Risk of subsequent contralateral breast carcinoma in a population of patients with in-situ breast carcinoma

[Synchronous bilateral breast cancer: experiences in the Mohammed VI Cancer Treatment Center, CHU Ibn Rochd, Casablanca]

Synchronous bilateral breast cancers (SBBC) are characterized by extensive clinical and morphological heterogeneity, with an frequency between 1.5 and 3.2%. Women treated for unilateral breast cancer are at higher risk of developing contralateral breast cancer. Screening and advances in breast imaging have improved detection rates of SBBC. Our study aims to analyze the epidemiological, clinical, histological and therapeutic features of bilateral breast cancer. We conducted a cross-sectional study of patients with breast cancer treated at the Mohammed VI Center over a two year period. Statistical analysis of the results was performed using R. software. 31 patients had SBBC, representing 2.4% of breast cancer cases in our Center. The average age was 47.8 ± 8.4 years, 22.6% of patients used oral contraceptives. A family history of breast cancer was observed in 22.6% of cases. The most common histological type was invasive ductal carcinoma (58.1%), SBR grade II and III were common (38.7%). Hormone receptors were positive for progesterone (38.7%) and for estrogen (41.9%). HER2 was overexpressed in 20.0% of cases. 29.0% of patients received hormonal therapy and 3.2% targeted therapies. Our study showed that bilateral breast cancer represents a small percentage of all breast cancers but have specific clinical features that help to differentiate it from unilateral breast cancer.

Development of new cancers in patients with DCIS: the M.D. Anderson experience

BACKGROUND

The purpose of this study was to describe clinical characteristics and outcome of mammographically and clinically detected new cancers in patients with previously diagnosed ductal carcinoma in situ (DCIS).

METHOD

Our database was searched to identify patients with a primary diagnosis of DCIS. Those with prior evidence of invasive carcinoma were excluded from the analysis. Cumulative incidence of new cancers was estimated according to the method of Gray. Survival times were estimated using the Kaplan Meier product limit method.

RESULTS

A total of 799 patients diagnosed and treated for DCIS were included in the analysis. Median age at diagnosis was 54 years (range 22-88 years) and median tumor size was 1.4 cm (range 0.2-15 cm). After a median follow-up of 2.9 years, 45 patients (5.6%) had a second event: 14 (31%) with in-situ and 31 (69%) with invasive disease. Median disease-free interval was 3.5 years (range 0.5-20.8 years). The majority of second events (63%) occurred in the opposite breast (P = 0.048) and the cumulative incidence at 5 years was 6.6%. Overall survival at 5 years was 97.4%; that for the second event was 76.1%. For mammography and self-palpation, respectively, the 5-year survival by method of detection of the second event was 63.2% and 100% (P = 0.08 with a 33% power to detect a difference).

CONCLUSION

Second events following DCIS occurs primarily in the opposite breast and have a negative impact on survival.

[Bilateral ductal carcinoma in situ of the breast: independent events or bilateral disease?]

OBJECTIVES

In a retrospective study of bilateral Ductal Carcinoma In Situ (DCIS), cases were analysed to determine the relationship between the two events.

MATERIAL AND METHODS

From 1971 to 2001, among 812 patients with DCIS in Bergonie Institute, 78 suffering from bilateral DCIS and only19 were treated entirely in our institute. It was either synchronous DCIS or asynchronous (before 6 months). We realised a comparative study between, clinical and pathological characteristics of each DCIS.

RESULTS

In case of asynchronous DCIS, contra lateral DCIS occurred after a median 75-months period and until 22 years after the first event. We found at least for one histological subtype an agreement in 53% of cases. In 31% of cases, the grade was the same. For low plus intermediary grade versus high grade, the agreement was 53%. There was a subtype and grade agreement of 32% and a subtype or grade agreement in 63% of cases.

CONCLUSION

Histological agreement between the two lesions indicated the possible existence of in situ bilateral disease in these women. The local relapse rate was 20% and all of them were invasive. The risk of relapse in controlateral breast is high and patient needs a long follow up even in case of mastectomy.

Histopathological and cell biological characteristics of ductal carcinoma in situ (DCIS) of the breast—a comparison between the primary DCIS and subsequent ipsilateral and contralateral tumours

The rate of ipsilateral local recurrence after ductal carcinoma in situ (DCIS) varies (between 5% and 30%) and depends on the type of operation (mastectomy vs. breast-conserving operation), and whether postoperative radiotherapy has been used. Ipsilateral local recurrence can either emanate from the primary lesion or be a new primary tumour. Contralateral lesions may also develop after DCIS. We compared histopathological and cell biological characteristics in 37 subsequent ipsilateral tumours (25 DCIS and 12 invasive cancers) and 13 subsequent contralateral invasive breast cancers with their corresponding primary DCIS. The histopathological parameters were re-evaluated and the cell biological factors were analysed using conventional immunohistochemical techniques in paraffin-embedded material. The concordance rate for high grade (nuclear grade 3) vs. non-high grade (nuclear grades 1+2) between the primary DCIS and the subsequent ipsilateral tumour was higher than between the primary DCIS and the subsequent contralateral invasive cancer (68% vs. 31%). Similar patterns in the concordance rates between the primary DCIS and ipsilateral vs. contralateral tumours were also found in the oestrogen receptor status (83% vs. 50%) and the progesterone receptor status (87% vs. 58%). The pattern persisted in the other factors examined (p53, c-erbB2, bcl-2 and Ki67), although it was less pronounced. The overall high rate of concordance in the characteristics between the primary DCIS and the subsequent ipsilateral tumours suggests that, in most cases, they represent true local recurrences. Subsequent contralateral tumours are more likely to be new primary cancers.

Phenotypic similarities in bilateral breast cancer

Bilateral breast cancers that develop at similar times in an individual are likely to have been subjected to similar hormonal, environmental and genetic influences during tumourogenesis compared with metachronous tumours. As such, it is possible that tumour phenotype in synchronous bilateral breast cancer may display similar biological characteristics. The aim of this study was to identify phenotypic similarities between synchronous and metachronous bilateral breast cancers which may suggest a common origin. Thirty-three cases of synchronous and 46 cases of metachronous bilateral breast cancer that displayed similar tumour type were analysed for concordance in relation to various histological and immunohistochemical parameters. A higher level of concordance was demonstrated for synchronous cases with the highest level seen for oestrogen receptor. It is likely that this is related to similar tumourogenic pathways occurring at equivalent exposure times to various environmental and hormonal influences, although, in a proportion of cases, inherited genetic factors may play a role.

Incidence of second cancers among women with in situ carcinoma of the breast

A population-based cohort of 371 women with carcinoma in situ (CIS) of the breast, collected by the Tuscany Cancer Registry, has been analysed for further invasive cancers. All cases, diagnosed between 1985 and 1997, have been followed up to the end of 1997. During 1707 person-years of follow-up, 27 further invasive cancers were diagnosed while 13.7 were expected (Observed/Expected=2.0, P<0.05). The relative risk for invasive breast cancers was 3.7 (P<0.05). According to the surgical treatment for CIS and the site of further invasive breast cancer, no side specific difference was evident. No significant increase was evident for other cancer sites; only non-melanomatous skin cancers occurred more frequently than expected (O/E=4.2). The cumulative risk of developing an invasive cancer after CIS was 13.2% at 10 years. There were also two deaths due to breast cancer (O/E=8.3; P<0.05) corresponding to a cumulative mortality risk of 2% at 10 years. We have quantified the risk of developing an invasive breast cancer among women with CIS of the breast as four times that of the general population.

Cancer du sein bilatéral. Incidence et facteurs de risque

OBJECTIVE

To clarify, thanks to a retrospective study of 24 bilateral breast cancer cases, the frequency, the risk factors and the prognosis of bilateral breast cancers.

PATIENTS AND METHOD

Between 1984 and 1999, out of 506 patients treated for unilateral non-metastatic breast cancer at Gynecologic and Obstetric ward, at Maternity Souissi of Rabat, 24 cases of bilateral breast cancers were diagnosed. Our results were compared to those of the literature.

RESULTS

The frequency of bilateral breast cancers was 4.7% (24/506). In 87.5% of cases, these were metachronous cancers with a mean interval of 45 months (12-144 months). Patients under 40 at first cancer ran a fivefold superior risk than women more than 40 (P < 0.05). In cases of T3 or T4 tumors, the risk was 10-fold superior to that in smaller ones (P < 0.05).

DISCUSSION AND CONCLUSION

Significantly more first metachronous tumors were invasive adenocarcinoma cancers. Histologic type of first and second tumor was the same in all cases. The prognosis depends at once on the first and second cancer staging and the treatment must be done according to the same rules as in the first cancer.

The risk of a contralateral breast cancer among women diagnosed with ductal and lobular breast carcinoma in situ: data from the Connecticut Tumor Registry

BACKGROUND

Women diagnosed with breast carcinoma in situ are at increased risk for developing a contralateral breast cancer. The magnitude of this risk and the relationship between this risk and age, time since diagnosis, histologic subtype, and treatment for the first breast cancer is continuing to be defined.

METHODS

The risk of developing a contralateral breast cancer is examined among 4198 women diagnosed with breast carcinoma in situ and reported to the Connecticut Tumor Registry (CTR) between January 1, 1975 and March 14, 1998 using Kaplan-Meier estimation. A Cox proportional hazards model is used to assess the effect of surgical treatment, radiation therapy, age at diagnosis, race, histology, marital status, anatomic location within the breast, and time since diagnosis upon this risk.

RESULTS

The cumulative 5- and 10-year probabilities of being diagnosed with a contralateral breast cancer among women initially diagnosed with a ductal breast carcinoma in situ (DCIS) were 4.3% (95% confidence interval, 3.6-5.0%) and 6.8% (95% confidence interval, 5.5-8.2%), respectively. These risks are 3.35 times greater than those for women without a history of breast cancer but are similar to those for women diagnosed with non-metastatic invasive ductal carcinomas of the breast. The cumulative 5- and 10-year probabilities of being diagnosed with a contralateral breast cancer among women initially diagnosed with a lobular breast carcinoma in situ (LCIS) were 11.9% (95% confidence interval, 9.5-14.3%) and 13.9% (95% confidence interval, 11.0-16.8%), respectively.

CONCLUSIONS

Women diagnosed with LCIS were 2.6 (95% confidence interval, 2.0-3.4%) times more likely than women with DCIS to be diagnosed with a contralateral breast cancer within the first six months of the first breast primary. The risk of developing a contralateral breast cancer more than 6 months after the initial breast cancer was independent of surgical or radiation therapy, time since diagnosis, age at diagnosis, histology, race, marital status, or anatomic location of the cancer within the breast.

Bilateral synchronous breast cancer and HER-2/neu overexpression

Bilateral synchronous breast cancer appears to have a worse prognosis than comparable unilateral breast cancer. HER-2/neu expression in bilateral breast cancer has not been reported. The purpose of this study was to review the characteristics of patients with bilateral synchronous breast cancer and to report the incidence of HER-2/neu overexpression. Between 1984 and 1998, 58 patients were diagnosed with bilateral synchronous breast cancer (defined as both cancers diagnosed within 3 months). The paraffin blocks from both breast specimens were available and immunostained in 21 patients. Of 42 breast specimens, there were 31 invasive carcinomas and 11 noninvasive carcinomas. Of the 21 paired specimens immunostained for HER-2/neu, 11 were invasive cancers in both breasts, nine were invasive cancers in one breast and noninvasive cancers in the other breast, and one was noninvasive cancers in both breasts. Of the 31 invasive carcinomas, HER-2/neu was overexpressed (2-3+) in 22 (71%) and negative (0-1+) in nine (29%). In contrast, 35 of 101 (34.7%) consecutive unilateral invasive breast cancer specimens from our institution overexpressed HER-2/neu. The difference in HER-2/neu overexpression between patients with bilateral synchronous breast cancer and unilateral breast cancer (22/31 v.s. 35/101) was statistically significant (chi square = 11.3, p < 0.001). In cases where both breasts had invasive carcinoma, HER-2/neu overexpression could be either in one (six patients) or both breasts (four patients). The increased mortality of patients with bilateral synchronous breast cancer may be due to the higher incidence of HER-21neu overexpression.

Ductal carcinoma in situ (DCIS) of the breast: evolving perspectives

Ductal carcinoma in situ (DCIS) of the breast is an early, localized stage of carcinoma in the process of multistep breast carcinogenesis. The incidence of DCIS is increasing, mainly due to screening mammography, which results in diagnosing the disease in an increasing proportion of asymptomatic patients. Consequently, clinicians are being confronted with growing numbers of women who present with DCIS of the breast; thus, the concepts of managing such patients are assuming greater importance. The most common presentation is calcifications on mammography. DCIS is a biologically and morphologically heterogeneous disease. If left untreated, a significant proportion of these tumours will evolve into invasive cancer. However, when appropriately treated, the prognosis of DCIS is excellent. Optimal management of DCIS remains controversial. The goal in the treatment of patients with DCIS is to control local disease and prevent subsequent development of invasive cancer. For several decades, total mastectomy was the treatment of choice for DCIS and it should still be considered the standard of care, to which more conservative forms of treatment must be compared. Mastectomy is associated with a risk for chest wall recurrence of approximately 1%. Axillary lymph node dissection is not routinely recommended in the management of DCIS. However, mastectomy probably represents overtreatment in a substantial number of patients, especially those with small, mammographically detected lesions. Local excision alone has been suggested in carefully selected patients, whilst the rest of the patients undergoing breast-conservation surgery should be treated with breast irradiation. There is evidence that breast-conservation therapy is an effective option in the management of selected patients with DCIS. The use of radiotherapy after lumpectomy significantly decreases the rate of recurrence. Nuclear grade, presence of comedo necrosis, and margin involvement are the most commonly used predictors of the likelihood of recurrence. There is no role for adjuvant chemotherapy in the management of this disease. The role of tamoxifen in the treatment of DCIS is not clearly defined; tamoxifen should be given only in patients enrolled in clinical trials. Following breast-conservation therapy, about 50% of the tumours recur as invasive cancer. Most patients with recurrent disease can be treated effectively, usually by salvage mastectomy, but also in selected cases by breast-conservation therapy.

The potential impact of breast cancer screening in Hong Kong

BACKGROUND

Breast cancer is the second most common cancer and cause of death in women from Hong Kong. The Well Women Clinic at Kwong Wah Hospital offers breast cancer screening (physical examination and mammography) for women over 40 years of age.

METHODS

Results of screening over a 2-year period revealed an overall malignancy detection rate of 2.6 per 1000 screens with a strong selection bias for symptomatic women.

RESULTS

Screening only slightly increased the proportion of stage I cancers detected; of the malignancies detected, a significant percentage were in situ cancers with doubtful effects on breast cancer mortality. Teamwork and communication were useful in keeping a low referral rate to the surgical clinic of 6.1%, as well as a low biopsy rate for mammographic abnormalities.

CONCLUSIONS

A re-evaluation of the real risk of breast cancer in young women together with the lack of proven value from screening has suggested a need for reconsideration of offering screening to women 40 years and over in Hong Kong.

Second cancers following in situ carcinoma of the breast

Carcinoma in situ (CIS) of the breast has increased many-fold in incidence rates and as a proportion of new breast cancers following the introduction of mammographic breast screening. To provide population-based estimates of invasive breast cancer risk following CIS, we linked data on 249 incident primary CIS (median age 53 years) to the Cancer Registry of the Swiss Canton of Vaud (about 600,000 inhabitants) over the period 1977-1994. Women with concurrent invasive cancers of the breast were not included. Standardized incidence ratios (SIR) were determined according to the exact Poisson distribution, with stratification for age and year of diagnosis. A total of 24 cases of breast cancer vs. 3.4 expected [SIR = 7.2, 95% confidence interval (CI): 4.6-10.6], and 7 cases of other neoplasms (except non-melanomatous skin cancer) vs. 6.9 expected (SIR=1.0, 95% CI: 0.4-2.1) were observed. The SIR was 10.4 during the first year, 5.6 between I and 4 years, and 7.7 after > or = 5 years after CIS diagnosis. SIRs were consistent in women below and above age 55 years, but somewhat higher for ductal (SIR=8.6) than lobular (SIR = 4.2) CIS. Six deaths from breast cancer were observed vs. 1.5 expected (standardized mortality ratio=4.0, 95% CI: 1.5-8.7). In 13/19 ductal CIS, but in 2/4 lobular CIS, invasive cancer occurred in the same breast. In most women, CIS and subsequent invasive cancer showed the same morphological (i.e., ductal or lobular) features. The cumulative risk of breast cancer was 16% 10 years after CIS diagnosis, emphasizing the importance of adequate surveillance of women after CIS of the breast.

Is steroid receptor profile in contralateral breast cancer a marker of independence of the corresponding primary tumour?

We compared oestrogen receptor (ER) and progesterone receptor (PgR) profiles between primary and corresponding contralateral breast cancer (CBC) to investigate whether CBC should be considered relapse of a primary or as a feature of the multicentric origin of breast cancer. We adjusted for patient age, menopausal status, histology and adjuvant therapy. In spite of the general application of a cut-off value to dichotomise ER and PgR, we considered them as continuous variables. Moreover, we considered as synchronous cancers only simultaneously occurring lesions. For 399 patients, ER and PgR receptor levels in primary and CBC did not differ significantly, but were significantly correlated within the same patient. The correlation was higher for synchronous than for metachronous lesions when considering ER, but not PgR. The correlation between ER and PgR levels in the same tumour (primary or CBC) appeared stronger than the correlation of either receptor type (ER or PgR) between primary and CBC. Age, histology and adjuvant treatment affected ER concentration, whereas age, menopausal status and histology affected PgR concentration. The analysis indicated that primary and CBC tend to be characterised by a similar steroid receptor profile. The finding may support the hypothesis of CBC as a second primary arising in a common predisposing milieu, rather than a primary-dependent contralateral lesion. In this light, the clinical management of patients with a bilateral breast cancer should be similar to that of a unilateral breast cancer.

Ductal carcinoma in situ. Part I: Definition and diagnosis

The frequency of diagnosis of ductal carcinoma in situ (DCIS) has increased in Australia, largely because of the national screening programme. Ductal carcinoma in situ presents a dilemma because of problems with its diagnosis and variations in reporting pathological and radiological findings, making it difficult to define optimal treatment and communicate information in a way that helps the patient understand the problems and make decisions. There is considerable inter-observer variation, particularly in differentiating low-grade DCIS from ductal hyperplasia, with or without atypia, but pathologists who participate in regular pathological review sessions vary less in their opinions. Mammography remains the main investigative tool for DCIS and the American College of Radiology has recommended standardized reports. A team approach is required for the removal and diagnosis of possible DCIS. Although the team may be best co-located in the one facility, this is not practical in many community hospital settings which lack on-site radiology and pathology services. The decision about how much breast tissue to remove will need to be made for each patient and depends on the size of the microcalcification and how suspicious the mammogram is for DCIS. We recommend the use of synoptic reports for DCIS, and we document the minimum factors that should be reported by pathologists. The evaluation and management of DCIS by a multidisciplinary team will allow the patient access to information required to make often difficult treatment decisions. In this paper, we review the literature about the natural history, pathology, cytology and radiology of DCIS and document the 20 critical steps required for the diagnosis of impalpable, mammographic microcalcifications suspected to be DCIS.

Risk of contralateral breast cancer among women with carcinoma in situ of the breast

BACKGROUND

Information is limited on the risk of contralateral breast cancer after a diagnosis of breast carcinoma in situ (BCIS).

METHODS

In western Washington, between 1974 and 1993, 1929 women with a first primary ductal carcinoma in situ (DCIS) and 282 women with a first primary lobular carcinoma in situ (LCIS) were followed for contralateral breast cancer. Rates of contralateral invasive breast cancer and BCIS were compared with population rates of first primary breast cancer using Poisson regression to adjust for age and calendar year.

RESULTS

The rate of contralateral invasive disease after BCIS was approximately twice the population rate for women with DCIS and three times the population rate for women with LCIS; relative rates decreased somewhat with increasing time since diagnosis of LCIS, but were fairly stable after DCIS. The relative rate of contralateral DCIS after BCIS was substantially higher than for contralateral invasive disease, but dropped dramatically after the first year after the initial BCIS, especially among women with LCIS. Contralateral BCIS usually was of the same histologic type as the initial BCIS; histologic concordance of BCIS was 71% for women with an initial LCIS and 78% for women with DCIS.

CONCLUSIONS

Data suggest that the rate of contralateral invasive breast cancer is elevated for at least 5 years after a diagnosis of BCIS compared with the rate of first primary breast cancer in the population, and that the rate is only slightly higher for women with LCIS than for women with DCIS. The markedly elevated rate of contralateral DCIS may result in large part from increased medical surveillance of women diagnosed with BCIS, especially during the first year after the initial diagnosis.

Management of ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) is an early, localized stage of breast carcinoma that has an excellent prognosis when it is properly treated. The significant increase in the frequency of diagnosis of DCIS in recent years is the result of both better recognition of DCIS among pathologists and widespread use of screening mammography. Multicentricity, bilaterality and histologic subtype are important considerations in the management of this disease. The clinical presentation of DCIS is the presence of either a palpable mass or a mammographic abnormality, most frequently in the form of an area of microcalcifications. For several decades, total mastectomy was considered the appropriate treatment for DCIS, and it should still be considered the standard to which more conservative forms of treatment must be compared. Breast conservation surgery has been used with increasing frequency in the treatment of DCIS but the adequacy of this approach remains subject to controversy. Segmental mastectomy alone may be applied with caution in carefully selected patients, while the rest of the patients undergoing breast conservation surgery should be treated with breast irradiation. Axillary node dissection is generally considered unnecessary in the treatment of DCIS. There is no role for adjuvant chemotherapy in the management of this disease. The role of tamoxifen in the treatment of DCIS is not clearly defined and it should be given only to patients enrolled in clinical trials. Ongoing research should clarify the controversies surrounding DCIS and enable us to define the optimal management for this disease.

Overview of the biology and management of ductal carcinoma in situ of the breast

Ductal carcinoma in situ of the breast (DCIS) is an early, noninvasive stage of breast malignancy that arises from ductal epithelium and has an especially favorable prognosis. Its biologic characteristics are consistent with a direct precursor to invasive carcinoma, which develops in the majority of cases if left untreated, generally within 10 years of diagnosis. Mammography has resulted in a substantial increase in its diagnosis, as well as a change in its presentation from large, palpable masses to nonpalpable lesions manifested primarily as microcalcifications. The same treatment options are available for DCIS as for invasive breast carcinoma, and there is also a limited role for wide local excision alone in incidental lesions. Most cases of DCIS currently are treated effectively by lumpectomy and radiation therapy, although the fact that 50% of all local breast recurrences are invasive lesions may affect survival adversely. Mastectomy is associated with the best survival rates and should be performed on any patient with factors known to pose a high risk of locoregional recurrence. There are still many outstanding issues to be resolved by further study before the intriguing potential of this disease can be realized fully.

Chest wall recurrence of ductal carcinoma in situ of the breast after mastectomy

BACKGROUND

Optimal management of ductal carcinoma in situ (DCIS) of the breast is a problem that is occurring with greater frequency, mostly because of the increasing use of mammographic screening. The traditional role of mastectomy for DCIS has been challenged by breast-conserving procedures. Regardless of the method of treatment used, local control with complete tumor eradication is the major goal in the management of DCIS.

METHODS AND RESULTS

A patient is reported in whom DCIS recurred in residual breast tissue in the chest wall several years after mastectomy.

CONCLUSIONS

Chest wall recurrence of DCIS within residual breast tissue probably is caused by failure of tumor excision, new primary tumor, or both. This observation underscores that (1) mastectomy may not result in complete removal of breast tissue, and (2) this residual breast tissue may be the substrate for "chest wall recurrences" in some patients with breast cancer.

Risk of invasive cancer in women with lobular carcinoma in situ of the breast

100 women underwent wide resection for palpable or mammographically detected breast lesions (1 woman had bilateral lesions). Histology excluded invasive cancer, but one or more foci of lobular carcinoma in situ (LCIS) were observed. There have been no recurrences in the 20 women who underwent total mastectomy. In the 12 patients who had a subsequent wide excision and the 68 who received no other treatment 5 presented with an invasive cancer in the same breast at some distance from the LCIS site (median follow-up 58 months). The (observed/expected) rate per 1000 per year is 10.3 for an untreated LCIS. LCIS is therefore a risk factor for invasive carcinoma. Nevertheless this risk does not indicate the use of mutilating procedures and a wait-and-see policy is appropriate.

Vexed surgeons, perplexed patients, and breast cancers which may not be cancer

In situ cancer of the breast is being diagnosed with increasing frequency due to the widespread use of mammography and heightened awareness of these lesions among pathologists. Treatment of these preinvasive cancers is controversial in light of recent data supporting breast-conserving therapy for small invasive cancers. Therapy for in situ breast cancer is discussed with attention to known risk factors for recurrence and breast cancer-related mortality. The controversies surrounding treatment of ductal and lobular carcinoma in situ compel the conscientious oncologist to seek fully informed consent and to respect the individual patient's feelings about cosmesis and breast cancer risk. Hopefully, prospective randomized studies such as the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-17 trial will relieve the oncology community of much of its confusion about the natural history and optimal therapy for these diseases.

The treatment of in situ breast cancer

Carcinoma in situ is the earliest histologically recognisable form of malignancy and as such provides an opportunity to treat the disease in a curative way. However, due to the comparative rarity of in situ breast carcinoma, there is no available information derived from controlled clinical trials. The two major variants, ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS) will be considered separately as the two conditions have divergent natural histories. DCIS is increasing in incidence since microcalcification, which is a frequent accompaniment, may be detected radiologically in the screening of asymptomatic women. The extent of microcalcification may not indicate the extent of disease. It has yet to be determined whether there is a difference in behaviour of the tumour forming and the asymptomatic types of DCIS. After a biopsy has shown DCIS there will be residual DCIS at the biopsy site in one-third of patients, and multifocal DCIS in another third. A coexistent infiltrating carcinoma may be present in up to 16%. Due to sampling problems areas of invasion may be missed. Axillary nodal metastases are found in only 1% of patients with histological DCIS. Radical surgery by total or modified mastectomy is almost curative, but 3% of patients will die of metastases. Taking results of uncontrolled trials, local relapse rates are as follows: excision alone 50%, wide excision 30%, wide excision plus radiotherapy 20%. Two prospective trials are underway run by the EORTC and NSABP in which patients with DCIS are treated by wide excision with or without external radiotherapy. LCIS is usually an incidental finding with a bilateral predisposition to subsequent infiltrating carcinomas. Curative procedures such as bilateral mastectomy with reconstruction may represent overtreatment. A systemic rather than local approach would seem appropriate and a trial is now underway run by the EORTC in which patients with histologically confirmed LCIS are randomised to observation alone or to receive tamoxifen 20 mg daily for 5 years. Cooperative studies will provide the way of acquiring important data on treatment regimens of both DCIS and LCIS. It is timely that treatment regimens for in situ carcinoma of the breast be examined by controlled clinical trials.

Risk of contralateral breast cancer. Associations with histologic, clinical, and therapeutic factors

A case-control study was conducted to assess the risk factors associated with the development of a contralateral primary breast cancer among women who had had a first primary breast cancer. Hospital records were reviewed for 292 women with an incident contralateral breast cancer, diagnosed in one of eight hospitals between July 1, 1975 and December 31, 1983, and for a comparison group of 264 surviving unilateral breast cancer patients, previously diagnosed in the same hospitals. All subjects were identified through the records of the Connecticut Tumor Registry. Having an initial tumor containing lobular carcinoma was associated with an almost twofold increased risk of developing a contralateral cancer (aOR = 1.8; 95% CI: 1.0-3.5). Among those for whom a progesterone receptor assay was available, a positive assay was associated with an increased risk of a contralateral primary (aOR = 3.2; 95% CI: 1.0-9.5). AB blood type was also associated with an elevated risk, but this elevation was not statistically significant (aOR = 2.3; 95% CI: 0.7-7.7). Having received radiation treatment was not significantly associated with the risk of a contralateral primary (aOR = 0.9; 95% CI: 0.6-1.4), whereas chemotherapy treatment was associated with a significantly lowered risk (aOR = 0.3; 95% CI: 0.1-0.7). The association with chemotherapy appeared to be modified by body build (ROR = 1.5; 95% CI: 1.0-2.3 for a 2.5-unit differential in Quetelet's index).

Breast cancer and atypia among young and middle-aged women: a study of 110 medicolegal autopsies

In 110 consecutive, medicolegal autopsies of young and middle-aged women (range 20-54 years) the breasts were examined by an extensive histopathologic method and by correlative specimen radiography. Malignancy was found in 22 women (20%) of which only one was known to have had clinical invasive breast cancer (IBC). At autopsy 2 women had IBC (2%), the remaining in situ carcinoma (in situ BC) of microfocal type (18%), i.e. 15 (14%) intraductal carcinomas (DCIS), 4 (3%) lobular carcinoma in situ (LCIS) and one (1%) both DCIS and LCIS. Forty-five per cent of the women with malignancy had multicentric and 41% had bilateral lesions. Forty-five per cent of all histologically confirmed malignant lesions were identified by specimen radiography. Adenosis, benign epithelial hyperplasia, papilloma and duct ectasia were positively associated with malignancy. In addition malignancy was significantly more frequent among women aged more than 40 years, with late age at first full-term pregnancy, with alcohol abuse and with steatosis or cirrhosis of the liver. The results suggest that clinically occult in situ BC are frequent in young and middle-aged women.

Factors associated with the risk of second primary breast cancer: an analysis of data from the Connecticut Tumor Registry

To examine further the epidemiology of contralateral primary breast cancer, a case-control analysis, utilizing information available from the Connecticut Tumor Registry, was conducted. Recent cases of second primary breast cancer were compared to control women who had survived a first breast cancer but had not developed a second. Three hundred and thirty eight incident cases of contralateral breast cancer diagnosed between 1979 and 1982 were identified and compared with an equal number of randomly selected controls and 336 controls frequency matched to the cases on the basis of age at initial cancer diagnosis and the calendar time elapsing since that diagnosis. Risk of second primary breast cancer was found to be significantly elevated among women whose initial cancer was lobular carcinoma and during the first year following diagnosis of the initial primary. Additionally, for women initially treated with radiotherapy, risk of a contralateral primary increased for 10-14 years following treatment, after which it declined. Among young women, having never married was protective whereas the opposite was found among older women. These findings and the methods used are discussed in the context of the epidemiology of both contralateral and initial breast primaries.

Contralateral cancerous breast lesions in women with clinical invasive breast carcinoma

Eighty-four consecutive autopsies of women with a clinical diagnosis of invasive breast carcinoma (BC) were examined by extensive histopathologic methods for malignant changes of the contralateral breast. Sixty-eight percent of the women were found to have primary contralateral BC, of which 33% were invasive and 35% in situ lesions. Another 16% had metastases to the breast. Only two women had had treatment for their contralateral BC. In eight cases a malignant lesion was diagnosed or suspected clinically, but in the remaining cases, the malignancies were identified only by histopathologic examination. No clinical data or histologic characteristics of the first BC had any predictive value for the risk of contralateral BC. In the contralateral breast, a significant coincidence was found between fibrocystic disease and the occurrence of primary malignant BC. The majority of the BC on both sides were of ductal type. Seventy-nine percent of the invasive contralateral BC were tumefacient, and 71% had axillary lymph node metastases. The mean survival time was comparable for women with and without contralateral primaries, but a significantly higher proportion of women with contralateral invasive BC died of disseminated BC. The frequency of contralateral malignancies is thus much higher than previously reported. The consequence of these findings may implicate a reevaluation of the treatment and control schedule regarding the contralateral breast in women with invasive BC.

Bilateral breast cancer

Between the years 1972 and 1982, 1,880 women were treated for breast cancer at the Tel-Aviv Medical Center. One thousand two hundred fifteen detailed charts are included in our study. Sixty-six patients (5.4%) were diagnosed as having bilateral breast cancer. The mean age at first tumor diagnosis was 55.1 years. Bilateral breast cancer appears to be more common in nulligravidas and women who have delivered up to two children. In patients where the first tumor was greater than 4 cm in diameter, there was a higher incidence of a second tumor. A total of 65.2% of all patients who developed a second breast tumor had no axillary lymph node metastasis at the time the first breast tumor was diagnosed. There was no correlation between the histological types of the first and second tumors. The longer the woman survived after the first cancer diagnosis, the greater the likelihood of her developing a second tumor; the longer the interval between the diagnosis of the two cancers, the better the survival rate.

Pathologic findings from the National Surgical Adjuvant Breast Project (Protocol No. 4). XI. Bilateral breast cancer

Sixty-six confirmed instances of clinically metachronous second breast cancers were encountered over a 10-year period in 1578 women with invasive breast cancer enrolled in Protocol 4 of the National Surgical Adjuvant Breast Project (NSABP). Seven of the second cancers were in situ, yielding an incidence of 3.7% invasive and 0.5% noninvasive cancers. Except for a peak of 1.75% in the second postoperative year, the annual incidence based on patients at risk was constant and less than 1%. Ninety-three percent of the second cancers occurred within 7 years and 80% within 5 years following mastectomy for the initial primary. All of the second cancers were regarded as being primarily of mammary origin exhibiting either: (1) an in situ component; (2) dissimilar but well-recognized patterns of primary breast cancers; or (3) the appearance of scar cancer, a recently described morphologic feature characteristically observed in some primary breast cancers. A search for factors that might be predictive of bilaterality was performed. Thirty-eight pathologic and eight clinical factors were assessed, including family history. Although the latter was 1.5 to 2 times more frequent in patients with bilateral disease, this estimate was not statistically significant. On the other hand, a statistically significant association with bilateral disease was found when the initial tumor measured more than 2.0 cm, was associated with invasive cancer or proliferative fibrocystic disease, nipple involvement, absent nodal sinus histiocytosis, lobular carcinoma in situ in the vicinity of the dominant mass, or was of the lobular invasive or tubular types. However, the degree of risk of these discriminants was no greater than 2 to 3:1. Despite the clinical scrutiny imposed by the NSABP protocol second tumors measured only 1 cm less than the first, measuring on average 2.4 cm, which reflects the difficulty attendant on the clinical detection of so-called early breast cancers. Yet, no significant difference in pathologic nodal status was noted between the first and second cancers or that of patients with unilateral disease. Furthermore, there was no difference in survival rate between patients who developed a second cancer and those with unilateral disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Possible immunological implications of an association between the stages of first and second independent breast cancers

Concepts regarding cell-mediated immunity and breast cancer are reviewed. Patients having in situ breast cancers have been found by in vivo and in vitro measurements to have cell-mediated immunity to autologous and homologous in situ breast cancer tissue which may last for some time after diagnosis. These observations suggest that antigenically similar cancers arising subsequently in the contralateral breast should be less likely to progress beyond the in situ stage and, if they do become invasive, should exhibit prognostically favorable signs of cell-mediated immunity, e.g. sinus histiocytosis in the lymph nodes and/or lymphoid infiltrate and perivenous lymphoid infiltrate associated with the primary tumor. Cell-mediated immunity has also been shown to be negatively associated with the stage of disease at diagnosis for invasive cancers, i.e. the proportion of patients exhibiting cell-mediated immunity decreases as the stage at diagnosis increases. These observations suggest that the stages of independent breast cancers occurring in the same woman should be positively correlated. Data from the SEER Program of the National Cancer Institute were examined in this regard and a strong positive association between the stage of first and second independent primary breast cancers was found with the effect on the stage of a second breast cancer following a the first invasive breast cancer appearing to decrease with time subsequent to diagnosis. These observations are consistent with the immunogenicity of breast cancer.

Pathobiology of breast cancer--treatment implications

In most patients (approximately 85%), breast cancer at the time of diagnosis is already a systemic disease. Multicentricity (20-40%) and synchronous (5-10%) and metachronous (15-30%) bilaterality are indicative of etiologically similar noxae. Ductal and lobular carcinoma in situ become invasive in approximately 50% of patients. Whereas ductal carcinoma in situ is mainly diagnosed clinically (lumpiness, tissue irregularity), lobular carcinoma in situ, a small, nonpalpable lesion, is usually discovered accidentally following biopsy for fibrocystic disease and/or suspicious mammography. Treatment of in situ and minimal (small invasive) breast cancer (less than or equal to 5 mm in diameter) is controversial, ranging from observation (lobular carcinoma in situ) over segmental excision to simple or radical mastectomy with or without lymphadenectomy and contralateral "mirror-image" biopsies. Long-term survival rates (90-95%) appear similar for patients with treated or untreated lobular carcinoma in situ. Patients with minimal breast cancer have as good a prognosis as those with ductal carcinoma in situ (long-term survival, 80-90%). Presently, a trend from radical to conservative surgery (lumpectomy, segmentectomy) is observed. Especially for in situ carcinoma, modified radical or even simple mastectomy may be considered overtreatment. For invasive carcinomas, lumpectomy and radiotherapy provide as good a chance of survival as radical mastectomy. Such equal survival indicates that although in 25% to 45% of patients with invasive carcinoma multifocal disease (in situ and invasive carcinoma) is left behind, subsequent radiotherapy is effective. Accordingly, patients with carcinoma in situ may be spared mutilating surgery in favor of radiotherapy. Because many patients at extraordinarily high risk of breast cancer cannot accept prophylactic mastectomy, thorough follow-up by clinical examination, mammography, sonography and biopsy is essential.

Second primary cancers of the breast: incidence and risk factors

Between 1946 and 1976 over 9,000 women with breast cancer were seen within one year of diagnosis at the A. Maxwell Evans Clinic (AMEC) in Vancouver, British Columbia. By 1978, 275 had a subsequent diagnosis of a second primary in the contralateral breast: 100 were diagnosed within 1 year, and 175 after 1 year of the first primary. Two separate comparison groups of AMEC patients with unilateral breast cancer were selected to identify risk factors for bilateral breast cancer and to determine the incidence. The average annual incidence rates for a second primary in the contralateral breast were 5.0, 4.1 and 3.0 per 1,000 women for women less than 45 years, 45-54 years, and over 55 years of age at diagnosis of first primary breast cancer, respectively. These rates remained stable for at least 15 years after the diagnosis of the first primary. Two risk factors were found for bilateral cancer within 1 year of the first primary, histologic diagnosis of lobular carcinoma and absence of pathologic involvement of axillary nodes; one risk factor was found for bilateral breast cancer after 1 year of the first primary, family history of breast cancer.

The contralateral breast at reconstructive surgery after breast cancer operation--a histopathological study

The present study concerns 73 patients with known unilateral breast carcinoma. Thirty of the patients had a primary invasive carcinoma removed and at a later operation contralateral subcutaneous mastectomy with implantation of a prosthesis. This was performed with or without ipsilateral breast reconstruction. Forty-three of the cases had an in situ carcinoma found by local excision, whereafter bilateral subcutaneous mastectomy was performed in 38 cases. Five cases had already had an ipsilateral mastectomy and contralateral subcutaneous mastectomy was performed. The histological examination of the subcutaneous mastectomy specimens was extensive with breasts cut into 3-5 mm slices, which were embedded and cut in large sections and cut in large sections allowing us to map all lesions. 42.5 per cent of the contralateral breasts contained invasive or in situ carcinoma. In about 70 per cent of the cases other histological lesions, considered more or less precancerous, were found in the contralateral breast. Our results speak in favor of an active approach to the contralateral breast at reconstruction, especially in cases with a long life expectancy after the first carcinoma. It is psychologically comforting to the patient to know that most of the breast gland, which could be the future origin of a new carcinoma, has been removed.