Biomedical subjects
Publications and source records attributed to D J Marchant.
Although much has been accomplished in the last few years toward the early detection of breast cancer, we are far from a goal of universal acceptance of the recommended preventive health program of screening mammography. To take an analogy from the Papanicolaou smear, we are somewhere in the 1960s. Both women and physicians have more to learn, and they need to transfer that knowledge into practice.
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The approach to these lesions is being reexamined in light of results with conservative surgery for invasive breast cancers. According to available data, the invasive potential of in situ lesions varies. Mammographic and pathologic findings may differentiate patients who will benefit from lumpectomy (with or without radiotherapy) from those requiring mastectomy.
Between 1982 and 1985, 108 women with AJC Stage I and II invasive mammary carcinoma were treated to 115 breasts with conservative surgery and irradiation. The irradiation dose was adjusted to the histopathological normal tissue margin around the carcinoma in the tumor excision specimens. Margins were arbitrarily determined negative, close, and positive with normal tissue margins in the inked tumor excision specimens of greater than 5 mm, 2-5 mm, and less than 2 mm, respectively. Negative, close, and positive tumor margin patients were treated to radiation doses of 60, 65, and 70 Gy, respectively. The boost in excess of 50 Gy was directed to the tumor bearing quadrant of the breast using interstitial Ir-192 implants for doses greater than or equal to 70 Gy. The draining lymphatics were irradiated to 50 Gy except in patients with tumor in the lateral half of the breast and no axillary lymph node metastases. Histopathological evaluation of re-excision specimens revealed the difficulty of obtaining negative margins for tumors greater than 2 cm. By our criteria, 54% of the patients had a positive resection margin. None of the patients experienced a local recurrence at 60 months median follow-up. Three patients failed regionally, two in un-irradiated lymph node areas, one in the skin of the contralateral breast; five patients failed systemically. Overall and disease-free survival for Stages T1/N0, T1/N1, T2/N0 was 100 and 95%, respectively, and for T2/N1, 90 and 80%, respectively. The cosmesis was excellent in 66% of the patients with minimal treatment related complications. Carefully planned standardized irradiation with assessment of resection margins yields both excellent local control rates and cosmetic results.
The records of 21 consecutive patients referred for breast-conservation treatment of early-stage mammary carcinoma contained insufficient histopathologic documentation of adequate resection margins after tumor excision at other hospitals. All patients underwent postbiopsy mammography before reexcision of the tumor bed. In 12 of the 21 cases, there was pathologic evidence of macroscopic or microscopic residual tumor. In seven of the 12 cases, there was no clinical or mammographic evidence to suggest residual carcinoma. The findings indicate that mammography is insufficient to evaluate the completeness of tumor excision in the absence of histopathologic documentation.
Forty consecutive cases of nonpalpable breast carcinoma presenting on the mammogram as microcalcifications without an associated mass were reviewed. The precise relationship between the mammographic microcalcification and the histologic carcinoma was determined in each case. In 25 cases (63%), the mammographic calcium was confined to the tumor, and in 13 cases (33%), the calcification was present both within the tumor and contiguous to the tumor margin. In two cases (5%), the calcium was not contained within the tumor but was located next to it. In one of these cases, the calcium was within 4 mm of the malignant neoplasm and in the other it was within 13 mm. No difference was seen between the appearance of the calcifications located within the tumor and the appearance of calcification next to the tumor. Precise histologic analysis revealed that microcalcifications that had prompted biopsy were confined to the tumor in 63%, within and contiguous to the tumor in 32%, and within 13 mm of the tumor in 5%.
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Controversy regarding the efficacy of surgical treatment of breast cancer has persisted since the earliest descriptions of this disease in the first and second centuries AD. It has been acknowledged for many years that patients with untreated breast cancer survive for a surprisingly predictable period of 5 yr. Hence, in recommending extensive surgical procedures, the surgeon must recognize the unique biology of breast cancer and the need for long-term follow-up. In spite of a voluminous body of literature concerning the treatment of breast cancer, the distention and contention still continue. However, there is now increasing support for conservative treatment, including the less radical modified mastectomy, and in selected cases, wide local excision, axillary dissection and radiotherapy. As knowledge accumulates, it is clear that the treatment of breast cancer requires a multidisciplinary approach reflecting our understanding of the biology of this disease.
During a period of two years, nine patients were found who had a solitary geographic cluster of microcalcifications which appeared to be intramammary on two standard mammographic views. In two instances, the women underwent unsuccessful excisional biopsies. In the other seven patients, the true location of the microcalcifications was recognized and proved preoperatively so biopsy was avoided. When intradermal microcalcifications are fortuitously imaged in tangent or when they assume characteristic polygonal shapes with lucent centers, their intradermal location should be suspected. However, if the form is not typical of intradermal calcifications and when the location appears to be intramammary on the routine mammographic views, an excisional biopsy will usually be recommended. If skin is not included in the excised tissue, then the biopsy will be unsuccessful. A simple technique using a metallic marker can confirm the true intradermal location of calcifications.
We reviewed 101 consecutive biopsy specimens of nonpalpable breast lesions obtained by needle localization. Forty-six biopsies were done on outpatients under local anesthesia and 16 more on inpatients under local anesthesia. The remaining 39 biopsies were performed on inpatients under general anesthesia. The complications and accuracy of the outpatient procedure were acceptable and comparable to those of the inpatient procedure. In our institution, there is almost a fivefold cost increase for the performance of this procedure under general anesthesia as an inpatient. We recommend that surgeons and radiologists work together to perfect preoperative localization techniques, and we strongly support the concept that this procedure should be performed on outpatients under local anesthesia for the majority of patients with nonpalpable mammographic abnormalities.
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A number of important factors determine the risk for breast cancer, and the most important of these seem to be related to estrogen and possibly prolactin. Additional research is necessary on the role of endogenous and exogenous estrogens and the effect of diet, drugs, and other factors on the levels of estrogen and prolactin. It is unlikely that with present epidemiologic evidence, breast cancer can be prevented. We cannot alter the age of menarche, and promotion of early pregnancy to protect against breast cancer is not feasible. One risk factor that is alterable is obesity, particularly in the postmenopausal woman. The risk factors associated with exogenous estrogens following the menopause require confirmation by other studies. However, because of the strong association of these drugs with increased risk of endometrial cancer, the physician should be cautious in prescribing them.
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Urinary incontinence is a sign of a disorder, not a diagnosis. Careful history and physical examination often suggest the correct diagnosis. However, complete accuracy can be obtained only by the judicious use of appropriate ancillary procedures including careful neurologic assessment and urodynamic evaluation of the bladder and urethra. The fact that the varieties of urinary incontinence occur infrequently poses a significant medical and legal problem. Unless the facilities for complete urologic evaluation are available and unless the surgeon by training and experience has demonstrated success in the treatment of urinary incontinence, most if not all of these patients should be considered for referral.