Ductal Carcinoma-In-Situ: Long-Term Results of Breast-Conserving Therapy

Background: The role of breast-conserving therapy (BCT) in the management of ductal carcinoma-in-situ (DCIS) is controversial because of reported high recurrence rates. We reviewed our experience to determine whether the rate and pattern of locoregional recurrence after BCT were similar in patients with DCIS and patients with early-stage (T1) invasive breast tumors and whether local recurrence affected survival.Methods: Between 1973 and 1994, 87 patients with DCIS alone, 22 patients with DCIS with microinvasion (DCIS-M), and 646 patients with invasive breast cancer 2 cm or smaller in diameter were treated with BCT (wide local excision with radiotherapy) at The University of Texas M. D. Anderson Cancer Center. Survival was calculated by the Kaplan-Meier method. The median follow-up times were 11 years for patients with DCIS alone, 12 years for patients with DCIS-M, and 8 years for patients with invasive breast cancer.Results: Eleven (13%) of 87 patients with DCIS and 5 (23%) of 22 patients with DCIS-M had developed locoregional recurrences at follow-up. Two patients with DCIS with locoregional recurrence died of breast cancer. Of the 646 patients with invasive breast cancer, 56 (9%) had a locoregional recurrence, and 16 (2%) died of breast cancer. The median time to locoregional recurrence was significantly longer in patients with DCIS or DCIS-M (9–10 years) than patients with invasive tumors (5 years).Conclusions: DCIS is a favorable disease with an excellent long-term survival. The locoregional recurrence rate in patients with DCIS treated with BCT is similar to that in patients with early-stage invasive breast cancer treated with BCT, but time to locoregional recurrence is significantly longer in patients with DCIS. In patients with DCIS treated with BCT, intense surveillance for locoregional recurrence needs to be maintained for the patients lifetime.Presented at the 53rd Annual Meeting of the Society of Surgical Oncology, New Orleans, Louisiana, March 16–19, 2000.     

Avoidance of Adjuvant Radiotherapy in Selected Patients With Invasive Breast Cancer

Background: Current standard therapy for invasive breast carcinoma is mastectomy or breast conservation with adjuvant radiation. Data from randomized trials suggest no advantage for radiotherapy after lumpectomy in highly selected patients. Selective radiotherapy would make contemporary breast cancer therapy more rational with decreased morbidity and expense.Methods: A total of 163 patients were treated by breast conservation without adjuvant radiation between 1978 and June 2003. They declined radiation after discussion or had medical contraindications. The great majority were postmenopausal and had lower-grade T1 tumors with resection margins 1 cm and no nodal metastases. The goal was to identify patients with favorable prognostic features for omission of postsurgical irradiation without impaired local recurrence or survival.Results: Twenty patients (12%) had local recurrences; 17 (10%) were invasive, and 3 (2%) were ductal carcinoma-in-situ. An ideal patient subgroup >50 years of age with grade 1 or 2 cancers 1.5 cm in diameter and with surgical margins 1 cm was empirically defined. Of 80 such patients, 5 (6%) had local recurrence; 3 (3.5%) were invasive, and 2 (2.5%) were ductal carcinoma-in-situ.Conclusions: A defined ideal subset of older breast cancer patients with smaller, lower-grade cancers and adequate excision margins can be treated with lumpectomy without irradiation and with minimal local recurrence.     

Retroperitoneoscopy-assisted cryoablation of renal tumors using multiple 1.5 mm ultrathin cryoprobes: a preliminary report

OBJECTIVES: Laparoscopic cryoablation has recently been proposed as a minimally invasive nephron-sparing treatment for selected patients. We report on our experience with a retroperitoneoscopic technique using multiple ultrathin cryoprobes. METHODS: Seven patients underwent retroperitoneoscopic renal cryoablation for solid renal masses. Mean tumor size on the CT scan was 2.6 (1.5-3.5) cm. A double freeze-thaw cycle of renal cryoablation was performed under real-time ultrasound monitoring using a total of six 1.5-mm cryoprobes simultaneously. RESULTS: Cryoablation was technically successful in all patients without any need for conversion. Mean duration of surgery was 161 (130-195) minutes and mean blood loss was 107 (50-250) ml. Perioperative biopsy of the tumor confirmed renal cell carcinoma in four patients and angiomyolipoma in two patients; it was inconclusive in one case. Mean follow-up for 13.6 (4-22) months showed no evidence of residual tumor or recurrence. CONCLUSIONS: Retroperitoneoscopy-assisted cryosurgical ablation using multiple ultrathin 1.5-mm cryoprobes is a minimally invasive treatment that is suitable to treat small renal tumors.     

Breast cancer tumor size: correlation between magnetic resonance imaging and pathology measurements

Background

As physicians increasingly use magnetic resonance imaging (MRI) for the evaluation of newly diagnosed breast cancers, a review of the correlation between MRI and pathology tumor size is imperative.

Methods

A retrospective review of 91 breast tumors comparing preoperative MRI tumor size to final pathology tumor size was performed.

Results

MRI and pathology tumor size were positively correlated (R = .650), but with an average overestimation by MRI of .63 cm (P <.0001). When stratified by MRI tumor size (≤2.0 cm and >2.0 cm), a significant difference was found only in tumors greater than 2.0 cm (average overestimation = 1.06 cm; P <.0001). This trend continued for the histological subtypes of ductal carcinoma in situ (DCIS), invasive ductal carcinoma (IDC), and invasive lobular carcinoma (ILC).

Conclusions

MRI tumor size correlates with pathology size; however, a significant overestimation exists, particularly for tumors >2.0 cm. Clinicians should therefore use caution in relying on MRI tumor size in determining candidacy for breast conservation therapy (BCT).     

Indication for sentinel lymph node biopsy for breast cancer when core biopsy shows ductal carcinoma in situ

Background

The use of sentinel lymph node biopsy (SLNB) for ductal carcinoma in situ (DCIS) is controversial.

Methods

A total of 103 primary breast cancer patients who were diagnosed with DCIS by needle biopsy preoperatively and underwent initial SLNB were analyzed retrospectively.

Results

No sentinel nodal metastasis was detected in 66 patients with the final diagnosis of DCIS. However, 2 (5.4%) of 37 patients with invasive ductal carcinoma at final diagnosis had positive sentinel nodes. Multivariate logistic regression analysis identified 2 independent significant predictors of existence of invasive components: presence of a palpable tumor (odds ratio, 4.091; 95% confidential interval, 1.399–11.959; P = .010) and tumor size of 2.0 cm or larger on magnetic resonance imaging (odds ratio, 4.506; 95% confidence interval, 1.322–15.358; P = .016).

Conclusions

Initial SLNB should be considered for patients diagnosed with DCIS by needle biopsy when they have a high risk for harboring invasive ductal cancer preoperatively.     

Concepts, Rationale, and Current Outcomes of Less Invasive Surgical Strategies for Early Gastric Cancer: Data from a quarter-century of experience in a single institution

Previously proposed criteria of less invasive surgery for early gastric cancer (EGC) were based mainly on the pathological analyses of the resected specimens; however, preoperative and intraoperative information are also obviously essential for decision making on stage-dependent patient management. Furthermore, most indications and treatment options have not been systematically integrated or evaluated by treatment outcomes. We investigate in this report the rationality of less invasive surgery employed for EGC. Distribution analyses of positive nodes were investigated among 684 patients with primary solitary EGC (379 mucosal and 305 submucosal) who underwent curative resection between 1976 and 2000. Clinicopathological factors highlighted and analyzed included clinical (preoperative and intraoperative) and pathological (postoperative) cancer depth and nodal involvement, gross form, histological type, and maximum cancer diameter, as well as postoperative morbidity and mortality. The scope of lymphadenectomy can be reduced to a modified D1 for clinically mucosal, node-negative, nonpalpable gastric cancer, or for clinically submucosal, node-negative gastric cancer 1.5 cm for intestinal type, or 1.0 cm for diffuse type. Otherwise, a modified D2 lymphadenectomy is sufficient. Local resection can be recommended for clinically mucosal, node-negative gastric cancer without apparent ulceration 4 cm if adjacent lymph nodes are proved cancer negative by a frozen section examination. If the gastric cancer has spread beyond the above criteria, a pylorus-preserving gastrectomy (PPG) can be recommended for tumors located in the middle or lower third of the stomach, provided the distal margin of the cancer is at least 4.5 cm from the pyloric ring. The PPG can be accompanied by a modified D1 or a modified D2 lymphadenectomy according to the respective dissection criteria. Results of these less invasive strategies showed reduced morbidity and mortality, as well as no recurrence or cancer-related deaths. These results suggest that each of our criteria for less invasive surgery for EGC is realistic, well stratified, and satisfactory.     

Six-Year Follow-Up of Patients With Microinvasive, T1a, and T1b Breast Carcinoma

Background: Management of patients with breast cancers 1 cm remains controversial. Reports of infrequent nodal metastases in tumors 5 mm has led to suggestions that axillary dissection should be selective, and that tumor characteristics should guide adjuvant therapy.Methods: A retrospective review of 290 patients with breast cancer 1 cm in size or smaller from 1989 to 1991 was done. Distant disease-free survival (DDFS) was the primary outcome measure.Results: There were 95 T1a (5 mm) and 196 T1b (6–10 mm) cancers. Nodal metastases were found in 8 T1a and 26 T1b tumors. Larger size, poorer differentiation, and lymphovascular invasion (LVI) were associated with more nodal metastases, but none of these trends reached statistical significance. The 6-year DDFS was 93% for node-negative and 87% for node-positive patients (P = .02). Overall, breast cancers with poorer differentiation and LVI trended toward a poorer outcome. For patients with node-negative tumors, LVI was associated with a poorer outcome (P = .03). The size of the primary tumor was not predictive of outcome. There were no nodal metastases or recurrences in the 18 patients with microinvasive breast cancer.Conclusions: Lymph node status is the major determinant of outcome in breast cancers 1 cm in size or smaller. Accurate axillary assessment remains crucial in management of small breast cancer.Presented at the 51st Annual Cancer Symposium of the Society of Surgical Oncology, San Diego, California, March 1998.     

An Overview of the History and Epidemiology of Ductal Carcinoma In Situ of the Breast

Abstract: Since the first pathologic studies of breast cancer were undertaken in the nineteenth century, an intraepithelial stage has been recognized in the transition from normal tissue to invasive cancer. In 1932 this was labeled in situ breast carcinoma, but was rarely diagnosed and considered only a clinical oddity. With the establishment of screening mammography over the past 20 years, both the ductal and lobular types of in situ breast carcinoma have been increasingly diagnosed. The lobular variant, lobular carcinoma in situ (LCIS), is now considered a marker of risk for subsequent invasive cancer, and is managed expectantly without surgical ablation. The ductal form, ductal carcinoma in situ (DCIS), is considered a true premalignant lesion, which should be treated largely in the same way as invasive breast carcinoma. An understanding of the epidemiology and biologic implications of DCIS is necessary for a rational approach to treatment.     

Clinicopathologic analysis of a large series of microinvasive breast cancers

Clinical management of microinvasive breast cancer (Tmic) remains controversial. Although metastases are infrequent in Tmic carcinoma patients, surgical treatment typically includes lymph node sampling. The objective of this study was to determine the rate and predictors of lymph node metastases, recurrence, and survival in a large series of Tmic breast carcinomas. Consecutive cases of Tmic were identified within our health care system from 2001 to 2015. We reviewed results of lymph node sampling and other pathologic factors including hormone receptor/HER2 status, associated in situ tumor size/grade, margin status, number of invasive foci, surgical/adjuvant therapies, and recurrence/survival outcomes. In this cohort, 294 Tmic cases were identified with mean follow‐up of 4.6 years. Of 260 patients who underwent axillary staging, lymph node metastases were identified in 1.5% (all of which were ductal type). All Tmic cases with positive lymph node metastases had associated DCIS with size > 5 cm (5.3‐8.5 cm) compared to a median DCIS tumor size of 2.5 cm (0.2‐19.0 cm) for the entire cohort. No lymph node metastases were seen with microinvasive lobular carcinoma. During the follow‐up period, there were no regional/distant recurrences or breast cancer‐associated deaths in a mean follow‐up period of 4.6 years. Two patients developed subsequent ipsilateral breast cancer (DCIS) in a different quadrant than the original Tmic. Clinical behavior of microinvasive breast cancer in this series is similar to DCIS. Lymph node metastases are uncommon and were only seen with ductal type microinvasive carcinoma. Our data suggest limited benefit for routine node sampling and support management of Tmic similar to DCIS, particularly for patients with DCIS < 5 cm in size.     

Plasminogen Activator System Localization in 60 Cases of Ductal Carcinoma In Situ

Background The lack of prognostic factors in ductal carcinoma in situ (DCIS) that reliably identifies biologically aggressive tumors adversely affects optimal management. The urokinase-type plasminogen activator (uPA) system, comprised of its receptor, uPAR, and its inhibitor (PAI-1), are critical elements for tumor invasion and their expression in invasive breast cancer can predict clinical outcome. Expression of the uPA system in DCIS may be relevant in defining histological subsets of DCIS with invasive potential. Methods Localization of uPA, uPAR, and PAI-1 was investigated immunohistochemically in 60 DCIS tumors. FISH experiments were performed to determine whether uPA was present in cancer cells themselves or derived from stromal elements. Results uPA was ubiquitously expressed in the malignant ductal epithelium of 95% (57/60) of DCIS tumors studied. uPA-mRNA was detected in the malignant ductal epithelium but not the adjacent normal ductal epithelium and stromal elements. uPAR was expressed in 27% (6/22) of high-grade and 24% (9/38) of non-high-grade DCIS. In comparing coexpression, uPA and uPAR were coexpressed in only 25% (15/60) of tumors. PAI-1 was infrequently expressed in high grade (3/22) and absent in non-high-grade DCIS. Conclusions This study identifies the presence of uPA, uPAR, and PAI-1 in both high-grade and non-high-grade DCIS. It may be speculated that coexpression of uPA and its receptor may identify subsets of DCIS with an increased risk for progression to invasive disease. If so, then expression of uPA system components may have prognostic and therapeutic significance in DCIS.     

A Phase II Trial of Image-Guided Radiofrequency Ablation of Small Invasive Breast Carcinomas: Use of Saline-Cooled Tip Electrode

Background Local ablative therapy of breast cancer represents the next frontier in the evolution of minimally-invasive breast conservation therapy. We performed this Phase II trial to determine the efficacy and safety of Radiofrequency (RF) ablation of small invasive breast carcinomas. Methods Seventeen patients with biopsy-proven invasive breast cancer, ≤ 1.5 cm in diameter were enrolled in this trial. Under ultrasound guidance, the tumor and a 5 mm margin of surrounding breast tissue were ablated with saline-cooled RF electrode followed by surgical resection. Pathologic and immunohistochemical stains were performed to assess tumor viability. We examined whether loss of ER, PR receptor and pancytokeratin expression following RF ablation would correlate with non-viability. Results Fifteen patients completed the treatment. The mean tumor size was 1.28 cm. The mean ablation time was 21 minutes using a mean power of 35.5 watts. During ablation, the tumors became progressively echogenic that corresponded with the region of severe electrocautery injury at pathological examination. Of the 15 treated patients, NADPH viability staining was available for 14 patients and in 13 (92.8%), there was no evidence of viable malignant cells. ER, PR expression and pancytokeratin immunohistochemistry analysis were unreliable surrogates for determining non-viability. Following RF ablation, 2 patients developed skin puckering. Conclusions RF ablation is a promising minimally invasive treatment of small breast carcinomas, as it can achieve effective cell killing with a low complication rate. Further research is necessary to optimize this image-guided technique and evaluate its future role as the sole local therapy.     

Distribution of hsp-27 and HER-2/neu in in situ and invasive ductal breast carcinomas

Background: The overexpression of heat shock protein 27 (hsp-27) in early-stage breast cancer is associated with histopathologic features of poor prognosis and clinically with an increased probability of disease recurrence. Hsp-27 is overexpressed in 25% of invasive ductal carcinomas (IDC); however, its distribution in ductal carcinoma in situ (DCIS) and DCIS associated with IDC has not been investigated. We postulated that hsp-27 might be detected and variably expressed in DCIS and, like HER-2/neu oncoprotein expression, might be a tumor-specific marker worthy of future clinical investigation. Methods: To test these hypotheses, the distribution of hsp-27 in noncomedo and comedo DCIS, and DCIS associated with IDC, was evaluated by immunohistochemistry and compared with HER-2/neu expression within the same cancers. Results: Hsp-27 was overexpressed in 28 of 47 (60%) cases of DCIS; expression in pure DCIS was 16 of 24 (67%), and 12 of 23 (50%) in DCIS associated with IDC. Hsp-27 expression by in situ and invasive components of the same neoplasm were concordant in 22 of 23 (95%) cases tested. Comedo variants appeared to have somewhat higher hsp-27 expression than noncomedo DCIS, whether or not there was an associated IDC. These results are reminiscent of HER-2/neu oncoprotein expression in DCIS and DCIS associated with IDC observed by others. However, although 4 of 22 (18%) cancers containing DCIS + IDC expressed HER-2/neu, no relationship with hsp-27 expression in the same cancers was observed. Conclusions: We found a high incidence of hsp-27 overexpression in DCIS and in DCIS associated with IDC. This rate is twice that previously observed in IDC alone. Hsp-27 expression is independent of HER-2/neu expression.     

Factors Associated with Preoperative Magnetic Resonance Imaging Use among Medicare Beneficiaries with Nonmetastatic Breast Cancer

Preoperative breast magnetic resonance imaging (MRI) use among Medicare beneficiaries with breast cancer has substantially increased from 2005 to 2009. We sought to identify factors associated with preoperative breast MRI use among women diagnosed with ductal carcinoma in situ (DCIS) or stage I–III invasive breast cancer (IBC). Using Surveillance, Epidemiology, and End Results and Medicare data from 2005 to 2009 we identified women ages 66 and older with DCIS or stage I–III IBC who underwent breast‐conserving surgery or mastectomy. We compared preoperative breast MRI use by patient, tumor and hospital characteristics stratified by DCIS and IBC using multivariable logistic regression. From 2005 to 2009, preoperative breast MRI use increased from 5.9% to 22.4% of women diagnosed with DCIS and 7.0% to 24.3% of women diagnosed with IBC. Preoperative breast MRI use was more common among women who were younger, married, lived in higher median income zip codes and had no comorbidities. Among women with IBC, those with lobular disease, smaller tumors (<1 cm) and those with estrogen receptor negative tumors were more likely to receive preoperative breast MRI. Women with DCIS were more likely to receive preoperative MRI if tumors were larger (>2 cm). The likelihood of receiving preoperative breast MRI is similar for women diagnosed with DCIS and IBC. Use of MRI is more common in women with IBC for tumors that are lobular and smaller while for DCIS MRI is used for evaluation of larger lesions.     

Adequacy of 1-cm Distal Margin After Restorative Rectal Cancer Resection With Sharp Mesorectal Excision and Preoperative Combined-Modality Therapy

Background: Preoperative combined-modality therapy (CMT) for rectal cancer allows a sphincter-sparing procedure in some individuals who would otherwise require an abdominoperineal resection. To further define the subset of rectal cancer patients suitable for this approach, we determined the adequacy of a distal margin of 1 cm in patients with locally advanced rectal cancer requiring preoperative CMT.Methods: Ninety-four consecutive patients, status post curative low anterior resection for rectal cancer after preoperative CMT, were identified from the prospective Colorectal Service Database. Distal margin length, tumor grade, tumor-node-metastasis stage, presence of lymphovascular and perineural invasion, and tumor distance from the anal verge were examined for their effect on recurrence and survival. Median follow-up was 44 months.Results: Distal margin length ranged from .1 to 9.5 cm (median, 2.0 cm) and did not correlate with local recurrence (hazard ratio, 1.1; P = .34) or recurrence-free survival (hazard ratio, 1.1; P = .29) by univariate analysis. Kaplan-Meier estimates of recurrence-free survival and local recurrence at 3 years for the 1 cm versus >1 cm and the 2 cm versus >2 cm groups were not significantly different. Groups were well matched for other clinicopathologic variables.Conclusions: Our data suggest that for patients with locally advanced rectal cancer undergoing resection and preoperative CMT, distal margins 1 cm do not seem to compromise oncological outcome.     

Office-based ultrasound-guided cryoablation of breast fibroadenomas

BACKGROUND: Fibroadenomas commonly found by palpation and routine mammography account for approximately 20% of open surgical breast biopsies. Alternatives to open surgery include tumor removal using an automated coring device and tumor ablation using heating or cooling elements. We report our initial experience with cryoablation of biopsy-proven benign fibroadenomas. METHODS: A table-top cryoablation system employing a 2.4-mm cryoprobe was used to treat biopsy-proven benign fibroadenomas up to 4 cm in maximum diameter in a prospective nonrandomized fashion. The cryoprobe was placed under ultrasound guidance. Using a treatment algorithm based on fibroadenoma size, all tumors were subjected to two freeze cycles with an interposing thaw. Skin appearance and temperature, probe temperature, iceball size, and patient comfort were closely monitored during the procedure. Follow-up examinations including ultrasonography and photographs were scheduled for up to 12 months postablation. RESULTS: Fifty patients with 57 core biopsy-proven benign fibroadenomas were treated. Seven early cases were treated in an ambulatory surgery center setting. The remaining procedures were completely office-based using only local anesthetic. Tumor diameter varied from 7 mm to 42 mm (mean 21 mm). The iceball engulfed the target lesion in each case. Transient postoperative side effects were local swelling and ecchymosis. Postoperative discomfort rarely required medication beyond acetaminophen or ibuprofen. Lesions showed progressive shrinkage and disappearance over 3 to 12 months. No skin injury was noted and appearance remained excellent. Patient satisfaction was excellent. CONCLUSIONS: With office-based use of ultrasound-guided cryoablation for fibroadenomas there was little or no pain, target lesions were reduced in size or eliminated, scarring was minimal, cosmesis outstanding, and patient satisfaction was excellent. Cryoablation offers a useful office-based alternative to surgical excision of benign fibroadenomas.     

美国临床肿瘤学会《早期乳腺癌病人前哨淋巴结活检指南》更新介绍与解读

2014年4月,临床肿瘤学杂志（Journal of Clinical Oncology,JCO）上发表了美国临床肿瘤学会（American Society of Clinical Oncology,ASCO）关于早期乳腺癌病人应用前哨淋巴结活检（sentinel node biopsy,SNB）的若干新推荐。这是继2005年该学会首次推荐《早期乳腺癌病人前哨淋巴结活检指南》后的第一次更新。基于随机临床试验（RCT）证据,该项指南提出3条推荐：（1）无前哨淋巴结（sentinel lymph node,SLN）转移的女性病人不必接受腋窝淋巴结清扫术（axillary lymph node dissection, ALND）;（2）大多数伴有1~2个SLN转移,且计划接受保乳术及术后全乳放疗者无需行ALND;（3）有SLN转移并行全乳切除术者应接受ALND。基于队列研究和（或）非正式共识,更新两组推荐：（1）可手术的多中心肿瘤的乳腺癌病人、将行乳房切除术的导管原位癌（ductal carcinoma in situ,DCIS）病人、之前接受过乳腺和（或）腋窝手术的以及接受术前或新辅助系统治疗的病人,可以行SNB;（2）对瘤体较大或局部晚期浸润性乳腺癌（肿瘤大小T3/T4）、炎性乳腺癌、拟接受保乳治疗的DCIS以及孕期妇女,不适于行SNB。     

Office-based cryoablation of breast fibroadenomas with long-term follow-up

Approximately 10% of women will experience a breast fibroadenoma in their lifetime. Cryoablation is a new treatment that combines the better attributes of the current standards: surveillance and surgery. It is a minimally invasive office-based procedure that is administered without the use of general anesthesia, involving minimal patient discomfort and little to no scarring. This work aimed to establish the long-term (2-3 years) efficacy, safety, and satisfaction of the procedure, as well as the impact of cryoablation on mammogram and ultrasound images. Thirty-seven treated fibroadenomas were available for assessment with an average follow-up period of 2.6 years. Of the original 84% that were palpable prior to treatment, only 16% remained palpable to the patient as of this writing. Of those fibroadenomas that were initially < or = 2.0 cm in size, only 6% remained palpable. A median volume reduction of 99% was observed with ultrasound. Ninety-seven percent of patients and 100% of physicians were satisfied with the long-term treatment results. Mammograms and ultrasounds showed cryoablation produced no artifact that would adversely affect interpretation. Cryoablation for breast fibroadenomas has previously been reported as safe and effective both acutely and at the 1-year follow-up mark, and thus has been implemented as a treatment option. At long-term follow-up, cryoablation as a primary therapy for breast fibroadenomas demonstrates progressive resolution of the treated area, durable safety, and excellent patient and physician satisfaction. The treatment is performed in an office setting rather than an operating room, resulting in a cost-effective and patient-friendly procedure. Cryoablation should be considered a preferred option for those patients desiring definitive therapy for their fibroadenomas without surgical intervention.     

The Florid Subtype of Lobular Carcinoma In Situ: Marker or Precursor for Invasive Lobular Carcinoma?

Background

Lobular carcinoma in situ (LCIS) is considered a risk factor—not a precursor—for both invasive lobular and ductal carcinoma. Florid LCIS (F-LCIS) is an architectural subtype of LCIS that does not express E-cadherin, yet has the histologic and often radiographic appearance of solid-type ductal carcinoma in situ (DCIS). Since DCIS is considered a precursor to invasive ductal carcinoma, should F-LCIS be considered a precursor to invasive lobular carcinoma (ILC)?

Methods

Review of an institutional database identified cases of LCIS and solid-type DCIS diagnosed by excisional biopsy, segmentectomy, or mastectomy between 1991 and 2000 to determine the prevalence of associated invasive breast cancer. Archival specimens were evaluated for florid and nonflorid LCIS, nuclear grade of LCIS, and the presence and subtype of invasive breast cancer. Solid-type DCIS that lacked E-cadherin expression was classified as F-LCIS.

Results

Of 210 consecutive specimens of LCIS examined, 171 had nonflorid LCIS (81%) and 39 had F-LCIS (19%). Nonflorid LCIS had a diffuse pattern, whereas F-LCIS appeared as discrete foci adjacent to ILC. An invasive component was identified with 87% of F-LCIS lesions versus 73% of nonflorid LCIS lesions (P = 0.064); this component was lobular in 100% of F-LCIS lesions versus 82% of nonflorid LCIS lesions, a significant difference (P = 0.0044) that persisted when the analysis was adjusted for nuclear grade (P = 0.0082).

Conclusion

Its close spatial relationship to an invasive component and increased association with ILC suggest that F-LCIS may be a precursor for ILC.

     

�����ٴ�����ѧ�ᡶ�������ٰ�����ǰ���ܰͽ���ָ�ϡ����½�������

??Express and interpretation on American society of clinical oncology guideline update for Sentinel lymph node biopsy in early-stage breast cancer WU Ke-jin.
Department of General Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
Abstract 2014 April, American Society of Clinical Oncology (ASCO) issued new clinical practice guideline on sentinel lymph node biopsy for patients with early-stage breast cancer in Journal of Clinical Oncology (JCO). This guideline update reflects some changes since the 2005 guideline. Based on randomized clinical trials (RCTs), there are three recommendations: (1) Women without sentinel lymph node (SLN) metastases should not accept axillary lymph node dissection (ALND). (2) In most cases, Women with 1-2 metastatic SLNs going to undergo breast-conserving surgery (BCS) with whole-breast radiotherapy should not adopt ALND. (3) Women with SLN metastases planning to receive mastectomy should be provided ALND. Based on cohort studies and/or informal consensus, there are two prime recommendations. (1) Sentinel node biopsy (SNB) may be offered to those women with operable breast cancer and multicentric tumors, with ductal carcinoma in situ (DCIS) planning to undergo mastectomy, who previously got breast and/or axillary surgery or who accepted preoperative/neoadjuvant systemic therapy. (2) SNB should not be offered to those women with large or locally advanced invasive breast cancer (tumor size T3/T4), inflammatory breast cancer, or DCIS will undergo BCS, or are pregnant.