Atypical ductal hyperplasia in breast core needle biopsies. Correlation of size of the lesion, complete removal of the lesion, and the incidence of carcinoma in follow-up biopsies.

We reviewed the results of all breast core needle biopsies with a diagnosis of atypical ductal hyperplasia (ADH) or atypia not otherwise specified and subsequent excisional biopsies for a 50-month period and correlated the results. Of 3,026 biopsies, 216 were diagnosed as ADH or atypia not otherwise specified, and subsequent resection was available for 105. After review, 95 qualified as ADH. Subsequent resection showed ductal carcinoma in situ (DCIS) in 13 excisions, ADH in 31, lobular carcinoma in situ in 6, and benign proliferative lesions in the remaining 45. In none of the 8 biopsies in which DCIS was found and radiographs were available for review was the radiographic lesion entirely removed. For comparison, the incidence of carcinoma in resections done for a diagnosis of DCIS, low or intermediate grade (solid, cribriform, or micropapillary type), on core needle biopsy was significantly greater (8 of 10 cases). However, the size of the lesions diagnosed as carcinoma also was significantly greater than that of the lesions diagnosed as ADH, and in none of the 8 biopsies with DCIS at excision was the lesion entirely removed at the time of biopsy. The incidence of carcinoma in excisional biopsies done for a diagnosis of ADH in core needle biopsies in our institution is relatively low, while the incidence of ADH is relatively high. Possible reasons for this include total removal of small lesions at the time of biopsy and use of the diagnostic term ADH for lesions that are not associated with coexistent DCIS.

Concerns about breast cancer and relations to psychosocial well-being in a multiethnic sample of early-stage patients.

Much work on psychosocial sequelae of breast cancer has been guided by the assumption that body image and partner reaction issues are focal. In a tri-ethnic sample of 223 women treated for early-stage breast cancer within the prior year, the authors assessed a wider range of concerns and relations to well-being. Strongest concerns were recurrence, pain, death, harm from adjuvant treatment, and bills. Body-image concerns were moderate; concern about rejection was minimal. Younger women had stronger sexual and partner-related concerns than older women. Hispanic women had many stronger concerns and more disruption than other women. Life and pain concerns and sexuality concerns contributed uniquely to predicting emotional and psychosexual disruption; life and pain concerns and rejection concerns contributed to predicting social disruption. In sum, adaptation to breast cancer is a process bearing on several aspects of the patient's life space.

Concern about aspects of body image and adjustment to early stage breast cancer.

OBJECTIVE: Several authors have suggested that patients adjust more poorly to breast cancer if they are heavily invested in body image as a source of their sense of self-worth. This prospective study examined this possibility, looking at two aspects of concern about body image as predictors of several indices of adjustment over the first postoperative year. METHODS: At diagnosis (and again a year later) 66 women with early stage breast cancer reported how much they valued a) a sense of body integrity (or intactness) and b) a good physical appearance. The day before surgery, a week afterward, and at 3-month, 6-month, and 12-month follow ups, they reported on their mood. At presurgery and at follow ups they also rated their attractiveness and sexual desirability and reported on frequency of sexual interaction. At follow-ups they also indicated how much their illness and treatment were interfering with social and recreational activities. RESULTS: Initial investment in appearance was related to distress across the postsurgical year. In contrast, investment in appearance made women more resilient against deterioration in their perceptions of attractiveness. Concern about body integrity did not strongly predict emotional distress, but it related to adverse impact on social and recreational activities in the follow-up period, to deterioration in feelings of sexual desirability, and to feelings of alienation from the self (feeling "not like yourself anymore"). CONCLUSIONS: Body image is often thought of in terms of physical appearance, but there is also a body image pertaining to integrity, wholeness, and normal functioning. People who are greatly concerned about either aspect of their body image are vulnerable to poorer psychosocial adjustment when confronting treatment for breast cancer. The poorer adjustment takes a different form, however, depending on the nature of the patient's body-image concern.

Early diagnosis of breast changes. Risk management and quality of care approach.

Breast cancer is the leading cancer diagnosis among women. Systematic use of mammography and other screening modalities can reduce mortality. The gap between potential benefit and clinical reality appears to be widening, however, as suggested by the fact that failure to diagnose is now the number one cause of malpractice lawsuits against physicians.

Conservative surgery and radiation therapy for intraductal carcinoma of the breast.

Nineteen women with intraductal carcinoma of the breast were treated with conservative surgery and radiotherapy from 1982 to 1990. All underwent excisional biopsy or wide local excision of the primary tumor. Definitive irradiation consisted of 4500 cGy in 180 cGy fractions given through tangential fields followed by a breast boost to the primary site to a total dose of 5900-6500 cGy. No patient received regional node irradiation. Median follow-up was 38 months. The five year actuarial rate of local failure was 9%. One patient failed with an infiltrating ductal carcinoma in the treated breast 31 months after initial treatment. Salvage mastectomy was performed. She remains without evidence of disease 43 months after initial treatment. Metastatic breast carcinoma has not developed in any of the patients. Cosmetic result was good to excellent in all patients. With short-term follow-up, conservative surgery and radiotherapy appear to be an acceptable alternative to mastectomy in carefully selected patients with ductal carcinoma in situ. As retrospective and randomized trials mature, the natural history of these lesions treated with conservative surgery and irradiation will be further defined.

Conservative surgery and radiation therapy for early stage breast cancer. Can large trial experiences be reproduced in a community hospital setting?

Conservative surgery and radiation therapy were used to treat 212 patients with AJC clinical Stage I or II breast carcinoma at the Baptist Hospital of Miami. All had lumpectomy and most axillary lymph node dissection, followed by breast irradiation to a dose of 45 Gy and a boost dose of 14 to 16 Gy to the surgical bed. Median follow-up was 55 months. The five-year actuarial local control and survival rates were 94% and 86% respectively. Eighty-six percent of the patients had excellent or good cosmetic results with minimal differences between the treated and untreated breasts. Treatment-related complications were minor and infrequent. These results appear comparable to retrospective reviews at major university centers and ongoing prospective randomized trials.

Centrifugal cytology of nipple aspirate cells.

Two improvements in the methodology for obtaining and preparing nipple aspirates from nonlactating women are reported. The first is the development and use of a new breast pump with a controllable vacuum and cups of various sizes. The second is the use of centrifugal cytology to prepare the dispersions. Twenty-one of 24 breasts of patients in the age range 30 to 49 years produced cellular dispersions which contained foam cells; of them, 13 contained ductal cells. A comparison of glutaraldehyde and ethanol fixation indicated that the cells appeared substantially the same.

Locally recurrent carcinoma after breast reconstruction.

The incidence of locally recurrent carcinoma after mastectomy is low--between 6 and 20%. Recent case histories of 4 patients who were clinically free of breast carcinoma and who developed local recurrence after reconstruction are reviewed. Possible relationships of breast reconstruction to local recurrence are discussed. The development of capsule formation in the reconstructed breast may denote recurrent disease.

Inflammatory oncotaxis.

Tumor recurrence after a prolonged disease-free interval suggests that neoplastic cells may remain dormant within the host. Activation and growth of these metastatic focuses may occur secondary to inflammation at sites distant from the primary tumor. The concept of inflammatory oncotaxis is presented as a mechanism of cancer cell attraction and facilitation of transcapillary migration into tissue spaces. Physicians should focus astutely on internal and external sites of inflammation as possible focuses for tumor recurrence in the follow-up of the cancer patient.