Not All
Nonpalpable Breast Cancers Are Alike
Dido Franceschi, MD; Joseph P. Crowe, MD; Sutek Lie, MD; Renate Duchesneau, MD; Robert Zollinger, MD; Robert Shenk, MD; Gladys Stefanek, RN; Jerry M. Shuck, MD, DSC
and mammographic data of 1009 consecutive patients were correlated with histopathologic data of 1144 biopsy specimens of nonpalpable breast lesions to better define the presentation and biologic behavior of early breast cancer. Patients with malignant neoplasms (269 [24%] of 1144 specimens) were older (mean age, 62.1 years) than patients with benign lesions (mean age, 54.9 years). Furthermore, patients with invasive disease were older (mean age, 63.3 years) than patients with noninvasive disease (mean age, 58.5 years) with an overall increased risk of invasive cancer per year of 1.035. A 58% incidence of invasive cancer was detected for lesions characterized by calcifications, while the incidence of invasive cancer was 84% for isolated mass lesions (relative risk, 4.31 for masses). Isolated mammographic calcifications associated with cancer appeared in a younger population and were significantly associated with noninvasive ductal cancer. Breast cancer presenting as a mammographic mass appeared in an older group and was highly associated with the presence of invasive dis\s=b\ Clinical
ease.
(Arch Surg. 1991;126:967-971) characterized by clinical facets of breast Themarked heterogeneity. Analysis of the breast and 19731 Connecticut between cancer are
cancer
mortality
rates in
1950 at least two forms of
supports the concept that there are breast cancer: an aggressive form, which accounts for most of the morbidity and mortality, and an indolent form. The recognition that patients at extreme ends of the disease spectrum are very different provides a basis for attempting to identify factors that would define this heterogeneity. This might help recognize groups of patients likely to ben¬ efit uniquely from one treatment strategy or another. Intuitively, one might assume that the preclinical phase of breast cancer should demonstrate similar variation in behavior. However, the biologic behavior of early breast cancer is still poorly understood. The widespread use of Accepted for publication April 28, 1991. From the University Hospitals of Cleveland (Ohio), Case Western
Reserve University. Read before the 98th Annual Meeting of the Western Surgical Association, Scottsdale, Ariz, November 12, 1990. Reprint requests to the Department of Surgery, University Hospitals of Cleveland, 2074 Abington Rd, Cleveland, OH 44106 (Dr
Crowe).
screening mammography during the last decade has re¬ sulted in a striking increase in the detection of nonpalpable
breast carcinoma.2"5 Because of the marked variability in clinical course, there has been considerable interest in identifying the important characteristics predictive of tu¬ mor behavior. We prospectively studied 1009 consecutive patients who underwent 1144 breast biopsies for mammographically suspicious, nonpalpable lesions. Histopathologic data were correlated with host characteristics and mammographie patterns in an attempt to better un¬ derstand the presentation and biologic behavior of early breast cancer. PATIENTS AND METHODS We prospectively studied 1009 consecutive patients who un¬ derwent breast biopsy for 1144 suspicious, nonpalpable lesions identified with mammography. Suspicious mammographie find¬ ings were classified as follows: (1) a mass or density; (2) calci¬ fications; or (3) a mass with associated calcifications. The decision to proceed with the breast biopsy was made before data were collected for this study. Two hundred sixty-nine cancers were identified in this group of patients. The study of these cancers represents the main focus of this report. Immediately before surgery, information concerning specific features of the mammogram were reclassified by two senior mammogram radiologists; these classifications were indepen¬ dent of the initial mammogram interpretation and recommen¬ dation. Demographic and clinical data were gathered by interviewing the patient before surgery and were entered in our Breast Center database. Clinical data collected included age, race, family his¬ tory of breast cancer, history of fibrocystic disease, menarche, age at birth of first child, number of pregnancies, menopausal status, and use of birth control pills. Tabulated data were correlated with mammographie and histopathologic findings after these results were obtained. In all cases, preoperative localization was performed by the radiologists using a hooked wire technique.6 An excisional bi¬ opsy was performed in the operating room using local or general anesthesia. All specimens were examined radiographically after excision to verify that the lesion was totally removed. Pathologic examination of the specimens was done by an in¬ vestigator blinded to the mammographie interpretation. The bi¬ opsy specimens were embedded in paraffin wax, cut in multiple sections, and processed in standard fashion. For this study, breast cancer was classified as ductal or lobular and in situ or invasive. Histologie findings in each biopsy specimen were tab¬ ulated and added to our database. Statistical methods used when appropriate included x2 anal¬ ysis with Yates' correction, Fisher's Exact Test, Student's f test,
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/11/2015
Histologie Distribution of Carcinoma and Age No. of Patients (Mean
Mammogram
Findings
Calcifications Mass
Calcifications and Total *P
Nonpalpable Breast Cancers Are Alike
Dido Franceschi, MD; Joseph P. Crowe, MD; Sutek Lie, MD; Renate Duchesneau, MD; Robert Zollinger, MD; Robert Shenk, MD; Gladys Stefanek, RN; Jerry M. Shuck, MD, DSC
and mammographic data of 1009 consecutive patients were correlated with histopathologic data of 1144 biopsy specimens of nonpalpable breast lesions to better define the presentation and biologic behavior of early breast cancer. Patients with malignant neoplasms (269 [24%] of 1144 specimens) were older (mean age, 62.1 years) than patients with benign lesions (mean age, 54.9 years). Furthermore, patients with invasive disease were older (mean age, 63.3 years) than patients with noninvasive disease (mean age, 58.5 years) with an overall increased risk of invasive cancer per year of 1.035. A 58% incidence of invasive cancer was detected for lesions characterized by calcifications, while the incidence of invasive cancer was 84% for isolated mass lesions (relative risk, 4.31 for masses). Isolated mammographic calcifications associated with cancer appeared in a younger population and were significantly associated with noninvasive ductal cancer. Breast cancer presenting as a mammographic mass appeared in an older group and was highly associated with the presence of invasive dis\s=b\ Clinical
ease.
(Arch Surg. 1991;126:967-971) characterized by clinical facets of breast Themarked heterogeneity. Analysis of the breast and 19731 Connecticut between cancer are
cancer
mortality
rates in
1950 at least two forms of
supports the concept that there are breast cancer: an aggressive form, which accounts for most of the morbidity and mortality, and an indolent form. The recognition that patients at extreme ends of the disease spectrum are very different provides a basis for attempting to identify factors that would define this heterogeneity. This might help recognize groups of patients likely to ben¬ efit uniquely from one treatment strategy or another. Intuitively, one might assume that the preclinical phase of breast cancer should demonstrate similar variation in behavior. However, the biologic behavior of early breast cancer is still poorly understood. The widespread use of Accepted for publication April 28, 1991. From the University Hospitals of Cleveland (Ohio), Case Western
Reserve University. Read before the 98th Annual Meeting of the Western Surgical Association, Scottsdale, Ariz, November 12, 1990. Reprint requests to the Department of Surgery, University Hospitals of Cleveland, 2074 Abington Rd, Cleveland, OH 44106 (Dr
Crowe).
screening mammography during the last decade has re¬ sulted in a striking increase in the detection of nonpalpable
breast carcinoma.2"5 Because of the marked variability in clinical course, there has been considerable interest in identifying the important characteristics predictive of tu¬ mor behavior. We prospectively studied 1009 consecutive patients who underwent 1144 breast biopsies for mammographically suspicious, nonpalpable lesions. Histopathologic data were correlated with host characteristics and mammographie patterns in an attempt to better un¬ derstand the presentation and biologic behavior of early breast cancer. PATIENTS AND METHODS We prospectively studied 1009 consecutive patients who un¬ derwent breast biopsy for 1144 suspicious, nonpalpable lesions identified with mammography. Suspicious mammographie find¬ ings were classified as follows: (1) a mass or density; (2) calci¬ fications; or (3) a mass with associated calcifications. The decision to proceed with the breast biopsy was made before data were collected for this study. Two hundred sixty-nine cancers were identified in this group of patients. The study of these cancers represents the main focus of this report. Immediately before surgery, information concerning specific features of the mammogram were reclassified by two senior mammogram radiologists; these classifications were indepen¬ dent of the initial mammogram interpretation and recommen¬ dation. Demographic and clinical data were gathered by interviewing the patient before surgery and were entered in our Breast Center database. Clinical data collected included age, race, family his¬ tory of breast cancer, history of fibrocystic disease, menarche, age at birth of first child, number of pregnancies, menopausal status, and use of birth control pills. Tabulated data were correlated with mammographie and histopathologic findings after these results were obtained. In all cases, preoperative localization was performed by the radiologists using a hooked wire technique.6 An excisional bi¬ opsy was performed in the operating room using local or general anesthesia. All specimens were examined radiographically after excision to verify that the lesion was totally removed. Pathologic examination of the specimens was done by an in¬ vestigator blinded to the mammographie interpretation. The bi¬ opsy specimens were embedded in paraffin wax, cut in multiple sections, and processed in standard fashion. For this study, breast cancer was classified as ductal or lobular and in situ or invasive. Histologie findings in each biopsy specimen were tab¬ ulated and added to our database. Statistical methods used when appropriate included x2 anal¬ ysis with Yates' correction, Fisher's Exact Test, Student's f test,
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/11/2015
Histologie Distribution of Carcinoma and Age No. of Patients (Mean
Mammogram
Findings
Calcifications Mass
Calcifications and Total *P
