Serum cholesterol and human colon cancer.

Comparison of serum cholesterol levels in a matched case-control study indicates that patients with colon cancer have serum cholesterol levels lower than those of controls. In 133 pairs matched by age and sex, serum cholesterol levels were 188 +/- 42 mg/dl for cases and 213 +/- 42 mg/dl for controls (paired t-test = 5.08; P less than 0.001). Following stratification by tumor stage, significant differences in serum cholesterol levels persisted between cases with advanced tumors (Duke's classification C1, C2, and D) and controls (mean serum cholesterol difference, 41 +/- 41 mg/dl; paired t-test = 6.16; P less than 0.001) but not between cases with early tumors (Duke's classification A, B1, and B2) and controls, although the same trend was noted. Matching of 130 early tumors to advanced tumors showed that women, but not men, had a significantly lower serum cholesterol level with advancing disease. The findings support the concept that low serum cholesterol levels observed in colon cancer patients may be the result of the metabolic influence of advanced tumors, at least in women, and may not necessarily precede tumor formation.

p53 haplotype determination in breast cancer.

Inheritance of certain germ line haplotypes consisting of three biallelic polymorphisms of p53 has been proposed as a risk factor for breast cancer and colorectal cancer [A. Själander et al., Carcinogenesis (Lond.), 17: 1313-1316, 1996, and Carcinogenesis (Lond.), 16: 1461-1464, 1995]. In their studies, pairwise haplotypes of these three polymorphisms were estimated. Extended haplotypes were further projected from the pairwise combinations. To overcome the necessity to estimate pairwise and extended haplotype frequencies, a PCR method has been developed to determine the absolute extended p53 haplotypes in diploid genomes. The method requires allele-specific PCR, confirmed by restriction analysis, and successive amplicon analysis. It has been applied to a nested case-control study of breast cancer (284 subjects; 99 cases and 185 controls; 182 Caucasians, 56 Hispanics, and 46 African-Americans). Evidence is presented that minor variants of the intron 3, codon 72, and intron 6 polymorphisms were moderately elevated in Caucasian breast cancer cases (intron 3, P = 0.03 for genotype and P = 0.01 for allelic frequency; codon 72, P = 0.07 for genotype and P = 0.054 for allelic frequency; and intron 6, P = 0.02 for genotype and P = 0.02 for allele frequency). Accordingly, analysis of haplotype distributions suggested an association of minor p53 haplotypes with breast cancer risk in Caucasians (P = 0.07). The relative allelic frequencies in breast cancer cases compared with controls also differed by age and menopausal status; the 1-2-1 haplotype was overrepresented in postmenopausal cases (P = 0.02) and cases older than 50 years (P = 0.02), whereas the other minor haplotypes (1-1-2 and rare variants) were overrepresented in premenopausal cases (P = 0.003) and cases 50 years of age and younger (P = 0.02). Genotype distributions at each locus and for all control groups were consistent with Hardy-Weinberg equilibria. Differences in haplotype distribution were associated with ethnicity (Caucasians versus African-Americans and Caucasians versus Hispanics, P < 0.001). The new haplotyping method may be useful in the study of gene-environment interactions.

Perioperative blood transfusion adversely affects prognosis after resection of Stage I (subset N0) non-oat cell lung cancer.

Recent studies suggest that pretransplant blood transfusions prolong kidney graft survival by nonspecific immune suppression. Since immune suppression in patients with cancer is associated with early recurrence and poor prognosis, we studied the relationship of perioperative blood transfusion to recurrence of Stage I (subset N0) lung cancer. Technique-related variables were minimized by limiting the study to one surgeon (P. A. K.). Life-table and Cox proportional hazards analysis of age, sex, tumor size, histopathology, admission and discharge hematocrit values, estimated operative blood loss, duration of operation, extent of resection, anesthetic agents, and blood transfusion revealed two statistically significant prognostic factors: extent of resection (p = 0.0056) and use or non-use of transfusions (p = 0.0283). The cumulative 5 year disease-free survival rate of the 15 patients undergoing pneumonectomy was 42% compared to 75% for 150 patients undergoing lobectomy and lesser procedures. Transfused patients had lower disease-free rates within 5 years than nontransfused patients (62% versus 76%, p = 0.0132). Survival advantage was also noted in nontransfused patients after deleting patients subjected to pneumonectomy. These results indicate that perioperative transfusion in patients with lung cancer undergoing resection accelerates the appearance of recurrent or metastatic cancer. This supports the findings of previous studies of breast and colon cancer that blood transfusion is detrimental to the patient with cancer.

Preoperative lymphocyte subsets and infectious complications after colorectal cancer surgery.

Peripheral lymphocytes, T cells, and T cell subsets of 141 consecutive patients with colorectal cancer were measured preoperatively to determine whether infectious complications could be predicted from derangements of T cell subsets. T cell subset abnormalities reportedly precede sepsis in patients with burn injuries. All patients received preoperative bowel preparation with laxatives, enemas, oral neomycin and erythromycin base, and intravenous cefazolin. Eighteen (13%) of the 141 patients had infectious complications and these complications accounted for two deaths. The variables of age, sex, tumor location, admission hematocrit, white blood count, lymphocytes, T cells (Leu-1), helper cells (Leu-3), suppressor cells (Leu-2), natural killer cells (Leu-7), operative blood loss, procedure, specimen length, duration of surgery, tumor size, tumor differentiation, nodal status, and Dukes' staging were not significantly (p greater than 0.05) related to the development of infectious complications. These results indicate that preoperative evaluation of T cell subsets in patients with colorectal cancer is not useful for predicting postoperative septic complications.

Perioperative blood transfusion has prognostic significance for breast cancer.

The transfusion-induced immune suppression that prolongs kidney graft survival for transplant patients may be detrimental to patients with malignancies. We studied the relationship of blood transfusion to the disease-free survival of 169 patients with operable breast cancer who had undergone mastectomy with axillary dissection at Mount Sinai Hospital between 1964 and 1972. The cumulative 5-year disease-free survival rate for patients who had received transfusions was 51% compared with 65% for patients who had not received blood (p = 0.0210). The two groups of patients were comparable in age, stage, discharge hemoglobin values, proportion of radical mastectomies, and duration of follow-up. Admission hemoglobin values were lower and operative blood loss was higher among patients who had received transfusions, and significant survival differences were noted in relation to operative blood loss: 69% of women with estimated blood loss less than the mean of 370 ml were free of disease at 5 years compared with 50% of women with higher intraoperative losses (p = 0.0279). However, the first year after operation the association of survival with transfusion was highly significant (77% for those who had received transfusions, 94% for those who had not, p = 0.0096), whereas survival rates in relation to operative blood loss differed by only 7% during the same interval (p = 0.1182). These results indicate that perioperative blood transfusion may be a significant prognostic factor for patients undergoing mastectomy for operable breast cancer.

Breast cancer diagnosed during hormone replacement therapy.

OBJECTIVE: Hormone replacement therapy (HRT) is associated with decreased breast cancer mortality despite increased incidence. We studied postmenopausal breast cancer patients to determine whether this paradox results from earlier diagnosis, biologically less aggressive tumors, or cessation of hormonal stimulation. METHODS: Demographic, clinical, pathologic, treatment, and outcome information for 455 postmenopausal breast cancer patients who had not used postmenopausal hormones was compared with that of 47 breast cancer patients who used postmenopausal hormones prior to diagnosis. RESULTS: Hormone users were significantly younger, more often white, and of lower body mass index than nonusers. Hormone users presented significantly more often with nonpalpable mammographic findings, resulting in significantly smaller tumors with less nodal involvement than nonusers. Cancers of hormone users were more commonly invasive lobular or in situ ductal and were more likely to be steroid receptor positive. Hormone users were treated with breast conservation significantly more frequently than nonusers. These differences persisted after matching for age and year of surgery and after controlling for race. At 5 years, none of the hormone users with invasive cancers had local recurrence compared with 8% of nonusers, and 7% of users had distant disease compared with 10% of nonusers. CONCLUSION: These results indicate that favorable breast cancer survival after postmenopausal hormone use might result from earlier detection through mammography. Possible hormonal influence on tumor biology and prognosis was not supported by our data.

The prognostic significance of natural killer cytotoxicity in patients with colorectal cancer.

We evaluate the prognostic significance of preoperative natural killer (NK) cytotoxicity for K562 cells and its relationship to other prognostic factors in 102 patients with colorectal cancer who underwent curative resections between February 1984 and February 1985. The 18 patients who had recurrences within two years of surgery had significantly higher numbers of preoperative peripheral blood suppressor/cytotoxic and NK cells and significantly lower preoperative NK cytotoxicity than disease-free patients. Low preoperative NK cytotoxicity was predictive of recurrence independent of age, sex, hematocrit, procedure, blood loss, duration of surgery, Dukes' stage, specimen length, tumor size, tumor differentiation, and post-operative therapy. Low levels of in vitro NK-cell cytotoxicity may identify a subgroup of patients at high risk for recurrence.

Factors associated with clear biopsy margins and clear reexcision margins in breast cancer specimens from candidates for breast conservation.

BACKGROUND: The aim of this study was to identify variables associated with clear biopsy margins and clear reexcision margins of breast cancer specimens from patients who are candidates for breast conservation. STUDY DESIGN: The records of breast cancer patients were reviewed to identify candidates considered for breast conservation after biopsy. Factors associated with obtaining histopathologically clear excisional biopsy margins and clear reexcision margins were studied in 674 excisional biopsy specimens and in 197 reexcision specimens. RESULTS: Clear biopsy margins were associated with older patient age (p = 0.0446), family history of breast cancer (p = 0.0008), diagnosis by fine needle aspiration (p = 0.0000), small tumor size (p = 0.0010), absence of ductal carcinoma in situ (p = 0.0004), and absence of extensive intraductal carcinoma (p = 0.0117). In multivariate analysis, only diagnosis by fine needle aspiration and small tumor size were associated with clear biopsy margins. Clear margins in reexcision specimens were associated with small tumor size (p = 0.0086), close or unknown biopsy margins (p = 0.0003), and absence of nodal involvement (p = 0.0014). In multivariate analysis only biopsy margin status and node status were associated with clear reexcision margins. CONCLUSIONS: These data indicate that obtaining clear biopsy margins is facilitated by small tumor size and by having a preoperative diagnosis by fine needle aspiration. The majority of patients undergoing reexcision will have clear margins although this is significantly less likely when the biopsy margins are involved or when nodal involvement is present.

Prognosis of patients with bilateral carcinoma of the breast.

Ninety-five patients with bilateral carcinoma of the breast treated with mastectomy (60 patients), conservation of the breast (17 patients), or both (18 patients), were studied. Cumulative five year local control rates for the 138 mastectomies was 94 percent and for the 52 breast conservations, 90 percent. Distant metastases appeared in one-third of the patients but one-half of them occurred beyond 60 months. Cumulative five year distant disease-free survival rate measured from treatment for the second carcinoma was 74 percent. Second carcinomas were diagnosed at significantly earlier stage than first carcinomas--28 percent of first carcinomas were stage I compared with 43 percent of second carcinomas (p < 0.05). Distant recurrence-free survival rates for metachronous carcinomas were better then for synchronous carcinomas, but this difference can be attributed to earlier overall staging of metachronous carcinomas. The interval between the diagnosis of first and second carcinomas had a profound effect on outcome for second carcinomas--cumulative five year distant recurrence-free survival rate of patients with second carcinomas diagnosed within five years was 58 percent compared with 95 percent for patients diagnosed more than five years after the first carcinoma.

Stage 0 to stage III breast cancer in young women.

BACKGROUND: Breast cancer survival is improving because mammography is leading to diagnosis at earlier stages of the disease. Because young women with breast cancer rarely undergo mammography before diagnosis, outcomes for breast cancer in young women may not be improving. In addition to advanced stage, young age at diagnosis is associated with biologically more aggressive cancers with higher rates of local and distant recurrence. STUDY DESIGN: Risk factors, clinical presentations, pathologic findings, tumor characteristics, extent of disease, treatment, and outcomes for 101 women under age 36 treated for breast cancer between 1989 and 1997 were compared with 631 patients 36 years and older treated by us during the same interval. Stage IV patients were excluded. RESULTS: Patients younger than 36 years were more likely to present with a palpable mass (87% versus 55%, p < 0.001) and were less likely to undergo spot localization breast biopsy for mammographic findings (40% versus 6%, p < 0.001). Patients younger than 36 years had larger tumors (median 2.0 cm versus 1.5 cm, p < 0.001), more nodal involvement (50% versus 37%, p = 0.022), more nodes involved (median 1.0 versus 0, p = 0.010), and were more likely to be diagnosed with stage II or III cancer (60% versus 43%, overall p < 0.001). Young patients' cancers were more poorly differentiated (80% versus 44%, overall p < 0.001), estrogen receptor-negative (52% versus 31%, p < 0.001), aneuploid (70% versus 49%, p = 0.013), and had higher S-phase fractions (59% versus 29%, p = 0.001). Patients less than 36 years were treated more often with mastectomy (59% versus 22%, p < 0.001) and adjuvant chemotherapy (80% versus 54%, p < 0.001) and less often with tamoxifen (36% versus 58%, p = 0.001). Cumulative 5-year local and distant disease-free survival were significantly worse for patients younger than 36 years (p = 0.011 and p = 0.044, respectively). The higher rate of local recurrence in patients less than 36 years was from an excess number of local recurrences in patients treated with breast conservation. After consideration for nodal involvement, chemotherapy, and tamoxifen using the Cox proportional hazards model, no other variable, including age, was significantly related to local disease-free outcomes. After consideration for tumor size and nodal involvement, no other variable was significantly related to distant disease failure rates. CONCLUSIONS: Patients diagnosed with breast cancer before age 36 differ from older patients in numerous respects. They present more often with a palpable mass rather than a mammographic finding and their cancers are more advanced with features that are more aggressive. Despite aggressive treatment, most commonly with mastectomy and chemotherapy, local and distant failure rates are higher than for patients 36 and older. The higher rate of local recurrence in patients less than 36 years reflects an excess number of local recurrences in patients treated with breast conservation.

Determinants of success with spot localization biopsy of the breast.

BACKGROUND: The accurate diagnosis of nonpalpable lesions of the breast by spot localization biopsy depends upon numerous variables. STUDY DESIGN: Multivariate analysis was used to identify variables influencing the success of spot localization biopsy of 757 lesions (27.3 percent of which were malignant) in 738 patients. RESULTS: Ninety percent of the lesions were removed with the first excision as documented by specimen radiography, but 2.3 percent (18 lesions) were not evident on specimen radiography with up to four excisional attempts. Eight (44 percent) of these 18 were in fact removed because they could not be seen on follow-up mammograms. Lesions with calcifications only were significantly more difficult to remove than were masses (87 compared with 96 percent, respectively, p < 0.001). The use of both hooked wire and methylene blue dye was significantly less successful than wire or dye alone (84 compared with 93 and 91 percent, respectively, p < 0.001). A second attempt was successful in 71 percent (52 lesions) of the remaining 75 percent lesions and additional attempts at excision were often associated with success. Success was highly variable among surgeons but could not be related to experience. CONCLUSIONS: Calcifications are more difficult to remove than masses, and combining hooked wire with dye does not improve the success rate. Additional excisional attempts are worthwhile if the lesion is not seen on the first radiograph of the specimen.

The significance of family history for patients with carcinoma of the breast.

BACKGROUND: Since the risk of carcinoma of the breast is increased in women with a family history of the disease, new primary carcinomas of the breast may be increased after treatment. Women with several relatives with carcinoma of the breast are thought to be at higher risk of having a second primary carcinoma of the breast develop and mastectomy is more frequently recommended. STUDY DESIGN: The computerized registry of the Mount Sinai Medical Center Breast Service was used to identify 1,337 patients with complete information concerning family history. Three hundred fifty-nine patients with a family history of carcinoma of the breast were compared with women with no family history. RESULTS: Compared with patients with no family history of carcinoma of the breast, patients with a family history of carcinoma of the breast were significantly younger (54.0 versus 55.8 years of age, p < 0.01), were significantly more likely to have used oral contraceptives (26 versus 13 percent, p < 0.001), had significantly more ductal carcinoma in situ (10 versus 4 percent, p < 0.01), and were significantly more often treated with breast conservation (42 versus 31 percent, p < 0.001). Simultaneous contralateral carcinoma of the breast was diagnosed more frequently in patients with a family history (3 versus 1 percent, p < 0.025), but metachronous contralateral carcinomas were not increased. In comparing the two groups, there were no significant differences in proportion premenopausal, parity, use of postmenopausal hormones, tumor size, tumor differentiation, nodal involvement, TNM stage, estrogen receptor status, or use of adjuvant radiation, chemotherapy, or tamoxifen. Complete five-year follow-up evaluation for 748 patients, 179 with a family history, found no differences in local, distant, or disease-free survival rates for mastectomy or breast conservation in relation to family history. Outcome for patients with first-degree affected relatives and those with more than one affected relative was the same as those with no family history. CONCLUSIONS: These results indicate that women with a family history of carcinoma of the breast should be treated no differently than women with no family history.

Complete removal of nonpalpable breast malignancies with a stereotactic percutaneous vacuum-assisted biopsy instrument.

BACKGROUND: Several devices have been developed for sampling nonpalpable mammographic breast lesions. Complete removal of malignancies with a stereotactic percutaneous directional vacuum-assisted biopsy instrument has been reported. STUDY DESIGN: We reviewed our experience with the percutaneous vacuum-assisted biopsy instrument to identify instances of complete excision of cancers: no residual carcinoma found at surgical excision for malignancies diagnosed by the percutaneous vacuum-assisted biopsy instrument. The radiologic and pathologic characteristics of malignancies completely removed by the percutaneous vacuum-assisted biopsy instrument were compared with those of malignancies with residual carcinoma found at surgical excision. RESULTS: Fifty-two malignancies were diagnosed by the percutaneous vacuum-assisted biopsy instrument: 16 infiltrating ductal carcinomas, 5 infiltrating lobular carcinomas, and 31 ductal carcinomas in situ. No residual carcinoma was found at surgical excision in 9 (17%) of the 52 malignancies. Patients with complete removal of the malignant lesion were younger than patients with incomplete removal (52 versus 58 years; p = 0.069). Completely removed malignancies were smaller on mammography (4 versus 17 mm; p = 0.213), and more specimens were removed (19 versus 15; p = 0.074). All nine completely removed malignancies presented with calcifications without a mass (p = 0.112), and all nine were ductal carcinoma in situ (p = 0.019). CONCLUSIONS: Complete removal of nonpalpable breast malignancies is possible with the stereotactic percutaneous directional vacuum-assisted biopsy device. Complete removal is more likely with removal of a large number of specimens from small areas of mammographic calcifications due to ductal carcinoma in situ.

Multivariate analysis of roentgenologic characteristics and risk factors for nonpalpable carcinoma of the breast.

Screening mammography improves carcinoma of the breast survival through early detection and treatment of nonpalpable, often noninvasive, carcinomas. Consideration of the roentgenologic characteristics of mammographic masses and calcifications in combination with risk factors of patients may improve the yield of spot localization breast biopsy. Risk factors solicited by questionnaire were correlated with the roentgenologic appearance and histopathologic factors of 482 specimens from spot localization breast biopsies (39 percent malignant). Masses with irregular contour (p < 0.001) and high density (p < 0.005) were associated with malignant tumors. Packed, coarse and round calcifications were associated with benignity (p < 0.001), whereas scattered, fine and mixed calcifications were associated with malignant tumors (p < 0.05). Malignant masses with smooth contour were significantly more likely to be associated with noninvasive histology. Patients found to have malignant tumors were significantly older than patients with benign lesions (58 versus 52 years, p < 0.001). Stepwise logistic regression was used to evaluate the relative usefulness of demographics and roentgenologic features in predicting benign and malignant pathology among masses and calcifications. Age and irregular contour were independent significant predictors of malignancy for masses. Age, round, coarse, packed or scattered calcifications were significant independent predictors of benignity among calcifications. The radiologist correctly predicted malignant pathology in 60 percent of the patients and benign pathology in 78 percent. Parity, age at menarche, age at first pregnancy, age at menopause, history of benign breast disease, history of carcinoma of the breast, family history of carcinoma of the breast, birth control pill exposure and smoking were not significantly associated with the diagnosis of malignant tumor. These results suggest that risk factors for carcinoma of the breast are insignificant for nonpalpable lesions because patients referred for needle localization are already selected for high risk. Roentgenologic patterns of masses are useful for predicting which lesions are invasive.

Carcinoma of the breast in postmenopausal hormone user and nonuser control groups.

The risk and prognosis of patients with carcinoma of the breast exposed to postmenopausal hormones are controversial. Carcinoma of the breast from 35 postmenopausal women who had taken hormones were compared with carcinomas from age and histologic matched postmenopausal women who had never taken hormones. Hormone users averaged 1.1 fewer pregnancies (p < 0.005) and 1.4 fewer live births (p < 0.0005). In addition, the carcinomas had significantly lower S-phase fractions (5.36 versus 6.77, p > 0.01) and less nodal involvement (1.2 versus 1.9, p < 0.0005). Estrogen and progesterone receptor content, ploidy and deoxyribonucleic acid index were comparable in both groups. These results indicate that hormone users present with slower growing tumors of earlier stage than nonusers, possibly resulting in improved prognosis.

The consequence of undertreating breast cancer in the elderly.

BACKGROUND: Recent studies have noted that a large fraction of elderly patients do not receive conventional treatment for breast cancer. The consequences of undertreatment of the elderly have not been adequately assessed. STUDY DESIGN: The senior author's database (PIT) was used to identify women undergoing potentially curative operations for breast cancer between 1978 and 1998. Risk factors, presentation, pathologic findings, treatment, and outcomes of 206 women aged over 70 years were compared with those of 920 younger patients. In addition, conventionally treated and "undertreated" elderly patients were identified, and their characteristics and outcomes were compared. RESULTS: Older patients' cancers were more often visible on mammography, usually as a mass; younger patients' mammograms were less frequently positive, presenting more often with calcifications (p = 0.002). Cancers of the elderly were better differentiated (p < 0.001) and more likely to be estrogen- and progesterone-receptor positive (p < 0.001; p = 0.007). Patients over 70 had fewer mastectomies (19% versus 33%; p < 0.001) and were also less likely to undergo axillary node dissection (71% versus 81%, p = 0.006), postoperative radiation (69% versus 92%, p < 0.001), and chemotherapy (18% versus 48%, p < 0.001). Fifty-seven percent of older patients were treated with tamoxifen compared with 36% of younger patients (p < 0.001). Elderly patients' rates of local and distant recurrence were comparable to those of younger patients after both mastectomy and breast conservation. Ninety-eight patients (54%) over 70 were undertreated by conventional criteria. Undertreated elderly patients were significantly older (78 versus 76 years, p = 0.003), were diagnosed with excisional biopsy more often (69% versus 57%, p = 0.069) and with fine-needle aspiration less frequently (22% versus 38%, p = 0.069), and were more likely to have breast conservation (90% versus 73%, p = 0.004). Local and distant disease-free survival rates of both groups were comparable. Tamoxifen treatment significantly reduced the chance of developing distant metastasis in node-negative elderly patients with invasive tumors (p = 0.028). Omission of chemotherapy had no impact on disease control in the elderly. Axillary node status and estrogen-receptor status were significantly related to local disease-free survival, and axillary node status was significantly related to distant disease-free survival in multivariate analysis in the elderly. CONCLUSIONS: Elderly breast cancer patients are frequently treated with breast conservation, omitting axillary dissection, radiation therapy, and chemotherapy. Despite undertreatment by conventional criteria, the rates of local recurrence and distant metastasis are not increased in comparison with conventionally treated elderly patients. Tamoxifen should be administered to elderly breast cancer patients with invasive tumors because it significantly improves distant control.

The prognostic significance of previous benign breast disease for women with carcinoma of the breast.

BACKGROUND: Risk factors for carcinoma of the breast may also have prognostic influence. Because benign breast disease is a risk factor for carcinoma of the breast, we compared the outcomes of patients with carcinoma of the breast with a history of benign breast disease to patients with carcinoma of the breast without a history of benign breast disease. STUDY DESIGN: Patients with benign breast disease and subsequent carcinoma of the breast were matched by age and ethnicity to patients with carcinoma of the breast with no prior history of benign breast disease. Risk factors, pathologic findings, and disease-free survival rates were compared. RESULTS: Patients with previous benign breast disease had a significantly greater family history of carcinoma of the breast (35 percent compared with 22 percent, p = 0.015) and used postmenopausal hormones significantly more frequently (16 percent compared with 5 percent; p < 0.001) than women without benign breast disease. In patients with benign breast disease, their subsequent carcinomas were smaller (T1, 53 percent compared with 43 percent), with significantly fewer nodes involved (1.8 compared with 2.7, p = 0.031), and were significantly more likely to contain an infiltrating lobular component (9 percent compared with 3 percent, p = 0.023). Significantly fewer patients with previous benign breast disease had metastatic disease (18 percent compared with 31 percent; p = 0.001). The ten-year cumulative disease-free survival rate for patients with benign breast disease was 68 percent compared with 59 percent for women without a history of benign breast disease. CONCLUSIONS: This study indicates that women with benign breast disease who have carcinoma of the breast develop may have a better outcome than women without a history of benign breast disease.

Breast carcinoma associated with pregnancy and lactation.

The most common malignancy concurrent with pregnancy is breast cancer. Since an increasing number of women are electing to postpone pregnancy to their late thirties and forties, the incidence of breast cancer concurrent with pregnancy is increasing. This article critically reviews the incidence, unique diagnostic and therapeutic considerations, the natural history and ultimate prognosis of breast carcinoma associated with pregnancy and lactation.

Pretreatment prognostic factors in colorectal cancer patients with synchronous liver metastases.

Potential pretreatment prognostic variables for patients presenting with liver metastases at the time of resection of primary colorectal cancers were evaluated in 42 consecutive patients resected over two years. Survival was bimodal with 12 patients dead within 6 months of surgery and the remaining patients dead or alive at follow-up at 6 to 27 months (median 9 months). Preoperative peripheral lymphocytes (P = 0.0008), alkaline phosphatase (P = 0.0056), and serum glutamic oxaloacetic and pyruvic transaminases (SGOT, P = 0.0048, and SGPT, P = 0.0031) were significant prognostic factors. The transaminases were prognostic within the normal ranges for the hospital laboratory. Age, sex, hematocrit, platelet count, bilirubin, cholesterol, albumin, protein, creatinine, tumor differentiation, bowel penetration, nodal involvement, operative blood loss, transfusions and chemotherapy were not related to survival. These results indicate that normal liver function tests in patients with colorectal liver metastases have significant prognostic value. Immune function as reflected by lymphocyte count may also play a role in these patients' survivals.

Multivariate analysis of recurrence after anterior resection for colorectal carcinoma.

We performed a multivariate analysis of survival data from 278 patients who underwent potentially curative anterior resection with hand-sewn anastomosis for nonobstructing colorectal carcinoma to evaluate the interaction of the resection margin with distance from the anal verge and their contributions to local and distant recurrence. Cumulative 5-year disease-free survival was 66 percent for the 258 patients with complete follow-up. Forty-nine patients (19 percent) had local recurrence and 42 (16 percent) developed initial distant metastases. Local recurrence rates increased with increasing age and with more advanced Dukes' stage. It developed in twice as many patients with colostomies as without colostomies. Distant metastases developed significantly more often in patients with nodal involvement and in patients with resection margins exceeding 3.5 cm. Forty-four percent of patients with lesions within 14 cm of the anal verge resected with margins of at least 3.5 cm developed distant recurrence. This study suggests that aggressive pelvic dissection to achieve resection margins greater than 3.5 cm may contribute to tumor dissemination and subsequent distant metastases.