Biomedical subjects
Publications and source records attributed to R V Hutter.
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Lobular carcinoma in situ (LCIS) was diagnosed in 165 surgical specimens (119 patients) at our institution between 1974 and 1987. LCIS was seen more often in younger women (mean age, 49 years) than other breast carcinomas were (mean age, 58 years). Sampling of a single breast revealed multifocal disease in 70% (96/138). When both breasts were sampled, bilateral foci were found in 50% (41/82). Of 165 breasts with foci of LCIS, 37% (61/165) had simultaneously occurring invasive cancers in the same breast. Direct mammographic-pathologic correlation of foci of LCIS was possible in 73 breasts (67 patients). Microcalcifications were an indication for biopsy in 49% (20/41) of breasts with a mammographic abnormality, but were a nonspecific finding often found in tissues adjacent to foci of LCIS. The mammogram was normal in 44% (32/73) of breasts with foci of LCIS. The mammograms of patients with LCIS and those from a group of age-matched control subjects were compared by using a modified form of Wolfe's criteria and the percentage of fibroglandular elements. LCIS was seldom found in an N1 breast (1% vs 29%) or in a breast with less than 25% of its parenchymal area occupied by fibroglandular density (3% vs 33%). Compared with the control group, breasts with LCIS had more than 50% fibroglandular density (85% vs 45%) and a much higher frequency of the DY pattern (56% vs 36%). More fibroglandular density was seen in the LCIS group at all ages. Postmenopausally, the frequencies of the DY pattern and fibroglandular density greater than 50% in LCIS patients were nearly double those in the control group. LCIS patients have disease of the entire breast parenchyma, characterized by multifocality and bilaterality of various forms of lobular disease. Their mammograms reveal a higher rate of the DY pattern and higher percentages of fibroglandular or parenchymal density than those of age-matched controls. In LCIS patients, persistence of the DY pattern, or large amounts of fibroglandular density postmenopausally supports the concept that mammographically dense breasts are a marker for increased cancer risk in women 50 years old and older.
The pathologist is a consultant in breast cancer patient management whose first responsibility is to establish the histologic diagnosis of cancer as well as its anatomic extent when sufficient tissue has been provided. The consultation also provides data that may be used to aid in selecting primary or adjuvant therapy, evaluating new therapies, estimating prognosis and assessing outcome. Examples of such data are the TNM histopathologic classification of the anatomic extent of the cancer used for the stage grouping (T: the extent of the primary tumor; N: the absence or presence and extent of regional lymph node metastasis; M: the absence or presence of distant metastasis), size, histologic type, histologic and/or nuclear grade, blood vessel and lymphatic vessel invasion assessment, steroid receptor analysis, and other special studies as appropriate.
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Ten epithelial-specific monoclonal antibodies, including monoclonal antibodies to antigens that have been used extensively in immunodiagnosis and immunotherapy experiments, were tested for reactivity with 20 human carcinomas each of the colon, lung, and breast. The antibodies tested included B72.3, OC125, and antibodies to carcinoembryonic antigen, the 17-1A antigen, and the milk fat globule mucin antigen (epithelial membrane antigen). Striking differences in the pattern of antigen distribution were seen, with each antibody having a fairly consistent staining pattern, which was dependent on the tumor type. Two antibodies reacted with most or all tumor specimens and, when positive, reacted homogeneously with apparently every cell in the specimen. Other antibodies consistently produced a variegated staining pattern, typically with areas of positive cells surrounded by areas of negative tumor cells. A third pattern was strong localization to the luminal edge and/or secretions of glandular tumors; this pattern was seen primarily in colon carcinomas which have more well-developed glandular structures than breast or lung carcinomas. A correlation with biochemical properties of the antigens was evident, in that mucins or mucin-related antigens generally produced variegated staining of lung and breast carcinomas and luminal edge/secretion staining of colon carcinomas. Such differences in antigen distribution are likely to be a major factor in developing methods for immunodiagnosis and immunotherapy.
At present, staging of malignant tumors is based on the anatomical extent of disease defined by the T(umor) N(odes) M(etastasis) classification. The main objective of further efforts in classifying tumors is to identify additional independent prognostic factors and to create mathematical models that may predict disease progression by prognostic grouping. This article summarizes problems, methods and the design of coordinated studies on prognostic grouping.
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The analysis of a data file comprising 776 lung cancer patients from the Tumor Registry at a 705-bed community hospital in New Jersey reveals that women are diagnosed with squamous cell and large cell lung cancer at an earlier age than men.
Today 50% of all people with newly diagnosed cancer will survive 5 years, compared with only 20% in the 1930s. This success has been accomplished by advances in early diagnosis and therapy. In 1980, the American Cancer Society (ACS) reasserted its emphasis on early detection with the publication of guidelines for the cancer-related check-up which include recommendations for the early detection of cancer of the cervix, breast, and large bowel. These recommendations as well as detection of early lung cancer are discussed. Prevention of death by early detection and effective therapy is a precursor to efforts to prevent clinical cancer entirely. Thirty-three percent of cancer deaths could be avoided if people chose not to use tobacco. Diet and nutrition probably account for another 33% of cancers. In 1984 the ACS published dietary recommendations for cancer risk reduction; these are discussed in the text. The status of prevention and detection is reviewed and some speculation is made about future prospects.
A major revision of the tumor, nodes, metastasis (TNM) classification has been published. It eliminates previous differences between the International Union Against Cancer (UICC) and American Joint Committee on Cancer (AJCC) versions. It also updates existing site classifications and adds chapters on previously unclassified tumors. This article summarizes the major changes from the past to the present editions of the TNM classification.
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A panel of Japanese and American pathologists reviewed existing histologic material used to study breast cancer risk among the A-bomb survivors in Hiroshima and Nagasaki, a population in which incidence studies have found a strong relationship between breast cancer risk and radiation dose. The primary charge to the panel was to define a body of confirmed cases in the Life Span Study sample of the Radiation Effects Research Foundation that would require little or no review for inclusion in future studies of breast cancer incidence. Broad agreement on histologic type was reached for 298 of 300 confirmed cases. The distribution of histologic types was, overall, similar to that seen in other studies of breast cancer in Japanese women, and did not appear to depend on dose; thus radiation-induced breast cancer appeared to be no different histologically from other breast cancer. Also, no evidence was found of variation in histologic type by city, age at exposure, age at diagnosis, or calendar time.
The management of patients with lobular carcinoma in situ (LCIS) has been an enigma for almost as long as the entity has been known. Continued follow-up of these patients has documented that about a quarter to a third will subsequently develop carcinoma in either breast after diagnostic excision, but no further therapy. Lobular carcinoma in situ has a 60% to 90% rate of multicentricity, and about 4% to 6% of mastectomy specimens from patients with LCIS have an invasive cancer elsewhere in the breast. Furthermore, 20% to 45% of women with LCIS have synchronous, or develop metachronous, contralateral breast cancer. The management programs range from clinical follow-up to bilateral mastectomy with reconstruction. These and various other choices are discussed. Since there is no conclusive evidence to justify the selection of any single program to the exclusion of all others, the informed patient must select from among the choices that program which will best satisfy her medical as well as psychosocial needs.
The Committee on the Pathologist as a Consultant in Cancer Patient Management, a committee of the Cancer Committee of the College of American Pathologists, was formed in response to the demands made on pathologists by other medical specialists to function as consultants. The Committee on the Pathologist as a Consultant in Cancer Patient Management has evolved from the Patterns of Care Steering Committee (1979) which in turn was spawned by the Patterns of Care Study initiated by The American College of Radiology (ACR) in 1973. The objective of the ACR was to improve the quality of care by establishing guidelines for the best current management in radiation oncology through a consensus by peers. Pathology is concerned with establishing a diagnosis, providing a rationale for treatment, estimating prognosis, and evaluating outcome. Consequently, the CAP Patterns of Care Study assumed a different form from that of the ACR, adapting itself to the role of the pathologist as a consultant. Its objective, however, remained the same - to improve the quality of care by providing quality assurance of pathology reports dealing with cancer patients. Three task forces, one for each site, have been established. Each is composed of pathologists and other medical specialists from small and large community hospitals, universities, and private office practice. The primary function of each task force is to develop guidelines for data to be included in routine pathology consultation reports. These guidelines include parameters that document adequate examination of the specimen, and those essential elements which can be used to guide selection of therapy, estimate prognosis, and evaluate outcome, such as the pathologic factors required for staging. Data to help establish these guidelines have been obtained in consultation with medical specialists who are members of the task forces, as well as from the medical literature. This entire process will be discussed. Currently there is great concern about improving the quality of medical care, particularly in a cost effective manner. Assuring the quality of consultation reports is yet another way in which pathology can contribute.