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M J Silverstein

Publications and source records attributed to M J Silverstein.

At least 37 records · Page 2Linked to original sources
PubMed1998

Hypothesis and practice: are there several types of treatment for ductal carcinoma in situ of the breast?

Currently, we approach DCIS based on its morphology rather than its etiology. However, morphologically normal-appearing tissue surrounding areas of DCIS may reveal losses of heterozygosity similar to the primary tumor (Lakhani et al. 1995; Stratton et al. 1995; Radford et al. 1995; Fujii et al. 1996). In all likelihood, genetic changes precede morphologic evidence of malignant transformation. We in medicine must learn how to recognize these genetic changes, exploit them, and, in the future, prevent them. DCIS is a lesion in which the complete malignant phenotype of unlimited growth, angiogenesis, genomic elasticity, invasion, and metastasis has not been fully expressed. With sufficient time, most noninvasive lesions will learn how to invade and metastasize. We must learn how to prevent this.

Axilla↗
PubMed1998

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.

Breast Neoplasms↗
PubMed1997

Predictors of axillary lymph node metastases in patients with T1 breast carcinoma.

BACKGROUND: Axillary lymph node metastases (ALNM) are the most important predictor of survival in patients with T1 breast carcinoma. Due to a relatively low incidence of axillary metastasis in tumors < or = 2 cm, the role of axillary lymph node dissection for these patients has been questioned. The purpose of this study was to determine the association between the incidence of ALNM and 11 clinical/pathologic factors by univariate and multivariate analysis. METHODS: The authors reviewed data from 918 patients with T1 breast carcinoma who underwent level I/II axillary dissection between 1979 and July 1995. The association between the incidence of ALNM and 11 clinical/pathologic factors (size, lymph/vascular invasion, nuclear grade, S-phase, ploidy, palpability, age, estrogen receptor status, progesterone receptor status, HER-2/neu, and histology) was analyzed by univariate and, when significant, by multivariate analysis. RESULTS: Approximately 23% of the 918 patients with T1 breast carcinoma had ALNM. Multivariate analysis identified four factors as independent predictors of ALNM: lymph/vascular invasion (P < 0.0001), tumor palpability (P < 0.0001), nuclear grade (P = 0.0004), and tumor size (P = 0.01). Among the 117 patients with nonpalpable, nonhigh grade tumors < or = 1 cm without lymph/vascular invasion, the incidence of ALNM was only 3%. However, the 43 patients with T1c tumors with all 3 additional risk factors had a 49% incidence of ALNM. CONCLUSIONS: Clinical and pathologic features of the primary tumor can be used to estimate the risk of ALNM in patients with T1 breast carcinoma. Such a risk assessment might facilitate appropriate management. Routine axillary dissection can be omitted in patients at minimal risk of ALNM, if the treatment decision is not influenced by lymph node status. Axillary lymph node dissection should be performed routinely for all patients with lesions > 1 cm. [See editorial counterpoint on pages 1856-61 and reply to counterpoint on pages 1862-4, this issue.]

Age Factors↗
PubMed1997

Use of predictors of recurrence to plan therapy for DCIS of the breast.

Despite the results of the National Surgical Adjuvant Breast and Bowel Project B-17, there continues to be debate regarding the most appropriate treatment for patients with ductal carcinoma in situ (DCIS) of the breast. Numerous clinical, pathologic, and laboratory factors can aid clinicians and patients wrestling with the difficult treatment decision-making process. Our research has shown that nuclear grade, the presence of comedo-type necrosis (coagulative necrosis), tumor size, and margin width are all important predictors of local recurrence in patients with DCIS. We used these factors to devise the Van Nuys Prognostic Index (VNPI), which assigns lesions a score from 1 to 3 for each of three factors: tumor size, margin width, and pathologic classification (determined by nuclear grade and necrosis). By scoring DCIS lesions according to this index, it may be possible to identify subgroups of patients who do not require irradiation, if breast conservation is elected, as well as patients whose recurrence rate is potentially so high, even with breast irradiation, that mastectomy is preferable.

Breast Neoplasms↗
PubMed1997

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.

Adult↗
PubMed1997

Ductal carcinoma in situ. The success of breast conservation therapy: a shared experience of two single institutional nonrandomized prospective studies.

A combined database of 342 patients with DCIS treated by lumpectomy alone versus lumpectomy and radiation therapy with a median 82-month follow-up is summarized in this joint study. Reproducible subtype classification and common methods of mammographic-pathologic correlation and complete tissue processing are unique features of this database, and they permit outcome to be analyzed by pathologic subtype, size, and margine status. Striking differences are noted in local control rates analyzed by subtype, which were largely independent of irradiation (see Table 1). Analysis of local recurrence-free survival restricted to those cases with a 10 mm or larger free margin width revealed no significant differences between the irradiated and nonirradiated groups. The local recurrence rates were 5% in those treated by lumpectomy alone and 4.5% in those treated by lumpectomy and irradiation (Table 4). Although differences in local recurrence rates for DCIS with a 10 mm plus free margin, with or without irradiation, were noted, they were not large. For DCIS patients with adequate (10 mm or more) or intermediate (1-9 mm) margin width, there was a reduction in local recurrence limited to the high-grade subtype (group III) with radiation therapy; an absolute 8% reduction for those with adequate margins and 11% for those with intermediate margins, but the difference was significant only for the latter group (Table 5). However, no significant differences were noted for the lower grade DCIS subtypes (groups I and II). For DCIS patients with inadequate margins (i.e., less than 1 mm), irradiation provided no benefit for local control. We conclude that an adequate surgical excision for DCIS, defined as a free margin of 10 mm or more, largely makes moot the question of local control related to pathologic subtype and treatment modality. Specifically, adequately excised high-grade (group III) DCIS received a benefit for local control from radiation therapy of only 8% within the median follow-up period. This difference is not significant. The impact of DCIS size or extent on local recurrence is much smaller than margin width (see Table 3). Significant differences achieved by radiation therapy were demonstrable only for the smallest size group (15 mm or less) in the highgrade subtype (group III). Differences in local recurrence rates for low and intermediate subtypes (group I and II) based on radiation therapy could not be demonstrated within the three size categories used in the study. We conclude that although adequate margins are more difficult to achieve for larger or more extensive DCIS, size alone is not a prohibition to breast conservation.

Breast Neoplasms↗
PubMed1996

A prognostic index for ductal carcinoma in situ of the breast.

BACKGROUND: There is controversy and confusion regarding therapy for patients with ductal carcinoma in situ (DCIS) of the breast. The Van Nuys Prognostic Index (VNPI) was developed to aid in the complex treatment selection process. METHODS: The VNPI combines three significant predictors of local recurrence: tumor size, margin width, and pathologic classification. Scores of 1 (best) to 3 (worst) were assigned for each of the 3 predictors and then totaled to give an overall VNPI score ranging from 3 to 9. Three hundred thirty-three patients with pure DCIS treated with breast preservation (195 by excision only and 138 by excision plus radiation therapy) were studied with detection of local recurrence as the end point. RESULTS: There was no statistical difference in the 8 year local recurrence free survival in patients with VNPI scores of 3 or 4, regardless of whether or not radiation therapy was used (100% vs. 97%; P = not significant). Patients with VNPI scores of 5, 6, or 7 received a statistically significant 17% local recurrence free survival benefit when treated with radiation therapy (85% vs. 68%; P = 0.017). Patients with scores of 8 or 9, although showing the greatest relative benefit from radiation therapy, experienced local recurrence rates in excess of 60% at 8 years. CONCLUSIONS: DCIS patients with VNPI scores of 3 or 4 can be considered for treatment with excision only. Patients with intermediate scores (5, 6, or 7) show a 17% decrease in local recurrence rates with radiation therapy. Patients with VNPI scores of 8 or 9 exhibit extremely high local recurrence rates, regardless of irradiation, and should be considered for mastectomy.

Breast Neoplasms↗
PubMed1996

Breast conservation therapy after augmentation mammaplasty: is it appropriate?

Breast conservation therapy, consisting of lumpectomy, axillary node dissection, whole-breast irradiation, and a boost to the tumor bed, is an increasingly popular option for the treatment of breast cancer. Among patients with stage I and stage II disease, breast conservation therapy yields survival rates equivalent to those for mastectomy. The cosmetic results of radiotherapy are usually good, and this approach preserves an intact, sensate breast. Most studies on breast conservation therapy, however, have been performed in nonaugmented patients. Relatively little has been published regarding breast conservation therapy in the presence of silicone implants. Between 1981 and 1994, we treated 33 augmented patients with breast conservation therapy. Among 26 individuals for whom complete follow-up data were available, 17 (65 percent) developed significant capsular contracture on the irradiated side. Thus far 8 patients with radiation-induced contracture have undergone corrective surgery. In our experience, augmented breast cancer patients treated with breast conservation therapy have less satisfactory cosmetic results than nonaugmented women. In addition, mammographic follow-up, critical for identifying local recurrence, may be impaired by the presence of an implant and capsular contracture. On the basis of these considerations, breast conservation therapy may be less than optimal in augmented cancer patients unless explantation is performed before treatment.

Adult↗
PubMed1995

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.

Bone Neoplasms↗
PubMed1995

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.

Adult↗