Needle-localized mammographic lesions. Results and evolving treatment strategy.

From January 1981 to December 1987, 932 needle-localization breast biopsies were performed at our institution for mammographically detected abnormalities. We reviewed 531 needle-localization breast biopsy procedures performed during two periods (January 1981 to June 1984, n = 311; and January to August 1987, n = 220) to compare results and treatment patterns, and to determine the prevalence of the missed lesions. Mammographic abnormalities detected on routine screening accounted for a larger proportion of needle-localization breast biopsies in the later series (94 [30%] of 311 vs 94 [43%] of 220). However, the rate at which carcinoma was identified remained constant at 29% as did the percentage of cancers that were invasive (46% vs 51%). Overall, the rate of malignant diagnoses after needle-localization breast biopsy was lowest in asymptomatic women undergoing routine screening mammography (44 [24%] of 188) and significantly higher in women undergoing mammographic follow-up of the contralateral breast after treatment for breast cancer (28 [43%] of 65). There were seven missed lesions in 531 needle-localization breast biopsies, necessitating a second procedure in six and interval mammograms in one.

Comparison of the conventional method of lymph node staging with a comprehensive fat-clearing method for gastric adenocarcinoma.

Discrepant results in long-term survival between United States and Japanese patients with resectable gastric adenocarcinoma may result from more accurate staging in the Japanese series. The authors compared a comprehensive fat-clearing method with the conventional pathology method of lymph node sampling in 11 patients undergoing curative gastrectomy and extended lymphadenectomy at their institution. Comprehensive fat-clearing doubled total lymph node counts (P less than 0.01), identified smaller lymph nodes (P less than 0.001), and identified more histologically involved nodes of significantly smaller size (P less than 0.001). Comprehensive fat-clearing pathologically upstaged 29% of the authors' eligible specimens. Accurate pathologic staging is necessary when comparing Japanese and United States survival data for resectable gastric adenocarcinomas.

The patterns of cervical lymph node metastases from squamous carcinoma of the oral cavity.

A retrospective review of the records of 501 previously untreated patients from January 1, 1965 through December 31, 1986 with squamous cell carcinoma of the oral cavity was undertaken to ascertain the prevalence of ipsilateral neck node metastases (NM) by neck level. The 501 patients underwent 516 radical neck dissections. Patients were grouped by clinical neck status at the time of neck dissection: elective dissection (ED) in the N0 neck, immediate therapeutic dissection (ITD) in the N+ neck, and subsequent therapeutic dissection (STD) in the neck observed which converted clinically to N+. Pathologically identified NM occurred 34% of the time in ED, 69% in ITD and 90% in STD. The sensitivity, specificity, and overall accuracy of the clinical exam was 70%, 65%, and 68%, respectively. Detailed analysis was performed for each group based on the primary site. This revealed a prevalence of NM in level IV of 3% (five of 167) for ED versus 17% (49/296) for ITD + STD (P less than 0.001). Tongue, retromolar trigone, and cheek did not have NM in level V in any group. The prevalence of NM in level V for floor of mouth or gum primaries was less than 1% (one of 109) in ED versus 6% (ten of 167) in ITD + STD (P less than 0.03). These data support the trend toward selective limited neck dissection in both N0 and N+ patients. Further, they provide the foundation for planning of future prospective trials to assess the efficacy of modifications in the extent of neck dissection.

Patterns of cervical node metastases from squamous carcinoma of the oropharynx and hypopharynx.

A retrospective review of 333 previously untreated patients from 1965 to 1986, with primary squamous cell carcinoma of the oropharynx or hypopharynx, was undertaken to ascertain the prevalence of neck node metastases by neck level. The 333 patients underwent 344 classical radical neck dissections. Patients were grouped by clinical neck status at the time of neck dissection: elective dissection in the N0 neck (N = 71), and immediate therapeutic dissection in the N+ neck (N = 259). Detailed analysis was performed for each group based on the specific primary site. This revealed a predominance of neck node metastases in levels II, III, and IV for both oropharyngeal and hypopharyngeal primaries. Isolated "skip" metastases outside of levels II, III, or IV occurred in only 1 patient (0.3%). Otherwise, level I or V involvement was always associated with nodal metastases at other levels (ie, N2 disease). These data support the trend toward selective limited neck dissection (anterior modified) in N0 patients. Furthermore, they provide the foundation for planning of future prospective trials to assess the efficacy of modifications in the extent of neck dissection for carcinomas of the oropharynx or hypopharynx.

Patterns of cervical node metastases from squamous carcinoma of the larynx.

We undertook a retrospective review of 247 previously untreated consecutive patients from 1965 to 1986 with primary squamous cell carcinoma of the supraglottic or glottic larynx to ascertain the prevalence of neck node metastases by neck level. The 247 patients underwent a total of 262 radical neck dissections. Patients were grouped by clinical neck status at the time of neck dissection: elective dissection in the NO neck; immediate therapeutic dissection in the N+ neck; and subsequent therapeutic dissection in the NO neck that over time converted clinically to N+. Detailed analysis revealed a predominance of neck node metastases in levels II, III, and IV for all clinical neck groups. Level V was rarely involved, but always in conjunction with neck node metastases in levels II, III, or IV (ie, N2 disease). Level I was rarely involved; involvement occurred with neck node metastases in levels II, III, or IV 75% of the time. Level I involvement correlated with T3 or T4 primary tumors exhibiting histologic extralaryngeal spread. These data support the trend toward selective limited neck dissection in both NO and N1 patients.

Occult breast cancer presenting with axillary metastases. Updated management.

An isolated axillary lymph node metastasis in a woman without an obvious clinical primary site most frequently originates from the breast. Mastectomy has been the historical treatment of choice. A retrospective study of 35 patients was undertaken to evaluate the roles of modern mammography, breast preservation, and adjuvant systemic therapy in the management of these patients. Twenty-eight patients underwent a mastectomy, while 7 were managed by a combination of limited resection and/or axillary dissection and radiation therapy. Twenty-two (67%) of the 33 breast specimens contained carcinoma. Comparison of the pathologic results with the preoperative mammograms showed a specificity of 73%, while the sensitivity was only 29%. Actuarial 5-year survival after mastectomy or breast preservation was similar (77% and 65%, respectively). Patients with more than one positive lymph node benefited from adjuvant therapy. Mammography does not locate the majority of occult stage II breast cancers, and both breast preservation and adjuvant therapy may have roles in the management of these patients.

Limitations of mammography in the identification of noninfiltrating carcinoma of the breast.

A retrospective study of 321 patients who underwent localizing mammography and excisional biopsy of the breast from 1984 to 1985 was performed. The study was undertaken to refine selection criteria for biopsy in women with nonpalpable mammographic abnormalities by comparing mammographic features and impression with histologic findings. Twenty-eight of 36 (78 per cent) noninfiltrating carcinomas presented with microcalcifications alone; in contrast, 27 of 39 (69 per cent) infiltrating carcinomas presented with a mass alone. As the number of microcalcifications increased, so did the incidence of carcinoma. The size of the mass was not a guide for predicting carcinoma. Although only 11 of 75 carcinomas presented as a mass with microcalcifications, 11 of 21 calcified masses were carcinoma. There were no significant differences in the mammographic presentation between ductal and lobular carcinoma. The sensitivity of the mammographic impression was 48/75 (0.64), and the specificity was 221/246 (0.898). The false-positive rate was 25/73 (0.34), and the false-negative rate was 10/141 (0.07). From this study, we concluded 1, the incidence of noninfiltrating carcinoma was significantly higher and the incidence of positive nodes was significantly lower in nonpalpable abnormalities than in palpable masses; 2, noninfiltrating carcinomas were generally associated with microcalcifications alone, but infiltrating carcinomas were generally associated with a mass alone, and 3, the diagnostic accuracy of mammography was limited by under-interpretation of the subtler signs of noninfiltrating carcinoma and by over-interpretation of mammographic findings generally accepted as criteria for carcinoma.