Histologic types of benign breast disease and the risk for breast cancer. The Cancer and Steroid Hormone Study Group

Specific histologic types of benign breast disease (BBD) may increase breast cancer risk. The authors analyzed data from a population-based, case-control study of women aged 20 to 54 with newly diagnosed breast cancer and control subjects randomly selected from the general population. A panel of pathologists classified the histologic findings of biopsy slides for 433 women with breast cancer and 261 control subjects, all of whom had a history of biopsy for BBD, as to the presence of epithelial hyperplasia, atypia, and other histologic features. When compared with women who had never had a breast biopsy, women with BBD without hyperplasia had an odds ratio of 1.5 (95% confidence limits [CL] 1.3 to 1.9), women with hyperplasia without atypia had an odds ratio of 1.8 (CL = 1.3, 2.4), and women with hyperplasia and atypia had an odds ratio of 2.6 (CL = 1.6, 4.1). Fibroadenoma was an independent risk factor for breast cancer (odds ratio = 1.7; CL = 1.1, 2.5). These findings suggest that women with BBD with epithelial hyperplasia either with or without atypia and women with fibroadenoma should be monitored carefully because of their elevated risk for breast cancer.

Pleomorphic adenoma of the breast: a clinicopathologic and immunohistochemical study of 10 cases

Pleomorphic adenomas of the breast (PAB) are uncommon tumors. We studied the clinicopathologic features of 10 cases of PAB, seven of which were assessed immunohistochemically. Nine patients were women, with a median age at diagnosis of 65 years. Eight patients presented with a palpable mass; two had a nipple discharge. Nine of the tumors were periareolar. The latter epidemiologic findings, coupled with histologic observations, appeared to indicate a preferential origin for PAB within large intramammary ducts. These neoplasms histologically resemble their analogues in salivary glands. Moreover, a gradual histologic transition between different morphologic areas in PAB, especially between mesenchymal and epithelial regions, supported the contention that the neoplasm arises from a single cell type capable of divergent differentiation and thus should not be considered a "mixed" tumor. This contention was further substantiated by immunohistochemical findings, in which three intermediate filaments (cytokeratin, vimentin, and glial fibrillary acidic protein) and muscle-specific actin were expressed conjointly in tumor cells with a variety of morphologic appearances. In addition, cells differentiating along mesenchymal lines by conventional microscopy were found to express epithelial membrane antigen or gross cystic disease fluid protein-15 in five cases. The benign nature of PAB was supported by a lack of metastases in this series during a median follow-up period of 4.9 years. However, one lesion recurred locally. Regarding therapy, we believe that PAB can be excised successfully with only a narrow circumferential margin of uninvolved breast.

Microglandular adenosis of the breast. An immunohistochemical comparison with tubular carcinoma

Microglandular adenosis (MA) of the breast is a benign, disorganized proliferation of glands lined by a single layer of cells. As such, differential diagnosis between MA and tubular carcinoma may be challenging in selected cases. A panel of antibodies was applied to 10 cases of MA and 10 of tubular carcinoma to investigate the potential benefit of immunohistochemistry in the separation of these lesions and the possible role of myoepithelial cells in MA. The luminal cells in nine cases of MA were surrounded by a cuff of muscle-specific actin-reactive cells, which also coexpressed cytokeratin and vimentin. The immunophenotype of these cells is characteristic of myoepithelial differentiation, which was heretofore thought to be lacking in MA. This finding demonstrates that myoepithelial cells are indeed present in MA subjacent to luminal epithelial cells; moreover, it distinghuishes MA from tubular carcinoma, all examples of which were actin negative in this analysis. In addition, circumferential type IV collagen deposition was observed around constituent glands of MA in nine cases but was lacking in all tubular carcinomas. Other markers included in this evaluation (S100 protein, gross cystic disease fluid protein 15, carcinoembryonic antigen, estrogen receptor protein) were of no differential diagnostic value.

Carcinoma arising within fibroadenomas of the breast. A clinicopathologic study of 105 patients

The authors report the clinicopathologic features of 105 carcinomas arising within fibroadenomas (FAs) of the breast. The mean age of the patients was 44 years. The presentation and gross characteristics of these tumors rarely differed from those of uncomplicated FAs. Carcinoma in situ (CIS) was the predominant type of malignancy (95%) found to arise in FAs, and lobular and ductal types occurred with equal frequency. Nine of ten FAs harboring an invasive carcinoma also contained CIS supporting the origin of the infiltrative component in the FAs. CIS within FAs was associated with in situ malignancy in surrounding breast tissue in 21% of cases. Age, fibroadenoma size, and type and extent of CIS were similar in patients with disease limited to the FA and in those with associated malignant disease in the remainder of the breast. Axillary nodal metastases were not detected. Sixty-three patients were observed for a mean period of 8.4 years. Only one of 26 patients with CIS within an FA who was treated conservatively developed an ipsilateral carcinoma. None of the 26 developed contralateral carcinoma; however, 3 of 23 with similar lesions, who were treated by mastectomy, did so. The contralateral carcinomas were invasive in two patients, one of whom died with distant metastases. Seven patients with FAs harboring lobular CIS underwent bilateral mastectomy. Their postoperative course was uneventful. None of seven patients with invasive carcinoma arising in an FA, two of whom were treated conservatively, succumbed to disease. However, one developed contralateral carcinoma. The authors recommend breast-conserving therapy for CIS arising in an FA.

Carcinoma within fibroadenomas: mammographic features

The mammographic features of carcinoma originating within a fibroadenoma in 24 patients were studied by means of retrospective review of pathologic slides. Histologic examination showed that the lesions were lobular carcinoma in situ (LCIS) (seven patients), ductal carcinoma in situ (DCIS) (13 patients), synchronous LCIS and invasive lobular carcinoma (one patient), and synchronous LCIS and DCIS (three patients). In all patients the mammographic manifestation was a mass 1.0 cm or greater in diameter; 14 masses were 1-2 cm in diameter, and the remainder were more than 2 cm in diameter. Features that were considered suspect included large size, indistinct margins, and clustered microcalcifications. In three patients, microcalcifications within the mass raised suspicion of malignancy. At histologic examination these microcalcifications were associated with the intraductal carcinoma harbored in the fibroadenoma in only one of these patients. Fibroadenomas that harbor carcinoma may be indistinguishable from common benign fibroadenomas, but their occurrence is rare. In this study, a single patient had invasive lobular carcinoma; all the other lesions were in situ lesions.

Flow cytometric analysis of breast needle aspirates

This study investigated two hypotheses: (1) sufficient cells may be obtained by needle aspiration of breast nodules to produce good flow cytometric DNA profiles; and (2) benign breast lesions do not produce aneuploid G0G1 peaks, and therefore a distinct aneuploid peak is sufficient for a diagnosis of malignancy. Breast specimens received in Surgical Pathology between December 1985 and February 1987 were aspirated, and the cells stained with propidium iodide for flow cytometric DNA analysis. A total of 344 specimens were aspirated, of which 204 (59%) were malignant and 140 (41%) benign. One hundred fifty-three malignant and 111 benign specimens contained sufficient cells for analysis. Cytologic smears were available for 177 malignant and 123 benign specimens. DNA histograms were considered diagnostic of malignancy if an aneuploid peak was present which contained at least 20% of the cells in the distribution, and had a DNA index greater than or equal to 1.2. Using these criteria, 73 of 153 (48%) carcinomas could be identified. None of the benign lesions satisfied these criteria. One fibroadenoma with atypical hyperplasia produced a distinct peak which contained less than 5% of the cells in the histogram, and had a DNA index of 1.25. Flow cytometric analysis provides objective data that complement the subjective cytologic interpretation of fine needle aspirates.

Heterogeneity in the production of collagens and fibronectin by morphologically distinct clones of a human tumor cell line: evidence for intratumoral diversity in matrix protein biosynthesis

Recent studies of murine tumor models and certain human tumor cell lines have provided evidence for intratumor heterogeneity in expression of extracellular matrix receptors and in the elaboration of matrix-degrading enzymes. However, little is known about possible intratumoral heterogeneity in the production of matrix macromolecules. We have, therefore, examined the biosynthesis and secretion of matrix proteins by cells derived from a polyclonal human cell line (JH-17) established from a large cell undifferentiated carcinoma of the lung. For the present studies, we focused on the production of collagens and structural glycoproteins by two phenotypically different aneuploid clones, designated C13 and C22. These clones were distinctive in their inability to grow in soft agar or to form tumors in nude mice and had identical DNA contents. Tumor cells were labeled with [3H]proline and the newly synthesized proteins accumulating in the culture medium were identified using biochemical and immunologic techniques. Clone C13 secreted at least three genetically distinct collagens, including type V procollagen (PC), type IV procollagen, and a type VIII-like collagen. By contrast, the clone C22 synthesized fibronectin, and a single bacterial collagenase-sensitive and pepsin-resistant component consistent with type I trimer. These studies emphasize the potential diversity of matrix proteins synthesized by neoplastic cells and suggest that there is intratumoral heterogeneity in matrix protein biosynthesis in vivo. These studies further suggest that tumor-derived matrix may be altered during tumor progression or cell selection in vivo.

Reliability and stability of the thymidine labeling index of breast carcinoma

We have approached the question of the reliability of the thymidine labeling index (TLI) of breast carcinoma by comparing paired samples. Because the distribution of the TLI is approximately lognormal, comparisons were made after transformation to the natural logarithm. For 38 paired samples from the primary carcinoma (biopsy versus residual tumor in mastectomy specimen), r, 0.89, p less than 0.0001. For 68 primary carcinomas versus their axillary metastases, r, 0.90, p less than 0.0001. Substantial correlation was also observed between the TLIs of 18 primary breast carcinomas and their recurrent or metastatic lesions studied after relapse (r, 0.75, p less than 0.0003), and between 14 pairs of first and second primary carcinomas recovered from the same breast (r, 0.72, p less than 0.003). Good agreement was achieved among three observers in measuring the TLI from a set of breast carcinoma autoradiographs. We conclude that the TLI is sufficiently reliable for semiquantitative use as a means of separating breast carcinomas into groups with slow, moderate, and rapid rates of proliferation. The substantial similarities between the TLIs of breast carcinoma samples from different sites of the primary tumor, between primary tumor and axillary metastases, and between primary tumor and subsequent samples of relapsed tumor suggest that clonal evolution either is infrequent or does not usually affect the cell kinetics of the carcinoma. The similarity of the TLIs of synchronous dual primary carcinomas is an additional interesting finding.

A proposed classification of breast cancer based on kinetic information: derived from a comparison of risk factors in 168 primary operable breast cancers

Flow cytometric DNA analysis was performed on 168 consecutive primary operable breast cancers and the results correlated with thymidine labeling, estrogen receptor (ER) and progesterone receptor values, and various histologic parameters. Seventy-five cancers (45.0%) were diploid and 93 (55.0%) aneuploid. In 83.9% of aneuploid cancers, the DNA index fell between 1.1 and 2.0. Thirteen cancers were hypertetraploid and three hypodiploid. The percent of S-phase cancers (SpF) varied from 1.1% to 24.4%, with a mean of 8.0% and a median of 7.1%. The mean SpF of diploid cancers was 5.2%; of aneuploid cancers, 10.3%. There was no significant correlation between SpF or ploidy and tumor size or axillary lymph node status. The thymidine labeling index (TLI) varied from 0.2 to 23.1, with a mean of 7.5 and a median of 6.1. There was good correlation between TLI and SpF (r = 0.892, P = 0.0001). ER-negative tumors had a significantly higher mean SpF (10.3%) than did ER-positive tumors (6.7%), but there was no significant correlation between ploidy and receptor positivity or negativity. There was a good correlation between invasive tumor necrosis, poor cytologic differentiation, aneuploidy, and above-median SpF. Only a fair correlation was observed between mitotic rate and SpF. A classification of invasive breast cancers based on ploidy and SpF is proposed.

Breast carcinoma cell kinetics, morphology, stage, and host characteristics. A thymidine labeling study

The thymidine labeling index (TLI) was measured in 757 primary, invasive breast carcinomas in women by an in vitro method that achieved intense labeling of S-phase cells. The frequency distribution of the TLI was positively skewed but could be normalized by taking logarithms. The mode was 2%; median, 5.2%; geometric mean, 4.5%; mean 7.1%. The TLI was significantly related to a number of pathological features. Carcinomas of large size, with inflammatory or otherwise locally aggressive, undifferentiated histologic and nuclear characteristics, necrosis, inflammatory cellular response, and circumscribed tumor border showed strong tendencies to have high TLIs. The TLI was not significantly related to race, axillary lymph nodal status, or invasion of lymphatics and blood vessels. Breast carcinomas replicated cells at high rates ("rapid growth") more often in young women than in aged women. Lack of either estrogen receptor (ER) or progesterone receptor (PgR) was associated with high TLI. Although the inverse relationship between TLI and PgR was more or less linear, and the relationship between TLI and ER was not, differences in TLI between PgR-negative and PgR-positive patients were no greater than between ER-negative and ER-positive tumors. The degree of inflammatory infiltrate was strongly related to both proliferative rate and evidence of cell-death, indicative of a secondary phenomenon rather than a role in regulation of tumor growth. The proliferative rate of breast carcinoma appears to be an important determinant of morphologic patterns. Although it modulates the pace of progress of the disease, it is at most a weak determinant of metastasis.

Short-term cryopreservation of human breast carcinoma cells for flow cytometry

A procedure is described for short-term cryopreservation of primary human tumor cells and tissue slices for later analysis by flow cytometry. Cells were mechanically dispersed into a freezing medium, which was then frozen at either -20 degrees C or -70 degrees C for delayed cell cycle analysis. The results show that a correlation coefficient of greater than 0.95 exists between cell cycle kinetic analyses performed immediately after surgical excision of the tumor and on cells frozen from 1 to 30 days at -70 degrees C in this freezing solution. Somewhat lower levels of correlation exist for cells frozen at -20 degrees C in this freezing medium. This procedure has also been successfully used to preserve freshly isolated breast carcinoma cells shipped from distant laboratories for analysis in the flow cytometer, thus expanding the data base on certain types of breast carcinoma.

Heterogeneity of breast carcinomas determined by flow cytometric analysis

Eight cases of primary breast carcinoma were studied for evidence of heterogeneity by flow cytometry using propidium iodide staining of DNA. Tumors ranged from 2.5 to 8.0 cm in greatest dimension, mean 4.2 cm. Five to 11 samples, determined by tumor size, were analyzed from each primary tumor in addition to 4 axillary lymph nodal metastases from 3 of the 8 cases. The presence of carcinoma was demonstrated histologically in each flow cytometric sample. Three of the carcinomas showed only diploid DNA content. Three showed the same single hyperdiploid population in each sample. Two carcinomas (2.5 and 3.5 cm) were heterogeneous and demonstrated 2 or 3 hyperdiploid populations. The 2 or 3 distinct hyperdiploid populations were present singly or sometimes in combination in one sample. Five of the 11 samples from 1 of the heterogeneous tumors and its axillary metastasis contained a single diploid population. Therefore, flow cytometric analysis of a single sample from a breast carcinoma may not be representative of the entire tumor. The study of multiple samples of breast carcinomas by flow cytometry is necessary for full characterization of the tumors.

A comparison of human breast cancer cell kinetics measured by flow cytometry and thymidine labeling

Flow cytometric determination of tumor ploidy and S-phase fraction following collagenase dissociation and thymidine labeling was performed on 75 consecutive breast cancers. Estrogen and progesterone receptor levels and routine histologic examination also were obtained on each tumor. Cell viability following collagenase dissociation varied from 13 to 95% with a mean of 71%. Thirty-six tumors were diploid, four tetraploid, and four hypertetraploid, and the remainder had DNA indices between 1.1 and 1.9. There was no significant correlation between tumor ploidy and tumor size or estrogen receptor positivity or negativity. The percentage of cells in S-phase varied from 1.2 to 20.0% with a mean of 6.0% utilizing a rectilinear model for histogram analysis that integrated a 10-contiguous channel sample containing the lowest number of cells in S-phase (S-pFL). The mean S-pFL of diploid carcinomas (3.43%) was significantly lower than that of hyperdiploid carcinomas (8.38%). There was good correlation between S-phase fraction determined by thymidine-labeling index (TLI) and S-pFL (r = 0.772, p = 0.0001). S-pFL predicted whether a tumor would be above or below median TLI with an accuracy of 90.5%. Estrogen receptor-negative cancers tended to have higher TLIs and S-pFLs than estrogen receptor-positive cancers; however, there was no correlation between progesterone receptor positivity or negativity and TLI and S-pFL.

A method for dissociation of viable human breast cancer cells that produces flow cytometric kinetic information similar to that obtained by thymidine labeling

Collagenase dissociation, performed on 40 human breast cancers, yielded between 1 million and 50 million cells from less than 1 g of tissue from each tumor. Approximately 60% of cells (mean) was considered viable as judged by trypan blue exclusion and phase microscopy. On subsequent flow cytometric analysis, 20 cancers (50%) were considered diploid, three were tetraploid, and the remainder, hyperdiploid. Thymidine labeling (TLI) and flow cytometry following mechanical dissociation also were performed on 23 of these 40 tumors. Among this group of 23 cases, the median percentage of S-phase cells obtained by collagenase dissociation was 5.4, by TLI was 5.7, and by mechanical dissociation was 9.7. There was excellent correlation between the percentage of S-phase cells obtained by collagenase and TLI (r = 0.847, p = 0.0001) but only fair correlation between the percentage of S-phase cells obtained by mechanical dissociation and TLI (r = 0.597, p = 0.0027). The percentage of S-phase cells obtained by either collagenase or mechanical dissociation predicted whether a tumor was above or below median TLI in 19 of 23 cases (p = 0.0018). Estrogen receptor positivity or negativity did not predict whether a tumor was above or below median TLI (r = 0.283, p = 0.130) or above or below median S-phase fraction following collagenase dissociation (r = 0.218, p = 0.182), nor did quantitative estrogen receptor correlate significantly with TLI (r = 0.283, p = 0.13) or S-phase fraction (r = 0.218, p = 0.18).

Practical breast carcinoma cell kinetics: review and update

The S-phase fraction (SP) measured by flow cytometry of DNA and the thymidine labeling index (TLI) measured autoradiographically indicate the proportion of carcinoma cells currently synthesizing DNA and reflect the rate of proliferation. The TLI and SPF are lognormally distributed. The median TLI performed to maximize precursor uptake is near 5% (5 labeled carcinoma cells per 100) the mean near 7%, and the range from less than 1% to near 40%. Corresponding values for the SPF measured by DNA flow cytometry are slightly higher when appropriate measures are taken to reduce background debris counts and other artefacts. Residual elevation of SPF above TLI may result from S-phase arrested cells. Flow cytometric histograms show that clearly aneuploid cell lines exist in 50-80% of primary breast carcinomas. Aneuploid breast carcinomas have higher mean TLI than diploid breast carcinomas, and therefore proliferate more rapidly. They also more frequently lack estrogen receptor (ER). Carcinomas with minimal nuclear anaplasia, particularly those of tubular, mucinous, infiltrating lobular and adenocystic types have low TLI and SPF, whereas carcinomas with highly anaplastic nuclei, including medullary carcinomas, have high TLI and SPF. TLI and SPF correlate inversely with ER and PgR content, have no relationship to axillary lymph nodal status, and have a weak positive correlation with tumor size and a weak negative correlation with age. High TLI predicts a high risk of early relapse after primary therapy for both node-negative and node-positive carcinomas. Carcinomas that produce brain metastases have particularly high TLI. Current evidence suggests that high SPF and aneuploidy may prove to have prognostic significance like TLI.

DNA flow cytometry of breast carcinoma after acetic-acid fixation

Aqueous acetic acid was used to fix and store specimens of tissue prior to dissociation into nuclear suspensions for flow cytometric quantitation of DNA. The optimum concentration was 20 volumes of glacial acetic acid in 80 volumes of distilled water. Both neoplastic and benign nuclei were easily released from the fixed tissue blocks by slicing and shaking. Residual undissociated tissue was suitable for microscopic examination to confirm its identity. The nuclei fluoresced brightly after staining with propidium iodide, and yielded histograms similar to those from unfixed samples. Acetic-acid fixation resulted in slightly broader G1 and G0 peaks in the DNA histograms in comparison to unfixed cells, but fluorescent debris was less and correlation between the flow cytometric S-phase fraction (SPF) and in vitro thymidine labelling index (TLI) was better than with unfixed cells. Twenty-one of thirty-nine acetic-acid-fixed breast carcinomas had DNA indices in excess of 1.0 (increased nuclear DNA content in comparison to benign cells), and eighteen had DNA indices of 1.0 (normal or near-normal). The SPF was usually in excess of the TLI, but the two were significantly correlated (r = 0.72, P less than 0.0001). However, a significant correlation of SPF with TLI held only for the group with DNA index greater than 1.0. DNA indices greater than 1.0 were associated with high SPF and TLI, and high SPF and TLI each associated with low content of estrogen receptor.

Tubular carcinoma of the breast. Clinical and pathological observations concerning 135 cases

Clinical and pathological features of 135 tubular carcinomas are discussed. Tumor size varied from 0.2 to 2.5 cm with a mean diameter of 0.9 cm. In situ carcinoma was found associated with tubular cancer in 86 cases (63.6%). In 82 of 86 (95.3%) it was of micropapillary/cribriform intraductal type. Twelve of 109 patients in whom axillary dissection was performed were found to have axillary metastases. Six patients (4%) developed recurrent or disseminated metastatic carcinoma during a mean follow-up period of 7.2 years. Two of these patients are dead of disease. Tubular carcinoma should be distinguished from microglandular adenosis, an uncommon form of sclerosing adenosis.

Proliferative fasciitis: ultrastructural study of two cases

Two cases of proliferative fasciitis were studied by light and electron microscopy. The light microscopic features appear to be identical to those of proliferative myositis. Ultrastructural features include numerous cytoplasmic thin filaments, with occasional dense bodies, abundant rough endoplasmic reticulum, and cellular membrane-based vesicles. No Z bands or specialized cell junctions were identified. These findings suggest that the large balloon cells characteristic of the lesion probably are of myofibroblastic origin.

Primary fenal angiosarcoma: a case report

A 67 year old white male presented with a two week history of mild hematuria and flank pain. Various radiologic studies demonstrated a vascular mass in the right kidney. At nephrectomy a large renal angiosarcoma with fixation to the liver and multiple pulmonary metastases was found.