- Email: [email protected]
Breast cancer in association with lobular carcinoma in situ
in Pssoc
with Loldar carcim
Ensitu
ReviewandTreatmmt Recommendation
a
WoUo 8wk, MD, Vancouver, BritishColumbia,Canada Robed Y. B&d, MD, FRCS (C), Vancouver, BritishColumbia,Canada
Lobular carcinoma in situ is a multicentric, often bilateral preinvasive breast neoplasm. Retrospective studies have demonstrated the frequency of subsequent infiltrating breast cancer to be 7 to 12 times greater than for the age-corrected general population [l-5]. This increased risk is equally distributed between both breasts. Lobular carcinoma in situ is thus viewed as a diffuse condition of mammary gland tissue. Treatment is controversial, ranging from close follow-up to simple mastectomy [2,3]. Patients who pmeentwithlobularcarcinomainsitucoexistingwith infiltrating breast cancer are therefore at risk of development of a second primary tumor of the contralateral b-t. A group of such patients have been studied, documenting the occurrence and location of disease, pathology, and folIow-up. In addition, recommendations are made regarding treatment. M&orisl and Methods Duriig the 5 year period from 1973 through 1977,3,337 patients with breast cancer were treated at the Cancer Control Agency of British Columbia (CCABC). Ninetyseven of these patiente (2.9 percent) were found to have lobularcar&oma in situ and simultaneousinvaeivecancer. Complete recordswith slidee were availablefor 80 patients who comprisedthe study group. Only patiente in whom the initial mastectomy specimen demonstrated lobular carcinoma in situ coexisting with invasive cancer were studied. All had pathology reviewedby pathologistaat the CCABC. Criteriaused for the diagnoeieof lobular carcinomain situ were as outlined by Rosen and co-workers[I ,2]. The World Health OrgarGationclaseificationwae used to describethe
vohmn 147, May lSa4
pathology of infiltrating carcinoma.&andard TNM classification ae adopted by the Union Internationale Centre de Cancerwae determined from document&ion provided by the attending surgeons. Follow-up &rough the outpatient department at the CCm wae av&ble for at least 5 years, including four examinationa during the first 2 postoperative years and then a biannual examination. Yearly screening mammography is recommended es a
routine [email protected] with III cancers underwent m&&.0 cent were of the modified radical variety. Adjuvant ra-
advanced tumors (stage IV) were treated with radiotherapy. ResUlta The average age of the women studied was 52.4 years (range 37 to 78 years). Forty-two (52 percent) were premenopausal and 38 (48 percent) were postmenopausal. Thislatter group included 11 women who had previously undergone hysterectomy. Twenty-nine patients (36 percent) had taken exogenous estrogen for a minimum of I year. Twelve patients (15 percent) were nulliparous. Sixteen (20 percent) had a positive family history of breast cancer of either maternal or paternal lineage. Nineteen patients had a breast biopsy before the development of invasive cancer. A total of 27 pathologic abnormalities were described and are listed in Table I. Five of these 19 patients were found to have lobular carcinoma in situ on review of the pathology report Biopsy development of invasive CanoBrby 1 to 8 years. The histologic characteristics of the infiltrating breast cancers are listed in Table II. Breasts demonstrating both lobular carcinoma in situ and intraductal cancer are listed separately. Group A, with lobular carcinoma in situ and infihrating cancer, had
841
Davis and Baird
TABLE I
Results of Btopsyot Etther Breast Before Development of lntiltratlng Cancer
Histopathoiogic Findina Lobularhyperpiasia Fibrocysticdisease Papiiiomatosis Ductectasta LCiS (in retrospect)
No. of Patients
ipsilateral breast. All eight patients in whom a second primary tumor developed had both lobular carcinoma and lobular carcinoma in situ as their initial breast cancer. Of the total group, 19 of 40 patients demonstrated lobular carcinoma in situ of the opposite breast: 12 had only lobular carcinoma in situ and 7 also had associated infiltrating tumors. Forty patients (50 percent) had a mammogram before mastectomy, 12 of which revealed benign tumor. Patients were followed at the CCABC over an average of 6.25 years. During this time period, 38 patients met the CCABC’s guidelines for annual mammography (they had not had bilateral mastectomy nor evidence of metastasis). Despite this policy, 23 patients had not had a mammogram during the first 2 years of follow-up.
Percentaoe
11 7 ;
40 26 4 11 19
5
LCIS = lobularcarcinomain situ.
almost an equal occurrence of lobular and infiltrating duct cancer. Group B, with lobular carcinoma in situ intraductal cancer, and infiltrating cancer, had a higher incidence of infiltrating duct cancer. Forty patients had a biopsy of the contralateral breast. Synchronous biopsy was defined as one performed within 1 month of initial diagnosis. Twenty-two patients had synchronous biopsies. Metachronous biopsies were performed from 3 months to 7.5 years after the initial biopsy in 18 patients. Indications for biopsy are presented in Table III. In the synchronous biopsy group, seven patients had a random biopsy due to the histopathologic diagnosis of lobular carcinoma in situ. Three of the seven patients demonstrated contralateral lobular carcinoma in situ. The indication for a metachronous biopsy was primarily a palpable mass; however, one patient requested a prophylactic mastectomy. The histopathologic findings and staging of bilateral infiltrating cancer of patients with bilateral disease are listed in Table IV. Three of six patients with simultaneous tumors had invasive lobular cancer in addition to lobular carcinoma in situ in the
TABLE II
Comments The occurrence and location of disease in this series of patients was compared with two groups of women with breast neoplasms: those with only lobular carcinoma in situ on biopsy specimens and those presenting with unilateral invasive cancer of all varieties. As mentioned earlier, the average age of our patients was 52.4 years and about half were premenopausal. In comparison, women with only lobular carcinoma in situ are, on average, younger (range 43 to 47 years) and are primarily premenopausal [1,2,4,5]. This suggests a latent period between the development of in situ changes and the subsequent evolution of infiltrating cancer. In contradistinction, women with breast cancer of all varieties present at a slightly older age than women in our series. The National Surgical Adjuvant Breast Project [6] reported the average age of women with breast cancer to be approximately 56 years. A third of these women
Pathologyof lntlltratlng Cancer Coexisting With Lobular Carcinoma In Situ’
Locationof CoexistinoCancer
PathologicStage
I
ii
iii
IV
Total
f
f 1
32 29 8 4
Grout A inffitratingduct Lobular inffitratingduct, lobular lnfiitratinocancer, unclassified
14 12 3 2
infiltratingduct Lobular infiitratingduct, lobular infiftratingcancer, unclassified infiltratingduct, Paget’sdisease
10 2 1 1 1 46
11 6 4 2
... ...
...
Group 6
Total
1 1 1
... ...
... ...
... ...
... ...
11 4 4 1 1
26
6
16
94
1
... 1 1
Patientsin soup A had iobuiarcarcinomain situwith coexistingcancer;patientsin groupB had lobuiarcar&omainsituandinb&uctal cancer in conjuncttonwith anothercoexistingcancer. l
642
TheAmwkanJoumalofslw!guy
were premenopausal. At least half of our patients were premenopausal and an additional 11 (14 percent) had hysterectomies and, hence, unknown ovarian function. Only 35 percent of patients were definitely -usaL The tendency of patients with coexisting lobular carcinoma in situ and infiltrating cancer to have the development of tumors at a young age while ovarian function persists suggests that endogenous hormones may have an etiologic role in the evolution of breast cancer when lobular in situ changes are evident. With regard to other etiologic factors known to increase the risk of developing breast cancer (that is, family history and nulliparity), there was no difference demonstrated between the groups of women. The National Surgical Adjuvant Breast Project reported that 26 percent of their patients had a family history of breast cancer, whereas the series of Rosen et al demonstrated a family history in 14.3 percent of their patients. Twenty percent of the patients in our study group had a positive family history. Similarly the incidence of nulliparity was comparable in all series. It has been well documented that lobular invasive tumors develop with a disproportionately high frequency in patients with lobular carcinoma in situ [I-5]. Similarly patients with simultaneous lobular carcinoma in situ and infiltrating tumors have a high incidence of lobular invasive disease. Thirty-five percent of our patients had this pathology documented. In a series of patients with all types of breast cancer, Fisher et al [7] reported the incidence of lobular invasive cancer to be 4.9 percent. Hence, in women without in situ lobular neoplasii, lobular carcinoma is relatively rare. This suggests that lobular carcinoma in situ is a preinvasive change that may develop into lobular cancer. Nonetheless, 46 percent of our patients had infiltrating duct tumors. Of note is that this histologic picture was encountered more frequently in patients who, in addition to lobular carcinoma in situ, had intraductal cancer recognized. This subgroup of patients (22 percent of the total), had infiltrating duct tumors in 52 percent of their biopsy specimens and lobular tumors in 19 percent of their specimens. It can be hypothesized that with multiple sectioning of mastectomy specimens, intraductal preinvasive neoplasia can be recognized more frequently in patients with infiltrating duct tumors in a background of lobular carcinoma in situ. Within the limits of the size of this series and a mean follow-up period of 6 years, this study has confirmed t&t patients with coexisting lobular carcinomainsituandbreustcaneerareatmcmasedrisk of the development of contralateral invasive breast cancer. The in&knee of eimultane~us bilahal tumorshasbeenrepor&lasO.8to2perCent[7-1O].In patients who undergo random biopsy of the con-
vakam 141, my leu
No.ol lndloatknl
Patlants
Banlpl
LCIS
Tumor
IO 37
. 54. .
:3
. 41. .
2
...
1’
it
synchronousmy
* E OthMlUllkllOWfl
MataohronousBloosY * tMerfunkmwn l
W.
Bllateral cancer
151
. 41. .
. 41. .
. 7. .
1
...
...
‘it
located by bilateral reduction mammop-
t Unknown. $ Found by prophylactic maslectomy at the paHent’s request.
tralateral breast, King et al [8] have reported an overall incidence of 4.5 percent of synchronous tumors. They included both infiltrating and noninfiltrating tumors in that calculation. Our patient population yielded six patients (7.5 percent) with synchronous infiltrating tumors and seven patients (8.8 percent) with lobular carcinoma in situ only. The combined incidence is thus 16.3 percent of the entire group, 4 to 8 times greater than other reported rates. Similarly, the patients we studied had a higher rate of development of a second primary tumor when compared with the estimated incidence. Slack et al [9] have determined from a prospective study of 2,734 patienti that the annual risk to women with breast canoer ofdavelopment,of a second primary tumor is 45:1,010 annually. Applying this data one would predict that 2 patients in a series of 36 would have a subsequent breast cancer within the subsequent 6 year period. In our series, in eight women with coexisting lobular carcinoma in situ and breast cancer, a second primary infiltrating tumor developed. metachronous con tected by palpation. classified T1, the remain&r be at presentation. The other stage was the result of a requested by the patient. Despite a well-structured program, 46 percent ofwomen who have a contralateral years of follow-up. It patient series compromised young premenopausal
643
Davis and Baird
TABLE IV Patient
Cases of Bilateral Bread Cancer Time Interval
Ipsilateral’ Disease
Stage
Contralateral Disease
stage
Synchronous Cancer
...
Lobular
I
...
Lobular
UK
...
Lobular
UK
...
Infiltrating duct
II
...
Infiltrating duct
I
...
Infiltrating duct
I
Lobular, infiltrating duct Infiltrating duct Infiltrating duct LCIS, infiltrating duct LCIS, inflftrating duct Intraductal, Infiltrating duct
II
5 yr
UK
1 yrt
IV
5yrq
II
7 yr
I
5 yr
I
5 yr
Methachronous Cancer 7
3.5 yr
Lobular
Ill
8
4 yr
Lobular
II
9 10
2 yr 3.5 yr
Lobular Lobular
IV I
11
4 yr
Lobular
II
12
6mo
II
13
5.5 yr
Lobular infiltrating duct Lobular
14
3 yr
Lobular
I
II
LCIS, and lobular LCIS, intraductal infiltrating duct Lobular LCIS and lobular Infiltrating duct Lobular, infiltrating duct LCIS, lobular, infiltrating duct lnflltratlng duct
UK
4yr
I
7yr
II I
7 yr 12yr
II
4yrs
...
5yr
UK
5 yr
UK
5 yr
l Lobular carcinoma In situ in biopsy specimen. t Tlme from initial biopsy. t Patient refused treatment. T Patient received radiotherapy. LCIS = lobular carcinoma in situ: UK = unknown.
women who faced a 10 to 30 year period of follow-up. No metachronous tumors were detected by mammography. In conclusion, patients with coexisting lobular carcinoma in situ and breast cancer have a high incidence of simultaneous and subsequent bilateral cancer. In our study, follow-up over a 6 year period was suboptimal in detecting subsequent cancers. Minimal treatment of the contraMera.l breast should include mammography with biopsy if findings are abnormal. Random contralateral biopsy is indicated even without clinical evidence of disease. Lobular carcinoma in situ of the opposite breast should be treated with simple mastectomy and axillary node sampling. The risk of development of a second primary cancer as well as the responsibility of long-term
644
follow-up must be discussed with the patient. Certainly, in young women with treatable early breast cancer and lobular in situ changes, contralateral prophylactic simple mastectomy should be considered as a treatment option. Summary A 6 year follow-up study of 60 women with coexisting lobular carcinoma in situ and infiltrating breast cancer has been conducted to emphasize the natural history and management of these cancers. Treatment of the contralateral breast is of utmost importance as lobular carcinoma in situ is a multicentric neoplasm associated with a subsequent high occurrence of invasive cancer. This series has documented a high incidence of bilateral cancer. Six patients (7.5 per-
l’ha Amerkan Journal ol Swgwy
cent) had simultaneous bilateral tumors and eight patients (10 percent) had the subsequent development of a second primary tumor, representing approximately four times the expected rate. Despite a well structured out-patient department, follow-up was suboptimal. Six of eight metachronous tumors were detected at a late stage (Tz and greater). AckuowIedgmenk We gratefully acknowledge the assistance of Dr. T. Rutherford and the staff of the medical records department of the Cancer Control Agency of British Columbia.
225-51. 3. HeageneenCD,LaneN,LattesR,BodlanC.LobularneopbM
4. 5. 6.
7.
8.
1. Rosen PP. Lob&r cercinorns in situ: recent cltniooqtho@lc stMkfs at Memorial Hospital. Pathol Res Pratt 1980; 166: 430-55. 2. RownPP, LMrmm PH. Braun DW. Kosloff C. Adsir F. Lobular carcinoma in situ of the breast. Am J Surg Pathol1978;2:
9.
10.
(s+called lobular carcinoma in situ) of the breast. Canoer 1978;42:737-69. HeaaeMwm CC. Diseases of the breast. Fhlbdetphia: WB saundem. 1971:503-28. Ashikai R, Huvos A, Synder R. PmqaMvastudyofnoo-infiltratingoarclmfnaofthet#mast.Cm$rJerl#7$f&~. FishsrB,McmtagwE,RedmondC,etakCaqMsonofndbd maste&q with alternatlve m forprhnrtybre@ cancer. Canoer 1977;3%2&?7-39. FlsherER,~ioRM,FkWer8,cd(3:~plhdPgyofkF vasivebreastcancer:asyt&busderhMfrumflndhgsofthe National Surgical Adjwant Braast Project @ro&ool no. 4). Cancer 197&3&l-81. KkrgRE,TerzJJ,LawrenceW.Exp&uxewtthoppo&ebraM biopsyinpatientswithoperabbtxastoanmr.Canou 1978;37:43-5. SlackNH,Bross!DJ,NemotoT,FisherB.&pHmoesw#th bilateral primary carcinoma of ths breast. Skug Gyneool obstet 1973;136:433-40. Cevitt JE. Bilateral mammary cancer. Ann Surg lB71;174: 174.
645
with Loldar carcim
Ensitu
ReviewandTreatmmt Recommendation
a
WoUo 8wk, MD, Vancouver, BritishColumbia,Canada Robed Y. B&d, MD, FRCS (C), Vancouver, BritishColumbia,Canada
Lobular carcinoma in situ is a multicentric, often bilateral preinvasive breast neoplasm. Retrospective studies have demonstrated the frequency of subsequent infiltrating breast cancer to be 7 to 12 times greater than for the age-corrected general population [l-5]. This increased risk is equally distributed between both breasts. Lobular carcinoma in situ is thus viewed as a diffuse condition of mammary gland tissue. Treatment is controversial, ranging from close follow-up to simple mastectomy [2,3]. Patients who pmeentwithlobularcarcinomainsitucoexistingwith infiltrating breast cancer are therefore at risk of development of a second primary tumor of the contralateral b-t. A group of such patients have been studied, documenting the occurrence and location of disease, pathology, and folIow-up. In addition, recommendations are made regarding treatment. M&orisl and Methods Duriig the 5 year period from 1973 through 1977,3,337 patients with breast cancer were treated at the Cancer Control Agency of British Columbia (CCABC). Ninetyseven of these patiente (2.9 percent) were found to have lobularcar&oma in situ and simultaneousinvaeivecancer. Complete recordswith slidee were availablefor 80 patients who comprisedthe study group. Only patiente in whom the initial mastectomy specimen demonstrated lobular carcinoma in situ coexisting with invasive cancer were studied. All had pathology reviewedby pathologistaat the CCABC. Criteriaused for the diagnoeieof lobular carcinomain situ were as outlined by Rosen and co-workers[I ,2]. The World Health OrgarGationclaseificationwae used to describethe
vohmn 147, May lSa4
pathology of infiltrating carcinoma.&andard TNM classification ae adopted by the Union Internationale Centre de Cancerwae determined from document&ion provided by the attending surgeons. Follow-up &rough the outpatient department at the CCm wae av&ble for at least 5 years, including four examinationa during the first 2 postoperative years and then a biannual examination. Yearly screening mammography is recommended es a
routine [email protected] with III cancers underwent m&&.0 cent were of the modified radical variety. Adjuvant ra-
advanced tumors (stage IV) were treated with radiotherapy. ResUlta The average age of the women studied was 52.4 years (range 37 to 78 years). Forty-two (52 percent) were premenopausal and 38 (48 percent) were postmenopausal. Thislatter group included 11 women who had previously undergone hysterectomy. Twenty-nine patients (36 percent) had taken exogenous estrogen for a minimum of I year. Twelve patients (15 percent) were nulliparous. Sixteen (20 percent) had a positive family history of breast cancer of either maternal or paternal lineage. Nineteen patients had a breast biopsy before the development of invasive cancer. A total of 27 pathologic abnormalities were described and are listed in Table I. Five of these 19 patients were found to have lobular carcinoma in situ on review of the pathology report Biopsy development of invasive CanoBrby 1 to 8 years. The histologic characteristics of the infiltrating breast cancers are listed in Table II. Breasts demonstrating both lobular carcinoma in situ and intraductal cancer are listed separately. Group A, with lobular carcinoma in situ and infihrating cancer, had
841
Davis and Baird
TABLE I
Results of Btopsyot Etther Breast Before Development of lntiltratlng Cancer
Histopathoiogic Findina Lobularhyperpiasia Fibrocysticdisease Papiiiomatosis Ductectasta LCiS (in retrospect)
No. of Patients
ipsilateral breast. All eight patients in whom a second primary tumor developed had both lobular carcinoma and lobular carcinoma in situ as their initial breast cancer. Of the total group, 19 of 40 patients demonstrated lobular carcinoma in situ of the opposite breast: 12 had only lobular carcinoma in situ and 7 also had associated infiltrating tumors. Forty patients (50 percent) had a mammogram before mastectomy, 12 of which revealed benign tumor. Patients were followed at the CCABC over an average of 6.25 years. During this time period, 38 patients met the CCABC’s guidelines for annual mammography (they had not had bilateral mastectomy nor evidence of metastasis). Despite this policy, 23 patients had not had a mammogram during the first 2 years of follow-up.
Percentaoe
11 7 ;
40 26 4 11 19
5
LCIS = lobularcarcinomain situ.
almost an equal occurrence of lobular and infiltrating duct cancer. Group B, with lobular carcinoma in situ intraductal cancer, and infiltrating cancer, had a higher incidence of infiltrating duct cancer. Forty patients had a biopsy of the contralateral breast. Synchronous biopsy was defined as one performed within 1 month of initial diagnosis. Twenty-two patients had synchronous biopsies. Metachronous biopsies were performed from 3 months to 7.5 years after the initial biopsy in 18 patients. Indications for biopsy are presented in Table III. In the synchronous biopsy group, seven patients had a random biopsy due to the histopathologic diagnosis of lobular carcinoma in situ. Three of the seven patients demonstrated contralateral lobular carcinoma in situ. The indication for a metachronous biopsy was primarily a palpable mass; however, one patient requested a prophylactic mastectomy. The histopathologic findings and staging of bilateral infiltrating cancer of patients with bilateral disease are listed in Table IV. Three of six patients with simultaneous tumors had invasive lobular cancer in addition to lobular carcinoma in situ in the
TABLE II
Comments The occurrence and location of disease in this series of patients was compared with two groups of women with breast neoplasms: those with only lobular carcinoma in situ on biopsy specimens and those presenting with unilateral invasive cancer of all varieties. As mentioned earlier, the average age of our patients was 52.4 years and about half were premenopausal. In comparison, women with only lobular carcinoma in situ are, on average, younger (range 43 to 47 years) and are primarily premenopausal [1,2,4,5]. This suggests a latent period between the development of in situ changes and the subsequent evolution of infiltrating cancer. In contradistinction, women with breast cancer of all varieties present at a slightly older age than women in our series. The National Surgical Adjuvant Breast Project [6] reported the average age of women with breast cancer to be approximately 56 years. A third of these women
Pathologyof lntlltratlng Cancer Coexisting With Lobular Carcinoma In Situ’
Locationof CoexistinoCancer
PathologicStage
I
ii
iii
IV
Total
f
f 1
32 29 8 4
Grout A inffitratingduct Lobular inffitratingduct, lobular lnfiitratinocancer, unclassified
14 12 3 2
infiltratingduct Lobular infiitratingduct, lobular infiftratingcancer, unclassified infiltratingduct, Paget’sdisease
10 2 1 1 1 46
11 6 4 2
... ...
...
Group 6
Total
1 1 1
... ...
... ...
... ...
... ...
11 4 4 1 1
26
6
16
94
1
... 1 1
Patientsin soup A had iobuiarcarcinomain situwith coexistingcancer;patientsin groupB had lobuiarcar&omainsituandinb&uctal cancer in conjuncttonwith anothercoexistingcancer. l
642
TheAmwkanJoumalofslw!guy
were premenopausal. At least half of our patients were premenopausal and an additional 11 (14 percent) had hysterectomies and, hence, unknown ovarian function. Only 35 percent of patients were definitely -usaL The tendency of patients with coexisting lobular carcinoma in situ and infiltrating cancer to have the development of tumors at a young age while ovarian function persists suggests that endogenous hormones may have an etiologic role in the evolution of breast cancer when lobular in situ changes are evident. With regard to other etiologic factors known to increase the risk of developing breast cancer (that is, family history and nulliparity), there was no difference demonstrated between the groups of women. The National Surgical Adjuvant Breast Project reported that 26 percent of their patients had a family history of breast cancer, whereas the series of Rosen et al demonstrated a family history in 14.3 percent of their patients. Twenty percent of the patients in our study group had a positive family history. Similarly the incidence of nulliparity was comparable in all series. It has been well documented that lobular invasive tumors develop with a disproportionately high frequency in patients with lobular carcinoma in situ [I-5]. Similarly patients with simultaneous lobular carcinoma in situ and infiltrating tumors have a high incidence of lobular invasive disease. Thirty-five percent of our patients had this pathology documented. In a series of patients with all types of breast cancer, Fisher et al [7] reported the incidence of lobular invasive cancer to be 4.9 percent. Hence, in women without in situ lobular neoplasii, lobular carcinoma is relatively rare. This suggests that lobular carcinoma in situ is a preinvasive change that may develop into lobular cancer. Nonetheless, 46 percent of our patients had infiltrating duct tumors. Of note is that this histologic picture was encountered more frequently in patients who, in addition to lobular carcinoma in situ, had intraductal cancer recognized. This subgroup of patients (22 percent of the total), had infiltrating duct tumors in 52 percent of their biopsy specimens and lobular tumors in 19 percent of their specimens. It can be hypothesized that with multiple sectioning of mastectomy specimens, intraductal preinvasive neoplasia can be recognized more frequently in patients with infiltrating duct tumors in a background of lobular carcinoma in situ. Within the limits of the size of this series and a mean follow-up period of 6 years, this study has confirmed t&t patients with coexisting lobular carcinomainsituandbreustcaneerareatmcmasedrisk of the development of contralateral invasive breast cancer. The in&knee of eimultane~us bilahal tumorshasbeenrepor&lasO.8to2perCent[7-1O].In patients who undergo random biopsy of the con-
vakam 141, my leu
No.ol lndloatknl
Patlants
Banlpl
LCIS
Tumor
IO 37
. 54. .
:3
. 41. .
2
...
1’
it
synchronousmy
* E OthMlUllkllOWfl
MataohronousBloosY * tMerfunkmwn l
W.
Bllateral cancer
151
. 41. .
. 41. .
. 7. .
1
...
...
‘it
located by bilateral reduction mammop-
t Unknown. $ Found by prophylactic maslectomy at the paHent’s request.
tralateral breast, King et al [8] have reported an overall incidence of 4.5 percent of synchronous tumors. They included both infiltrating and noninfiltrating tumors in that calculation. Our patient population yielded six patients (7.5 percent) with synchronous infiltrating tumors and seven patients (8.8 percent) with lobular carcinoma in situ only. The combined incidence is thus 16.3 percent of the entire group, 4 to 8 times greater than other reported rates. Similarly, the patients we studied had a higher rate of development of a second primary tumor when compared with the estimated incidence. Slack et al [9] have determined from a prospective study of 2,734 patienti that the annual risk to women with breast canoer ofdavelopment,of a second primary tumor is 45:1,010 annually. Applying this data one would predict that 2 patients in a series of 36 would have a subsequent breast cancer within the subsequent 6 year period. In our series, in eight women with coexisting lobular carcinoma in situ and breast cancer, a second primary infiltrating tumor developed. metachronous con tected by palpation. classified T1, the remain&r be at presentation. The other stage was the result of a requested by the patient. Despite a well-structured program, 46 percent ofwomen who have a contralateral years of follow-up. It patient series compromised young premenopausal
643
Davis and Baird
TABLE IV Patient
Cases of Bilateral Bread Cancer Time Interval
Ipsilateral’ Disease
Stage
Contralateral Disease
stage
Synchronous Cancer
...
Lobular
I
...
Lobular
UK
...
Lobular
UK
...
Infiltrating duct
II
...
Infiltrating duct
I
...
Infiltrating duct
I
Lobular, infiltrating duct Infiltrating duct Infiltrating duct LCIS, infiltrating duct LCIS, inflftrating duct Intraductal, Infiltrating duct
II
5 yr
UK
1 yrt
IV
5yrq
II
7 yr
I
5 yr
I
5 yr
Methachronous Cancer 7
3.5 yr
Lobular
Ill
8
4 yr
Lobular
II
9 10
2 yr 3.5 yr
Lobular Lobular
IV I
11
4 yr
Lobular
II
12
6mo
II
13
5.5 yr
Lobular infiltrating duct Lobular
14
3 yr
Lobular
I
II
LCIS, and lobular LCIS, intraductal infiltrating duct Lobular LCIS and lobular Infiltrating duct Lobular, infiltrating duct LCIS, lobular, infiltrating duct lnflltratlng duct
UK
4yr
I
7yr
II I
7 yr 12yr
II
4yrs
...
5yr
UK
5 yr
UK
5 yr
l Lobular carcinoma In situ in biopsy specimen. t Tlme from initial biopsy. t Patient refused treatment. T Patient received radiotherapy. LCIS = lobular carcinoma in situ: UK = unknown.
women who faced a 10 to 30 year period of follow-up. No metachronous tumors were detected by mammography. In conclusion, patients with coexisting lobular carcinoma in situ and breast cancer have a high incidence of simultaneous and subsequent bilateral cancer. In our study, follow-up over a 6 year period was suboptimal in detecting subsequent cancers. Minimal treatment of the contraMera.l breast should include mammography with biopsy if findings are abnormal. Random contralateral biopsy is indicated even without clinical evidence of disease. Lobular carcinoma in situ of the opposite breast should be treated with simple mastectomy and axillary node sampling. The risk of development of a second primary cancer as well as the responsibility of long-term
644
follow-up must be discussed with the patient. Certainly, in young women with treatable early breast cancer and lobular in situ changes, contralateral prophylactic simple mastectomy should be considered as a treatment option. Summary A 6 year follow-up study of 60 women with coexisting lobular carcinoma in situ and infiltrating breast cancer has been conducted to emphasize the natural history and management of these cancers. Treatment of the contralateral breast is of utmost importance as lobular carcinoma in situ is a multicentric neoplasm associated with a subsequent high occurrence of invasive cancer. This series has documented a high incidence of bilateral cancer. Six patients (7.5 per-
l’ha Amerkan Journal ol Swgwy
cent) had simultaneous bilateral tumors and eight patients (10 percent) had the subsequent development of a second primary tumor, representing approximately four times the expected rate. Despite a well structured out-patient department, follow-up was suboptimal. Six of eight metachronous tumors were detected at a late stage (Tz and greater). AckuowIedgmenk We gratefully acknowledge the assistance of Dr. T. Rutherford and the staff of the medical records department of the Cancer Control Agency of British Columbia.
225-51. 3. HeageneenCD,LaneN,LattesR,BodlanC.LobularneopbM
4. 5. 6.
7.
8.
1. Rosen PP. Lob&r cercinorns in situ: recent cltniooqtho@lc stMkfs at Memorial Hospital. Pathol Res Pratt 1980; 166: 430-55. 2. RownPP, LMrmm PH. Braun DW. Kosloff C. Adsir F. Lobular carcinoma in situ of the breast. Am J Surg Pathol1978;2:
9.
10.
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