Breast conservation therapy for invasive lobular carcinoma: the impact of lobular carcinoma in situ in the surgical specimen on local recurrence and axillary node status.

Forty patients undergoing breast-conserving therapy for invasive lobular carcinoma were studied for the volume of lobular carcinoma in situ (LCIS) in the surgical specimen and its relationship to the surgical margins. The pathology of all cases was reviewed for margin status as well as the volume of LCIS in the surgical specimen. Mean follow-up time was 67 months. There were no local recurrences despite the fact that 38 per cent of patients had close or involved margins. There was one cancer-related death. Increasing tumor size and moderate or extensive involvement of the surgical specimen with LCIS were found to be independent predictors of axillary node metastases. The volume of LCIS in the surgical did not appear to have an impact on local recurrence. This paper adds to the growing body of literature suggesting that in patients undergoing breast-conserving therapy, LCIS in the surgical margin does not impact the risk of local recurrence and therefore may not require reexcision for close or involved surgical margins.

An argument against routine sentinel node mapping for DCIS.

Indications for sentinel lymph node mapping (SLNM) for patients with ductal carcinoma in situ (DCIS) of the breast are controversial. We reviewed our institutional experience with SLNM for DCIS to determine the node positive rate and clarify indications for nodal staging in patients with DCIS. Since 1998 we have used SLNM to stage breast cancer patients using both blue dye and radiocolloid. In DCIS patients, SLNM has been reserved for patients considered at high risk for harboring coexistent invasive carcinoma or treated by mastectomy. All sentinel nodes were evaluated with serial sectioning, hematoxylin and eosin staining, and immunohistochemical evaluation for cytokeratins. We identified 44 patients with 46 cases of DCIS (two patients with bilateral disease). SLNM identified at least one sentinel node in all cases. In all cases, the sentinel node(s) were negative for axillary metastasis. We calculated the binomial probability of observing 0 of 46 cases as negative when the expected incidence according to published reports in the surgical literature was 13 per cent and found a P value of <0.01. Based on this case-series observation, we conclude SLNM should not be routinely performed for patients with DCIS. We now use SLNM only for DCIS patients treated by mastectomy.

A mass on breast imaging predicts coexisting invasive carcinoma in patients with a core biopsy diagnosis of ductal carcinoma in situ.

An image-guided core-needle breast biopsy (IGCNBB) diagnosis of ductal carcinoma in situ (DCIS) is often upgraded to invasive carcinoma (IC) after complete excision. When IC is identified after excision patients must be returned to the operating room for evaluation of their axillary nodes. We performed this study to identify histologic or mammographic features that would predict the presence of invasion when DCIS is documented by IGCNBB. Patients with an IGCNBB diagnosis of DCIS were identified from a prospective database. Imaging abnormalities were classified as either calcification only or mass with or without calcifications. IGCNBB specimens were reviewed to document nuclear grade and the presence of comedo-type necrosis, periductal fibrosis, and periductal inflammation. Patients were divided into two groups, DCIS and IC, on the basis of the final diagnosis after complete excision. From July 1993 through May 2000, 148 of 2995 (4.9%) IGCNBBs demonstrated DCIS; eight were excluded after pathologic review. Of the remaining 140 patients 36 (26%) demonstrated IC after complete excision. The presence of a mass on breast imaging was the only significant predictor of IC (P = 0.04). On the basis of the results of this study we now perform sentinel lymph node mapping and biopsy at the initial surgical procedure for patients with an IGCNBB diagnosis of DCIS and an associated mass on breast imaging.

The impact of current use of hormone replacement therapy on prognostic factors and surgical treatment of new breast cancers.

When postmenopausal women were diagnosed with breast cancer while taking hormone replacement, no adverse effects were noted in either clinical or prognostic factors when compared to a similar group not on hormones. Younger age at diagnosis and an increased chance of carcinoma in situ were noted in those on hormones. A surveillance or observational bias is one explanation for these findings. A promotional effect of hormone replacement therapy could not be eliminated based on this study.

The impact of image-directed core biopsy on the practice of breast surgery: a new algorithm for a changing technology.

Open surgical biopsy has long been the standard of care for the diagnosis of breast pathology. As more lesions are diagnosed by mammography, image-directed core biopsy has taken on increasing importance. This study consisted of a consecutive group of 540 patients who underwent breast biopsy for mammographically or sonographically detected lesions. The percentage of those undergoing image-directed biopsy and open biopsy were determined as well as the rate of positive biopsy for each method. Results showed that for patients with nonpalpable lesions, the proportion of image-directed core biopsies rose steadily during the study period, from 0 per cent in early 1993 to 70.1 per cent by early 1996. During this same period, positive biopsy rate rose from 23.9 to 31.0 per cent in the first 18 months of the study to a range of 45.2 to 48.3 per cent in the last 18 months. It was concluded that image-directed core biopsies have begun to impact the practice of breast surgery by replacing, to a great extent, the open surgical biopsy. This study also demonstrates an increased proportion of positive biopsies done by open surgical technique. It was suggested that many of the mammographically benign lesions are diagnosed by image-directed core biopsy, obviating the need for an open technique. An algorithm for managing nonpalpable breast lesions is presented.

Stereotactic breast biopsy: a surgical series.

BACKGROUND: Stereotactic core needle biopsy (SCNB) is increasing in popularity and is currently being performed by both radiologists and surgeons. It has been shown to be accurate and cost effective, but the appropriate use of SCNB in the probably benign mammographic lesion has not been determined. Nor has it been determined whether a learning curve affects performance of the procedure. STUDY DESIGN: The records of all patients undergoing SCNB by the author from August 1993 through May 1996 were reviewed. Two hundred forty-two patients underwent 244 procedures. Indications for biopsy, results, and complications were examined. RESULTS: Probably benign mass was the most common indication for biopsy (45%), and microcalcifications were the indication for biopsy in 24%. A diagnosis of cancer was made in 11.1%. Patients with microcalcifications and probably benign masses were diagnosed with cancer in 18.4 and 1.8%, respectively. Three of eight patients undergoing open biopsy for atypical hyperplasia were diagnosed with cancer. Accuracy rate for the entire series was 97.7%. The effect of operator experience on the indication for SCNB was studied. As experience increased from the first to the last third of the study, microcalcifications as an indication increased from 23.5-37.5%. During this same time period, "probably benign" mass decreased from 53.1-32.5%. CONCLUSION: This study demonstrates that accuracy of this surgical series is comparable to other published series. Biopsies for more difficult lesions were noted to increase as operator experience increased. It was likely that this "learning curve" was owing to improvements in technique and an increased confidence in the accuracy of the procedure. With an incidence of cancer of less than 2% in patients with a probably benign mass, interval mammography represents for many, a cost-effective alternative.