The contralateral synchronous breast carcinoma: a comparison of histology, localization, and magnetic resonance imaging characteristics with the primary index cancer

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.

Impact of pre-operative breast magnetic resonance imaging on contralateral synchronous and metachronous breast cancer detection-A case control comparison study with 1468 primary operable breast cancer patients with mean follow-up of 102 months

Background

Women with unilateral breast cancer are at an increased risk for the development of contralateral breast cancers. We hypothesis that combined breast MRI would detect more contralateral synchronous breast cancer than conventional imaging alone, and resulted in less contralateral metachronous breast cancer during follow-up.

Methods

We retrospectively collected two groups of breast cancer patients diagnosed from 2009 to 2013 for evaluating the effectiveness and value of adding pre-operative breast MRI to conventional breast images (mammography and sonography) for detection of contralateral synchronous breast cancer. The new metachronous contralateral breast cancer diagnosed during follow-up was prospectively evaluated and compared.

Results

Group A (n = 733) comprised patients who underwent conventional preoperative imaging and group B (n = 735) combined with MRI were enrolled and compared. Seventy (9.5%) of the group B patients were found to have contralateral lesions detected by breast MRI, and 65.7% of these lesions only visible with MRI. The positive predictive value of breast MRI detected contralateral lesions was 48.8%. With the addition of breast MRI to conventional imaging studies, more surgical excisions were performed in contralateral breasts (6% (44/735) versus 1.4% (10/733), P< 0.01), more synchronous contralateral breast cancer detected (2.9% (21/735) versus 1.1% (8/733), P = 0.02), and resulted in numerical less (2.2% (16/714) versus 3% (22/725), p = 0.3) metachronous contralateral breast cancer during a mean follow-up of 102 months.

Conclusions

Our study provides useful estimates of the pre-operative breast MRI for the increased detection of contralateral synchronous breast cancer and less subsequent contralateral metachronous breast cancer.

Association of molecular subtype concordance and survival outcome in synchronous and metachronous bilateral breast cancer

Background

The aim of this study was to analyze the association of molecular subtype concordance and disease outcome in patients with synchronous bilateral breast cancer (SBBC) and metachronous breast cancer (MBBC).

Patients and methods

Patients diagnosed with SBBC or MBBC in the Surveillance, Epidemiology, and End Results (SEER) database or Comprehensive Breast Health Center (CBHC) Ruijin Hospital, Shanghai were retrospectively reviewed and included. Clinicopathologic features, molecular subtype status concordance, and prognosis were compared in patients with SBBC and MBBC. Other prognostic factors for breast cancer-specific survival (BCSS) and overall survival (OS) were also identified for bilateral breast cancer patients.

Results

Totally, 3395 and 115 patients were included from the SEER and Ruijin CBHC cohorts. Molecular subtype concordance rate was higher in the SBBC group compared to MBBC in both SEER cohort (75.8% vs 57.7%, p < 0.001) and Ruijin CBHC cohort (76.2% vs 45.2%, p = 0.002). Survival analyses indicated that SBBC was related to worse BCSS than MBBC (p = 0.015). Molecular subtype discordance was related to worse BCSS (hazard ratio (HR), 1.64, 95% confidential interval (CI), 1.18–2.27, p = 0.003) and OS (HR, 1.59, 95% CI, 1.24–2.04, p < 0.001) in the SBBC group, but not for the MBBC group (p = 0.650 for BCSS, p = 0.669 for OS).

Conclusions

Molecular subtype concordance rate was higher in the SBBC group than MBBC group. Patients with discordant molecular subtype was associated with worse disease outcome in the SBBC patients, but not in MBBC, which deserves further clinical evaluation.

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SBBC was associated with higher concordance rates of ER, PR, HER2, and molecular subtype status compared to MBBC.

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SBBC had worse BCSS than MBBC.

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Molecular subtype discordance was independently related to worse prognosis in SBBC but has no impact on prognosis of MBBC.

Clinicopathological Characteristics, Treatment and Outcome of 123 Patients with Synchronous or Metachronous Bilateral Breast Cancer in a Swiss Institutional Retrospective Series

Objective

To evaluate the prognosis, the patient and tumor characteristics, and the treatment of bilateral breast cancer (BBC) and to compare synchronous (sBBC) and metachronous BBC (mBBC).

Materials and Methods

For this retrospective study, data from 123 consecutive BBC patients (56 sBBC and 67 mBBC) that were presented at the Sion Hospital tumor board between 2007 and 2018 were collected retrospectively.

Results

Mean follow-up was 85 months. 2^nd tumors in both groups were more often diagnosed radiologically. Mean time interval between mBBC was 115 months. A shorter interval was positively correlated with a negative hormonal receptor (HR) status and higher grade for the 2^nd tumor. There was no difference in overall survival (OS) and relapse-free survival (RFS) between sBBC and mBBC. OS was longer if both tumors were hormonal receptor (HR) positive. mBBC exhibited a higher local recurrence rate than sBBC (p=0.03).

Conclusion

sBBC and mBBC patients did not show any difference in OS or RFS, although mBBC patients were more prone to local relapses.

The number of FoxP3-positive tumor-infiltrating lymphocytes in patients with synchronous bilateral breast cancer

PURPOSE

In breast cancer, FoxP3-positive tumor-infiltrating lymphocytes (FoxP3+ TILs) vary depending on lymph node status, histological grade, and subtype. All these studies have compared the numbers of FoxP3+ TILs among different hosts, but recruitment of FoxP3+ TILs might depend on each individual's immune environment and each tumor's biological characteristics. In the present study, FoxP3+ TIL numbers were investigated in patients with synchronous bilateral breast cancer (SBBC) to determine the factors that affect FoxP3+ TIL recruitment in the same anti-tumor immune environment.

METHODS

Patients diagnosed with SBBC who underwent curative surgery at two institutions were enrolled in this study. Patients who underwent primary systemic therapy or who were diagnosed with ductal carcinoma in situ or who had distant metastases at diagnosis were excluded. The average numbers of Foxp3+ TILs were determined from the scores of five high-power microscopic fields (HPF). The associations between Foxp3+ TIL numbers and the clinicopathological features of bilateral breasts in a single individual were examined.

RESULTS

Nuclear grade (NG) (p = 0.007) and subtype (p = 0.03), but not size (p = 0.18) and axillary lymph node (p = 0.23) were significantly associated with increase of FoxP3 + TIL numbers by univariate analysis. Further, only NG was a statistically significant clinicopathological factor for change in the number of FoxP3+ TILs by multivariate analysis (p = 0.046) CONCLUSIONS: There was no relationship between FoxP3+ TIL numbers and cancer progression as reflected in tumor size and axillary lymph node in patients with SBBC. Aggressive biological factors, especially high NG, were significantly related to enhanced recruitment of FoxP3+ TILs.

Classification of breast mass lesions on dynamic contrast-enhanced magnetic resonance imaging by a computer-assisted diagnosis system based on quantitative analysis

The aim of the current study was to develop a semi-automatic and quantitative method for the analysis of a time-intensity curve (TIC) from breast dynamic contrast-enhanced magnetic resonance imaging. The performance of the proposed method, based on the level set segmentation algorithm, was evaluated by comparison with the traditional method. In the traditional method, the lesion area is delineated manually and the corresponding mean TIC is classified subjectively as one of three washout patterns. In addition, only one quantitative parameter, the maximum slope of increase (MSI), is calculated. In the proposed method, the lesion region was determined semi-automatically and the corresponding mean TIC was categorized quantitatively. In addition to MSI, a number of quantitative parameters were derived from the mean TIC and lesion area, including signal intensity slope (SI_slope), initial percentage of enhancement (E_initial), percentage of peak enhancement (E_peak), early signal enhancement ratio (ESER) and second enhancement percentage (SEP). Wilcoxon signed-rank test and receiver operating characteristic analyses were performed for statistical analysis. For TIC categorization the accuracy was 61.54% for the traditional method and 82.05% for the proposed method. Using the proposed method, mean curve accuracies were 84.0% for SI_slope, 66.7% for MSI, 66.0% for E_initial, 66.0% for E_peak, 68.0% for ESER and 44.9% for SEP. In the lesion region, the accuracies for the aforementioned parameters were 80.8, 65.4, 66.7, 62.2, 69.2 and 57.1%, respectively. Accuracy of the MSI value derived from the traditional method was 63.4%. Compared with the traditional method, the proposed semi-automatic method in the current study may provide results with a higher accuracy to differentiate benign and malignant lesions. Therefore, the proposed method should be considered as a supplementary tool for the diagnosis of breast lesions.

Breast cancer mortality in synchronous bilateral breast cancer patients

Background

Evidence suggests that patients with synchronous bilateral breast cancer (SBBC), diagnosed within 4 months, have an inferior prognosis compared to unilateral breast cancer (UBC) patients. Using data from nationwide Danish clinical databases, this cohort study investigated whether the inferior prognosis could be explained by SBBC patients having a more aggressive disease, or whether the prognosis could be explained by the fact that they have two simultaneous cancers.

Methods

Patients were diagnosed from 1999–2015. The main outcome was excess mortality, subtracting background population mortality from observed mortality. Differences between SBBC and UBC patients were evaluated by rate ratios (RR) and estimated by Poisson regression.

Results

In total, 1214 SBBC and 59 177 UBC patients were included. SBBC patients had a significantly higher excess mortality than UBC patients after adjustment for age and period (RR = 1.73; 95% CI:1.44–2.08; p < 0.01) and after adjusting for characteristics of the worst tumour as traditionally done (RR = 1.31; 95% CI:1.08–1.57; p = 0.01). However, adjusting for characteristics of both tumours, using a more advanced competing risks model, no difference was observed (RR = 1.01; 95% CI:0.83–1.22; p = 0.93).

Conclusions

Our study does not support that the inferior prognosis in SBBC patients is due to having more aggressive tumours per se, but rather the combined effect of having two simultaneous cancers.

Detection of multicentric and contralateral breast cancers on MRI based on primary cancer biomarker status: will this change surgical or medical management?

PURPOSE

The utilization of staging preoperative breast MRI in biopsy-proven cancer patients varies based on institution and individual clinicians. It is unclear whether primary breast cancer subtype influences a clinician's decision to obtain a preoperative breast MRI based on likelihood of multicentric or contralateral disease, which may change surgical or medical management. Our purpose was to compare the four main breast cancer subtypes in our patient population (i.e., luminal A, luminal B, HER2 enriched and triple-negative) who underwent pretreatment staging MRIs to determine whether certain breast cancer subtypes are more likely to have multicentric or contralateral disease.

METHODS

We retrospectively reviewed 435 patients with biopsy-proven invasive breast cancer who had staging MRI.

RESULTS

Of these patients, 14 had biopsy-proven multicentric disease (3.2% of total) and 15 had biopsy-proven contralateral second tumor sites (3.4% of total). There was no statistically significant difference between primary tumor subtype and likelihood of multicentric or contralateral disease (p = 0.3065).

CONCLUSION

Pretreatment staging MRI can detect multicentric and/or contralateral additional tumor sites, which ultimately changes staging, treatment options, and outcomes for patients with biopsy-proven breast cancer. There is no correlation between primary breast cancer subtype and likelihood of multicentric or contralateral disease.

Synchronous Bilateral Breast Cancers

BACKGROUND

Bilateral breast cancer (BBC) is not an uncommon entity in contemporary breast clinics. Improved life expectancy after breast cancer treatment and routine use of contra-lateral breast mammography has led to increased incidence of BBC. Our study objective was to define the epidemiological and tumour characteristics of BBC in India.

MATERIALS AND METHODS

A total of 1251 breast cancer patients were treated during the period January 2007 to March 2015 and 30 patients were found to have BBC who constituted the study population (60 tumour samples). Synchronous bilateral breast cancers (SBC) was defined as two tumours diagnosed within an interval of 6 months and a second cancer diagnosed after 6 months was labelled as metachronous breast cancer (MBC). Analyses of patient and tumour characteristics were done in this prospective data base of BBC patients.

RESULTS

Median patient age was 66 years (range 39-85). Majority of the patients had SBC (n=28) and in 12 patients the second tumour was clinically occult and detected only by mammography of the contra-lateral breast. The second tumour was found at lower tumour size compared to the first in 73% of cases and was negative for axillary metastasis in 80% of cases (24/30). Infiltrating ductal carcinoma was the commonest histological type (n=51) and majority of the tumours were ER/PR positive (50/60). Her2 was overexpressed in 13 tumours (21%). Over 70% (22/30) of patients had similar histology in both breasts and amongst them grade concordance was present in about 69% (15/22) of patients. Concordance rates of ER, PR and Her2 statuses were 83%, 80% and 90% respectively. Bilateral mastectomy was the commonest surgery performed in 80% of the patients followed by bilateral breast conservation in 13%. At the end of study period, 26 patients were alive and disease free. Median survival was 29 months (range 3-86 months).

CONCLUSION

In most patients with BBC, the second tumour is identified at an early stage than index tumours supporting the importance of contralateral breast cancer screening at the time of primary diagnosis and during follow-up. BBC occurs more frequently in old age group and majority of these tumours are estrogen dependent. There is good pathological concordance between the index tumour and the contralateral breast cancer.

Synchronous and metachronous breast malignancies: a cross-sectional retrospective study and review of the literature

Objective. There is increasing interest in patients with metachronous (MBC) and synchronous breast cancer (SBC). The objective of this study was to evaluate the occurrence and outcome of MBCs and SBCs. Methods. A retrospective study on women operated in our department for breast cancer between 2002 and 2005 was carried out. Patients were divided into three groups: women with MBC, SBC, and unilateral breast cancer (UBC). Moreover, we performed a meta-analysis of the English literature about multiple breast cancers between 2000 and 2011 taking into consideration their prevalence and overall survival (OS). Results. We identified 584 breast cancer patients: 16 women (3%) presented SBC and 40 MBC (7%, second cancer after 72-month follow-up IQR 40–145). Although the meta-analysis showed significant OS differences between MBC or SBC and UBC, we did not observe any significant OS difference among the three groups of our population. Anyway, we found a significant worse disease-free survival in MBC than UBC and a significant higher prevalence of radical surgery in MBC and SBC than UBC. Conclusions. Despite the low prevalence of MBC and SBC, the presence of a long time risk of MBC confirms the crucial role of ipsi- and contralateral mammographies in the postoperative follow-up.

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.

Occult carcinoma in 866 reduction mammaplasties: preserving the choice of lumpectomy

BACKGROUND

Occult breast carcinoma is occasionally found in reduction mammaplasty specimens. Historically, these patients were treated with mastectomy because the exact location of the tumor was unknown. Currently, breast conservation is the treatment of choice in 50 to 85 percent of breast cancers. The authors present a technique of routine specimen marking that allows localization of the tumor and preservation of the choice of lumpectomy.

METHODS

This is a retrospective review of 866 patients who underwent reduction mammaplasty performed by a single surgeon between 1990 and 2009. Data were collected for patients who had occult cancer found in their specimens, including age, cancer risk factors, abnormality, nodal status, selected treatment, and survival status. Specimens were marked and oriented and then sent in separate bags to the pathologist.

RESULTS

There were 10 cases of occult carcinoma among the 866 women (1.15 percent) who underwent reduction mammaplasty. Six cancers were found in patients undergoing reduction for symptomatic macromastia [n = 629 (0.95 percent)]. Four new cancers were found in the group of patients with a personal history of cancer [n = 237 (1.69 percent)]. All 10 patients had normal preoperative mammograms. Location, size, and margin status were easily identified and patients were offered the choice of lumpectomy or mastectomy.

CONCLUSIONS

This article demonstrates that careful marking of reduction specimens in high-risk patients or in women older than 40 years allows the pathologist to orient, localize, and further section tissue for margin status. Communication among plastic surgeon, pathologist, oncologist, and radiation therapist preserves the choice of breast conserving therapy for early cancers.