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The majority of patients with breast cancer can be treated by partial mastectomy and radiation therapy. Ineligibility for breast conservation usually is related to previous radiation or the inability to receive radiation for other reasons. For patients who can receive radiation, selection for breast conservation involves the estimation of the risk for in-breast recurrence and the ability to achieve a satisfactory cosmetic result. Multiple sites of cancer within the breast and the inability to attain negative pathologic margins on the excised breast specimen are predictive for an increased risk of recurrence. The cosmetic result is compromised by excision of large volumes of breast tissue. Although the size of the tumor is not an important consideration for in-breast recurrence, the relation of the size of the tumor, and hence the volume of tissue excised, to the size of the breast is an important cosmetic consideration. Compared to invasive ductal carcinoma, an extensive intraductal component or invasive lobular carcinoma tends to be more difficult to define within the breast and may require excision of a large volume of tissue to obtain negative pathologic margins.

Background. Previous National Cancer Data Base data have been used to examine time trends in stage of disease and treatment patterns for breast cancer. The most current (1990) data are described here. Methods. Two calls for data have yielded a total of 143,051 breast cancer cases for 1985, 1988, and 1990 from hospital cancer registries across the United States. Results. The percentage of in situ cancers increased between 1985 and 1988 but was essentially constant between 1988 and 1990. The use of breast-conserving partial mastectomy across the country increased between 1988 and 1990. Some interesting regional differences appeared in the use of multimodality treatment. Conclusions. These data suggest a plateau in the use of mammographic screening. Cancer 1994; 73:1994-2000. Key words: breast cancer, mammography, partial mastectomy, National Cancer Data Base.

Background: Alkylating agents administered as single agents or in combination with antimetabolites or anthracyclines delay the appearance of metastases and prolong the survival of breast cancer patients after surgery. Purpose: This phase Ill clinical trial was designed to evaluate the therapeutic efficacy and toxicity of the alkylating agent cyclophosphamide in combination with the antimetabolites methotrexate and fluorouracil adjuvant to breast cancer surgery. Methods: This study consisted of 255 breast cancer patients (a) with one to three histologically positive axillary lymph nodes and either no detectable primary tumor or operable primary tumors 5 cm or less (T0-T2) (95% of the patients) or (b) with tumors larger than 5 cm (T3) and with negative axillary nodes. Patients were randomly allocated to receive either methotrexate (60 mg/[m.sup.2]) and fluorouracil (600 mg/ [m.sup.2]) (MF) intravenously on days 1 and 8 every 28 days for eight cycles or cyclophosphamide (100 mg/[m.sup.2]) orally on days 1-14 plus MF (CMF) every 28 days for the same duration. Median follow-up was 7.8 years, and maximum follow-up was 13 years. Results: There were no statistically significant differences in time to treatment failure or overall survival for patients treated with MF or CMF. At 8 years after completion of treatment, time to treatment failure was 55% (95% confidence interval [CI] = 50%-60%) and 59% (95% CI = 54%-64%) and overall survival was 69% (95% CI = 65%-73%) and 67% (95% CI = 62%-72%) for MF-and CMF-treated patients, respectively. The hazard ratios (MF to CMF) for time to treatment failure and for survival, estimated with a proportional hazards model, were 1.02 (95% CI = 0.69-1.50) and 0.87 (95% CI = 0.56-1.34), respectively. Myelosuppression was significantly greater (P

Background. The etiology of Hodgkin disease remains uncertain. Patterns of presentation of Hodgkin disease are analyzed by histologic subtype with implications for etiology and pathogenesis. Methods. The authors performed a detailed analysis of anatomic sites of involvement, histopathologic findings, and clinical features in 719 patients with Hodgkin disease who underwent staging laparotomy with splenectomy between April 1969 and December 1986. The presence of disease in each of 17 sites of potential nodal involvement was determined for each patient from a combination of clinical and surgical staging. Association among nodal sites was assessed in 2 X 2 tables by estimating the odds ratio and testing the significance with the chi-square test. A strict significance level (P = 0.01) was used. Log-linear models were used for assessing association in 2 X 2 tables while adjusting for other factors. Results. The mediastinum, left side of neck, and right side of neck were the most common sites involved for patients with nodular sclerosing (NS) or mixed cellularity (MC) histologic subtypes. Each of these sites was involved 60% of the time. These sites were four or more times as common as other nodal sites above or below the diaphragm. In contrast, the mediastinum was involved in only 8% of patients with lymphocyte predominance (LP) histologic subtype. Significant associations were found between mediastinal disease and low cervical/supraclavicular lymph node disease, mediastinal disease and NS histologic subtypes, peripheral nodal disease and LP histologic subtypes, and between splenic disease and mixed cellularity/lymphocyte depletion (MC/LD) Hodgkin disease. The age at onset and sex of patients with Hodgkin disease and the patterns of nodal distribution were somewhat different for NS and MC/LD histologic subtypes. Even greater differences were seen between LP and other histologic subtypes. Conclusions. This study supports the conclusion that NS and MC Hodgkin disease spread by continguity, most often originating in the neck or mediastinum, and is consistent with evidence suggesting an infectious agent in the pathogenesis of these subtypes of Hodgkin disease. In contrast, LP Hodgkin disease is characterized by different sites of presentation and patterns of spread. This suggests that two or perhaps three clinicopathologic subtypes of Hodgkin disease exist. Implications for etiology and pathogenesis are discussed. Cancer 1993; 71:2062-71.

Ductal carcinoma in situ (DCIS) is a breast cancer arising in the ducts that has not yet invaded surrounding tissue. In the past, the specter of breast cancer was sufficiently ominous that virtually all cases of DCIS were treated with mastectomy. This treatment has been reviewed in recent years, in no small part due to the fact that the growth of mammography is turning up larger numbers of DCIS than were ever diagnosed at such an early stage in the past. Breast-conserving surgery is becoming more popular, but experience with breast-conserving surgery for DCIS is still limited. For this reason, the authors report their experience treating DCIS with conservative surgery and radiation therapy during the period from 1976 to 1985. During this period, 38 patients were diagnosed at a median age of 49 years. In 20 of the patients, the tumor was detectable only by mammography. The tumor was surgically removed in all patients and the tumor bed was treated with an average dose of 6,400 cGy of radiation. An important aspect of the treatment of DCIS is the success of salvage treatment if the cancer recurs after the initial surgery and radiotherapy. In the present study, the cancer recurred in eight patients. These patients underwent mastectomy, and all but one are presently free of disease after a follow-up ranging from 1 to 73 months. Reported local recurrence rates for DCIS after mastectomy range from 0 to 2 percent. Mastectomy, therefore, remains the ''gold standard'' against which other treatments are compared. Only the patient can decide how to balance the small but real risks with the palpable benefits of breast-conserving surgery. (Consumer Summary produced by Reliance Medical Information, Inc.)

It has been well established that for women with early breast cancers of the appropriate characteristics, conservative surgery in combination with radiotherapy is as effective as mastectomy. However, numerous questions remain to be answered and many research studies are currently in progress. As might be expected, key questions involve factors that influence the risk of local recurrence of the breast cancer. The histological appearance of the cancer affects the risk of recurrence. For example, when intraductal carcinoma cells are found in grossly normal tissue outside the margin of tumor invasion, the risk of recurrence is 25 percent, in contrast to the 5 percent risk overall. Young age is also thought to be an important risk factor, with a recurrence rate of well over 50 percent among patients under 35. Since younger patients usually have riskier histological findings, it might be thought that this alone accounts for the increased risk of younger patients. However, even when the histological findings of the tumor are accounted for, age under 35 carries an increased risk of recurrence. It is well established that conservative surgery alone is far riskier for recurrence than conservative surgery with radiotherapy of the breast. All patients receiving conservative surgery may be considered to be at high risk for recurrence. Curiously, however, it is not at all clear that local recurrence has a statistically significant effect on mortality in these patients. (Consumer Summary produced by Reliance Medical Information, Inc.)

Recurrence of breast cancer following conservative surgery (removal of the tumor without examining the remaining tissue margins to determine that they were unaffected by malignant change) and radiation therapy may be partly a function of tumor size. To investigate this issue, 783 patients who were treated in this manner were followed-up for an average of 91 months. Biopsies of the tumor material were evaluated for several features, including the status of associated lymph nodes, presence or absence of estrogen receptors (tumors with receptors for estrogen, a female hormone, were called estrogen receptor-positive, or ERP-positive), extent to which blood vessels had been invaded, malignant grade of the tumor, and the presence of intraductal carcinoma (EIC, extensive intraductal component, representing a widespread distribution of cancer within the ducts of the breasts). Results showed that cancer recurred in 100 patients, with 56 (13 percent) local recurrences among women who had had T1 tumors (2.0 centimeters or less), and 45 (12 percent) local recurrences among women with T2 tumors (2.1 to five centimeters). Thus, there was no trend toward increasing recurrence for larger tumors. There was a five percent higher recurrence rate for ERP-negative tumors than for ERP-positive tumors (15 percent versus 10 percent, respectively). Within the categories of ERP-negative or -positive tumors, size did not correlate with recurrence rate. Patients with EIC-negative tumors had a local recurrence rate of seven percent; however, EIC-positive tumors recurred much more often, at an overall rate of 27 percent. For both EIC categories of tumor, smaller tumors demonstrated higher recurrence rates. A table of clinical trials reporting breast cancer recurrence rates is provided. Results from one study showed that, regardless of the size of the primary tumor, the number of tumor foci (other malignant regions) in other regions of the breast did not differ. Overall, the findings show that tumor size does not predict recurrence when conservative surgery and radiation are the methods of treatment. They also indicate that such treatment is not sufficient for EIC-positive tumors. (Consumer Summary produced by Reliance Medical Information, Inc.)