In-situ breast cancer: the EORTC consensus meeting

Ductal carcinoma in situ is presumably not a metastatic disease: a reply to "Commentary: Wherein the authors attempt to minimize the confusion generated by their study 'Breast cancer mortality after a diagnosis of ductal carcinoma in situ' by several commentators who disagree with them and a few who don't: a qualitative study"

Ductal carcinoma in situ (dcis) is presumably not a metastatic disease [...]

Risk of Infiltrating Breast Cancer Subsequent to Lobular Carcinoma in Situ

The authors report on a retrospective consecutive multicentric series of 60 cases with histologic evidence of lobular carcinoma in situ (LCIS), followed for an average of 5.3 years. In the course of the follow-up, ipsilateral LCIS or infiltrating carcinoma occurred in 3 or 5 cases, respectively. Two LCIS reoccurrences and all ipsilateral infiltrating carcinomas were observed in 37 patients treated by limited surgery. Contralateral synchronous or metachronous carcinoma was observed in 3 or 2 cases, respectively (intraductal = 3, infiltrating = 2). Three patients died of breast cancer (2 with Ipsilateral, 1 with ipsilateral and contralateral infiltrating carcinoma). The study confirms the higher risk of ipsilateral and contralateral cancer in LCIS patients and warns about the possible hazards of limited surgery in these cases.

Intraductal Breast Carcinoma. Review of a Multicenter Series of 350 Cases

A multicentrer series of 350 intraductal breast cancers (DCIS) is reported. Mammography was the most sensitive test but suspicion arose only at palpation in 13% of cases whereas in 10% of cases biopsy was recommended for a benign lesion and DCIS was an unexpected finding. Mammography, physical examination and cytology must be combined to achieve optimal sensitivity. Systematic biopsy of apparently benign masses would increase DCIS detection rates but the cost-effectiveness of such a policy is questionable. A trend of conservative surgery was evident over time (from 1968-79, 28%; 1985-1989, 50%) but breast irradiation followed only in one fourth of the cases. The local recurrence rate was significantly higher in cases of limited surgery (with or without irradiation) with respect to mastectomy (1.2 vs 0.2 × 100 patient-years at risk). Most recurrences (7 of 8) in the conserved breast were infiltrating, but no recurrence was seen in subclinical DCIS cases. Three patients died of breast cancer after local recurrence in the conserved breast (2 cases) or mastectomy scar (1 case). Eligibility for conservative surgery of DCIS needs to be carefully discussed to avoid under-treatment. Contralateral breast cancer was recorded in 44 cases and the incidence of further metachronous cancer to the other breast was ten times higher than expected in normal breasts. Four patients died of contralateral breast cancer, free of ipsilateral recurrence. A careful follow-up of the contralateral breast in DCIS cases looks as important as surveillance of the conserved breast.

Breast Cancer Screening in Women over Age 50

Breast cancer screening with mammography is strongly advocated by some and rejected by others. Discussions in the medical literature focus on the beneficial and unfavourable effects of breast cancer screening. Among the latter are the suggested excess mortality rate of screen-detected breast cancer patients, the high number of unnecessary biopsies, the possibility of overdiagnosis and subsequent unnecessary treatment, and the occurrence of interval breast cancer cases. It is concluded that screening can to a certain extent prevent women from dying of breast cancer but some negative effects are unavoidable. However, adequate training of the screening team can minimize the number of unnecessary biopsies and the occurrence of interval cancers. Research is needed to evaluate the natural course of so-called ‘minimal’ lesions, and to optimize screening tests. The search for new (imaging) techniques is needed to detect lobular cancers in dense breasts.

Changes in CpG islands promoter methylation patterns during ductal breast carcinoma progression

Aberrant promoter methylation of several known or putative tumor suppressor genes occurs frequently during carcinogenesis, and this epigenetic change has been considered as a potential molecular marker for cancer. We examined the methylation status of nine genes (APC, CDH1, CTNNB1, TIMP3, ESR1, GSTP1, MGMT, THBS1, and TMS1), by quantitative methylation specific PCR. Synchronous preinvasive lesions (atypical ductal hyperplasia and/or ductal carcinoma in situ) and invasive ductal breast carcinoma from 52 patients, together with pure lesions from 24 patients and 12 normal tissues paired to tumor and 20 normal breast distant from tumor were analyzed. Aberrant promoter methylation was detected in both preinvasive and invasive lesions for genes APC, CDH1, CTNNB1, TIMP3, ESR1, and GSTP1. However, hierarchical mixed model and Generalized Estimating Equations model analyses showed that only APC, CDH1, and CTNNB1 promoter regions showed a higher frequency and methylation levels in pathologic samples when compared with normal breast. Whereas APC and CTNNB1 did not show differences in methylation levels or frequencies, CDH1 showed higher methylation levels in invasive tumors as compared with preinvasive lesions (P < 0.04, Mann-Whitney test with permutation correction). The analysis of APC, CDH1, and CTNNB1 methylation status was able to distinguish between normal and pathologic samples with a sensitivity of 67% (95% confidence interval, 60-71%) and a specificity of 75% (95% confidence interval, 69-81%). Our data point to the direct involvement of APC, CDH1, and CTNNB1 promoter methylation in the early stages of breast cancer progression and suggest that they may represent a useful tool for the detection of tumor cells in clinical specimens.

Nipple discharge: a sign of breast cancer?

INTRODUCTION

Nipple discharge is regarded a sign of breast cancer. Type of discharge and cytology are unreliable for diagnosis. Most malignant cases have a detectable breast mass. The aim of this study was to assess the association between nipple discharge and breast cancer.

PATIENTS AND METHODS

Patients who underwent operation for nipple discharge at a district general hospital (population 460,000) over a 3-year period were included. All had normal clinical, radiological and cytological examination. Operation and histopathology reports were reviewed.

RESULTS

Eighty-six patients underwent operation for nipple discharge. Median age was 54 years (range, 32-84 years). Analysis of nipple discharge revealed red blood cells (RBCs) in 35 patients (40%). At operation, 81 patients underwent radical sub-areola duct excision (Hadfield's procedure) and five microdochectomy. Histopathology reported duct ectasia in 59 patients and benign ductal papilloma in 25. Two patients had occult malignancy - DCIS (1) and LCIS (1). No invasive cancer was found.

CONCLUSIONS

Nipple discharge alone is not usually a sign of breast cancer. Occult malignancy is rare. A period of 'watchful waiting' may prevent patients undergoing unnecessary surgery.

Overdiagnosis and overtreatment of breast cancer: progression of ductal carcinoma in situ: the pathological perspective

Ductal carcinoma in situ (DCIS) is encountered much more frequently in the screening population compared to the symptomatic setting. The behaviour of DCIS is highly variable and this presents difficulties in choosing appropriate treatment strategies for individual cases. This review discusses the current data on the frequency and rate of progression of DCIS, the value and limitations of clinicopathological and biological variables in predicting disease behaviour and suggests strategies to develop more robust means of predicting progression of DCIS.

Imaging in situ breast carcinoma (with or without an invasive component) with technetium-99m pentavalent dimercaptosuccinic acid and technetium-99m 2-methoxy isobutyl isonitrile scintimammography

Introduction

The aim of the study was to retrospectively define specific features of the technetium-99m pentavalent dimercaptosuccinic acid (^99mTc-(V)DMSA) and technetium-99m 2-methoxy isobutyl isonitrile (^99mTc-Sestamibi [^99mTc-MIBI]) distribution in ductal breast carcinoma in situ and lobular breast carcinoma in situ (DCIS/LCIS), in relation to mammographic, histological and immunohistochemical parameters.

Materials and methods

One hundred and two patients with suspicious palpation or mammographic findings were submitted preoperatively to scintimammography (a total of 72 patients with ^99mTc-(V)DMSA and a total of 75 patients with ^99mTc-Sestamibi, 45 patients receiving both radiotracers). Images were acquired at 10 min and 60 min, and were evaluated for a pattern of diffuse radiotracer accumulation. The tumor-to-background ratios were correlated (T-pair test) with mammographic, histological and immunohistochemical characteristics.

Results

Histology confirmed malignancy in 46/102 patients: 20/46 patients had DCIS/LCIS, with or without coexistent invasive lesions, and 26/46 patients had isolated invasive carcinomas. Diffuse ^99mTc-(V)DMSA accumulation was noticed in 18/19 cases and ^99mTc-Sestamibi in 6/13 DCIS/LCIS cases. Epithelial hyperplasia demonstrated a similar accumulation pattern. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value for each tracer were calculated. Solely for ^99mTc-(V)DMSA, the tumor-to-background ratio was significantly higher at 60 min than at 10 min and the diffuse uptake was significantly associated with suspicious microcalcifications, with the cell proliferation index ≥ 40% and with c-erbB-2 ≥ 10%.

Conclusion

^99mTc-(V)DMSA showed high sensitivity and ^99mTc-Sestamibi showed high specificity in detecting in situ breast carcinoma (^99mTc-(V)DMSA especially in cases with increased cell proliferation), and these radiotracers could provide clinicians with preoperative information not always obtainable by mammography.

The diagnosis and management of pre-invasive breast disease: ductal carcinoma in situ (DCIS) and atypical ductal hyperplasia (ADH)--current definitions and classification

Intraductal epithelial proliferations of the breast are at present classified into three groups; distinction is made histologically and clinically between usual epithelial hyperplasia and atypical ductal hyperplasia (ADH) and between ADH and ductal carcinoma in situ (DCIS). Although evidence indicates that these boundaries are not ideal on a morphological, immunohistochemical, or genetic basis, this three-tier system is accepted and used at present. The current definitions, histological features, and system of classification of ADH and DCIS are described in this manuscript.

Extent of ductal carcinoma in situ within and surrounding invasive primary breast carcinoma

BACKGROUND

The aim of this study was to evaluate the pathological and morphological features of ductal carcinoma in situ (DCIS) within and surrounding invasive ductal carcinoma, and to investigate its relationship with clinical outcome and established prognostic variables.

METHODS

One hundred and seven patients with primary operable invasive breast carcinoma and associated DCIS treated by simple or subcutaneous mastectomy or wide local excision with radiotherapy were assessed. Those with pure DCIS and insufficient tumour available for examination were excluded. The most representative haematoxylin and eosin-stained sections from the remaining 91 samples were selected and examined at x 100 magnification using a 45-point, 2-mm grid graticule. The entire section was assessed and the cell under each point of the graticule was classed as either normal (a), DCIS surrounded by normal tissue (b), invasive tumour (c) or DCIS surrounded by invasive malignancy (d). The volume ratio of DCIS in the normal (b/(a + b)) and invasive (d/(c + d)) tissue was then calculated.

RESULTS

The DCIS volume within invasive tumour was not associated with outcome. The DCIS volume within adjacent normal tissue, however, was associated with local recurrence (P = 0.025), disease-free interval (P = 0.048), the occurrence of distant metastases (P = 0.019), death (P = 0.049) and disease-free survival (P = 0.048). Volume ratios of DCIS in normal and invasive tissue were not related to known prognostic factors including lymph node stage, grade, tumour size, vascular invasion or patient age.

CONCLUSION

There is a significant prognostic effect relating to the extent of DCIS associated with an invasive cancer, particularly with respect to local recurrence of tumour. This effect is restricted to the volume of DCIS in the tissue surrounding the invasive lesion rather than the intratumoral component.

Prospective comparison of stereotactic core biopsy and surgical excision as diagnostic procedures for breast cancer patients

OBJECTIVE

To determine whether stereotactic core biopsy (SCNB) is the diagnostic method of choice for all mammographic abnormalities requiring tissue sampling.

SUMMARY BACKGROUND DATA

Stereotactic core needle biopsy decreases the cost of diagnosis, but its impact on the number of surgical procedures needed to complete local therapy has not been studied in a large, unselected patient population.

METHODS

A total of 1,852 mammographic abnormalities in 1,550 consecutive patients were prospectively categorized for level of cancer risk and underwent SCNB or diagnostic needle localization and surgical excision. Diagnosis, type of cancer surgery, and number of surgical procedures to complete local therapy were obtained from surgical and pathology databases.

RESULTS

The malignancy rate was 24%. Surgical biopsy patients were older, more likely to have cancer, and more likely to be treated with breast-conserving therapy than those in the SCNB group. For all types of lesions, regardless of degree of suspicion, patients diagnosed by SCNB were almost three times more likely to have one surgical procedure. However, for patients treated with lumpectomy alone, the number of surgical procedures and the rate of negative margins did not differ between groups.

CONCLUSIONS

Stereotactic core needle biopsy is the diagnostic procedure of choice for most mammographic abnormalities. However, for patients undergoing lumpectomy without axillary surgery, it is an extra invasive procedure that does not facilitate obtaining negative margins.

Relationship between the morphological and biological characteristics of intraductal components accompanying invasive ductal breast carcinoma and patient age

We divided 324 cases with invasive ductal breast carcinoma into three age groups, and investigated the differences in proliferative activity and extension of the intraductal components among the age cohorts. Proliferative activity was expressed as the number of MIB1-positive nuclei per 1000 cancer cells in the intraductal components (MLI), and the intraductal component extension farthest from the invasive focus was defined as the maximum distance of ductal spread (MXDS). Moreover, analyses were conducted for three grade types, classified according to the classification system of ductal carcinoma in situ. The under-40 age group had significantly higher MXDS values than the other two age groups (p = 0.0280), and this trend was more marked in those with the non-high grade without necrosis type (p = 0.0045). The under-40 age group had higher MLIs, but the differences did not reach statistical significance (p = 0.0793). In regard to those with the high grade type, the under-40 age group had significantly higher MLIs than the other two age groups (p = 0.0269), and this trend was not significant in the cases with any other grade types. Associations between the age group and the margin status of the lumpectomy specimens were investigated in the 143 cases in which breast conserving surgery was tried. The under-40s had a significantly higher margin-positive rate in their lumpectomy specimens than the other two age groups (= 0.0362), and this trend was also seen in the groups with the non-high grade without necrosis type (p = 0.0256). These results confirm the importance of considering patient age when designing surgical procedures for breast conserving therapy.

Nucleotide sequence of a highly conserved region of the canine p53 tumour suppressor gene

An evolutionary conserved region of the canine tumour suppressor gene, p53, was PCR amplified and its DNA sequence determined. The 1003 bp fragment consisted of exons 5 to 8 and the intervening introns. A high level of sequence homology was demonstrated with human sequences, with the evolutionary conserved domains II, III, IV and V being identical.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ductal carcinoma in situ: assessment of necrosis and nuclear morphology and their association with biological markers

One hundred and five cases of pure ductal carcinoma in situ (DCIS) seen in the Guy's Hospital breast unit between 1975 and 1991 were reviewed. The presence and extent of necrosis and the degree of cytonuclear differentiation were assessed and the expression of p53 protein, cerbB2 protein, progesterone receptor, and a proliferation antigen KiS1, all factors reported to be of prognostic significance in invasive ductal carcinoma, was evaluated using immunohistochemical methods. A strong correlation was seen between the presence and extent of necrosis and the degree of cytonuclear differentiation and between both these morphological criteria and the biological markers as well as between the individual markers. The presence of extensive necrosis was associated with lack of cytonuclear differentiation and both were associated with a high proliferation rate, the presence of cerbB2 and p53 protein, and the absence of progesterone receptors. In cases with little or no necrosis, there was good nuclear differentiation and a strong correlation with the presence of progesterone receptor, absence of cerbB2 and p53 protein, and a low rate of proliferation.

Nucleotide sequence of exons 5 to 9 of the p53 tumour-suppressor gene of the donkey (Equus asinus)

The evolutionary conserved region of the equine homologue of the p53 gene from the donkey genome was PCR amplified and cloned. The 1380 bp fragment consisted of exons 5 to 9 and the intervening introns. The exonic and intronic DNA sequences showed a variable but high level of homology with previously published human sequences. The aminoacid sequences corresponding to the evolutionary conserved domains II, III, and V were identical to the human regions, whilst domain IV was 96% homologous.

Management of in situ and minimally invasive breast carcinoma

In situ breast carcinoma represents an early localized stage in the transition to invasive breast carcinoma and has an especially favorable prognosis with appropriate management. The widespread use of mammography has contributed to its increased rate of diagnosis. The two histologic forms of this entity have distinct pathologic and biologic characteristics, with different therapeutic implications. Lobular carcinoma in situ is considered a marker of increased risk for subsequent invasive carcinoma and is most commonly managed by nonoperative surveillance. Ductal carcinoma in situ behaves more as a true anatomic precursor of invasive disease and has the same therapeutic options as invasive breast carcinoma. Minimally invasive breast carcinoma should be considered a fundamentally different entity, primarily because of its potential for systemic metastasis that in situ lesions do not theoretically have. There are still many outstanding issues and dilemmas to be resolved by scientific investigation before the intriguing potential of these early forms of breast malignancy are fully understood.

Mammographic follow up: a vital component of breast cancer management

Women with proven breast cancer are at high risk for development of a second breast malignancy or a recurrence. An important component of clinical care is regular mammographic follow up, to enable preclinical diagnosis and avoid delay in treatment. One hundred and forty-two women with previous breast cancer attended a pilot mammographic screening program. Eleven had suspicious mammographic lesions, all clinically occult; nine breast cancers were diagnosed (two recurrences and seven new tumours). The cancer detection rate in this high-risk group of women was 6.3%, compared with 0.8% in 16,283 women screened with no history of breast cancer. Examination of the mammographic history of the 142 women showed that mammography was used infrequently as part of their clinical surveillance, and this led to a delay in diagnosis of the new or recurrent cancer. Recommendations for an appropriate regimen for use of mammography in new and established cases of breast cancer are made.

Molecular aspects of early stages of breast cancer progression

It is clear that breast cancer progression is associated with inactivation of a number of different recessive oncogenes. The most widely evaluated tumor suppressor gene, p53, is mutated in approximately 30-50% of sporadic breast cancers. Mutations usually occur early in malignant progression. Loss of heterozygosity (LOH) studies have identified numerous chromosomal regions where other recessive oncogenes relevant to breast cancer may be located. Each LOH is seen in a varying proportion of breast cancers and may appear either early or late in progression. High-grade ductal carcinoma in situ (DCIS) and invasive carcinoma have similar genetic lesions, showing that aberrations can occur before invasive disease. Direct evidence that the same aberrations can be acquired later in progression comes from a study of multiple metastases from the same patient; other studies found that primary invasive cancers are characterized by marked intratumor heterogeneity for each lesion examined. The model we propose to account for these results hypothesizes that multiple genetic lesions can accomplish each phenotype required for malignancy (i.e., dysregulated proliferation, invasion, angiogenesis, etc.) and that, for a given tumor, at least one aberrant gene for each phenotypic change is stochastically selected. Biological heterogeneity of breast cancer results from the stochastic acquisition of various genetic aberrations. We further propose that the lymphocytic reaction in high-grade DCIS may select for aggressive tumor subpopulations capable of escaping immune surveillance. Another aspect of tumor heterogeneity may be the multiple mechanisms employed by various tumors to escape immune surveillance.

Trends in the diagnosis of in situ breast cancer in the Detroit metropolitan area, 1973 to 1987

The recent increase in incidence in situ breast cancer has been marked by a higher detection rate among white women. Although the increase in incidence may reflect the concomitant uptrend in mammographic screening, the lower proportion of cases among black women is of major public health concern. Time trends in the diagnosis of in situ breast cancer were evaluated in a population-based analysis of data accrued from the Metropolitan Detroit Cancer Surveillance System. The proportions of in situ cases detected among all women with breast cancer were measured annually between 1973 and 1987, and the average interval percentage changes were calculated for eight subgroups of women stratified by race and age at diagnosis. Although the proportions of in situ cancers were generally higher among white than black women, the greatest increase in average interval percentage change was observed in the oldest age category of black women. The disparity seen in younger black and white women suggests possible implications for breast cancer screening. From 1973 through 1987, the largest increase in diagnosis of in situ breast cancer occurred in black women older than 70.

Impact of an Extensive in Situ Component on the Presence of Residual Disease in Screen Detected Breast Cancer

This study investigates the histopathological characteristics of a consecutive series of 100 screen detected breast cancers in relation to residual disease. Tumour type, size, grade, resection margins and extent of primary or associated in situ disease were all assessed by one pathologist. Thirty-seven women underwent further surgery (wider excision or mastectomy) and the resected specimen was examined for residual in situ or invasive cancer.

In total, 36 cancers had an extensive in situ component, of which 69% were predominantly intra-duct carcinoma of comedo type. Of the 37 women who underwent further resection, 21 (57%) women had residual cancer. Of those with initial disease at the resection margin, 16/25 (64%) had residual disease. Five of 12 (42%) with disease close to (within 2–3 mm) but not at the margin had residual disease. Of those with an extensive in situ component, 18/25 (72%) had residual disease, whereas only 2/12 (17%) women with none or some in situ disease had residual cancer.

In screen detected breast cancer, residual cancer was present in 72% of women with an extensive in situ component at initial surgery. These women comprise a group in whom conservation surgery may be inappropriate if completeness of excision is considered a prerequisite for breast conserving surgery.

Breast conservation, the problem of treating the excision site effectively: physical criteria for the choice of technique used

This paper examines how physical factors such as the depth of the excision cavity below the skin surface and its distance from the underlying lung may impact upon the choice between the use of an electron field (from a Varian Clinac 1800) or an implant (using a double plane of iridium-192 wires). Data have been derived from a phantom dosimetry experiment simulating different permutations of breast size and depth of excision cavity. An anthropomorphic female phantom with two different-sized wax breast phantoms has been used to simulate the clinical circumstances envisaged and isodose distributions have been estimated from an array of TLD readings. The biological significance of doses measured in skin and lung have been examined using the linear-quadratic (LQ) model. Both on physical and biological grounds, the results favour the implant under the experimental conditions adopted. The use of the electron beam to definitively treat the excision cavity (omitting breast tangents) to 60 Gy would result in unacceptable late effects in the skin and an observable incidence of pneumonitis if the excision cavity were near the chest wall. Small carcinogenic risks, particularly to the lung, are apparent with each modality, but may be moderated for the iridium-192 implant by a reduced carcinogenic potential associated with low-dose rate radiation. The use of the newer radionuclides iodine-125 and samarium-145, with less penetrating gamma ray emissions, might be preferred to iridium-192 from the point of view of bronchial carcinogenesis if definitive treatment of the excision cavity became widespread practice.

Results of treating ductal carcinoma in situ of the breast with conservative surgery and radiation therapy

To determine the frequency, pattern, and time course of tumor recurrence in the breast, the outcome of 38 women with ductal carcinoma in situ (DCIS) treated with conservative surgery and radiation therapy between 1976 and 1985 was studied. Surgery typically consisted of local excision without evaluation of the microscopic margins of resection. The median radiation dose to the tumor site was 6400 cGy. With a median follow-up time of 81 months, eight patients (21%) have experienced a recurrence in the breast. The time course to recurrence was protracted in some cases, with failures occurring at 17, 27, 43, 63, 71, 83, 92, and 104 months. The 5-year and 8-year actuarial rates of tumor recurrence in the breast were 8% and 27%, respectively. Seven patients had a recurrence at or near the primary tumor site, four with invasive carcinoma, and one had an invasive recurrence at a site elsewhere in the breast. No clinical or pathologic factor was significantly associated with an increased risk of recurrence, but the number of patients in the study population was small. The authors reached the following conclusions for patients with DCIS treated with conservative surgery and radiation therapy without careful mammographic and pathologic evaluation: (1) recurrence in the breast may be seen in at least one fifth of the patients; (2) recurrence typically occurs at or near the primary site; and (3) recurrence can occur long after treatment. Careful mammographic and pathologic assessment may be useful in reducing the local recurrence rate and should be considered essential if patients are considered for conservative surgery and radiation therapy.

Risk of invasive cancer in women with lobular carcinoma in situ of the breast

100 women underwent wide resection for palpable or mammographically detected breast lesions (1 woman had bilateral lesions). Histology excluded invasive cancer, but one or more foci of lobular carcinoma in situ (LCIS) were observed. There have been no recurrences in the 20 women who underwent total mastectomy. In the 12 patients who had a subsequent wide excision and the 68 who received no other treatment 5 presented with an invasive cancer in the same breast at some distance from the LCIS site (median follow-up 58 months). The (observed/expected) rate per 1000 per year is 10.3 for an untreated LCIS. LCIS is therefore a risk factor for invasive carcinoma. Nevertheless this risk does not indicate the use of mutilating procedures and a wait-and-see policy is appropriate.

What can a woman do about her risk of dying of breast cancer?

Every day, American women are told that one in ten will develop breast cancer, and some groups perceive their risk to be so high as to justify immediate bilateral mastectomy. Many associations with breast cancer have been identified, including a history of benign breast diseases, in situ carcinoma, a family history of breast cancer, prolonged menstruation as a result of early menarche or delayed menopause, few or late pregnancies, excessive alcohol intake, obesity, and possibly the use of estrogens as oral contraceptives or postmenopausal replacement therapy. In spite of these associations, our understanding of either the cause(s) of breast cancer or the sequence of events leading to a diagnosis of breast cancer is still inadequate to make global public health recommendations regarding life style--or even to initiate well-designed studies. The epidemiologic evidence strongly suggests, however, that events relatively early in a woman's life are more important than later events, even though most of the risk of developing breast cancer will be expressed after the age of 75. Possibly one of the greatest contributions we can make to our patients' welfare is to share the knowledge that the risk of dying of breast cancer is considerably smaller than the risk of developing breast cancer; that the risk of early death from breast cancer rarely exceeds 10% in even the highest risk groups; and that the life styles most likely to reduce the risk of cardiovascular disease and other scourges of womankind are also those most likely to reduce the risk of developing breast cancer.

Breast imaging. A critical aspect of breast conserving treatment

Breast imaging provides essential information for the selection and management of patients with early breast cancer who are treated by lumpectomy, irradiation, or both. In addition to its role in the detection and localization of early breast cancer, imaging is also important in the postoperative evaluation and in the long-term monitoring of these patients for the early detection of recurrence. The need for tailoring the examination at each stage and the significance of the findings for clinical and surgical management are discussed.

Early experience with needle localization and biopsy of mammographic lesions

Increasing awareness of the value of mammography by both physicians and the public has resulted in women presenting more commonly with impalpable breast lesions. This study reviews the radiology and pathology of 58 such lesions biopsied by the Monash Medical Centre Breast Unit between August 1987 and October 1988. Abnormal mammograms were reported by one of two independent radiologists in the normal course of practice and placed into one of five categories according to the radiological appearance. Those lesions scoring greater than or equal to 3 were then needle localized, excised and examined histologically. All mammograms were later reported as unknowns by the other radiologist and similarly scored. Sixteen (28%) of these lesions were invasive or in situ carcinoma and of these a significant number were scored differently by the two radiologists. The results indicate that needle localization biopsy of suspicious mammographic lesions is a safe, accurate method for the diagnosis of early breast cancer. The results also show significant variation between radiologists and demonstrate the need for double reading of screening mammographic films. It is suggested that doubtful lesions require more extensive work-up with compression/magnification and other special views, the aim being more accurate radiological assessment and a reduction in the benign biopsy rate.