Prognostic significance of synchronous and metachronous bilateral breast cancer

Ultrafast sequence-based prediction model and nomogram to differentiate additional suspicious lesions on preoperative breast MRI

OBJECTIVES

To investigate whether ultrafast sequence improves the diagnostic performance of conventional dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in differentiating additional suspicious lesions (ASLs) on preoperative breast MRI.

MATERIALS AND METHODS

A retrospective database search identified 668 consecutive patients who underwent preoperative breast DCE-MRI with ultrafast sequence between June 2020 and July 2021. Among these, 107 ASLs from 98 patients with breast cancer (36 multifocal, 42 multicentric, and 29 contralateral) were identified. Clinical, pathological, conventional MRI findings, and ultrafast sequence-derived parameters were collected. A prediction model that adds ultrafast sequence-derived parameters to clinical, pathological, and conventional MRI findings was developed and validated internally. Decision curve analysis and net reclassification index statistics were performed. A nomogram was constructed.

RESULTS

The ultrafast model adding time to peak enhancement, time to enhancement, and maximum slope showed a significantly increased area under the receiver operating characteristic curve compared with the conventional model which includes age, human epidermal growth factor receptor 2 expression of index cancer, size of index cancer, lesion type of index cancer, location of ASL, and size of ASL (0.92 vs. 0.82; p = 0.002). The decision curve analysis showed that the ultrafast model had a higher overall net benefit than the conventional model. The net reclassification index of ultrafast model was 23.3% (p = 0.001).

CONCLUSION

A combination of ultrafast sequence-derived parameters with clinical, pathological, and conventional MRI findings can aid in the differentiation of ASL on preoperative breast MRI.

CLINICAL RELEVANCE STATEMENT

Our prediction model and nomogram that was based on ultrafast sequence-derived parameters could help radiologists differentiate ASLs on preoperative breast MRI.

KEY POINTS

Ultrafast MRI can diminish background parenchymal enhancement and possibly improve diagnostic accuracy for additional suspicious lesions (ASLs). Location of ASL, larger size of ASL, and higher maximum slope were associated with malignant ASL. The ultrafast model and nomogram can help preoperatively differentiate additional malignancies.

Tumor Characteristics of Bilateral Breast Cancer Compared with Unilateral Breast Cancer

BACKGROUND

Bilateral breast cancer (BC) has an incidence of 1 to 3 %. This study aimed to describe the clinicopathologic characteristics and management of bilateral BC, estimate disease-free survival (DFS), and compare DFS with unilateral BC.

METHODS

A retrospective analysis was performed for patients who had bilateral invasive BC or unilateral invasive BC and contralateral ductal carcinoma in situ (DCIS) treated at Mayo Clinic Rochester from 2008 to 2022. A 4:1 matched cohort of patients with unilateral invasive BC was used for comparison. The groups were compared using Wilcoxon rank-sum or chi-square tests. Disease-free survival was analyzed using the Kaplan-Meier method and log-rank test, with Cox proportional hazards regression used for multivariable analysis.

RESULTS

The study identified 278 cases of bilateral breast cancer (177 cases of bilateral invasive cancer and 101 cases of unilateral invasive cancer with contralateral DCIS), representing 4.1 % of invasive BCs. Biologic subtype was concordant between sides in 79.8 % of the patients. Initial surgery was bilateral mastectomy for 76.6 %, bilateral lumpectomy for 20.5 %, and unilateral mastectomy with unilateral lumpectomy for 2.9 % of the patients. Pathogenic variants in breast cancer predisposition genes were present in 21.7 % of those tested. The patients who had bilateral BC presented with a higher cT category than the patients who had unilateral BC (p = 0.02), and a higher proportion presented with ILC (17.3 % vs 10.9 %; p = 0.004), estrogen receptor-positive (ER+) disease (89.2 % vs 84.2 %; p = 0.04), multicentric/multifocal disease (37.1 % vs 24.3 %; p < 0.001), breast cancer pathogenic variant (21.7 % vs 12.4 %; p = 0.02), and palpable presentation (48.2 % vs 40.8 %; p = 0.03). The patients with bilateral BC showed DFS similar to that for the unilateral BC cohort (p = 0.71).

CONCLUSIONS

Bilateral BCs most commonly are biologically concordant between sides. Bilateral BC presented more commonly with larger tumors, lobular histology, ER+ status, multicentricity or multifocality, pathogenic variant, and palpable disease. Bilateral BC is not associated with worse DFS than unilateral BC.

Breast Cancer Screening and Diagnosis: Recent Advances in Imaging and Current Limitations

Breast cancer detection has a significant impact on population health. Although there are many breast imaging modalities, mammography is the predominant tool for breast cancer screening. The introduction of digital breast tomosynthesis to mammography has contributed to increased cancer detection rates and decreased recall rates. In average-risk women, starting annual screening mammography at age 40 years has demonstrated the highest mortality reduction. In intermediate- and high-risk women as well as in those with dense breasts, additional modalities, including MRI, ultrasound, and molecular breast imaging, can also be considered for adjunct screening to improve the detection of mammographically occult malignancy.

Consecutive bilateral breast reconstruction using different autologous flaps: can symmetrical results still be achieved? A case report

We report a 60-year-old patient who underwent bilateral mastectomy at different times, followed by immediate autologous reconstruction with different flaps: deep-inferior epigastric-perforator flap on one breast, and fat-augmented latissimus dorsi on the contralateral side. At 20-month follow-up, good symmetry was recorded; patient-reported outcome measurements revealed high satisfaction scores.

The impact of coding germline variants on contralateral breast cancer risk and survival

Evidence linking coding germline variants in breast cancer (BC)-susceptibility genes other than BRCA1, BRCA2, and CHEK2 with contralateral breast cancer (CBC) risk and breast cancer-specific survival (BCSS) is scarce. The aim of this study was to assess the association of protein-truncating variants (PTVs) and rare missense variants (MSVs) in nine known (ATM, BARD1, BRCA1, BRCA2, CHEK2, PALB2, RAD51C, RAD51D, and TP53) and 25 suspected BC-susceptibility genes with CBC risk and BCSS. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated with Cox regression models. Analyses included 34,401 women of European ancestry diagnosed with BC, including 676 CBCs and 3,449 BC deaths; the median follow-up was 10.9 years. Subtype analyses were based on estrogen receptor (ER) status of the first BC. Combined PTVs and pathogenic/likely pathogenic MSVs in BRCA1, BRCA2, and TP53 and PTVs in CHEK2 and PALB2 were associated with increased CBC risk [HRs (95% CIs): 2.88 (1.70-4.87), 2.31 (1.39-3.85), 8.29 (2.53-27.21), 2.25 (1.55-3.27), and 2.67 (1.33-5.35), respectively]. The strongest evidence of association with BCSS was for PTVs and pathogenic/likely pathogenic MSVs in BRCA2 (ER-positive BC) and TP53 and PTVs in CHEK2 [HRs (95% CIs): 1.53 (1.13-2.07), 2.08 (0.95-4.57), and 1.39 (1.13-1.72), respectively, after adjusting for tumor characteristics and treatment]. HRs were essentially unchanged when censoring for CBC, suggesting that these associations are not completely explained by increased CBC risk, tumor characteristics, or treatment. There was limited evidence of associations of PTVs and/or rare MSVs with CBC risk or BCSS for the 25 suspected BC genes. The CBC findings are relevant to treatment decisions, follow-up, and screening after BC diagnosis.

The Influence of Adjuvant Systemic Regimens on Contralateral Breast Cancer Risk and Receptor Subtype

BACKGROUND

An increasing number of breast cancer (BC) survivors are at risk of developing contralateral breast cancer (CBC). We aimed to investigate the influence of various adjuvant systemic regimens on, subtype-specific, risk of CBC.

METHODS

This population-based cohort study included female patients diagnosed with first invasive BC between 2003 and 2010; follow-up was complete until 2016. Clinico-pathological data were obtained from the Netherlands Cancer Registry and additional data on receptor status through linkage with PALGA: the Dutch Pathology Registry. Cumulative incidences (death and distant metastases as competing risk) and hazard ratios (HRs) were estimated for all invasive metachronous CBC and CBC subtypes.

RESULTS

Of 83 144 BC patients, 2816 developed a CBC; the 10-year cumulative incidence was 3.8% (95% confidence interval [CI] = 3.7% to 4.0%). Overall, adjuvant chemotherapy (HR = 0.70, 95% CI = 0.62 to 0.80), endocrine therapy (HR = 0.46, 95% CI = 0.41 to 0.52), and trastuzumab with chemotherapy (HR = 0.57, 95% CI = 0.45 to 0.73) were strongly associated with a reduced CBC risk. Specifically, taxane-containing chemotherapy (HR = 0.48, 95% CI = 0.36 to 0.62) and aromatase inhibitors (HR = 0.32, 95% CI = 0.23 to 0.44) were associated with a large CBC risk reduction. More detailed analyses showed that endocrine therapy statistically significantly decreased the risk of estrogen receptor (ER)-positive CBC (HR = 0.41, 95% CI = 0.36 to 0.47) but not ER-negative CBC (HR = 1.32, 95% CI = 0.90 to 1.93) compared with no endocrine therapy. Patients receiving chemotherapy for ER-negative first BC had a higher risk of ER-negative CBC from 5 years of follow-up (HR = 2.84, 95% CI = 1.62 to 4.99) compared with patients not receiving chemotherapy for ER-negative first BC.

CONCLUSION

Endocrine therapy, chemotherapy, as well as trastuzumab with chemotherapy reduce CBC risk. However, each adjuvant therapy regimen had a different impact on the CBC subtype distribution. Taxane-containing chemotherapy and aromatase inhibitors were associated with the largest CBC risk reduction.

Concordance of Hormone Receptor Status and BRCA1/2 Mutation Among Women With Synchronous Bilateral Breast Cancer

Goals: BRCA1/2 mutations are associated with bilateral breast cancer. The extent of concordance between synchronous bilateral breast cancer (SBBC) tumors with respect to hormone receptor expression and BRCA1/2 mutations is unknown. We investigated the distribution of BRCA1/2 mutations and bilateral estrogen receptor (ER) status in SBBC. Methods: A retrospective analysis was performed on 15,337 patients with primary breast cancer who underwent surgical treatment at the Fudan University Shanghai Cancer Center between 2007 and 2014. We included 163 patients with synchronous bilateral breast cancer who had germline BRCA1/2 mutations testing. BRCA1/2 pathogenic/likely pathogenic mutations and other clinicopathological characteristics were studied in further analyses. Results: Patients with SBBC developed breast cancer at an older age and had a higher rate of ER positivity than patients with UBC (p < 0.001, separately). In contrast, 14.1% of SBBC patients had carcinomas with a lobular component in either breast based on pathological reports (p < 0.001). Twelve patients had BRCA1 mutations, and 14 patients had BRCA2 mutations, while no patients had mutations in both genes. The BRCA1/2 mutation rate was higher in younger patients (23.4 vs. 11.1%, p = 0.036). SBBC patients with a family history of breast cancer or bilateral ER-negative disease had a higher frequency of BRCA1/2 mutations than the cohort without a history of these conditions. SBBC with a bilateral ER-discordant status had a very low frequency of BRCA1/2 mutations (5.6%). Patients with an ER-positive (concordant or discordant) status had better 3-year disease-free survival than patients with a concordant ER-negative status (HR = 0.324, 95% CI: 0.126-0.837, P = 0.020). However, the outcomes were similar during long-term follow-up. Pathological lymph node stage was the only prognostic factor for SBBC in both univariate and multivariate Cox analyses. Conclusions: Our study shows that Chinese women with SBBC have different characteristics from their UBC counterparts. SBBC patients with a younger age, family history of breast cancer, or bilateral ER-negative disease are more likely to have BRCA1/2 mutations. SBBC patients with a concordant ER-negative status had worse early outcomes. Our results suggest that there may be additional factors underlying the tumor biology and genetics of SBBC.

MRI Evaluation of the Contralateral Breast in Women with Recently Diagnosed Breast Cancer: 2-Year Follow-up

Objective

The American College of Radiology Imaging Network Trial 6667 showed that MRI can detect cancer in the contralateral breast that is missed by mammography and clinical examination at the time of the initial breast cancer diagnosis, based on 1-year follow-up. This study is a continuation of the trial that evaluates the diagnostic accuracy of MRI for contralateral breast cancer after 2 years of follow-up.

Methods

In total, 969 women with a diagnosis of unilateral breast cancer and no clinical or imaging abnormalities in the contralateral breast underwent breast MRI. The cancer status of all participants was monitored for 2 years after the initial MRI. Follow-up included documentation of any clinical, imaging, or interventional procedures performed. A study participant was considered positive for cancer if she had a tissue diagnosis of in situ or invasive breast cancer in the contralateral breast within 730 days of her initial MRI.

Results

Three additional cancers were diagnosed in the study population in the second year of the trial. The diagnostic yield for MRI for the 2-year period was 3% (31/969). After 2 years of follow-up, breast MRI has a sensitivity of 86% and specificity of 88% for detection of contralateral breast cancer. Its negative predictive value was 99%, and its positive predictive value was 22%. These values did not change significantly from the 1-year data.

Conclusion

A negative contralateral breast MRI has a very high and reliable negative predictive value over 2 years, and, therefore, is helpful in managing and counseling patients during the period of initial diagnosis and early treatment.

Quantitative mRNA Expression Assays and Synchronous Breast Cancers: A Case Report

Quantitative mRNA analysis of breast tumors represents a routinely applied example of precision oncology. Currently the National Comprehensive Cancer Network (NCCN) recommends quantitative mRNA profiling (e.g., 21-gene RT PCR or Oncotype Dx assay) for nearly all surgically resected lymph node (LN) negative hormone receptor (HR) positive, HER2 negative breast cancers in order to predict recurrence risk with endocrine therapy compared to chemotherapy followed by endocrine therapy after surgery. The incidence of synchronous breast cancers is low and evidence concerning distant recurrence risk is limited, but the risk of distant recurrence from one or the other of two primary breast cancers appears to be higher than the recurrence risk of the single largest of the two cancers. In this report, a woman with synchronous primary breast cancers is described. Oncotype Dx testing was done on each of her two cancers. By assuming that the recurrence risk from each with adjuvant endocrine therapy is an independent event, the recurrence likelihood from one or the other or both is calculated. I propose that this calculated value more accurately should predict the recurrence from one or the other or both tumors with endocrine therapy or chemotherapy followed by endocrine therapy compared with using only the higher of the two Oncotype Dx estimated risks.

Clinicopathological Profile and Treatment Outcomes of Bilateral Breast Cancer: A Study from Tertiary Cancer Center in South India

Background: Bilateral breast cancer (BBC) is a rare clinical entity with limited data regarding clinicopathological aspects and treatment guidelines. Materials and Methods: This was an observational study of patients diagnosed with BBC from August 2012 to July 2014. Synchronous breast cancers (SBCs) was defined as two tumors diagnosed within an interval of 6 months and metachronous breast cancer (MBC) as second cancer diagnosed after 6 months. Results: Out of 750 breast cancer patients seen during a 2-year period, 35 had BBC. Ten patients were diagnosed as SBC whereas 25 patients as MBC. Among patients with MBC, the average time for development of contralateral breast cancer was 5 years. In 8 patients, the contralateral breast cancer was detected mammography whereas rest 27 patients were detected by clinical breast examination. At a median follow-up of 24 months, 23 (66%) patients were disease free, 9 (26%) patients had disease relapse, and 3 (8%) patients succumbed to the progressive disease. Conclusions: Every patient with breast cancer should be regularly followed up with clinical breast examination at a more frequent interval. The role of frequent clinical breast examination appears more than mammography especially beyond 5 years for early detection of contralateral breast cancer.

Do Second Primary Cancers Affect the Risk of Biochemical Recurrence in Prostate Cancer Patients Undergoing Radical Prostatectomy? A Propensity Score-Matched Analysis

INTRODUCTION

The present study evaluated the incidence and prognostic value of second primary cancers in patients with prostate cancer (PCa) who had undergone radical prostatectomy (RP).

MATERIALS AND METHODS

From 2003 to 2013, 1915 patients who had undergone RP were included in the present analysis. We calculated the propensity scores of various clinicopathologic factors and matched 298 patients with and without second primary cancers in a 1:1 ratio. To assess the baseline variables, we compared the descriptive statistics between the 2 groups. The postoperative biochemical recurrence (BCR)-free survival rates were calculated using the Kaplan-Meier method. Multivariate Cox regression analysis was performed to identify the independent predictors of BCR after RP.

RESULTS

Overall, 159 patients with PCa (8.3%) who had undergone RP were diagnosed with second primary cancers. After adjusting the patient characteristics in the propensity score-matched analysis, no variables were significantly different between the 2 groups with 149 with and 149 without other primary cancers. Moreover, the BCR-free survival rates were not significantly associated with the incidence of a second primary malignancy or the time to diagnosis. In the multivariate Cox regression model, serum prostate-specific antigen (hazard ratio [HR], 1.04), extraprostatic extension (HR, 3.29), seminal vesicle invasion (SVI; HR, 2.85), and surgical margin positivity (HR, 4.11) remained as independent predictors for BCR. However, the presence of a second primary malignancy was not predictive for BCR. In patients with a second primary cancer, multivariate analysis identified SVI (HR, 10.38) and positive surgical margin (HR, 3.48) as significant predictors for BCR.

CONCLUSIONS

Our results suggest that the presence of second primary malignancies might not affect BCR in patients with PCa who undergo RP.

[Synchronous bilateral breast cancer in Morocco: epidemiological and clinical characteristics]

Préciser la fréquence, les facteurs de risque et le pronostic du cancer du sein bilatéral, à partir d'une étude rétrospective de 22 cas de cancer du sein bilatéral synchrone dans un pays du Maghreb. De 2002 à 2010, 625 patientes étaient prises en charge pour cancer du sein au service de Gynécologie-Obstétrique «C» du centre hospitalier universitaire de Casablanca. 22 cas de cancer bilatéral synchrone étaient diagnostiqués. Nos résultats sont comparés avec ceux de la littérature. La fréquence de la bilatéralité du cancer du sein synchrone était de 3,52% (22/625). L'intervalle de temps moyen entre les deux cancers est de 4 mois (0 à 6 mois). Les patientes âgées de moins de 40 ans lors du premier cancer avaient six fois plus de risque de développer un cancer au niveau du sein controlatéral que les femmes âgées de plus de 40 ans. Les patientes atteintes d'une tumeur T3 ou T4 avaient un risque neuf fois plus élevé que les autres. 90,9% (2/22) des cas des premiers cancers sont des adénocarcinomes infiltrants. Les types histologiques du premier et du douzième cancer étaient identiques dans 86,4% (19/22) des cas. Quant au pronostic, il dépend à la fois du stade du premier et du deuxième cancer et le traitement de ce dernier doit obéir aux mêmes règles du traitement du premier cancer. L'incidence du cancer bilatéral synchrone du sein est de 3,52% dans notre série. Le cancer du sein unilatéral constitue un facteur de risque de développement d'un cancer du sein controlatéral. Une surveillance à vie est nécessaire au cours d'un cancer du sein pour détecter un cancer controlatéral.

Is symptom-oriented follow-up still up to date?

The main objective of following patients after the primary treatment of breast cancer is the detection of potentially curable events, particularly the detection of local recurrences and contralateral breast cancer. Additionally, medical counseling on therapies, psychosocial aspects, side effects of therapies, and lifestyle interventions is important to improve the quality of life. There is an ongoing discussion about whether early detection of asymptomatic metastasis could improve the course of disease. Today, the follow-up is still symptom-orientated. Intensified imaging and laboratory check-ups have not been beneficial for the patients' survival. A follow-up in the first 2-3 years is recommended every 3 months. Because of the decreasing incidence of recurrence from year 4, 6-monthly screening intervals are recommended. The screening should include a history, physical examination, and a consultation. Routine diagnostic imaging - except for mammography/ultrasound - is not indicated in asymptomatic patients. Innovative therapies for patients with metastatic breast cancer have been introduced. Therefore, measures of an intensified follow-up could change in the future as novel endocrine combination or targeted therapies in molecular subtypes could significantly improve the survival in early detected metastasis. In the future, more individualized follow-up programs are conceivable. However, this idea is so far not supported by the available data.

Genetic factors and breast cancer laterality

BACKGROUND

Women are more likely to develop cancer in the left breast than the right. Such laterality may influence subsequent management, especially in elderly patients with heart disease who may require radiation therapy. The purpose of this study was to explore possible factors for such cancer laterality.

METHODS

In this work, clinical data for consecutive patients with histologically confirmed breast cancer were reviewed, with emphasis on clinical presentation and family history.

RESULTS

Between 2005 and 2012, 687 patients with breast cancer were seen. Two women with incomplete data and eleven men were excluded. In total, 343 (50.9%) patients presented with left breast cancer, 311 (46.1%) with right breast cancer, and 20 (3.0%) with simultaneous bilateral malignancy. There were no significant differences between the three groups, especially in regards to clinical presentation and tumor characteristics. A total of 622 (92.3%) patients had unilateral primary, 20 (3.0%) had simultaneous bilateral, and 32 (4.7%) had metachronous primary breast cancer with subsequent contralateral breast cancer after 7.5-236 months. The worst 10-year survival was for bilateral simultaneous (18%) compared with unilateral (28%) and metachronous primaries (90%). There were no differences in survival in relation to breast cancer laterality, handedness, and presence or absence of a family history of cancer. There were significant similarities between patients and first-degree relatives in regards to breast cancer laterality, namely same breast (30/66, 45.5%), opposite breast (9/66, 13.6%), and bilateral cancer (27/66, 40.9, P=0.01163). This was more evident among patients and their sisters (17/32, 53.1%) or mothers (11/27, 40.7%, P=0.0689). There were also close similarities in relation to age at initial diagnosis of cancer for patients and their first-degree relatives for age differences of ≤5 years (48/166, 28.9%), 6-10 years (34/166, 20.5%), and >11 years (84/166, 50.6%, P=0.12065).

CONCLUSION

High similarities between patients and their first-degree relatives in regards to cancer laterality and possibly age at initial diagnosis of cancer may suggest an underlying inherited genetic predisposition.

A clinicopathological study of early-stage synchronous bilateral breast cancer: a retrospective evaluation and prospective validation of potential risk factors

Background

The aim of the present study was to investigate potential risk factors for synchronous bilateral breast cancer sBBC).

Methods

A retrospective analysis was performed of patients diagnosed and treated with operable bilateral breast cancer (BBC) between June 2007 and December 2011. Risk factors for sBBC were evaluated in this cohort and further validated in a prospective observational validation analysis of patients between January 2012 and December 2012. Patients treated with operable unilateral breast cancer during the same period were used as a control group.

Results

A total of 11,247 patients with primary breast cancer underwent operations at the Fudan University Shanghai Cancer Center between June 2007 and December 2012. The incidence of sBBC was 1.6%. The age at diagnosis (HR = 2.4, 95% C.I.: 1.4–4.0, p = 0.001), presence of sclerosing adenosis (HR = 11.8, 95% C.I.: 5.3–26.3, p<0.001), lobular carcinoma component involvement (HR = 5.6, 95% C.I.: 2.6–12.1, p<0.001), and family history of first-degree relatives with breast cancer (HR = 2.0, 95% C.I.: 1.1–3.4, p<0.001) were independent risk factors for sBBC. A subsequent validation study failed to confirm the significance of family history. No significant difference on survival was found between patients with early-stage sBBC and control cases.

Conclusions

Patients with the presence of sclerosing in the affected breast, and lobular carcinoma component involvement may be at high risk for developing sBBC. This study supports the hypothesis that the host-carcinoma biological relationship, especially for the tumor microenvironment, played a critical role in the carcinogenesis of sBBC.

Multiple neoplasms, single primaries, and patient survival

Background

Multiple primary neoplasms in surviving cancer patients are relatively common, with an increasing incidence. Their impact on survival has not been clearly defined.

Methods

This was a retrospective review of clinical data for all consecutive patients with histologically confirmed cancer, with emphasis on single versus multiple primary neoplasms. Second primaries discovered at the workup of the index (first) primary were termed simultaneous, if discovered within 6 months of the index primary were called synchronous, and if discovered after 6 months were termed metachronous.

Results

Between 2005 and 2012, of 1,873 cancer patients, 322 developed second malignancies; these included two primaries (n=284), and three or more primaries (n=38). Forty-seven patients had synchronous primaries and 275 had metachronous primaries. Patients with multiple primaries were predominantly of Caucasian ancestry (91.0%), with a tendency to develop thrombosis (20.2%), had a strong family history of similar cancer (22.3%), and usually presented with earlier stage 0 through stage II disease (78.9%). When compared with 1,551 patients with a single primary, these figures were 8.9%, 15.6%, 18.3%, and 50.9%, respectively (P≤0.001). Five-year survival rates were higher for metachronous cancers (95%) than for synchronous primaries (59%) and single primaries (59%). The worst survival rate was for simultaneous concomitant multiple primaries, being a median of 1.9 years. The best survival was for patients with three or more primaries (median 10.9 years) and was similar to the expected survival for the age-matched and sex-matched general population (P=0.06991).

Conclusion

Patients with multiple primaries are usually of Caucasian ancestry, have less aggressive malignancies, present at earlier stages, frequently have a strong family history of similar cancer, and their cancers tend to have indolent clinical behavior with longer survival rates, possibly related to genetic predisposition.

Survival analysis of patients with unilateral and bilateral primary breast cancer in Northeast China

BACKGROUND

Previous reports have shown that patients with bilateral primary breast cancer (BPBC) had comparable or moderately poor survival compared with patients experiencing unilateral primary breast cancer (UPBC). However, studies are conflicting in their analyses of correlations between survival and clinicopathological and prognostic characteristics in BPBC patients. The aim of our study was to compare the clinicopathological features and prognoses of BPBC and UPBC patients in Heilongjiang Province, northeast China.

METHODS

We retrospectively reviewed the records of 2,695 patients who underwent modified radical mastectomy or lumpectomy from 2005 to 2008 in the Tumor Hospital of Harbin Medical University. Eighty-one patients (3.0 %) had BPBC and 2,614 patients had UPBC. Multivariate analysis was performed using Cox's proportional hazards model.

RESULTS

There were significant differences between patients with BPBC and UPBC in the age of onset (referring to the age when the first tumor in BPBC was diagnosed), T stage, menopause status (referring to the age when the second tumor in BPBC was diagnosed), and breast cancer family history. The overall 5-year survival of patients with BPBC was 70.1 % compared with 87.1 % for patients with UPBC (p = 0.004). Furthermore, multivariate analysis showed that HER-2 status, menopause status, and mammary disease history were significant factors affecting survival among the patients with BPBC.

CONCLUSIONS

Our results confirmed previous findings that BPBC patients had moderately poor survival. However, when T stages were matched, BPBC patients had a survival rate similar to UPBC patients. Premenopause status, HER-2 positivity and family history of breast cancer were major risk factors for BPBC.

Histo-biological comparative analysis of bilateral breast cancer

Bilateral breast cancer occurs in approximately 7% of surviving breast cancer patients. However, a dilemma exists concerning the notion of whether this represents a de novo second primary tumor versus a breast metastasis. We analyzed 81 patients with bilateral breast cancer, 47 (58%) synchronous tumors and 34 (42%) metachronous tumors. Additionally, charts were reviewed for age, family history, full histology data and biological receptors. We found there were no significant differences in concordance between the first and second primary tumors (in both synchronous and metachronous bilateral breast cancer) with respect to histology; grade; T-category; N-category; ER, PR and HER-2 status. In addition, there was no significant difference in the strength of correlation between ER and PR in the first and secondary primary tumors. Our findings suggest that the differentiation of the origin of contralateral breast cancer based on routine histological and biological concordance is inconclusive. Furthermore, the dilemma will continue to exist until additional molecular approaches are applied routinely for research purposes to resolve the debate.

Histo-biological comparative analysis of bilateral breast cancer

Bilateral breast cancer occurs in approximately 7% of surviving breast cancer patients. However, a dilemma exists concerning the notion of whether this represents a de novo second primary tumor versus a breast metastasis. We analyzed 81 patients with bilateral breast cancer, 47 (58%) synchronous tumors and 34 (42%) metachronous tumors. Additionally, charts were reviewed for age, family history, full histology data and biological receptors. We found there were no significant differences in concordance between the first and second primary tumors (in both synchronous and metachronous bilateral breast cancer) with respect to histology; grade; T-category; N-category; ER, PR and HER-2 status. In addition, there was no significant difference in the strength of correlation between ER and PR in the first and secondary primary tumors. Our findings suggest that the differentiation of the origin of contralateral breast cancer based on routine histological and biological concordance is inconclusive. Furthermore, the dilemma will continue to exist until additional molecular approaches are applied routinely for research purposes to resolve the debate.

A population perspective to mitigating risk for second primary breast cancer

SUMMARY There are more than 2 million breast cancer survivors in the USA. Approximately 5–10% of survivors will develop a second, metachronous breast cancer within 10 years’ time; a risk two- to six-times higher than that in the general population. Women who develop metachronous cancer are more likely to die from the disease compared with women with unilateral cancer. Risk factors for metachronous cancer include BRCA mutation status, young age, family history and tumor phenotype, while adjuvant chemotherapy and endocrine therapy may attenuate the risk. Surveillance guidelines recommend annual mammography, but MRI is not currently indicated for most women. An increasing number of women are choosing prophylactic contralateral mastectomy, although it is not likely to be beneficial for most women. Improved strategies are needed for identifying survivors at an increased risk in order to help guide clinical decisions regarding follow-up care. This review presents an overview of the burden and risk factors for metachronous breast cancer and discusses challenges and opportunities for a population approach to mitigating risk and adverse outcomes from these cancers.

Survival from synchronous bilateral breast cancer: the experience of surgeons participating in the breast audit of the Society of Breast Surgeons of Australia and New Zealand

BACKGROUND

Previous studies generally indicate that synchronous bilateral breast cancers (SBBC) have an equivalent or moderately poorer survival compared with unilateral cases. The prognostic characteristics of SBBC would be relevant when planning adjuvant therapies and follow-up medical surveillance. The frequency of SBBC among early breast cancers in clinical settings in Australia and New Zealand were investigated, plus their prognostic significance, using the Breast Cancer Audit Database of the Society of Breast Surgeons of Australia and New Zealand, which covered an estimated 60% of early invasive lesions in those countries.

DESIGN

Rate ratios (95% confidence limits) of SBBC were investigated among 35,370 female breast cancer cases by age of woman, histology type, grade, tumour diameter, nodal status, lymphatic/vascular invasion and oestrogen receptor status. Univariate and multivariable disease-specific survival analyses were undertaken.

RESULTS

2.3% of cases were found to be SBBC (i.e., diagnoses occurring within 3 months). The figure increased from 1.4% in women less than 40 years to 4.1% in those aged 80 years or more. Disease-specific survivals did not vary by SBBC status (p=0.206). After adjusting for age, histology type, diameter, grade, nodal status, lymphatic/vascular invasion, and oestrogen receptor status, the relative risk of breast cancer death for SBBC was 1.17 (95% CL: 0.91, 1.51). After adjusting for favourable prognostic factors more common in SBBC cases (i.e., histology type, grade, lymphatic/ vascular invasion, and oestrogen receptor status), the relative risk of breast cancer death for SBBC was 1.42 (95% CL: 1.10, 1.82). After adjusting for unfavourable prognostic factors more common in SBBC cases (i.e., older age and large tumour diameter), the relative risk of breast cancer death for SBBC was 0.98 (95% CL: 0.76, 1.26).

CONCLUSIONS

Results confirm previous findings of an equivalent or moderately poorer survival for SBBC but indicate that SBBC status is likely to be an important prognostic indicator for some cases.

A case-match study comparing unilateral with synchronous bilateral breast cancer outcomes

PURPOSE

There is controversy about whether patients with synchronous bilateral breast cancer (SBBC) have similar or worse outcomes compared with patients with unilateral breast cancer. The purpose of this study was to determine whether survival outcomes for patients with SBBC can be estimated from the characteristics of their individual cancers.

PATIENTS AND METHODS

Patients had invasive breast cancer, without metastases or inflammatory disease, diagnosed in British Columbia between 1989 and 2000. There were 207 cases with SBBC (diagnosed ≤ 2 months apart) and 15,497 with unilateral breast cancer. By using 10-year breast cancer-specific survival (BCSS) estimates, the higher-risk cancer of each SBBC case was determined and matched with three breast cancers from the unilateral cohort to select 621 high-risk matches. The priority sequence of matching the prognostic and predictive variables was positive lymph node number, primary tumor size, age, grade, lymphovascular invasion, estrogen receptor status, local therapy used, margin status, treating clinic, diagnosis year, and type of systemic therapy used.

RESULTS

With a median follow-up of 10.2 years, the overall 10-year BCSS was significantly higher for the unilateral cohort (81%; 95% CI, 81% to 82%) than for the SBBC cases (71%; 95% CI, 63% to 77%). The SBBC cases had significantly higher mean age and stage at presentation. The 10-year BCSS was 74% (95% CI, 69% to 77%) for the high-risk matches.

CONCLUSION

BCSS was not significantly different between the SBBC cases and their high-risk matches.

Prognosis of early-stage synchronous bilateral invasive breast cancer

BACKGROUND

Contradictory data exists concerning the prognosis of patients with synchronous bilateral breast cancer (SBBC). Most authors report a worse prognosis for SBBC patients compared to unilateral breast cancer (UBC) patients. There are a few studies that did not support these findings. This study gives a comprehensive picture of SBBC and tests the hypothesis that outcome of this entity is based on the tumor with the worse prognosis (reference lesion).

PATIENTS & METHODS

The data of two prospective Swiss breast cancer databases covering a 20-year period (1990-2009) was reviewed. Forty-six cases of SBBC were identified. In 34 patients with early-stage SBBC, the reference lesions (defined as the tumor with the more advanced stage or, in cases where both tumors had the same stage, the larger tumor) were compared in a case-control approach with 100 patients having UBC (SBBC/UBC ratio = 1/3). The controls were matched for age, time of diagnosis, tumor size, axillary node status, histological grade and estrogen-receptor status. Differences in terms of survival curves were analyzed using the log rank test; the possible correlation between matched groups was evaluated by a frailty Cox model.

RESULTS

There were no significant differences in disease-specific survival between SBBC and its unilateral controls (HR, 0.932; 95% CI, 0.322-1.07; p = 0.90).

CONCLUSIONS

The prognosis of SBBC was determined by the reference lesion; the contralateral second tumor had no additional impact on outcome.

Pancreatic cancer screening employing noncontrast magnetic resonance imaging combined with ultrasonography

PURPOSE

We have conducted an initial evaluation on the potential of combining noncontrast magnetic resonance imaging (MRI) and ultrasonography (US) to screen for pancreatic cancer.

MATERIALS AND METHODS

An independent ethics committee approved this study. A total of 2511 patients who underwent US were enrolled. Among them, noncontrast MRI was performed in patients in whom the entire pancreas was difficult to depict or in those with US-suspected pancreatic lesions. In total, using 1.5-T MRI, T1- and T2-weighted imaging, magnetic resonance cholangiopancreatography, and diffusion-weighted imaging, we acquired a variety of images. The efficacy of US and MRI in screening for pancreatic lesions, including pancreatic cancer, was evaluated.

RESULTS

Of 2511 patients, 184 underwent MRI, and the pancreas was demonstrated in all of them. Among the 2511, five pancreatic cancers were detected by MRI combined with US (detection rate 0.20%). Of the five pancreatic cancers, three were detected by US (detection rate 0.12%) and two by MRI. Four of the five pancreatic cancers were resectable.

CONCLUSION

By combining noncontrast MRI with US, pancreatic cancer can be detected with high accuracy. Other pancreatic lesions that require follow-up, including intraductal papillary mucinous neoplasms, can also be detected. Thus, pancreatic cancer screening with a combination of US and MRI is suggested.

Magnetic resonance imaging screening of the contralateral breast in women with newly diagnosed breast cancer: systematic review and meta-analysis of incremental cancer detection and impact on surgical management

PURPOSE

Preoperative magnetic resonance imaging (MRI) is increasingly used for staging women with breast cancer, including screening for occult contralateral cancer. This article is a review and meta-analysis of studies reporting contralateral MRI in women with newly diagnosed invasive breast cancer.

METHODS

We systematically reviewed the evidence on contralateral MRI, calculating pooled estimates for positive predictive value (PPV), true-positive:false-positive ratio (TP:FP), and incremental cancer detection rate (ICDR) over conventional imaging. Random effects logistic regression examined whether estimates were associated with study quality or clinical variables.

RESULTS

Twenty-two studies reported contralateral malignancies detected only by MRI in 131 of 3,253 women. Summary estimates were as follows: MRI-detected suspicious findings (TP plus FP), 9.3% (95% CI, 5.8% to 14.7%); ICDR, 4.1% (95% CI, 2.7% to 6.0%), PPV, 47.9% (95% CI, 31.8% to 64.6%); TP:FP ratio, 0.92 (95% CI, 0.47 to 1.82). PPV was associated with the number of test positives and baseline imaging. Few studies included consecutive women, and few ascertained outcomes in all subjects. Where reported, 35.1% of MRI-detected cancers were ductal carcinoma in situ (mean size = 6.9 mm), 64.9% were invasive cancers (mean size = 9.3 mm), and the majority were stage pTis or pT1 and node negative. Effect on treatment was inconsistently reported, but many women underwent contralateral mastectomy.

CONCLUSION

MRI detects contralateral lesions in a substantial proportion of women, but does not reliably distinguish benign from malignant findings. Relatively high ICDR may be due to selection bias and/or overdetection. Women must be informed of the uncertain benefit and potential harm, including additional investigations and surgery.

Tumor marker phenotype concordance in second primary breast cancer, California, 1999-2004

Breast cancer is the most common cancer among women. It is estimated that 7% of women who have breast cancer will develop a subsequent second independent breast tumor within 10 years of the first. The status of estrogen (ER), progesterone (PR) and human growth hormone (HER2) receptors, individually and as phenotypic combinations, impacts the clinical course of breast cancer and may impact the course of subsequent primary tumors and patient survival. Our aims were to determine tumor marker phenotype concordance between first and second primary breast cancers (FPBC and SPBC), describe demographic and clinical characteristics, and examine first tumor treatments associated with phenotype concordance. A total of 76,209 cases of female invasive breast cancer were identified in the California Cancer Registry from 1999 to 2004. Of those, 1,407 women who had not undergone a prophylactic mastectomy, had information on the status of three tumor markers, and were diagnosed with an SPBC during the study period were selected. SPBCs were significantly smaller, diagnosed at a higher stage and were node positive. Patients whose FPBC was ER(+)/-/PR(+)/-/HER2- and triple negative (TN) (ER-/PR-/HER2-), often had concordant phenotypes for their SPBC. ER(+)/-/PR(+)/-/HER2+ and HER2-positive (ER-/PR-/HER2+) FPBCs, often had discordant phenotypes for their SPBC. ER(+)/-/PR(+)/-/HER2- SPBCs often lacked HER2 expression and were ER and/or PR positive. Tumor laterality and synchronicity significantly predicted concordance as did having a FPBC whose phenotypes were ER(+)/-/PR(+)/-/HER2+, HER2-positive and TN, while first primary tumor treatment with chemotherapy predicted discordance. The relationship between multiple primary breast cancer phenotype concordance and patient prognosis has yet to be determined. Our results indicate that SPBC surveillance strategies include consideration of FPBC phenotype. Although our results are provocative, they may have been influenced by current criteria used to determine tumor independence.

Prognosis of synchronous bilateral breast cancer

Background

The prognosis of patients with synchronous bilateral breast cancer (SBBC) is usually based on the tumour with the worst pathological features. There is little evidence in the literature for this assumption, potentially impairing reasoned decisions on optimal adjuvant therapy.

Methods

This was a case–control study in which 68 women with SBBC were matched with 128 women with unilateral breast cancer. Both the GuysRisk prognostic model and the Nottingham Prognostic Index were used to determine the bilateral tumour with the poorer prognosis. Controls were matched for age, menopausal status, date of diagnosis, histological type and grade, and oestrogen receptor and axillary node status.

Results

Both prognostic models indicated the same side tumour with the worst prognosis. Kaplan–Meier survival curves for both disease-free and overall survival showed no significant difference in outcome between the two groups.

Conclusion

Prognosis was determined by the tumour with the worst prognosis, with no additional worsening of outcome incurred from the second tumour.

Cumulative survival in early-onset unilateral and bilateral breast cancer: an analysis of 1907 Taiwanese women

As the epidemiological pattern of breast cancer in modernising Asian countries differs greatly from that in Western countries, it is worthwhile to investigate the long-term prognoses of unilateral and bilateral breast cancer in these nations. A retrospective cohort study composed of 1907 Taiwanese women was conducted to follow 1863 unilateral and 44 bilateral cases of breast cancer. Time-dependent Cox regression was used to assess the risk of breast cancer death by considering the time course of unilateral and bilateral tumour development. The 15-year survival rates were 68.37, 62.63, and 26.42% for unilateral, synchronous bilateral, and metachronous bilateral breast cancer, respectively. Differences among types were most apparent after 5 years of follow-up. After adjusting for significant prognostic factors, the risk of death for overall bilateral breast cancer was 2.50-fold greater (95% CI, 1.43-4.37) compared to unilateral breast cancer. The corresponding figures were 1.12-fold (95% CI, 0.42-3.02) and 6.11-fold (95% CI, 3.14-11.89) for synchronous and metachronous bilateral breast cancer, respectively. Taiwanese women, who are frequently diagnosed with breast cancer before 50 years of age, showed poorer survival for metachronous bilateral than for synchronous bilateral or unilateral breast cancer. Survival was markedly poorer compared to recent data from Sweden.

Does multicentric/multifocal breast cancer differ from unifocal breast cancer? An analysis of survival and contralateral breast cancer incidence

Purpose we evaluated whether patients with multifocal/multicentric (M/M) breast cancer have different outcomes compared to unifocal (U) disease in terms of survival and the development of contralateral breast cancer (CBC) disease. Methods women diagnosed with stage I-III breast cancer were classified as having U or M/M disease. Prognostic factors were prospectively collected and obtained from the breast cancer outcome unit database. Univariate and multivariable analyses for the incidence of CBC were performed as well as Kaplan-Meier plots. Results 25,320 women met inclusion criteria. The 5-year cumulative incidence of CBC in the U versus M/M group was 2.3% (95% CI 2.1, 2.5) versus 2.4% (95% CI 1.6, 3.4) (P = 0.349). Breast cancer specific survival (BCSS) rate revealed a slightly worse outcome with M/M disease, RR = 1.174 (95% CI 1,004, 1.372). Conclusions M/M breast cancer did not increase the risk of metachronous CBC, but was associated with inferior BCSS.

Diagnostic and prognostic utility of molecular markers in synchronous bilateral breast carcinoma

Histologic criteria have a limited role in determining whether the synchronous bilateral breast carcinomas represent two primaries or a metastasis to the contralateral breast. We studied the molecular analysis of synchronous bilateral breast carcinoma and whether they are originating from a single or different clone. We examined 17 patients with breast carcinoma, including 12 patients with synchronous bilateral carcinomas and control group of 5 infiltrating ductal carcinomas with regional lymph node metastases. Mutations were quantitatively determined to detect loss of heterozygosity (LOH) and microsatellite size alterations for a broad panel of 15 markers, involving 10 chromosomes using polymerase chain reaction. The carcinomas were classified as de novo or metastasis based on three levels of concordance: (1) marker-affected tumors were considered concordant if 50% or more of the same markers were mutated, (2) same gene copy affected, and (3) temporal sequence of mutation acquisition. In synchronous bilateral breast carcinoma patients, molecular analysis showed discordant mutations in all cases, supporting the diagnosis of de novo bilateral primary breast carcinomas. In patients with lymph node metastases, the primary breast carcinoma and metastases shared the same mutations, revealing a metastatic lesion. In conclusion, the application of molecular technology may play an important role for the differential diagnosis of dual primary carcinomas vs a metastatic breast cancer to contralateral breast. In this study, synchronous bilateral breast cancers represent two independent primaries rather than metastatic events.

Receptor Characteristics of the Second Tumor in Synchronous versus Metachronous Breast Cancer

Presently, there is no consensus on whether synchronous breast cancer has the same disease origin as the primary tumor, or if it is a completely independent second primary. This study explores this concept in both synchronous and metachronous breast cancer looking specifically at their receptor characteristics and level of differentiation. A retrospective chart analysis of 114 patients with synchronous or metachronous breast cancer treated at a single institution between January 1991 and March 2004 was done. Sixty-three per cent of the patients were diagnosed with metachronous breast cancer. Synchronous breast cancer was histologically more aggressive ( P < 0.05) with a significantly higher number of patients having poorly differentiated tumors, a greater number of metastases involving a larger number of organs ( P < 0.05), and lower average survival compared with the metachronous group ( P < 0.005). Both the first and second tumor in both groups were similar in hormone receptor status, histologic subtype, and grade. Synchronous breast cancer is more aggressive and has a poorer outcome than metachronous breast cancer. Concordance in hormone receptor status, grade, and histologic subtype between different tumors within the same patient suggests, but does not completely support, a monoclonal origin. Analysis applied here is crude and more specific methods of analysis such as DNA microarray would be required to infer such a conclusion.

The impact of adjuvant therapy on contralateral breast cancer risk and the prognostic significance of contralateral breast cancer: a population based study in the Netherlands

Background The impact of age and adjuvant therapy on contralateral breast cancer (CBC) risk and prognostic significance of CBC were evaluated. Patients and Methods In 45,229 surgically treated stage I–IIIA patients diagnosed in the Netherlands between 1989 and 2002 CBC risk was quantified using standardised incidence ratios (SIRs), cumulative incidence and Cox regression analysis, adjusted for competing risks. Results Median follow-up was 5.8 years, in which 624 CBC occurred <6 months after the index cancer (synchronous) and 1,477 thereafter (metachronous). Older age and lobular histology were associated with increased synchronous CBC risk. Standardised incidence ratio (SIR) of CBC was 2.5 (95% confidence interval (95% CI) 2.4–2.7). The SIR of metachronous CBC decreased with index cancer age, from 11.4 (95% CI 8.6–14.8) when <35 to 1.5 (95% CI 1.4–1.7) for ≥60 years. The absolute excess risk of metachronous CBC was 26.8/10,000 person-years. The cumulative incidence increased with 0.4% per year, reaching 5.9% after 15 years. Adjuvant hormonal (Hazard rate ratio (HR) 0.58; 95% CI 0.48–0.69) and chemotherapy (HR 0.73; 95% CI 0.60–0.90) were associated with a markedly decreased CBC risk. A metachronous CBC worsened survival (HR 1.44; 95% CI 1.33–1.56). Conclusion Young breast cancer patients experience high synchronous and metachronous CBC risk. Adjuvant hormonal or chemotherapy considerably reduced the risk of CBC. CBC occurrence adversely affects prognosis, emphasizing the necessity of long-term surveillance directed at early CBC-detection.

An overview of prognostic factors for long-term survivors of breast cancer

BACKGROUND

Numerous studies have examined prognostic factors for survival of breast cancer patients, but relatively few have dealt specifically with 10+-year survivors.

METHODS

A review of the PubMed database from 1995 to 2006 was undertaken with the following inclusion criteria: median/mean follow-up time at least 10 years; overall survival and/or disease-specific survival known; and relative risk and statistical probability values reported. In addition, we used data from the long-standing Eindhoven Cancer Registry to illustrate survival probability as indicated by various prognostic factors.

RESULTS

10-year breast cancer survivors showed 90% 5-year relative survival. Tumor size, nodal status and grade remained the most important prognostic factors for long-term survival, although their role decreased over time. Most studies agreed on the long-term prognostic values of MI (mitotic index), LVI (lymphovascular invasion), Her2-positivity, gene profiling and comorbidity for either all or a subgroup of breast cancer patients (node-positive or negative). The roles of age, socioeconomic status, histological type, BRCA and p53 mutation were mixed, often decreasing after correction for stronger prognosticators, thus limiting their clinical value. Local and regional recurrence, metastases and second cancer may substantially impair long-term survival. Healthy lifestyle was consistently related to lower overall mortality.

CONCLUSIONS

Effects of traditional prognostic factors persist in the long term and more recent factors need further follow-up. The prognosis for breast cancer patients who have survived at least 10 years is favourable and increases over time. Improved long-term survival can be achieved by earlier detection, more effective modern therapy and healthier lifestyle.

Detecting Breast Cancer with Non-contrast MR Imaging: Combining Diffusion-weighted and STIR Imaging

We combined diffusion-weighted (DWI) and short TI inversion recovery (STIR) imaging to evaluate the diagnostic capability of non-contrast magnetic resonance (MR) imaging to detect breast cancer. Seventy women patients underwent mammography and MR imaging with combined DWI (b factor: 1000) and STIR that revealed malignancy, and postoperative pathological examination confirmed breast cancer. Interpreted images were evaluated for sensitivity, false negative rate (FN), sensitivity by pT, and sensitivity by background density of the mammary gland. Of the 70 cases, 68 were diagnosed as cancer by DWI and STIR (sensitivity, 97% [68/70]; FN, 2.9% [2/70]). Sensitivities by pT were: pTis, 67% (4/6); pT1, 100% (33/33); and pT2-4, 100% (31/31). No significant differences were observed in sensitivity between pT1 and pT2-4 (P<0.001). Sensitivities by background density of mammary gland were: fatty/scattered fibroglandular tissue, 95% (20/21) and heterogeneous fibroglandular tissue/mostly fibroglandular tissue, 98% (48/49). No significant differences were observed (P<0.001). Two cases, an intraductal and an apocrine carcinoma, were incorrectly diagnosed by MR imaging. Precise diagnosis of breast cancer is possible with combined DWI and STIR, even in non-contrast MR imaging, regardless of the diameter or background density of mammary gland. It is hoped that non-contrast MR imaging that combines DWI and STIR will become an established clinical screening method.

Survival after bilateral breast cancer: results from a population-based study

BACKGROUND

Controversy exists on the impact of bilaterality of breast cancer on survival. We used population-based data to compare survival of women with unilateral versus bilateral breast cancer.

PATIENTS AND METHODS

At the Geneva cancer registry, we identified all 7,912 women diagnosed with invasive breast cancer between 1970 and 2002. Breast cancers were categorized as unilateral, synchronous bilateral (contralateral tumour diagnosed within six months after the first tumour) and metachronous bilateral (contralateral tumour diagnosed over six months after the first tumour). With multivariate modelling we compared characteristics and survival between women with unilateral and bilateral disease.

RESULTS

Patients with synchronous bilateral tumours (n = 155, 2.0%) had more often lobular histology and less frequently stage I disease than women with unilateral disease. Women with metachronous breast cancer (n = 219, 2.8%) received less often chemotherapy or hormone therapy for their first tumours. Ten-year disease-specific survival was similar (66%) after unilateral and metachronous bilateral breast cancer, but worse after synchronous bilateral cancer (51%). After adjustment, breast cancer mortality risks were not significantly increased for women with either synchronous or metachronous bilateral disease (Hazard ratios 1.1 (0.8-1.5) and 0.8 (0.5-1.4), respectively).

CONCLUSION

This large population-based study indicates that bilaterality of breast cancer is not associated with impaired survival.

Added cancer yield of MRI in screening the contralateral breast of women recently diagnosed with breast cancer: results from the International Breast Magnetic Resonance Consortium (IBMC) trial

OBJECTIVE

To estimate the added cancer yield of magnetic resonance imaging (MRI) over mammography in the contralateral breast of patients with a recent diagnosis of breast cancer.

METHODS

We conducted a prospective, international study of mammography and MRI in women with a recent diagnosis of unilateral breast cancer. Each subject received a mammogram, clinical breast exam (CBE), and MRI of the unaffected breast within a 90 day time period. Definitive diagnosis of suspicious findings was determined through biopsy and central pathology review.

RESULTS

Of the 103 eligible women included in study analyses, MRI detected 4 cancers in the contralateral breast while mammography detected none. MRI resulted in 12% (95% CI, 6%-20%) of women recommended for biopsy and 10% of women undergoing additional biopsy. The added cancer yield of MRI was 4% (95% CI, 1%-10%) and the positive predictive value of an abnormal MRI was 33% (95% CI, 10%-65%). Forty percent (4/10) of the biopsies performed based on the MRI recommendation were positive for malignancy.

CONCLUSION

In women with a recent breast cancer diagnosis, approximately 4% will have an otherwise occult invasive breast cancer detected in the opposite breast by MRI alone.