Gaetano Cardona

Non-palpable lesions of the breast detected by mammography — Review of 1182 consecutive histologically confirmed cases

We report on 1182 consecutive histologically confirmed non-palpable breast lesions detected by mammography (infiltrating carcinoma 427, in situ carcinoma 121, benign 634). The proportion of cancer cases varied according to age (< 50 years = 33%; 50-59 years = 46%; > 59 years = 63%), mammographic pattern (regular opacities = 8%, parenchymal distortions = 20%, isolated calcifications = 42%, irregular opacities = 62%, stellate opacities = 73%), and calendar period (1970-1985 = 29%, 1986-1989 = 56%; 1990-1992 = 69%). A sharp decrease of the benign/malignant biopsy ratio was evident after routine fine-needle aspiration cytology (sonography-guided or stereotaxic) was introduced in 1986. The independent significant association of cancer frequency to age, calendar period and mammographic pattern was confirmed by multivariate analysis. A significant trend over time in favour of conservative surgery was also observed for cancer cases (1970-1979 = 6%, 1980-1985 = 41%, 1986-1992 = 83%). Among invasive cancers, node involvement was observed in 11.5% of cases, being associated with tumour size (pT1a = 0%, pT1b = 7%, pT1c = 13%, pT2a = 33%). Five-, ten- and fifteen-year overall survivals of invasive cancers were 98.1, 95.7 and 87.3%, respectively.

LONG-TERM SEQUELAE OF BREAST CANCER SURGERY

Background Quality of care is today a major issue in oncology, and much attention is given to research on the outcome of breast cancer care. Too little attention has been devoted in the scientific literature to the consequences of treatment in long-term survivors, and in particular to the possible side effects. The specific aim of this contribution is to present population-based data about the long-term impact of breast cancer care in women who had an incident cancer in 1985/1986. Patients and Methods The cases are 476 breast cancers incident in the City of Florence in 1985-86. Women still living 5 years later were invited to have an interview and a physical examination. Lymphedema, peripheral nerve lesions and damage to the shoulder were assessed. Results Of the 346 5-year survivors, 238 accepted our invitation: 35.2% of the women reported some early postoperative sequelae, 30.2% had a chronic lymphedema and 18.9% a shoulder deficit. Comparing breast-conserving surgery with radical mastectomy, the risk of chronic lymphedema (OR=1.62; 95% CI: 0.91-2.88) and other lesions was higher for women who had a radical surgery. Women who had a breast-conserving surgery more often reported an early lymphedema (OR=1.60; 95% CI: 0.88-2.88). Conclusions The proportion of women who complained of (or manifested at the physical examination) a minor or major disability of the arm in our study was high. The impact of these functional problems in terms of quality of life should also be assessed, but it is our impression that there is need for much greater attention to the issue of long-term survivor sequelae.

Intraductal breast carcinoma :review of a multicenter series of 350 cases

A multicentrer series of 350 intraductal breast cancers (DCIS) is reported. Mammography was the most sensitive test but suspicion arose only at palpation in 13% of cases whereas in 10% of cases bio...A multicentrer series of 350 intraductal breast cancers (DCIS) is reported. Mammography was the most sensitive test but suspicion arose only at palpation in 13% of cases whereas in 10% of cases biopsy was recommended for a benign lesion and DCIS was an unexpected finding. Mammography, physical examination and cytology must be combined to achieve optimal sensitivity. Systematic biopsy of apparently benign masses would increase DCIS detection rates but the cost-effectiveness of such a policy is questionable. A trend of conservative surgery was evident over time (from 1968-79, 28%; 1985-1989, 50%) but breast irradiation followed only in one fourth of the cases. The local recurrence rate was significantly higher in cases of limited surgery (with or without irradiation) with respect to mastectomy (1.2 vs 0.2 × 100 patient-years at risk). Most recurrences (7 of 8) in the conserved breast were infiltrating, but no recurrence was seen in subclinical DCIS cases. Three patients died of breast cancer after local recurrence in the conserved breast (2 cases) or mastectomy scar (1 case). Eligibility for conservative surgery of DCIS needs to be carefully discussed to avoid under-treatment. Contralateral breast cancer was recorded in 44 cases and the incidence of further metachronous cancer to the other breast was ten times higher than expected in normal breasts. Four patients died of contralateral breast cancer, free of ipsilateral recurrence. A careful follow-up of the contralateral breast in DCIS cases looks as important as surveillance of the conserved breast.

Does family history influence survival in breast cancer cases

A few studies have suggested a relatively better prognosis for breast cancer (BC) cases reporting a positive family history (FH). We aimed at comparing the survival of patients according to FH in a large hospital‐based series of 1,278 BC cases. Information on FH for BC was obtained at diagnosis by interview. All cases reporting a first‐ or second‐degree FH for breast carcinoma were compared with cases without FH. Overall survival was estimated using a product‐limit method. Hazard ratios (HRs) and the corresponding 95% confidence intervals (95% CIs), adjusted for confounding factors, were computed using proportional hazard models. Overall, 240 (18.8%) cases reporting, at diagnosis, a positive FH (156 with at least 1 first‐degree relative and 84 with at least 1 second‐degree relative) were compared with 1,038 patients without FH for BC. No significant differences were found in terms of distribution of age at diagnosis, tumor stage, nodal involvement, receptor status and histology. Cumulative survival rates at 5 years for cases without FH and with first‐degree and second‐degree FH for BC were 79.8 (95% CI 77.0–83.0), 78.6 (95% CI 70.0–88.0) and 80.2 (95% CI 68.0–92.0), respectively (log‐rank test, χ22 = 0.02, p = 1.0). After adjustment for age, pathologic size and nodal involvement, the HR among cases of invasive cancer with a first‐degree FH of BC was 0.91 (95% CI 0.55–1.48); however, the HR for cases with second‐degree FH was 1.18 (95% CI 0.62–2.25) compared to cases without FH. Our study, based on a large series of consecutive invasive BC cases, did not find any significant survival differences associated with a positive FH for breast carcinoma, suggesting the existence of a large heterogeneity among BC cases with FH.

Follow-up of colorectal cancer resected for cure

Sixty-four consecutive patients who had undergone curative resection for colorectal carcinoma were studied prospectively to evaluate the roles of sequential CEA determinations and independent instrumental follow-up in the early detection of resectable recurrences. Fifty-two of these patients also were submitted to sequential determinations of other tumor antigens: TPA (tissue polypeptide antigen) and Ca 19-9 (colon cancer antigen detected with a monoclonal antibody), for a retrospective evaluation of their utility as markers of recurrent tumors. Twenty-two recurrences were detected in a period ranging from 12 to 72 months (median, 47 months). CEA was the best predictor of recurrence (sensitivity, 90 percent) when compared with the other two markers (TPA sensitivity, 60 percent; Ca 19-9 sensitivity, 20 percent). When compared with the instrumental or biochemical examinations of the follow-up. CEA was still the most sensitive indicator of relapse although the specificity was quite low (78 percent) if minimal significative increases were considered. History and physical examination were more useful than CEA in detecting local recurrences in rectal cancer where the preoperative CEA level was low. A few second-look explorations based solely on small CEA increases failed to demonstrate recurrence or revealed peritoneal carcinomatosis. Selected second-look surgery based on demonstrated recurrences resulted in a resectability rate of 57 percent. A follow-up program based on frequent CEA assays, history, and physical examinations, including rectal, vaginal, and perineal exploration, is proposed. Extensive instrumental investigations should follow when a minimal significative CEA rise is observed, or when history and physical examinations suggest a possible recurrence. Second look surgery should be evaluated after confirmed or highly suspected diagnosis of recurrence, on the basis of instrumental or clinical examinations.

Prognostic value of proliferating cell nuclear antigen in lymph node—negative breast cancer patients

Background. The prognostic value of proliferating cell nuclear antigen (PCNA) has been demonstrated in recent studies of human tumors including breast cancer.

Limitations of CEA monitoring as a guide to second-look surgery in colorectal cancer follow-up.

Forty-two patients with localized colorectal cancer (Dukes’ A, B, C stages) were treated with potentially curative surgery and controlled with a follow-up program, which included CEA monitoring, for a period ranging from 12 to 48 months (median 33 months). During this period, we observed recurrent neoplastic disease in 14 patients. A retrospective analysis of the results showed that: 1. patients with a preoperative CEA value > 20 ng/ml have a significantly higher risk of recurrence than the patients with CEA < 20 ng/ml; 2. sensitivity of the CEA test was good for metastatic recurrent disease, fairly good for residual neoplastic disease, but insufficient for local recurrence; 3. test-specificity was poor, as demonstrated by the negative results of four exploratory laparotomies performed exclusively on the basis of increased CEA levels. Since the principal aim of a second-look operation is the cure of local recurrence, this type of surgery cannot be proposed only on the basis of increased CEA levels.

Lack of prognostic value of p53 protein expression in node-negative breast cancer.

Aims and background The association of p53 protein accumulation and prognosis in node-negative breast cancer patients has been alternately demonstrated and denied in literature reports, and opinions on the use of p53 expression as an indicator of high risk of recurrence and as a guide for adjuvant therapy are controversial. Study design The association of p53 protein accumulation with prognosis was retrospectively evaluated in a series of 221 node-negative breast cancer patients treated with surgery alone and followed up for a minimum of 10 years. p53 accumulation was determined by immunohistochemistry on archive material, and classified into four grades of increasing immunostaining. Results No association was observed between p53 and age or pT category, whereas a significant association with nuclear grade was found (P = 0.0014). Univariate and multivariate analysis of 10-yr disease-free and overall survival showed a significant and independent prognostic association for tumor size (pT category) and nuclear grading but not for p53 expression, whatever grade grouping was used. Conclusions We did not find any evidence supporting the use of p53 immunostaining in current practice as an independent prognostic indicator or as a discriminant factor for adjuvant treatment of node-negative breast cancer patients.

Staging breast cancer--screening for occult metastases.

The authors report on 1,017 consecutive breast cancer cases without symptomatic metastases staged by means of chest X-ray (CXR), skeletal survey (BXR) and bone scintigraphy (BS). Occult metastases (DM) detection rate was 0.88 %: 0.29 % for lung and 0.59 % for bone DM. The detection rate was correlated with clinical stage: 0.36 % for stage I, 0.20 % for stage II, 0.26 % for stages I and II, and 2.77 % for stage III cases. The sensitivity based on DM cases prevalent or surfacing within 6 months of follow-up was 0.30 for CXR, 0.22 for BXR and 0.55 for BS; specificity was 0.99, 0.98 and 0.90, respectively. The study confirms the possibility of early detection of DM with preoperative staging, but the extremely low detection rates in stage I and II cancers do not advise such a routine procedure. The higher detection rate of DM may suggest adoption of the routine staging procedure in stage III cancers. In these cases, although no evidence is available of a favorable prognostic impact of early detection and treatment of DM, an unnecessary mastectomy could be avoided in about 3 % of cases in the presence of DM detected by the staging procedure.

Patterns of axillary metastases in breast cancer

Thirty-seven (4.1%) cases of nodal metastases skipping the first level are reported in a consecutive series of 912 breast cancer axillary dissections including 392 N+ cases. First level nodes examination is sufficiently accurate in assessing the quality of nodal status (negative or positive) but not the extent of nodal involvement (number of involved nodes).