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While sentinel lymph node biopsy (SLNB) has virtually replaced axillary dissection as the initial diagnostic procedure for invasive breast cancer, the role of SLNB in ductal carcinoma in situ (DCIS) remains controversial. The purpose of this study was to review our experience with SLNB in DCIS. All patients with DCIS or DCIS with microinvasion (DCISM) who underwent SLNB from June 1997 to April 2002 at the University of Florida were included for analysis. The indications for SLNB were at the discretion of the treating surgeon. Lymphatic mapping involved a sequential dermal-peritumoral radiocolloid injection and dynamic lymphoscintigraphy followed by an intraoperative assessment of radioactivity with a handheld gamma probe. All sentinel lymph nodes (SLNs) with radioactive counts>or=10% of the ex vivo counts of the most radioactive SLN were removed. Pathologic analysis consisted of slicing the SLN at 2 mm intervals for permanent section. All paraffin blocks of the SLNs were step sectioned in 4 microm sections (92 microm spacing) through the entire lymph node. Slides were then stained with an immunohistochemical stain for cytokeratin (AE1/AE3) and evaluated by microscopy. Nodal metastases were classified using the 6th edition of the American Joint Committee on Cancer (AJCC) staging manual. From April 1998 to April 2002, 43 patients with DCIS underwent SLNB at the University of Florida. Seven patients (16%) with multifocal or extensive DCIS (five patients) or DCISM (two patients) who underwent SLNB had a positive sentinel node. Two of the three patients considered positive by immunohistochemistry alone had either DCISM or invasive disease. Four (80%) of the five patients with extensive DCIS and a positive sentinel node were ultimately determined to have invasive or microinvasive disease. While SLNB remains controversial in DCIS, our data suggest that patients with extensive DCIS should undergo SLNB at the initial procedure to avoid the need for a second operation. Data from clinical trials are needed to determine the impact of SLNB results on overall survival in patients with DCIS.

The technique of identifying the sentinel lymph node (SLN) varies from each individual institution. Generally, the highest isotope count in a lymph node is considered the SLN, whereas other radioactive nodes might also be removed. The purpose of our study was to determine if the hottest node was always the tumor-containing node. Two hundred forty-seven breast cancer patients underwent SLN biopsy from April 1998 to April 2002. Lymphatic mapping involved a radiocolloid injection and lymphoscintigraphy followed by intraoperative assessment with a hand-held gamma probe. All SLN(s) with radioactive counts 10 per cent or more of the ex vivo counts of the most radioactive SLN were removed. The SLN were sliced at 2-mm intervals with 4-microm step-sections (92-microm spacing) and evaluated by microscopy and immunohistochemistry. One hundred twenty (49%) of the 247 patients had 2 or more nodes resected. Of these 120 patients, 33 (28%) had a tumor-bearing node. In 25 (74%) cases, the tumor-bearing node was the most radioactive; however, in 8 (26%) cases, the positive node was a lesser reactive node. Although the most radioactive node in a draining basin is considered the SLN, this is often not the metastatic node. Therefore, all nodes with significant radioactive counts must be removed to ensure accurate staging.

Although sentinel lymph node (SLN) biopsy is rapidly becoming the standard of care for small breast cancers the optimal radiocolloid injection technique remains controversial. We report our experience with sequential dermal-peritumoral radiocolloid injection that takes advantage of both techniques. One hundred eighteen patients with clinical stage T(is), T1, T2 and N0 breast cancer underwent SLN biopsy at the University of Florida. Twelve to 18 hours before surgery patients received either an injection of 0.5 to 1.0 mCi 50:50 filtered:unfiltered technetium sulfur colloid into the dermis overlying the tumor and/or a peritumoral injection of a 3 to 4-mCi of radiocolloid 30 minutes later. Dynamic lymphoscintigraphy was performed and the topographical location of all imaged lymph nodes was marked on the skin. The next morning the surgeon utilized a hand-held gamma probe to remove all SLN(s) defined as any lymph node with radioactive counts 10 per cent or more of the ex vivo counts of the most radioactive SLN [internal mammary (IM) nodes were not removed]. The SLN identification rate was 98.5 per cent (3 IM nodes) for dermal injection (d.), 83.3 per cent (1 IM node) for peritumoral injection (p.), and 100 per cent (14 IM nodes) for sequential dermal-peritumoral injection (d.p.) (p < 0.05 DP versus D). Sequential d.p. 50:50 filtered:unfiltered technetium sulfur colloid injection results in a rapid, high SLN identification rate that persists until surgery the next morning. Delineation of nonaxillary SLNs may lead to more accurate breast cancer staging and may also influence the delivery of IM node radiation.

Estrogen receptor (ER) content in breast cancer specimens is correlated with a prolonged disease free survival and increased likelihood of response to hormone therapy. Relatively few anti-ER antibodies are currently available for use in formalin-fixed, paraffin-embedded tissue. Recently, a new anti-ER monoclonal antibody (ERID5; AMAC, Westbrook, Maine) was generated which requires antigen retrieval by microwave oven heating for detection in routinely processed tissue. The specific aim of this study was to compare the ERID5 antibody with the commercially available rat monoclonal (ER-ICA; Abbott, Chicago, IL) which requires proteolytic enzyme digestion for detection in paraffin-embedded tissue. Sections from 20 cases of primary breast carcinoma previously assayed by dextran-coated charcoal (DCC) analysis were examined. Quantitation of ER antibody staining was performed without knowledge of the DCC values. Specimens containing > or = 20% specifically stained malignant cells were considered ER positive. The sensitivity and specificity of visual ER-ICA immunostaining were 57% and 83%, respectively. The sensitivity and specificity of visual ERID5 immunostaining were 93% and 50%, respectively. The predictive value of positive staining was 89% for the ER-ICA antibody and 81% for the ERID5 antibody. The predictive value of negative staining was 45% for the ER-ICA antibody and 75% for the ERID5 antibody. Previous studies have demonstrated a linear correlation between DCC values and the positive nuclear area (PNA) generated by image analysis for ER-ICA immunostaining. In the present study, a similar correlation between DCC value and ERID5 percentage PNA was observed (R = 0.670; P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Two methods have emerged for measuring the DNA content of paraffin-embedded tissue using image cytometry: (1) analysis of thin sections, and (2) analysis of nuclei extracted from thick sections. These methods were evaluated using 31 breast tumors for which paraffin-embedded material was available. Cases selected represented 11 diploid, 11 tetraploid, and 9 aneuploid tumors. Results generated using image cytometry methods were compared with those obtained using flow cytometry. For thin sections, the tissue correction feature of the CAS 200 Image Cytometer was used to estimate the DNA content of whole nuclei from measurements made on sectioned nuclei. DNA histograms were generated from tissue sections cut at the same microtome setting (5 microns) before and after software corrections of 4.5 microns, 5.0 microns, 5.5 microns, 6.0 microns. 6.5 microns, 7.0 microns, and 7.5 microns. A comparison of flow cytometry and thin-section image analysis in the absence of tissue correction showed 90% concordance for diploid, 27% concordance for tetraploid, and 77% concordance for aneuploid tumors. The ploidy estimated on thin sections by at least one of the correction values was discordant in 72% of diploid, 91% of tetraploid, and 78% of aneuploid tumors. For cell nuclei extracted from paraffin, excellent agreement was found between flow and image cytometry (r = 0.933). It was concluded that in most cases, cell nuclei extracted from paraffin are preferable to tissue sections for ploidy analysis of breast tumors using image cytometry.

Fine needle aspiration (FNA) of the breast is a well-tolerated procedure used to evaluate palpable breast masses, has a reported mean specificity of 99%, and a reported sensitivity of 70-99%. The false positive rate varies from 0-0.4% in most larger series, with a reported false negative rate ranging from 0.7-22%; however, higher false negative rates have been reported in tumors under 2 cm in diameter. The FNA technique uses a fine, 20 gauge or less, needle and is not associated with a significant risk of tumor growing out the needle tract. FNA cytology is not effectively used if a breast mass cannot be palpated or distinguished from fibrous tissue within the breast. The procedure can be applied to nonpalpable masses detected by mammography by employing stereotactic techniques. The cytologic samples obtained from FNA can be used to distinguish atypical ductal hyperplasia from in situ or invasive ductal carcinoma; however, cytologic criteria to effectively distinguish ductal carcinoma in situ (DCIS) from invasive adenocarcinoma are not definitive in many cases, and are dependent on variables related to the type of intraductal tumor, the size and character of the cell groups, and the presence of single or disaggregated tumor cells. Employing current cytologic criteria, lobular carcinoma in situ (LCIS) may be distinguished from invasive lobular carcinoma in some cases; however, the individual LCIS cells are not morphologically distinct from lobular carcinoma cells. Atypical lobular hyperplasia has cellular features essentially the same as those seen in LCIS. Needle biopsy (NB) employs larger needles of 14-16 gauge.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of fine needle aspiration to obtain cellular material for pathologic examination was introduced in 1930 but fell out of favor for several years. In today's medical environment, fine needle aspiration is proving to be more efficacious and cost effective than conventional breast biopsy. The authors detail the technique, its complications, the reliability of the results and ways to improve it, and the suitability of the material for hormone receptor assays, detection of tumor-related problems, and ultrastructural study as well as for standard cytologic diagnosis.

The presence of occult breast carcinoma in breast biopsy specimens originally interpreted pathologically as benign has been reported in up to 2.4% of cases. Paraffin-block radiography of 658 blocks from 119 breast biopsies obtained prior to the use of mammography and initially interpreted as benign was performed to determine the frequency and relevance of "significant" calcifications. Of all cases 87.4% demonstrated some calcifications within the breast tissue; 19.3% contained calcifications considered significant. Step sections of the original blocks containing significant calcifications did not demonstrate malignant neoplasms.

Vulvar Paget's disease is an intraepithelial change which is locally recurrent and has minimal if any propensity to invasion. Its major significance lies in the frequency with which concomitant carcinomas are discovered in association with the vulvar skin lesion. Adenocarcinoma of the vulvar apocrine glands is the most commonly associated tumor. Another apocrine adenocarcinoma, carcinoma of the breast, either antecedent or concomitant, is the second most frequently associated tumor, having been noted in 14 cases of vulvar Paget's disease. A case report illustrating this association is presented, and the importance of preoperative breast screening procedures in all patients with vulvar Paget's disease is demonstrated.

A study of 276 consecutive fine needle aspirations (FNAs) of the breast in 240 cases is presented. Of these cases, 108 underwent subsequent biopsy of the breast; correlations between the FNA cytology and the surgical pathology findings revealed that FNA had a sensitivity of 79.4%, a specificity of 100% and a predictive value of a positive diagnosis of 100%. The overall diagnostic accuracy was 92.4%. These results are compared with those in other published series, and the pitfalls in and methods of improvement of breast FNA are discussed.

A prospective study of 123 patients was undertaken to determine whether carcinoembryonic antigen (CEA) or L-fucose could be used as "tumor markers" to distinguish patients who had mammary cancer (41) from patients who had benign mammary disease (41) and patients who did not have mammary cancer (41). The predictive value of positive test results for both L-fucose and CEA was lower for patients who smoked than for those who did not. The sensitivities of CEA and L-fucose indicators are both below 55%. There were frequent false-positive and false-negative results. A substantial overlap in the levels of CEA and L-fucose was found for the patients who had mammary cancer and those who had benign mammary disease. CEA and L-fucose performed similarly in distinguishing cancer from benign disease. For patients who smoked, however, the predictive value of L-fucose was only 44%. The effect of smoking on L-fucose levels may account for discrepancies in L-fucose data reported in previous studies of mammary cancer. Neither CEA nor L-fucose were found to be of value in screening for mammary cancer.