Henry P. Leis

Managing the remaining breast.

Bilateral breast cancer is discussed as to 1) the criteria for determining whether a cancer in the other breast is primary or metastatic; 2) the incidence of simultaneous and subsequent primary cancers in the second breast and the factors that could account for the reported frequency variance by different authors; 3) the influence that a second primary cancer in the contralateral breast makes on the survival of the patient; 4) the psychologic and physical importance of the remaining breast to the patient; and 5) the management of the other breast using preoperative x‐rays and random biopsies as added modalities for detection and reserving prophylactic mastectomy of the remaining breast for those patients at high risk for developing cancer in it with a definition of these risk factors. Forty‐two simultaneous primary cancers were found in the other breast in a series of 500 (8.4%) patients undergoing primary therapy for cancer in their first breast of which 19(45.2%) were invasive, and 23 (54.8%) were non‐invasive. Two (0.4%) were detected clinically, 16 (3.2%) by x‐rays, and 24 (7.5%) by random biopsies in 321 patients. In a series of 846 patients with potentially curable breast cancer, the absolute ten‐year survival rate was 63%. They were operated on before the routine use of preoperative x‐rays and random biopsies. Eleven (1.3%) had either clinical or x‐ray detected simultaneous cancers in the other breast. Of the remaining 835, 48 had prophylactic mastectomies in which 8 (16.6%) unsuspected cancers were found. In the remaining 787, 70 (8.9%) developed subsequent cancers making a total subsequent rate of 78 of 835 (9.3%).

Cellular hypersensitivity to breast cancer. Assessment by a leukocyte migration procedure

Cellular hypersensitivity against autologous and homologous breast cancer was evaluated by means of a leukocyte migration procedure. The antigens employed were cryostat sections of breast tissue. The relative leukocyte migration in the presence of the antigen as compared with migration without antigen was termed the migration index (MI), and used to quantify the response. The cryostat sections were also used for parallel studies of cellular hypersensitivity against autologous breast cancer by means of the skin window procedure. Both procedures demonstrated a stage‐response relationship against autologous breast cancer; in situ < Stage I < Stage II. Both procedures demonstrated the persistence of hypersensitivity in patients who were apparently free of cancer more than 2 years postoperatively. Cross reactivity (MI procedure) was uncommon against homologous invasive breast cancer, but was found in approximately half of the tests against homologous in situ carcinoma tissue. Such reactivity against homologous in situ carcinoma was observed in Stage II patients as frequently as in Stage I patients. The data corroborate our previous observations on the unique antigenicity of in situ carcinoma and emphasize the need for careful correlations between clinicopathologic findings and in vitro measurements.

Cellular responses to autologous breast cancer tissue: Correlation with stage and lymphoreticuloendothelial reactive

Cellular responses to autologous benign and malignant breast tissue were studied by means of a modified skin window procedure, using cryostat sections of autologous breast tissue mounted on coverslips as the antigen. The coverslips were applied to microabrasions of the skin for 28 to 33 hours. The cellular exudates on such windows were evaluated in terms of: type of mononuclear cell response, total basophil count, and the occurrence of basophil‐associated mononuclear (BAM) cell aggregates. Distinctive types of basophil‐associated aggregations were seen in response to autologous cancer tissue but not to autologous benign breast tissue. Elevated basophil counts and BAM responses were more frequent postmastectomy (≥30 days) than during the perioperative period (< 14 days). Elevated basophil counts and BAM responses postoperatively (≥30 days) were found more frequently in Stage I than in Stage II patients and more frequently in patients showing lymphoreticuloendothelial reactions in their axillary lymph nodes and primary tumors than in patients without such structural features. The findings support previous conclusions regarding the immunologic significance of sinus histiocytosis of axillary lymph nodes and further implicate immunologic phenomena in the biological behavior of human breast carcinoma.

Selective, elective, prophylactic contralateral mastectomy

There is a “high risk” group of patients in which the incidence of primary contralateral breast cancer is much higher than the overall figure of 7–10%. In addition, if cancer develops in the remaining breast it has a truly deleterious influence on the survival of the patient. Management of the other breast is, therefore, one of grave concern. It is suggested that this could best be accomplished by a random biopsy of the opposite breast in all patients undergoing primary therapy for operable Stage I and II cancers in the first breast. If a cancer is detected, then appropriate therapy is carried out. If not, the patient is carefully followed by regular physical examinations and by diagnostic aids (thermography and mammography). Only if the patient is in a “high risk” group for developing primary contralateral breast cancer is prophylactic, delayed simple mastectomy of the remaining breast advised. In 91 cases where this has been done, 16 unsuspected primary cancers were found for an incidence of 17%. The survival rate for 56 of these patients followed for over 5 years was 96.5%.

RELATIONSHIP OF FIBROCYSTIC DISEASE TO CARCINOMA OF THE BREAST.

This investigation evaluated the relationship of proliferative chang es to the development of human breast cancer. Of 838 consecutive cases of breast lesions operated on at Flower and Fifth Avenue Hospitals data were adequate in 719: 74 fibroadenomas and 645 which were included in the study. In 226 of these patients the diagnosis were malignant lesions. Histologic variants of fibrocystic disease were cysts adenosis apocrine epithelium epithelial hyperplasia and papillomatosis. Minimal changes were observed in some. Breasts with malignant disease showed moderate to marked epithelial proliferation in 14% compared to 1% in the group with nonmalignant lesions. Of 52 patients with breast malignancies who had proliferative morphologic variants 32 (62%) showed atypical epithelial changes while only 4% with nonmalignant lesions with proliferations showed atypica. Findings indicate that there is a relationship between fibrocystic disease showing atypical epithelial hyperplasia and cancer. Although relatively rare these lesions tend to be bilateral and multiple throughout the breast tissue. Atypical hyperplasia is considered a precancerous lesion. For adequate protection bilateral simple mastectomy or a modification of this operation is recommended.

Cellular responses to autologous breast cancer tissue. Sequential observations

A skin window procedure was employed to study the cellular responses to ether‐alcohol‐fixed cryostat sections of benign and malignant autologous breast tissue. Responses consistent with cellular hypersensitivity were found in approximately 40% of the tests with cancer tissue but less than 10% of the benign tissue. The relative frequency of positive responses to autologous cancer tissue was correlated with the stage of disease and sinus histiocytosis of the axillary lymph nodes at the time of mastectomy. These correlations were maintained in tests conducted 1‐2 years postoperatively. The findings indicate that immunogenicity accompanies the earliest recognizable stages (in situ) of breast carcinoma and that cellular hypersensitivity is an important variable in the biological behavior of breast cancer. The skin window procedure provides an additional aid in prognosis and follow‐up and may serve as a guide to the individualization of therapy.

Family history and oral contraceptives unique relationships in breast cancer patients

The relative frequency of a history of breast cancer among specific blood relatives was determined for breast cancer patients according to their prior use of oral contraceptives (OC). These data were compared with those derived from patients having various types of noninvasive breast lesions and from control women. It was found that a history of breast cancer among grandmothers or aunts was significantly more frequent among breast cancer patients who had used OC for one or more years continuously than among OC‐negative breast cancer patients, and among patients with noninvasive breast lesions and control women, regardless of OC usage. Breast cancer patients whose grandmothers or aunts had breast cancer used OC significantly more frequently than did family history (FH)‐negative breast cancer patients and breast cancer patients having a history of breast cancer limited to relatives other than grandmothers and aunts (mothers, sisters, cousins). It appears that the family history is a significant covariable in the relationship between OC usage and breast cancer. There is a need for specific studies to test the possibilities that OC usage increases the risk of breast cancer among women whose grandmothers or aunts had breast cancer, and reduces the risk of breast cancer in FH‐negative women.

Family history, oral contraceptive usage, and breast cancer

When breast cancer patients were grouped according to their family history of breast cancer striking differences were found in age distribution. Thus, the proportion of cases <45 years of age was grandmother > aunt > mother > FH‐negative > sister. A similar FH‐related sequence was observed in regard to current OC usage among breast cancer patients <45 years of age. It also appeared that current oral contraceptive (OC) usage increased the risk of invasive breast cancer among grandmother‐ or aunt‐positive women while decreasing the risk among FH‐negative women. There are important practical and conceptual reasons for further studies of the influence of interactions between age, OC usage and family history on the stepwise development of breast cancer.

Liposarcoma of the female breast. Review of the literature and report of a case.

Liposarcoma is one of the rarest types of malignant neoplasm to affect the breast. McGregor (1) estimated that it accounts for about 0.3 per cent of all sarcomas of the breast-which are themselves relatively uncommon. The incidence of mammary sarcoma as given by different authors, shows considerable variation; it ranges between 0.5 to 3.0 per cent of all malignant breast neoplasms, with an average of about 0.85 per cent (2-5). Higher percentages reported by earlier investigators were probably due, as Ewing (6) stated, to the inclusion of some atypical carcinomas as sarcomas. In reviewing the world literature, one is struck by the paucity of reports on liposarcoma of the breast. In 1930 Lifvendahl (7) described a case of mammary liposarcoma and stated that he could find no other reports of this tumor. In his summary of the literature in 1951, however, Michalany (8) listed 20 cases including those reported by Neumann (9) in 1862, Delage and Massabiau (10) in 1904, Merkel (11) in 1906 and Binkert (12) in 1924. Since Michalanys review, cases have been reported by Breckenridge (3) in 1954, Cuthbertson (14) in 1957, MacFarlane (15) in 1957 and McGregor (1) in 1960, bringing the total to 24. If the doubtful cases and those involving mixed tumors are excluded from this group, the total number of recorded cases of liposarcoma of the breast is 19. The case reported here would bring the total to either 20 or 25, depending upon the rigidity of the criteria for acceptance of the diagnosis (1-25).

The surgeon's role in breast cancer: changing concepts.

SummaryThe magnitude of the breast cancer problem is presented along with changing therapeutic concepts, the surgeons role in breast cancer therapy, and therapeutic options including the evaluation studies by the National Surgical Adjuvant Breast Project.The importance of selective surgery and the criteria utilized for choosing the appropriate procedure, as well as the currently most popular surgical procedure and the major selective surgical approaches are discussed. A moderate selective surgical approach is presented along with a discussion about the possible implementation of lesser surgical procedures.The results in 1,147 patients with potentially curable breast cancers (Stage 0, 1 and 2), followed for ten or more years, 82.9% of which were treated by less than a radical procedure, with the most popular procedure being a modified radical mastectomy, are presented. The ten year absolute, no evidence of disease survival rate for the entire group of patients was 64.8%, and for the 1,062 patients with only invasive cancers it was 62.1%. The local recurrence rate for the entire group was 7.3%, with an axillary recurrence rate of 0.7%. Only 2.1% of the patients were skin grafted.7.3% unsuspected cancers were found in a series of 561 random biopsies of the other breast, and 19.7% unsuspected cancers were found in 127 prophylactic contralateral mastectomies in patients who were in the high risk group for developing cancer in the remaining breast. The better cosmetic and functional result obtained with lesser surgical procedures is emphasized along with the discussion regarding reconstructive surgery. Finally, the results are compared to those obtained with other types of surgical approaches and with primary radiotherapy.The magnitude of the breast cancer problem is presented along with changing therapeutic concepts, the surgeons role in breast cancer therapy, and therapeutic options including the evaluation studies by the National Surgical Adjuvant Breast Project.The magnitude of the breast cancer problem is presented along with changing therapeutic concepts, the surgeons role in breast cancer therapy, and therapeutic options including the evaluation studies by the National Surgical Adjuvant Breast Project. The importance of selective surgery and the criteria utilized for choosing the appropriate procedure, as well as the currently most popular surgical procedure and the major selective surgical approaches are discussed. A moderate selective surgical approach is presented along with a discussion about the possible implementation of lesser surgical procedures. The results in 1,147 patients with potentially curable breast cancers (Stage 0, 1 and 2), followed for ten or more years, 82.9% of which were treated by less than a radical procedure, with the most popular procedure being a modified radical mastectomy, are presented. The ten year absolute, no evidence of disease survival rate for the entire group of patients was 64.8%, and for the 1,062 patients with only invasive cancers it was 62.1%. The local recurrence rate for the entire group was 7.3%, with an axillary recurrence rate of 0.7%. Only 2.1% of the patients were skin grafted. 7.3% unsuspected cancers were found in a series of 561 random biopsies of the other breast, and 19.7% unsuspected cancers were found in 127 prophylactic contralateral mastectomies in patients who were in the high risk group for developing cancer in the remaining breast. The better cosmetic and functional result obtained with lesser surgical procedures is emphasized along with the discussion regarding reconstructive surgery. Finally, the results are compared to those obtained with other types of surgical approaches and with primary radiotherapy.