Breast cancer after augmentation mammoplasty.

BACKGROUND: It is thought that implants interfere with breast cancer diagnosis and that cancers in women who have had breast augmentation carry a worse prognosis. METHODS: A prospective breast cancer database was reviewed, comparing augmented and nonaugmented patients for details of histology, palpability, tumor size, nodal status, mammographic status, receptor status, nuclear grade, stage, and outcome. RESULTS: Ninety-nine cancers in augmented women and 2857 cancers in nonaugmented women were identified. Among these women, mammography was normal in 43% of those who had had augmentation and in 5% of those who had not. Augmented women were more likely to have palpable cancers (83% vs. 59%) and nodal involvement (48% vs. 36%), and less likely to have ductal carcinoma in situ (DCIS) (18% vs. 28%). When comparing only women younger than 50, the differences in invasiveness and nodal status lost significance. Cancers diagnosed in the 1990s were more likely to be nonpalpable and noninvasive than those diagnosed in the 1980s. This trend was more pronounced in the augmented population. CONCLUSIONS: Augmented patients were more likely to have palpable cancers, although the overall stage and outcome were similar to those of nonaugmented women. Although there have been significant improvements in our ability to diagnose early breast cancer over the past two decades, mammography continues to be suboptimal in augmented women.

The influence of margin width on local control of ductal carcinoma in situ of the breast.

BACKGROUND: Ductal carcinoma in situ is a non-invasive carcinoma that is unlikely to recur if completely excised. Margin width, the distance between the boundary of the lesion and the edge of the excised specimen, may be an important determinant of local recurrence. METHODS: Margin widths, determined by direct measurement or ocular micrometry, and standardized evaluation of the tumor for nuclear grade, comedonecrosis, and size were performed on 469 specimens of ductal carcinoma in situ from patients who had been treated with breast-conserving surgery with or without postoperative radiation therapy, according to the choice of the patient or her physician. We analyzed the results in relation to margin width and whether the patient received postoperative radiation therapy. RESULTS: The mean (+/-SE) estimated probability of recurrence at eight years was 0.04+/-0.02 among 133 patients whose excised lesions had margin widths of 10 mm or more in every direction. Among these patients there was no benefit from postoperative radiation therapy. There was also no statistically significant benefit from postoperative radiation therapy among patients with margin widths of 1 to <10 mm. In contrast, there was a statistically significant benefit from radiation among patients in whom margin widths were less than 1 mm. CONCLUSIONS: Postoperative radiation therapy did not lower the recurrence rate among patients with ductal carcinoma in situ that was excised with margins of 10 mm or more. Patients in whom the margin width is less than 1 mm can benefit from postoperative radiation therapy.

Outcome after invasive local recurrence in patients with ductal carcinoma in situ of the breast.

PURPOSE: To detail the outcome, in terms of local recurrence, local invasive recurrence, distant recurrence, and breast cancer mortality for patients previously treated for ductal carcinoma in situ (DCIS). PATIENTS AND METHODS: Clinical, pathologic, and outcome data were collected prospectively for 707 patients with DCIS accrued from 1972 through June 1997. RESULTS: There were 74 local recurrences; 39 were noninvasive (DCIS) and 35 were invasive. Fifty-one percent of patients with invasive recurrences presented with stage 1 disease; the remainder presented with more advanced disease. Invasive local recurrence after mastectomy was a rare event that occurred in 0.8% of patients. Invasive recurrence after breast preservation was more common and occurred in 7.4% of patients. The 8-year probability of breast cancer mortality after breast preservation was 2.1%, a number that is likely to increase with longer follow-up. The 8-year breast cancer-specific mortality and distant-disease probability for the subgroup of 74 patients with locally recurrent disease was 8.8% and 20.8%, respectively. If only the 35 invasive recurrences are considered as events, the 8-year breast cancer-specific mortality and distant-disease probability was 14.4% and 27.1%, respectively. CONCLUSION: Invasive local recurrence after breast-preservation treatment for patients with DCIS is a serious event that converts patients with previous stage 0 disease to patients with disease that ranges from stage I to stage IV. These results, however, indicate that most DCIS patients with local recurrence can be salvaged.

Results from a multidisciplinary breast center. Analysis of disease discovered.

This study was undertaken to report the clinical, pathologic, and outcome data of our nonrandomized series of patients with nonpalpable breast cancer and to understand better the differences between patients with palpable and nonpalpable lesions, particularly those patients aged 49 and younger. The clinical, pathologic, recurrence, and survival data from 560 patients with nonpalpable breast carcinomas found by mammography and wire-directed breast biopsy were compared with similar data from 1640 patients who presented with palpable breast cancer (see Table 3). All node dissections in patients with noninvasive disease were negative. In patients with invasive breast cancer, the chances of axillary node involvement increased as lesions increased in size. When patients were grouped by tumor size, nodal involvement was more likely for palpable than nonpalpable lesions. The 10-year disease-free survival rate probability for patients with nonpalpable invasive cancer was 81% compared with 65% for patients with palpable invasive cancer. The 10-year breast cancer-specific survival rate (including deaths only from carcinoma of the breast) was 91% versus 73%, whereas the 10-year overall survival (rate including deaths from any cause) was 79% for nonpalpable invasive cancer versus 68% for patients with palpable invasive cancer (all P values < 0.001) (see Table 6). Patients under age 50 with nonpalpable invasive cancer fared just as well as older patients with nonpalpable invasive cancer; both had 10-year breast cancer-specific survival rates of 94% (see Table 8). However, biopsy of nonpalpable lesions in patients aged 49 and younger was only half as likely to reveal cancer than biopsy of nonpalpable lesions in patients aged 50 and older (17% versus 32%, P < 0.0001) (see Table 7). When cancer was found in younger women, it was more likely to be noninvasive. Wire-directed breast biopsy of nonpalpable mammographically suspicious areas yields a subgroup of breast cancer patients with a lower probability of recurrence and a higher probability of survival at 10 years when compared with patients who present with palpable breast cancer.

Predicting axillary node positivity in patients with invasive carcinoma of the breast by using a combination of T category and palpability.

BACKGROUND: In spite of the development of numerous new tumor markers, axillary lymph node status continues to be the single most important prognostic variable regarding survival of patients with carcinoma of the breast. This study was undertaken to determine whether or not the combination of T category (TNM staging system) and palpability would be a better predictor of nodal positivity than T category alone. STUDY DESIGN: Clinical and pathologic data were analyzed for 1,554 patients who underwent axillary lymph node dissection as part of their treatment for invasive carcinoma of the breast. Data were analyzed by the primary lesion's T category and whether or not the lesion was palpable. RESULTS: Five hundred fifty-one (35 percent) of 1,554 axillary node dissections contained metastases. The probability of nodal involvement was significantly higher and the average tumor diameter was slightly, but significantly, larger for palpable T1b, T1c, and T2 lesions when compared with nonpalpable lesions within the same T category (all p values less than or equal to 0.003). The probability of lymphatic tumor emboli or vascular invasion was generally higher for palpable lesions compared with nonpalpable lesions and increased as lesions got larger. The percentage of patients with low nuclear grade and favorable histology was generally lower for patients with palpable lesions compared with those having nonpalpable lesions and decreased as lesions got larger. CONCLUSIONS: Nodal positivity was significantly higher for palpable T1b, T1c, and T2 carcinoma of the breast when compared with nonpalpable carcinoma of the breast within the same T category. The combination of T category and palpability was a more accurate predictor of nodal positivity than T category alone.

Prognostic classification of breast ductal carcinoma-in-situ.

We present a new prognostic classification designated the Van Nuys classification for ductal carcinoma-in-situ (DCIS). The classification combines high nuclear grade and comedo-type necrosis to predict clinical recurrence. Three groups of DCIS patients were defined by the presence or absence of high nuclear grade and comedo-type necrosis: 1--non-high-grade DCIS without comedo-type necrosis, 2--non-high-grade DCIS with comedo-type necrosis, 3--high-grade DCIS with or without comedo-type necrosis. There were 31 local recurrences in 238 patients after breast-conservation surgery 3.8% (3/80) in group 1, 11.1% (10/90) in group 2, and 26.5% (18/68) in group 3. The 8-year actuarial disease-free survivals were 93%, 84%, and 61%, respectively (all p < or = 0.05). The Van Nuys classification defines three distinct and easily recognisable groups, each of which has a different likelihood of local recurrence if treated with breast conservation.

Ten-year results comparing mastectomy to excision and radiation therapy for ductal carcinoma in situ of the breast.

The 10-year results of 300 patients with ductal carcinoma in situ (DCIS) without microinvasion are reported; 167 treated with mastectomy and 133 treated with excision and radiation therapy. There was a significant difference in disease-free survival at 10 years, in favour of those treated with mastectomy, 98% versus 81% (P = 0.0004). Multivariate analysis confirmed nuclear grade as the only significant predictor of local recurrence (P = 0.02) or invasive local recurrence (P = 0.03) in patients with DCIS treated with excision and radiation therapy. There was no difference in breast cancer-specific survival or overall survival between the two treatment groups.

Can intraductal breast carcinoma be excised completely by local excision? Clinical and pathologic predictors.

BACKGROUND: Microscopic evaluation of excised intraductal breast carcinoma (DCIS) specimens using a serial subgross technique reveals that in many patients the lesion is larger than expected, often making complete excision impossible with less than a true quadrantectomy. Data is presented on 181 patients with DCIS in whom the initial biopsy was performed using a more cosmetic wide local excision rather than a true quadrantectomy. METHODS: Clear margins were defined as no tumor within 1 mm of any inked or dyed margin. All of these patients subsequently underwent mastectomy or reexcision of the initial biopsy site. This allowed pathologic evaluation for residual disease. RESULTS: At mastectomy or reexcision, 76% of patients with initially involved margins had residual DCIS, as did 43% of patients with initially clear margins (P < 0.0001). Larger tumor size was a statistically significant predictor of initial margin involvement and residual DCIS (P < 0.05). Patients with comedo-DCIS had a greater tendency toward positive initial histologic margins and residual DCIS, but this trend was not statistically significant (P < 0.1). CONCLUSION: DCIS presents major problems to both surgeons and pathologists. It is difficult to excise completely using a wide local excision. Histologically negative margins do not guarantee that residual DCIS has not been left behind. Inadequate excision of the primary lesions may be the most important cause of local failure after conservative treatment for intraductal breast carcinoma.

Infiltrating lobular carcinoma. Is it different from infiltrating duct carcinoma?

BACKGROUND: Infiltrating lobular carcinomas (ILC) represent approximately 10% of all breast cancers. The literature is mixed regarding their prognosis when compared with infiltrating duct carcinomas (IDC). There are few data regarding the treatment of ILC with radiation therapy. METHODS: The clinical, pathologic, laboratory, and survival data of 161 patients with ILC were compared with the data of 1138 patients with IDC. RESULTS: ILCs were larger, more difficult to excise completely, and more difficult to diagnose clinically. All prognostic factors measured were more favorable for ILC. Nodal positivity for ILC was 32%, compared with 37% for IDC (P = 0.22). The 7-year disease-free Kaplan-Meier survival (DFS) was 74% for patients with ILC and 63% for patients with IDC (P < 0.03). The 7-year breast cancer specific survival (BCSS) was 83% for patients with ILC and 77% for patients with IDC (P < 0.04). Selected patients with smaller lesions were treated with excision and radiation therapy. Patients with ILC treated with radiation therapy had a better DFS and BCSS than did patients with IDC treated with radiation therapy. CONCLUSIONS: ILCs often are homogeneous, small cell tumors of low nuclear grade. Their desmoplastic reaction may be absent or less marked than that of IDC, making them more difficult to palpate and to visualize mammographically. Despite this, they can be treated successfully with either mastectomy or excision and radiation therapy.

Axillary lymph node dissection for T1a breast carcinoma. Is it indicated?

BACKGROUND: Axillary dissection has been a routine part of breast cancer treatment for more than 100 years. Axillary node involvement is the single most important prognostic variable in patients with breast cancer. Recently, routine node dissection has been eliminated for intraductal carcinoma because so few patients had positive nodes. With the availability of numerous histologic prognosticators and the development of new immunochemical prognostic indicators, it is time to consider eliminating routine node dissection for lesions more advanced than duct carcinoma in situ (DCIS) but with extremely low likelihood of axillary involvement. METHODS: Axillary node positivity, disease-free survival, and breast cancer-specific survival were determined for six breast cancer subgroups by T category: Tis (DCIS), T1a, T1b, T1c, T2, and T3. RESULTS: Nodal positivity for DCIS was 0%; for T1a lesions, 3%. A large increase in nodal positivity was seen in lesions larger than 5 mm. (T1b, 17%; T1c, 32%; T2, 44%; T3, 60%). The rate of nodal positivity was statistically different as each T category was compared with the next more advanced T category. The disease-free survival and breast cancer-specific survival decreased with every increment in T value. CONCLUSIONS: Axillary node positivity increases as the size of the invasive component increases and is an excellent predictor of DSF and breast cancer-specific survival. Consideration should be given to eliminating axillary node dissection for T1a lesions because of the low yield of positive nodes. Axillary node dissection should be performed routinely for T1b lesions and larger.

An in vivo study of the effect of various breast implant filler materials on mammography.

Silicone breast implants have the potential to interfere with mammography through a variety of different mechanisms. One important factor is the radiopacity of the implant. A comparison was made of the effect of six different implant filler materials on visualization of known breast lesions in a living subject. The materials studied were normal saline, a triglyceride solution, silicone gel, a solution of 50% polyvinylpyrrolidone (PVP) in saline, a solution of 10% PVP in saline, and a solution of 2.5% PVP in glycerine. The ease with which known breast lesions could be identified through different materials varied dramatically. The poorest visualization was through the silicone gel-filled implant. The best visualization was through the prosthesis containing a triglyceride solution. Physical density, atomic number, and electron density are the factors which determine the radiopacity of materials used to fabricate breast implants. Radiopacity, in turn, affects the ease with which breast lesions can be imaged in vivo. The radiologic characteristics of filler materials will be an important consideration in the design of future breast implants.

Factors affecting mammographic visualization of the breast after augmentation mammaplasty.

OBJECTIVE: To measure the effect of various parameters on mammographic visualization of the breast after augmentation mammaplasty. DESIGN: Preoperative and postoperative mammography was performed in patients undergoing augmentation mammaplasty. The area of breast tissue visualized on each film was measured. Changes in the area visualized were correlated with a variety of different parameters. SETTING: The Breast Center, Van Nuys, Calif, a free-standing multidisciplinary breast diagnostic and treatment facility. PATIENTS: The 68 women (126 breasts) represent a consecutive sample of patients undergoing augmentation mammaplasty for whom preoperative and postoperative mammograms were available. MAIN OUTCOME MEASURES: Area visualized was correlated with degree of capsular contracture, implant position, type of mammography, preoperative breast size, implant size, and implant type. RESULTS: The major factor affecting mammography is capsular contracture. Little or no capsular contracture results in a 30% reduction in the area visualized; moderate or severe contracture results in a 50% reduction. Other important factors include implant position (improved visualization with implant beneath pectoral muscle) and type of mammography performed (slightly more tissue seen with displacement technique). Very small preoperative breast size yields increased visualization. Implant size and type have little or no effect. CONCLUSIONS: In most women with breast implants, there is a decrease in measurable breast tissue on the postaugmentation mammogram. Capsular contracture and implant position exert a profound effect; type of mammography performed and preoperative breast size are also significant.

Duct carcinoma in situ: 227 cases without microinvasion.

From 1979 to 1990, 227 patients with intraductal carcinomas (DCIS) without microinvasion were selectively treated; the least favourable (large lesions with involved biopsy margins) with mastectomy, the most favourable (small lesions with clear margins) with breast preservation. The preservation group was further subdivided into those who received radiation therapy (excision and radiation) and those who did not (excision alone). In the mastectomy group, there were 98 patients (43%) with an average lesional size of 3.3 cm; 41% had multifocal lesions, 15% had multicentric lesions. There has been one local invasive recurrence and no deaths. The 7-year actuarial disease-free survival is 98% with mastectomy. In the excision and radiation group, there were 103 patients (45%) with an average lesional size of 1.4 cm. 10 patients have had local recurrences (5 invasive and 5 noninvasive) one of whom has died. The 7-year actuarial disease-free survival is 84%, a statistically significant difference when excision and radiation is compared with mastectomy (P = 0.038). In the excision alone group, there were 26 patients (11%) with an average lesional size of 1.0 cm. There have been two local recurrences (8%), one of which was invasive and no deaths. The 7-year actuarial disease-free survival is 67%, but only 3 patients have been followed for more than 4 years. A total of 163 axillary node dissections were done; all were negative. Since DCIS without microinvasion rarely metastasizes to axillary lymph nodes, routine dissection should not be performed. Patients in this series with intraductal carcinoma treated with excision and radiation recurred locally at a statistically higher rate than those treated with mastectomy, in spite of the fact that those chosen for excision and radiation had clinically more favourable lesions. 6 of 12 (50%) local recurrences in conservatively treated patients were invasive. There was, however, no significant difference in overall survival in any subgroup regardless of treatment.

Breast cancer diagnosis and prognosis in women following augmentation with silicone gel-filled prostheses.

62 healthy women were studied mammographically before and after augmentation mammoplasty. Postaugmentation mammograms were done using both the implant compression and implant displacement technique. The amount of visualisable tissue was measured in all films before and after augmentation. We concluded: State-of-the-art film-screen mammography is extremely difficult to obtain in most patients augmented with silicone-gel-filled prostheses. On average, there is a decrease in measurable visualised breast tissue after augmentation mammoplasty with silicone-gel-filled prostheses. The area of mammographically measurable tissue is no different whether smooth or textured implants are used. Textured implants are less likely to form an early capsular contracture and are therefore preferred. However, the cancer-causing potential of polyurethane in humans is currently unknown. Anterior breast tissue is generally seen better with displacement mammography; posterior breast tissue with compression mammography. Better films are generally obtained when the implant is in the subpectoral position rather than subglandular. The more severe the capsular contracture, the poorer the mammogram. In addition 42 previously augmented patients developed breast carcinomas an average of 8.4 years after augmentation with silicone-gel-filled implants; 95% had palpable lesions (only 60% of which could be seen on mammography), 90% had infiltrating carcinomas, 45% had metastases to axillary nodes, and 7 patients have recurred, 5 of whom have died. We concluded: Augmented women who develop breast cancer are similar, in terms of tumour size and nodal positivity, to non-augmented breast cancer patients who present with palpable masses. When compared with non-augmented women whose breast cancers are found with screening mammography, augmented patients with breast cancer present with a higher percentage of invasive lesions and involved axillary lymph nodes, resulting in a poorer prognosis. The 40% false negative rate for mammography in this series is unduly high and alarming. Augmentation mammoplasty with silicone-gel-filled implants should be discouraged in women with a high risk of developing breast cancer.

The effect of silicone-gel-filled implants on mammography.

Fifty-four women who had previously undergone breast augmentation underwent film-screen mammography using both the standard implant compression technique and, when possible, the implant displacement technique. All had preaugmentation mammography available for evaluation. The area of mammographically visualized breast tissue before and after augmentation mammoplasty was measured using a transparent grid. Patients with subglandular implants had a mean 44% decrease of measurable tissue area with compression mammography and 36% decrease with displacement mammography. Patients with submuscular implants had a mean 25% decrease in measurable tissue area with compression mammography and 15% decrease with displacement mammography. Anterior breast tissue was seen better with displacement mammography, and posterior breast tissue was seen better with compression mammography. Most patients had some degree of parenchymal scarring and lower image quality after augmentation. State-of-the-art mammography was not possible in most patients whose breasts were augmented with silicone-gel-filled implants.

Radiation therapy for intraductal carcinoma. Is it an equal alternative?

Of 213 consecutive patients with intraductal carcinoma, 109 were selectively treated with mastectomy and 104 with radiation therapy. There were eight local recurrences, seven in patients treated with radiation therapy and one in a patient treated with mastectomy. Histologically, there were 110 comedocarcinomas and 103 noncomedocarcinomas. Seven local recurrences occurred in patients with comedocarcinomas and one in a patient with a noncomedo tumor. Three (38%) of eight local recurrences (all comedo) were invasive. The 5-year actuarial survival for all subgroups was 100%. The median follow-up was 51 months. Intraductal carcinoma is unlikely to metastasize to axillary lymph nodes, and routine dissection is unnecessary. Ductal carcinoma in situ of the comedo variety is more aggressive and more likely to recur than its noncomedo counterpart. We currently view conservative therapy for patients with intraductal comedocarcinoma with caution.

Axillary lymphadenectomy for intraductal carcinoma of the breast.

During a ten year period, 175 axillary lymph node dissections were done as part of the treatment for intraductal carcinoma of the breast; 98 patients were treated with modified radical mastectomy and 77 were treated by mammary preservation, consisting of excision of the lesion, axillary dissection and radiation therapy. One of 175 axillary node dissections yielded positive nodes. Axillary dissection for intraductal carcinoma of the breast is unlikely to yield involved nodes and is not indicated for use in most instances. It should be reserved for lesions demonstrating microinvasion.

Mammographic measurements before and after augmentation mammaplasty.

Thirty-five augmented women underwent mammography using both the standard implant-compression technique and, when possible, the implant-displacement technique; all had preaugmentation film-screen mammography available for evaluation. The area of mammographically visualized breast tissue before and after augmentation mammaplasty was measured using a transparent grid. Patients with subglandular implants had a mean decrease of 49 percent of measurable tissue area with compression mammography and a 39 percent decrease with displacement mammography. Patients with submuscular implants had a 28 percent decrease in measurable tissue area with compression mammography and a 9 percent decrease with displacement mammography. Anterior breast tissue was seen better with displacement mammography; posterior breast tissue, with compression mammography. Most patients had some degree of parenchymal scarring and lower image quality after augmentation. State-of-the-art mammography was not possible in most patients augmented with silicone-gel-filled implants.

Missed breast cancer in an augmented woman using implant displacement mammography.

Good mammography in the augmented patient is often difficult to achieve. A case is described that illustrates that posterior breast tissue is generally better seen with standard compression mammography and that physical examination by the radiologist must accompany mammography. Implant displacement mammography, while helpful, does not eliminate the need for standard compression mammography in selected patients.