Contralateral cancerous breast lesions in women with clinical invasive breast carcinoma

Modeling of the growth kinetics of occult breast tumors: role in interpretation of studies of prevention and menopausal hormone therapy

BACKGROUND

Autopsy studies report a reservoir of small, occult, undiagnosed breast cancers in up to 15.6% of women dying from unrelated causes. The effective doubling times (EDT) of these occult neoplasms range from 70 to 350 days and mammographic detection threshold diameters from 0.88 to 1.66 cm. Modeling of the biologic behavior of these occult tumors facilitates interpretation of tamoxifen breast cancer prevention and menopausal hormone therapy studies.

METHODS

We used iterative and mathematical techniques to develop a model of occult tumor growth (OTG) whose parameters included prevalence, EDT, and detection threshold. The model was validated by comparing predicted with observed incidence of breast cancer in several populations.

RESULTS

Iterative analysis identified a 200-day EDT, 7% prevalence and 1.16 cm detection threshold as optimal parameters for an OTG model as judged by comparison with Surveillance Epidemiology and End Results (SEER) population incidence rates in the United States. We validated the model by comparing predicted incidence rates with those observed in five separate population databases, in three long-term contralateral breast cancer detection studies, and with data from a computer-simulated tumor growth (CSTG) model. Our model strongly suggests that breast cancer prevention with anti-estrogens or aromatase inhibitors represents early treatment not prevention. In addition, menopausal hormone therapy does not primarily induce de novo tumors but promotes the growth of occult lesions.

CONCLUSIONS

Our OGTG model suggests that occult, undiagnosed tumors are prevalent, grow slowly, and are the biologic targets of anti-estrogen therapy for prevention and hormone therapy for menopausal women.

Predictors of contralateral breast cancer in patients with unilateral breast cancer undergoing contralateral prophylactic mastectomy

BACKGROUND

Although contralateral prophylactic mastectomy (CPM) reduced the risk of contralateral breast cancer in unilateral breast cancer patients, it was difficult to predict which patients were most likely to benefit from the procedure. The objective of this study was to identify the clinicopathologic factors that predict contralateral breast cancer and thereby inform decisions regarding performing CPM in unilateral breast cancer patients.

METHODS

A total of 542 unilateral breast cancer patients who underwent CPM at The University of Texas M. D. Anderson Cancer Center from January 2000 to April 2007 were included in the current study. A logistic regression analysis was used to identify clinicopathologic factors that predict contralateral breast cancer.

RESULTS

Of the 542 patients included in this study, 25 (5%) had an occult malignancy in the contralateral breast. Eighty-two patients (15%) had moderate-risk to high-risk histologic findings identified at final pathologic evaluation of the contralateral breast. Multivariate analysis revealed that 3 independent factors predicted malignancy in the contralateral breast: an ipsilateral invasive lobular histology, an ipsilateral multicentric tumor, and a 5-year Gail risk >or=1.67%. Multivariate analysis also revealed that an age >or=50 years at the time of the initial cancer diagnosis and an additional ipsilateral moderate-risk to high-risk pathology were independent predictors of moderate-risk to high-risk histologic findings in the contralateral breast.

CONCLUSIONS

The findings indicated that CPM may be a rational choice for breast cancer patients who have a 5-year Gail risk >or=1.67%, an additional ipsilateral moderate-risk to high-risk pathology, an ipsilateral multicentric tumor, or an ipsilateral tumor of invasive lobular histology.

The impact of bilateral breast cancer on the prognosis of breast cancer: a comparative study with unilateral breast cancer

BACKGROUND

The clinical significance of bilateral breast cancer is unclear and its influence on prognosis is controversial. We assessed the impact of synchronous and metachronous bilateral breast cancer on the prognosis compared with unilateral breast cancer.

METHODS

Between January 1, 1960 and December 31, 2001, 1,214 women were treated for primary operable breast cancers. Thirteen (1.1%) had synchronous bilateral breast cancer; 33 (2.7%) had a metachronous contralateral breast cancer. We compared age at operation, menopausal status, clinical stage, tumor size and histology, lymph node status, hormone receptor status, and use of adjuvant chemotherapy or hormone therapy, and we analyzed the impact of these factors on recurrence and survival in the 46 patients with bilateral breast cancer and the 1,168 patients with unilateral breast cancer.

RESULTS

The 5-and 10-year disease-free survival rates, respectively, were 65% and 65% in metachronous cases, 85.7% and 64.3% in synchronous cases, and 77.9% and 72.1% in unilateral cases. There was no significant difference in overall survival among the three groups. On multivariate analysis, metachronous bilaterality, tumor size, lymph node status and adjuvant hormone therapy were each independent risk factors for recurrence, whereas bilaterality of breast cancer did not influence overall survival.

CONCLUSIONS

Our data suggest that metachronous bilateral breast cancer is associated with shorter disease-free survival than synchronous bilateral or unilateral breast cancer, although overall survival does not differ among the 3 groups. Patients with metachronous bilateral breast cancer should be followed particularly closely in order to detect recurrence early and maximize quality of life.

Morphologically similar epithelial and stromal cells in primary bilateral breast tumors display different genetic profiles: implications for treatment

The morphologic features of primary bilateral breast carcinoma have been well elucidated, but it is not known whether tumors at two sides share a common genetic profile and undergo the same clinical course. To address this issue, morphologically comparable epithelial and stromal cells in 18 paired primary bilateral breast tumors were microdissected and subjected to comparisons for the frequency and pattern of loss of heterozygosity (LOH) and microsatellite instability (MI), as well as the profiles of comparative genomic hybridization. Of 18 paired bilateral epithelial samples assessed with 10 DNA markers at five chromosomes, 78 altered loci were found; of these, 23 (29.5%) displayed concurrent and 55 (70.5%) showed independent LOH, MI, or both. Of 18 paired bilateral stromal samples assessed with the same markers, 70 altered loci were seen; of these, 9 (12.9%) displayed concurrent and 61 (87.1%) showed independent LOH, MI, or both. Collectively, all the markers and 30 (83.3%) of 36 paired bilateral epithelial and stromal cells displayed significantly more (P < 0.01) independent than concurrent LOH, MI, or both. In contrast, the epithelial cells of a pulmonary small cell carcinoma metastasized to both breasts displayed concurrent LOH at each of the four altered loci. Of seven selected cases for comparative genomic hybridization, six (86%) displayed chromosomal changes, but none showed an identical pattern and frequency of changes in both breasts. The significantly higher rate of independent genetic alterations in morphologically comparable cells of paired bilateral primary breast tumors supports the notion that the development and clinical course of tumors in two sides differ substantially; consequently, different interventions might be needed for the optimal management of bilateral breast tumors.

Risk estimation for breast cancer development; a clinical perspective

Breast cancer is the commonest cancer among women and the second highest cause of cancer death. It remains a significant health problem and represents a significant worry for many women and their physician. During the last years, intensive research has been focused on accurate risk estimation for breast cancer development. The aim of these efforts is to identify the "high-risk" group of women for breast cancer development. Preventive strategies (including intensive surveillance, chemoprevention, or prophylactic mastectomy) may be applied for the women at high risk for breast cancer development. Given the many management options, it seems reasonable that management of the high-risk woman be tailored to the level of risk she is willing to accept. In estimating the risk for breast cancer development, several factors should be taken into account (including age, reproductive factors, such as age at menarche and age at menopause or pregnancy and age at first live birth, history of benign breast lesions or breast cancer in situ [LCIS/DCIS], prior history of breast cancer, history of familiar or hereditary breast cancer, and environmental and lifestyle factors). Recently, quantitative risk estimation is possible by combining multiple risk factors into a comprehensible risk expression; this is of significant clinical importance, since it will reduce the considerable variation in management among health care providers. The Gail and the Claus model are the most widely used models for quantitative risk estimation. However, the clinician should understand that all models have some limitations that should be recalled as they are applied. It should be emphasized that risk assessment is a serious undertaking and should only be performed by those who have in-depth knowledge about risk factors, family pedigree analysis, comparative statistics, genetics susceptibility testing and the science of probability.

Prophylactic mastectomy; evolving perspectives

It is not at all uncommon for surgeons dealing with breast disease to be confronted with the issue of prophylactic mastectomy. Recent advances in understanding the genetic basis of susceptibility to breast cancer and a better identification of the histological factors affecting a woman's lifetime risk of developing breast cancer have contributed to placing prophylactic mastectomy in a proper clinical perspective. Existing data suggest that prophylactic total mastectomy significantly reduces, but does not totally eliminate, the risk of subsequent development of cancer. However, the benefit of prophylactic mastectomy over alternative strategies (surveillance and chemoprevention) remains to be proven. Currently, prophylactic mastectomy may be considered in a few, carefully selected patients. The decision to perform a prophylactic mastectomy should be a multidisciplinary one. Detailed patient' counselling is very important; the patient should understand the limitations of prophylactic mastectomy and the need for postoperative follow-up. Furthermore, she should be well informed about the alternative strategies.

Evolving perspectives in contralateral breast cancer

Despite extensive publications reviewing contralateral breast cancer (CBC), the role of screening and preventative measures for contralateral tumours is controversial and optimal clinical management remains undefined. This paper addresses the incidence, the predisposing factors, the prevention and the treatment of bilateral breast cancer based on a review of the literature. Risk factors for CBC include young age at primary breast cancer diagnosis, hereditary breast cancer (due to a germline mutation), familial breast cancer (one or more affected relatives), radiation exposure at a young age, lobular carcinoma in situ (LCIS), lobular invasive carcinoma and multicentricity. Retrospective studies suggest that contralateral mammographic surveillance results in the early detection of breast cancer, but no clear survival benefit has been demonstrated. Trials of adjuvant tamoxifen in breast cancer patients have shown a reduction in the incidence of CBC in both pre- and postmenopausal women. In addition, breast cancer patients treated with ovarian ablation and prednisone have significantly reduced CBC versus controls. In patients with primary breast cancer there is no evidence that contralateral breast biopsies or contralateral prophylactic mastectomy reduce mortality. Randomised, prospective trials to determine optimal surveillance, prevention and treatment strategies for the contralateral breast in breast cancer patients have not been conducted. Based on the published literature, contralateral breast surveillance in breast cancer patients reasonably includes breast self-examination, regular physical examinations and annual mammography. In women who have no evidence of distant metastasis at the time of CBC diagnosis, we recommend that the CBC be treated in the same manner as a first breast cancer, taking into account prior local and systemic therapy.

Is steroid receptor profile in contralateral breast cancer a marker of independence of the corresponding primary tumour?

We compared oestrogen receptor (ER) and progesterone receptor (PgR) profiles between primary and corresponding contralateral breast cancer (CBC) to investigate whether CBC should be considered relapse of a primary or as a feature of the multicentric origin of breast cancer. We adjusted for patient age, menopausal status, histology and adjuvant therapy. In spite of the general application of a cut-off value to dichotomise ER and PgR, we considered them as continuous variables. Moreover, we considered as synchronous cancers only simultaneously occurring lesions. For 399 patients, ER and PgR receptor levels in primary and CBC did not differ significantly, but were significantly correlated within the same patient. The correlation was higher for synchronous than for metachronous lesions when considering ER, but not PgR. The correlation between ER and PgR levels in the same tumour (primary or CBC) appeared stronger than the correlation of either receptor type (ER or PgR) between primary and CBC. Age, histology and adjuvant treatment affected ER concentration, whereas age, menopausal status and histology affected PgR concentration. The analysis indicated that primary and CBC tend to be characterised by a similar steroid receptor profile. The finding may support the hypothesis of CBC as a second primary arising in a common predisposing milieu, rather than a primary-dependent contralateral lesion. In this light, the clinical management of patients with a bilateral breast cancer should be similar to that of a unilateral breast cancer.

Bilateral breast carcinoma versus unilateral disease. Review of 498 patients

In literature data, an uncertainty exists whether occurrence of bilateral breast cancer decreases the survival probability of affected patients. Therefore, we analyzed the medical records of 498 postoperatively irradiated (1977-1982) female breast cancer patients (T1-4,N0-3,M0). In the follow-up time, in 36 patients a bilateral breast carcinoma treated by surgery with or without radiotherapy was found. The 10-year overall survival rates were 54% in patients who had unilateral disease, compared with 56% in bilateral carcinoma patients, respectively. The incidence of metastasis did not differ between both groups: 24.2% versus 38.8%. Eleven percent of unilateral cancers recurred; in the other group, local failure of the first and second tumor was observed in 19.4% and 11.1%, respectively. We conclude that the occurrence of bilateral breast cancer has no significant impact on survival, although the development of local failures and metastases seems to be more frequent. The therapeutic strategy in bilateral carcinoma should resemble the treatment procedure in unilaterally affected patients.

Prognostic significance of in situ carcinoma associated with invasive breast carcinoma. A natural experiment in cancer immunology?

BACKGROUND

Our previous studies indicate that the in situ phase of mammary carcinogenesis is characteristically associated with cell-mediated immunity (CMI against an immunogen shared by most breast carcinomas. Such reactivity is inversely correlated with stage and appears to impede in situ-to-invasive progression and lethality from invasive breast carcinoma. If in situ carcinomas are indeed associated with ambient, prognostically favorable immunity against such an immunogen, one would expect lethality from invasive breast carcinoma to be reduced in patients with a diagnosis of a prior, simultaneous, or subsequent in situ breast carcinoma. The present study provides a test of such relationships.

METHODS

Patient survival was analyzed for 129,394 female patients with invasive breast carcinoma diagnosed in areas covered by the Surveillance, Epidemiology, and End Results (SEER) Program based at the National Cancer Institute (NCI). Patients were classified according to whether they had a prior, simultaneous, or subsequent in situ breast carcinoma and survival was examined for up to 15 years subsequent to diagnosis using life tables and the Cox regression model.

RESULTS

The findings indicate that patients with an invasive breast carcinoma who had a prior, simultaneous, or subsequent in situ breast carcinoma did experience significantly better survival than comparison groups of patients who either did not have an associated cancer of any type, had an associated invasive breast carcinoma, or had an in situ or invasive cancer of non-breast origin.

CONCLUSIONS

Our prior and current observations warrant more direct studies of the prognostic, therapeutic, and prophylactic significance of the in situ carcinoma-associated type of specific CMI in breast cancer patients.

Chromosome abnormalities in bilateral breast carcinomas. Cytogenetic evaluation of the clonal origin of multiple primary tumors

BACKGROUND

Although acquired somatic mutations presumably are crucial in carcinogenesis, nothing is known about the chromosome aberrations of bilateral breast carcinomas.

METHODS

Eighteen specimens from 16 bilateral carcinomas were analyzed cytogenetically. The banding analysis was supplemented with fluorescence in situ hybridization with painting probes.

RESULTS

In two cases, the finding of the same clonal abnormalities in samples from both breasts indicated that the bilaterality had arisen through a metastatic process. In the remaining cases, the absence of similarities between the two sides indicated an independent origin of the two carcinomas. Also, in multifocal lesions within the same breast, examples were found both of karyotypically related and unrelated clones. Altogether, multiple clones without similarities were detected in nine specimens, sometimes together with other, karyotypically related clones. There was no indication that bilateral carcinomas of the breast are cytogenetically different from unilateral ones. The following chromosomal abnormalities were recurrent: der(1;16)(q10;p10), del(1)(q11-n12), del(1)(q42), and del(3)(p12-n13p14-n21).

CONCLUSIONS

Bilateral breast carcinomas have the same cytogenetic aberrations, including evidence of polyclonality, as unilateral carcinomas. The majority apparently arise independently, but some result from a metastasis from one breast to the other. In this sense, bilateral breast carcinomas are similar to multifocal breast cancer in general, of which bilateral tumors may represent a special case.

Selection of women at high risk of breast cancer using two lifestyle markers: a case control study

OBJECTIVE

To select a population of women with high risk of invasive breast cancer by using two markers of high risk lifestyle--age at first delivery > = 25 and daily alcohol intake > = 7 g.

DESIGN

Case control study based on a structural interview.

SETTING

Two general practices in Copenhagen, Denmark.

PARTICIPANTS

30 patients with invasive breast cancer and 30 age-matched controls.

MAIN OUTCOME MEASURE

The combined selection power of the two markers of high risk lifestyle.

RESULTS

The combined selection power of the two markers was significant (P < 0.025, odds ratio 4.3, 95% CI 1.2-15.6).

CONCLUSION

Using these markers it may be possible to select about 80% of all cases of invasive breast cancer in a high risk group comprising only 49% of the female population. This could be of importance for mammography screening; rather than unselectively screening all women in a given age bracket, it might be preferable selectively to screen only the high risk group.

Prevalence of aneuploidy, overexpressed ER, and overexpressed EGFR in random breast aspirates of women at high and low risk for breast cancer

Breast tissue biomarkers which accurately predict breast cancer development within a 10 year period in high risk women are needed but currently not available. We initiated this study to determine 1) the prevalence of one or more breast tissue abnormalities in a group of women at high risk for breast cancer, and 2) if the prevalence of biomarker abnormalities is greater in high risk than in low risk women. Eligible high risk women were those with a first degree relative with breast cancer, prior breast cancer, or precancerous mastopathy. Low risk women were those without these or other major identifiable risk factors. Ductal cells were obtained via random fine needle aspirations and cytologically classified. Biomarkers included DNA ploidy, estrogen receptor (ER), and epidermal growth factor receptor (EGFR). The prevalence of DNA aneuploidy was 30%, overexpression of ER 10%, and overexpression of EGFR 35%, in the 206 high risk women whose median 10 year Gail risk (projected probability) of developing breast cancer was 4.5%. The prevalence of aneuploidy and overexpressed EGFR was significantly higher in the high risk women than in the 25 low risk controls (p < 0.002), whose median 10 year Gail risk was 0.7%. The difference in the prevalence of ER overexpression between high and low risk groups was not statistically significant (p = 0.095). This may be due to the low prevalence of overexpressed ER and the small number of controls. A significant difference was noted in the prevalence of one or more abnormal biomarkers between the high risk and low risk women (p < 0.001). A large prospective trial is needed to determine if one or more of these biomarkers, is predictive of breast cancer development.

The pattern of diagnosis of a second primary tumor in the breast

One hundred and sixty-seven patients with metachronous bilateral breast cancer were diagnosed at the Northern Israel Oncology Center during the years 1950-1989. The group at high risk to develop a second breast tumor included Jewish women born in Europe whose first tumor was diagnosed when the patient was under the age of 55. The mean time interval between tumors was 88 months. Seventy percent of the patients were diagnosed within nine years of the diagnosis of the first tumor. The characteristics of the 27% of patients with single breast cancers who did not comply with follow-up recommendations were compared to those who did comply. Patients who were under follow-up had smaller tumor and less lymph node involvement. Nevertheless, their survival rate did not differ from those who did not keep their follow-up appointments. This was ascribed to the fact that follow-up procedures for many years used mainly clinical examination and this was not enough to decrease mortality. The diagnosis of non-palpable breast cancer by routine yearly mammography has proved to reduce mortality in patients over the age of 50 with single breast cancers. Therefore, yearly mammography of the contralateral breast in patients with single breast tumors must be done in order to increase the cure rate of contralateral breast cancer. Less patient delay in diagnosis was found before the diagnosis of the second tumor than in patients with a single tumor.

Survival of first and second primary breast cancer

BACKGROUND

A second primary tumor (SPT) in the breast is the most common one seen in clinical practice. There are conflicting reports regarding the incidence and survival of patients with SPT in the breast.

METHODS

To elucidate this, data on 139,932 patients with primary breast cancer, reported to the Surveillance, Epidemiology, and End Results Program between 1973 and 1986, were analyzed. Of these, 3431 patients had a contralateral metachronous breast cancer (interval, > 6 months).

RESULTS

Survival from the date of diagnosis of the metachronous breast tumors was compared with that of patients with single breast tumors, controlling for age at diagnosis, stage, race, and treatment. In the multivariate analysis, age and stage at diagnosis of first and second tumors were the only variables that significantly influenced survival. The survival of patients with localized SPT was similar to that of patients with a localized single breast tumor. Patients with regionally advanced SPT lived for a shorter time than did corresponding patients with only one tumor.

CONCLUSIONS

Patients with single breast cancer were at increased risk of having a SPT in the breast. As a result, efforts for early detection by physical examination and mammography of survivors of single breast cancer are advocated because the survival of patients with a localized SPT in the breast is as good as that of those with a single localized tumor.

Metastatic pattern of infiltrating lobular carcinoma of the breast: an autopsy study

We analyzed the autopsy records and autopsy histological slides of 261 patients with breast carcinoma who died at the Institute of Oncology, Ljubljana, from January 1972 to October 1989, with particular attention to the metastatic pattern of infiltrating lobular carcinoma (ILC) which we compared with infiltrating ductal carcinoma (IDC). In 226 of 261 patients who died with metastatic disease there were 25 cases of ILC, 195 cases of IDC, 4 cases of mixed IDC-ILC, and 2 cases of mucinous carcinoma. There was no statistically significant difference in frequency of metastases to common metastatic sites, such as the liver, bone, and pleura, with the exception of the lungs, in which IDC metastases prevailed (P less than 0.006). By contrast, a statistically highly significant prevalence of ILC metastases to the peritoneum/retroperitoneum, hollow viscera, internal genital organs, leptomeninges, and myocardium was found (P values of less than 0.006- less than 10(-6). The metastases to these sites were characterized by diffuse growth of neoplastic cells that infiltrated in a lymphoma or leukemia-like fashion. Such metastases may remain clinically silent for a long time, in spite of their extensiveness. The difference of metastatic pattern between ILC and IDC is insufficiently appreciated in most of the published studies on ILC.

A comparison of the clinical metastatic patterns of invasive lobular and ductal carcinomas of the breast

Seventy seven patients with metastases from an invasive lobular carcinoma of the breast have been compared with 72 consecutive metastatic ductal carcinomas. There was no difference in the metastatic free interval between the two groups. A distinct pattern of clinical presentation of metastases was seen; hepatic (P = 0.01) and peritoneal metastases (P = 0.0003) occurred more commonly in lobular tumours. Bilateral cancers were more common in the lobular group (P = 0.01). No difference was seen in terms of meningeal and pulmonary metastases. Survival after metastases was significantly longer in patients with metastatic lobular carcinoma (P = 0.02).

Premorphological metabolic changes in human breast carcinogenesis

Malignant breast tissue is characterized by morphological and metabolic changes when compared with normal breast tissue. In this study, the cytochemical measurement of glucose-6-phosphate dehydrogenase (G6PD) activity was used to detect abnormal metabolism in breast tissue and to determine whether abnormal metabolic activity precedes morphological change during human breast carcinogenesis. Normal and benign breast tissue, morphologically normal tissue from cancer-containing breasts, and malignant breast tissue were studied. In malignant tissue, mean(s.e.m.) G6PD activity was significantly increased when compared with normal and benign tissue (9.69(2.3) versus 27.02(1.7) mean integrated extinction (MIE) x 100, P less than 0.01). G6PD activity was increased in morphologically normal tissue from cancer-containing breasts when compared with normal and benign breast tissue from breasts with no known cancer (27.02(1.7) versus 18.42(2.6) MIE x 100, P less than 0.05). These findings suggest that metabolic abnormalities precede morphological changes in breast carcinogenesis. Abnormal metabolism can be detected widely within a cancer-containing breast. The detection of such abnormality may prove helpful in identifying patients at high risk of developing breast cancer.

Natural history of in situ breast cancer in a defined population

The entire experience of in situ breast cancer in Alberta from 1953 to 1984 was examined. Of 243 patients coded, 226 were available for review by a panel of three pathologists. In 149 cases the diagnosis of in situ disease was confirmed. One hundred and eight patients had 109 ductal carcinomas in situ, 38 patients had lobular carcinomas in situ, with 3 patients having both. A multitude of treatments was used, ranging from local excision to radical mastectomy. Survival at a mean of 6 years follow-up was equal in all groups, with only two patients with a confirmed diagnosis of ductal carcinoma in situ dying from clinically suspected systemic disease. In patients treated by local excision, ipsilateral cancers were seen in 12% of ductal carcinoma in situ patients who had local excision and 13% of patients with lobular carcinoma in situ. Contralateral metachronous invasive cancers were seen in 6% of ductal carcinoma in situ patients and 3% of lobular carcinoma in situ patients. No lymph node involvement was seen in any of these patients, either with prophylactic dissection or in follow-up. The conclusion reached was that both in situ lesions are similar in their clinical course. Lymph node dissection is not necessary. Pathologic review is critical for accurate studies, with a change in diagnosis of 36% of diagnoses. Treatment does not appear to affect prognosis. The most appropriate treatment needs to be determined in prospective randomized trials.

Bilateral breast carcinoma treated with definitive irradiation

From 1977 to 1987, 30 women were treated with definitive irradiation following breast-conserving surgery for bilateral carcinoma of the breast for a total of 60 treated breasts. Eleven women presented with concurrent bilateral carcinoma, and 19 women had sequential bilateral carcinoma. Pathologic axillary staging was performed in 51 of the 60 treated breasts. A total dose of greater than or equal to 6,000 cGy was delivered from breast tangential irradiation plus an electron or Iridium boost to 95% (57/60) of the treated breasts. A third field was used to treat the regional axillary and supraclavicular lymph nodes bilaterally in three women (10%) and unilaterally in ten women (33%). Tangential fields were matched at midline in 17 patients, and in ten patients, the tangential fields overlapped by up to 3 cm on skin. In two patients, the tangential fields were matched to an internal mammary nodal field, and in one patient, tangential fields were matched to a mediastinal field given for postoperative radiotherapy for lung cancer. For the overall group of 30 patients, the 5-year actuarial NED survival following treatment of the first breast cancer was 79%, and the 5-year actuarial relapse-free survival was 72%. For the 60 treated breasts, the 5-year actuarial local failure rate was 6%. An analysis of complications and cosmesis showed results similar to previously reported results for unilateral breast cancer. These results show that definitive irradiation following breast-conserving surgery for patients with bilateral breast cancer can technically be delivered with low complication rates and with acceptable survival and local control rates. Definitive irradiation should be considered as an acceptable alternative treatment to bilateral mastectomy for appropriately selected patients with concurrent or sequential bilateral early stage carcinoma of the breast.

Primary synchronous bilateral breast cancer: epidemiological approach

Twenty-eight (1.69%) cases of primary synchronous bilateral breast cancer (PSBC) out of 1,654 new cases were studied. PSBC compared with unilateral cases had a significantly higher (p less than 0.001) first degree family history of breast cancer; high frequency of subareolar location; no predominance of lobular and non-invasive types; no significantly different percentage of pathological stage I presentation. As there is no complete agreement on what constitutes a PSBC, studies should be carried out to formulate a more precise definition of this entity.

Prognosis in bilateral breast cancer. Effects of time interval between first and second primary tumours

Survival rates for 67 women with bilateral breast cancer were compared to those for 1282 women with unilateral disease in a follow-up of 1349 women participating in a population-based study. Relative survival at 8 years of follow-up was 69% for women with unilateral disease as compared to 53% for women with bilateral cancer. When possible confounding histopathological differences--data about which were prospectively collected--and age were adjusted for in a multivariate analysis, the relative hazard rate was significantly higher for women with bilateral versus unilateral breast cancer (P = 0.006). The impact of interval time between the two primaries was analysed and a roughly two-fold higher hazard rate was seen for synchronous cancers with regularly falling risk for increasing interval times. This trend was however not statistically significant. The results indicate that the two tumours contribute independently to the patient's excess risk of dying and thus occur as two seemingly biologically unrelated events with respect to the tumour-host relationship and metastatic behaviour.

In situ carcinomas of the female breast. Incidence, clinical findings and DBCG proposals for management

In situ carcinomas of the female breast (CIS) include lobular carcinoma in situ (LCIS) and ductal carcinoma in situ (DCIS). Also associated are controversial forms of epithelial hyperplasia, lobular cell atypia (ALH) and ductal cell atypia (ADH). Based upon recent Danish autopsy studies, it has been estimated that about 25% of all women will develop in situ carcinoma, predominantly in the form of DCIS. Only a fraction of these lesions will evolve into a clinical manifest form, however. Thus, in a clinical setting, the frequency of CIS is 0.09 cases per 1,000 woman-years for a Danish female population aged twenty years or more. The lifetime risk of having CIS demonstrated is estimated at 0.53% for women in this age group. CIS makes up a few per cent of all newly diagnosed breast cancers in Denmark. Enforced employment of mammography in the early detection of breast cancer will increase CIS incidence from about 4-6% to about 9-10% of all newly diagnosed breast cancers, and aggressive DCIS growths will mainly constitute the increment. In concurrence with the new DBCG protocols in 1988, new strategies for the management of in situ carcinomas, based upon histogenetic types and growth patterns, are being introduced. The aim will be breast-conserving treatment whenever it can be achieved.

The growth pattern of in situ carcinoma in the female breast

The histopathological growth pattern of in situ carcinoma in the female breast is divided into three forms: 1) microfocal, 2) diffuse, and 3) tumour forming. This classification is clearly correlated to our diagnostic findings and forms furthermore the basis for our planning of treatment, as the growth pattern is probably of prognostic relevance.

Breast cancer and atypia among young and middle-aged women: a study of 110 medicolegal autopsies

In 110 consecutive, medicolegal autopsies of young and middle-aged women (range 20-54 years) the breasts were examined by an extensive histopathologic method and by correlative specimen radiography. Malignancy was found in 22 women (20%) of which only one was known to have had clinical invasive breast cancer (IBC). At autopsy 2 women had IBC (2%), the remaining in situ carcinoma (in situ BC) of microfocal type (18%), i.e. 15 (14%) intraductal carcinomas (DCIS), 4 (3%) lobular carcinoma in situ (LCIS) and one (1%) both DCIS and LCIS. Forty-five per cent of the women with malignancy had multicentric and 41% had bilateral lesions. Forty-five per cent of all histologically confirmed malignant lesions were identified by specimen radiography. Adenosis, benign epithelial hyperplasia, papilloma and duct ectasia were positively associated with malignancy. In addition malignancy was significantly more frequent among women aged more than 40 years, with late age at first full-term pregnancy, with alcohol abuse and with steatosis or cirrhosis of the liver. The results suggest that clinically occult in situ BC are frequent in young and middle-aged women.

Feulgen DNA content and mitotic activity in proliferative breast disease. A comparison with ductal carcinoma in situ

Nuclear Feulgen DNA content was measured by cytophotometry and the number of mitoses per 40 high power fields was determined in hyperplastic and atypical hyperplastic lesions of fibrocystic disease in 18 patients, in ductal carcinoma in situ in 14 patients and in ductal carcinoma in situ associated with infiltrating carcinoma in 11 patients. These parameters were also investigated in the hyperplastic lesions accompanying ductal carcinoma in situ and ductal carcinoma in situ associated with infiltrating carcinoma. The nuclear Feulgen DNA content could not discriminate between atypical hyperplasia and ductal carcinoma in situ. Although differences in the mitotic count between hyperplastic and atypical breast lesions were not statistically significant, there was a statistically significant greater mitotic count in ductal carcinoma in situ alone or associated with infiltrating carcinoma. These findings suggest that the mitotic count is useful for the differential diagnosis between atypical hyperplasia and ductal carcinoma in situ. In addition, hyperplastic lesions associated with ductal carcinoma in situ, with or without infiltrating carcinoma, exhibited a statistically significant higher mitotic count than those in benign fibrocystic disease. Hyperplastic breast lesions exhibiting high mitotic counts may indicate the presence of a neighbouring ductal malignancy and suggest an increased proliferative activity in breast tissue in the neighbourhood of malignancy.

Radial scars in women with breast cancer

In 84 consecutive autopsies of women with a clinical diagnosis of invasive breast cancer, radial scars were found in the contralateral breast in 35 cases (42%) by an extensive histopathologic method. Four women had radial scars on the ipsilateral side in the breast tissue available from the primary surgical procedure or at autopsy. One woman had an invasive breast cancer with morphologic features compatible with but not diagnostic of transition from a radial scar. Of the six radial scars with carcinoma in situ occurring in three women, three were of ductal and three of lobular type. In the remaining cases only radial scars with a benign appearance were found except for two with atypical hyperplasia. The frequency of radial scars was significantly higher in women with fibrocystic disease (55%) compared to women without (24%). Contralateral primary invasive and in situ breast cancer occurred in 68%. No difference in the frequency of radial scars in women with and without breast cancer was found and radial scars were not associated with any specific type of breast cancer. Our findings do not indicate a higher malignant potential of radial scars than of fibrocystic disease. It is suggested that only radial scars containing high-risk epithelial changes such as atypical hyperplasia and carcinoma in situ are associated with an increased risk of subsequent breast cancer development.

Risk of contralateral breast cancer in Denmark 1943-80

The incidence of a second primary breast cancer in the contralateral breast among 56,237 women with a first primary breast cancer diagnosed between the years 1943-80 in Denmark was established. The relative risk (RR) for a breast cancer patient to get yet another breast cancer was studied, taking account of age, stage and treatment of the first primary breast cancer. Based on 345,573 women years at risk and 1,840 non simultaneous contralateral breast cancer cases the overall relative risk (RR) of invasive cancer in the contralateral breast following a first primary breast cancer, was found to be 2.8 (95% Confidence Interval (CI); 2.7-3.0). Among women who survived 10 or more years the risk was higher among those irradiated for the primary breast cancer (RR = 2.6) than among non-irradiated (RR = 2.0). In the large group of patients with localized disease the association with radiation was obvious for all ages combined (irradiated RR = 3.0, not irradiated RR = 1.6), but not obvious among premenopausal (age less than 45 years) and perimenopausal (age 45-54 years) women at primary breast cancer until followed for 20 years. The RR was higher among irradiated than non-irradiated post-menopausal (age greater than 55 years) women from the time of diagnosis of the first cancer, but was not significant after 14 years of follow-up. The probability for a woman diagnosed with breast cancer at 45 years of age or younger, of developing a contralateral breast cancer if surviving to the age of 75 years, is 25%. Close surveillance of the remaining breast of breast cancer patients is advised, especially if young or following an irradiated localized primary breast cancer.