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Background. To evaluate the pathologic characteristics of the primary tumor relative to local control, survival, and freedom from distant metastases, an analysis was performed of 172 patients with ductal carcinoma in situ (intraductal carcinoma) of the breast treated with breast-conserving surgery and definitive breast irradiation. Methods. The clinical records and pathology slides were reviewed from 172 women with ductal carcinoma in situ treated with breast-conserving surgery and definitive breast irradiation at multiple institutions in Europe and the United States. Central pathology review was performed by one pathologist without knowledge of the clinical outcome. The clinical outcome was measured in terms of local control, overall survival, cause-specific survival, and freedom from distant metastases. The median follow-up time was 84 months (range, 17-177 months). Results. The pathologic parameters evaluated were histologic subtype, nuclear grade, amount of necrosis, and final pathology margin. The only pathologic parameter that correlated with the rate of local recurrence was the presence versus the absence of the combination of the histologic subtype of comedo carcinoma plus nuclear grade 3 (8-year actuarial rate of local recurrence of 20% versus 5%, respectively; P = 0.009 on univariate analysis; P = 0.017 on multivariate analysis). None of the pathologic parameters evaluated correlated with overall survival (all P [is greater than or equal to] 0.16), cause-specific survival (all P [is greater than or equal to] 0.13), or freedom from distant metastases (all P [is greater than or equal to] 0.13). Conclusions. These results have demonstrated that there are important differences in the rate of local recurrence based on the pathologic characteristics of the primary tumor for women with ductal carcinoma in situ treated with breast-conserving surgery and definitive irradiation. However, the differences in local recurrence have not been associated with differences in survival or freedom from distant metastases. Careful follow-up for patients at increased risk for local recurrence is warranted because of the potential ability to salvage patients with local recurrence. Cancer 1993; 71:2532-42.

It is unusual for a patient with breast cancer to have two or more tumor masses in the same breast. Often a high risk of local cancer recurrence is assumed for these patients, and they are therefore not treated with breast-conserving therapy. An analysis of breast-conserving therapy carried out in this group of patients is presented. There were 586 patients treated conservatively (wide excision of only the tumor, followed by radiotherapy); 61 patients had two or more tumors. After an average follow-up of 71 months, 15 of the 61 patients (25 percent) had developed recurrence of the cancer in the treated breast; patients who had single tumors had an 11 percent incidence of recurrence. The recurrence rate for patients with two tumors was 16 percent, whereas those with three or more had a recurrence rate of 35 percent. If the multiple tumor could be diagnosed by a clinician or by mammography, it was more likely to recur (36 percent) than if it could only be diagnosed at the time of pathological study of the tissue specimen (18 percent). When the excised tissue margins were clearly free of tumor, only in one of 22 patients did the cancer recur. It is concluded that multiple breast cancers are at higher risk for local recurrence, especially if the multiplicity is apparent, of if there are three or more nodules present. If a good result is to be achieved, negative surgical margins are essential. (Consumer Summary produced by Reliance Medical Information, Inc.)

The cases of 496 women treated for ductal breast cancer with breast-conserving surgery were reviewed to determine those factors which best predicted the risk of local recurrence in the remaining breast tissue. Twenty-one different factors were studied. Nine factors were significantly associated with increased risk of local tumor recurrence: mononuclear cell reaction, high tumor grade, extensive intraductal component, tumor necrosis, macroscopic multiplicity, absence of estrogen receptors, tumor size, vascular invasion, and age under 40. Not all of these factors are independent, however. Upon multivariate analysis, the most significant factors were found to be mononuclear cell reaction, tumor grade, and intraductal component. It is interesting to consider the correlation of age under 40 years with increased risk of recurrence. Women under 40 are at significantly higher risk of local recurrence; this seems to be due to the fact that extensive intraductal components are more common among women under 50, and both mononuclear cell reaction and high tumor grade are more common in women under 40. Thus, virtually all of the important prognostic factors are related to the histopathological examination of the tumor rather than extrinsic factors, such as radiation dose or family history. The overall risk of local recurrence of ductal breast cancer was 12.3 percent. Patients with moderate or severe mononuclear cell reactions had a 28 percent chance of recurrence. The recurrence rate of premenopausal women without any risk factor was only 2.6 percent at five years. For postmenopausal women, risk was determined primarily by tumor grade and the adequate margins obtained during the surgery. Those with grade 3 tumor and tumor extending to the margin of the removed tissue had a 31 percent chance of local recurrence within five years. Clearly, careful pathological evaluation of the tumor tissue is by far the most important step in evaluating the risk of recurrence in patients with ductal breast cancer. (Consumer Summary produced by Reliance Medical Information, Inc.)