Early breast cancer: part I: surgical pathology and preoperative assessment

A surgeon's view of oncology

The past thirty years has seen a profound change in emphasis and direction in the management of cancer. In many countries this has been away from traditional surgical management towards specialists trained primarily in medical oncology or radiotherapy. This trend has occurred despite the fact that surgery is still by far the most effective method of treatment of most common cancers. The effectiveness of sound cancer surgery and the importance of local disease control as an element in improving cure rates and palliation needs to be emphasised so that patients are not denied optimal treatment. The case for surgery can best be developed by encouraging special training and expertise in the field of surgical oncology, as one element in the provision of a surgical service for cancer patients.

Management and survival of female patients with "minimal" breast cancer: as observed in the long-term and short-term surveys of the American College of Surgeons

The American College of Surgeons' long-term breast cancer survey in 1978 included 16,894 pathologically confirmed carcinomas of the female breast, in situ or infiltrative, with negative or positive nodes. Of these, 1.9% were in situ carcinoma of any size, and 8.4% were minimal invasive carcinomas 1 cm or less in diameter. No significant difference was found between the survival of patients with in situ tumors of any size and minimal invasive tumors with negative axillary nodes measuring 1 cm or less in diameter. In patients with invasive tumors with negative axillary lymph nodes, no statistically significant difference was found in survival of patients with tumors of 0.5 cm or less, when compared either with survival of patients with tumors measuring 0.6-1.0 cm. Recurrence rates observed in those groups were not statistically significant. Among 157 patients with invasive tumors measuring 0.5 cm or less, 23.0% presented with axillary lymph node metastasis. Tumors measuring 0.6 to 1.0 cm showed 20.9% positive axillary nodes in 964 patients. Statistically significant differences in survival and recurrence rates were achieved only for invasive tumors smaller than 1 cm. Survival and recurrence rates were significantly better (P less than 0.001) in patients with minimal invasive cancer with negative axillary nodes (P less than 0.001) than rates of patients with invasive tumors larger than 1 cm and with negative lymph nodes. Similar statistical results were obtained for patients with positive axillary nodes only for invasive cancers smaller than 1 cm. However, survival and recurrence rates observed in invasive cancers of 1 cm or less with positive axillary nodes suggest that tumor size alone cannot be used as the only defining criterion for minimal invasive breast cancer. Only the status of axillary nodes may determine whether a small invasive tumor below 1 cm may be considered as minimal breast cancer.

Node-positive breast cancer: a comparison of clinical and pathological findings and assessment of axillary clearance

The Breast Adjuvant Chemotherapy Study of the Anti-Cancer Council of Victoria was set up to encourage the cooperation of clinicians from many centres who are involved in the management of early node-positive breast cancer in Victoria. Data sheets were completed by participants, and an analysis was made of the first 100 registered patients to determine the reliability of clinical assessment related to pathological findings and to study the extent of axillary node clearance. Although all subjects were histologically node positive, 47 had no palpable axillary lymph nodes, and in only 38 were nodes considered to be clinically involved. Correlation between clinical and pathological measurements of breast tumour size was significantly better (86%) with tumours over 5 cm in extent than with tumours of 5 cm or less (70%). Total mastectomy with total axillary clearance was the most common operative procedure performed. The pectoralis major was preserved in 97 and the pectoralis minor was divided or removed in 71 cases as part of the axillary clearance. In a subgroup (33) the location of involved nodes in the axilla was studied, and of these seven (21%) were found to have involved upper axillary nodes in the absence of lower axillary nodal involvement, emphasizing the inadequacy of axillary sampling in determining nodal status.

Metastatic carcinoma in axillary lymph nodes without pathologic evidence of a primary mammary lesion: a case report

A 56-year-old nullipara presented with a mass in the right axilla. Pathologically, two enlarged lymph nodes were found to contain metastatic adenocarcinoma consistent with a primary from the breast. Clinically, no breast mass was palpable, and xeromammography showed diffuse ductal hyperplasia and a small focus suggestive of malignancy. Modified radical mastectomy was done, and no tumor was found pathologically in the excised breast. The patient received local radiotherapy and is alive and well one year postoperatively. Attention is drawn to this rare occurrence, and patient management is briefly discussed.