Robert L. Egan

Multicentric breast carcinomas: Clinical‐radiographic‐pathologic whole organ studies and 10‐year survival

Selection of breast cancer patients with microscopically limited disease but with excess mortality or women with regional disease and lessened mortality has remained an unsolved and critical challenge. The many usual histologic features such as tumor size, stage of disease or tumor differentiations were found reduced to lessened significant prognostic factors by the presence of multicentricity of tumors and multiplicity of histologic types of carcinoma. This observation was noted upon review of 161 clinical, radiographic and histopathologic whole breast studies on 156 patients with follow‐up from 11–15 years. Epidemiologic, clinical, and radiographic data had been compiled prospectively prior to diagnosis. Women with a single site and single type of carcinoma had a better prognosis (2.5% mortality per year) than those with multiple sites and multiple types (15% mortality per year) even though the stage of the disease may be similar. When the latter groups contained a scirrhous type duct carcinoma, the annual mortality rate appraoched 25%.

Breast cancer mammography patterns

Mammography studies, from 1963 through 1972, on 5,918 women over age 30 years with 327 breast cancers on initial studies, were prospectively categorized on a scale of 1 to 4 of increasing amounts of fibroglandular tissue. Approximately 60% of the cancers occurred in classes 1 and 2 breasts, about one‐third of the patients, while 40% of the cancers were in the remaining two‐thirds, comprising classes 3 and 4. There were 54 cancers that developed in breasts that previously were free of symptoms, clinical signs, and x‐ray abnormality. Up to 36 months one cancer was found in class 1, while 26 cancers were detected in class 4 breasts; two cancers developed in class 2 and seven in class 3. Cancers developing 38 to 88 months after normal examinations had an incidence of 0.23% in combined classes 1 and 2 and an incidence of 0.21% in classes 3 and 4. Dense fibroglandular tissue delays detection of breast cancer by mammography. Apparent increase in cancer risk in such breasts is due to this delay. More than a 3‐year follow‐up is required to assess the life history of breast cancer by mammography.

Intramammary lymph nodes

Radiographic, gross, and histopathologic studies on 158 whole breasts with primary operable carcinoma revealed intramammary lymph nodes in 28%, and of these breasts, 10% contained a metastatic deposit of carcinoma. Cancerous and noncancerous nodes were found in all quadrants of the breast with the positive ones being in the same quadrant as the carcinoma only 50% of the time. There was no demonstrable connection with the usual lymphatic drainage of the breast. With Stage II carcinoma, positive intramammary lymph nodes had no direct effect on prognosis, merely representing advanced disease and indicating a greater likelihood of axillary metastatic disease. There was a trend toward poorer prognosis in Stage I lesions with positive intramammary lymph nodes. This may indicate the Stage I carcinomas that have a similar prognosis as Stage II tumors. Conceivably, a Stage Ia, positive intramammary lymph node(s) but normal axillary lymph nodes, could be defined and used.

Bilateral breast carcinomas. Role of mammography

From 1963 to 1973, at Emory Clinic, out of a total of 1112 patients with breast carcinoma studied with mammography, 83 had carcinoma in both breasts. The carcinoma in the second breast was primary in 67 patients and metastatic in 16 patients; in 18 patients there were simultaneous bilateral primary carcinomas. Mammography proved highly effective in detecting the second carcinoma and was reliable in differentiating a second primary from metastatic carcinoma. Forty‐one of the second primary carcinomas were not associated with a palpable mass; 31 of these were having mammography as a routine check‐up. The second nonsimultaneous carcinoma was considerably smaller than the first and with fewer axillary lymph node metastasis. The second primary occurred within 6 years of the first in 86% of the cases with the remaining 14% scattered evenly up to 23 years. At 4 years after the diagnosis of the second primary, 25 of 27 deaths had occurred and only 1 patient was alive with cancer. Breast cancer patients need close follow‐up for at least 6 years after the first primary carcinoma; and 4 years past the second primary signals a more optimistic prognosis.

Mammographic parenchymal patterns and risk of breast cancer.

A 15-year prospective study of mammographic parenchymal patterns in 7,123 women over 30 with 658 prevalent and 131 incident primary breast neoplasms demonstrated that no pattern is a reliable indicator of initial or developing cancer. Cancer in glandular breasts is less frequent, more difficult to detect by mammography, and tends to remain prevalent compared with the more frequent tumors in fatty breasts. As women get older, their breasts assume similar patterns and the incidence of both prevalent and incident tumors increases. Parenchymal patterns cannot signify which breasts may remain glandular, nor which women may be at risk of cancer.

Conventional mammography, physical examination, thermography and xeroradiography in the detection of breast cancer

From July 1, 1973, through January 15, 1975, at the Emory University Clinic independent physical examinations, conventional mammography, thermography and xeroradiography of the breast were carried out on 1,003 symptomatic patients by both physicians and radiologic technologists. One year after completion of the study there had been 360 breasts biopsied with 53 malignant and 307 benign lesions demonstrated. Seventy‐three percent of the cancers were histologically Stage 0 or Stage I. The detection rate of the cancers by physician and technologist respectively were: 1) conventional mammography 87 and 74%; 2) xeroradiography 65 and 46%; 3) physical examination 62 and 51%; and 4) thermography 29 and 27%. In non‐malignant breasts the physician and technologist designated cancer respectively in: 1) thermography 4 and 6%; 2) conventional mammography 6 and 6%; 3) xeroradiography 8 and 10%; and 4) physical examination 11 and 12%.

Roles of mammography in the early detection of breast cancer

The roles of mammography in early detection of breast cancer are many—both direct and indirect. Mammography appeals to the patient; it is the only procedure that consistently detects breast cancer prior to signs and symptoms. Mammography has proved to be a most valuable adjunctive diagnostic procedure in the management of die patient with breast disease. It continues to stimulate the team approach of the surgeon, radiologist, and pathologist with increased interest in breast cancer. Better treatment planning, increased knowledge about breast diseases—benign, malignant, and premalignant—and resultant better patient care are emerging. Mammography is giving every indication of adding to the control of breast cancer and eventually lowering mortality from this disease.

Contributions of mammography in the detection of early breast cancer

Mammography often eliminates the hesitancy of women to present themselves for diagnosis of breast cancer especially high-risk groups. This shortening of the patient delay aids in the detection of early cancer as 10% of cancers found by mammography are clinically unsuspected. At Emory University Hospital where rapport has been established with the community 80% of operable cases are not beyond Stage 1 of the disease. Of previously unsuspected cancer cases 92% have been found to have negative axillary lymph nodes. This early detection influences treatment and prognosis. Less extensive surgery with subsequent better use of the arm has a favorable psychological effect. Mammography is the best means of detecting unsuspected cancer and particularly a 2nd primary cancer in the opposite breast. The overall accuracy is 88%. Many breast cancers can be detected by mammography 2 years prior to clinical recognition. At present the method is used for patients in high-risk groups. Its potential use in screening of the general population may be developed.

Estimated risk and occurrence of breast cancer in asymptomatic and minimally symptomatic patients

Mathematical procedures, some unique to this study, were applied to 114 suggested risk factors, with as many as 10 subsets, from history, physical and x‐ray examination on 30,904 breast studies on 7,252 patients referred from the Emory University Clinic since 1963. One‐fifth of the cancers were unrelated to symptoms; 82% of the cancers were free of axillary lymph node metastasis. There was no sign or symptom that predicted preclinical cancer. Interaction of numerous indicators subjected to strong statistical procedures could contribute to establishing risk of even early breast cancer. The results of hierarchic discriminant analyses demonstrated the feasibility of using simultaneously large numbers of risk factors in a systematic way to pinpoint patient with mammary cancer. Based on usual clinical and x‐ray assessment of the women 12.5% of the noncancer patients required biopsy to demonstrate 70% of the cancers with a cancer to benign rate of 1 to 4. Using the same data with discriminant analyses, 5.6% of the patients would require biopsy, at the rate of one cancer to 1.8 benign lesions; 92% of the cancer patients could be placed in 11.9% of the population. A computerized system has been developed for widespread application to provide the clinician with a highly objective and totally consistent assessment of risk for breast cancer in each of his patients. Cancer 43:871–877, 1979.

Mammographic detection of early breast cancer

Abstract The concept of early breast cancer as a palpable mass with limited secondary manifestations is changing rapidly. Thanks largely to mammography, a malignant breast neoplasm can be detected long before it forms a mass. Because cure rates in this stage are high, reliable means of early detection and diagnosis are of deep concern. Early detection certainly has been the major influence in reducing mortality from carcinoma of the uterine cervix, and results of recent studies indicate that this also will be true for cancer of the breast.