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Background Surgical excision is currently recommended after pathologic radial scar is found on breast core needle biopsy because surgical upgrade to carcinoma is not uncommon. The goal of our study was to identify the true pathologic upgrade rate for a "pure" radial scar, those without associated proliferative lesion, based on indication for biopsy, biopsy type, and needle size. Study Design The pathology database of Continuum Health Partners was searched for the terms radial scar and radial sclerosing lesion , from January 2007 to December 2015. From review of 1,513 pathology reports, 292 cases of core biopsies without malignancy were identified. Age, indication for biopsy, type of biopsy, and excisional pathology were obtained. Data were then analyzed using SPSS. Results Two hundred nineteen (75%) of the 292 core biopsies showed pure radial scar without associated proliferative lesion, and 161 (74%) of these patients had surgical excision. Only 1 of these patients had disease that was upgraded to ductal carcinoma in situ—a 2-mm focus located 5 mm away from the radial scar biopsy cavity. This patient also had residual calcifications on mammography after the stereotactic biopsy. Six additional malignant upgrades were found in patients who had radial scar associated with atypical ductal hyperplasia (n = 5) or lobular neoplasia (n = 1) on needle biopsy. Conclusions Surgical excision is unnecessary when radial scar is found at percutaneous needle biopsy without an associated proliferative lesion. Surgical excision is still indicated when radial scar is associated with atypical ductal hyperplasia or lobular neoplasia.

Background The use of clinical features to allocate adjuvant therapy in the treatment of ductal carcinoma in situ with breast-conserving therapy remains controversial. Methods A review of patients with ductal carcinoma in situ treated with breast-conserving therapy was performed. The recurrence rate was examined in relation to patient age, tumor characteristics, Van Nuys Prognostic Index, and the receipt of prescribed adjuvant therapies. Results Six percent of patients (17 of 294) had developed local recurrences after a median follow-up period of 63 months. Fifty-nine percent of patients (91 of 154) with estrogen receptor–positive tumors did not receive prescribed tamoxifen. Thirty-one percent of patients (45 of 147) with Van Nuys Prognostic Index scores ≥7 did not receive recommended radiation therapy. Receipt of prescribed adjuvant therapy did not result in a decrease in the rate of local recurrence. Patient age was the only factor associated with local recurrence on univariate but not on multivariate analysis ( P = .374). Conclusions A low rate of local recurrence was achieved despite a large number of patients' not receiving prescribed adjuvant therapies.

The significance of lobular neoplasia (LN), lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH)) found at core needle biopsy (CNB) of the breast remains uncertain. There is a consistent risk of underestimating malignancy after the diagnosis of LN on CNB. The aim of this study was to determine if patients with a CNB result of LN need surgical excision.Patients were identified by searching the institutions pathology database for the terms "lobular carcinoma in situ" and "atypical lobular hyperplasia" over 20 years. Excluded from this study were those with core needle biopsy (CNB) results of ductal carcinoma in situ, atypical ductal hyperplasia, radial scar, or papilloma. Upgrade was defined as final surgical pathology of invasive carcinoma and/or ductal carcinoma in situ that was directly correlated to the site of the initial biopsy containing LN.LN was found at CNB in 285 patients, and 71 % (n = 201) had subsequent surgical excisions. All patients with pleomorphic LCIS (pLCIS) underwent surgical excision. Following patients with pLCIS, patients with the diagnosis of LCIS were most likely to undergo surgical excision (80 %). Final pathology of the surgically excised specimens confirmed LN in 72 % (n = 144). Also, 13 % (n = 26) of the operated patients were upgraded to malignancy, including 8 % of ALH and 19 % of LCIS cases.This is the largest series of surgical excisional pathology following LN on CNB ever reported. The likelihood of finding malignancy at surgical excision after CNB showing LN was 13 %. Patients with the diagnosis of LN on CNB should be considered for surgical excision.

Guidelines for screening mammography have been established by numerous medical societies. Guidelines have not been established for follow-up mammography for patients who have been treated with breast-conserving surgery. Many radiologists recommend mammography of the treated breast 6 months after completion of treatment. The purpose of this study was to determine the value of interval mammography.Patients were identified by searching the breast cancer database for the diagnoses of ductal carcinoma in situ, infiltrating ductal carcinoma and infiltrating lobular carcinoma. Postoperative mammogram dates and results were obtained. Patients with mammography within 8 months of surgery were included in the study.Ductal carcinoma in situ, infiltrating ductal carcinoma, and infiltrating lobular carcinoma were found in 1,000 patients who underwent breast-conserving surgery, and 789 patients had complete mammographic follow-up data available. Postoperative interval mammography was performed in 169 patients (21 %), including 23 patients who had preradiation mammography. Ninety percent of the interval mammograms were BI-RADS 1 to 3 and 10 % were BI-RADS 4 or 5. Two cancers were found on interval mammography (1.2 % of 169) and 4 of 620 (0.6 %) patients who did not have interval mammography were found to have malignancy within 1 year of surgery (1.2 % vs. 0.6 %, P = 0.614). The use of interval mammography was not related to the mammographic findings at diagnosis. Interval mammography did not affect local and distant disease-free survival.The likelihood of obtaining a significant finding on short interval follow-up mammography after conservative surgery for breast cancer is 1.2 %.

Objectives. To determine the incidence and type of premalignant or malignant changes in mammaplasty specimens and to determine the incidence of these changes according to age distribution.Methods. Retrospective database review of patients who underwent a reduction mammaplasty between 1999 and 2009 was performed from pathology records at a single institution.Results. 700 patients were identified. Of the 644 patients who had bilateral reductions, 25 (4%) had significant pathologic findings. The likelihood of finding premalignant changes or cancer increased with advancing patient age (0.8 percent for patients 60 years old). Of the 56 patients who underwent unilateral mammaplasty, 12 patients (21%) had significant pathologic findings. The incidence of finding premalignant changes or cancer in this population also increased with advancing patient age (0 for patients 60 years old).Conclusions. When a unilateral mammaplasty is performed to match a breast reconstructed after cancer surgery, the likelihood of identifying premalignant changes or cancer increases more than fourfold. Therefore, one should consider additional radiologic imaging in the preoperative workup of patients with a history of carcinoma prior to undergoing unilateral mammaplasty.

The present study investigated relations between reported childhood abuse and recent traumatic stress symptoms in women newly diagnosed with breast cancer (n=330).As part of a larger ongoing study, patients from eight public and private hospitals were referred by their physicians and completed the Childhood Trauma Questionnaire (CTQ), and the Impact of Events Scale-breast cancer (IES), which measured breast cancer-related intrusive and avoidant symptoms.Emotional abuse, physical abuse, and sexual abuse were correlated with intrusive symptoms. Cancer-related avoidant symptoms approached significance in their relation to emotional and sexual abuse. Multivariate analysis, controlling for age and time since diagnosis, revealed that childhood emotional abuse was an independent predictor of breast cancer-related intrusive symptoms, but that childhood physical abuse and sexual abuse were not significant predictors.Childhood emotional, physical, and sexual abuse were associated with breast cancer-related intrusive symptoms. Emotional abuse uniquely predicted intrusive symptoms after controlling for other predictors. Results suggest that a cancer diagnosis may trigger cognitive and emotional responses that relate to patients' prior trauma experiences.Physicians and psychologists treating women with breast cancer should be aware that a history of childhood abuse may exacerbate patients' cancer-related intrusive symptoms. Interventions for women affected by both childhood abuse and breast cancer may be most effective when they address both stressors and associated emotional responses. Findings highlight the importance of additional research to explore links between prior trauma and distress following a cancer diagnosis stress.

Breast cancer in African-American (AA) women occurs at an earlier age than in European-American (EA) women and is more likely to have aggressive features associated with poorer prognosis, such as high-grade and negative estrogen receptor (ER) status. The mechanisms underlying these differences are unknown. To address this, we conducted a case-control study to evaluate risk factors for high-grade ER- disease in both AA and EA women. With the onset of the Health Insurance Portability and Accountability Act of 1996, creative measures were needed to adapt case ascertainment and contact procedures to this new environment of patient privacy. In this paper, we report on our approach to establishing a multicenter study of breast cancer in New York and New Jersey, provide preliminary distributions of demographic and pathologic characteristics among case and control participants by race, and contrast participation rates by approaches to case ascertainment, with discussion of strengths and weaknesses.

Background The role of sonography as a sole identifier of breast malignancy remains undetermined. Currently, the American College of Radiology Imaging Network (ACRIN) trial, protocol 6666, is accruing high risk patients, with dense breast tissue on mammography, to evaluate the performance of screening sonography. Study design We conducted a retrospective single institution review to identify the detection rate of nonpalpable, mammographically occult breast malignancies identified solely by sonography. Results A total of 34,694 breast sonograms were performed at our outpatient radiology affiliate between April 1998 and April 2006. This number includes unilateral and bilateral examinations, and, 6-month followup examinations. Computerized databases and individual charts were retrospectively reviewed. Sonographic and mammographic findings were compared to determine concordance of identified lesions. Four thousand ninety-one ultrasound guided biopsies, (fine needle aspiration biopsy [FNA] and core needle biopsy [CNB]) were performed over the 8-year period, and 452 malignancies were identified. Discarded fluid contents of pure cyst aspirations were not included in this number. Seven percent (32) of the biopsy-proved malignancies were mammographically occult, of which 59% (19) were palpable, and 31% (10) were not palpable. Of all cancers diagnosed, 2.2% were identified solely by sonography. The number of cancers identified solely by sonography relative to the total number of sonograms done was 0.03%. Conclusions Given these results, we advocate the selective use of sonography in appropriate populations, namely, in those with palpable findings, mammographic abnormalities, and in women with dense tissue who have personal or family history of breast cancer.

The recent American Joint Committee on Cancer revision of the staging system for breast cancer classifies sentinel node metastases0.2 mm (pN0[i+]) as node negative and those0.2 mm but2 mm are designated pN1(mi). We examined the association between size of sentinel node metastases and rate of nonsentinel node metastases, specifically in the subgroup of patients with micrometastases.We examined the nonsentinel nodes of 124 patients with positive sentinel nodes and correlated the likelihood of nonsentinel node involvement with the size of the metastasis in the sentinel node and primary tumor characteristics.Nonsentinel node metastases were found in 19% (6 of 31) of patients with sentinel node metastasesor= 0.2 mm, 20% (6 of 30) of patients with metastases 0.2 mm to 2 mm, and 46% (29 of 63) of patients with metastases2 mm. Multivariate analysis found that involvement of the majority of sentinel nodes (p = 0.01) and sentinel metastases2 mm (p = 0.001) were significantly related to presence of metastases in nonsentinel nodes. Age, tumor size, pathology, multifocality, satellites, and lymphovascular invasion were not significantly related to nonsentinel node metastases in multivariate analysis.These findings indicate that frequency of nonsentinel node metastases with sentinel node metastasesor= 0.2 mm is comparable to the frequency when sentinel metastases are0.2 to 2 mm. Omitting complete axillary dissection in pN1(mi) and pN0(i+) patients may leave residual disease in up to 20% of these patients.

Background Because breast cancer survival after breast conservation has proved comparable to mastectomy, contraindications to mastectomy are increasingly being challenged. We treated the majority of our patients with multiple synchronous ipsilateral cancers with breast conservation and we compared them with patients who underwent mastectomy for comparable disease during the same interval. Study design Patients with multiple ipsilateral synchronous breast cancers between 1989 and 2002 were identified from prospective databases maintained by us. A comparison was made between 36 patients treated with lumpectomy and 19 patients treated with mastectomy. Results There were no significant (all p values >0.2) differences between mastectomy and breast conservation patients in age, racial distribution, size of cancers, pathology, tumor differentiation, nodal involvement, or hormone receptor positivity. The majority of patients treated with breast conservation underwent at least one reexcision to obtain clear pathologic margins, and they were more likely to receive postoperative radiotherapy than patients treated with mastectomy. There were no significant differences in the local (97% versus 100%, p=0.54) or distant (97% versus 95%, p=0.20) 5-year disease- free survival between the group treated with breast conservation and the group treated with mastectomy. One patient in each group developed distant metastases. One patient in the breast conservation group developed local recurrence at both primary sites simultaneously 39 months after lumpectomies. She is free of disease 78 months after mastectomy. The remaining 52 patients are alive and free of disease. Conclusions Breast conservation is an effective treatment for patients with synchronous ipsilateral breast cancers.

Background: Incidental breast cancer is occasionally found in spot localization biopsy specimens adjacent to mirocalcifications in benign breast disease. Because this phenomenon could prove problematic for percutaneous sampling of microcalcifications without excisional biopsy, we studied surgical specimens from patients with cancers incidental to microcalcifications and compared them with specimens with microcalcifications within the malignancy. Methods: The pathology database at the Mount Sinai Medical Center from January 1993 to July 1998 was reviewed to identify breast cancer patients who underwent spot localization biopsy for microcalcifications. Patients presenting with microcalcifications within malignancy (determinate) were compared with patients with mirocalcifications in benign breast tissue adjacent to malignancy (incidental). Results: Thirty-two (13%) of the 241 specimens had microcalcifications in benign tissue adjacent to malignancy and 209 (87%) had microcalcifications within the malignancy. Fifty-six percent of the incidental cases and 65% of the controls had ductal carcinoma in situ. Infiltrating lobular carcinoma accounted for 25% of the incidental cancers and 2% of the determinate cancers (P

Background: Breast cancer survival is improving because mammography is leading to diagnosis at earlier stages of the disease. Because young women with breast cancer rarely undergo mammography before diagnosis, outcomes for breast cancer in young women may not be improving. In addition to advanced stage, young age at diagnosis is associated with biologically more aggressive cancers with higher rates of local and distant recurrence. Study Design: Risk factors, clinical presentations, pathologic findings, tumor characteristics, extent of disease, treatment, and outcomes for 101 women under age 36 treated for breast cancer between 1989 and 1997 were compared with 631 patients 36 years and older treated by us during the same interval. Stage IV patients were excluded. Results: Patients younger than 36 years were more likely to present with a palpable mass (87% versus 55%, p Conclusions: Patients diagnosed with breast cancer before age 36 differ from older patients in numerous respects. They present more often with a palpable mass rather than a mammographic finding and their cancers are more advanced with features that are more aggressive. Despite aggressive treatment, most commonly with mastectomy and chemotherapy, local and distant failure rates are higher than for patients 36 and older. The higher rate of local recurrence in patients less than 36 years reflects an excess number of local recurrences in patients treated with breast conservation.

Objective: Hormone replacement therapy (HRT) is associated with decreased breast cancer mortality despite increased incidence. We studied postmenopausal breast cancer patients to determine whether this paradox results from earlier diagnosis, biologically less aggressive tumors, or cessation of hormonal stimulation. Methods: Demographic, clinical, pathologic, treatment, and outcome information for 455 postmenopausal breast cancer patients who had not used postmenopausal hormones was compared with that of 47 breast cancer patients who used postmenopausal hormones prior to diagnosis. Results: Hormone users were significantly younger, more often white, and of lower body mass index than nonusers. Hormone users presented significantly more often with nonpalpable mammographic findings, resulting in significantly smaller tumors with less nodal involvement than nonusers. Cancers of hormone users were more commonly invasive lobular or in situ ductal and were more likely to be steroid receptor positive. Hormone users were treated with breast conservation significantly more frequently than nonusers. These differences persisted after matching for age and year of surgery and after controlling for race. At 5 years, none of the hormone users with invasive cancers had local recurrence compared with 8% of nonusers, and 7% of users had distant disease compared with 10% of nonusers. Conclusion: These results indicate that favorable breast cancer survival after postmenopausal hormone use might result from earlier detection through mammography. Possible hormonal influence on tumor biology and prognosis was not supported by our data.

Background and objectives A significant proportion of breast cancer patients treated with breast conservation surgery do not receive adjuvant radiation therapy because of advanced age, severe intercurrent disease, or their own preference. We studied patients for whom adjuvant radiation was not performed, to determine whether the rate of local recurrence was acceptable in particular clinical circumstances. Methods Patients who had undergone breast conservation surgery for breast cancer were identified. The charts of patients who did not receive adjuvant radiation therapy were reviewed to identify the reason for omitting radiation. Local and distant recurrence rates were examined in relation to radiation and reason for omitting radiation. Results Forty-three (9%, two bilateral) of the 487 patients did not receive radiation; 9 because of advanced age, 8 refused, 7 had severe intercurrent diseases, 6 developed stage IV disease while getting chemotherapy for stage III disease, 5 patients (1 bilateral) had two reasons for omission (3 cases: age + intercurrent disease; 2 cases: age + stage IV disease; and 1 case: age + small focus of ductal carcinoma in situ) and the remainder for miscellaneous reasons. None of the 13 patients with intercurrent disease or progression to stage IV disease developed local recurrence in their life time; 5 (63%) of 8 patients who refused radiation recurred in the breast; 2 (22%) 9 of the elderly patients developed local recurrences and none of the 6 cases with more than one reason for omission developed local recurrences. Conclusions Omission of radiation therapy after breast conservation is appropriate for patients with intercurrent diseases, for those who develop metastases while receiving preoperative chemotherapy and for selected elderly patients. Patients who refuse recommended adjuvant radiation therapy have unacceptably high rates of local recurrence. Omission of radiation for advanced age alone is associated with local recurrence rates comparable to those for younger patients.

OBJECTIVES: To assess the consequences of physician delay in the diagnosis of breast cancer by comparing stage, treatment, and outcome of patients with and without delay, and to identify patient characteristics that may make diagnosis more difficult. SUMMARY BACKGROUND INFORMATION: Delay in diagnosis of breast cancer is the most common clinical scenario resulting in malpractice litigation. METHODS: The records of 1014 patients were reviewed and the events preceding the diagnosis were reconstructed. Accurate assessment of the physician delay in diagnosis could be made for 606 patients, 51 (8%) with physician delay >3 months. Patients with delay were comparable to patients without delay in terms of age, height, weight, age at menarche, pregnancies, children, proportion in menopause, age at menopause, and family history of breast cancer. RESULTS: Thirty-six percent of patients who had a delay in diagnosis had normal mammograms versus 7% of patients without delay. Cancers in patients with delay were significantly larger on average than in those without delay, but there were no significant differences in pathology, differentiation, nodal status, TNM stage, treatment, or outcome. CONCLUSIONS: Physician delay in the diagnosis of breast cancer is common, and patients with delay are similar to patients without delay, although they are more likely to have normal mammograms. The consequences of physician delay in terms of stage at diagnosis, treatment, and outcome were not statistically significant.

A small percentage of breast cancers are not visible on mammography. Since mammographically occult malignancies may be more difficult to diagnose, we hypothesized that the lack of visualization would cause a delay in detection, more aggressive surgical and adjuvant therapy, and poorer outcome. Patients with mammographically occult malignancies were compared to patients with cancers visible on mammogram. The significance of mammographic visibility for treatment and local and distant recurrence rates were evaluated. Ninety-one of the 813 (11%) cancers were mammographically occult. Patients with mammographically occult malignancies were significantly younger, of lower body weight, and had fewer pregnancies than patients with cancers visible on mammography: age, body weight, and parity were statistically significant (p < 0.001) in stepwise logistic regression. Ductal carcinoma in situ was significantly more frequently diagnosed in patients with mammographically visible malignancies (14% versus 4%, p = 0.0163) and nodal involvement was significantly more frequent in patients with mammographically occult malignancies (35% versus 24%, p = 0.0391). Diagnostic delays exceeding 3 months were experienced by 24% of patients with mammographically occult malignancies compared to 13% of patients with tumor visible on mammography (p < 0.0001). Adjuvant chemotherapy was given to 63% of patients with occult malignancies compared to 41% of patients with mammographically visible cancers (p = 0.0027). The use of breast-conserving therapy and adjuvant radiation and tamoxifen were comparable. Survival free of local recurrence and distant metastases for the 403 patients followed for 5 years or more was not related to mammographic visibility.

Background Onco type DX is a 21-gene assay that calculates a risk of distant recurrence in women with estrogen-receptor–positive, lymph node–negative breast cancer. The purpose of this study was to determine whether the results of Onco type DX influence the decision to administer chemotherapy. Methods A retrospective study was performed on 85 consecutive patients with estrogen-receptor–positive, lymph node–negative breast cancer who had an Onco type DX recurrence score (RS) obtained. Tumor size, tumor grade, and treatment were then compared within each risk category. Statistical analysis was performed using STATA software. Results Tumors that were high grade and Her-2/neu positive more frequently had a high RS. Treatment was changed as a result of Onco type DX in 44% of patients. Conclusions Onco type DX RS is significantly related to tumor grade and Her2/neu status. In this study, the treatment of 44% of patients was altered as a consequence of Onco type DX RS.

SummaryBased on breast cancer families with multiple and/or early-onset cases, estimates of the lifetime risk of breast cancer in carriers of BRCA1 or BRCA2 mutations may be as high as 85%. The risk for individuals not selected for family history or other risk factors is uncertain. We determined the frequency of the common BRCA1 (185delAG and 5382insC) and BRCA2 (6174delT) mutations in a series of 268 anonymous Ashkenazi Jewish women with breast cancer, regardless of family history or age at onset. DNA was analyzed for the three mutations by allele-specific oligonucleotide hybridization. Eight patients (3.0%, 95% confidence interval [CI] 1.5%–5.8%) were heterozygous for the 185delAG mutation, two (0.75%, 95% CI 0.20–2.7) for the 5382insC mutation, and eight (3.0%, 95% CI 1.5–5.8) for the 6174delT mutation. The lifetime risk for breast cancer in Ashkenazi Jewish carriers of the BRCA1 185delAG or BRCA2 6174delT mutations was calculated to be 36%, approximately three times the overall risk for the general population (relative risk 2.9, 95% CI 1.5–5.8). For the 5382insC mutation, because of the low number of carriers found, further studies are necessary. The results differ markedly from previous estimates based on high-risk breast cancer families and are consistent with lower estimates derived from a recent population-based study in the Baltimore area. Thus, presymptomatic screening and counseling for these common mutations in Ashkenazi Jewish women not selected for family history of breast cancer should be reconsidered until the risk associated with these mutations is firmly established, especially since early diagnostic and preventive-treatment modalities are limited.

Thirty-five patients with pregnancy-associated breast carcinoma diagnosed between 1985 and 1995 were identified and characterized from a prospectively generated database. Twenty-two of these patients had stage 1 or 2 disease and were therefore potential candiates for conservative surgical management. The median age was 36 years. Two thirds of the patients were pregnant at the time of diagnosis; the median gestational age of the fetus at diagnosis was 7 months. Twenty-one of the 22 of the patients presented with a palpable mass. The majority of tumors were estrogen-receptor negative. Nine patients were treated with breast-conservation therapy, and 13 were treated with mastectomy. In the breast-conservation therapy group, there were three distant recurrences and no local recurrences with a median follow-up of 24 months. In the mastectomy group, two patients developed distant metastases and one developed a local recurrence with a median follow-up of 28 months. The results of breast-conservation therapy are similar to the results of mastectomy for stage 1 and 2 cancers associated with pregnancy. Therefore, breast-conservation therapy is an option for selected patients with pregnancy-associated breast cancer.

Background: The aim of this study was to identify variables associated with clear biopsy margins and clear reexcision margins of breast cancer specimens from patients who are candidates for breast conservation. Study Design: The records of breast cancer patients were reviewed to identify candidates considered for breast conservation after biopsy. Factors associated with obtaining histopathologically clear excisional biopsy margins and clear reexcision margins were studied in 674 excisional biopsy specimens and in 197 reexcision specimens. Results: Clear biopsy margins were associated with older patient age (p = 0.0446), family history of breast cancer (p = 0.0008), diagnosis by fine needle aspiration (p = 0.0000), small tumor size (p = 0.0010), absence of ductal carcinoma in situ (p = 0.0004), and absence of extensive intraductal carcinoma (p = 0.0117). In multivariate analysis, only diagnosis by fine needle aspiration and small tumor size were associated with clear biopsy margins. Clear margins in reexcision specimens were associated with small tumor size (p = 0.0086), close or unknown biopsy margins (p = 0.0003), and absence of nodal involvement (p = 0.0014). In multivariate analysis only biopsy margin status and node status were associated with clear reexcision margins. Conclusions: These data indicate that obtaining clear biopsy margins is facilitated by small tumor size and by having a preoperative diagnosis by fine needle aspiration. The majority of patients undergoing reexcision will have clear margins although this is significantly less likely when the biopsy margins are involved or when nodal involvement is present.

The combination of examination, mammography, and fine-needle aspiration cytology is increasingly being used to identify palpable breast masses that can be followed rather than excised. Since all three modalities are highly dependent on training and experience, causing the accuracy of the triple test to be highly variable, we examined the results of our own experience, expecting to find at least one triply false-negative cancer. Consecutive patients (198) with breast masses subjected to clinical examination, mammography, fine-needle aspiration cytology, and confirmatory excisional biopsy were studied. Sensitivity and specificity were calculated for all combinations of the three diagnostic methods and the significance of concordant and discordant findings was evaluated. The sensitivities of examination, mammography, and cytology were 96%, 82%, and 85% respectively and the specificities were 75%, 90%, and 82%. No cancers were missed when all three diagnostic modalities were used together. Benign concordance of examination, mammography, and cytology was invariably associated with benign pathology. These results validate the use of the triple test in our hands. However, the accuracy of the triple test will vary from physician to physician and its validity in following benign lesions must be evaluated with confirmatory excisional biopsies.

OBJECTIVE: To determine whether fine needle aspiration of palpable breast cancers increases the risk of local or distant recurrence. STUDY DESIGN: The study group consisted of 58 patients with palpable breast cancers who were treated with breast conservation following diagnosis by fine needle aspiration. The control group consisted of 308 patients with palpable cancers treated in the same way following diagnosis by excisional biopsy. All patients were followed for five years. RESULTS: The 58 cases diagnosed by fine needle aspiration were significantly younger than the 308 patients diagnosed by excisional biopsy (55 vs. 63, P

Numerous studies have convincingly shown that women with low bone mineral density have lower risk of breast cancer. As many risk factors for breast cancer are also prognostic factors, we hypothesized that women with breast cancer and low bone mineral density will have lower breast cancer recurrence rates than women with normal bone densities. A prospectively collected data base of breast cancer patients was used to identify postmenopausal Caucasian women. Their records were reviewed and 309 patients with complete follow-up and bone density tests within 1 year of their surgery were identified. The outcome of patients with low bone density (t > -1.0) was compared to the outcome for patients with normal bone density (t

The effect of undertreatment with adjuvant hormonal therapy, chemotherapy, or radiation was studied in elderly women with breast cancer. A prospectively maintained database was used to identify women undergoing potentially curative surgery between 1978 and 2012. The presentation, pathologic findings, treatment, and outcomes of 382 women over 70 were compared to the findings in 2065 younger patients. Subsequently, conventionally treated and undertreated elderly patients were identified and their characteristics and outcomes were compared. Both young and old patients presented most frequently with mammographic findings, but older patients presented more frequently with mammographic masses while younger patients presented more frequently with mammographic calcifications. Cancers of older patients were significantly more favorable than cancers in younger patients: smaller, with more infiltrating lobular, fewer ductal carcinoma in situ, and more frequently estrogen receptor positive and fewer were poorly differentiated. Elderly patients had less axillary sampling, fewer mastectomies, less adjuvant radiation therapy, and more hormonal therapy. Fifty-one percent of the 382 elderly patients were undertreated by conventional criteria. Undertreated patients were more frequently in situ, better differentiated, smaller, and more often estrogen receptor positive. Forty-four percent of the undertreated patients died during followup without disease recurrence. Despite undertreatment, local and distant disease-free survival was comparable to patients who were not undertreated.

Objective The author's objective was to determine whether the length of postoperative stay for patients after colorectal cancer surgery is associated with prognosis. Summary Background Data Financial pressure to reduce hospital costs has caused physicians to reduce hospital stays by changes in patient care, which reduce hospital stay but may compromise long-term results. Methods Using multivariate analysis, the author examined the relationship between postoperative stay and prognosis in a consecutive series of 341 prospectively studied patients with colorectal cancer undergoing potentially curative surgery. Results In multivariate analysis, patients staying beyond the median of 11 days had more complications (p = 0.000), more left hemicolectomies and procedures with colostomies (p = 0.000), were older (p = 0.002), and lost more blood (p = 0.012) than patients staying less than the median. Disease-free survival was significantly and independently related to Dukes' stage (p = 0.000), postoperative stay (p = 0.001), and blood transfusion (p = 0.011). The mean postoperative stay for the 98 patients who later developed recurrence was 15 days compared to 12 days for the 243 patients who remained disease free (p = 0.0008). Cumulative disease-free survival of the 142 patients who stayed more than the median of 11 days was 60% compared to 77% for the 199 patients with shorter stays (p = 0.000). Conclusions These data indicate that shorter hospital stays do not compromise disease-free survival of patients with colorectal cancer.

Prognostic factors are used routinely in the management of breast cancer. However, their potential for identifying precursor malignant lesions has not been assessed.We have examined 285 breast biopsy specimens (140 benign, 145 malignant) for DNA ploidy, S-phase fraction, Ki-67 nuclear antigen proliferative indices, and HER-2/neu and epidermal growth factor receptor oncoproteins.When proliferative indices were compared between the benign and malignant groups, differences were noted for DNA ploidy, S-phase fraction, and cell cycling index (p0.0005). When the benign nonproliferative specimens were compared with the atypical/proliferative benign specimens, proliferative indices failed to show any differences. When the specific subset of proliferative/atypical benign breast tissue was compared with the malignant specimens, DNA index, S-phase fraction, and cell cycling index showed significant differences. The mean for epidermal growth factor receptor was greater in the non-proliferative group but not statistically significant (p0.1). HER-2/neu oncoprotein failed to show any differences between the benign and malignant groups. Within the atypical benign group, Ki-67 correlated strongly with S-phase fraction and HER-2/neu (p0.01).We have demonstrated that proliferative indices can differentiate between benign and malignant breast tissues but not among specific subgroups. In addition, epidermal growth factor may differentiate between nonproliferative and proliferative/atypical benign biopsy results. Oncoprotein determination, ploidy, and DNA proliferative indices may be useful in defining malignant and benign breast disease but are not useful in distinguishing between benign and malignant breast disease with an increased likelihood for malignant transformation.

Phyllodes tumors of the breast are rare lesions that historically have been presumed to be related to fibroadenomata, largely by virtue of the entities' histologic similarities. We report four cases of malignant phyllodes tumors (cystosarcoma phyllodes) of the breast, three showing liposarcomatous differentiation and one showing chondrosarcomatous and osteosarcomatous differentiation, each of which had demonstrable histologic continuity with benign fibroadenomata; one patient had a prior and concurrent history of multiple bilateral fibroadenomata. We postulate that fibroadenomata and phyllodes tumors (benign, borderline, and malignant) may constitute a spectrum of one stromal disease analogous to mammary epithelial hyperplasia, atypical hyperplasia, in situ, and invasive carcinoma. Int J Surg Pathol 3(1):17-22, 1995

Atypical lobular hyperplasia (ALH) is occasionally found in specimens obtained by percutaneous stereotactic vacuum-assisted breast biopsy for microcalcifications. Since malignancy is often found at surgical excision when atypical ductal hyperplasia is found at percutaneous biopsy, we reviewed our pathologic findings from surgery for ALH at percutaneous biopsy. This was a retrospective review of all percutaneous breast biopsy specimens for mammographic microcalcifications obtained from a single institution over a 30-month period. The pathologic findings from percutaneous biopsy were correlated with the radiologic appearance and the pathology from surgical excision. ALH was found in 13 of 766 (1.7%) stereotactic vacuum-assisted core needle biopsies performed for mammographic microcalcifications. Subsequent surgery in six patients revealed ductal carcinoma in situ (DCIS) in two patients and one case of invasive ductal carcinoma. Surgical excision is indicated for areas with ALH discovered by percutaneous biopsy for mammographic microcalcifications.

The most expeditious way of reducing surgical costs is through reducing hospital stay. Multivariate analysis was used to identify potentially alterable factors affecting postoperative hospital stay for 73 consecutive patients undergoing modified radical mastectomy by 6 surgeons during a 12-month period. Stepwise logistic regression was used to identify independently significant preoperative variables associated with hospital stays equal to or greater than the median of 5 days. Intraoperative techniques and postoperative management were then evaluated using Cox proportional hazards model, with length of stay as the dependent variable after consideration for the significant independent preoperative factors. Age, history of heart disease, hypertension, diabetes, obesity, and American Society of Anesthesiologists (ASA) risk were significantly associated with prolonged stay (more than 4 days) in univariate analysis. Only age (P0.001) and cardiac history (P = 0.013) were significant independent predictors of hospital stay in multivariate analysis. After consideration for age and cardiac history, the only significant intraoperative or postoperative factor associated with hospital stay was the use of dressings incorporating Steri-Strips. This study suggests that the attribution of the reduction in hospital stay to discharge with drains in place is due to numerous factors, only one of which is the willingness to send patients home with the drains.

A palpable 3.2 cm infiltrating ductal carcinoma was removed from a 27-year-old woman. Radiologic evaluation of the breasts with mammography and sonography identified an intramammary node between the carcinoma and the axilla. This was localized and removed at the time of axillary dissection. Isosulfan blue, which had been injected into the walls of the lumpectomy cavity to facilitate identification of the sentinel node in the axilla, stained the intramammary node. It contained several foci of carcinoma. Excision of the intramammary nodes may be indicated in breast cancer patients treated with breast conservation.

The relationship between blood transfusion, disease-free survival, and other potential prognostic factors was prospectively studied in 339 consecutive patients with colorectal cancer. Admission and discharge hematocrit, Dukes' stage, and blood loss were significantly related to both blood transfusion and disease-free survival. Using Cox proportional hazards model, however, the association of transfusion with disease-free survival was significant (p = 0.0196) after controlling for age, sex, blood loss, procedure, tumor differentiation, stage, admission hematocrit, duration of surgery, length of the specimen, and tumor size. Dukes' stage (p < 0.0001) and blood transfusion (p < 0.0001) were the only variables independently related to disease-free survival. Forty per cent (44) of the 110 patients who received transfusions developed cancer recurrence, compared with 22% (50) of the 229 patients who did not receive blood (p < 0.0001). Five-year disease-free survival of the transfused patients was 57%, compared with 77% for nontransfused patients. Patients who developed recurrence received an average of twice as much blood as patients without recurrence (1.26 versus 0.61 units, p = 0.0128). Perioperative blood transfusion is a significant independent prognostic factor for colorectal cancer.

Introduction There is little information on patient-driven noncompliance of adjuvant therapies and its consequences. Methods This retrospective study compares clinical, pathological features and outcomes of breast cancer patients who were compliant to recommended radiation, chemotherapy, and hormonal therapies to those who were noncompliant. Results Noncompliance rates for chemotherapy, radiation, and tamoxifen were 31 of 421 (7%), 30 of 855 (4%), and 294 of (37%) respectively. Old age was associated with noncompliance to chemotherapy and radiation, but younger women tend to be more often noncompliant to tamoxifen. Noncompliance with chemotherapy or radiation did not significantly affect 5-year local and distant disease-free survival rates. Noncompliance with tamoxifen was associated with decreased 5-year local and distant disease-free survivals (87% versus 96%, 76% versus 87%, respectively, P Conclusion Noncompliance with tamoxifen is the most common, resulting in significantly increased risk of local and distant disease recurrence.

Background Sentinel lymph node biopsy (SLNB) is considered a standard of care in the staging of breast cancer. The objective was to examine our experience with reoperative SLNB. Methods We identified19 patients in our breast cancer database who had a SLNB in the reoperative setting. All 19 patients had undergone previous breast-conserving surgery with either an axillary lymph node dissection or an SLNB. The reoperative sentinel lymph node (SLN) was identified using blue dye, radioisotope, or both. Results The SLN was identified in 84% of the reoperative cases. Of these successful cases, both blue dye and radioisotope were used in five cases, and radioisotope alone was used in 11 cases. Radioisotope identified the SLN in the 100% of successful SLNB cases ( P = .0003). There were 3 unsuccessful cases in which blue dye and radioisotope failed to identify the sentinel node. Conclusions Reoperative SLNB after previous axillary surgery is technically feasible.

Background The significance of surgical margins for patients with atypical ductal hyperplasia is unknown. Patients and Methods We reviewed our experience with atypical ductal hyperplasia and correlated the margin status of the specimens removed with the risk of recurrence as atypical ductal hyperplasia, ductal carcinoma in situ, and invasive carcinoma. Seven hundred forty-seven patients were identified between February 1995 and September 2005 as having biopsy proven atypical ductal hyperplasia (ADH). One hundred fifty-five of these patients were found to have “pure” atypical ductal hyperplasia without associated premalignant or malignant breast disease or a history of ipsilateral disease. Margin status of the initial excisional biopsy was noted and was correlated with the risk of recurrence. Results Of the 155 patients whose excisional biopsy specimens were “pure” atypical ductal hyperplasia, 44% (68) had negative margins, 5% (7) had positive margins, and 52% (80) were not reported. No patient underwent re-excision for close or positive margins. Follow-up ranged from 0 to 119 months, with a mean of 26 months. Seven patients (5%) presented with new findings at the site of their initial excisional biopsy, 1 of whom was found to have an invasive ductal carcinoma and 6 of whom had benign findings. Of the 87 patients with margins positive or unknown for ADH at surgical excision, none went on to develop malignancy. Conclusion Our results suggest that clear surgical margins at surgical excision for atypical ductal hyperplasia did not affect the risk of subsequently developing a malignancy.

A diagnosis of atypical ductal hyperplasia (ADH) after breast core biopsy usually is followed by an excisional biopsy to exclude the presence of a more significant lesion. To determine whether the immunohistochemical expression of cyclin D1 (CyD1) and Ki-67 can aid in case stratification for the likelihood of finding ductal carcinoma in situ (DCIS) on subsequent excision, we immunohistochemically stained 21 consecutive ADH cases diagnosed by core biopsy, and proliferation indices (PIs) were calculated for each case. Fluorescence in situ hybridization to detect CCND1 amplification was performed in 10 cases. In 5 cases, DCIS (with or without invasive carcinoma) was identified in the subsequent excision. The mean PI CyD1 and PI Ki-67 for these cases were significantly higher than in the remainder (P = .03 and P = .05, respectively). The sensitivities of PI CyD1 and PI Ki-67 for the presence of DCIS on subsequent excision were 100%, and the specificities were 75% and 69%, respectively. The specificity of the 2 markers combined was 88%. The number of cells with CCND1 amplification was higher in cases with DCIS or ADH on subsequent excision. Immunostaining for CyD1 and Ki-67 might help stratify cases of ADH on core biopsy and identify patients unlikely to have DCIS found on excision.

The management of nonpalpable papillary lesions found in specimens obtained by percutaneous breast biopsy is controversial. We reviewed the treatment of patients found to have papillary lesions by stereotactic, sonographic, or fine-needle aspiration breast biopsy to identify indications for surgical excision. Consecutive patients with intraductal papilloma, atypical papilloma/papilloma with atypical ductal hyperplasia, papillary neoplasm, and papillomatosis according to percutaneous breast biopsy were identified from radiology records. The charts were reviewed to identify patients who had subsequent surgical excision, and the pathologic findings were correlated with the biopsy method and indications for surgery. Papillary lesions were found in 120 biopsy samples from 109 patients. Malignancy was found at operation in 19 (24%) of 80 lesions that underwent surgical excision: 12 (63%) were ductal carcinoma-in-situ, 4 (21%) were infiltrating ductal carcinoma, 2 (11%) were infiltrating papillary carcinoma, and 1 (5%) was intracystic papillary carcinoma. Malignancy was found in 9 (30%) of 30 fine-needle biopsy papillary lesions, 6 (35%) of 17 core biopsy papillary lesions, and 4 (12%) of 33 stereotactic biopsy papillary lesions. Malignancy was missed significantly less frequently with stereotactic biopsy (P < .05). Malignancy is frequently found at surgical excision for papillary lesions found on percutaneous breast biopsy. Malignancy is missed significantly less frequently with stereotactic biopsy.

The preferred technique for intraoperative evaluation of the sentinel lymph node has not been determined. The purpose of this study was to compare the sensitivity and accuracy of intraoperative evaluation of the sentinel lymph node by touch preparation cytology and frozen section.A total of 117 patients with clinically node-negative breast cancer or ductal carcinoma-in-situ undergoing sentinel lymph node biopsy had intraoperative evaluation of the sentinel node by touch preparation, frozen section, or both. The results of the intraoperative evaluation were compared with the final histological results of hematoxylin and eosin (HE) paraffin section and immunohistochemistry (IHC).Twenty-six (57%) of the 46 patients with nodal involvement had metastases detected during surgery. The sensitivity of touch preparation for detecting macrometastases was 78%; for detecting all HE metastases, including micrometastases, was 57%; and for detecting all metastases, including those seen on IHC, was 40%. The sensitivity of frozen section for detecting macrometastases was 83%; for detecting all HE metastases, including micrometastases, was 78%; and for detecting all metastases, including those seen on IHC, was 64%. Both have a low sensitivity for micrometastases seen by HE paraffin section: 57% and 78%, respectively. Neither detected micrometastases diagnosed by IHC only.Both touch preparation and frozen section seem to be accurate in detecting macrometastases, but not micrometastases. Intraoperative evaluation of the sentinel lymph node by touch preparation allows for a quick evaluation of the node without wasting significant tissue and without detecting occult microscopic metastases, which may be beneficial because the clinical importance of these has yet to be elucidated.

Background and Objectives Neoadjuvant chemotherapy in locally advanced breast cancers produces histologically evaluable changes and frequently reduces the size of the primary tumor. Local clinical response to neoadjuvant chemotherapy may correlate with response of distant metastases. Therefore, clinical or pathological factors, which predict or assess response to treatment, may predict outcome after consideration for initial extent of disease. Methods To identify pretreatment characteristics of locally advanced breast cancers which predict clinical and pathologic response to neoadjuvant chemotherapy as well as survival and to assess the utility of postoperative histologic changes, we retrospectively studied one hundred forty-four patients with locally advanced breast cancer treated with neoadjuvant chemotherapy between January 1975 and July 1996. Patients were identified through pathology records of the Mount Sinai Medical Center and via one of the author's clinical databases. Pathologic and clinical responses to neoadjuvant chemotherapy were correlated with survival. Stepwise logistic regression was used to identify variables most significantly related to clinical response and pathologic axillary lymph node involvement. Results Complete clinical response with no palpable tumor was noted in 7/86 patients (8%) and complete pathologic response was achieved in 18/138 patients (13%). Both clinical (P = 0.038) and pathologic response (P = 0.011) were related to tumor size at the time of diagnosis: smaller tumors were more likely to respond to chemotherapy than larger tumors. Histologic evidence of chemotherapeutic effect, i.e., cytoplasmic vacuolization, change in the number of mitoses and localized fibrosis in lymph nodes did not correlate with clinical or pathologically measured response. Clinical and pathologic response was not associated with age, histology, differentiation, or type of chemotherapy. No residual tumor was found in the axillary nodes of 27% (37) of the patients. Age and complete pathologic response were the only variables significantly related to pathologic nodal status. Eighty-four percent of the 61 patients under 50 years of age had nodal involvement compared to 65% of older patients (P = 0.014). Fifty percent of complete pathologic responders had positive axillary lymph nodes compared to 76% of patients who did not have a complete pathologic response (P = 0.020). Distant disease-free (P = 0.039) and overall survival (P = 0.035) were related to the number of involved axillary lymph nodes. After consideration for pathologic lymph node status, no other variable was significantly related to distant disease-free or overall survival in multivariate analysis. No variable was significantly related to local disease-free survival. Age, clinical tumor size, clinical lymph node status, clinical response, type of chemotherapy, histology, differentiation, chemotherapy effects on primary tumor and lymph nodes, decline in the number of mitoses, and degree of fibrosis in nodes were not predictive of distant recurrence or overall survival. Conclusions This study of patients treated with neoadjuvant chemotherapy for locally advanced breast cancers found little evidence that measurable clinical or pathologic changes attributable to chemotherapy predicted survival. Axillary lymph node status, associated with young age, was the most important prognostic indicator in these patients. J. Surg. Oncol. 2002;80:4–11. © 2002 Wiley-Liss, Inc.

To study the relationship of mammographic appearance of nonpalpable breast cancer to the pathologic characteristics.The mammographic appearance of nonpalpable breast cancer may be associated with pathologic variables having prognostic significance, which could influence clinical management.The authors correlated the mammographic appearance and pathologic characteristics of 543 nonpalpable malignancies diagnosed in a single institution between July 1993 and July 1999. Cancers were divided into four groups based on mammographic presentation: mass, calcification, mass with calcification, and architectural distortion.The majority of masses (95%), masses with calcifications (68%), and architectural distortions (79%) were due to invasive cancers, whereas the majority of calcifications (68%) were due to ductal carcinoma in situ (DCIS). Among invasive cancers, calcifications were associated with more extensive intraductal carcinoma, more Her2/neu immunoreactivity, and more necrosis of DCIS. Lymphatic invasion was more common in cancers presenting as a mass with calcifications. Sixty-nine percent of DCIS associated with invasive cancers presenting as calcifications were of high grade according to the European Organization for Research and Treatment of Cancer. Calcifications in noninvasive tumors were associated with necrosis in DCIS. Two thirds of cancers presenting as architectural distortion had positive margins (65%) compared with 35% to 37% of other mammographic presentations. Mammographic presentation was not significantly related to tumor differentiation or estrogen or progesterone receptor status. The ratio of invasive to noninvasive malignancies increased progressively with increasing age from 1:1 in patients younger than 50 years of age to 3:1 in patients older than 70 years, whereas the proportion presenting as calcifications declined from 63% in patients younger than 50 years to 26% in patients older than 70 years.Malignancies presenting as calcifications on mammography are most commonly DCIS. When invasive malignancies presented as calcifications, the calcifications were associated with accompanying high-grade DCIS, and the invasive cancers were often Her2/Neu positive. Mammographic masses with calcifications were associated with lymphatic invasion. Excisional biopsy margins were most commonly positive with architectural distortions. The mammographic appearance of nonpalpable malignancies is related to pathologic characteristics with prognostic value, which varies with patient age and influences clinical management.

Recent studies have noted that a large fraction of elderly patients do not receive conventional treatment for breast cancer. The consequences of undertreatment of the elderly have not been adequately assessed.The senior author's database (PIT) was used to identify women undergoing potentially curative operations for breast cancer between 1978 and 1998. Risk factors, presentation, pathologic findings, treatment, and outcomes of 206 women aged over 70 years were compared with those of 920 younger patients. In addition, conventionally treated and "undertreated" elderly patients were identified, and their characteristics and outcomes were compared.Older patients' cancers were more often visible on mammography, usually as a mass; younger patients' mammograms were less frequently positive, presenting more often with calcifications (p = 0.002). Cancers of the elderly were better differentiated (p0.001) and more likely to be estrogen- and progesterone-receptor positive (p0.001; p = 0.007). Patients over 70 had fewer mastectomies (19% versus 33%; p0.001) and were also less likely to undergo axillary node dissection (71% versus 81%, p = 0.006), postoperative radiation (69% versus 92%, p0.001), and chemotherapy (18% versus 48%, p0.001). Fifty-seven percent of older patients were treated with tamoxifen compared with 36% of younger patients (p0.001). Elderly patients' rates of local and distant recurrence were comparable to those of younger patients after both mastectomy and breast conservation. Ninety-eight patients (54%) over 70 were undertreated by conventional criteria. Undertreated elderly patients were significantly older (78 versus 76 years, p = 0.003), were diagnosed with excisional biopsy more often (69% versus 57%, p = 0.069) and with fine-needle aspiration less frequently (22% versus 38%, p = 0.069), and were more likely to have breast conservation (90% versus 73%, p = 0.004). Local and distant disease-free survival rates of both groups were comparable. Tamoxifen treatment significantly reduced the chance of developing distant metastasis in node-negative elderly patients with invasive tumors (p = 0.028). Omission of chemotherapy had no impact on disease control in the elderly. Axillary node status and estrogen-receptor status were significantly related to local disease-free survival, and axillary node status was significantly related to distant disease-free survival in multivariate analysis in the elderly.Elderly breast cancer patients are frequently treated with breast conservation, omitting axillary dissection, radiation therapy, and chemotherapy. Despite undertreatment by conventional criteria, the rates of local recurrence and distant metastasis are not increased in comparison with conventionally treated elderly patients. Tamoxifen should be administered to elderly breast cancer patients with invasive tumors because it significantly improves distant control.

Lumpectomy with axillary dissection for breast cancer is usually followed by at least an overnight stay in the hospital for drain management. We eliminated drains and discharged patients following lumpectomy and axillary dissection. A retrospective study of 80 consecutive patients from July 1, 1994, to June 30, 1995, formed the basis for this study. Drains were omitted in 20 consecutive patients discharged to home after undergoing lumpectomy with axillary dissection. This group was compared to the 62 previous patients who had 7 mm closed suction drains until the drainage was less than 25 ml/shift. Seroma formation occurred in 40% of the undrained patients compared to 6% of patients kept overnight in the hospital with a closed-suction drain (p < 0.001). Tumors were smaller and the number of nodes examined by the pathologists was fewer in the patients managed without drains. Patients developing seromas were older, heavier, and shorter than those who did not develop seromas. The use of a drain was related significantly to seroma formation in multivariate analysis.

Despite the high rate of pathologic involvement of the nipple-areola complex (NAC) with subareolar cancers and the suboptimal cosmetic results when lumpectomy removes the NAC, breast conservation surgery has been extended to include these patients.Ninety-five patients with subareolar cancers operated on between 1979 and 1998 were identified and the relationships between the pathologic findings, treatment, and outcome were studied.Clinical involvement of the NAC (P = 0.001), clinical presentation (P0.001, mammographic calcium or Paget's disease), and pathologic tumor size (P = 0.019) were significantly related to pathologic involvement of the NAC in univariate analysis. After consideration for clinical NAC involvement, no other variable was significantly related to pathologic NAC involvement in multivariate analysis. Thirty-three patients underwent mastectomy, and 62 were treated with breast conservation. Radiation therapy (P = 0.005), clinical (P = 0.031), and pathologic (P = 0.037) involvement of the NAC were significantly related to local disease-free survival in breast conservation patients in univariate analysis. After consideration for radiation therapy in multivariate analysis, clinical involvement of the NAC was the only additional variable significantly related to local recurrence in breast conservation patients. Clinical or pathologic involvement of the NAC was not significantly associated with local and distant recurrence after mastectomy. No other variable was significantly related to local outcome in univariate analysis in patients treated with mastectomy.Subareolar cancers can be successfully treated with breast conservation surgery provided adjuvant radiation therapy is always given. Clinical involvement of the nipple-areola complex is associated with high risk of local failure when treated with breast conservation without radiation therapy.

A hospital-based case-control study of breast cancer risk related to organochlorine (OC) exposure was conducted in a multiethnic setting in New York City. We enrolled 175 breast cancer patients and 355 control patients. The overall racial/ethnic distribution was 57% Caucasian, 21% Hispanic, 22% African-American; cases and controls were frequency-matched by age and race/ethnicity. Tumor markers (estrogen and progesterone receptors, p53, erbB-2) were assessed and organochlorines (DDE, DDT, trans-nonachlor, and higher (HPCB) and lower (LPCB) chlorinated biphenyls) were measured in blood serum. Tumors among minority women were of slightly higher stage than among Caucasians, but tumor markers were similar across the racial/ethnic groups. DDE levels were highest among African-American and Hispanic women; DDT was highest among Hispanics; HPCBs were highest among African-Americans; LPCBs were lowest among Hispanics; and trans-nonachlor was highest among African-Americans. However, OC levels were not associated with risk for breast cancer, nor did OCs differ with respect to tumor stage or tumor markers. Higher DDE levels were associated with increasing body mass index (BMI), but with decreasing level of education, frequency of nulliparity, and frequency of family history of breast cancer. HPCB levels decreased with BMI and were not correlated with breast cancer risk factors. These relationships can be attributed to historical patterns of exposure and to metabolic differences in OCs related to BMI.

The diagnosis of breast cancer is often made by excisional biopsy without margin assessment for mammographic findings or palpable masses. Many patients treated with breast conservation undergo reexcision to obtain clear margins although the relationship between clear margins and local recurrence remains controversial.Patients undergoing breast conservation and adjuvant radiation therapy with complete follow-up over 5 years were studied. Factors associated with obtaining clear histopathologic margins and undergoing reexcision to obtain clear margins were studied in relation to the risk of local recurrence.Clear biopsy margins were associated with diagnosis by fine-needle aspiration cytology (fine-needle aspiration 42%, spot localization 11%, excisional biopsy 10%; P0.001). Reexcision was significantly related to diagnostic method (spot localization 63%, excisional biopsy 36%, fine-needle aspiration 10%; P0.001), first margin status (clear 0%, close 11%, positive 46%, unknown 48%; P0.001), patient age (54 years for reexcised patients and 58 for non-reexcised patients; P0.001), and tumor size (mean tumor size 1. 4 cm for reexcised patients and 1.7 cm for non-reexcised patients; P = 0.003). Patients undergoing reexcision were significantly more likely to be diagnosed by spot localization, have nonnegative excisional biopsy margins, be younger, and have smaller tumors than patients not undergoing reexcision. Local recurrence was not significantly related to margin status (8% with clear margins, 7% with positive margins, 19% with close margins, and 11% with unknown margins) or reexcision (10% local recurrence rate for patients with negative final margins after reexcision and 12% with positive, close or unknown first margin without reexcision). Estrogen receptor status was the only variable related to local recurrence in Cox proportional hazards model (P = 0.009). Estrogen receptor negative patients with nonnegative margins experienced a 20% rate of local recurrence compared with 10% for estrogen receptor negative patients with negative margins and 7% for estrogen receptor positive patients regardless of margin status (P = 0.021).Clear excision margins are facilitated by preoperative diagnosis by fine-needle cytology. For patients with nonnegative margins, reexcision was more commonly performed in young patients with small tumors diagnosed by spot localization biopsy. The relationship of local recurrence to margins and reexcision was not statistically significant. Estrogen receptor negative tumors with nonnegative margins had a significantly higher rate of local recurrence than estrogen receptor negative tumors with clear margins and estrogen receptor positive tumors regardless of margin status.

To identify characteristics of the primary tumor highly associated with lymph node metastases.Recent enthusiasm for limiting axillary lymph node dissection (ALND) in women with breast cancer may increase the likelihood that nodal metastases will be missed. Identification of characteristics of primary tumors predictive of lymph node metastases may prompt a more extensive surgical and pathologic search for metastases in patients with negative sentinel lymph nodes or limited ALND.The authors studied 850 consecutive patients who underwent ALND for T1 breast cancer. Age, tumor size, histopathologic diagnosis, tumor differentiation, presence of lymphatic invasion, and estrogen and progesterone receptor results were studied prospectively. Stepwise logistic regression was used to identify variables independently associated with axillary lymph node metastases.Lymphatic invasion, tumor size, and age were independently associated with lymph node metastases. Fifty-one percent of the 181 patients with lymphatic invasion had axillary lymph node metastases, compared with 19% of the 669 patients without lymphatic invasion. Thirty-five percent of the 470 patients with tumors1 cm had nodal involvement compared with 13% of the 380 patients with smaller cancers. Thirty-seven percent of the 63 women younger than age 40 had lymph node involvement compared with 25% of the 787 women older than age 40. Significant correlations were noted between lymphatic invasion and patient age and between lymphatic invasion and tumor size. The proportion of tumors with lymphatic invasion decreased progressively with increasing age and increased with increasing tumor size.Axillary lymph node metastases are most significantly related to lymphatic invasion in the primary tumor, followed, in order of significance, by tumor size and patient age. Axillary nodal metastases should be suspected in the presence of lymphatic invasion of large tumors in young patients.

Background: Several devices have been developed for sampling nonpalpable mammographic breast lesions. Complete removal of malignancies with a stereotactic percutaneous directional vacuum-assisted biopsy instrument has been reported. Study Design: We reviewed our experience with the percutaneous vacuum-assisted biopsy instrument to identify instances of complete excision of cancers: no residual carcinoma found at surgical excision for malignancies diagnosed by the percutaneous vacuum-assisted biopsy instrument. The radiologic and pathologic characteristics of malignancies completely removed by the percutaneous vacuum-assisted biopsy instrument were compared with those of malignancies with residual carcinoma found at surgical excision. Results: Fifty-two malignancies were diagnosed by the percutaneous vacuum-assisted biopsy instrument: 16 infiltrating ductal carcinomas, 5 infiltrating lobular carcinomas, and 31 ductal carcinomas in situ. No residual carcinoma was found at surgical excision in 9 (17%) of the 52 malignancies. Patients with complete removal of the malignant lesion were younger than patients with incomplete removal (52 versus 58 years; p=0.069). Completely removed malignancies were smaller on mammography (4 versus 17 mm; p=0.213), and more specimens were removed (19 versus 15; p=0.074). All nine completely removed malignancies presented with calcifications without a mass (p = 0.112), and all nine were ductal carcinoma in situ (p = 0.019). Conclusions: Complete removal of nonpalpable breast malignancies is possible with the stereotactic percutaneous directional vacuum-assisted biopsy device. Complete removal is more likely with removal of a large number of specimens from small areas of mammographic calcifications due to ductal carcinoma in situ.

BACKGROUND: Allogeneic transfusion is associated with postoperative infections that significantly prolong hospital stays and increase costs. Recent studies suggest that filtering leukocytes from blood prior to transfusion reduces the risk of postoperative infection associated with blood transfusion. We compared the incidence of postoperative infections, hospital stays, and hospital charges of gastrointestinal surgery patients transfused with packed red cells or leukocyte-depleted cells. METHODS: Consecutive patients admitted for elective gastrointestinal surgery without previous blood transfusion were randomized to receive routine packed red cells or packed red cells filtered to remove leukocytes if transfusion was required. Multivariate analysis was used to assess the significance of the relationship between leukocyte-depleted blood and postoperative infectious complications, postoperative stay, and hospital charges. RESULTS: Fifty-nine (27%) of the 221 patients were transfused. The most significant variable related to transfusion was intraoperative blood loss (P