December 1983, Volume 33, Issue 12

Original Article

Selected Abstracts

Tubular Carcinoma of the Breast; Clinical Pathologic Correlations Based on 100 Cases. George N. Peters, Marianne Wolff and C.D. Haagensen. Ann. Surg., 1981, 193: 138.
One hundred patients with tubular carcinoma of the breast were reviewed. The studies included a review of previously reported studies.
The patients with tubular carcinoma were divided into five groups-group 1 consisted of only pure tubular carcinoma of the breast; group 3 had 51 to 75 per cent tubular components, group 4 had 31 to 50 per cent tubular carcinoma and group 5, control group, had 5 to 30 per cent tubular carcinoma.
The axillary nodes in patients were examined for metastases; an average of 33 lymph nodes were studied in each instance. All patients bad periodic follow.up examinations through December 1979 or until death. The right breast was more frequently the site of pure tubular carcinoma, the ratio being 1.6 to 1. The upper outer quadrant was the most common location.
In group 1, none of the patients had metastases to the lymph node. There were no recurrences or deaths in the follow-up periods from three months to 20 years, mean five years. In group 2, the follow-up period was two to 27 years, mean seven years. Twenty patients had metastases to the lymph node or local recurrence.
There were two deaths not related to the carcinoma. In group 3, four of 16 patients had axillary metastases. Follow-up periods ranged from one to 15 years, mean five and one half years. All four patients were alive at one month, seven years, 11 years and five months after operation, respectively. In group 4,31 to 50 per cent tubular, 11 of 23 patients had metastases to the lymph node and viscera. Follow-up periods were two months to 16 years, mean six years. Fortyeight per cent of the patients had metastases and 17 per cent died of disease. In group 5, 5 to 30 per cent tubular, six of 24 patients, 25 per cent, bad axillary node metastases and four per cent died of their disease. Bilateral carcinomas were greater than the expected incidence in general and included three patients with bilateral tubular carcinoma.
On. the basis of the study, it is advised that lesions composed of 90 per cent or more of tubular carcinoma may be treated by simple mastectomy. Axillary dissection is not needed. For all carcinomas with a lower portion of tubula; elements, at least total mastectomy with axillary dissectiàn is indicated, although the safest treatment is probably radical mastectomy.
-John J. Hudock.

Staging of Breast Cancer; a New Rationale for Internal Mammary Node Biopsy. Monica Morrow and Roger S. Foster, Jr. Arch. Surg., 1981, 116:748.
Metastases to the lymph nodes, axillary, internal mammary, or both, define a group of patients at very high risk of having systemic micrometastases lead to death if surgical treatment alone is used. Patients with carcinoma of the breast, 7,070, in whom both axillaiy and internal mammary nodes were examined histologically were studied at the university of Vermont College of Medicine, Burlington, Vermont.
Five to ten per cent of the patients had internal mammary node metastases in the absence of axillary node metastases. With the availability of effective systemic therapy that can improve the survival of patients with metastases to the lymph node, biopsies of the internal mammary node become significant. Biopsies of the internal mammary node are recommended in patients with carcinoma of the breast who have medial and central primary tumors, 2cm. or greater, if a frozen section of the most suspicious node in the axillary dissection shows no histologic evidence of metastases.
-E. ThecdoreRbn.

Treatment of Primary Breast Cancer with Chemotherapy and Tamoxifen. Bernard Fisher, Carol Redmond, Ann Brown and others. N. Engl. J.Med., 1981,305:1.
The possibility that the addition of tamoxifen to L-phenylalanine mustard combined with 5-fluorouracil enhances the benefit from the latter two drugs that has been observed in women with primary carcinoma of the breast and positive a.xillary nodes was studied. Recurrence of disease was reduced at two years in patients who were given the three drug regimen whose tumor estrogen receptor levels were < 10 fmol. Among patients who were more than 50 years old treatment failure was significantly reduced, by 51 per cent in those with one to three positive nodes and by 64 per cent in those with four or more.
Higher receptor levels were associated with a greater probability of patients surviving free of disease. Patients who were less than 49 years old were less responsive. Those patients with one to three positive nodes received no benefit from tamoxifen at any receptor level; whereas, those with four or more appeared to have reduced treatment failure associated with higher receptor levels. This adjuvant chemotherapy is not indicated in patients who are less than 49 years old whose tumor receptor levels are below 10 fmol. It was suggested that patients who are more than SQ years old whose levels are low would benefit from this treatment.
-Ernest D. Bloomenthal.

Breast Cancer. A. B. Miller. Cancer, 1981. Suppi., 47:1109.
The role of dietary risk factors in carcinoma of the breast is presented. Carcinoma of the breast is the most prevalent cancer of women in North America and the most important single cause of death from cancer in women between the ages of 35 and 54.
Four lines of evidence support the importance of dietary factors. The first is derived from animal experimental studies both in the presence and absence of mammary carcinogens. The feeding of high fat diets increases the incidence of mammary carcinoma in rats. The second line of evidence comes from population correlation studies which show a strong correlation between carcinoma of the breast incidence or mortality and total dietary fat intake. The third line of evidence is derived from data which demonstrates the importance of height and weight as risk factors for carcinoma of the breast. The final line of evidence comes from a patient control study in Canada in which an attempt was made to directly assess the dietary intake in patients. From these studies there is some evidence of an association between total fat intake and carcinoma of the breast in premenopausal and postmenopausal women.
In conclusion, it is stated that it seems unlikely that an approach to prevention of carcinoma of the breast based on hormonal risk factor could have any impact on carcinoma of the breast in the foreseeable future. However, results of studies point to the probability of nutritional factors as relevant. To change these would require a change in our life style. This would require public education and the time is ripe for an active program in evaluating the above factors both as aspects of national policy and special investigation in defmed population groups.
-John J. Hudock.

Subcutaneous Mastectomy and Breast Replacement; its Role in the Treatment of Benign, Premalignant, and Malignant Breast Disease. Phfflip K. Blevins.Am. Surg., 1981, 47:281.
Subcutaneous mastectomy is the removal of most, but clearly not all, of the glandular tissue of the breast with the intent of reconstruction to a normal appearance. The indications, which are likely to be modified with time and experience, include mammary dysplasia, contralateral malignant condition of the breast, mastodynia and possibly minimal noninvasive carcinoma of the breast.
Several facts should be impressed upon the patient preoperatively: some breast tissue will remain and regular breast examination will be required, the removed tissue will be subjected to pathologic examination and the discovery of an unsuspected malignant condition will mandate more radical operation, and the procedure carries with it the certainty of scarring and the risk of hematoma, infection, flap necrosis, implant extrusion and capsular contracture.
The incision is most commonly placed in the inframammary fold and should allow re-excision if necessary. Operative margins shoffid he wider for premalignant than for benign disease and should in the former instance probably include the pectoral fascia and the nipple areolar complex. Delayed reconstruction should be considered in patients with impaired or questionable circulation to the skin flaps, possible contamination from infected lesions, from possible malignant conditions or to give the patient time to appreciate the deformity.
-Michael G. Cedars.

Survival Following Breast Cancer Surgery in the Elderly. Horace Herbsman, Joseph Feldman, Juanilito  Seldera and others. Cancer, 1981, 472358.
A retrospective analysis was performed upon a series of 780 patients with carcinoma of the breast who underwent operation. There seemed to be a larger proportion of localized instances in the elderly group of patients than in the younger group of patients. The group of patients under 50 years appeared to have more instances regional metastases. There was no difference in the present series in survival among the various age groups for those who were treated by radical mastectomy. The elderly group of patients who were treated with simple mastectomy did not do as well as those with radical operations. This may be a matter of selection since often elderly incapacitated patients are treated with simple mastectomy.
A group of 63 elderly patients who were examined for the exact cause of death showed no postoperative death which suggests that the operative mortality is not increased by age alone. The ability of the elderly to tolerate operation for carcinoma has been demonstrated at the Memorial Hospital. While it has been argued that the limited life expectancy of the elderly is a basis for withholding more extensive operation, reduced life expectancy should not be a deterrent to surgical therapy since 90 per cent of the patient population age 70 and 73 per cent of those age 75 and 63 per cent of those age 80 are expected to survive five years. The present results of the studies indicate that the elderly patient with carcinoma of the breast can attain a survival rate equal to that of the younger patient with carcinoma of the breast when treated by conventional surgical therapy.
-Rudolph W. Roesel.

Stage III Carcinoma of the  Breast; a Detailed Analysis.  A. A. Fracchia, J.F. Evans and B.L . Eisenberg. Ann. Surg., 1980, 192:705.
A ten year detailed follow-up study of 488 patients with Stage III carcinoma of the breast has convinced the authors of the importance of the predictive value of involvement of axifiary lymph nodes, irrespective of the presence of other clinical signs and symptoms and the importance of aggressive treatment of patients from the beginning. Four hundred and thirty patients with metastases to the axifiary nodes had five and ten year recurrence rates of 68 and 77 per cent, respectively, with corresponding survival rates of 41 and 21 per cent. Of the 58 patients without metastases to the nodes, 82 per cent were alive at five years and 75 per cent were alive at ten years.
It is strongly believed that skin edema, infiltration, or ulceration should not be taken as evidence of poor prognosis and allowed to influence primary surgical treatment toward operations which are too conservative. Only a study of lymph nodes is a reliable prognosticator.
-John E. Jesseph.

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