Management of ductal carcinoma in situ with nipple discharge. Intraductal spreading of carcinoma is an unfavorable pathologic factor for breast-conserving surgery

Clinical implications of growth pattern and extension of tumor-associated intraductal carcinoma of the breast

Tumor specimens from 410 patients with primary invasive breast cancer were investigated to identify the clinically relevant features of tumor-associated intraductal component (IDC) surrounding invasive breast cancer. A tumor-associated IDC associated with invasive tumor was mostly localized between the tumor and nipple. Thus, segmental resection of breast tissue is suggested.

INTRODUCTION

The goal of the present study was to identify the clinically relevant features of tumor-associated intraductal component (IDC) surrounding invasive breast cancer.

PATIENTS AND METHODS

The tumor specimens from 410 patients with primary invasive breast cancer were investigated. The distance between the surgical margins and tumor edge (invasive and intraductal areas) was measured prospectively.

RESULTS

Of the 410 investigated patients, 395 were eligible for analysis. An IDC was observed in 241 specimens (61.0%) and was associated with a younger age at diagnosis, postmenopausal status, and positive estrogen receptor, progesterone receptor, and human epidermal growth factor 2 (HER2) expression status. Most cases with tumor-associated ductal carcinoma in situ (DCIS) were found in the upper-outer quadrants of the breasts. An extended intraductal component (EIC) tended to be present in the outer and lower quadrants of the breasts. In the study cohort of 187 patients with tumor-associated DCIS, 1496 surgical margins were investigated. IDC was associated with invasive tumor growth predominantly in the nipple direction. The nipple-associated growth of DCIS correlated with patient age > 40 years, tumor size ≤ 2 cm, poor histologic differentiation of the noninvasive and invasive components, and positive estrogen and progesterone receptor status and negative HER2 status.

CONCLUSIONS

Our data provide evidence that in patients with primary breast cancer, the EIC areas will be mostly segmentally localized between the invasive tumor and the nipple. Therefore, if EIC is present or assumed, surgery should consist of segmental resection of the breast tissue, at least in patients with breast cancer who are > 40 years old, with a tumor size of < 2 cm, and with hormone receptor-positive and HER2-negative, poorly differentiated tumors.

Significance of irradiation in breast-conserving treatment: comparison of local recurrence rates in irradiated and nonirradiated groups

Breast-conserving treatment (BCT) is a standard therapy for early breast cancer. Many reports have described the effectiveness of post-BCT radiation therapy. However, the post-BCT local recurrence rate of only 5% to 10% indicates that radiation therapy may be unnecessary in many cases. To accurately select those patients who do not require post-BCT radiation therapy, we investigated the significance of irradiation in BCT by comparing local recurrence rates in irradiated and nonirradiated patients, grouped according to clinicopathological criteria that we evaluated. The patients were divided into two groups: a previous-criteria group and a present-criteria group. The former group included 85 patients in whom only two factors were considered as the criteria for radiation therapy: margin-positivity and lymphatic metastasis-positivity. The latter group included 318 patients in whom three additional factors were also considered: lymphatic invasion, intraductal extension, and metachronous/synchronous bilateral breast cancer. The use of five clinicopathological factors rather than two as the criteria for irradiation led to an increase in the irradiation ratio from 47.1% to 63.2% and a decrease in local recurrence from 12.9% to 2.2%. Because of the short average follow-up period of this study, further careful, regular follow-up and randomized comparative studies are required. It may also be necessary to include the patient age and margin condition as mandatory criteria for irradiation.

Non-palpable and non-invasive ductal carcinoma with bloody nipple discharge successfully resected after cancer spread was accurately diagnosed with three-dimensional computed tomography and galactography

A case of ductal carcinoma in situ (DCIS) that was treated by partial mastectomy is reported. The operation was performed after accurate estimation of cancer spread by three-dimensional computed tomography (3D-CT). The patient was a 39-year-old woman without a palpable lump who had a bloody nipple discharge. Ultrasonography showed distended mammary ducts with intraductal components. Fine needle aspiration cytology revealed ductal carcinoma. Galactography showed two subsegmental ducts and peripheral branches in the upper-inner quadrant of the right breast. 3D-CT depicted a well enhanced segmental-clumped lesion including two subsegments of a duct lobular system shown in galactograms. DCIS was diagnosed and partial mastectomy following the video assisted thoracoscopic surgery (VATS) marker insertion was performed, after cancer spread was accurately diagnosed by 3D-CT guidance. DCIS resected by minimally sufficient partial mastectomy with negative surgical margins was diagnosed histopathologically.

Dynamic helical CT mammography of breast cancer

PURPOSE

The purpose of this study was to determine whether dynamic helical computed tomography (CT)-mammography could assist in selecting the most appropriate surgical method in women with breast cancer.

MATERIALS AND METHODS

Preoperative contrast-enhanced helical CT scanning of the breast was performed on 133 female patients with suspicion of breast cancer at the same time as clinical, mammographic, and/or ultrasonographic examinations. The patients were scanned in the prone position with a specially designed CT-compatible device. A helical scan was made with rapid intravenous bolus injection (3 ml/s) of 100 ml of iodine contrast material. Three-dimensional maximum intensity projection (MIP) images were reconstructed, and CT findings were correlated with surgical and histopathological findings.

RESULTS

Histopathological analysis revealed 84 malignant lesions and seven benign lesions. The sensitivity, specificity, and accuracy levels of the CT scanning were 94.6%, 58.6%, and 78.9%. Helical scanning alone revealed additional contralateral carcinomas in three of four patients and additional ipsilateral carcinomas in three of five patients. However, the technique gave false-positive readings in 24 patients. The preoperative CT-mammogram altered the surgical method in six patients.

CONCLUSION

Dynamic helical CT-mammography in the prone position may be one of the choices of adjunct imaging in patients with suspected breast cancer scheduled for surgery.

A Review of Mammary Ductoscopy in Breast Cancer

Breast carcinoma and hyperplasia are thought to start in the lining of the breast duct. Mammary ductoscopy is an emerging technique allowing direct visual access of the ductal system of the breast through the nipple. This article reviews and discusses the utility of mammary ductoscopy. Abnormalities can be identified successfully by mammary ductoscopy, and intraductal biopsy can be used when the tumor is a polypoid type. Ductal lavage using microcatheters is effective in identifying malignant cells in high-risk women and this has stimulated interest in exploring the role of mammary ductoscopy in breast cancer screening. Mammary ductoscopy combined with ductal lavage may have a role in the management of patients with nipple discharge, the guiding of breast-conserving surgery for cancer, and in screening for high-risk women. The addition of molecular and genetic analysis of cells obtained by mammary ductoscopy are likely to enhance the use of this technique. Mammary ductoscopy techniques are safe and appear useful for detecting abnormalities in the breast. The additional molecular biologic study or ductal lavage may enhance the ability to direct and limit subsequent surgery when removing the offending lesions.

Intraductal biopsy for diagnosis and treatment of intraductal lesions of the breast

BACKGROUND

Bloody nipple discharge is a significant clue in the detection of ductal carcinoma of the breast. In the past, pathologic diagnoses were obtained exclusively via excision, but recently developed mammoscopic techniques have been found to yield valuable information relating to the diagnosis of intraductal lesions.

METHODS

Mammary duct endoscopy (i.e., mammoscopy) was performed a combined total of 407 times for 295 patients who experienced nipple discharge. Intraductal breast biopsy (IDBB) under mammoscopic observation was performed in 193 intraductal papillomas (from a total of 107 patients) and 30 ductal carcinomas (from a total of 27 patients); IDBB was performed a combined total of 36 times in the 27 patients who had breast carcinoma and yielded 21 diagnostic specimens (58.3%). In addition, the therapeutic value of IDBB was assessed in 70 patients with intraductal papilloma who had undergone more than 3 years of follow-up; these 70 patients harbored a combined total of 75 intraductal papillomas.

RESULTS

IDBB correctly identified the presence of carcinoma in 9 of 27 patients (33.3%); 7 other lesions (25.9%) were placed in the suspected carcinoma (i.e., atypical papillary lesion) category, and 5 (18.5%) were identified as intraductal papillomas. Using IDBB, it was difficult to collect diagnostic specimens from patients with breast carcinoma, because of the location and weak tissue cohesiveness of these lesions compared with intraductal papillomas. The 193 intraductal biopsies performed on intraductal papillomas yielded only 20 specimens that were insufficient for diagnosis. IDBB exhibited therapeutic efficacy in 54 of 70 patients with intraductal papilloma (77.6%) who had more than 3 years of clinical follow-up. Therapeutic results tended to be less favorable for patients who had intraductal lesions in multiple duct lobular units.

CONCLUSIONS

Mammoscopy can contribute not only to the diagnosis of cases of nipple discharge but also to the treatment of intraductal papilloma.

Ductal carcinoma in situ

DCIS is a heterogeneous disease whose natural history is poorly defined. Screening mammography has increased the detection rate of DCIS, but we remain unable to identify cases of DCIS that will not progress to invasive carcinoma during an individual's lifetime. Genomics holds great promise in this regard, but prospective studies with long-term follow-up will be needed before concluding that a subset of DCIS is clinically insignificant. The varying intensity of treatment options for DCIS, ranging from mastectomy to excision, RT, and tamoxifen to excision alone, reflects the uncertainty about the natural history of DCIS as well as differing physician values regarding the impact of local recurrence. The extent of DCIS within the breast is the major determinant of whether the patient is a candidate for a breast-conserving approach, and contraindications to the use of breast conservation treatment and to the use of irradiation have been defined. The clinical decision-making process in DCIS would benefit greatly from improvements in our ability to convey information about the long-term risks and benefits of therapy, as well as the tradeoffs in health-related quality of life, to patients, and to incorporate their preferences into the decision-making process.

Endoscopic classification of intraductal lesions and histological diagnosis

BACKGROUND

To diagnose intraductal lesions endoscopically the Japanese Association of Mammary Ductoscopy classified the endoscopical appearance of lesions into three types. We investigated the correlation between endoscopic classification and histological diagnosis.

METHODS

From April 1998 to February 2001, we enrolled 129 female patients who were diagnosed histologically and whose intraductal lesions were detected by mammary ductoscopy. The endoscopic classification consists of three types. The polypoid type is a localized expansive lesion. This type is divided into two subtypes, the solitary subtype (solitary polypoid lesion) and the multiple subtype (multiple polypoid lesions). The combined type is polypoid lesion(s)coexisting with a superficial type. The superficial type is a superficial spreading lesion such as a continuous luminal irregularity accompanied by no obvious elevations.

RESULTS

There were 65 cases of breast cancer and 64 cases of benign papillary lesions. Fifty-four cases of benign papillary lesions and 7 cases of breast cancer were classified as the polypoid-solitary type. Seven benign cases and 13 cases of cancer were classified as the polypoid-multiple type. Two benign cases and 16 cases of cancer were classified as the combined type. Only one benign case and 29 cases of cancer were classified as the superficial type. There is significant correlation between endoscopical types and the histological diagnosis (p<0.0001).

CONCLUSIONS

Endoscopic classification is useful to diagnose intraductal lesions.

Detection of chromosomal aneusomy by fluorescence in situ hybridization for patients with nipple discharge

BACKGROUND

Breast carcinoma and precancer are believed to start in the lining of the milk duct or lobule. Ductography and fiberoptic ductoscopy (FDS) are used to identify abnormal intraductal lesions, although it is difficult to distinguish malignant from benign cases. Therefore, we studied the clinical usefulness of fluorescence in situ hybridization (FISH) analysis of a numerical aberration of chromosomes (aneusomy) using ductal lavage from patients with nipple discharge.

METHODS

We applied ductography and FDS to 90 women who had nipple discharge. Ductal lavages obtained from patients with positive ductography and/or FDS findings were subjected to cytology and FISH analysis using centromere probes for chromosomes 1, 11, and 17. Patients with samples that showed aneusomy in at least one of the three chromosomes were diagnosed as positive.

RESULTS

Histologic evaluation revealed 54 benign lesions and six malignancies. The sensitivity, specificity, and diagnostic accuracy were 33.3%, 88.9%, and 83.3%, respectively, for cytology and 100%, 100%, and 100%, respectively, for FISH.

CONCLUSION

The results demonstrated that FISH has a diagnostic accuracy comparable to cytology. This technique has 100% specificity is making a definitive diagnosis of malignancy in patients with indeterminate cytologic results, suggesting that FISH diagnosis can be a good adjunct to cytology.

Location and extent of positive resection margins and ductal carcinoma in situ in lumpectomy specimens of ductal breast carcinoma examined with a microscopic three-dimensional view

The location of positive margins in lumpectomy specimens for ductal carcinoma could be predicted due to the common pattern of the geographic relationship between the intraductal and invasive carcinomas. To test this hypothesis, 62 lumpectomy specimens for ductal carcinoma of the breast were submitted for this study. The specimens were microscopically examined by serially sectioning them into giant sections in a plane parallel to the chest wall (frontal plane). The margins were identified as proximal (closest to the nipple), distal (opposite to proximal), and peripheral (nonproximal or distal). We found that the location of positive or close margins was proximal in 6 cases, peripheral in 13 cases, and none were found to be distal. Ductal carcinoma in situ (DCIS) was found to be located in the area adjacent to the invasive carcinoma. The invasive carcinoma was located at the periphery of the intraductal carcinoma. All six specimens with invasive carcinoma without DCIS had free margins. Nine of 16 specimens (56%) with extensive intraductal carcinoma (EIC) component and 7 of 40 (18%) with DCIS but negative EIC contained positive or close margins involved by DCIS. One case with multifocal invasive carcinoma measuring 3.5 cm in diameter and with DCIS but EIC negative had margins involved by both DCIS and invasive carcinoma. In conclusion, in ductal carcinoma, invasive carcinoma arose at the peripheral areas of the DCIS. DCIS tends to spread toward the nipple and the peripheral margins of the resected specimens. Incomplete excision of the ductal carcinoma and the wide positive margins are most likely caused by the failure to estimate the extent and location of DCIS.

Routine operative breast endoscopy for bloody nipple discharge

BACKGROUND

Submillimeter endoscopes are now available and have been described to assist surgeons in the evaluation and management of symptomatic nipple discharge.

METHODS

To evaluate its potential use, a microendoscope (0.9 mm Acueity) was used on all patients in a single surgeon's practice who were undergoing nipple exploration for spontaneous hemoccult positive nipple discharge. This procedure was performed at the surgical resection of the symptomatic retro-areolar duct, and 27 patients underwent the endoscopy during the period from January 2000 to August 2001.

RESULTS

In 96% (26 of 27) of the patients, the endoscope was successfully introduced into the lactiferous sinus, and the proximal breast ducts were successfully visualized. A lesion accounting for the bleeding was seen in all 26 patients, with 70% (n = 19) having multiple intraluminal defects. Cancers were identified in two cases (7.4%), and in both cases, there was a more proximal papilloma in the same ductal system. Similarly, in 33% of the benign cases, both papillomas and usual or atypical ductal hyperplasia were present. Lesions were identified that extended up to 7.5 cm deep to the nipple. The deepest lesion was one of the endoscopically identified cancers in a patient with normal mammogram and breast ultrasound. Surgical resection could be directed by simple transillumination of the skin during endoscopy.

CONCLUSIONS

This series demonstrates the clinical feasibility of routine operative breast endoscopy in the management of bloody nipple discharge. The high incidence of multiple lesion identification suggests that the classic blind resection of a limited distance of duct in the retroareolar space may significantly underestimate the true extent of proliferative disease accounting for pathologic nipple discharge.

Is a one-step operation for breast cancer patients presenting nipple discharge without palpable mass feasible?

Although spontaneous nipple discharge without mass is a common complaint, only about 5-15% of patients with nipple discharge have cancer. The standard preoperative evaluations, including mammography, physical examination, ultrasonography and squeezing cytology, do not provide enough definite data to make a decision for surgery. We have investigated whether preoperative intraductal aspiration cytology and galactography supply sufficient information about the location and nature of the lesion, and have carried out a one-step operative procedure by adding frozen section diagnosis during surgery. A retrospective review of Kaohsiung Medical University Hospital patients presenting symptoms of nonpalpable mass was conducted from January 1989 to June 2000. The medical charts, pathology and cytology reports, and imaging studies were reviewed. Of 487 patients with spontaneous nipple discharge, 190 with pathologic discharge had complete preoperative galactography and intraductal aspiration cytology, and 176 received surgery. Fourteen cases with negative cytology and normal galactography, who had not had an operation, did not develop cancer during an average 7 years follow-up. The diagnostic accuracy rates of 35 cancer patients using galactography and cytology were 91.4% and 88.6%, respectively, and 97.1% in combination, which is better than those of 141 patients with benign lesions (77.3% and 84.4%, and 90.0% in combination, P<0.05). The results show a 91.5% preoperative diagnostic accuracy rate in all patients with nipple discharge, and can be used to discuss the diagnosis with the patient during the preoperative period. All 35 cases with cancer received the one-step procedure under general anesthesia. Sixteen patients received mastectomies, and the other 19 cases had ductolobular resections, depending on their preoperative evaluations and frozen section in pathology. There were no false positives or false negatives in frozen section when comparing permanent histology and residual cancer in mastectomy specimens. There were no symptoms of recurrence in any of the patients who had undergone the two different procedures during 7 years of follow-up. In patients with spontaneous nipple discharge without palpable mass, the preoperative intraductal cytology and galactography were reliable methods to evaluate intraductal lesions. The one-step procedure will be selected for those patients if the frozen section is added. The ductolobular resection with an adequate surgical margin should be the first choice for those nonpalpable breast cancers with nipple discharge. Due to the limited number of breast cancer cases studied, more cases and a long follow-up period are necessary in future.

Mammary ductoscopy for diagnosis and treatment of intraductal lesions of the breast

BACKGROUND

Mammary ductoscopy (mammoscopy) is an ideal diagnostic method for intraductal lesions. The usefulness of mammoscopy for intraductal lesions was evaluated.

METHODS

Mammoscopy was performed in 315 cases with nipple discharge. The mammoscopic findings of 46 breast cancer cases (47 lesions) and 109 intraductal papilloma cases (119 lesions) were compared with pathological findings.

RESULTS

Carcinoma was recognized by mammoscopy in 38 of 47 lesions (80.9%). Intraductal masses were detected by mammoscopy in 115 of 119 intraductal papilloma lesions. The shape of the mass was classified as hemispheric, papillary, or flat protrusion. The hemispheric and papillary shapes were most common in cases of intraductal papilloma and the flat protrusion type was most common in cases of carcinoma. The amount of material collected by intraductal biopsy under mammoscopic observation was smaller in carcinoma than in intraductal papilloma because the carcinoma lesions were usually located in peripheral duct-lobular units and had weak tissue cohesion compared with that of intraductal papilloma. Of 133 intraductal biopsies performed for 69 intraductal papillomas, 17 biopsies yielded material insufficient for diagnosis in. The effectiveness of treatment by intraductal biopsy was recognized in 38 of 46 intraductal papillomas in which clinical follow-up continued for more than two years (82.6%). The therapeutic results of biopsy were poor in cases of multiple intraductal masses in multiple duct-lobular units.

CONCLUSIONS

Mammoscopy contributes not only the diagnosis in cases of nipple discharge, but is also of benefit in the treatment of intraductal papilloma.

Image-guided surgery of small breast cancers

BACKGROUND

Widespread screening mammography has resulted in detection of many breast cancers smaller than one cm. Image-guided percutaneous needle sampling provides accurate diagnostic and prognostic information for adjuvant therapy. Less invasive methods based on imaging techniques are emerging as an alternative to wire localization and lumpectomy.

DATA SOURCES

Information presented in this overview was provided by seven investigators from five medical centers in the United States. These researchers are currently developing various techniques of image-guided percutaneous therapy of small (Tis, 1) breast cancers.

CONCLUSIONS

Several percutaneous treatment modalities for treatment of early breast cancer, either excisional or in-situ ablative, are described in this overview and their potential applications are discussed.

Nipple discharge: current diagnostic and therapeutic approaches

Nipple discharge is a complex diagnostic challenge for the clinician. A variety of diseases (such as intraductal papillomas, mammary duct ectasia, breast cancer, pituitary adenomas, breast abscesses/infections, etc.) can manifest as nipple discharge. The importance of nipple discharge for both the patient and the physician is the possible association of this condition with an underlying carcinoma. With heightened public awareness of breast cancer, an increasing number of women are asking their health care providers about nipple discharge. A detailed clinical evaluation is invaluable to determine the pathophysiology, assess the risk of malignancy, and plan treatment of the patient with nipple discharge. A combination of diagnostic tests, including mammography, breast ultrasonography, and possibly galactography can help the clinician to establish the diagnosis and plan proper management. Depending on the underlying breast pathology, a central or single lactiferous duct excision is the procedure of choice. Breast carcinoma associated with nipple discharge should be treated by either a modified radical mastectomy of breast-conservation therapy (i.e. duct-lobular segmentectomy with adequate, free margins [ideally>1cm], levels I and II axillary lymph node dissection, followed by breast irradiation).

A new method of margin evaluation in breast conservation surgery using an adjustable mould during fixation

AIMS

We have developed a new method of breast resection margin assessment in quadrantectomy using an adjustable mould to prevent the three-dimensional specimen from distorting during fixation.

METHODS AND RESULTS

The new method has been applied to 10 consecutive quadrantectomies (six invasive duct carcinomas, four duct carcinoma in situ with or without microinvasion). The precise configuration of the fixed specimen enabled pathologists to examine the side slices, the 5 mm thick slices cut parallel to the flat lateral margins of the specimen, permitting the separation of margin evaluation from tumour characterization. Eight cases with negative margins by our method would also be negative by assessment of inked margins since the margin widths were estimated to be from 5 to 30 mm (average 16.3 mm); two cases with positive margins would also be positive by inked margins.

CONCLUSIONS

Our new method was as reliable as the inked margins employing sequential slicing of the entire tissue, although it reduced the number of blocks by more than half in invasive carcinomas. A further advantage of this method is that the accuracy in margin evaluation is not influenced by the extent of tumour sampling. In addition, our system can pinpoint the positive margins facilitating re-excision to obtain tumour-free margins.

Computer-assisted complete three-dimensional reconstruction of the mammary ductal/lobular systems: implications of ductal anastomoses for breast-conserving surgery

BACKGROUND

The intraductal spread of breast carcinoma can occur along the mammary ductal/lobular systems (MDLS) with no invasion of tissues. Because ductal anastomoses in the MDLS are considered to be a possible risk factor for extensive intraductal spread of breast carcinoma, the architecture of the MDLS has important therapeutic implications for patients treated with breast-conserving surgery.

METHODS

An entire breast resected by subcutaneous mastectomy from a 69-year-old woman with ductal carcinoma in situ (DCIS) was examined in submacroscopic sections by stereomicroscopic and histologic techniques. Serial 2-mm sections underwent computer-assisted complete three-dimensional reconstruction of all MDLS.

RESULTS

The entire breast that was studied contained 16 MDLS that were arranged radially, with the nipple at the center. Of these 16 MDLS, 4 (25.0%) had ductal anastomoses whereas the remaining 12 MDLS had no ductal anastomoses and completely independent regional anatomy. Ductal anastomoses were observed at 11 sites in the 4 MDLS. The 2 of 11 ductal anastomoses that connected different MDLS (18.2%) were situated > 4 cm from the nipple. The remaining nine ductal anastomoses connected ducts within the same MDLS; their location varied from near the nipple to the peripheral region. In the specimen examined, DCIS extended only within a single MDLS and did not spread between different MDLS via ductal anastomoses.

CONCLUSIONS

To the authors' knowledge, the current study is the first time the complete architecture of all MDLS in an entire breast has been studied three-dimensionally. The risk of promoting the intraductal spread of disease during surgery may be greater when intraductal lesions extend more peripherally than centrally. The features of ductal anastomoses may provide a significant anatomic clue regarding negative surgical margins in breast-conserving surgery.

Pattern of distribution of intraductal and infiltrating ductal carcinoma: a three-dimensional study using serial coronal giant sections of the breast

The purpose of this study was to establish the 3-dimensional (3D) structure of the breast tissue and to study the distribution and relationship between the intraductal and infiltrating components of ductal carcinoma and other proliferative epithelial lesions of the breast. Thirty mastectomy specimens with infiltrating carcinoma less than 3.0 cm in diameter were serially cut in the coronal plane. Each giant section was divided into small sections for routine processing. Using Photoshop (Adobe) and PowerPoint (Microsoft) software programs, the routinely stained sections were scanned and assembled to reestablish complete giant sections of the breast and subsequently the 3D structure. Intraductal and infiltrating ductal carcinomas, epithelial hyperplasia with atypia, and marked epithelial hyperplasia without atypia were mostly confined to a single duct (27 cases), resulting in an increase in size of the involved breast segment. Three remaining cases included a case of Paget's disease with tumor appearing to spread from one duct system to another system through the epidermis and two cases with multiple separate foci of carcinomas located in different quadrants and accompanied by ductal spread in different lactiferous ducts. Both intraductal and infiltrating carcinomas were often located in the superficial segments (near the subcutaneous tissue) (28 cases). The infiltrating components were often located adjacent to area of pure intraductal carcinoma and were often peripheral (nearer the chest wall than the nipple). Intraductal carcinomas showed a "fanned out" pattern of distribution, frequently extended toward the nipple (with involvement of the nipple or subareolar tissue in 7 cases), and occasionally were seen in the breast tissue peripheral to the infiltrating carcinoma. Multiple ducts with intraductal carcinoma could be seen to be connected with each other with serial sections. However, in at least 6 cases, foci of intraductal carcinomas were separated from each other by segments of duct with benign epithelium. Breast carcinoma often arise from the breast segment close to the subcutaneous tissue. Infiltrating carcinoma lesser than 3.0 cm in diameter is usually located adjacent to the area of pure intraductal. The pattern of spread of intraductal carcinoma has a pyramid-like shape, with the summit toward and occasionally extending up to the nipple. These findings should be considered in the surgical strategy for segmental resections of breast carcinomas.

Detection of microsatellite alterations in nipple discharge accompanied by breast cancer

Nipple discharge in breast cancer cases was examined loss of heterozygosity (LOH). DNA samples were extracted from both supernatant and cell pellet components of the discharge, and examined for LOH at microsatellite markers, D11S1818, D11S2000, D16S402, D16S504, D16S518, D17S520, and D17S786. At least one LOH was found in either the supernatant or cell pellet in seven out of 10 patients (70%). Five of seven samples, which were cytologically negative, were LOH positive, and only one case, which was cytologically positive, showed no LOH on the markers examined. All three samples, which were judged 'negative' by CEA measurement (<400 ng/ml), were LOH positive. This method could be a useful novel diagnostic modality for nonpalpable breast cancer with nipple discharge.

Correlation of three-dimensional magnetic resonance imaging with precise histopathological map concerning carcinoma extension in the breast

This study was initiated to clarify the ability of magnetic resonance imaging (MRI) in defining breast carcinoma extension by comparing MRI to detailed histopathological analysis. Mastectomy (n = 14) or quadrantectomy (n = 44) specimens were sub-serially sectioned and mapped in detail in 58 breast cancer patients. Morphologically, we classified the lesions utilizing MRI into three patterns in relation to their histology. Numerically, we assessed the maximum distance of carcinoma extension using MRI, mammography, and ultrasonography (US). Linear regression was calculated for each of the three imaging measurements versus histopathological measurements. Three imaging patterns were observed by MRI, (1) localized (n = 30), (2) segmentally extended (n = 19), and (3) irregularly extended (n = 5). The localized pattern showed a distinct focal mass, but in 10 cases, microscopic ductal carcinoma in situ (DCIS), or invasive lobular carcinoma, which were not depicted by MRI, existed. The segmentally extended pattern showed diffuse enhancement along duct-lobular segments, forming a 'cone' shape. Histologically, pure (n = 4) or predominant (n = 10) DCIS was distributed segmentally. The irregularly extended pattern showed thick branches extending out from the index tumor which were histologically revealed to be stromal invasion of ductal carcinoma. From the results of linear regressions, MRI was the most accurate modality in histologically measuring the extent of the cancer. When cases were limited to patients who were classified into segmentally or irregularly extended pattern by MRI (n = 24), MRI was more accurate than mammography and US, even if they were combined (P < 0.05). MRI may provide additional information concerning carcinoma extension prior to surgery, especially in patients classified into 'extended patterns' by MRI.

Breast-conserving surgery for invasive cancer: a principle based on segmental anatomy

As the incidence of breast cancer increases in Japan, breast-conserving surgery becomes an important issue in the light of quality of life. We have demonstrated by 3-D reconstruction studies that ductal carcinoma in situ (DCIS) originates from the terminal duct-lobular unit (TDLU). Normal mammary epithelium anatomically located in the TDLU was shown to be biologically associated with cancerous change, particularly in specimens from patients who subsequently developed invasive carcinoma. Atypical ductal hyperplasia as well as DCIS expressed breast cancer associated antigen, providing further biological evidence that the atypical lesion at the TDLU are premalignant. Intraductal spread of carcinoma was defined as "DCIS was present clearly extending beyond the TDLU, or present prominently within the large ducts," and was classified into 3 grades according to the distribution of carcinoma in the duct-lobular system. We have developed a breast-conserving surgery consisting of quadrantectomy and regional lymph node dissection and immediate volume replacement using lateral tissue-flap (LTF). The quadrantectomy was employed on the basis of segmental anatomy of the duct-lobular system in which breast carcinoma originates. Fairly good cosmetic outcome as well as local control were obtained in the patients who underwent the immediate volume replacement using LTF. It must be emphasized that the quadrantectomy is a radical procedure in the sense that it aims at removal of all the carcinoma cells of the primary tumor.

Ductal carcinoma in situ-associated nipple discharge: a clinical marker for locally extensive disease

BACKGROUND

This study evaluates the diagnosis and treatment of women with pathologic nipple discharge caused by ductal carcinoma in situ (DCIS).

METHODS

Women with unilateral spontaneous bloody, serous, or brown nipple discharge who presented between January 1, 1988 and August 1, 1996 were identified by retrospective chart review. Women with nonspontaneous, physiologic discharge were excluded.

RESULTS

Two hundred seventy-seven women with a mean age of 59.5 years (range, 24 to 88 years) underwent duct exploration and biopsy for pathologic discharge, with 43 (15.5%) found to have DCIS. The discharge was bloody in 29, clear in eight, and brown in six women. Seven of 12 (58%) women with an associated breast mass were found to have a microinvasive component with the DCIS. Discharge cytology showed malignant cells in only two of 12 (16%) women examined. A ductogram was performed on 20 women, with filling defects seen in 10, ectasia in 3, narrowing in 4, and normal ducts in 3. The DCIS included 17 (40%) specimens with cribriform pattern, 17 (40%) micropapillary, 8 (18%) comedo, and 2 (2%) solid. Twelve microinvasive cancers were found in combination with DCIS. After duct exploration, 37 (86%) patients were found to have extensive or multifocal DCIS to the margin, or both, with 32 (74%) patients requiring mastectomy to achieve free surgical margins. There was residual disease in 27 of 32 (84%) mastectomy specimens after initial biopsy. Breast conservation was possible in only 11 (26%) women. Forty of 43 (93%) are disease-free with a median follow-up of 37 months.

CONCLUSION

Women presenting with pathologic nipple discharge require duct exploration regardless of cytologic or radiologic findings. When discharge is the result of DCIS, extensiveness of disease in relation to central location and intraductal spread may preclude breast conservation in as many as 27 of 43 (63%) cases.

Extensive intraductal component (EIC) and estrogen receptor (ER) status in breast cancer

The extensive intraductal component (EIC) of primary breast carcinoma is a special spread pattern observed in the breast. Extensive intraductal component may extend diffusely over the entire breast. Therefore, EIC is considered to be an important risk factor for local recurrence in breast-conserving therapy. However, the pathogenesis of EIC remains uncertain. Whether or not the estrogen receptor (ER) has an influence on its biologic behavior has not been fully studied. A consecutive series of 142 breast carcinomas submitted to the pathology department were examined on step gross sections of 5.0 mm thick. Extensive intraductal component was determined and divided into three types. Estrogen receptor was examined using both immunohistochemistry (ER-IHC) and enzyme immunoassay (ER-EIA). Extensive intraductal component was found in 78 of 138 (56.52%) invasive carcinomas including invasive ductal carcinoma with a predominant intraductal component. Estrogen receptor-IHC positivity was 42.96% (61/142) in the invasive breast carcinoma. Estrogen receptor positivity showed no significant difference between EIC-positive and -negative cases, as well as between EIC and invasive main tumor in the EIC-positive cases. But within the EIC-positive group, ER positivity was found to be higher in the peripheral type of EIC-II and EIC-III than in the central type of EIC-I (P < 0.05). Although ER may not play an essential role in the pathogenesis of EIC, it has shown some significance in the development of peripheral type EIC because of its higher presence in the peripheral type of EIC-II and EIC-III than in the central type of EIC-I.

Rapid Intraoperative Scrape Cytology Assessment of Surgical Margins in Breast Conservation Surgery

Rapid intraoperative scrape cytologic examination for diagnosing surgical margin involvement of specimens obtained by breast conservation surgery was evaluated. Four surgical margins(nipple side, two lateral sides and distal side)of the removed breast tissue were cytologically examined and histologically compared following segmentectomy in 50 breast cancer patients(200 margins). Intraductal carcinoma had a tendency to spread most extensively to the nipple, compared with other margins. The margin positive rate of tumors with ductal spread(DS)of over 20mm was significantly higher than in tumors with a DS under 20 mm(52.2% vs 7.4%)(P < 0.001). of 50 canditates 10 patients underwent total mastectomy due to positive margins on repeat cytologic examination after re-excision. Four of the 10 patients had an extensive intraductal component on microscopy. The sensitivity, specificity and accuracy of cytology were 96.4 %, 90.7% and 91.5%, respectively.Scrape cytology is useful to determine surgical margin involvement after segmentectomy for breast cancer, although overestimation of involvement will tend to result.

Breast-Coserving Surgery for Primary Breast Cancer: Immediate Volume Replacement Using Lateral Tissue Flap

We have developed a breast-conserving surgery consisting of quadrantectomy and regional lymph node dissection and immediate volume replacement using lateral tissue flap (LTF). The quadrantectomy was employed on the basis of segmental anatomy of the duct-lobular system in which breast carcinoma originates. Lateral skin incision was performed from the apex of mid-axillary line to the inframammary fold, without removing the skin overlying the tumor, In the early period of breast reconstruction embraced latissmus dorsi flap (LDF) for 10 patients(reconstruction was not performed on 35 patients), but in the late period we employed LTF for 56 patients. Four of the 101 patients developed ipsilateral breast cancer during a mean follow-up period of 48 months, but none died of breast cancer, Among the 56 patients with LTF replacement no patient developed ipsilateral breast cancer. Fairly good cosmetic outcome was obtained in the patients who underwent the immediate volume replacement. Breast-conserving surgeries are reviewed, and the surgical procedure using LTF for immediate volume replacement is described.

Recent Progress in Breast Conserving Therapy: From Experiences in Japan

Breast conserving therapy (BCT) was conducted in 22.1% of breast cancer patients in 1994 in Japan and is being performed with increasing frequency. According to the data already published, 10-27% of patients treated with BCT had a positive surgical margin. The recurrence rate in the breast is 1-2% annually, The 5-year overall survival in patients mostly consisting of stage I is 90% or higher at the present time. A case-control analysis of a multicenter study revealed that significant risk factors for breast recurrence were a positive surgical margin and absence of radiation therapy. Progress in basic research and diagnosis has also been instrumental in improving treatment results.

Controversies in the local management of invasive and non-invasive breast cancer

Since the recent acceptance of partial mastectomy (lumpectomy or segmentectomy) as equivalent to mastectomy for survival, design of the local management of breast cancers has centered around concerns of local recurrence. There has been wide acceptance of the tumorectomy or lumpectomy approach by most authors in North America, while in Italy, following the Milan trials, there has been a preference for a segmental or quadrantectomy approach. The latter preferentially includes more ductal tissue toward and distant from the nipple and has shown a local recurrence rate less than 50% as great as that seen with lumpectomy. Radiotherapy dosages and techniques are of concern as well. If extensive ductal carcinoma in situ is a determinant of local recurrence, and if DCIS spreads preferentially along ducts in a radial fashion, then the extent of DCIS is most likely to be preferentially arrayed toward the nipple as well as in tissue on the other side of a tumor mass away from the nipple--such has been our knowledge of the ramifications of the ductal tree, in a radial fashion around the nipple. Acceptable cosmesis after a segmental approach to excision may be more difficult to obtain, but has been acceptable in some groups of patients. We may soon see a situation in which the operation is tailored to the specifics of an individual patient. The size of a resection, based on an even margin around a tumor mass (lumpectomy) or the number of degrees subtended by the arc representing the peripheral aspect of a segmental excision will depend on the size of the dominant lesion being resected, the size of the breast and any available data concerning the likely extent of the lesion, with DCIS having a special concern.