Annual mammography screening: is it necessary?

Recent recommendations from the U.S. Preventative Services Task Force suggest that screening mammography for women should be biennial starting at age 50 years and continue to age 74 years. With these recommendations in mind, we proposed a study to evaluate women at our institution in whom breast cancer is diagnosed within 1 year of a previously benign mammogram. A retrospective chart review was performed over a 4-year period. Only patients who had both diagnostic mammograms and previous mammograms performed at our institution and a pathologic diagnosis of breast cancer were included. Benign mammograms were defined as either Breast Imaging Reporting And Data System 1 or 2. Analysis of the time elapse between benign mammogram and subsequent mammogram indicative of the diagnosis of breast cancer was performed. A total of 205 patients were included. The average age was 64 years. From our results, 48 patients, 23 per cent of the total, had a documented benign mammogram at 12 months or less before a breast cancer diagnosis. One hundred forty-three (70%) patients had a benign mammogram at 18 months or less prior. This study raises concern that 2 years between screening mammograms may delay diagnosis and possible treatment options for many women.     

Breast cancer in the elderly.

OBJECTIVE/METHODS: To determine the clinical behavior and outcome of breast cancer in the elderly, a series of 184 women older than age 69 years who received treatment for locoregional breast cancer at The University of Texas M. D. Anderson Cancer Center between 1976 and 1985 were studied for a median of 80 months. RESULTS: The results indicate that elderly women can tolerate standard surgical therapy and survive disease-free for many years; the breast cancer-specific survival rate of patients in this study was 79% at 7 years. Although 33% of patients had stage I disease, only 10% underwent breast conservation surgery. Despite 46% of patients having stage II and 21% having stage III breast cancer, fewer than 13% received systemic adjuvant therapy. Noncompliance with breast screening guidelines was evident in that only 3% of patients had tumors detected by routine screening mammograms and only 12% by routine physical examinations. CONCLUSIONS: Women with breast cancer should be informed of treatment options and the advantages and disadvantages of each choice based on physiologic rather than chronologic age.     

Osteoporosis and breast cancer

Osteoporosis affects one in three women after the menopause and the incidence of osteoporotic fractures increases steadily throughout life. Breast cancer is the most common cancer in women, both before and after the menopause. In younger women, recovery from breast cancer has been achieved using aggressive chemotherapy and radiotherapy that can adversely affect bone tissue or induce premature menopause. In postmenopausal women, breast cancer and osteoporosis are common, and although both are dependent on estrogens this leads to conflicting implications for the diagnosis and treatment: estrogens reduce the risk of fractures but increase the risk of breast cancer. Estrogen supplementation is, therefore, contraindicated in patients with a history of breast cancer. Selective estrogen response modifiers (SERMs) hold great promise, as they decrease both the fracture risk via an estrogen-agonist effect on bone and the breast cancer risk via an estrogen-antagonist effect on the breast tissue. SERMs can be used after successful treatment for breast cancer. Bisphosphonates, which are potent bone resorption inhibitors, are widely used both in cancer patients and in the prevention and treatment of spinal and peripheral osteoporotic fractures. Contraindications are exceedingly rare, and the satisfactory safety profile of these agents can be expected to improve further with newly developed modes of administration. Whether the bisphosphonates currently used to treat osteoporosis (alendronate and risendronate) have beneficial effects on skeletal events related to cancer progression remains to be determined, however. In sum, selection of the optimal treatment for osteoporosis in a patient with breast cancer involves assessment of the risk/benefit ratio of each treatment option, based on patient age, other risk factors for osteoporosis, and the stage of breast cancer progression.     

Mammographic screening in women at increased risk of breast cancer after treatment of Hodgkin's disease

Treatment regimens for Hodgkin's disease (HD) that have included radiation to lymph node regions in the thorax have contributed to high rates of long-term disease-free survival. However, incidental radiation exposure of breast tissue in young women has significantly increased the risk of breast cancer compared to expected rates in the general population. After informing patients about risks associated with previous treatment of HD, we studied screening mammograms and call-back rates in women at increased risk for developing breast cancer at a younger age. We contacted by mail a cohort of 291 women between 25 and 55 years of age who had received thoracic irradiation before 35 years of age for HD with or without chemotherapy. Subjects were offered information about risks identified after HD therapy with questionnaires to assess response to this information. Ten patients refused participation, 93 did not respond, and 21 were excluded after they reported a prior diagnosis of invasive (1) or in situ (2) breast cancer. One hundred and sixty seven women received information about secondary breast cancer risk and were advised to initiate or maintain mammographic screening. Available mammograms were reviewed by two radiologists and classified according to the ACR BI-RADS Mammography Lexicon. Abnormal findings were correlated to pathology results from biopsies. One hundred and fifteen subjects reported that they obtained new mammograms during the period of the study. Ninety-nine were available for secondary review. Patients were studied an average of 16.9 years after HD treatment (Range: 4.5-32.5 years) at an average of 41 years of age (range 25-55 years). High density breast tissue was identified in 60% (60/99). Seventeen of the women (17.2%) were recalled for further imaging. This was more common in women with heterogeneously dense breast tissue. Seven of those recalled (41%) were advised to undergo biopsies that identified ductal carcinoma in situ (DCIS) in one and benign findings in the others. Among 16 women whose mammograms were unavailable for review, three were diagnosed with DCIS; two of these had microscopic evidence of invasive breast cancer. The four in situ or microinvasive cancers were diagnosed in the study participants at 25-40 years of age and from 5 to 23 years after HD therapy. Biopsies were performed because mammograms detected microcalcifications without palpable abnormality in three of these cases. Women who have had thoracic nodal irradiation for Hodgkin's disease have an increased risk of developing secondary breast cancer at an unusually young age. As expected in younger women, high density breast tissue was common on mammography, and the recall and biopsy rates were unusually high. However, early mammographic screening facilitated diagnosis of in situ and early invasive cancer in 3.5% of our subjects.     

Causes of breast cancer malpractice litigation. A 20-year civil court review.

To determine objectively the patient and physician factors that lead to breast cancer malpractice litigation, a review was undertaken of all cases tried in the US federal and state civil court system over a 20-year period from 1971 through 1990. Forty-five cases were identified and all involved a delayed diagnosis of breast cancer (the mean delay was 15 months). The patients were young (mean age, 40 years). Of 45 cases studied, the majority of patients (37 [82%]) found a painless mass by self-examination of the breast. Only 22 patients (49%) had further workup, mostly by mammography (20 [44%]). The results of 16 mammograms (80%) were read as normal. Obstetricians and gynecologists were involved in the greatest number of cases (21 [50%]), followed by family practitioners and internists (17 [41%]), general surgeons (12 [28%]), and radiologists (4 [10%]).     

双侧原发性乳腺癌16例临床病理分析

目的 探讨双侧原发性乳腺癌的临床病理特征及其防治.方法 回顾性分析2001年1月至2009年12月江苏省肿瘤医院收治的确诊为双侧原发性乳腺癌16例的临床病理资料.结果 16例均为女性,占同期收治乳腺癌的0.47%,发病年龄41～69岁,中位年龄53岁.同时性双侧乳腺癌7例,发病年龄41～54岁,中位年龄47岁,5例为绝经前患者.异时性双侧乳腺癌9例,第2癌的发病年龄43～69岁,中位年龄58岁,1例为绝经前患者.异时性双侧乳腺癌第1癌与第2癌间隔14个月至196个月不等,中位间隔时间52个月.结论 同时性双侧原发性乳腺癌较异时性双侧乳腺癌发病年龄早,多见于绝经前.异时性双侧乳腺癌发生间隔时间不定,一侧发生乳腺癌后宜积极随访对侧乳腺,对雌激素受体阳性的患者应坚持内分泌治疗.     

Is surgical management compromised in elderly patients with breast cancer?

OBJECTIVE: The suggestion that breast cancer management is compromised in elderly patients had prompted our review of the results of policies regarding screening and early detection of breast cancer and the adequacy of primary treatment in older women (> or = 65 years of age) compared to younger women (40 to 64 years of age). SUMMARY BACKGROUND DATA: Although breast cancer in elderly patients is considered biologically less aggressive than similar staged cancer in younger counterparts, outcome still is a matter of stage and adequate treatment of primary cancer. For many reasons, physicians appear reluctant to treat elderly patients according to the same standards used for younger patients. There is even government-mandated alterations in early detection programs. Thus, since 1993, Medicare has mandated screening mammography on a biennial basis for women older than 65 year of age compared to the current accepted standard of yearly mammograms for women older than 50 years of age. Using State Health Department and tumor registry data, the authors reviewed screening practice and management of elderly patients with primary breast cancer to determine the effects of age on screening, detection policies (as reflected in stage at diagnosis), treatment strategies, and outcome. METHODS: Data were analyzed from 5962 patients with breast cancer recorded in the state-wide Tumor Registry of the Hospital Association of Rhoda Island between 1987 and 1995. The focus of the data collection was nine institutions with established tumor registries using AJCC classified tumor data. Additional data were provided by the State Health Department on screening mammography practice in 2536 women during the years 1987, 1989, and 1995. RESULTS: The frequency of mammographic screening for all averaged 40% in 1987, 52% in 1987, and 63% in 1995. In the 65-year-old and older patients, the frequency of screening was 34% in 1987, 45% in 1989, and 48% in 1995, whereas in the 40- to 49-year-old age group, the frequency of mammography was 47% in 1987, 61% in 1989, and 74% in 1995 (p < 0.001). There was a lower detection rate of preinvasive cancer in the 65-year-old and older patients, 8.8% versus 13.7% in patients within the 40- to 64-year-old age group (p < 0.001). There was a higher percentage of treatment by limited surgery among elderly patients with highly curable Stage IA and IB cancer with 26.6% having lumpectomy alone versus 9.4% in the younger patients. Five-year survival in that group was significantly worse (63%) than in patients treated by mastectomy (80%) or lumpectomy with axillary dissection and radiation (95%, < 0.001). A similar effect was seen in patients with Stage II cancer. CONCLUSIONS: Breast cancer management appears compromised in elderly patients (older than 65 years of age). Frequency of mammography screening is significantly less in elderly women older than 65 years of age. Early detection of preinvasive (curative cancers) is significantly less than in younger patients. The recent requirement by Medicare of mammography every other year may further reduce the opportunity to detect potentially curable cancers. Approximately 20% of patients had inferior treatment of favorable stage early primary cancer with worsened survival. Detection and treatment strategy changes are needed to remedy these deficiencies.     

Breast reduction as an alternative treatment option for early breast cancer in women with macromastia

Macromastia has been considered a relative contraindication to breast conservation therapy because of difficulties with postoperative radiation therapy and cosmesis. This study evaluates the feasibility of the inferior pedicle reduction mammaplasty as a component of breast conservation therapy for patients with early breast cancer. A retrospective review identified 6 patients with macromastia receiving oncologic treatment of breast cancer and simultaneous breast reduction. Mean age was 43.5 +/- 8.7 (mean +/- SD) years, and all breast cancers were stage I or II, averaging 2.3 +/- 1.5 cm in size. All patients underwent a Wise-pattern inferior pedicle breast reduction after cancer extirpation and received postoperative radiation as part of their treatment. They were evaluated for postoperative complications, esthetic outcome of the breasts, and local recurrence. Patients in this series were followed for an average of 30.3 months, with no significant postoperative complications and recurrences. Breast reduction incisions healed primarily and adjuvant radiation was completed without a delay. All patients were pleased with the esthetic result and had improvement of their symptoms related to macromastia. Thus, we believe that breast reduction is a reasonable and safe option for early breast cancer patients with macromastia who desire breast conservation therapy. Our combined oncologic and reconstructive approach may improve the outcome of this group of patients with early breast cancers.     

Presentation, Management and Outcome of 32 Patients with Pregnancy-Associated Breast Cancer: A Matched Controlled Study

Abstract:  Pregnancy-associated breast cancer (PABC) is a rare and challenging problem. We sought to describe epidemiology, management and outcome of women in whom breast cancer was diagnosed during pregnancy or within one year after delivery. Thirty-two women with PABC were referred to two European Union oncology centers between 1995 and 2007, 16 during pregnancy and 16 within 1 year after delivery. Data concerning diagnosis, management, delivery and fetal and maternal outcome were recorded. A group of 32 patients (matched controls) presenting with nonpregnancy-associated breast cancer (non-PABC) was matched for age at diagnosis, tumor size and stage to each PABC patient. Differences in outcome between the PABC and non-PABC groups were then assessed. Histological features were similar in both groups, except that estrogen receptor-negative tumors were more common in the PABC group. Three patients received chemotherapy and two others underwent surgery during pregnancy, with no excess toxicity or severe maternal/fetal adverse effects. All children in the PABC group were healthy, except for one exposed to epirubicin in utero and born with rectal atresia. Overall survival was similar in PABC and non-PABC patients (p = 0.449). The subgroup of patients with breast cancer diagnosed within one year after delivery showed a shorter time to relapse than controls or patients with gestational cancer (p = 0.0178). PABC is a special situation, necessitating individualized, multi-disciplinary management. Prognosis is similar for women with nongestational cancer matched for age and stage though poorer outcome postpartum should be further investigated.     

Breast cancer in the young patient

Patients under 40 years of age comprise about 5 per cent of the overall breast cancer population. These patients are often considered to have a more aggressive disease and are often treated differently as well. A review was performed of all breast cancer patients reported in the American College of Surgeons Cancer Database from 1998 to 2005. The study cohort included all patients less than 40 years of age. Data collected included stage at time of diagnosis, histologic type, and initial treatment performed. These data were then compared with those of patients age 40 or older. The 70,437 cohort patients identified comprised 5.0 per cent of all breast cancer patients reported. There was a statistically significant difference in stage at the time of presentation: 20 per cent of younger patients presented with advanced disease (stage III or IV) versus 13.5 per cent of older patients. A significantly greater percentage of younger patients also presented with infiltrating ductal carcinoma as opposed to the older population (76.9% vs 67.9%). A significantly greater percentage of young patients was treated with mastectomy when compared with the older population (47.7% vs 36.7%, respectively). This difference persisted even when data were controlled for stage. The younger breast cancer patient presents with more advanced disease, suggesting either a more aggressive disease or a greater delay in diagnosis. Also, at all stages, the young patient tends to be treated more "aggressively" surgically, suggesting that the prevailing concept that breast cancer is a "worse" disease in the young may be directing treatment options and patient choices.     

乳腺癌治疗后高骨质疏松患病率及相关因素分析

目的探索乳腺癌治疗后患者的骨质疏松患病率及相关影响因素。方法回顾性分析147例治疗后并已绝经的乳腺癌患者的临床资料,采用双能X线骨密度吸收仪进行骨密度检测(包括腰椎正位L1~4、股骨颈以及全髋的骨密度测定),分析乳腺癌受体不同表达(ER、PR、HER-2)、年龄、体质量指数(bone mass index,BMI)、绝经时间、术后时间、治疗方法对骨质疏松的影响。结果147例乳腺癌患者治疗后的骨质疏松患病率为40.8%;单因素分析显示年龄、BMI、绝经时间、治疗(内分泌治疗+化疗)、术后时间与骨密度减低呈显著相关(P<0.05),多因素Logistic回归分析显示影响治疗后乳腺癌患者骨密度的主要因素是年龄、BMI、术后时间(P<0.05)。结论乳腺癌治疗后患者具有较高的骨质疏松患病率,乳腺癌治疗的多种因素都能够降低骨密度。     

Breast Cancer Litigation: A Retrospective Analysis

Abstract: To understand reasons patients or relatives initiate litigation in breast cancer cases, 16 cases personally reviewed by the author as an expert witness and 224 cases obtained by literature search were analyzed. The major allegation (206/224) was related to diagnosis. These included failure to diagnose (183/206) and improper interpretation of mammograms or biopsies (23/206). In the 147 cases in which age was available, the median patient age of 42 was markedly younger than the expected median of 62. Primary care physicians or obstetricians/gynecologists were most likely to be defendants. Physical exam (31/51) and mammograms (83/112) were felt to be normal on initial physician contact by primary care physicians and Radiologists respectively. Failure to give follow-up visits after initial contact with the patient was noted in 30/45 cases. Poor chartkeeping was noted in 10/16 personally reviewed cases. An appearance of altered records was noted in 4 cases. Policies to decrease legal exposure to breast cancer litigation based on analysis of cases are presented.     

Mammography in hospital patients: use and misuse.

Of 1433 consecutive patients who underwent mammography, 90 were subsequently found to have histologically confirmed carcinoma of the breast (85 invasive carcinoma, three lobular carcinoma in situ, two intraduct carcinoma). Sixty (67%) of the mammograms of the patients with cancer were reported correctly as carcinoma. There were 27 (30%) false negative reports and three (3%) equivocal reports. In 14 (16%) patients with false negative reports the biopsy was delayed by between 2 and 24 months. The false reassurance of the mammogram report was responsible for the delay in diagnosis in nine and may have contributed in the remainder. The mammogram was most likely to be misleading when used as an investigation for a palpable lump in the breast. The mean age of patients with a false negative mammogram (44 years) was significantly less than that of patients with a true positive mammogram (57 years). In 23 of the 60 patients with positive mammograms management was changed as a result of the investigation. The mammogram was most helpful when no breast lump was palpable and there was either some other clinical evidence of local malignancy (ten patients, 11%) or metastatic disease (three patients, 3%), or the mammogram had been performed to screen a high-risk patient (three patients, 3%). The positive mammogram was also useful in two patients with residual or recurrent disease following local excision of a breast cancer. There were 15 patients with bilateral breast cancer (17%). Three (3%) were diagnosed within 2 months of the first tumour but mammography did not contribute to the diagnosis of any of these.     

Delay in Presentation,Diagnosis, and Treatment for Breast Cancer Patients in Jordan

Breast cancer is the most common cancer, and one of the leading causes of death for females in Jordan and many countries in the world. Studies have shown that delay in symptoms presentation, diagnosis or treatment would result in poor prognosis. There has been no published study from Jordan on delays in patient presentation, delays in diagnosis, or delays in treatment. Therefore, we conducted this study to assess these important quality indicators aiming to improve prognosis for breast cancer patients in Jordan. This project was a cross‐sectional study on female breast cancer patients in Jordan. The total number of participants was 327. The proportion of patients with presentation delay, diagnosis delay, and treatment delay was 32.2%, 49.1%, or 32.4%, respectively. The main reported reasons for delay in presentation were ignorance of the nature of the problem (65.6%), limited/lack of knowledge that symptoms were suggestive of cancer diagnosis (16.7%), and misdiagnosis (16.7%). Predictors of delay and mean time for presentation, diagnosis, and treatment were identified. Our results reveal that breast cancer patients in Jordan are experiencing delays in presentation, diagnosis, and treatment. This could justify the advanced stages at diagnosis and poor outcomes for breast cancer patients in Jordan. We recommend revising the current early detection and down‐staging programs in Jordan.     

Breast conservation therapy in affiliated county, university, and private hospitals

BACKGROUND: Breast conservation therapy (BCT) offers equivalent survival to modified radical mastectomy in patients with early-stage (I and IIa) breast cancer, but is utilized in less than 50% of eligible patients. While patient demographics have been linked to BCT rates, we suspected that physician influence was a major factor. The purpose of this study was to compare BCT at three affiliated centers staffed by similarly trained surgeons yet serving widely disparate populations, in order to assess the importance of physician influence on the utilization of BCT. METHODS: Tumor registry data were reviewed from 1993 through 1997 at affiliated city/county (CH), university (UH), and private hospitals (PH). Data were analyzed for clinical stage, treatment, and age of patient. RESULTS: The utilization of BCT for stage I and IIa breast cancer is similar at the three hospitals: 45% of patients at CH, 55% of patient at UH, and 57% of patients at PH (P>0.05). Rates of BCT were similar across all patient age groups at all sites. CONCLUSIONS: Similar BCT utilization rates can be achieved despite widely disparate patient populations. The three affiliated hospitals are staffed by surgeons with similar training, and all offer a multidisciplinary approach to breast cancer care. This suggests that physician influence may override patients' socioeconomic issues in providing optimal breast cancer therapy.     

Significance of Family History in Breast Cancer Treated with Breast Conservation Therapy

Abstract: The purpose of this study was to evaluate the impact of family history (FH) of breast cancer on the outcome of patients with local-regional breast cancer treated with breast conservation therapy. Of 974 patients treated with breast conservation therapy, a total of 794 consecutive cases were evaluable with adequate FH data and a greater-than-1-year follow-up. All patients had local-regional disease (stages O-IIIA) and underwent lumpectomy, axillary node dissection, and radiation therapy. Seventeen percent of patients had a positive family history of breast cancer, which was defined as a first degree relative (mother, sister, daughter). A significant difference was seen in overall survival in patients with and without an FH of breast cancer (p = 0.027). While FH did not correlate with differences in local failure, distant failure, disease specific survival, or overall survival in patients less than or equal to age 50, a positive FH correlated with a worse disease specific survival (p = 0.045) and a worse overall survival (p = 0.017) in patients over age 50. Multivariate (Cox) analysis confirmed the significance of FH (p = 0.008), tumor size (p = 0.001), and nodal status (p = 0.015). Comparing patients with and without an FH, no differences were seen in age at presentation, age of menarche, age of menopause, parity, tumor size, histologic and nuclear grade, nodal status, or estrogen receptor status. In patients with an FH of breast cancer, the most commonly affected relative was the mother (9.4%). While FH did not impact on outcome of patients age 50 or younger, it was prognostic for a poorer overall survival in older patients, and poorer disease-specific survival. Patients with an FH of breast cancer are similar to patients without a family history in tumor and patient characteristics. An FH of breast cancer does not correlate with an increased local or distant failure in our study population as a whole, but does correlate with a poorer overall survival when compared to patients without an FH of breast cancer.?     

Relationship between mammographic breast density and tamoxifen in women with breast cancer

Previous studies have reported that tamoxifen use is associated with a decrease in mammographic breast density. This is a potentially valuable finding since mammographic sensitivity is limited by breast density. Anything that reduces breast density would theoretically enhance the sensitivity of mammography for the detection of breast cancer in women at an earlier stage when it is more curable. We performed a retrospective study investigating the potential effect of tamoxifen on breast density. The data for this retrospective study were collected from the records of 52 charts from a single medical oncologist. Patients with breast cancer were selected regardless of stage or age at the time of diagnosis or treatment, as long as their charts had records of bilateral mammograms. For each breast on each woman, both mediolateral oblique and craniocaudal views were reviewed independently by two radiologists on two separate occasions to obtain inter- and intraobserver variability. Two methods of classifying breast density were used: the Breast Imaging Reporting and Data System (BI-RADS), and measurements of percent density. Only age and menopausal status were found to be associated with breast density. There was no correlation between breast density and tamoxifen use (past or present). Our study shows no association between tamoxifen use and breast density. We confirm previous observations that breast density is inversely correlated with age and postmenopausal status.     

Causes of late diagnosis in cases of colorectal cancer seen in a district general hospital over a 2-year period.

Our aim in this prospective study was to identify those patients who were found to have a colorectal cancer after a delay we considered unacceptable; this was taken as 6 months or more from initial presentation to a physician to diagnosis. It was then possible to determine the presenting complaints (always multiple) and the reasons for delay, in the hope that recommendations could be made regarding appropriate, rapid and thorough investigation of patients suspected of having a colorectal cancer. Of the total of 141 patients with colorectal cancer (108 elective, 33 emergency cases) under the care of one consultant during the period studied, 17 patients (12%) (10 men and 7 women), satisfied the criteria for late diagnosis. The mean age was 72.4 years (range 43-86 years). Five common presenting complaints were identified. They were, symptomatic iron deficiency anaemia, rectal bleeding, change in bowel habit, abdominal pain and weight loss. Incomplete imaging of the colon in patients with sinister presenting symptoms was the most commonly identified factor in delay of diagnosis. Inappropriate iron therapy and false-negative reporting of double contrast barium enema investigations were both seen in a number of cases. Other causes were, inappropriate surgical treatment and both clerical error and delay. The mean time for delay was 17.6 months (median 15 months). Late diagnosed cancers were most commonly found in the caecum and least commonly in the rectum. Colonic tumours of each Dukes' stage were identified, Dukes' B most common and Dukes' A least.     

Utility of Breast Magnetic Resonance Imaging in Patients With Occult Primary Breast Cancer

Background Although carcinoma presenting as axillary metastases is assumed to be due to breast cancer, identification of the primary lesion may prove problematic. We investigated the ability of breast magnetic resonance imaging (MRI) to identify the primary tumor, thereby confirming the diagnosis and broadening treatment options. Methods From 1995 to 2001, 69 patients at our institution presented with occult primary breast cancer. All patients had negative breast examinations and mammograms and underwent breast MRI. Results Of 69 patients, 55 had axillary adenopathy without evidence of distant disease (stage II); 14 had stage IV disease. In patients with stage II disease, MRI revealed suspicious lesions in 76% (42 of 55). In 62% (26 of 42), the MRI finding proved to be the occult primary tumor. Of these, 58% (15 of 26) were candidates for breast conservation. MRI did not identify the primary tumor in 25 women; 12 underwent mastectomy. Cancer was found in 33% (4 of 12) of these. Thirteen patients were treated with primary breast irradiation; three were lost to follow-up, one developed distant disease, and nine were without evidence of disease with a median follow-up of 4.5 years. In women with stage IV disease, MRI identified the primary tumor in 5 of 9 patients with regional adenopathy and 2 of 5 patients with distant disease (overall 50%; 7 of 14). MRI identified the primary tumor in women with both mammographically dense (19 of 44; 43%) and less dense (10 of 20; 50%) breasts. Conclusions Breast MRI detects mammographically occult cancer in half of women with axillary metastases, regardless of breast density. MRI is a powerful tool for stage II and stage IV patients with occult primary breast cancer. Claire L. Buchanan, MD, is now at Swedish Cancer Institute, 500 17th Avenue, Seattle, WA 98108     

Inflammatory Breast Carcinoma: A Community Hospital Experience

Background: Inflammatory breast cancer (IBC) is a rare form of rapidly progressive breast cancer. We reviewed the diagnosis, treatment, and outcome of IBC in our inner city community-based hospital and compared results with previous published reports.

Study Design: Twenty-five patients were diagnosed and treated for IBC at the Catholic Medical Center of Brooklyn and Queens during the 6-year period of January 1989 through December 1995. Criteria for inclusion in this study were clinical or histopathologic evidence, or both, of inflammatory carcinoma.

Results: IBC comprised 2.0% (25 of 1,257) of all breast cancer patients initially diagnosed during this study. All presented with clinical signs of IBC. Invasion of dermal lymphatics by neoplastic cells was demonstrated in 68% (17 of 25) of biopsy specimens. Sixty-eight percent (17 of 25) of patients presented with metastatic (ie, stage IV) disease and 28% (7 of 25) with stage IIIb; one patient (4%) died before staging. Estrogen and progesterone receptor studies were done on 72% (18 of 25) of all specimens. Of those patients who died, 85% were estrogen and progesterone receptor negative; of those surviving, 60% were estrogen receptor positive. Twenty (80%) of the 25 patients died, after a mean survival of 11.8 months and 5 (20%) remain alive, with a mean survival of 44.8 months. Of those who died, 85% were stage IV at presentation. All five survivors were stage IIIb at presentation. Patients underwent a variety of multimodal therapies. Survival was significantly associated with earlier stage at diagnosis and estrogen receptor positivity.

Conclusions: IBC is characterized by rapid progression and dismal outcome. Earlier stage at diagnosis and positive estrogen receptor status suggest a more favorable prognosis. Neoadjuvant chemotherapy, as part of a multimodal approach, has significantly improved the outcome for IBC, but this is limited to patients with stage IIIb disease. Most of our patients presented with stage IV disease. If improvement is to be realized at the community level, limited health care resources must be directed toward aggressive physician and public education.