Current treatment for lobular carcinoma in situ.

BACKGROUND: We thought that observation for patients with lobular carcinoma in situ (LCIS) had been generally accepted by the mid-1980s. A questionnaire mailed to oncologic surgeons in 1988 revealed that 33% of the respondents still advised unilateral mastectomy, although a slim majority (54%) advised observation. New studies have been published in the intervening 8 years, and we decided it would be worth recirculating the 1988 questionnaire. METHODS: The identical questionnaire was mailed to members of the same oncologic societies (Society of Surgical Oncology [SSO] and Society for the Study of Breast Disease), but changes in membership necessitated new mailing lists. RESULTS: Observation has yet to be universally accepted by the oncologic community, but at this time 85% of the respondents suggest it as the preferred option for their patients. CONCLUSIONS: Recent studies have questioned some of the tenets laid down by Haagensen in 1978, but it appears clear that his formulation of LCIS as a marker of increased risk continues to gain ground over the original concept of inevitable progression to invasive disease.

Carcinoma of the breast metastatic to the ureter presenting with flank pain and recurrent urinary tract infection.

Urinary tract infection in the female patient is not an uncommon finding. Flank pain associated with urinary tract infection is usually due to calculus disease or pyelonephritis. In patients with history of breast carcinoma, metastasis to the periureteral area with resulting obstruction should be considered. The incidence of metastatic breast carcinoma presenting in this fashion is as high as 7.8 per cent. This case shows a patient with metastatic lobular carcinoma of the breast with ureteral obstruction, causing flank pain and recurrent urinary tract infection. This report emphasizes the importance of long-term follow-up in patients with history of breast cancer, especially invasive lobular carcinoma, and the high degree of suspicion required to diagnose and institute proper therapy.

Lobular carcinoma in situ (LCIS): pathology and treatment.

Lobular carcinoma in situ (LCIS) is not only a relative newcomer among breast lesions, but in its short span of 50 years it has gradually evolved from a rare form of breast cancer to being merely a marker of increased risk. This change has not been without controversy which persists to the present day, although there is now general agreement on the natural history of the disease. The present report represents an update on current thinking about LCIS as well as a review of the limited number of studies dealing with the natural history of the lesion when treated by biopsy alone. Invasive cancer will develop in approximately 20-25% of women with LCIS provided there is sufficient follow-up after biopsy. Precise estimates are not possible since LCIS is an asymptomatic lesion that never makes a mass or reveals itself on mammography. It is found only by biopsy and thus the population being followed is a selected one. Every study has shown that when invasive cancer develops, it is just as likely to appear in the contralateral as in the biopsied breast, and invasive ductal cancers are more common than lobular. Clearly, the small round cells with pale cytoplasm that characterize LCIS do not go on to invasion in the usual patient; rather they serve to identify women who are more likely to develop breast cancer. Such patients represent a clearly defined group at increased risk, and for that reason are ideal candidates for chemoprevention. If tamoxifen or some other agent proves to be effective, the remaining arguments favoring mastectomy for LCIS will finally disappear.

Multicentricity in early breast cancer.

Breast preservation has focused attention on the extent and distribution of cancer in the breast. Recent studies suggest that there is spread from the primary tumor rather than a random distribution of cancer throughout the breast. As a result the term multicentric has largely been replaced by multifocal. Evidence that there is a geographic relationship of secondary deposits to the primary lesions opens the way to wide excision as definative treatment for selected patients with both invasive and in situ breast cancer.

Lobular carcinoma in situ. Pathology and treatment.

Lobular carcinoma in situ is a relatively "new" breast lesion, having been described only 50 years ago. It was originally thought to be a stage in the progression to invasive lobular cancer, but current evidence suggests that it is a marker of increased risk. It is certainly the most powerful of all risk factors, with studies suggesting that approximately 20 to 30 per cent of patients will go on to develop invasive cancer of various histologic types and with equal frequency in the biopsied and the opposite breast. There is general agreement concerning these facts, but considerable controversy remains about treatment. Haagensen and coworkers pioneered the concept of observation at a time when unilateral mastectomy was the standard treatment. Observation has gradually been accepted by the majority of American physicians, but it is a slim majority, and the patient's wishes will properly continue to play a role in the final decision.

Fibrous disease of the breast in juvenile diabetes.

The association between Type I diabetes mellitus and breast masses whose extreme hardness suggests cancer has only recently been recognized. The present report consists of 11 cases of patients with juvenile diabetes who were identified by a retrospective review of 3,219 patients seen in our breast clinic over an eight-year period. All 11 patients were referred for possible biopsy and this was carried out routinely before the condition was recognized. The patients with diabetes were carefully reviewed in order to identify specific features of the breast lesions and a management plan was devised that should reduce the need for biopsy in these patients in the future.

Stage I and II breast carcinoma: treatment with limited surgery and radiation therapy versus mastectomy.

Between 1980 and 1986, 2,140 patients with surgical stage I or II breast carcinoma were treated including 1,179 patients with T1-2N0 disease and 961 patients with T1-2N1 disease. Among the 1,179 patients without node involvement, 215 underwent limited surgery (complete excision and axillary node dissection) and radiation therapy; 964 patients underwent modified radical mastectomy only. Of the 961 patients with node involvement, 106 were treated by means of limited surgery and radiation therapy; of these, 48 also received chemotherapy. The remaining 855 patients underwent mastectomy; of these, 381 also received chemotherapy and/or hormone therapy. The 5-year survival rates for patients with no node involvement were 96% for the group treated by means of limited surgery and radiation therapy and 88% for the group treated by means of mastectomy (P greater than .05). The 5-year survival rates for patients with node involvement were 96% for the group treated by means of limited surgery and radiation therapy with or without chemotherapy and 77% for the group treated by means of mastectomy with or without chemotherapy (P less than .01). This study demonstrates no disadvantage from treatment by means of limited surgery and radiation therapy and suggests that adjuvant radiation therapy may be important in increasing survival among patients with T1-2 breast carcinoma and positive axillary nodes.

Effect of incentive spirometry on diaphragmatic function after surgery.

Many of the alterations in lung function that occur after upper abdominal surgery are attributable to reduced diaphragmatic activity. This study was undertaken to determine whether incentive spirometry produces a voluntary activation of diaphragmatic movement in patients with postoperative diaphragmatic dysfunction. Inductance plethysmography was used to measure the tidal volumes of the abdomen and chest in eight women before cholecystectomy and on the first and third postoperative days. In resting patients the relative contribution of the abdominal compartment decreased from 0.520 +/- 0.100 preoperatively to 0.274 +/- 0.265 on postoperative day 1 (p less than 0.01), reflecting the effect of surgery on diaphragmatic function. Inspiratory flow (an index of inspiratory drive) was unaltered by surgery during both resting and incentive spirometry breaths, despite changes in tidal volume. Preoperatively, incentive spirometry increased the tidal volume of the abdominal compartment from 141 +/- 26 ml to 285 +/- 188 ml (p less than 0.005) as a result of increased diaphragmatic movement. This effect was not seen postoperatively; instead, postoperative patients responded to incentive spirometry by increasing the tidal excursion of the chest compartment (158 +/- 37 to 630 +/- 253, p less than 0.005), without any increase in abdominal tidal volume. Thus, incentive spirometry failed to increase diaphragmatic movement in postoperative patients.

Tumor to fascia margin as a factor in local recurrence after modified radical mastectomy.

A new problem has arisen for surgeons now that the pectoralis major muscle is routinely left in place after mastectomy. When the pathologist reports a tumor close to the fascial margin, there has been uncertainty regarding the significance of this finding. In the present study, the histories of 346 women with negative nodes who underwent modified radical mastectomy and had an uninvolved plane under the breast were reviewed. The distance from tumor to fascia was recorded by the pathologist, and the patients were divided into "Close" and "Not Close" groups. The "Close" group (90 patients) had tumors within one low power field (4 millimeters) of the fascia while the "Not Close" group (256 patients) had tumors more than 4 millimeters from the fascial margin. Twelve of the patients had local recurrence within an average follow-up period of 47 months, and a variety of analyses failed to show a statistically significant difference in local recurrence rates between the two groups. The results of this study indicate that tumor to fascia margin, as recorded by the pathologist, is not a strong determinant of local recurrence provided the areolar plane between the breast and the underlying fascia appears uninvolved at the time of mastectomy.

Ductal carcinoma in situ (DCIS): a revised concept.

The in situ concept was introduced in an effort to clarify the transition between benign epithelium and invasive cancer, and for that reason it focused on histologic changes. Lobular carcinoma in situ was first described in these terms and continues to be considered a purely microscopic lesion that never makes a mass in the breast. A very different situation exists in cases of ductal carcinoma in situ (DCIS), because both gross and microscopic disease exists together. As a result, it has been difficult to evaluate competing treatment options for the DCIS lesion. This study was undertaken to better characterize patients with DCIS lesions. Seventy consecutive patients with DCIS who underwent treatment at our institution were analyzed and two subgroups were identified. The method of presentation and the distribution of cancer in the breast as well as in the regional lymph nodes were examined. The study shows that differentiation between gross and purely microscopic DCIS is feasible and must be accomplished if treatment recommendations are to be made on a rational basis.

Energy expenditure after infusion of glucose-based total parenteral nutrition.

Resting energy expenditure (REE), carbohydrate balance, and lipogenesis were calculated after administration of glucose-based total parenteral nutrition (TPN) to determine whether the thermic effect of glucose is equal to the energy cost of storing the glucose. Estimated cost of storage as glycogen (5.3%) and fat (19%) was compared with measured increases in REE. Patients with malnutrition received 5% dextrose in water and 6 days of TPN with a low (1.2 times REE, group 1) or high (2.0 times REE, group 2) level of glucose intake. Increases in REE by day 6 were 10% (group 1) and 28% (group 2). The theoretical cost of glucose storage as glycogen and fat accounted for approximately 40% of the measured increase in REE in patients in group 2. The thermic effect of TPN (derived from patients in group 1) accounted for most of the balance. The majority of the thermic effect of high levels of glucose infused with TPN can be explained on the basis of the thermic effect of TPN and glucose storage.

The critically ill surgical patient: nutritional considerations.

The nutritional care of the patient in the surgical intensive care unit is one of the most challenging in the field of nutritional support. Each patient must be assessed individually and specific goals of nutritional support established. Specialized nutritional solutions may be needed for the patient with significant renal, hepatic, or pulmonary disease, as well as patients in a chronic septic state. Knowledge of the infectious and metabolic complications that frequently occur in this population is essential in order to keep nutritionally related morbidity at a minimum. Finally, the realization that, in the surgical intensive care unit, nutritional therapy is often a supportive measure used in an attempt to gain time to eradicate the primary process will enable the clinician to establish the proper approach to the nutritional care of these patients.

The extent and distribution of cancer in breasts with palpable primary tumors.

The term multicentricity has been employed to describe cancer cells beyond the borders of the primary tumor. However, it is not clear if there are multiple independent sites of origin or if the process simply represents spread of the cancer. The present study was designed to examine the distribution and extent of cancer in the breast and identify factors that bear on these events. All mastectomy specimens between 1980 and 1983 were systematically examined by means of multiple sections. One hundred seventy-nine of 657 patients (27%) were found to have separate foci. The most common histologic type (invasive ductal) was least likely to have multifocal disease (19%), while it was extremely common in the small group of patients with intraductal lesions (81%). Size was a factor in ductal but not in lobular lesions. Ninety per cent of the secondary foci were found in close proximity to the primary, suggesting spread rather than multicentricity. This implies a more limited and predictable distribution of cancer cells and opens the way to more rational selection and surgical preparation of patients for breast preservation.

Nutrition and lung water.

Lung water homeostasis and the subsequent prevention of pulmonary edema involve a balance of many forces and safety factors. Malnutrition and its effects on fluid distribution within body compartments and on oncotic pressure gradients can play a crucial role in this balance of forces. These forces are discussed, with emphasis on the complications of superimposed malnutrition.