Roy Ashikari

Paget's disease of the breast

Two‐hundred and fourteen cases of histologically proven Pagets disease of the breast were seen at Memorial Hospital during the period 1950 through 1968. Ninety‐six patients were without palpable masses, clinically, and 113 had Pagets disease of the nipple with palpable masses. Two thirds of the patients without palpable masses, clinically, had noninfiltrating carcinoma, and the majority of them had negative nodes in the axilla; accordingly, they have a good prognosis. Ninety percent of the patients with palpable masses had infiltrating carcinoma, and two thirds of them had positive nodes in the axilla. According to this study, modified radical mastectomy is the treatment of choice for the patient who does not have a palpable mass. Radical mastectomy should be performed on the patient who has a palpable mass.

Male breast cancer: a clinicopathologic study of 97 cases.

From 1949 through 1976, 97 men have been treated at Memorial Hospital for primary operable breast cancer. Seven per cent had intraductal carcinoma. Of the patients with invasive carcinoma 30% were pathologic stage I, 54% stage II, and 16% stage III. Fourty-six per cent had pathologically negative axillary lymph nodes. The most common type of tumor was infiltrating duct carcinoma. Fourty per cent of the patients had microscopic gynecomastia. None of the eight patients with intraductal or intracystic carcinoma died of cancer. Survival of the entire group of men with invasive carcinoma was 40% after ten years. The ten-year survival for men with negative nodes was 79%, for men with positive nodes 11%. Comparison with a series of 304 women with breast cancer operated on at Memorial Hospital in 1960 revealed no difference with regard to incidence of positive axillary lymph nodes or stage of disease. There was, however, a significantly lower survival rate for men. This poorer prognosis was limited to those men with pathologically positive axillary nodes.

Intraductal carcinoma of the breast. (1960-1969).

One‐hundred and twelve patients with intraductal carcinoma of the breast were studied. This lesion was more commonly seen in elderly patients and Negro females than lobular carcinoma in situ. The lesion is histologically multicentric in origin. Three fourths of the lesions were accompanied with benign or atypical papillomatosis or duct hyperplasia. It often requires paraffin section examination of the surgical specimen to establish diagnosis. Total removal of the breast tissue with adjacent lymph nodes is the treatment of choice. There was one patient with positive axillary lymph nodes and one patient who died with metastases in this study.

Noninvasive breast carcinoma: frequency of unsuspected invasion and implications for treatment.

One hundred twenty-nine biopsies from 121 patients with a frozen or paraffin section diagnosis of noninvasive breast carcinoma were studied. Eight women had bilateral noninvasive carcinoma. Seven biopsies reported as intraductal on frozen section contained invasive carcinoma on paraffin section. Of the remaining 122 biopsies proven to have noninvasive carcinoma on paraffin section, 39 (34%) were reported at frozen section and as noninvasive carcinoma, 24 (20%) as atypical and 59 (48%) as benign. Intraductal carcinoma (IDC) was identified more often at frozen section (45%) than was lobular carcinoma in situ (19%). Among 41 patients who had bilateral carcinoma with invasive disease in one breast, 76% of contralateral noninvasive carcinoma was LCIS. After excisional biopsy, carcinoma was found in 56% of 103 mastectomy specimens, including invasive carcinoma in 6% of breasts with IDC and 4% with LCIS. Residual noninvasive carcinoma was usually of the same type found at biopsy (90% IDC and 88% LCIS) and involved quadrants other than the biopsy site in 33% with IDC and in 80% with LCIS. When the frozen or paraffin section diagnosis of a generous excisional biopsy was noninvasive breast carcinoma, there was a substantial risk that foci of the same type of noninvasive carcinoma were also present in other quadrants. However, occult foci of invasive carcinoma were quite infrequent and the risk of axillary metastases was very low. Adequate treatment for noninvasive carcinoma requires elimination of all residual foci of noninvasive disease. At present this can best be accomplished by total mastectomy if the operation is properly performed. To insure removal of the axillary extension of the breast and for staging, in continuity dissection of the lowest axillary lymph nodes is also prudent.

Infiltrating lobular carcinoma of the breast.

Three hundred and fifty‐four patients with histologically proven infiltrating lobular carcinoma of the breast were seen at Memorial Hospital, New York City, between 1956 and 1970. This comprised 5.8% of all breast cancers seen during this interval. Infiltrating lobular breast cancer is found less frequently in the Negro female—3.7% vs. 5.8% for all breast cancer. Histologic differentiation from infiltrating duct carcinoma may be difficult. Clinical diagnosis is often complicated by its gross similiarty to “localized mastitis.” Bilaterality is more frequent with infiltrating lobular carcinoma—23% vs. 16% for infiltrating duct carcinoma. Infiltrating lobular carcinoma is lethal in its behavior, 5‐ and 10‐year salvage rates, after similar therapy, being slightly below those for infiltrating breast carcinoma generally. During its in‐situ stage, lobular carcinoma can be cured consistently by total mastectomy. When definitive surgical therapy is delayed until infiltrating breast cancer has developed, the patient is exposed to a greater long‐term risk because of the uncertain prognosis of infiltrating lobular carcinoma.

Prospective study of non‐infiltrating carcinoma of the breast

A long‐term prospective study of non‐infiltrating breast carcinoma is being carried out in order to study the natural history and proper management of such lesions with particular interest in patients treated solely by local excision. During an 11‐year period, 175 patients with lobular Ca in situ and intraductal Ca have been followed. None has developed recurrent disease including 18 undergoing wide local excision only. Histologic examination revealed that 36% of mastectomy specimens showed multifocal lesions, whereas only one of the patients treated by wide local excision had more than one microscopic focus. For these reasons total mastectomy is recommended as the treatment of non‐infiltrating breast carcinoma. Subsequent development of contralateral cancer has occurred in ten patients.

Breast cancer presenting as an axillary mass.

Experience with breast cancer presenting as an axillary mass in 42 patients has been reviewed according to initial clinical findings, treatment and survival. In the absence of an obvious inflammatory lesion, an axillary node may prove to be the first sign of breast cancer. It has been demonstrated that such a node should be biopsied and if positive for adenocarcinoma, a radical mastectomy performed presuming other primary sites have been ruled out. The survival rate after surgery in this group of patients is better than in those who present with a palpable breast mass and have axillary metastases.

Histologic and ultrastructural features of adenoid cystic carcinoma of the breast

Five examples of adenoid cystic carcinoma of the breast were examined histologically, and an electron microscopic study was carried out in one of them. In 2 tumors, areas histologically indistinguishable from benign mixed tumors of salivary gland origin were observed. Ultrastructural studies disclosed that the cysts which give the tumor its name are extracellular compartments lined by a basement membrane and filled with material apparently derived from the lamina densa. Infrequent true ducts and intercellular spaces containing cilia were observed. There was no evidence of secretory activity in tumor cells. It was concluded that adenoid cystic carcinoma of the breast is most likely of duct origin. Comparable studies of salivary gland tumors and of the role of the myoepithelial cells in the formation of adenoid cystic carcinoma were discussed.

A clinicopathologic study of atypical lesions of the breast

Following the detection of non‐infiltrating cancer, there have been more extensive microscopic studies for various atypical lesions of the breast. At Memorial Hospital, 296 patients with these lesions were seen during the period 1960 to 1972. These lesions were found more often in middle aged women than is the case in average cancer patients, commonly seen in nulliparous women, in patients in whom breast cancer was found in the opposite breast, and in patients with a history of breast cancer in the family. The clinical and mammographic findings are quite similar to those in non‐infiltrating cancer. Occasionally, these lesions are quite difficult to distinguish from minimal breast cancer by histologic examination. In this study, the cumulative risk of breast cancer was approximately 4‐5% at 30 months and 9% at 48 months.

A Clinicopathologic Study of Atypical Lesions of the Breast Further Follow Up

On the assumption that both the lobular and intraductal atypical lesions of the breast are precancerous in nature, a group of 572 such patients have been closely followed during the past 12 years. Thirty-four patients eventually developed cancer during this period. The cumulative incidence of breast cancer was 7.74% at 10 years in the group of patients with atypical lesions only and 16.15% at 10 years in the patients with atypical lesions in one breast and cancer in the contralateral breast. The transformation of this probable precancerous state into cancer apparently takes a long interval of time.