Breast carcinoma

Comparing the Diagnostic Outcomes of Staining Various Breast Lesions with Either Anti-CK 5/6 or Anti-CK 5

Background and Objective:

Anti-CK5/6 monoclonal antibodies have an established role in breast disease diagnosis. Anti-CK5 monoclonal antibodies have recently become commercially available. There has been growing interest in the staining characteristics of anti-CK5 and its potential diagnostic role in place of anti-CK5/6. We aim to compare and contrast the staining characteristics of anti-CK5/6 vs anti-CK5.

Material and Methods:

58 tissue blocks containing 122 different lesions were selected from tissue archives. Two specimens (groups) were taken from each lesion One (group) was stained with anti-CK5 and the other (group) with anti-CK5/6 monoclonal antibodies, using the Streptavidin-biotin immuno-peroxidase method. The two groups of slides were compared and contrasted for lesion staining pattern and for intensity, using light microscopy.

Results:

Results showed that the diagnostic staining pattern was exactly the same in both anti-CK5 and anti-CK5/6 groups, and also showed that anti-CK5, stained most of the lesions more intensely than anti-CK5/6.

Conclusion:

Anti-CK5 performed at least as well (for lesion-pattern staining), and better (for lesion staining intensity) than did anti-CK5/6 in the diagnosis of a wide range of breast tissues and lesions. It may be justified to safely replace anti-CK5/6 with anti-CK5 in future routine clinical use, with resultant diagnostic and economic benefits.

Problems in Fine-Needle Aspiration Biopsy Cytology of Clinically or Mammographically Uncertain Breast Tumors

From June 1978 to December 1980 at the Istituto Nazionale Tumori of Milano, a fine-needle aspiration biopsy was performed on each of 4834 cases of palpable mammary nodules, the large majority of which were clinically and mammographically suspicious for cancer and only a small part clinically definitely positive. Of these, 1173 underwent surgery at this institution, and 534 (45.5%) had a histologically proven carcinoma. The aspirations were performed by individuals different from those who read the cytologic smears. The aspirations were never repeated, and methods for the retrieval of cells were never applied. Under the circumstances, sensitivity was 0.67, specificity 0.98, and the predictive value for positive results 0.97. The high percentage of inadequate samples (25.5%) influenced the low sensitivity. The few false-positive results occurred exclusively during the first year. Frozen sections can be avoided in those cases (about 50%) with definitely positive cytologic diagnosis by the application of strict criteria. The intrinsc incapability of cytology to yield any information on the extent and the invasiveness of a malignant lesion does not seem to effect its pre-operatory conclusiveness.

Breast Cancer: Primary Tumor Characteristics Related to Lymph Node Involvement

From November 1st 1977 to August 31st 1978, 842 consecutive patients with operable breast cancer were observed at the National Cancer Institute of Milan. Characteristics of the primary tumor and the status of regional lymph nodes were evaluated at clinical and postsurgical examination: it was found that qualitative characteristics of the primary were properly defined by clinicians, who usually overestimated maximum diameter of the primary. The status of regional lymph nodes is not reliable at clinical examination: 34.5 % of clinically uninvolved nodes were found to contain metastatic growth at histologic examination. Age of patients, maximum diameter of the primary, histologic type and quadrant of origin of the primary tumor were significantly related to the frequency of regional node metastases. Multifactorial analysis showed that the last three factors were independent variables, while age, which is significant by itself, loses importance when adjusted by at least one of the other three factors. Frequency of extension of node metastases beyond the lymph node capsule was found to be related to the number of involved nodes: maximum diameter, histologic type and site of origin are significantly related to the frequency of extracapsular invasion. This study confirms that the evaluation of the status of regional lymph nodes is not reliable at clinical examination and indicates that characteristics of the primary may be useful in predicting regional lymph node involvement. The direct correlation between the number of involved nodes and the frequency of infiltration beyond the capsule suggests that prognosis of patients with positive nodes depends more on this factor than on the number of involved nodes.

[Retrospective multivariate analysis of radio-pathological correlations of nonpalpable breast lesions. Experience of the Hospital Saint-Louis]

PURPOSE

Several studies have demonstrated that systematic breast cancer screening increases overall survival. We report our experience regarding diagnosis of breast lesions detected using mammography.

METHODS

Case reports of patients operated on in either 1992 or 1993 were retrospectively reviewed. A multivariate analysis of the clinico-pathological correlation was performed.

RESULTS

Four hundred fifty seven patients representing on total 544 procedures, were included in the study. Mean age was 50.5 years (range 19-80 years). Most of the patients had no previous history of mammary lesion. Mammography was performed with prophylactic intent in more than 60% of the cases. Four hundred twelve (75.7%) benign lesions were diagnosed. Main lesions were: adenofibroma (15.7%), fibrocystic mastopathy (66.3%), adenosis (26.2%), ductal hyperplasia (23.9%), lobular hyperplasia (10.7%), and combined ductal and lobular hyperplasia (8.5%). Hyperplasia accompanied by cytonuclear atypia was observed in 49 (11%) cases. One hundred thirty two (24.3%) malignant lesions were reported, including 69 (52.3%) invasive carcinomas and 63 (47.7%) in situ carcinomas. Only nine axillary lymph node dissections were positive and 75 minimal breast cancers were diagnosed. The multivariate analysis showed that only radiological signs are a risk factor for cancer. The relative risk for cancer when focus of irregular and vermicular microcalcifications are diagnosed is 4.2 (2.0-8.5). It is 5.6 (2.5-12.5) in case of spiculated opacity.

CONCLUSION

Exeresis following radiological prophylactic screening allows diagnosis of high-risk benign lesions and low-stage breast cancer. Radiological parameters are the most powerful predictive factors for malignancy.

Desmoplasia in benign and malignant breast disease is characterized by alterations in level of mRNAs coding for types I and III procollagen

Desmoplasia, the formation of excessive connective tissue surrounding some neoplasms, is a well documented, but incompletely understood phenomenon. To characterize the fibrotic response in benign breast conditions and malignancy, we examined the steady state levels of mRNA coding for types I and III procollagen in mild fibrocystic changes, in fibroadenoma, and in infiltrating ductal carcinoma. The results indicate that in mild fibrocystic change there is a relative increase in type III procollagen mRNA. In contrast, fibroadenoma and carcinoma are characterized by increased levels of type I procollagen mRNA.

Ultrastructure of human fetal mammary gland

Early cytodifferentiation of human fetal mammary gland was studied at the time of the beginning of the sexual differentiation during the sixth to eleventh developmental weeks. The gland appeared as a solid epithelial ingrowth into the underlying mesenchyme on both sides of the thoracic wall at the age of 5 weeks in both sexes. These ingrowths contained primitive glycogen-rich cells with large nuclei. The surrounding mesenchymal cells gathered around the basal lamina. These cells differentiated into fibroblasts, and collagen fibers were seen in the mesenchyme near the mammary buds. No lumina appeared within the buds during this study. Differences between the male and female mammary epithelium or mesenchyme were not observed, although androgen synthesis and secretion in the fetal testis had already begun. The close connections and concomitant differentiation of the mammary bud epithelium and mesenchyme during the early embryogenesis in this study suggest that epithelio-mesenchymal interaction plays an important role in the differentiation of human mammary gland.

Lymphatic metastasis and its treatment

The treatment of lymphatic metastasis depends on an understanding of its basic biology. We are still uncertain as to how human cancer cells enter lymphatic vessels and as to what reactions if any in the draining lymph node inhibit metastasis. We are uncertain as to whether lymphatic metastasis is an indicator or a governor of rapid dissemination, and poor prognosis. We are uncertain as to whether it is worth attempting to treat lymphatic metastases by means supplementary to those used in treating systemic tumour dissemination. It may be possible to obtain local cure of a local lesion by local lymphatic therapy and to concentrate therapy locally by intralymphatic infusion of a chemotherapeutic agent or encapsulation in liposomes. This is at best accessory to obtaining systemic cure of systemically disseminated neoplasm. Optimal results could be expected from appropriate combinations of local and systemic immunotherapy, chemotherapy and radiotherapy, after appropriate surgical reduction in tumour bulk.

Role of the regional lymph node in cancer metastasis

At an early phase of tumor growth, T-cell responses, i.e. the proliferation of T cells and the generation of cytotoxic T cells or killer-augmenting T cells are induced in the regional lymph node depending upon the immunological properties of the tumor cells. A small number of tumor cells seems to be rejected in the regional lymph node in situ. A progressive tumor induces suppressor activity in the regional node. Suppressor cells facilitate tumor growth and lead to lymphatic metastasis. Thus, the regional lymph node operates only as a temporary barrier to tumor growth. Experimental studies have demonstrated that eradication of the suppressor cells and effective immunization, or both, lead to tumor rejection by augmenting the immunological activity of the regional lymph node.

Mammary hyperplastic and preneoplastic changes: taxonomy and grading

Mammary lobular and ductal carcinoma in situ are thought to originate from preneoplastic precursors. Most of our knowledge on mammary tumorigenesis is based on experimental data obtained in rodents, which are focused on the biology of hyperplastic alveolar nodules (HAN). The morphology of HAN is analyzed and compared with possible analogous lesions in humans. The microarchitecture of the terminal duct lobular unit (TDLU) is described with reference to descriptions and nomenclature appearing in the literature. A comparison is intended between existing classifications of human hyperplastic and preneoplastic changes.

Reconstruction of the breast: where do we fall short? An evolution of ideas

We have analyzed our 5 year experience with 153 breast reconstructions. There were 83 latissimus dorsi reconstructions, 16 simple silicone implant insertions, 21 transverse rectus abdominus myocutaneous flaps, and 33 reconstructions using a variety of other methods. The rate of postoperative complications was 24 percent. The most common shortcoming was the inability to obtain symmetry with the other breast. Persistent problems included inability to fill the subclavicular hollow or the superior con-cavity due to partial atrophy of the pectoralis major muscle, and particularly, the lack of projection and ptosis in the reconstructed breast.

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.

Peanut lectin histochemistry of 120 mammary carcinomas and its relation to tumor type, grading, staging, and receptor status

Peanut lectin (PNL) is known to bind beta-D-galactosyl-(1-3)-N-acetyl-D-galactosamine, which provides antigenic determination of the Thomsen-Friedenreich antigen ( TFAg ). The aim of this study was to analyse the expression of peanut lectin binding sites in mammary carcinomas and to correlate these with tumor type, histological grading, staging and biochemical receptor status. The series comprised 120 invasive mammary carcinomas and 14 cases with normal breast tissue or benign epithelial proliferations as controls. In controls mainly luminal or apical PNL-binding was discovered, however, in all except three carcinomas a cytoplasmatic localisation of TFAg with three major patterns was found: diffuse, granular-globular and vacuolar reactions. The quantitative-qualitative evaluation of the PNL-staining revealed a statistically significant correlation between globular-vacuolar PNL-reaction and tumor type with a higher percentage of this type of reaction in invasive lobular carcinomas as opposed to tubular and invasive ductal carcinomas. Furthermore a statistically significant relationship was disclosed between PNL- histopositivity and estrogen positive - progesterone positive cases. However, the findings of contradictory PNL-status and hormone-receptor status illustrates clearly the difficulty of predicting the biochemical receptor status. No correlation was found between PNL-histochemistry, histological grading, and pathological staging. The practical implications of PNL-histochemistry of mammary carcinomas are discussed.

Fine-needle aspiration cytology in the management of breast disease

The results of a series of fine needle aspiration biopsies of breast lumps were reviewed to evaluate the accuracy of this diagnostic method and its place in the clinical management of breast lesions. A high level of diagnostic accuracy was achieved. There were no false positive diagnoses of malignancy and fewer than 3% of diagnoses were falsely negative. Eighty per cent of carcinomas could be confidently diagnosed by means of cytological investigation. The patient with a benign cytological diagnosis can either be reassured, or her surgical management planned as a day case. For the patient with a cytological diagnosis of malignancy, discussion of the nature of her surgery and subsequent care is possible before operation. In selected cases of carcinoma, mastectomy can be performed without frozen-section confirmation. Diagnostic accuracy is dependent upon experience, especially in aspiration technique, and optimum results are obtained if the pathologist/cytologist also performs the procedure.

Lymphatic metastasis

Lymphatic metastasis is an important mechanism in the spread of human cancer. During its course, tumor cells first penetrate the basement of membrane of the epithelium, in which they arise, and then the underlying connective tissue, carried partly by hydrostatic pressure. They enter the lymphatic partly by active movement, pass up the lymphatic trunk; they then settle and proliferate in the subcapsular sinus, penetrate its endothelium and proliferate and destroy the node. There are varied forms of immune response in the node and in human nodes often a complex fibrous and vascular response. The degree of lymphocytic response may be important for prognosis. The nodal reaction may be stimulated by release of antigens from the tumor. One of the most studied animal models of lymphatic metastasis is that which occurs in the politeal node after injection of tumor into the footpad. This model has been used to show that tumor cells enter lymphatics through gaps in endothelium, probably between endothelial cells, and that lymph nodes can destroy small numbers of tumor cells. Local immunotherapy and chemotherapy can sterilize a lymph node of tumor cells; the modes of treatment used have included intralymphatic injection and encapsulation of chemotherapeutic agents in liposomes. Prior radiotherapy may accelerate metastasis possibly by making tumor cells shed into lymphatic vessels. Lymph nodes are rather poor barriers to tumor cells. The prognostic significance of lymph node metastasis varies within tumor type; if hematogenous metastasis is early, then the presence of lymph node metastasis is of lesser prognostic significance. Lymph nodes can probably destroy only small numbers of tumor cells. Tumor cell heterogeneity is of importance in many aspects of metastasis; while clonal variation may be of importance in determining lymph node metastasis, it is not yet clear how important this is, nor whether specific clones metastasize specifically to lymph nodes. Lymphography is well established in diagnosis of lymphatic metastasis. A recent interesting development has been to inject antibodies labeled with a radioactive label, and image the label in lymph nodes with a gamma-camera. If anti-tumor antibodies are used in this way it may be possible to detect lymph node metastasis. Within the expanding field of tumor metastasis, lymphatic metastasis needs much more attention, particularly in relation to the diagnosis and treatment of the lymphatic spread of human cancer.

Current surgical management of in situ cancer of the female breast

Surgical procedures for breast cancer were compared in 468 cases with in-situ and 4,967 cases with invasive lesions. The cases were obtained from the Michigan Cancer Foundation Registry, a Surveillance, Epidemiology, and End Results (SEER) participant, and were incident-resident cases diagnosed from 1973-1978. For single, primary in situ or invasive cancer, the preferred mastectomy was modified radical. Partial and simple resections were used more often than radical procedures for non-infiltrating, especially lobular lesions. For cases with bilateral primates, with at least one in situ, the mastectomy of choice was the simple procedure for the in situ malignancy and modified radical for the invasive cancer. The change in preferred surgery for in situ lesions, from modified radical to simple mastectomy, was not due to any change in strategy for treatment of bilateral invasive disease, which remained modified radical resection.

Aspects of breast cancer control: is prophylactic mastectomy a feasible modality?

Even though mammographic techniques have improved and small tumors of 0.5 cm in diameter can be detected, decreased breast cancer mortality has not yet resulted. Because small tumors may cause systemic spread, in many patients breast cancer at the time of diagnosis is a systemic disease which is incurable. A reduction in breast cancer mortality seems possible by prophylactic bilateral mastectomy in women at extraordinary high risk of breast cancer. These are patients with (a) breast cancer in mother and sister, (b) breast cancer in mother or sister and a combination of various risk factors (early menarche - late menopause, nulliparity, late first pregnancy), (c) noninvasive malignant breast disease (carcinoma in situ), (d) therapy-resistant fibrocystic disease with intolerable pain and/or extreme anxiety (carcinophobia, and (e) benign breast neoplasia with malignant potentials (cellular atypia = precancerosis). Also, in breast cancer patients without regional and systemic spread and who are at high risk for developing cancer in the other breast, prophylactic contralateral mastectomy may be indicated. These are patients with (a) unilateral invasive breast cancer in the premenopause and a family history (mother or sister) of breast cancer, (b) unilateral invasive lobular carcinoma or tubular (ductal) carcinoma, and (c) unilateral invasive breast cancer and precancerous lesions in the other breast.

On the relevant model for human cancer

A conceptual structure for the relevancy assessment of cancer theories to clinical cancer is presented. The organism is stratified into hierarchies among which, the cell represents the lowest. Cells are aggregated into tissues and tissues, into organs. Organs are assembled into organ systems constituting the human organism. In each hierarchy an elementary unit, or holon is defined. Since structures in the organism are generally characterized by specific functions they perform, it is possible to define also hierarchies of functions and assess their importance quo ad vitam. This hierarchical classification serves here for the grouping of theories and observations in cancer. Genetic mutation or cell fusion for instance belong to the subcellular hierarchy. Observations made on single cells e.g. locomotion or adhesion, belong to the cell hierarchy. Tissue culture experiments are grouped into the tissue hierarchy, while carcinogen induced neoplasms are organ system hierarchy experiments. Medicine operates in the organismic hierarchy regarded herewith as the highest.

The influence of pathologic factors on breast cancer management

The pathologist routinely provides to the therapist data which are used in the management of breast cancer patients. Clinical as well as gross and microscopic examination provides information used for staging and treatment selection. Biologic neoplasia precedes the usual morphologic and cytologic changes that characterize precancer and in situ carcinoma to the pathologist. Minimal breast cancer, including in situ carcinoma and small (0.5 cm) infiltrating cancers, is now a recognized entity separable from clinical cancer, although therapy is not yet uniform. The pathologist can routinely report the gross size and contour of the cancer; microscopic evaluation of the primary cancer adds information on the histologic type, differentiation (histologic or cytologic grade), and such other data as blood vessel invasion and cellular infiltration. One of the most useful bits of information is the status of axillary lymph nodes: whether or not there are metastases, the number of nodes with metastases, and whether they are micrometastases or macrometastases that extend through the capsule and involve pericapsular vessels. All of these data can be recorded routinely and are useful in developing management criteria. The pathologist, as any other consultant, reports to the attending physician who then uses these data with all other pertinent facts to formulate an individualized therapeutic program.