Mammography Microcalcifications
A 45-year-old woman visits her gynecologist after having her yearly mammogram done. The mammogram reveals a “cluster” of microcalcifications.
Diagnosis. A geographic cluster of microcalcifications is nonpalpable. Although most of theselesions are benign, approximately 15–20% represent early cancer. An occult lesion requires stereotactic needle localization and biopsy under mammographic guidance. The coordinates of the lesion are calculated by the computer according to the basic principles of stereotaxis. The radiologist selects the length of the biopsy needle, and a core biopsy is obtained. The procedure is performed in an outpatient setting.
Management. Treatment is based on the established histologic diagnosis.
Persistent Breast Mass
A 35-year-old woman has a persistent breast mass after a fine-needle aspiration has been performed. The breast mass is confirmed by ultrasonography.
Diagnosis. With the combination of physical examination, fine-needle aspiration or corebiopsy, and mammography, open biopsies are being performed less frequently. Excisional biopsy has the advantage of a complete evaluation of the size and histologic characteristics of the tumor before definitive therapy is selected. An excisional biopsy is usually recommended in the following circumstances:
• Cellular bloody cyst fluid on aspiration
• Failure of a suspicious mass to disappear completely upon fluid aspiration
• Bloody nipple discharge, with or without a palpable mass
• Skin edema and erythema suggestive of inflammatory breast carcinoma, and a needle core biopsy cannot be performed
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In the past, recurrent or persistent simple breast cysts were routinely excised. Because of improve-ment in ultrasonographic technology, these cysts may now be followed conservatively. This patient, who has had a fine-needle aspiration before, is a candidate for an excisional biopsy.
Management. Treatment is based on the established histologic diagnosis.
Bloody Nipple Discharge
A 60-year-old woman comes to the gynecologist’s office complaining of a left breast bloody nipple discharge.
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Diagnosis. A bloody nipple discharge usually results from an intraductal papilloma. The treat-ment is total excision of the duct and papilloma through a circumareolar incision. Modern ductography does not reliably exclude intraductal pathology and is not a substitute for surgery in patients with pathologic discharge. Its utility is in identifying multiple lesions or lesions in the periphery of the breast.
Management. Treatment is based on the established histologic diagnosis.
BREAST CANCER
Breast Cancer Prognosis
A 65-year-old woman visits the gynecologist with a solid 2-cm mass in the upper outer quadrant of the left breast. A biopsy of the lesion is done, which is consistent with “infiltrating ductal breast cancer.”
Epidemiology. Breast cancer continues to be the most common cancer diagnosed in womenof western industrialized countries. An estimated 182,000 new cases of invasive breast cancer were expected to occur among women in the United States during 2000. After increasing by approximately 4% per year in the l980s, breast cancer incidence rates in women have leveled off in the l990s to approximately 110 cases per 100,000 women.
Management. The preferred treatment for most patients with stage I or II breast cancer is con-sidered to be breast-conserving therapy with a wide excision, axillary lymph node dissection or sentinel lymph node biopsy, and radiotherapy. Lymphatic mapping and sentinel lymph node biopsy are new procedures that offer the ability to avoid axillary lymph node dissection and its associated morbidity in patients with small primary tumors who are at low risk of axillary node involvement, while still offering nodal staging information.
Prognostic Factors. Some of the key decisions in the current management of primary breastcancer involve the need for prognostication. Prognostic factors serve to identity those patients who might benefit from adjuvant therapy.
• Lymph node status. This is important in determining cancer staging and treatmentoptions. Axillary lymph node status is the most important factor in the prognosis of patients with breast cancer. As the number of positive axillary lymph nodes increases, survival rate decreases and relapse rate increases. An adequate dissection usually con-tains at least 10 lymph nodes; however, because these tumors in 25–30% of patients with negative nodes eventually recur, other biologic prognostic factors also are needed.
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• Tumor size. This correlates with the number of histologically involved lymph nodes;however, it is also an independent prognostic factor, particularly in node-negative women. The use of size of the tumor, as the most significant prognostic factor, is prob-lematic because 15% of patients with small tumors have positive nodal involvement.
• Receptor status. It is standard practice to determine both estrogen and progesteronereceptor status at the time of diagnosis for definitive surgical therapy. Although hor-mone receptor status correlates with the prognosis, it does so to a lesser degree than nodal status. Hormone receptor determination is, however, of critical importance as a predictive factor. A predictive factor is any measurement associated with response or lack of response of a particular therapy.
Estrogen receptor status has clearly shown to be a predictive factor for hormone therapy, either in the adjuvant therapy or the metastatic disease setting. HER-2 (also known as HER-2.neu and c-erbB-2) is an epidermal growth factor receptor on the surface of a cell that transmits growth signals to the cell nucleus.
Approximately 25–30% of breast cancers overexpress HER-2, and overexpression of the receptor is associated with poor prognosis. This may be more of a reflection of the biologic correlates of HER-2 overexpression, e.g., rapid tumor cell proliferation, larger tumor size, and loss of hormone receptors, than an independent prognostic indicator.
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• DNA ploidy status. DNA ploidy status of tumors is determined by flow cytometry.It measures the average DNA per cell. Tumors can be classified as diploid with nor-mal DNA content or aneuploid. Disease-free survival rates are significantly worse
in patients with aneuploid tumors than in those with diploid tumors; however, it is unclear whether ploidy has an independent prognostic value.
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