Stereotactic breast biopsy: a study of first core samples.

Stereotactic core needle biopsy (SCNB) is a sensitive and specific indicator of breast pathology. Commonly the first biopsy core is taken from the center of the lesion in question. Multiple cores are then taken from points peripheral to the central core. The sensitivity and specificity of the central core to diagnose breast disease is unclear. We compared the pathology of the central core biopsy with that of the remaining cores in a prospective study to determine the sensitivity and specificity of the central core to diagnose breast disease. All patients undergoing SCNB for breast lesions in a single surgical office during a 7-month period were eligible for inclusion. One hundred thirty-three patients with first cores from 145 biopsy sites were included. The histologic diagnosis from 117 (81%) of the first cores from these 145 biopsy sites were representative of their respective samples as a whole. Seventy-seven (53%) of the first cores were in complete agreement with the final histologic diagnosis whereas 40 (28%) had minor differences with the histologic diagnosis that had little or no clinical significance. Twenty-eight (19%) central core samples did not agree with the final pathologic diagnosis. Seven of these 28 patients each had a final diagnosis of cancer missed by the central core biopsy. The first core sample had a sensitivity for cancer detection of 79 per cent and specificity 100 per cent. SCNB remains a sensitive and specific identifier of breast pathology. When mammographic evidence of calcifications was the primary indication for SCNB (n = 75) calcification was present in the central core in 51 (68%). In these 51 patients the central core biopsy was in agreement with the final histologic diagnosis in 46 (90%) specimens. Histologic review of the first core sample alone lends no increased benefits and in fact misrepresents the pathology present in a significant number of patients. When analyzed as an independent predictor of breast pathology the first core is a more sensitive indicator than subsequent individual cores, but the most accurate predictor of pathology is examination of the entire group of core samples. This study confirms the need for acquisition of multiple cores from each lesion in question.

Breast cellulitis following breast conservation therapy: a novel complication of medical progress.

Breast cellulitis is a novel complication of the recently accepted practice of breast conservation therapy. This phenomenon represents an anatomic shift from ipsilateral upper extremity cellulitis seen in past years when mastectomy with axillary lymph node dissection was performed for treatment of limited disease due to breast cancer. Thirteen episodes of breast cellulitis in nine women who underwent breast conservation therapy for stage I or II breast cancer are presented. The mean duration from the end of radiotherapy to the initial episode of cellulitis was 4.9 months. Eighty-three percent of episodes occurred in patients who had radiologically demonstrated fluid collections at the surgical lumpectomy site prior to the onset of cellulitis. Eight (61.5%) of 13 episodes occurred within 3 months of a follow-up mammogram of the treated breast. Two patients developed recurrent cellulitis within a 6-month period. Breast cellulitis may be more commonly seen in clinical practice as an increasing number of patients undergo breast-sparing procedures for treatment of limited disease due to cancer.

Ductal carcinoma in situ of the breast: correlation of pathologic and mammographic features with extent of disease.

Optimal treatment of ductal carcinoma in situ (DCIS) of the breast requires an improved understanding of its pathologic extent and propensity for local recurrence. This study was performed to analyze mammographic and pathologic features of DCIS that might predict the extent of disease within the breast and facilitate treatment selection between lumpectomy alone, lumpectomy and radiotherapy, and mastectomy. At our institution, 60 cases of DCIS were diagnosed in 59 patients from June 1985 to February 1995 and form the basis of this retrospective study. Demographic and treatment-related information was obtained from hospital and tumor registry records. Mammograms were reviewed and size estimates of the abnormalities were determined. Pathologic slides from all cases were reviewed and classified according to size group, focality, nuclear grade, necrosis, and histologic subtype. DNA ploidy status and proliferation indices were available for 28 patients. Pathologically, 43 (72%) cases were < 15 mm, 14 (23%) were 16 to 40 mm, and 3 (5%) were > 40 mm. Five (8%) of the lesions were multicentric, 28 (47%) focal, and 27 (45%) multifocal. Thirty-three (55%) patients were treated by mastectomy, 16 (27%) by lumpectomy alone, and 11 (18%) by lumpectomy and radiation therapy. Mammographic size, histologic grade, presence or absence of necrosis, histologic subtype, DNA ploidy, and proliferative index were compared with pathologic size and focality by chi 2 analysis. Mammographic size correlated significantly with pathologic size (chi 2 = 11.3; P = 0.02) but underestimated the extent of disease in 9 cases. Although focality correlated significantly with pathologic size (chi 2 = 15.8; P = 0.003), the remaining histopathologic features did not significantly correlate with pathologic size or focality. Histopathologic features, including DNA studies, do not reliably predict the pathologic extent of DCIS, but mammographic size and focality do significantly correlate with pathologic size. Nevertheless, most cases of DCIS are small focal or multifocal lesions that are amenable to breast conservation approaches; further studies are needed to determine the appropriate use of lumpectomy, radiation therapy, and mastectomy in the treatment of DCIS.

Role of LFA-3, ICAM-1, and MHC class I on the sensitivity of human tumor cells to LAK cells.

Cellular adhesion molecules have been shown to be involved in tumor cell killing by cytotoxic cells such as natural killer (NK), lymphokine-activated killer (LAK), and T cells, but the precise mechanisms involved have not been clearly determined and a single target molecule has not been identified. We have examined the relative sensitivities of a panel of human tumor cell lines to LAK cell-mediated killing, in order to correlate their sensitivities with LAK cell-tumor cell binding determined by flow cytometry, and also with expression of molecules putatively involved in both the adhesion and recognition process. Two cell adhesion molecules in the immunoglobulin supergene family lymphocyte function-associated antigen (LFA-3) and intercellular adhesion molecule (ICAM-1) expression by tumor cells were examined in detail with respect to the degree of LAK cell-tumor cell conjugation and cytotoxicity. LAK sensitivity of the tumor cell lines was not clearly related to the degree of binding and correlated most strongly with the level of LFA-3 expressed on these cell lines. Major histocompatability complex (MHC) Class I antigen (Ag) expression by tumors was also examined and correlated with an inhibitory effect on LAK cell-mediated killing. Interferon-gamma(IFN) treatment of two of these tumor lines decreased their sensitivity to LAK, and treated cells exhibited a higher level of MHC Class I Ag and ICAM-1 and an increased degree of conjugation with LAK cells. These findings demonstrate roles for LFA-3, ICAM-1, and MHC Class I expression in the LAK cell-tumor cell recognition and triggering of the lytic process.

Interval mammography after needle localization biopsy of breast abnormalities that are pathologically benign.

BACKGROUND: Needle localization biopsy is commonly performed for the diagnosis of mammographic abnormalities. Routine specimen radiography is generally recommended, but the value of routine short-interval postbiopsy mammography has not been analyzed. PATIENTS AND METHODS: We performed a retrospective review of 299 consecutive localized biopsies in 286 women from March 1989 to November 1993. Of these biopsies, 217 from the basis for this study; all yielded a benign pathologic diagnosis and had both specimen radiography and 3-month interval mammograms performed. RESULTS: A total of 192 (88%) of postbiopsy mammograms were interpreted as negative, while 22 (10%) were suspicious. Three patients had second biopsies and all had benign diagnoses, 16 had follow-up mammograms that were interpreted as normal or stable, and 3 patients were lost to follow-up. A suspicious postbiopsy mammogram had no significant relationship to initial mammographic abnormality or pathologic diagnosis, but did correlate with specimen radiograph interpretation (P = 0.02) by chi-square comparison). CONCLUSIONS: In a series of needle localization biopsies with intraoperative specimen radiography, postbiopsy mammography failed to reveal any missed cancers. Short-interval follow-up mammography is unnecessary to assess for residual abnormalities when specimen radiography confirms excision of the abnormality.

p53 and disease progression in patients with non-small cell lung cancer.

Present methods of predicting nodal progression preoperatively in patients with non-small cell lung cancer (NSCLC) are inadequate. Our hypothesis was that p53 expression in primary NSCLC would predict disease progression, making it a useful marker of adverse outcome. From 1987 to 1992, sixty-eight consecutive NSCLC patients underwent potentially curative lung resection and mediastinal lymph node dissection by one surgeon. Primary tumours were analysed using the p53 monoclonal antibody 1801. p53 overexpression was found in 53% of tumours. p53 expression did not correlate with age, gender, histology or stage. A trend toward a higher incidence of p53 expression was seen in tumours with nodal spread (P = 0.06), and p53 expression correlated significantly (P = 0.03) with improved disease-free survival in patients with squamous cell carcinoma (SCC). p53 was the fourth most important independent predictor of survival, behind histology, gender and nodal disease. As a weak independent predictor of survival, the correlation of p53 expression with survival in patients with SCC must be evaluated with caution. If borne out in a larger patient population, p53 expression may be a marker of nodal disease progression in patients with NSCLC.

Loss of blood group antigen A in non-small cell lung cancer.

BACKGROUND: Many human tumor cells display alterations in blood group antigen expression, and the loss of antigen A expression by non-small cell lung cancer (NSCLC) in blood group A patients has recently been associated with decreased survival. METHODS: To confirm this finding, we performed a retrospective study of 62 NSCLC patients undergoing potentially curative resection between August 1987 and December 1991 who were blood group A and had paraffin-embedded primary lung cancer tissue suitable for immunohistological analysis of antigen A expression. Twenty-seven patients expressed antigen A in their tumors, whereas 35 had loss of antigen expression. Disease-free survival (DFS) curves were calculated for stage I (n = 26) and IIIA (n = 25) patients. RESULTS: The two groups of patients with or without antigen A expression did not have significantly different DFS. A proportional hazards regression analysis identified no significant difference in the DFS of stage I patients with or without antigen A, but stage IIIA patients who had preservation of antigen A had significantly shorter DFS than did those who lost antigen A (p = 0.0002). CONCLUSIONS: The loss of expression of antigen A by primary tumor cells was not a significant adverse prognostic factor in DFS in our series, and we would recommend further studies to define clearly the clinical importance of antigen A expression in pulmonary carcinoma.

Optimizing local control in soft tissue sarcoma of the extremity.

Extremity soft tissue sarcoma is a rare malignancy in which a high rate of local control can be achieved with multimodal regimens and without excessive treatment-related morbidity. This article reviews the current status of evaluation, staging, and local treatment of these tumors. Evidence shows that surgical approaches that maximize local control have little effect on the development of distant metastasis and overall survival. The goal of local treatment, therefore, is a balance of adequate local control with limb salvage and minimal therapeutic morbidity. A variety of limb-sparing approaches using various adjuvant modalities in addition to conservative resection are discussed, including reported local control and complication rates. Treatment paradigms are then presented for the management of extremity soft tissue sarcoma of varying stages. Further studies are needed to define precisely the role, type, and timing of chemotherapy and radiotherapy in addition to surgery in the management of this disease with respect to local control and distant metastasis.

Incidence of gross and microscopic carcinoma in specimens from patients with breast cancer after re-excision lumpectomy.

OBJECTIVE: The aims of this study were to quantify the amount of the residual carcinoma in re-excision lumpectomy specimens and retrospectively analyze the relationship between clinical parameters and the characteristics of the primary excision to these quantities of the residual tumor. SUMMARY BACKGROUND DATA: Because complete gross surgical excision of the primary tumor is important in minimizing local recurrence in women undergoing breast conservation therapy, re-excision of the initial biopsy site is commonly practiced when the initial primary tumor excision shows inadequate or undeterminable margins. Several studies have reported a significant proportion of re-excision specimens to contain residual tumor (32% to 63%), but to the authors' knowledge, none have quantified the amount of residual tumor. METHODS: The authors reviewed 192 re-excisions retrospectively to quantify the amount of residual carcinoma and correlate the quantities with the characteristics of the primary tumor resection. RESULTS: No tumor was found in 105 (54.7%) specimens, 46 (23.9%) had minimal microscopic disease, 23 (12.0%) had extensive microscopic disease, and 18 (9.4%) had gross residual cancer. Characteristics significantly associated with the quantity of residual disease included clinical tumor stage (T stage), pathologic T stage, and the margin status of the primary excision. The majority (62.1%) of re-excision specimens containing residual carcinoma had an invasive component. CONCLUSIONS: It was concluded that re-excision lumpectomy yields an important number of patients with residual carcinoma and that characteristics of both the primary tumor and primary excision significantly predict the quantity of residual cancer in the specimen. In addition, these results support the policy of performing re-excision for patients with inadequate or undeterminable margins for the primary excision.

Blood transfusion practices after resection of intrathoracic neoplasms.

A heightened awareness of the risks of blood transfusion and the previously reported common administration of blood products (31-55%) following thoracic surgery prompted us to evaluate our recent transfusion practices. Of 355 patients who underwent a thoracotomy or median sternotomy from July 1987 through September 1991, 91 (25.6%) were transfused a mean 3.1 units of blood within the first 30 postoperative days. Transfused and nontransfused patients were compared with respect to age, body surface area, preoperative hemoglobin, estimated operative blood loss, and estimated postoperative hemoglobin. Univariate analyses of variance indicate significant (P < 0.01) differences between the two groups of patients for preoperative hemoglobin, blood loss, and estimated postoperative hemoglobin. Transfusion frequencies by year of operation are: 1987, 36%; 1988, 31%; 1989, 33%; 1990, 23%; 1991, 15%. We conclude that our transfusion requirements are lower than reported rates and that clinical parameters may help predict the need for subsequent transfusion.

Surgical management of nonhepatic intra-abdominal recurrence of carcinoma of the colon.

The role of surgery in the management of intra-abdominal recurrence of colon cancer has not been clearly determined. We reviewed the charts of 28 patients operated upon at our institution for nonhepatic intra-abdominal recurrence of carcinoma of the colon and followed for a median of 10.5 months after reoperation. Total resection of gross disease was possible in 15 patients, who had a median overall actuarial survival of 25.5 months and a disease-free survival of 13 months. Within this group, disease-free survival was significantly prolonged when time to first recurrence was greater than 16 months and when patients had not had a prior operation for recurrent disease (P < 0.05). Six patients having a partial resection and seven patients having only a bypass or ostomy had significantly shorter survivals than those in the totally resected group, with median survivals of 8 and 3.5 months, respectively (P < 0.05). Operative management of recurrent colon cancer may prolong survival when disease can be eradicated, and palliative operations appear more successful when tumor is resected rather than bypassed.