Clinical and histopathological studies on surgical breast diseases among Koreans

의학과/석사[한글] Clinical and Histopathological Studies on surgical Breast Diseases among Koreans Jae Yun Ro Department of Medical Science, The Graduate School Yonsei University (Directed by Prof. Dong Sik Kim, M.D.) ( Prof. Yoo Bock Lee, M.D.) Lesions of the breast are preponderantly confined to the female. In the male and female prior to puberty the breast is a rudimentary structure relatively insensitive to endocrine influence, such as ovarian, pituitary and adrenal hormones and apparently resistive to neoplastic growth. In the female after puberty, on the other hand, the more complex breast structure, the greater breast volume and the extreme sensitivity to endocrine influences all prediosposed this organ to a number of pathologic conditions. To an almost exclusive degree, then, the woman who today presents herself with a dominant complaint related to the mammary glands will prove to be diagnosable as one of the "big three": (1) dysplasia, (2) benign neoplasia, most often fibroadenoma, or (3) malignant neoplasia, most often carcinoma. The many patterns of breast pathology included under the designation fibrocytic diseases and other benign tumors have great clinical importance for two reasons, (1) They produce masses in the breast that require differentiation from carcinoma, and (2) They may predisposed to the subsequent development of carcinoma. Two diametrically opposite viewpoints have long been held equally vehemently; that fibrocytic disease predispose to cancer, and there is no causal relationship between the two disorders. Wawen(1946) in several year follow-up of 1200 cases of cystic diseases, cites a cancer rate 4.5 times greater than in patients with normal breast. Other reports indicate that between 10 and 12 per cent of breasts with preexisting fibrocystic diseases of the breast develop cancer, two or threefold increased attack rate (Killgore et al., 1953; Pessagno, 1957). Looked at from the opposite point of view, 60 to 90 per cent of breasts with carcinoma have accompanying cystic diseases. Notwithstanding these findings, the issue of the relationship of fibrocystic diseases to carcinoma is still unsettled, and many still contend that there is no increased attack rate of carcinoma in breast having the pathologic changes of mammary dysplasia. The incidence of breast carcinoma is different geographically and racially. among women in the United States and Europe, breast is the leading site of cancer in both incidence and mortality. but in Korean, Japan, other Asian and African countries, the incidence of breast cancer is low. Breast carcinoma may appear at any age in either sex. However, it is rarely encountered in persons under the age of 30 years of womon and men. It occurs about 100 times as frequently in women as in men. The pathogenesis of the breast carcinoma is unknow, but hormonal factor, genetic factor, viral and traumatic factors are important role and the precancerous lesions are considered from chronic cystic mastitis and papilloma of the breast. The overwhelming number of malignant tumors of breast parenchyma are carcinomas, and almost carcinomas of the breast are ductal in origin. It is important to divide breast carcinomas into different types. If these types can be identified, then some statement can be made of the probable extent of the lymph node metastases and thereby prognosis. so recently Tornberg's classification (1960) is widely used. Tumor size, histologic types of breast cancer, location, nuclear grade, sinus histiocytosis of lymph nodes and invasion of blood vessels are features that have been claimed to be of prognostic significance of breast cancer. The most important single prognostic factor is the presence or absence of involved axillary lymph nodes. There are several reports on breast disorders among Koreans based on clinical and statistical aspects but there is no report on breast disorder, especially breast carcinomas based on histopathological aspects. The present study is an attempt to investigate mainly histopathological characteristics, such as classification of breast carcinoma according to cellular growth pattern, nuclear grade, sinus histiocytosis of lymph nodes, relationship between histologic types of breast carcinoms, location, nuclear grade and size vs axillary lymph node metastases, and combined diseases of uninvolved breast parencyma in breast carcinoma. Materials and Methods. The materials used in this study consists of 640 surgically resected breast tissues for 11 years from 1960 to 1970. Examinations of axillary contents were made when they were available. all specimens were fixed in 10% formalin. Grossly, the location and size of the tumor were examined. For histologic examinations, paraffin embedded blocks were cut in 6u thickness and sections were stained by hematoxyline-eosin method. Histopathological studies on all cases of breast carcinoma are performed as follows; 1. histopathological classification of primary breast carcinoma by cellular growth pattern of Tornberg's classification (1960); 2. combined diseases of uninvolved parenchyma in breast carcinoma were determined by Kern and Brooks study (1969). 3. nuclear grade and sinus histiocytosis of lymph nodes; 4. size, location, nuclear grade and histologic types of primary breast carcinoma in relation to axillary lymph nodes. 5. lymphocytic infiltration to breast carcinoma. Other breast disorders, such as benign tumors fibrocystic diseases and inflammatory diseases were also examined. For the all cases of primary breast carcinoma whose clinical records were available, sex, age, chief complaints, duration, blood types, marital and menstrual history and clinical axillary status were reviewed. Results and Summary Clinical and histopathological studies were made on 640 surgically removed cases of breast lesions, that were submitted to the Department of Pathology, Yonsei University College of Medicine, during the period of 11 years from 1960 to 1970. 1. Among 64o cases, 584 cases (91.3%) were female, in which 217 cases (37.2%) breat carcinoma, 124 cases (21.2%) fibroadenoma and 134 cases (22.9%) mammary dysplasia were included. The ratio of male and female breast carcinoma was 1:37.2. 2. The average age of female breast carcinoma was 47.0 year-old, male breast carcinoma 56.3, fibroadenoma 27.6 and mammary dysplasia 37.6. 3. The side distribution of the overall breast diseases was not significantly different, but breast carcinoma and mammary dysplasia were tend to the left slightly. 4. Clincal symptoms in order of frequency were as follows: palpable mass (95.2%), skin change (31.5%), pain (23.6%) and discharge (18.9%). The duration of chief complaints was the most common within six months (46.1%) and the average duration was 20.2 months. 5. Among 122 cases of female breast carcinoma, 115 cases (95.3%) was married, in which 36 cases (29.5%) had had history of sterility, and among 152 cases of female breast carcinoma, 43 cases (28.3%) the menstruation was irregular. 6. There is no relation between blood groups and incidence of breast carcinoma. 7. the location of the female breast carcinoma was the highest in upper out quadrant (40.0%) and the most frequent size was 3-6cm (53.4%) in diameter of the mass and the average size was 4.5cm. 8. The histological types of the female breast carcinoma according to cellular growth pattern in order of frquency were as follows. Type Ⅲ(39.2%), type Ⅱ(27.2%), Type Ⅳ(27.2%) and Type Ⅰ(6.7%) 9. Different from clinical vs. microscopic axillary nodes findings as follows: Clinically - and Pathologically - (53.5%) Clincially - and Pathologically + (46.5%) Clinically + and Pathologically + (80%) Clincially + and Pathologically _ (20%) 10. The metastases to axillary lymphnodes disclosed 63.7% and the larger the tumor the more laterally located, the poorer the histopathological types and the poorer the nuclear grade, the more likely that axillary lymphnodes were involved. 11. There is no relation between nuclear grade, sinus histocytosis or lymphocytic infiltration and histological types of breast carcinoma. 12. The cystic change was found in 62.6% of the breast carcinoma cases and was nearly as common as in the mammary dysplasia. Sclerosing adenosis, apocrine metaplasia and ductal papillomatosis were slightly more common in mammary dysplasia, but marked duct and lobular epithelial hyperplasia were more commonly assoicated with breast carcinoma. In conclusion based on above findings, it can be stated that breast carcinoma among Koreans examined in surgically removed specimens exbibited far advanced stage, both clinically and histologically. The mammary dysplasia, especially combined with large duct hyperplasia was important to solve of pathogenesis of the breast carcinoma. [영문] Lesions of the breast are preponderantly confined to the female. In the male and female prior to puberty the breast is a rudimentary structure relatively insensitive to endocrine influence, such as ovarian, pituitary and adrenal hormones and apparently resistive to neoplastic growth. In the female after puberty, on the other hand, the more complex breast structure, the greater breast volume and the extreme sensitivity to endocrine influences all prediosposed this organ to a number of pathologic conditions. To an almost exclusive degree, then, the woman who today presents herself with a dominant complaint related to the mammary glands will prove to be diagnosable as one of the "big three": (1) dysplasia, (2) benign neoplasia, most often fibroadenoma, or (3) malignant neoplasia, most often carcinoma. The many patterns of breast pathology included under the designation fibrocytic diseases and other benign tumors have great clinical importance for two reasons, (1) They produce masses in the breast that require differentiation from carcinoma, and (2) They may predisposed to the subsequent development of carcinoma. Two diametrically opposite viewpoints have long been held equally vehemently; that fibrocytic disease predispose to cancer, and there is no causal relationship between the two disorders. Wawen(1946) in several year follow-up of 1200 cases of cystic diseases, cites a cancer rate 4.5 times greater than in patients with normal breast. Other reports indicate that between 10 and 12 per cent of breasts with preexisting fibrocystic diseases of the breast develop cancer, two or threefold increased attack rate (Killgore et al., 1953; Pessagno, 1957). Looked at from the opposite point of view, 60 to 90 per cent of breasts with carcinoma have accompanying cystic diseases. Notwithstanding these findings, the issue of the relationship of fibrocystic diseases to carcinoma is still unsettled, and many still contend that there is no increased attack rate of carcinoma in breast having the pathologic changes of mammary dysplasia. The incidence of breast carcinoma is different geographically and racially. among women in the United States and Europe, breast is the leading site of cancer in both incidence and mortality. but in Korean, Japan, other Asian and African countries, the incidence of breast cancer is low. Breast carcinoma may appear at any age in either sex. However, it is rarely encountered in persons under the age of 30 years of womon and men. It occurs about 100 times as frequently in women as in men. The pathogenesis of the breast carcinoma is unknow, but hormonal factor, genetic factor, viral and traumatic factors are important role and the precancerous lesions are considered from chronic cystic mastitis and papilloma of the breast. The overwhelming number of malignant tumors of breast parenchyma are carcinomas, and almost carcinomas of the breast are ductal in origin. It is important to divide breast carcinomas into different types. If these types can be identified, then some statement can be made of the probable extent of the lymph node metastases and thereby prognosis. so recently Tornberg's classification (1960) is widely used. Tumor size, histologic types of breast cancer, location, nuclear grade, sinus histiocytosis of lymph nodes and invasion of blood vessels are features that have been claimed to be of prognostic significance of breast cancer. The most important single prognostic factor is the presence or absence of involved axillary lymph nodes. There are several reports on breast disorders among Koreans based on clinical and statistical aspects but there is no report on breast disorder, especially breast carcinomas based on histopathological aspects. The present study is an attempt to investigate mainly histopathological characteristics, such as classification of breast carcinoma according to cellular growth pattern, nuclear grade, sinus histiocytosis of lymph nodes, relationship between histologic types of breast carcinoms, location, nuclear grade and size vs axillary lymph node metastases, and combined diseases of uninvolved breast parencyma in breast carcinoma. Materials and Methods. The materials used in this study consists of 640 surgically resected breast tissues for 11 years from 1960 to 1970. Examinations of axillary contents were made when they were available. all specimens were fixed in 10% formalin. Grossly, the location and size of the tumor were examined. For histologic examinations, paraffin embedded blocks were cut in 6u thickness and sections were stained by hematoxyline-eosin method. Histopathological studies on all cases of breast carcinoma are performed as follows; 1. histopathological classification of primary breast carcinoma by cellular growth pattern of Tornberg's classification (1960); 2. combined diseases of uninvolved parenchyma in breast carcinoma were determined by Kern and Brooks study (1969). 3. nuclear grade and sinus histiocytosis of lymph nodes; 4. size, location, nuclear grade and histologic types of primary breast carcinoma in relation to axillary lymph nodes. 5. lymphocytic infiltration to breast carcinoma. Other breast disorders, such as benign tumors fibrocystic diseases and inflammatory diseases were also examined. For the all cases of primary breast carcinoma whose clinical records were available, sex, age, chief complaints, duration, blood types, marital and menstrual history and clinical axillary status were reviewed. Results and Summary Clinical and histopathological studies were made on 640 surgically removed cases of breast lesions, that were submitted to the Department of Pathology, Yonsei University College of Medicine, during the period of 11 years from 1960 to 1970. 1. Among 64o cases, 584 cases (91.3%) were female, in which 217 cases (37.2%) breat carcinoma, 124 cases (21.2%) fibroadenoma and 134 cases (22.9%) mammary dysplasia were included. The ratio of male and female breast carcinoma was 1:37.2. 2. The average age of female breast carcinoma was 47.0 year-old, male breast carcinoma 56.3, fibroadenoma 27.6 and mammary dysplasia 37.6. 3. The side distribution of the overall breast diseases was not significantly different, but breast carcinoma and mammary dysplasia were tend to the left slightly. 4. Clincal symptoms in order of frequency were as follows: palpable mass (95.2%), skin change (31.5%), pain (23.6%) and discharge (18.9%). The duration of chief complaints was the most common within six months (46.1%) and the average duration was 20.2 months. 5. Among 122 cases of female breast carcinoma, 115 cases (95.3%) was married, in which 36 cases (29.5%) had had history of sterility, and among 152 cases of female breast carcinoma, 43 cases (28.3%) the menstruation was irregular. 6. There is no relation between blood groups and incidence of breast carcinoma. 7. the location of the female breast carcinoma was the highest in upper out quadrant (40.0%) and the most frequent size was 3-6cm (53.4%) in diameter of the mass and the average size was 4.5cm. 8. The histological types of the female breast carcinoma according to cellular growth pattern in order of frquency were as follows. Type Ⅲ(39.2%), type Ⅱ(27.2%), Type Ⅳ(27.2%) and Type Ⅰ(6.7%) 9. Different from clinical vs. microscopic axillary nodes findings as follows: Clinically - and Pathologically - (53.5%) Clincially - and Pathologically + (46.5%) Clinically + and Pathologically + (80%) Clincially + and Pathologically _ (20%) 10. The metastases to axillary lymphnodes disclosed 63.7% and the larger the tumor the more laterally located, the poorer the histopathological types and the poorer the nuclear grade, the more likely that axillary lymphnodes were involved. 11. There is no relation between nuclear grade, sinus histocytosis or lymphocytic infiltration and histological types of breast carcinoma. 12. The cystic change was found in 62.6% of the breast carcinoma cases and was nearly as common as in the mammary dysplasia. Sclerosing adenosis, apocrine metaplasia and ductal papillomatosis were slightly more common in mammary dysplasia, but marked duct and lobular epithelial hyperplasia were more commonly assoicated with breast carcinoma. In conclusion based on above findings, it can be stated that breast carcinoma among Koreans examined in surgically removed specimens exbibited far advanced stage, both clinically and histologically. The mammary dysplasia, especially combined with large duct hyperplasia was important to solve of pathogenesis of the breast carcinoma.restrictio