between lymph node status, tumor size, and multifocality were modeled using univariate and multivariate logistic regression, for each modality of tumor size assessment.

RESULTS

The logistic curves for multifocal and unifocal tumors were significantly different when the largest diameter was used as a tumor size estimate. Multifocal cases had higher frequencies of lymph node involvement than unifocal lesions of similar size category. In a multivariate logistic regression, the odds ratio of positive lymph node status in multifocal versus unifocal cases was 2.8 using largest diameter as a tumor size estimate (P < 0.0001). When the combined diameter assessment was used, however, the regression curve of multifocal cases was similar to that of unifocal cases, and the frequency of lymph node positivity was not significantly different in multifocal versus unifocal cases of the same size (odds ratio, 1.4; P = 0.13).

CONCLUSIONS

The authors' results show that, if aggregate diameters are used, unifocal and multifocal breast carcinomas are similar with respect to frequency of regional lymph node metastasis. Currently used algorithms, which use the diameter of the largest nodule, result in understaging of multifocal breast carcinomas due to underestimation of actual tumor size.

Pure mucinous carcinoma of the breast: is axillary staging necessary?

BACKGROUND

Mucinous carcinoma of the breast (MCB) may be associated with a low risk of axillary metastases.

METHODS

To evaluate the incidence of axillary nodal metastasis in MCB, a review of all cases from January 1990 to July 2000 was performed. Pure MCB was defined as all tumor cells being completely surrounded by mucin. Patient demographics, tumor size, estrogen receptor status, total number of dissected lymph nodes, and incidence of nodal metastasis were studied. Deeper sections on the lymph nodes from the pure tumors were performed and stained with low-molecular cytokeratin.

RESULTS

Nineteen cases of pure MCB and 41 cases of mixed MCB were identified. Patients with pure MCB were older than those with mixed MCB. Tumor size and estrogen receptor status showed no statistically significant differences between the two groups. None of the patients with pure MCB demonstrated lymph node metastases, whereas 12 of 41 cases with mixed MCB demonstrated metastatic lymph node involvement.

CONCLUSIONS

Because pure MCB seems unlikely to metastasize, axillary lymph node staging in these patients may not be necessary. The presence of lymph node metastases strongly indicates the presence of a mixed MCB.

Atypical squamous metaplasia of seromas in breast needle aspirates from irradiated lumpectomy sites: a potential pitfall for false-positive diagnoses of carcinoma

The presence of squamous metaplasic cells is an uncommon finding in fine-needle aspiration (FNA) biopsies of the breast. We report that FNA smears containing atypical squamous metaplastic cells derived from the lining of seroma-type cavities following lumpectomy and irradiation in patients with breast cancer can be a potential pitfall for a false-positive diagnosis of recurrent malignancy. Four fine-needle breast aspirates from two adult patients with previous histories of invasive breast carcinoma were retrieved. One specimen was from a 56-yr-old female, while the remaining three FNAs aspirates were from a 75-yr-old female. Both patients presented with indurated cystic lesions arising at irradiated lumpectomy sites. The cytospins from the 56-yr-old patient showed markedly atypical cells having enlarged, degenerating, hyperchromatic nuclei and surrounding dense cytoplasm with sharp borders that were suspicious for carcinoma. A mastectomy revealed irradiation changes and atypical squamous metaplastic cells lining a cystic cavity consistent with a seroma, but there was no evidence of residual cancer. After three aspirations yielded "atypical" diagnoses, the second patient underwent core needle biopsies that also revealed changes consistent with a seroma cavity lined by atypical squamous metaplastic cells. We believe this is the first report of squamous metaplasia occurring in a seroma cavity following lumpectomy and irradiation of the breast. The squamous metaplastic cells in aspirates of these cystic lesions may display significant cellular atypia that can potentially result in a false-positive diagnosis of malignancy.

Prognostic significance of tumor cell proliferation analyzed in fine needle aspirates from primary breast cancer

The objective of this study was to analyze the role of proliferating fraction (PF) measured with Ki-67/MIB-1 antibody in a large series of preoperative fine-needle aspirate (FNA) biopsies as a prognosticator of disease recurrence. The study comprised 732 patients who all had a conclusive cytological diagnosis of breast cancer. The follow-up time ranged from 1.2 to 10.2 years with a median of 5.7 years. In multivariate analysis Ki-67/MIB-1 value was a strong (p < 0.001) significant, prognosticator of disease recurrence free interval (DRFI) independent of lymph node status, progesterone receptor content, and tumor size. In the subgroup analysis of 430 node-negative patients the distant recurrence-free rate after 5 years was 94.4% in patients with Ki-67/MIB-1 value < 15% compared to 88.7% in patients with Ki-67/MIB-1 value > or = 15% (p = 0.03). Test of the interaction between tumor size and the value of PF revealed a p-value of 0.06. If the patients, in addition, had a tumor size >20 mm the distant recurrence-free rate after 5 years was 93.2% if Ki-67/MIB-1 < 15% compared to 80.7% in patients with Ki-67/MIB-1 value > or = 15%. This difference was statistically significant (p < 0.01). For patients with tumors <20mm Ki-67/MIB-1 value did not add any prognostic information. In the subgroup of 302 node-positive patients the distant recurrence-free rate after 5 years was 86.0% in patients with Ki-67/MIB-1 value < 15% compared to 70.6% in patients with Ki-67/MIB-1 value > or = 15% (p < 0.01). We conclude that PF assessed by Ki-67/MIB-1 antibodies in preoperative FNA biopsies has a significant prognostic value independent of lymph node status, PgR status and tumor size. To our knowledge, this is the first study demonstrating PF, which can contribute prognostic information when analyzed in preoperative smears.

Primary and metastatic lobular carcinoma of the breast

Invasive lobular carcinoma of the breast is the second most common type of primary breast cancer, accounting for 8-14% of cases, but is often difficult to diagnose early. It typically shows a diffuse pattern of infiltration within the breast, resulting in a variety of often subtle radiological appearances. A similar infiltrative pattern is seen in its metastatic form, with involvement of the gastrointestinal tract, peritoneum, retroperitoneum, bone marrow, meninges and uterus occurring more frequently than with the more common infiltrating ductal carcinoma of the breast. This pictorial essay illustrates the spectrum of radiological appearances which may be encountered with both primary and secondary lobular carcinoma.

Clinical and pathologic features of breast cancers in women treated for Hodgkin's disease: a case-control study

The goal of this study was to assess whether there are clinical or pathologic differences between radiation-associated breast cancers developing after treatment for Hodgkin's disease and spontaneously arising breast cancers. Clinical and pathologic data were reviewed for 26 Hodgkin's disease patients who received irradiation and subsequently developed breast cancer (cases) and 26 age- and stage-matched patients with sporadic breast cancers (controls). The median age at diagnosis of Hodgkin's disease was 21 years (range 11-40 years), and the median interval between Hodgkin's disease and breast cancer diagnosis was 15 years (range 4-27 years). There were no differences between cases and controls with regard to clinical factors. Cases had a lower frequency of histologic grade III tumors (38% versus 65%, p = 0.09) and moderate to marked mononuclear inflammatory cell reaction (11% versus 35%, p = 0.03). When these covariates were combined, grade III tumors in conjunction with mononuclear inflammatory cell reaction were also seen less frequently in the case group than in the control group (11% versus 31%, p = 0.06). Seven cases developed additional cancers, but no additional cancers developed in the control group (p = 0.01). Patients who developed breast cancers after Hodgkin's disease did not differ from patients with spontaneous breast cancers, with regard to clinical factors. However, the lower frequency of high-grade tumors and moderate to marked mononuclear inflammatory cell reaction among the cases suggests that radiation-associated breast cancers may differ from spontaneously arising cancers in their pathogenesis. Cases appeared to be at increased risk of developing additional cancers, but we cannot exclude surveillance as a possible contributing factor.

Early distant relapse in "node-negative" breast cancer patients is not predicted by occult axillary lymph node metastases, but by the features of the primary tumour

Early distant relapse occurs in a minority of node-negative breast cancer patients. Whether this poor prognosis can be predicted by the features of the primary tumour, or by the presence of occult metastases in the "negative" lymph nodes (LNs), remains a matter of debate. One hundred and four T(1-2)N(0)M(0) breast carcinoma patients were divided into two groups: group 1 (44%) showing early distant relapse with a median disease-free survival of 25 months, and group 2 (56%) showing no evidence of disease after a median follow-up of 91.5 months. All patients had received locoregional treatment only. All tumours were evaluated for medial/lateral location, histological type, size, grade, mitotic activity, fibrotic focus, necrosis, angiogenesis, growth pattern, and lymphatic vessel permeation. The haematoxylin and eosin-stained slides of all axillary LNs were revised and two additional levels were cut from each paraffin block for cytokeratin immunohistochemistry. In 24 patients (23%), occult metastases were found. These consisted of single cells or small clusters (SCs) in the marginal sinus in 17 patients (16%) and of larger colonies of cells in seven patients (7%). All detected metastases were smaller than 2 mm in diameter (micrometastases). There was no significant correlation between the presence of occult LN metastases (SCs or colonies) and the prognostically important features of the primary tumour. Early metastatic disease was significantly correlated with larger tumour size (p=0.02), higher histological grade (p=0.0008), mitotic activity (p<0.0001), presence of necrosis (p=0.0004), presence of fibrotic foci (p=0.0005), angiogenesis (p=0.0009), and lymphatic vessel permeation (p=0.018). Multiple logistic regression analysis showed that histological grade and the presence of a fibrotic focus were the only independent prognostic factors and that the presence of occult LN metastases was inversely correlated with early distant relapse. Prospective prognostic studies of occult LN metastases should consider the features of the primary tumour in a multivariate analysis.

Tubular Carcinoma of the Breast: A Population-Based Study of Nodal Metastases at Presentation and of Patterns of Relapse

Tubular carcinoma of the breast (TCB) is a recognized histologic variant of infiltrating ductal carcinoma (IDC) and has been considered to have a comparatively favorable prognosis. However, previous studies have been based on small numbers of cases, some pure TCB and some mixed histology, or have not employed an appropriate comparison group. In this study 171 pure TCB cases and a comparison group of 386 cases with grade I (well differentiated) IDC were identified in a population-based database maintained by the British Columbia Cancer Agency (BCCA). The proportion of cases with axillary nodal involvement at presentation was lower in TCB cases than in the grade I IDC comparison group (12.9% and 23.9%, respectively; p < 0.05). Low-risk tumors (T1 and without vascular lymphatic or perineural invasion) were more prevalent in the TCB patients than in the grade I IDC patients (66.7% and 60.0%; p < 0.05). Low-risk TCB cases had a significantly lower rate of nodal metastases at presentation than low-risk grade I IDC cases (7.0% and 13.2%; p < 0.05). Kaplan-Meier and log-rank analyses indicated a statistically significantly lower rate of local recurrence in TCB cases than among IDC cases (p < 0.05) and a trend toward a lower rate of systemic relapse in TCB cases (p = 0.07). However, no difference in disease-specific survival was observed between TCB cases and grade I IDC comparisons. We conclude that the biologic behavior of TCB was more favorable than that of a comparison group of IDC cases. In view of the low incidence of axillary node metastases at presentation in the low-risk TCB subset (7%), axillary dissection may be omitted as part of the initial surgical management in these patients.