Ruby T. Senie

Tumor size is the primary prognosticator for pancreatic cancer after regional pancreatectomy

OBJECTIVE The purpose of this study was to evaluate the regional pancreatectomy as surgical therapy for ductal adenocarcinoma of the pancreas and to evaluate potential prognostic factors. SUMMARY BACKGROUND DATA Regional pancreatectomy was developed as a more adequate surgical procedure for pancreatic cancer in an attempt to improve the cure rate for this highly lethal disease. Few studies have evaluated large numbers of patients treated with this technique, and in recent years the emphasis has been on more limited surgery for pancreatic cancer. METHODS Fifty-six patients with ductal adenocarcinoma of the pancreatic head were treated by regional subtotal or total pancreatectomy. Clinical and pathologic parameters were reviewed and potential prognostic factors were compared statistically. The three patients who died within 30 days of the operation were excluded from the survival analysis. RESULTS Primary tumor size was the strongest determinant of prognosis. The mean tumor size was 3.9 cm (range, 1-7 cm). Eighty-five percent of patients had peripancreatic soft tissue invasion microscopically, and 58% had regional lymph node metastasis. Kaplan-Meier survival curves indicated a 33% 5-year survival for patients with tumor 2.5 cm or less in diameter (n=12) and 12% for patients with larger tumors (n=39). No patient with a tumor larger than 5 cm survived more than 5 years. Mean tumor size was not significantly associated with lymph node metastases, but 5 of 12 patients (42%) with primary tumor < or =2.5 cm had lymph node metastases. Twenty-four percent of patients with negative lymph nodes and 14% with positive lymph nodes survived 5 years. The difference was not statistically significant (p=0.3), but this is likely related to sample size. The 30- day operative mortality was 5.3%. The most common complications were infection, gastrointestinal bleeding, and gastric stasis. CONCLUSIONS After regional pancreatectomy, tumor size is the strongest predictor of prognosis. A multi- institutional randomized prospective trial of regional pancreatectomy versus pancreaticoduodenectomy is warranted in previously untreated, noninfected cases.

Obesity at Diagnosis of Breast Carcinoma Influences Duration of Disease-free Survival

OBJECTIVE To study disease-free survival at 10 years in relation to obesity at the time of diagnosis. DESIGN A prospective study of consecutively treated patients with primary breast cancer. SETTING Memorial Sloan-Kettering Cancer Center, New York. PATIENTS Nine hundred twenty-three women treated by mastectomy and axillary dissection. MAIN RESULTS Women who were obese (25% or more over optimal weight for height) at the time of primary breast cancer treatment were at significantly greater risk for recurrence (42%) compared with nonobese patients (32%) 10 years after diagnosis (P less than 0.01). In multivariate analyses, obesity remained a statistically significant prognostic factor after controlling for measured tumor size, number of positive axillary lymph nodes, age at diagnosis, and adjuvant chemotherapy with a hazard ratio of 1.29 (95% CI, 1.0 to 1.67). When analyses were restricted to the 557 patients free of lymph node metastases, the hazard ratio of recurrence associated with obesity was 1.59 (CI, 1.06 to 2.39); 32% of obese patients developed recurrent disease compared with 19% of nonobese women. CONCLUSIONS Obesity at the time of diagnosis is a significant prognostic factor that may limit the reduction in breast cancer mortality attainable through detection at an early stage of disease. Because obesity and the risk for breast cancer increase with age, interventions that encourage weight control may influence breast cancer survival rates.

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.

Breast self-examination and medical examination related to breast cancer stage.

The frequency and type of breast examinations reported by 1,216 primary breast cancer patients was studied in relation to local stage of disease. No significant relationship was found between the reported frequency of breast self-examination (BSE) and stage of disease; however, annual medical examination was significantly associated with small tumor size (P less than .04) and absence of axillary lymph node metastases (P less than .001). Regardless of the frequency of any method of examination, the majority (80 per cent) of tumors were first detected by the patients. Among those who detected their lesion, a greater frequency of medical examination was associated with an earlier pathological stage of disease (P less than .001). Patients who were examined more frequently by a physician appeared to be more sensitive to clinically significant breast abnormalities. These findings underscore the importance of examiner skill in the successful use of palpation to detect breast cancer. Instruction in BSE by a health professional during periodic examinations may provide the optimal opportunity for improved proficiency in self-examination.

Timing of breast cancer excision during the menstrual cycle influences duration of disease-free survival.

OBJECTIVE To study disease-free survival at 10 years in relation to timing of breast tumor excision during the menstrual cycle. DESIGN A prospective study of consecutively treated patients with primary breast cancer. SETTING Memorial Sloan-Kettering Cancer Center, New York. PATIENTS Two hundred and eighty-three premenopausal patients treated by mastectomy and axillary dissection. MAIN RESULTS When the tumor was excised during the follicular phase, approximated by setting the putative day of ovulation on day 14 after the onset of last menses, a higher recurrence risk (43%) was observed compared with excision later in the menstrual cycle (29%, P = 0.02). The rate peaked among patients treated between days 7 and 14 and was lowest between days 20 and 30. Multivariate analysis using the Cox regression model to control for tumor size, nodal status, estrogen receptor status, adjuvant chemotherapy, and family history indicated that the hazard rate of breast cancer recurrence after excision during the follicular phase was 1.53 (95% Cl, 1.02 to 2.29). Stratification by nodal status indicated that the effect of phase was statistically significant only among patients with positive nodes (hazard ratio, 2.10; Cl, 1.19 to 3.70). CONCLUSIONS Our results support the hypothesis that the risk for recurrence may be affected by the hormonal milieu of the menstrual cycle; these findings must be confirmed, however, by a prospective study in which cycle phase at time of tumor excision is biochemically documented.

Association between HIV infection and cervical neoplasia: Implications for clinical care of women at risk for both conditions

ObjectiveBoth AIDS and cervical neoplasia (CN) can result from sexual transmission of HIV infection and may affect similar groups of women. Available data on the association between AIDS and CN have practical implications for gynecological care. We review these data to provide an estimate of the magnitude of the association between CN and HIV infection. DesignTwenty-one studies were reviewed, including reports and abstracts published from January 1986 to July 1990. Of these, five included a comparison group and had sufficient data for inclusion in the analysis. ResultsAll five controlled studies reported a significant association between HIV infection and CN. One included women with both intraepithelial and invasive lesions; the other four considered women with intraepithelial lesions only. The summary odds ratio indicated that the odds of HIV-infected women having CN are 4.9 (95% confidence interval, 3.0–8.2) times that of HIV-negative women. ConclusionsResearch is needed to clarify etiological relationships and the role of human papillomavirus in the causal pathway of the observed association. Meanwhile, available data are sufficient to encourage regular Papanicolaous smear screening of HIV-infected women, and HIV testing and counseling of women with CN considered at risk for HIV infection.

Estrogen and progesterone receptors in breast carcinoma: Correlations with epidemiology and pathology

Analysis of estrogen receptor protein (ERP) was carried out on 784 patients with primary breast carcinomas. Significant relationships were found with the following epidemiologic features; age at diagnosis, menstrual status, race, and use of exogenous hormones (contraceptive and menopausal estrogens). Patients taking either type of hormone at diagnosis had lower median total ERP binding levels. Although the data do not explain how recent hormone usage affects tumor ERP, it seems advisable to discontinue these hormones as early as possible before a breast biopsy because they may cause spuriously low ERP levels. Correlation with pathology variables confirmed most prior observations relating to tumor type, histologic grade, and lymphocytic infiltrate. However, in this large series, infiltrating lobular carcinomas were not ERP‐positive more frequently than duct carcinomas to any significant degree. The pattern of progesterone receptors (PRP) did not vary significantly with menstrual status, but in other respects correlations of epidemiologic and pathologic variables were similar for ERP and PRP.

Carcinoma of the male breast: analysis of prognosis compared with matched female patients.

AbstractBackground: Considerable debate exists concerning the prognosis of breast cancer in male patients compared with that in female patients. Some studies have observed worse prognosis for men; others suggested the higher mortality rates were primarily due to delayed diagnosis. Methods: Survival time from diagnosis with invasive disease to death resulting from breast cancer of 58 men treated between 1973 and 1989 was compared with survival of 174 women treated between 1976 and 1978 who were matched by stage of disease and age at diagnosis. All patients were treated by mastectomy and axillary dissection. Results: Tumors were ⩽2 cm in 70% of cases and 55% were free of axillary metastases. The histology of the tumors differed significantly by gender (p<0.05). Significantly more men had estrogen receptor-positive tumors (87%) than did women (55%, p<0.001). Survival at 10 years was similar for male and female patients. Multivariate analysis controlling for tumor size, number of positive axillary lymph nodes, age at diagnosis, histology, and receptor status indicated no significant difference in survival of male compared with female patients. Conclusions: These data conflict with the conventional wisdom that breast cancer in men carries a worse prognosis than the disease in women. Although histology of the tumor and receptor status differed by gender, these factors did not have an impact on survival in these paired patients. Our data indicate that breast carcinoma in males is not biologically more aggressive than in females.

Pregnancy influences breast cancer stage at diagnosis in women 30 years of age and younger

AbstractBackground: To evaluate the purported decreased survival of pregnancy-associated (PA) breast cancer, a previously described homogeneous cohort of women of childbearing age with primary operable cancer was studied. The current analysis was designed to (a) identify those patients among the cohort known to have PA cancer and (b) compare clinical factors, pathologic characteristics, stage at diagnosis, and survival statistics for PA and non-PA cancer subgroups. Methods: All patients ⩽30 years of age who underwent definitive operation between 1950 and 1989 at the Memorial Sloan-Kettering Cancer Center (MSKCC) for primary operable (stages 0-IIIA) breast adenocarcinoma were analyzed. Results:|Twenty-two of the 227 young women with primary operable breast cancer had PA cancer. Disease-related survival was decreased (p=0.004) in these 22 women compared with the remaining 205 patients with non-PA cancer. PA cancer patients were found to have larger tumors (p<0.005), and a greater proportion had advanced staged (IIB or IIIA) cancers (p<0.02). Among patients diagnosed with early invasive cancers (stages I or IIA), no difference (p=NS) in survival was observed comparing PA and non-PA subgroups (73% vs. 74% 10-year survival). Patients with stage IIIA cancer had shorter disease-free and overall survival when associated with pregnancy (0% vs. 35% 10-year survival). Conclusions: Women 30 years of age or younger with PA breast cancer have decreased survival compared with patients with non-PA cancer from the same cohort. Women with PA cancer have larger, more advanced cancers at the time of definitive surgery. Women with early staged PA cancers appear to have survival similar to that for women with early staged non-PA cancer.

Epidemiology of breast carcinoma III relationship of family history to tumor type

Previous breast carcinoma in at least one female relative was reported by 31% of 1024 women treated consecutively for breast carcinoma at Memorial Hospital. Eighty (7.9%) of their mothers had had breast cancer. Maternal breast cancer was significantly (P ≤ 0.006) more frequent among women with medullary carcinoma than those with other tumor types and among those who were pre‐ or perimenopausal at diagnosis (P ≤ 0.001). Among the 727 patients who had one or more sisters, 12% had a sister who had been treated for breast cancer. The highest frequency of carcinoma in at least one sister occurred in patients with lobular carcinoma while the medullary carcinoma group had the least number of patients with an affected sister (P ≤ 0.03). Occurrence of breast cancer in a sister was almost twice as common in patients who were postmenopausal at diagnosis (P ≤ 0.005) than in premenopausal patients. When stratified by histologic type, the mean age at diagnosis of the patients did not differ appreciably from the age at diagnosis of their sisters. Detailed analyses of histologic type and other more distant familial relationships were also obtained but were considered to be less reliable because of problems in ascertainment and there were fewer affected relatives. No single histologic type of carcinoma was consistently linked to a disproportionately high or low frequency of carcinoma in all classes of relatives. It is possible that studies of family history limited to information available when the patient is first treated present an incomplete picture of familial aggregation. Further follow‐up after diagnosis is needed to obtain a more reliable measure of the extent to which relatives are affected by breast cancer and patterns of family distribution associated with specific tumor types. Cancer 50:171–179, 1982.