Microscopic extracapsular extension in the axilla: is this an indication for axillary radiotherapy?

PURPOSE: Although the axilla is often treated with radiotherapy (RT) postoperatively when microscopic extracapsular extension (ECE) of lymph nodal metastases is present, little data are available to assess axillary failure in the absence of such treatment. As it has been the practice at this institution to withhold axillary irradiation in the presence of microscopic extracapsular spread, we retrospectively analyzed our results for axillary recurrence, disease-free survival (DFS), and overall survival (OS). METHODS AND MATERIALS: Clinical records were reviewed of 82 women with Stage II node positive breast cancer treated with lumpectomy, axillary dissection, and RT in addition to systemic chemo/hormonal therapy. Axillary surgery consisted of a level I, II, +/- III dissection, with a median of 16.5 nodes removed. Tangential radiotherapy fields were used to treat the breast. All patients were also treated with an abbreviated supraclavicular field with the lateral border medial to the humeral head. Pathological sections were available for review in 72 of the 82 women. RESULTS: Twenty-seven of 72 (37.5%) had evidence of ECE; 45 of 72 (62.5%) had metastatic carcinoma confined within the nodal capsule. Clinical characteristics were comparable between the patients with and without ECE with the exception of (a) pathologic subtype, with a greater percentage of infiltrating ductal tumors associated with ECE (p = 0.044), and (b) number of positive lymph nodes, with 93% of patients without ECE having one to three positive nodes vs. only 56% among patients with ECE (p < 0.001). With a median follow-up of 40 months, 1 of 27 patients (4%) with ECE experienced an axillary failure as a component of first failure compared to 0 of 45 patients without ECE (p = 0.4). There were no isolated axillary failures. Five-year disease-free survival (72% without ECE vs. 57% with ECE, p = 0.12) and overall survival (83% vs. 53%, respectively, p = 0.068) suggested a less favorable outcome for patients with ECE. CONCLUSIONS: Microscopic ECE appears to be associated with increased axillary involvement and decreased survival rather than subsequent axillary failure. Our data suggest that radiotherapy to a dissected axilla may be omitted for the sole indication of microscopic extracapsular disease.

Metaplastic carcinoma of the breast. A clinicopathologic study of 29 patients.

The clinical and pathologic findings in 29 patients whose primary breast neoplasm manifested the microscopic pattern of spindle cell carcinoma or extensive squamous or pseudosarcomatous metaplasia were studied. In several of the tumors, the diagnosis of primary sarcoma or squamous cell carcinoma was excluded only after a prolonged search for evidence of invasive ductal carcinoma. The paucity of axillary lymph node metastases and the circumscription of these neoplasms belied their aggressive clinical behavior. The size of the neoplasm at the time of initial treatment best correlated with prognosis, since the majority of patients whose carcinoma was less than 4 cm in diameter pursued a favorable course. The lack of correlation of the microscopic pattern of these neoplasms with prognosis, as well as the presence of apparent overlapping microscopic findings, supports the concept that they are variants of a single entity.

Secretory carcinoma of the breast in adults.

Six examples of a breast neoplasm distinguished by gross and microscopic circumscription and prominent intracellular and intraacinar mucin are presented. These neoplasms are analogous to similar tumors which, although rare, more characteristically occur in the breasts of children. They apparently are slow-growing lesions and none manifested either local recurrence or metastases.

Cellular adenomyoepithelioma of the breast.

This report is the second documented case of an adenomyoepithelioma arising in the breast. The neoplasm was well circumscribed and possessed cytologic features suggestive of a low-grade cancer; however, its biologic behavior remains undefined. The epithelial and myoepithelial elements are characterized ultrastructurally, and both are active participants in the neoplastic process. There are some histologic similarities of this lesion to the salivary gland epithelial-myoepithelial carcinoma; however, the growth pattern of cellular interductal proliferation of myoepithelium is unique.

Tubular carcinoma of the breast.

Twenty-five patients with tubular carcinoma of the breast were reviewed. All of the lesions were small, averaging 0.9 cm in diameter, and none exceeded 2.0 cm in diameter. Regardless of treatment, the prognosis proved favorable. Only three of the patients manifested axillary lymph nodal metastases, and none died of recurrent or metastatic neoplasm. These neoplasms frequently were associated with intraductal carcinoma and, to a lesser extent, with lobular carcinoma in situ. It is concluded that tubular carcinoma represents a slow-growing expression of invasive mammary carcinoma; nevertheless, it is likely that, if inadequately treated, these lesions will evolve into more common patterns of invasive carcinoma.

Adenoid cystic carcinoma of the breast: value of histologic grading and proliferative activity.

Adenoid cystic carcinoma of the breast is an uncommon carcinoma with a distinctive histology. Prognosis is favorable, although recurrence and distant metastases have been described. We assessed whether histologic features and proliferative activity can identify aggressive neoplasms. We studied 31 cases of adenoid cystic carcinoma (age range of patients, 33 to 74 years). Three histologic grades were defined: grade I: completely glandular; grade II: < 30% solid areas, and grade III: > or = 30% solid pattern. In 19 of 31 cases, immunohistochemical stains for estrogen receptor were available. Twelve of 31 cases were immunohistochemically stained for Ki-67 antigen using MIB1 antibody. Ten of 20 tumors were subareolar. All tumors were grossly circumscribed; however, 12 of 20 (60%) had focal infiltration peripherally. Five of 19 tumors were estrogen receptor positive. There was no statistical correlation between MIB1 score and histologic grade, nuclear grade, infiltration of the adjacent fat or breast parenchyma, or estrogen receptor status. All patients were alive with no evidence of disease after a median follow-up of 7 years. Neither histologic or nuclear grading nor proliferative activity were useful prognosticators. None of the tumors had lymph node metastases. Therefore, axillary lymph node dissection may not be necessary. Because more than half of adenoid cystic carcinomas are infiltrative focally, the most important therapeutic goal is complete tumor removal with uninvolved margins of excision.

Juvenile (cellular) adenofibromas. A clinicopathologic study.

"Juvenile" adenofibromas that presented in 25 patients were reviewed. All of the patients were in the second decade of life. The tumors were solitary in 19 patients and multiple and bilateral in six patients. All were distinguished microscopically by prominent cellularity of both epithelium and stroma. Patients who presented with solitary tumors, regardless of size, microscopic pattern, or manner of excision, had no recurrence. In contrast, all patients who presented with multiple tumors developed additional benign masses, often requiring re-excision. We believe that solitary "juvenile adenofibromas," regardless of size, should be excised so as to preserve as much breast tissue as possible. Those patients with multiple, bilateral tumors may anticipate recurrences, but malignant change is not seen. Tumors with this microscopic pattern also may occur, albeit uncommonly, in adults.

Infarction and squamous metaplasia of intraductal papilloma: a benign breast lesion that may simulate carcinoma.

Infarction of intraductal papillomas is uncommon. Six lesions of this type was referred to the authors as diagnostic problems, and two additional cases were found in a review of in-patient material. The patients' median age was 62 years (range, 30 to 81 years), and in each case the mass had been asymptomatic. Although the architectural pattern of the papillomas remained intact, ischemic necrosis rendered histologic evaluation difficult. Squamous metaplastic epithelium was present in three cases. Distortion of residual viable ductal epithelium by fibrosis at the periphery of the papillomas closely simulated invasive carcinoma. The appearance of the lesion on low-power magnification, the absence of malignancy elsewhere in the sample, and the absence of cytologic features of malignancy are useful criteria for distinguishing this lesion from carcinoma. None of these lesions recurred in the six patients for whom follow-up information was available (follow-up period, one to 20 years).

Invasive lobular carcinoma. Imaging features and clinical detection.

RATIONALE AND OBJECTIVES: Mammographic findings and method of detection of 52 cases of invasive lobular carcinoma (ILC), the second most common breast carcinoma, are reported. METHODS: Preoperative mammograms and clinical records of all patients with ILC not associated with a second mammary carcinoma (other than lobular carcinoma in situ) from 1979-1991 at the authors' institution were retrospectively reviewed. RESULTS: Abnormal mammographic findings were present in 48/52 (92%) and included irregular spiculated masses (33/52, 63%), asymmetric densities (7/52, 13%), architectural distortion (5/52, 10%), microcalcifications (2/52, 4%), and well circumscribed masses (1/52, 2%). The mean mammographic diameter was 2.1 cm. The tumor was most often best visualized in the craniocaudal projection. At the time of diagnosis, 54% of women had coexistent suggestive breast physical findings and 35% had metastatic carcinoma in axillary lymph nodes. CONCLUSIONS: The infrequency of microcalcifications in pure ILC may hinder mammographic detection and contrasts markedly with ductal carcinoma. Mammography and breast physical examination play complementary roles in the detection of ILC.

Invasive carcinoma of the breast with granulomatous response.

Three patients are described who had invasive ductal carcinoma associated with noncaseating epithelioid granulomas. Multinucleated giant cells, predominantly of Langhans' type, were present in the granulomas. The granulomas were restricted to the carcinoma, and no granulomatous response was evident in regional lymph nodes. None of the patients had clinical evidence of systemic granulomatous disease, although one patient subsequently was found to have hepatic portal granulomas. This uncommon tissue response to neoplasm is distinct from carcinomas with osteoclast-like multinucleated giant cells. Similarly, the process differs from the granulomas presenting in axillary lymph nodes that drain a carcinoma.

Cystosarcoma phyllodes. A clinicopathologic study of twenty-six hypercellular periductal stromal tumors of the breast.

A series of 26 hypercellular periductal stromal tumors of the breast, commonly referred to as cystosarcoma phyllodes, is reported. Twelve neoplasms were classified histologically as benign and 14 (54%) as maligant after microscopic assessment of the stromal elements. None of the histologically benign cystosarcomas metastasized, although two recurred locally. Malignant transformation was not observed in the recurrent tumors. Local recurrences developed in four women with histologically malignant cystosarcomas and caused the death of one by direct extension into the lung. Pulmonary metastases of the sarcomatous element occurred in three. Two of these women died and one has survived 16 years after pulmonary lobectomy. Separation of cystosarcomas into benign and malignant categories on the basis of their histopathologic features is advocated. It is likely that overgrowth of the sarcomatous stroma is a prerequisite for metastasis.