In this issue of the World Journal of Surgery experts review the complex management issues that confront the clinician treating and the researcher studying breast cancer. We outline areas of progress and share insights into management perspectives for the controversial issues that pertain to the basic and clinical research of breast cancer.
This material can be differentiated into three broad categories relative to the presentation of the disease. The family cancer syndromes and hereditary breast cancer have been explored by Henry T. Lynch and co-authors from Creighton University, Institut Gustave-Roussy and Montreal General Hospital. Their report is followed by a methodology for treating high risk and premalignant lesions, which is distilled from the experience of the Department of Pathology at Vanderbilt University under the direction of David Page. Differentiation of the proliferative atypical lesion from nonproliferative disease is being recognized as increasingly important in ascribing risk for subsequent development of carcinoma. Page and associates provide objective measures that define risk for various pathologic entities.
Marc E. Lippmann and associates at the Vincent T. Lombardi Cancer Center at Georgetown University provide an overview of evolving research methodology at a molecular level. The study of proto-oncogenes, which are cellular homologs of genes that are transduced or activated by transforming retroviruses, may be extraordinarily important in the etiology of a number of human cancers. At this writing, at least 20 proto-oncogenes have been identified and are organized into five general categories. It is possible that cellular transformation is initiated by point mutations, gene truncation, transcriptional activation, gene rearrangement, or gene amplification of these proto-oncogenes. Great potential exists for the amplification of gene rearrangement, and the molecular recognition of oncogenes in human breast cancer may allow early identification of patients at risk for transformation to clinical disease.
The second area of concern addresses contemporary biologic investigations of in situ and minimally invasive disease. Erik R. Frykberg and myself from the University of Florida and Brown University and William C. Wood from Emory University give an overview of "early" breast cancer and the integration of risk factors that allow proper selection of therapy for the lymph node-negative patient. These articles are followed by discussions of conservation approaches to the management of stage I and II carcinomas from the NSABP and the Milan Cancer Institute trials. These randomized trials, under the leadership of Bernard Fisher and Umberto Veronesi, have made great contributions to breast cancer research and have created the paradigm on which future studies will be modeled. Robert