Faculty Bibliography

Discussion of benign breast disease, including signs, symptoms, diagnosis, and suggested treatment, is presented. Helpful means for distinguishing between benign and malignant breast disease include biopsy, patient and family history, age, frequency of pregnancies, and timing of menstruation in relation to examination. The presence of a mass during examination, along with changes in size or firmness of one breast, skin changes, nipple discharge, or changes in nipple epithelium, may provide information helpful to establishing diagnostic procedure. Fibrocystic disease ranging from epithelium-lined cyst to sclerosing adenosis presents with symptoms of breast discomfort. Histopathological changes include hyperplasia of duct epithelium, duct papillomatosis, and blunt duct adenosis. Treatment includes aspiration and re-examination or possibly mammography. When mammography is insufficient to distinguish from carcinoma, a biopsy is indicated. Mammary duct ectasia is characterized by a yellowish-brown discharge, thickening of the duct wall, and shortening and retraction of the nipple. Ductal excision is indicated; excisional biopsy should be performed if a mass is present. Intraductal papilloma presents with bloody nipple and should be further evaluated by biopsy and possibly mammography. Fat necrosis can sometimes mimic cancer; biopsy and mammography may be needed for definitive diagnosis. Fibroadenomas are solid, rubbery, movable lesions. Re-examination during another part of the menstrual cycle and excisional biopsy are indicated for diagnosis. Accurate diagnosis and patient reassurance are necessary when dealing with benign breast disease

Fifty-two patients who were biopsied because of the presence of clustered microcalcifications on mammography, in the absence of any definable mass on x-ray or physical examination, were studied. Localization of the microcalcifications was obtained by measuring the area in relation to the vertical and horizontal axes from the nipple on both lateral and cephalocaudad views. Specimen radiography was obtained to ensure that the area with microcalcifications had been included in the specimen. Carcinoma was found in 17 instances (33%). In four (24%) the detected microcalcifications corresponded to fibrocystic disease, with carcinoma being found only in adjacent tissue with little or no calcifications. Precise localization and removal of only the area containing calcifications without excision of a generous margin of surrounding tissue may result in the exclusion of an adjacent carcinoma

A series of 206 patients with cutaneous melanoma of the head and neck has been studied. Ninety patients had a regional lymph node dissections performed. Seventeen lymph node dissections were done therapeutically and 73 were done electively. Thirty-one patients had histologically positive lymph nodes and, of these, 30 patients have been followed to the present time or death. Twenty-nine of these patients (97%) have developed systemic melanoma. Twenty-six patients have died and three are alive with disease. No patient had local recurrence alone while four had local recurrence synchronously with systemic metastases. This contrasts with 29 patients followed for greater than five years with histologically negative nodes, 27 (93.1%) of whom are alive with no evidence of recurrent disease. Regional node metastases with melanoma of the head and neck is an almost certain indication of systemic disease. A selective surgical approach to invasive melanoma in this region is proposed based on the observation in the 31 patients who had radical neck dissections with histologically positive nodes. The metastases always involved the nodal group adjacent to the primary site. This selective approach should allow optimal local control and accurate pathologic staging while limiting the extent of the surgery

A series of 21 patients treated surgically for primary melanoma of the skin of the breast has been studied. Melanomas in this location accounted for 1.8% of a total of 1,140 patients with primary clinical Stage I and Stage II melanomas treated during a 28 year period. Wide excision with axillary lymph node dissection in selected instances has resulted in no mortality and no local recurrence to date. This approach allowed the preservation of a major portion of the breast in eight female patients. It is emphasized that melanoma is a cutaneous lesion and considerations applying to lymphatic dissemination of parenchymal disease of the breast need not apply

One hundred eighty-two patients undergoing initial surgical therapy for primary malignant melanoma were evaluated for delayed hypersensitivity using a battery of recall antigens prior to surgery. Fifty-six patients were also sensitized with 2, 4-dinitrochlorobenzene. All tumors were classified by Clark-Mihm levels and the patients were clinically staged. They were followed up for an average period of 55 months. There was no significant difference in the ability of patients with varied Clark-Mihm level lesions to mount a delayed hypersensitivity response to the recall battery or to 2, 4-dinitrochlorobenzene. Thirteen stage I melanoma patients in whom recurrence developed at a distant site exhibited no difference in immune responsiveness when compared to 148 patients in whom recurrence did not develop when both groups were tested with recall antigens. No difference was noted in patients with stage II disease in whom recurrence developed, as measured by reaction to these same antigens. Twelve patients demonstrated anergy to recall antigens, in none of whom has recurrence developed to date. Fifty-six patients who were tested with 2, 4-dinitrochlorobenzene showed no difference in reactivity with tumors classified at any of the Clark-Mihm levels. Anergy demonstrated by delayed hypersensitivity skin testing appears to reflect increasing tumor burden, rather than a preexisting deficiency that can be used to predict patients at high risk for the development of recurrent disease