Adenoid cystic carcinoma of the breast: mammographic appearance and pathologic correlation

OBJECTIVE: The objective of our study was to describe the mammographic features of adenoid cystic carcinoma of the breast and to correlate mammography findings with histopathologic findings. CONCLUSION: Adenoid cystic carcinoma is a rare type of breast neoplasm that usually appears as a slowly enlarging nodule. In spite of its low incidence, recognition is important because early detection ensures good prognosis. On mammography, these tumors often appear as moderately circumscribed, lobulated nodules that are similar to other types of benign and malignant tumors. Therefore, cytologic and histologic evaluations are needed for accurate diagnosis.     

Metaplastic carcinoma of the breast: mammographic appearance with pathologic correlation

OBJECTIVE: The objective of this study was to describe the mammographic appearance with pathologic correlation of metaplastic carcinoma of the breast. CONCLUSION: Metaplastic carcinomas of the breast are masses with mammographic characteristics of low suspicion because of their histologic appearance. Metaplastic carcinoma should be included in the differential assessment of predominately circumscribed, noncalcified masses revealed on mammography. One salient feature that may distinguish metaplastic carcinomas is the occurrence of a circumscribed portion with a spiculated portion, which is seen in carcinomas that have a significant mixture of metaplastic and invasive carcinoma growth patterns.     

Angiogenin expression and prognosis in primary breast carcinoma

Angiogenin is a protein originally isolated as an inducer of new blood vessel growth, and it has been reported to be an effective substrate for tumor cell adhesion. To understand the role of angiogenin in cancer progression, we evaluated the expression of angiogenin in 459 cases with primary breast carcinoma and in 40 benign breast specimens using an immunoassay. Higher angiogenin concentrations were observed in carcinomas in comparison with fibrocystic disease (mean, 17.3 versus 10.9 ng/mg; P = 0.008), but not with fibroadenomas. We selected 5 ng/mg cytosol protein of angiogenin as the normal cutoff for primary breast carcinoma. Eighty-eight percent of carcinomas expressed elevated angiogenin levels and 12% had low levels. We observed an association between elevated levels of angiogenin and low/ moderate histological grade (P = 0.001) and small tumor size (P = 0.026), but not with age, menopausal status, lymph node status, stage of disease, or hormonal receptor status. With a median follow-up of 31 months, breast cancer patients with elevated angiogenin levels had significantly longer disease-free survival (DFS) than patients with low angiogenin (log-rank, P = 0.003). This effect was equally observed in node-negative and node-positive cases. In a multivariate analysis of DFS, only angiogenin, tumor size, and histological grade showed statistical significance. A multivariate analysis of overall survival showed that angiogenin and tumor size were the only significant variables. Serum samples from the breast cancer patients at the time of surgery were available in 194 cases. We evaluated the levels of circulating angiogenin using the same immunoassay as in tumor tissue. Serum angiogenin levels were higher in cancer patients than in 40 healthy controls (mean, 401.2 versus 206.0 ng/ml; P < 0.0001). In breast cancer patients, we observed no correlation between the serum concentrations and the tissue levels of angiogenin (r = 0.115; P = 0.110). In addition, serum levels of angiogenin did not have a prognostic impact on the DFS of breast cancer patients (log-rank, P = 0.581). Our results indicate that elevated levels of tissue angiogenin, but not of circulating angiogenin, are a favorable prognostic factor in primary breast carcinoma, which is consistent with a role of angiogenin as a cancer cell substrate.     

Ductal carcinoma in situ of the breast: correlation of pathologic and mammographic features with extent of disease

Optimal treatment of ductal carcinoma in situ (DCIS) of the breast requires an improved understanding of its pathologic extent and propensity for local recurrence. This study was performed to analyze mammographic and pathologic features of DCIS that might predict the extent of disease within the breast and facilitate treatment selection between lumpectomy alone, lumpectomy and radiotherapy, and mastectomy. At our institution, 60 cases of DCIS were diagnosed in 59 patients from June 1985 to February 1995 and form the basis of this retrospective study. Demographic and treatment-related information was obtained from hospital and tumor registry records. Mammograms were reviewed and size estimates of the abnormalities were determined. Pathologic slides from all cases were reviewed and classified according to size group, focality, nuclear grade, necrosis, and histologic subtype. DNA ploidy status and proliferation indices were available for 28 patients. Pathologically, 43 (72%) cases were < 15 mm, 14 (23%) were 16 to 40 mm, and 3 (5%) were > 40 mm. Five (8%) of the lesions were multicentric, 28 (47%) focal, and 27 (45%) multifocal. Thirty-three (55%) patients were treated by mastectomy, 16 (27%) by lumpectomy alone, and 11 (18%) by lumpectomy and radiation therapy. Mammographic size, histologic grade, presence or absence of necrosis, histologic subtype, DNA ploidy, and proliferative index were compared with pathologic size and focality by chi 2 analysis. Mammographic size correlated significantly with pathologic size (chi 2 = 11.3; P = 0.02) but underestimated the extent of disease in 9 cases. Although focality correlated significantly with pathologic size (chi 2 = 15.8; P = 0.003), the remaining histopathologic features did not significantly correlate with pathologic size or focality. Histopathologic features, including DNA studies, do not reliably predict the pathologic extent of DCIS, but mammographic size and focality do significantly correlate with pathologic size. Nevertheless, most cases of DCIS are small focal or multifocal lesions that are amenable to breast conservation approaches; further studies are needed to determine the appropriate use of lumpectomy, radiation therapy, and mastectomy in the treatment of DCIS.     

int-2 oncogene amplification and prognosis in node-negative breast carcinoma

The role of int-2 oncogene amplification on the prognosis of breast cancer patients was investigated in 128 patients with node-negative primary breast cancers given first-line local-regional treatments until relapse and with a median follow-up of 65 months. Tumours had been previously characterised for oestrogen (ER) and progesterone receptor (PgR) status and proliferative activity (3H-thymidine labelling index). Amplification of the int-2 oncogene occurred in 18% of cases and was significantly related to the presence of hormone receptors and to menopausal status or age, but not to proliferative status. Patients with tumours exhibiting int-2 amplification had a lower probability of disease-free survival than patients with non-amplified tumours and frequently developed local-regional recurrence. Disease-free survival analysis, adjusted for the prognostic contribution provided by tumour size, steroid receptors and proliferative rate, indicated that the association between int-2 amplification and risk of relapse was maintained and remained constant even in the presence of the other co-variates. Interestingly, int-2 amplification was a further prognostic discriminant within subsets of patients with a putatively good (i.e., tumour size <20 mm, ER+ and PgR+) or poor prognosis (i.e., high labelling index). Our exploratory study suggests that within node-negative patients, int-2 amplification could be a valuable and independent prognosticator, useful to identify patients at high risk of local-regional recurrence.     

CT appearance of the normal and abnormal breast with mammographic correlation

Mammography is the preferred technique to evaluate the breast but computed tomography (CT) performed for extramammary disease often images breast tissue. We reviewed studies of patients who underwent both CT and mammography to identify abnormalities that were visible with both techniques. The CT appearance of the normal breast, breast cancer, and several other abnormalities is demonstrated in this study. CT may occasionally allow for a precise diagnosis of a previously unsuspected breast lesion but a mammogram is usually required.     

Brain metastases of bronchial and breast carcinoma. Differences in metastatic behavior and prognosis

Evaluation of 135 cases with brain metastases from non-small-cell lung cancer (group 1) compared with 51 cases from small-cell lung cancer (group 2) and 56 cases from breast cancer (group 3) showed that the frequency of solitary metastases was significantly higher in group 1 and 3. However, in group 2 lesions without surrounding edema occurred more frequently. The rate of patients with extracerebral metastases was significantly higher in groups 2 and 3. The longest median interval between primary tumor and brain metastases was observed in breast cancer patients. The highest local remission rate was seen in small-cell lung cancer if patients who received whole-brain irradiation of 30 Gy alone were compared (63% vs 45% in group 1 and 52% in group 3). However, with regard to clinical course no significant differences were recorded. Survival of lung cancer cases was similar, whereas breast cancer cases survived significantly longer, both after radiotherapy alone and after surgery plus radiotherapy. This might be caused by differences in the natural course of the two diseases as well as adjuvant treatment modalities like hormone and chemotherapy. In conclusion, because long-term survivors were observed only in the breast cancer group, these patients probably have the highest chance of profiting from a locally aggressive treatment approach.     

Analysis of mammographic density and breast cancer risk from digitized mammograms

To evaluate the association between mammographic density and breast cancer risk, a simple, observer-assisted technique called interactive thresholding was developed that allows reliable quantitative assessment of mammographic density with use of a computer workstation. Use of this technique helps confirm that mammographic density is one of the strongest risk factors for breast cancer and is present in a large proportion of breast cancer cases. The strong relationship between mammographic density and breast cancer risk suggests that the causes of breast cancer may be better understood by identifying the factors associated with mammographically dense tissue and determining how such tissue changes as these factors vary. Furthermore, because it can be modified, mammographic density may also be a good vehicle for the development and monitoring of potential preventive strategies. Areas of ongoing investigation include evaluating a potential genetic component of mammographic density by comparing density measurements in twins and understanding changes in density relative to age, menopausal status, exogenous hormone use, and exposure to environmental carcinogens. In addition, work is ongoing to establish measurements from imaging modalities other than mammography and to relate these measurements directly to breast cancer risk.     

Parity and prognosis in breast cancer

Analysis of five-year disease-free survival rates in 608 women with operable breast cancer revealed that the reproductive history is a significant prognostic determinant. Overall parous women had a significantly higher cumulative five-year disease-free survival rate (60%), compared to the nulliparous (46%) (z = 2.5, p = 0.012). Significant differences were also noted when gravidity in addition to parity was taken as the determinant. The corresponding disease-free survival rates were 61% and 50%, respectively (z = 1.98, p = 0.048). Five-year survival rates were influenced in a similar manner by these variables but the observed differences were less significant. The trend toward higher survival rates in parous and gravidae women were noted in all tumor stages but achieved statistical significance only in stage III. The findings indicate that parity and gravidity affect not only the risk of breast cancer development but also the subsequent course of the disease. Parity seems to be a strong risk and prognostic factor than gravidity.     

Inflammatory carcinoma of the breast

Eighty-six patients with the clinical features of inflammatory carcinoma of the breast (erythema, peau d'orange, wheals or ridges) were treated with irradiation for potential cure between July 1948 and December 1970. Long protracted irradiation alone with a strong skin reaction offers 50% local control, which is the best rate yet reported. Any surgical procedure beyond biopsy is probably damaging: all patients subjected to mastectomy developed distant metastases and died. Ninety per cent of the patients were dead by five years and only 3 patients remain alive without evidence of disease 7, 10 and 14 years after radiotherapy. Analysis of survival rates, incidence, sites and times of appearance of local recurrences, and distant metastases is presented.     

Tubulolobular carcinoma of the breast

To assess the adequacy of antihypertensive treatment in the French population, a survey was conducted from October 1990 to April 1991 in five French cities during sales exhibitions. A total of 7107 individuals visited the stand of the French National Committee to have their blood pressure (BP) measured. Among them, 1289 were treated hypertensive subjects fully aware of their treatment. The efficacy of antihypertensive treatment was assessed in this population. Among those hypertensive treated subjects 35 to 65 years old, 60% had a BP < 160/95 mm Hg and 27% < 140/90 mm Hg. Among those > 64 years of age, 44% had a BP < 160/90 mm Hg. In 1992, these results were included in a publication by the World Hypertension League. Data obtained with this new and interesting approach were reviewed 4 years later. The approach is inexpensive (the equivalent of US $28,000) and made it possible to directly inform thousands of people, normotensive and hypertensive, about arterial hypertension and antihypertensive drug therapy, as well as risk factors for cardiovascular disease. This kind of approach may be worth a strict evaluation, to assess whether it is really useful in improving high blood pressure control in the population.     

Stereotactic fine needle aspiration in the management of mammographic abnormalities detected in breast screening

BACKGROUND: Fine needle aspiration (FNA) is used routinely in the management of palpable breast lumps; with the implementation of the stereotactic technique its use has been extended to the investigation of mammographic abnormalities. The advent of breast screening means that many mammographic abnormalities will be detected; because routine open biopsy is impractical and undesirable, stereotactic fine needle aspiration becomes the method of choice for investigation. METHOD: Within a 28 month interval, 81 Chinese women underwent stereotactic FNA in Kwong Wah Hospital, Hong Kong. RESULTS: Fifty-one women (62.9%) had a benign cytology result and no further investigations were required. Inconclusive results were obtained in 18.6% of the aspirates. Open biopsy was required in 16 women (19.8%). CONCLUSION: Stereotactic FNA is very useful in the exclusion of malignancy and the avoidance of open biopsy in asymptomatic women who have mammographic abnormalities.     

Survival and prognosis in renal carcinoma

A study of the survival and prognosis of renal cancer was performed in 97 patients in different stage of the disease. Mean survival was 2.9 years for males and 3.1 years for females (no statistical significance as to sex). It was shown that with advancing stage of the disease decreased patient survival (T-2 = 4.1 yrs., T-3A = 2.5 yrs., T-3B = 1.3 yrs). The same tendency was observed to a higher degree in N-stage, according to the TNM classification: no single patient survived in N-2 stage beyond 3 years. Observations in M-2 stage showed a much shorter survival time: there was no survival beyond 1 year in M-2 stage.     

A mammographic evaluation of the morphostructural variations of the breast during hormone-replacement therapy in the postmenopause

OBJECTIVE: To compare i.v. ketorolac with i.v. prochlorperazine as the initial treatment of migraine headaches in the ED. METHODS: A prospective, double-blind comparison study was performed, using a convenience sample of 64 patients suffering from migraine headaches presenting to the ED at a tertiary care university teaching hospital. Patients were randomly assigned to receive either 10 mg of prochlorperazine i.v. or 30 mg of ketorolac i.v.. Patients scored the severity of their headaches using a 10-cm visual analog pain scale. An initial mark was made on the scale at the time of entry into the study and later another mark was made on a new unmarked pain scale 1 hour after medication administration. Changes in pain scores within each treatment group and between groups were analyzed using the Wilcoxon rank sum test. RESULTS: Prior to treatment, the patients assigned to receive prochlorperazine had a median score of 9.2 cm (mean +/- SD pain score of 8.3 cm +/- 2.1 cm), while the patients receiving ketorolac had a median score of 9.0 (mean pain score of 8.4 cm +/- 1.7 cm). There was no significant difference between the pain scores of the participants in the 2 groups prior to treatment (p = 0.80). One hour after medication administration, the patients in the prochlorperazine group had a median score of 0.5 cm (mean 2.1 +/- 3.2 cm), while those patients receiving ketorolac had a median pain score of 3.9 (mean 4.0 +/- 3.3 cm). The decrease in pain score was significant for both groups of patients (p = 0.0001). The change in pain score for the patients in the prochlorperazine group (median 7.1) was significantly greater than the change in pain score for the patients in the ketorolac group (median 4.0; p = 0.04). CONCLUSION: Although both drugs were associated with a significant reduction in pain scores, benefit over a placebo agent was not tested. Furthermore, the patients who received prochlorperazine i.v. for migraine headaches had a statistically significant greater decrease in their pain scores than did those receiving ketorolac i.v.     

The cost-effectiveness of mammographic screening strategies

OBJECTIVE: To compare and analyze the cost-effectiveness of different mammographic screening strategies. DESIGN: A computer simulation model was developed to compare mammographic screening with observation without screening. Cost-effectiveness was expressed as marginal cost per year of life saved (MCYLS) and was calculated for the following mammographic screening strategies: (1) annual for ages 40 to 79 years; (2) annual for ages 50 to 79 years; (3) biennial for ages 50 to 79 years; (4) annual for ages 40 to 49 years with biennial for ages 50 to 79 years; (5) annual for ages 40 to 64 years with biennial for ages 65 to 79 years; (6) biennial for ages 40 to 49 years with annual for ages 50 to 79 years; and (7) annual for high-risk and biennial for normal-risk women aged 40 to 49 years with annual for ages 50 to 79 years. DATA SOURCES: The probability and cost of all outcomes were established from previously published data or community experience. RESULTS: The most cost-effective screening strategy is biennial mammography for women aged 50 to 79 years, with an MCYLS of $16,000. Adding annual mammography for women aged 40 to 49 years increases the MCYLS to $20,200, but is more cost-effective than other tested protocols that included women in their 40s; annual mammography for ages 40 to 49 years with biennial for ages 50 to 79 years is also more cost-effective than annual mammography for ages 50 to 79 years. CONCLUSION: Screening programs that include women in their 40s can be as cost-effective as some that exclude such women. Choice of a screening strategy depends on financial resources and desired effectiveness.     

Relationship between mammographic screening intervals and size and histology of ductal carcinoma in situ

We have explored the nature of the sudden viral amplification observed during the ageing of P22-infected lysogenic colonies of Salmonella typhimurium [Ramírez, E, and Villaverde, A. (1997) Gene 202, 147-149]. By a comparative analysis of the wild-type P22 and a P22 integration mutant, it has been shown that the conditions promoting prophage induction occur in only a small portion of the bacterial population and briefly during the transition between the exponential growth and the stationary phase. The viral burst is RecA-dependent and cannot be reproduced in continuous culture by a mere decrease of the growth rate. This suggests that the limited viral propagation in colonies is probably linked to heterogeneous physiological conditions within colonial populations, distinct from those of the homogeneous liquid cultures.