Results from a multidisciplinary breast center. Analysis of disease discovered

This study was undertaken to report the clinical, pathologic, and outcome data of our nonrandomized series of patients with nonpalpable breast cancer and to understand better the differences between patients with palpable and nonpalpable lesions, particularly those patients aged 49 and younger. The clinical, pathologic, recurrence, and survival data from 560 patients with nonpalpable breast carcinomas found by mammography and wire-directed breast biopsy were compared with similar data from 1640 patients who presented with palpable breast cancer (see Table 3). All node dissections in patients with noninvasive disease were negative. In patients with invasive breast cancer, the chances of axillary node involvement increased as lesions increased in size. When patients were grouped by tumor size, nodal involvement was more likely for palpable than nonpalpable lesions. The 10-year disease-free survival rate probability for patients with nonpalpable invasive cancer was 81% compared with 65% for patients with palpable invasive cancer. The 10-year breast cancer-specific survival rate (including deaths only from carcinoma of the breast) was 91% versus 73%, whereas the 10-year overall survival (rate including deaths from any cause) was 79% for nonpalpable invasive cancer versus 68% for patients with palpable invasive cancer (all P values < 0.001) (see Table 6). Patients under age 50 with nonpalpable invasive cancer fared just as well as older patients with nonpalpable invasive cancer; both had 10-year breast cancer-specific survival rates of 94% (see Table 8). However, biopsy of nonpalpable lesions in patients aged 49 and younger was only half as likely to reveal cancer than biopsy of nonpalpable lesions in patients aged 50 and older (17% versus 32%, P < 0.0001) (see Table 7). When cancer was found in younger women, it was more likely to be noninvasive. Wire-directed breast biopsy of nonpalpable mammographically suspicious areas yields a subgroup of breast cancer patients with a lower probability of recurrence and a higher probability of survival at 10 years when compared with patients who present with palpable breast cancer.

Extended skin island delay of the unipedicle TRAM flap: experience in 35 patients

A technique to surgically delay a single-pedicle TRAM flap is described. This extended skin island delay essentially divides the unipedicle TRAM flap into two stages separated by 1 week. Experience with this flap in 35 patients is reported. On the basis of this experience, we believe that the extended skin island delayed TRAM flap should be considered a safe and reliable alternative to double muscle pedicle and free tissue transfer in high-risk patients.

Ten-year results comparing mastectomy to excision and radiation therapy for ductal carcinoma in situ of the breast

The 10-year results of 300 patients with ductal carcinoma in situ (DCIS) without microinvasion are reported; 167 treated with mastectomy and 133 treated with excision and radiation therapy. There was a significant difference in disease-free survival at 10 years, in favour of those treated with mastectomy, 98% versus 81% (P = 0.0004). Multivariate analysis confirmed nuclear grade as the only significant predictor of local recurrence (P = 0.02) or invasive local recurrence (P = 0.03) in patients with DCIS treated with excision and radiation therapy. There was no difference in breast cancer-specific survival or overall survival between the two treatment groups.

Predicting axillary node positivity in patients with invasive carcinoma of the breast by using a combination of T category and palpability

BACKGROUND

In spite of the development of numerous new tumor markers, axillary lymph node status continues to be the single most important prognostic variable regarding survival of patients with carcinoma of the breast. This study was undertaken to determine whether or not the combination of T category (TNM staging system) and palpability would be a better predictor of nodal positivity than T category alone.

STUDY DESIGN

Clinical and pathologic data were analyzed for 1,554 patients who underwent axillary lymph node dissection as part of their treatment for invasive carcinoma of the breast. Data were analyzed by the primary lesion's T category and whether or not the lesion was palpable.

RESULTS

Five hundred fifty-one (35 percent) of 1,554 axillary node dissections contained metastases. The probability of nodal involvement was significantly higher and the average tumor diameter was slightly, but significantly, larger for palpable T1b, T1c, and T2 lesions when compared with nonpalpable lesions within the same T category (all p values less than or equal to 0.003). The probability of lymphatic tumor emboli or vascular invasion was generally higher for palpable lesions compared with nonpalpable lesions and increased as lesions got larger. The percentage of patients with low nuclear grade and favorable histology was generally lower for patients with palpable lesions compared with those having nonpalpable lesions and decreased as lesions got larger.

CONCLUSIONS

Nodal positivity was significantly higher for palpable T1b, T1c, and T2 carcinoma of the breast when compared with nonpalpable carcinoma of the breast within the same T category. The combination of T category and palpability was a more accurate predictor of nodal positivity than T category alone.

Prognostic classification of breast ductal carcinoma-in-situ

We present a new prognostic classification designated the Van Nuys classification for ductal carcinoma-in-situ (DCIS). The classification combines high nuclear grade and comedo-type necrosis to predict clinical recurrence. Three groups of DCIS patients were defined by the presence or absence of high nuclear grade and comedo-type necrosis: 1--non-high-grade DCIS without comedo-type necrosis, 2--non-high-grade DCIS with comedo-type necrosis, 3--high-grade DCIS with or without comedo-type necrosis. There were 31 local recurrences in 238 patients after breast-conservation surgery 3.8% (3/80) in group 1, 11.1% (10/90) in group 2, and 26.5% (18/68) in group 3. The 8-year actuarial disease-free survivals were 93%, 84%, and 61%, respectively (all p < or = 0.05). The Van Nuys classification defines three distinct and easily recognisable groups, each of which has a different likelihood of local recurrence if treated with breast conservation.

Can intraductal breast carcinoma be excised completely by local excision? Clinical and pathologic predictors

BACKGROUND

Microscopic evaluation of excised intraductal breast carcinoma (DCIS) specimens using a serial subgross technique reveals that in many patients the lesion is larger than expected, often making complete excision impossible with less than a true quadrantectomy. Data is presented on 181 patients with DCIS in whom the initial biopsy was performed using a more cosmetic wide local excision rather than a true quadrantectomy.

METHODS

Clear margins were defined as no tumor within 1 mm of any inked or dyed margin. All of these patients subsequently underwent mastectomy or reexcision of the initial biopsy site. This allowed pathologic evaluation for residual disease.

RESULTS

At mastectomy or reexcision, 76% of patients with initially involved margins had residual DCIS, as did 43% of patients with initially clear margins (P < 0.0001). Larger tumor size was a statistically significant predictor of initial margin involvement and residual DCIS (P < 0.05). Patients with comedo-DCIS had a greater tendency toward positive initial histologic margins and residual DCIS, but this trend was not statistically significant (P < 0.1).

CONCLUSION

DCIS presents major problems to both surgeons and pathologists. It is difficult to excise completely using a wide local excision. Histologically negative margins do not guarantee that residual DCIS has not been left behind. Inadequate excision of the primary lesions may be the most important cause of local failure after conservative treatment for intraductal breast carcinoma.

Infiltrating lobular carcinoma. Is it different from infiltrating duct carcinoma?

BACKGROUND

Infiltrating lobular carcinomas (ILC) represent approximately 10% of all breast cancers. The literature is mixed regarding their prognosis when compared with infiltrating duct carcinomas (IDC). There are few data regarding the treatment of ILC with radiation therapy.

METHODS

The clinical, pathologic, laboratory, and survival data of 161 patients with ILC were compared with the data of 1138 patients with IDC.

RESULTS

ILCs were larger, more difficult to excise completely, and more difficult to diagnose clinically. All prognostic factors measured were more favorable for ILC. Nodal positivity for ILC was 32%, compared with 37% for IDC (P = 0.22). The 7-year disease-free Kaplan-Meier survival (DFS) was 74% for patients with ILC and 63% for patients with IDC (P < 0.03). The 7-year breast cancer specific survival (BCSS) was 83% for patients with ILC and 77% for patients with IDC (P < 0.04). Selected patients with smaller lesions were treated with excision and radiation therapy. Patients with ILC treated with radiation therapy had a better DFS and BCSS than did patients with IDC treated with radiation therapy.

CONCLUSIONS

ILCs often are homogeneous, small cell tumors of low nuclear grade. Their desmoplastic reaction may be absent or less marked than that of IDC, making them more difficult to palpate and to visualize mammographically. Despite this, they can be treated successfully with either mastectomy or excision and radiation therapy.

Axillary lymph node dissection for T1a breast carcinoma. Is it indicated?

BACKGROUND

Axillary dissection has been a routine part of breast cancer treatment for more than 100 years. Axillary node involvement is the single most important prognostic variable in patients with breast cancer. Recently, routine node dissection has been eliminated for intraductal carcinoma because so few patients had positive nodes. With the availability of numerous histologic prognosticators and the development of new immunochemical prognostic indicators, it is time to consider eliminating routine node dissection for lesions more advanced than duct carcinoma in situ (DCIS) but with extremely low likelihood of axillary involvement.

METHODS

Axillary node positivity, disease-free survival, and breast cancer-specific survival were determined for six breast cancer subgroups by T category: Tis (DCIS), T1a, T1b, T1c, T2, and T3.

RESULTS

Nodal positivity for DCIS was 0%; for T1a lesions, 3%. A large increase in nodal positivity was seen in lesions larger than 5 mm. (T1b, 17%; T1c, 32%; T2, 44%; T3, 60%). The rate of nodal positivity was statistically different as each T category was compared with the next more advanced T category. The disease-free survival and breast cancer-specific survival decreased with every increment in T value.

CONCLUSIONS

Axillary node positivity increases as the size of the invasive component increases and is an excellent predictor of DSF and breast cancer-specific survival. Consideration should be given to eliminating axillary node dissection for T1a lesions because of the low yield of positive nodes. Axillary node dissection should be performed routinely for T1b lesions and larger.

Duct carcinoma in situ: 227 cases without microinvasion

From 1979 to 1990, 227 patients with intraductal carcinomas (DCIS) without microinvasion were selectively treated; the least favourable (large lesions with involved biopsy margins) with mastectomy, the most favourable (small lesions with clear margins) with breast preservation. The preservation group was further subdivided into those who received radiation therapy (excision and radiation) and those who did not (excision alone). In the mastectomy group, there were 98 patients (43%) with an average lesional size of 3.3 cm; 41% had multifocal lesions, 15% had multicentric lesions. There has been one local invasive recurrence and no deaths. The 7-year actuarial disease-free survival is 98% with mastectomy. In the excision and radiation group, there were 103 patients (45%) with an average lesional size of 1.4 cm. 10 patients have had local recurrences (5 invasive and 5 noninvasive) one of whom has died. The 7-year actuarial disease-free survival is 84%, a statistically significant difference when excision and radiation is compared with mastectomy (P = 0.038). In the excision alone group, there were 26 patients (11%) with an average lesional size of 1.0 cm. There have been two local recurrences (8%), one of which was invasive and no deaths. The 7-year actuarial disease-free survival is 67%, but only 3 patients have been followed for more than 4 years. A total of 163 axillary node dissections were done; all were negative. Since DCIS without microinvasion rarely metastasizes to axillary lymph nodes, routine dissection should not be performed. Patients in this series with intraductal carcinoma treated with excision and radiation recurred locally at a statistically higher rate than those treated with mastectomy, in spite of the fact that those chosen for excision and radiation had clinically more favourable lesions. 6 of 12 (50%) local recurrences in conservatively treated patients were invasive. There was, however, no significant difference in overall survival in any subgroup regardless of treatment.

Breast cancer diagnosis and prognosis in women following augmentation with silicone gel-filled prostheses

62 healthy women were studied mammographically before and after augmentation mammoplasty. Postaugmentation mammograms were done using both the implant compression and implant displacement technique. The amount of visualisable tissue was measured in all films before and after augmentation. We concluded: State-of-the-art film-screen mammography is extremely difficult to obtain in most patients augmented with silicone-gel-filled prostheses. On average, there is a decrease in measurable visualised breast tissue after augmentation mammoplasty with silicone-gel-filled prostheses. The area of mammographically measurable tissue is no different whether smooth or textured implants are used. Textured implants are less likely to form an early capsular contracture and are therefore preferred. However, the cancer-causing potential of polyurethane in humans is currently unknown. Anterior breast tissue is generally seen better with displacement mammography; posterior breast tissue with compression mammography. Better films are generally obtained when the implant is in the subpectoral position rather than subglandular. The more severe the capsular contracture, the poorer the mammogram. In addition 42 previously augmented patients developed breast carcinomas an average of 8.4 years after augmentation with silicone-gel-filled implants; 95% had palpable lesions (only 60% of which could be seen on mammography), 90% had infiltrating carcinomas, 45% had metastases to axillary nodes, and 7 patients have recurred, 5 of whom have died. We concluded: Augmented women who develop breast cancer are similar, in terms of tumour size and nodal positivity, to non-augmented breast cancer patients who present with palpable masses. When compared with non-augmented women whose breast cancers are found with screening mammography, augmented patients with breast cancer present with a higher percentage of invasive lesions and involved axillary lymph nodes, resulting in a poorer prognosis. The 40% false negative rate for mammography in this series is unduly high and alarming. Augmentation mammoplasty with silicone-gel-filled implants should be discouraged in women with a high risk of developing breast cancer.

Radiation therapy for intraductal carcinoma. Is it an equal alternative?

Of 213 consecutive patients with intraductal carcinoma, 109 were selectively treated with mastectomy and 104 with radiation therapy. There were eight local recurrences, seven in patients treated with radiation therapy and one in a patient treated with mastectomy. Histologically, there were 110 comedocarcinomas and 103 noncomedocarcinomas. Seven local recurrences occurred in patients with comedocarcinomas and one in a patient with a noncomedo tumor. Three (38%) of eight local recurrences (all comedo) were invasive. The 5-year actuarial survival for all subgroups was 100%. The median follow-up was 51 months. Intraductal carcinoma is unlikely to metastasize to axillary lymph nodes, and routine dissection is unnecessary. Ductal carcinoma in situ of the comedo variety is more aggressive and more likely to recur than its noncomedo counterpart. We currently view conservative therapy for patients with intraductal comedocarcinoma with caution.

Axillary lymphadenectomy for intraductal carcinoma of the breast

During a ten year period, 175 axillary lymph node dissections were done as part of the treatment for intraductal carcinoma of the breast; 98 patients were treated with modified radical mastectomy and 77 were treated by mammary preservation, consisting of excision of the lesion, axillary dissection and radiation therapy. One of 175 axillary node dissections yielded positive nodes. Axillary dissection for intraductal carcinoma of the breast is unlikely to yield involved nodes and is not indicated for use in most instances. It should be reserved for lesions demonstrating microinvasion.

Mammographic measurements before and after augmentation mammaplasty

Thirty-five augmented women underwent mammography using both the standard implant-compression technique and, when possible, the implant-displacement technique; all had preaugmentation film-screen mammography available for evaluation. The area of mammographically visualized breast tissue before and after augmentation mammaplasty was measured using a transparent grid. Patients with subglandular implants had a mean decrease of 49 percent of measurable tissue area with compression mammography and a 39 percent decrease with displacement mammography. Patients with submuscular implants had a 28 percent decrease in measurable tissue area with compression mammography and a 9 percent decrease with displacement mammography. Anterior breast tissue was seen better with displacement mammography; posterior breast tissue, with compression mammography. Most patients had some degree of parenchymal scarring and lower image quality after augmentation. State-of-the-art mammography was not possible in most patients augmented with silicone-gel-filled implants.

Intraductal carcinoma of the breast (208 cases). Clinical factors influencing treatment choice

Two hundred eight cases of intraductal breast carcinoma (DCIS) were selectively treated; 97 with mastectomy, 96 with radiation therapy, and 15 using excisional biopsy only. Mastectomy patients tended to have larger tumors, involved biopsy margins, palpable and often multifocal tumors. Breast preservation patients tended to have smaller, often occult, tumors with clear surgical margins. Before 1983, mastectomy was more common; during and after 1983, breast preservation was more common. Comedocarcinomas were the most frequent tumors. They were the largest, had the highest percentage of microinvasion (20%), and had the highest recurrence rate (8%). Noncomedo DCIS had a recurrence rate of 1%, one of 103 tumors. The recurrence rate for comedocarcinomas treated with radiation therapy was nearly three times higher than for those treated with mastectomy (11% versus 4%). One of 164 (0.6%) axillary lymph node dissections yielded positive nodes. Nine patients have recurred: two in the mastectomy group and seven in the breast conservation group (P less than 0.1). Eight of nine recurrences were the comedo subtype (P less than 0.05). Three patients developed metastatic disease, two of whom have died. Axillary dissection for intraductal carcinoma of the breast is unlikely to yield involved nodes and is not indicated for most cases. It should be reserved for lesions revealing microinvasion. Conservative therapy for comedocarcinoma must be viewed with caution.

Breast cancer diagnosis and prognosis in women augmented with silicone gel-filled implants

From 1981 through 1988, 35 patients with prior augmentation mammoplasty were treated for breast carcinoma. Thirty-two patients had unilateral infiltrating carcinomas; three had noninvasive (in situ) lesions. Thirty-four of 35 (97%) lesions were palpable. One noninvasive cancer was occult, discovered mammographically in the absence of physical findings. Prebiopsy mammography was performed in 29 patients with palpable masses and failed to reveal an abnormality in 12 patients, a false-negative rate of 41%. Fifteen patients were treated with mastectomy; the remaining 20 with breast preservation. Thirty-two patients underwent axillary node dissection; 15 (47%) patients had lymph node metastases. There have been seven (20%) recurrences: one local and six metastatic. Four (11%) patients have died. The median follow-up time is 48 months. Women, previously augmented with silicone gel-filled implants, who develop breast cancer are similar in terms of nodal positivity and prognosis, to nonaugmented breast cancer patients who present with palpable masses. When compared with nonaugmented women whose cancers were found with screening mammography, augmented patients with breast cancer present with a higher percentage of invasive lesion and involved axillary lymph nodes, resulting in a poorer prognosis.

Nonpalpable breast lesions: diagnosis with slightly overpenetrated screen-film mammography and hook wire-directed biopsy in 1,014 cases

Slightly overpenetrated screen-film mammography and hook wire-directed localization were used in 1,014 breast biopsies performed for nonpalpable, mammographically detected breast abnormalities. One lymphoma and 205 breast cancers (20%) were found; 115 breast cancers (56%) were noninvasive, and 90 (44%) were invasive. Mastectomy was performed in 69 breast cancers (34%); 136 (66%) were treated conservatively, 28 with biopsy only and 108 with lumpectomy, node dissection, and radiation therapy. All patients with noninvasive breast cancers treated with axillary dissection had uninvolved lymph nodes. Of the 90 invasive breast cancers, six (7%) had metastases to axillary nodes, which, to the authors' knowledge, is lower than percentages reported in other studies of wire-directed breast biopsies. The authors believe that the slightly overpenetrated technique is a valuable adjunct to screen-film mammography.

Breast cancer in women after augmentation mammoplasty

More than 1 million American women have undergone augmentation mammoplasty; 100,000 (10%) will develop or already have developed breast cancer. Between March 1981 and August 1986, 20 patients with previous augmentation mammoplasty were treated for breast carcinoma. All patients had unilateral infiltrating carcinomas and presented with a palpable mass. None of the cancers were occult (discovered mammographically). Thirteen patients (65%) had metastases to axillary lymph nodes. During the same period, 733 nonaugmented patients with breast cancer were treated: 207 (28%) had involved axillary nodes, 194 (26%) had in situ lesions, and 154 cancers (21%) were occult. Augmentation mammoplasty with sillicone-gel-filled implants reduces the ability of mammography, our best diagnostic tool, to visualize breast parenchyma. When compared with our own nonaugmented breast cancer population, augmented patients with breast cancer presented with more advanced disease; they had a higher percentage of invasive lesions and positive axillary nodes, resulting in a worsened prognosis.

Axillary lymph node dissection for intraductal breast carcinoma--is it indicated?

One hundred patients with intraductal breast carcinoma (DCIS) were treated with either mastectomy (49 patients) or radiation therapy (51 patients). All patients underwent axillary lymph node dissection (average number of nodes removed, 16) as part of their treatment. No patient had any positive axillary lymph nodes. There has been one recurrence in each treatment group (median follow-up, 27 months) and no deaths. Intraductal breast carcinoma has little potential for metastasis to axillary lymph nodes.

Hooked-wire-directed breast biopsy and overpenetrated mammography

Six hundred fifty-three biopsies were performed for clinically occult, mammographically detected breast abnormalities. One hundred forty-seven cancers (22.5%) were found. Eighty-nine of those cancers (60.5%) were noninvasive. None of the in situ lesions had involved axillary lymph nodes. Of the 58 invasive cancers, only six (10.3%) had metastases to axillary nodes. Fifty-four patients (36.7%) were treated by mastectomy while 93 patients (63.3%) were treated conservatively, 20 by biopsy only, and 73 by lumpectomy, axillary node dissection, and radiation therapy. Only four patients (0.7%) had significant complications.

Renal vein leiomyosarcoma

The third reported case of renal vein leiomyosarcoma is presented. Diagnosis was not made until exploratory celiotomy revealed a tumor originating from the left renal vein. The tumor was resected with margins of normal vein, and the patient was alive without recurrence 12 months after operation. Review of 65 cases of leiomyosarcoma originating in other retroperitoneal structures revealed a two-year survival rate of 20%. Therefore, we recommend consideration of postoperative adjunctive chemotherapy for renal vein leiomyosarcomas.

Celiac artery obstruction after arteriography

The first case of celiac artery obstruction due to selective arteriography is reported. Impairment of flow to liver and duodenum was present; but the patient recovered uneventfully with non-operative treatment. Management of this problem centers around observation, liver support, and putting the gut at rest. If non-operative treatment is failing, operation should be done, vascular reconstruction carried out, and the duodenum inspected to ensure its viability.

Caecal rupture due to colonic ileus

Caecal rupture due to colonic ileus is rare and has a mortality rate of 43 per cent. Three new cases are presented and the 18 previously reported cases are reviewed. The disease has always occurred in association with another illness, has usually afflicted patients over the age of 55 and has only resulted when the caecum was at least 9 cm in diameter. The technique of 'blow-hole' caecostomy, a method for decompressing the distended caecum, is described.

Blowhold cecostomy for cecal decompression

Blowhole cecostomy is a method for achieving decompression of the distended cecum. Emphasis is placed on a McBurney-type incision, a watertight suture line joining bowel to muscle, and avoidance of opening the cecum until the suturing is done.

Valley triage: an approach to mass casuality care

Organizations prepared to respond to war, fire, flood, earthquake, or attack are essential for effective disaster control. "Valley Triage" the San Fernando Valley Medical Triage Team in Los Angeles, was formed to meet this need. The team is a mobile medical unit staffed by physicians and coordinated with civilian and military emergency services. It incorporates innovative means of communication, transportation, equipment, and training. The primary aim of Valley Triage is to provide on-site medical attention to disaster victims, and to coordinate their transfer to adequately staffed and equipped hospitals. Valley Triage offers a new approach to disaster management and can serve as a model for the development of other teams throughout the nation.

Autogenous vein bypass grafts: biological effects of mechanical dilatation and adventitial stripping in dogs

To evaluate whether mechanical vein dilatation and stripping of adventitia at the time of harvest may adversely alter the long-term fate of autogenous vein grafts, dogs were subjected to reversed femoral vein interposition grafting with either normal veins, mechanically dilated veins, or adventitially stripped veins. Vein segments taken before grafting and veins exposed in situ but not grafted served as controls. Animals were killed at 3 months, and five vein segments in each category were evaluated for gross and microscopic changes. All grafts subjected to arterial interposition displayed marked neointimal proliferation and fibrosis of the media and adventitia. Notably, both dilated and stripped veins appeared to be similar and were indistinguishable from normal veins that had been subjected to arterial interposition for the same duration. Veins exposed in situ but not subjected to arterial flow remained essentially normal. Adverse alterations attributed to vein dilatation or adventitial stripping were not apparent and should not be invoked in the mechanism of graft failure at 3 months' duration.