The authors thank Ms. Nadia Crose for establishing the data base and for data management and D. C. Ward for help with the English.

al., 1988) comparing surgery with tamoxifen did not find a difference in survival between the two groups but locoregional control led to a better result in the surgically treated patients. This led to the conclusion that optimum treatment for elderly patients could include both surgery and tamoxifen. A randomised study (Bates et al., 1991) compared tamoxifen only with optimal surgery followed by adjuvant tamoxifen. The overall survival after 3 years was similar between the two groups but a statistically significant higher locoregional relapse rate was reported in the group treated by tamoxifen only.The rationale of the present study was that non-randomised clinical studies (Helleberg et al., 1982;Preece et al., 1982;Allan et al., 1985) showed that tamoxifen as first-line treatment was of value in a selected group of elderly breast cancer patients. The question was whether surgery without axillary dissection combined with tamoxifen in patients with breast cancer and without clinical nodal involvement could give the same results in terms of overall survival, disease-free survival and quality of life compared with more radical treatments.In a previous paper (Martelli et al., 1993) (Hermanek et al., 1987), 77 (24%) a T2, 1 (0.3%) a T3 and 24 patients (7.5%) presented with a tumour infiltrating the skin but not the underlying muscle (T4b). All patients had surgery performed under local anaesthesia without axillary dissection; 298 underwent wide lumpectomy or quadrantectomy and 23 total mastectomy. The conservative surgical techniques have been previously described (Veronesi et al., 1990;Galante et al., 1992).All patients underwent resection of the tumour with removal of at least 2 cm of normal tissue to ensure a specimen with tumour-free margins. Patients with the margins of resection in tumour tissue were excluded from the analysis, since they were candidates for a re-excision or radiotherapy.Independent of hormone receptor status, all patients received indefinitely 20 mg tamoxifen daily from the time of surgery. Tumour specimens were assayed for both oestrogen receptor (ER) and progesterone receptor (PgR) levels by using the dextran-coated charcoal Scatchard analysis. RecepCorrespondence: G Martelli

It has been proposed that knowledge of estrogen receptor b (ER-b) expression may refine estrogen receptor a (ER-a) predictivity of response to endocrine therapy. We challenged this hypothesis in ERa-positive breast cancers subjected to preoperative antiestrogen treatment. Forty-seven elderly (!65 years old) women with nonmetastatic, ER-a-positive (by immunohistochemistry) primary breast cancers (> 2 cm in diameter) entered a neoadjuvant hormone therapy protocol (60 mg/day toremifene for 3 months). ER-a and ER-b (ERs) mRNA was determined by semiquantitative RT-PCR, before (on core needle biopsy) and after (on surgical specimens) neoadjuvant treatment. Study end points included: (1) relation between treatment response and ER mRNA expression; and (2) changes in ER expression after treatment. The response was clinically assessed as tumor size change at the end of the preoperative treatment. ER mRNA expression was assessable before and after treatment in 38 and 20 cases respectively. ER-b was co-expressed with ER-a at variable levels and significantly correlated only with progesterone receptor ðP ¼ 0:0285Þ. Objective clinical response, including patients with minor change (!25-<50% tumor shrinkage after treatment), was documented in 68.4% of cases and was independent of ER-b levels or changes. ER-a levels were higher in tumors from patients in complete remission than in those from women achieving partial response or minor change compared with non-responsive patients (median expression values: 801 versus 516 versus 320 arbitrary units) and were consistently down-regulated by preoperative treatment. We conclude that in this elderly patient population with ER-a-positive tumors, ER-b mRNA was neither predictive of response to preoperative toremifene nor provided additional information to the knowledge of ER-a mRNA levels, which, conversely, were directly correlated with likelihood of response.

The Advanced Breast Biopsy Instrumentation (ABBI) system, which uses surgical cannulas up to 20 mm in diameter, is an alternative to conventional surgical biopsy for the diagnosis of non-palpable breast lesions. Since the need for radiological skill outweighs the surgical content of the technique, we evaluated the feasibility of complete management of the procedure by interventional radiologists. 35 of the 111 patients originally scheduled for the procedure were excluded, three because the lesion could not be visualized and 32 because of insufficient thickness of the compressed breast. The procedure had to be abandoned in one case due to a technical failure. 77 stereotactic excisional breast biopsy procedures were performed using the ABBI system in 75 patients with suspicious non-palpable mammographic lesions. The procedure was carried out under local anaesthesia in the radiology department, using a dedicated Lorad (R) radiographic system. 31 (40%) masses without calcifications, 11 (14%) masses with calcifications and 35 (46%) clusters of microcalcifications without tumour mass were sampled. 43 (56%) benign lesions and 34 (44%) malignant lesions were diagnosed. The overall mean diameter of the lesions was 8.7 mm (range 3-22 mm). All 34 patients with malignancies and lobular carcinoma in situ subsequently underwent surgery, the results of which are reported. Three (4%) haematomas were detected and aspirated percutaneously. Two technical problems occurred: an ABBI cannula malfunction, and a computer failure of the digital imaging system during the procedure. The average procedure time was 80 min and the cost of each procedure was 2,800,000 Italian lire (1555 US$). It is concluded that tissue sampling with the ABBI system can be performed entirely by radiologists without significant problems. The procedure was well tolerated by all patients. The quality of the biopsy specimen was identical to that of a surgical specimen but with the advantages of stereotactic precision for localization of the lesion.

Summary The disease-free probabilities after 3 to 7 years of follow-up of 180 breast cancers of known doubling times were studied to assess the prognostic significance and clinical implications of the growth characteristics of primary breast cancer. Fast-growing tumours, N+ >3, showed a prognosis significantly worse (P<0.01) than that of slow-growing tumours of the same class; no significant differences were found among N-or N+ (1-3) fast-, intermediate-and slow-growing tumours. Highly significant differences were found among fast-and intermediate-growing tumours with different degrees of lymph node involvement (respectively P<0.0001 and P<0.001), with the worst prognosis for N+ >3 tumours. In contrast, no significant differences were found among slow-growing tumours of the different N classes. When the Cox model was applied, the relationship between lymph node involvement and doubling time was significant, as was the interaction term. It is suggested that growth rate and metastatic potential are not the same in primary breast cancers, and their relation should be investigated.The prognostic significance of the mammary tumour growth rate has been evaluated in some retrospective studies (Kusama et al., 1972;Pearlman, 1976;Slack et al., 1969;Spratt et al., 1977Spratt et al., , 1983, and a relation between patient survival and the tumour growth rate recognized. Nevertheless, the growth rate, normally expressed as mass tumour doubling time (DT), is not a prognostic parameter used in clinical practice because of the difficulty of evaluating it in the usually short time preceding surgical treatment.This paper reports the results of a prospective study of 180 breast cancers followed since 1975, for which the growth rate was evaluated before surgical treatment by means of a double mammographic examination. The aim of this study was to assess the biological meaning of the growth rate and its clinical implications. Owing to the relatively short average follow-up, our analysis was related to the disease-free interval, and the reported results should be considered as preliminary. Materials and methods From 1975 to 1980, 196 woman had to have two mammographic examinations with an interval of more than 20 days. The delays before the intervention were mainly due to the time required for staging examinations or delayed admission because of a long waiting list for hospitalization.Mammographic examinations, performed in two perpendicular projections for each side, revealed the iconographic characteristics (borders, opacity, shape, microcalcifications) as well as the size of the neoplasm along three perpendicular axes in the case of clearly defined radiological images (more than 95% in our series). The mammographic volume was estimated using the formula for spheroids:where a, b and c are the radii derived from the three axes of the tumour. Since two depth values were obtained (one from the craniocaudal position and the other from the latero-lateral projection), the mean of these two values was used. If the neoplastic shadow wa...