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The histologic distinction between benign and malignant Phyllodes tumors (PT) is often difficult and arbitrary. We analyzed a group of benign and malignant PT to determine whether specific histologic features and expression of Ki-67 and p53 could be useful in distinguishing benign PT from malignant tumors. We also determined whether deletions in Chromosome 3p at the FHIT and hMLH1 loci are common abnormalities in PT. Twenty PT were histologically classified as benign (7) or malignant (13). Seven of the malignant PT were low grade, and six were high grade. Ki-67 and p53 immunohistochemistry was performed on all tumors and analyzed for the stromal and for the epithelial component. PCR-based loss of heterozygosity analyses were performed with the following markers on Chromosome 3p: D3S1478 (3p21.2--21.3), D3S1289 (3p21.1--21.2), and D3S1295 (3p14.3--21.1). The distribution of immunoreactivity for Ki-67 was analyzed by quantifying the percentage of positive nuclei and expressed as the labeling index (LI). Patients' ages ranged from 13 to 71 years (median: 51 y). After a mean follow-up period of 8 years, none of the PT metastasized, whereas three recurred locally. Although malignant PT were larger than benign PT (means, 7.1 versus 4.3 cm), this difference was not statistically significant. Five tumors had infiltrating margins, and 14 were circumscribed. The Ki-67 LI in low-grade malignant PT (16 +/- 25.5) was significantly higher than that in benign PT (3.6 +/- 4.8), whereas the LI in the high-grade malignant PT group (50 +/- 21.9) was significantly higher than that in low-grade malignant tumors (P =.012). The Ki-67 LI in the three tumors that recurred was less than 10%. Two of seven (29%) benign PT were focally positive for p53, whereas four of seven (57%) low-grade malignant and three of six (50%) high-grade malignant PT were diffusely positive for p53. The three tumors that recurred initially were histologically benign, as were two of the recurrences. One recurrent tumor evolved to a high-grade malignant PT. Margins were greater than 1 cm in all tumors except four, three of which recurred locally. No allelic loss of 3p was found. In summary, Ki-67 expression may assist in distinguishing benign from malignant PT in diagnostically difficult cases. 3p deletions do not play a significant role in the development of these tumors. Neither Ki-67 nor p53 can reliably predict recurrence. Histologically high-grade malignant PT have a favorable prognosis if widely excised. We emphasize the importance of adequate margins in the treatment of benign and malignant PT.

Objective: The objective of this study was to determine how the length of time between mammographic screenings is related to the size, grade, and histology of mammographically detected ductal carcinoma in situ (DCIS)., Materials and Methods: We retrospectively reviewed 166 consecutive mammograms of women evaluated for DCIS with (n = 24) and without (n = 142) microinvasion. The size of the DCIS was determined by the maximum diameter as measured on the mammogram. After pathologic analysis, DCIS was classified by histologic architecture, nuclear grade, presence of microinvasion, and presence of multifocality. Four screening intervals were defined: annual (6-17 months), biennial (18-29 months), triennial (> or = 30 months), and first time. Patients were grouped according to screening intervals. The average age of all groups was 55 years., Results: The annual group (mean size of DCIS, 1.69 cm) had significantly smaller DCIS than did the biennial (mean size, 2.27 cm), triennial (mean size, 3.49 cm), or first time groups (mean size, 3.29 cm) (p = .003). Comedo histology was more frequently observed in patients screened biennially (73.7%) than in those screened annually (46.8%) (p = .05). High-grade nuclear histology was more commonly seen in the biennial (76.3%) than in the annual (48.1%) screening group (p = .008). We found no significant correlation between screening interval and the incidence of microinvasion and multifocality., Conclusion: Small, low-grade noncomedo DCIS was more common in the annual mammographic screening group than in the biennial screening group. A direct relationship was found between DCIS size and length of screening interval: DCIS detected at annual screening was smaller than that found at biennial screening, which in turn was smaller than DCIS revealed at triennial screening. This study provides inferential support for annual screening mammography for DCIS detection and management.

Background: Skin-sparing mastectomy with immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction is being used more often for the treatment of breast cancer. Mammography is not used routinely to evaluate TRAM flaps in women who have undergone mastectomy. We have identified the potential value of its use in selected patients., Methods and Results: We report on four women who manifested local recurrences in TRAM flaps after initial treatment for ductal carcinoma in situ (DCIS) or DCIS with microinvasion undergoing skin-sparing mastectomy and immediate reconstruction. All four patients presented with extensive, high-grade, multifocal DCIS that precluded breast conservation. Three of four mastectomy specimens demonstrated tumor close to the surgical margin. Three of the four recurrences were detected by physical examination; the remaining local recurrence was documented by screening mammography. The recurrences had features suggestive of malignancy on mammography., Conclusion: We conclude that all patients undergoing mastectomy and TRAM reconstruction for extensive, multifocal DCIS should undergo regular routine mammography of the reconstructed breast. Our experience with this subgroup of patients raises concern about the value of skin-sparing mastectomy with immediate reconstruction for therapy. Adjuvant radiation therapy should be recommended for those patients with negative but close surgical margins.

Adenoid cystic carcinoma of the breast is an uncommon carcinoma with a distinctive histology. Prognosis is favorable, although recurrence and distant metastases have been described. We assessed whether histologic features and proliferative activity can identify aggressive neoplasms. We studied 31 cases of adenoid cystic carcinoma (age range of patients, 33 to 74 years). Three histologic grades were defined: grade I: completely glandular; grade II: < 30% solid areas, and grade III: > or = 30% solid pattern. In 19 of 31 cases, immunohistochemical stains for estrogen receptor were available. Twelve of 31 cases were immunohistochemically stained for Ki-67 antigen using MIB1 antibody. Ten of 20 tumors were subareolar. All tumors were grossly circumscribed; however, 12 of 20 (60%) had focal infiltration peripherally. Five of 19 tumors were estrogen receptor positive. There was no statistical correlation between MIB1 score and histologic grade, nuclear grade, infiltration of the adjacent fat or breast parenchyma, or estrogen receptor status. All patients were alive with no evidence of disease after a median follow-up of 7 years. Neither histologic or nuclear grading nor proliferative activity were useful prognosticators. None of the tumors had lymph node metastases. Therefore, axillary lymph node dissection may not be necessary. Because more than half of adenoid cystic carcinomas are infiltrative focally, the most important therapeutic goal is complete tumor removal with uninvolved margins of excision.

Objective: The objective of this study was to describe the mammographic appearance with pathologic correlation of metaplastic carcinoma of the breast., Conclusion: Metaplastic carcinomas of the breast are masses with mammographic characteristics of low suspicion because of their histologic appearance. Metaplastic carcinoma should be included in the differential assessment of predominately circumscribed, noncalcified masses revealed on mammography. One salient feature that may distinguish metaplastic carcinomas is the occurrence of a circumscribed portion with a spiculated portion, which is seen in carcinomas that have a significant mixture of metaplastic and invasive carcinoma growth patterns.

Purpose: Although the axilla is often treated with radiotherapy (RT) postoperatively when microscopic extracapsular extension (ECE) of lymph nodal metastases is present, little data are available to assess axillary failure in the absence of such treatment. As it has been the practice at this institution to withhold axillary irradiation in the presence of microscopic extracapsular spread, we retrospectively analyzed our results for axillary recurrence, disease-free survival (DFS), and overall survival (OS)., Methods and Materials: Clinical records were reviewed of 82 women with Stage II node positive breast cancer treated with lumpectomy, axillary dissection, and RT in addition to systemic chemo/hormonal therapy. Axillary surgery consisted of a level I, II, +/- III dissection, with a median of 16.5 nodes removed. Tangential radiotherapy fields were used to treat the breast. All patients were also treated with an abbreviated supraclavicular field with the lateral border medial to the humeral head. Pathological sections were available for review in 72 of the 82 women., Results: Twenty-seven of 72 (37.5%) had evidence of ECE; 45 of 72 (62.5%) had metastatic carcinoma confined within the nodal capsule. Clinical characteristics were comparable between the patients with and without ECE with the exception of (a) pathologic subtype, with a greater percentage of infiltrating ductal tumors associated with ECE (p = 0.044), and (b) number of positive lymph nodes, with 93% of patients without ECE having one to three positive nodes vs. only 56% among patients with ECE (p < 0.001). With a median follow-up of 40 months, 1 of 27 patients (4%) with ECE experienced an axillary failure as a component of first failure compared to 0 of 45 patients without ECE (p = 0.4). There were no isolated axillary failures. Five-year disease-free survival (72% without ECE vs. 57% with ECE, p = 0.12) and overall survival (83% vs. 53%, respectively, p = 0.068) suggested a less favorable outcome for patients with ECE., Conclusions: Microscopic ECE appears to be associated with increased axillary involvement and decreased survival rather than subsequent axillary failure. Our data suggest that radiotherapy to a dissected axilla may be omitted for the sole indication of microscopic extracapsular disease.

Objective: It is important to differentiate pure and mixed mucinous carcinomas of the breast because the former have a more favorable prognosis. We correlate histopathologic findings with mammographic findings for 20 patients with pure or mixed mucinous carcinomas to determine differential characteristics and their pathologic basis., Materials and Methods: We searched our pathology database of 2219 consecutive women with a diagnosis of breast cancer and found that 31 (1.4%) had mucinous carcinomas. Eleven women were excluded because the mammograms (n = 6) or the microscopic slides (n = 5) were not available. The remaining 20 women, who were 37-92 years old (mean, 64 years), were the subjects of the study. Their clinical records, mammograms, and microscopic slides were reviewed. Tumor size was based on the maximum mammographic diameter or measured diameter of the excised tumor., Results: Seventeen patients (85%) had tumors that were mammographically apparent. Histopathologic review confirmed 15 pure mucinous tumors and five mixed mucinous tumors having an overall mean diameter of 3.4 cm. The pure-tumor group contained three incidentally detected tumors (all < or = 0.8 cm in diameter); six that had a circumscribed, lobular contour on mammograms (mean diameter, 3.6 cm); and six that had a poorly defined, irregular contour (mean diameter, 1.2 cm). One of the mammographically apparent small pure tumors contained histologically confirmed psammomatous microcalcifications. All pure tumors had microscopically evident circumscribed margins that could have accounted for the circumscribed mammographic appearance of the larger masses. All mixed tumors had mammographically and histologically evident irregular margins because of the associated fibrosis and infiltrative margins of the nonmucinous component (mean diameter, 5.3 cm)., Conclusion: There are differences in the mammographic appearances of pure and mixed mucinous carcinomas that have a histopathologic basis. Circumscribed, lobular margins on mammograms are characteristic of large pure tumors and are the result of their microscopically evident circumscribed margins and expansile growth pattern. Irregular margins on mammograms are more characteristic of mixed mucinous tumors, regardless of tumor size, and are attributable to the fibrotic and infiltrative nature of the nonmucinous component.

Background: This article describes standard operating procedures (SOPs) for a computer crossmatch to replace the immediate-spin crossmatch for ABO incompatibility between patient blood samples submitted for pretransfusion testing and the blood component selected for transfusion. These SOPs were developed following recent changes to the Standards for Blood Banks and Transfusion Services of the American Association of Blood Banks (AABB)., Study Design and Methods: SOPs were developed, utilizing currently available software, for pretransfusion testing. The SOP for donor unit processing entails bar code entry of the unit number, component name, and ABO/Rh type; computer entry and interpretation of serologic reactions; warning of discrepancies between bar code-entered blood type and result interpretation; and quarantine of the donor unit in such instances. The SOP for patient sample testing requires bar code entry of specimen accession number, which accesses patient demographics; computer entry and interpretation of ABO/Rh tests; repeat blood typing at the time of crossmatch if only one patient blood type is on record; and warning if there are nonconcordant current and historical blood types. The computer crossmatch SOP requires bar code entry of specimen accession and donor unit numbers; release of group O red cells pending resolution of discrepancies; and immediate-spin crossmatch during computer downtime. Tables validated on-site prompt warning messages and prevent both computer crossmatch and release if blood components of the wrong ABO type are selected., Results: These SOPs meet the requirements of the 15th edition of the AABB Standards. Projected annual time savings at this institution are > 100,000 workload recording units. Further benefits include reduced patient sample volume requirements, less handling of biohazardous material, and elimination of unwanted positive or negative reactions associated with the immediate-spin crossmatch. Release of incompatible blood components when the wrong patient blood type is on record is addressed by requiring the use of group O red cells in the absence of two concordant blood types, one of which must be from a current sample., Conclusion: A combination of existing computer programs and carefully developed SOPs can provide a safe and efficient means of detecting donor-recipient incompatibility without performance of serologic crossmatch.

Rationale and Objectives: Mammographic findings and method of detection of 52 cases of invasive lobular carcinoma (ILC), the second most common breast carcinoma, are reported., Methods: Preoperative mammograms and clinical records of all patients with ILC not associated with a second mammary carcinoma (other than lobular carcinoma in situ) from 1979-1991 at the authors' institution were retrospectively reviewed., Results: Abnormal mammographic findings were present in 48/52 (92%) and included irregular spiculated masses (33/52, 63%), asymmetric densities (7/52, 13%), architectural distortion (5/52, 10%), microcalcifications (2/52, 4%), and well circumscribed masses (1/52, 2%). The mean mammographic diameter was 2.1 cm. The tumor was most often best visualized in the craniocaudal projection. At the time of diagnosis, 54% of women had coexistent suggestive breast physical findings and 35% had metastatic carcinoma in axillary lymph nodes., Conclusions: The infrequency of microcalcifications in pure ILC may hinder mammographic detection and contrasts markedly with ductal carcinoma. Mammography and breast physical examination play complementary roles in the detection of ILC.