Casting-type calcifications with invasion and high-grade ductal carcinoma in situ: a more aggressive disease?

HYPOTHESIS: Women with breast cancer who have casting-type microcalcifications associated with multifocal invasion and extensive ductal carcinoma in situ (DCIS) form a subset of patients with a poor prognosis. Our study aims to identify the mammographic and pathologic features of this group. DESIGN: Women with casting-type microcalcifications, multifocal invasion, and extensive DCIS were identified from our tumor board registry. Mammographic features, tumor characteristics, treatment, and survival rates were evaluated. Invasive tumors were limited to 14 mm or smaller. SETTING: University medical teaching hospital and breast cancer specialty clinic. RESULTS: Of the 984 patients with breast cancer treated at our center, 15 patients were identified who had extensive casting-type calcifications and DCIS. Twelve of these patients also had multifocal invasive breast cancer. All had casting-type microcalcifications occupying more than 1 breast quadrant. All but 1 of the patients were treated using mastectomy with sentinel node biopsy or axillary node dissection. All but 1 patient had extensive grade 3 DCIS. Invasive tumors were negative for estrogen receptor and progesterone receptor expression in half of the patients, and 60% were positive for the HER-2-neu receptor. Positive axillary lymph nodes were found in 33% of patients, and 75% received adjuvant chemotherapy. After a median follow-up period of 20.5 months (range, 6-72 months), 1 patient had died and 1 had distant metastases. Of the 3 patients who had DCIS without invasion, 1 experienced a recurrence with infiltrating ductal carcinoma. CONCLUSIONS: In women with small multifocal breast cancers with extensive casting calcifications and DCIS, the incidence of positive lymph nodes was 33%, with a tendency for poor tumor markers. These women appear to be at substantial risk for systemic disease; lymph node sampling and adjuvant systemic therapy are recommended.

Benign breast disease.

This article describes 25 years of clinical experience in the setting of a Breast Health Center devoted to benign and malignant disease of the breast. During this period, more than 100,000 patients have been evaluated and treated for a wide variety of breast problems. This experience has provided an extraordinary opportunity to evaluate the natural history of benign breast disease and the frequent observation that the relevant medical literature does not reflect the entire spectrum of these conditions or the appropriate treatment. Most textbooks on breast disease emphasize breast cancer and the late manifestations of benign breast disease that often require surgical treatment. More than 180,000 cases of breast cancer occur each year in the United States. The number of women with benign breast disease is far greater and can be counted in the millions. For these patients, the well-trained primary care physician can provide appropriate evaluation and treatment, including appropriate recommendations for referral. For most patients with breast symptomatology, the goal is relief of symptoms and resolution of the problem. To accomplish this requires a contemporary knowledgebase combined with adequate time spent with the patient.

The diagnostic evaluation.

Diagnostic evaluation is performed to confirm the diagnosis and extent of the disease. The evaluation begins with a careful history and physical examination. Major changes have occurred in the diagnostic evaluation of patients. Frequently the diagnosis is suspected because of an abnormal mammogram or ultrasound, and image-guided biopsies have all but replaced open biopsy. For the primary care physician, the best strategy is to refer the patient to a specialist or a multidisciplinary breast center.

Inflammation of the breast.

The primary care physician usually is the first person to see patients complaining of breast pain or nipple discharge. The diagnosis of lactational mastitis is evident because of the history The major consideration is prompt and effective treatment and close follow-up evaluation. Failure to respond to appropriate therapy should suggest abscess formation, and prompt intervention is required. Any diagnosis of mastitis in a patient who is not lactating should be viewed with suspicion. Although several benign and non-life-threatening conditions have been discussed herein, inflammatory breast cancer must always be considered.