Incidental radiologic findings at breast cancer diagnosis and likelihood of disease recurrence

Bone Scans in Preoperative Investigations of Breast Cancer Cases

BACKGROUND

Breast cancer constitutes about 28% of all new cancer diagnoses in women, making it the most frequently diagnosed cancer among them. Our objective was to assess the role of bone scans (BS) in preoperative investigations of breast cancer.

METHODS

This study involved 105 patients with varying stages of breast cancer, ranging from T1 to T4. We categorized them into three groups: group 1 comprised 40 women with breast cancer who underwent retrospective BS, group 2 included 30 patients with breast cancer who prospectively did not require BS for all cases, and group 3 consisted of 35 women retrospectively diagnosed with breast cancer who did not necessitate BS for all cases. The diagnosis of bone metastasis was confirmed upon obtaining a positive result through bone scintigraphy, subsequently affirmed by another imaging technique such as CT, X-ray, or MRI.

RESULTS

The hospital costs were significantly lower in groups 2 and 3 compared to that of group 1, indicating that performing a BS for every case is unnecessary. It was observed that the time taken for surgery was notably shorter in groups 2 and 3 compared to that of group 1. BS in cases classified as M stage were deemed both costly and time-consuming.

CONCLUSIONS

Routine BS are not cost-effective and represent an unnecessary investment of time. They should not be deemed mandatory as preoperative investigations in breast cancer cases. Instead, they should be considered in conjunction with MRI, particularly in cases of T4 breast cancer.

Staging for Breast Cancer: A Comparison Between Old and New Approaches

Background/Aim

Staging for breast cancer in advanced stages or prior to neoadjuvant chemotherapy is recommended to be performed with CT scan of the chest and abdomen and a bone scan. This recommendation is valid since 2012, when conventional staging with chest x-ray and ultrasound of the abdomen was replaced by the more sensitive CT scan. However, it remains unclear if this approach improves patient outcome and prognosis.

Patients and Methods

We identified patients who were treated for breast cancer at the breast center of the St. Elisabeth Hospital, Cologne, in 2012 and 2014. Clinical information such as age at diagnosis, stage, tumor biology, grading, and the applied method for staging was abstracted from the patient chart. We also looked for local or distant recurrence and data of survival.

Results

A total of 1,122 patients were identified. Of those, 104 patients developed local or distant recurrence and 54 died. Conventional staging with chest x-ray, abdominal ultrasound and a bone scan was more often in 2012 (482 cases) than in 2014 (135), but CT-staging was more often in 2014 (180 vs. 29 cases). In general, less patients were staged in 2014 than in 2012. There were no significant survival differences between the two groups.

Conclusion

Staging habits changed in 2012 compared to 2014 according to the changes in guidelines. This change did not affect disease-free survival.

Breast Cancer, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology

The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. These NCCN Clinical Practice Guidelines for Breast Cancer include recommendations for clinical management of patients with carcinoma in situ, invasive breast cancer, Paget disease, phyllodes tumor, inflammatory breast cancer, and management of breast cancer during pregnancy. The content featured in this issue focuses on the recommendations for overall management of ductal carcinoma in situ and the workup and locoregional management of early stage invasive breast cancer. For the full version of the NCCN Guidelines for Breast Cancer, visit NCCN.org.

Performance, clinical utility, and cost-effectiveness of selective use of staging investigations in early breast cancers

BACKGROUND

International guidelines do not recommend routine staging of EBCs. However, most clinicians still perform staging investigations (SI) selectively for several reasons. We examined our practice of selective use of SI to determine its performance, clinical utility, and cost-effectiveness.

METHODS

We performed this retrospective study on patients who had treatment for AJCC stage I or stage II breast cancer through Eastern health Breast and cancer centre, Melbourne, for 50 months from January 2012.

RESULT

Our practice of selective use resulted in SI in 41% of all EBCs (95% CI 37-46%). Overall yield was 3% (95% CI 0.4-5.4%) with a false positive rate of 22% (95% CI 1628%) and a false-negative rate of 45% (95% CI 11-79%). The sensitivity of SI is 55% (95% CI 21-89%) with a negative predictive value of 97% (95% CI 94.8-99.9%). None of the treatment components was found to be significantly changed based on findings on SI. There was no significant difference in all-cause mortality or new distant recurrence in the staged and non-staged groups. Identification of six new metastases cost at least 422 021 AUD. The approximate cost to stage one EBC is 2069 AUD. 'Number needed to scan' to detect one new metastasis is 34 at the expense of 70337AUD.

CONCLUSION

Selective use of SI results in better yield. However, the clinical utility of these results is not significant. It is debatable if this level of expenditure is cost-effective. Our results point to a need for change in practice.

A critical review of abdominopelvic computed tomography for the detection of asymptomatic metastasis in new and recurrent breast cancers

AIM

Abdominopelvic computed tomography (APCT) is a commonly used staging investigation to detect asymptomatic metastasis in breast cancer including early breast cancer (EBC). This study aimed to assess the usefulness of APCT in breast cancers at each clinical stage.

METHODS

Patients with new or recurrent invasive breast cancer between January 2009 and December 2014 were included in the study. All staging APCT results were reviewed to evaluate its yield and false positive rate (FPR) and how many investigations are needed to confirm indeterminate results. Odds ratios (ORs) for positive APCT results were calculated for possible risk factors for asymptomatic metastasis.

RESULTS

Sixty-five asymptomatic metastases were detected from 1002 APCTs, giving an overall yield of 6.5%. The overall false-positive rate was 14.9 % due to 149 indeterminate findings that were found not to be metastases after further investigations or observation. Whereas the APCTs have a low yield of 3.1% in EBC, but advanced breast cancer and recurrent breast cancer have a high incidence of asymptomatic metastases (13.8% and 16.3%, respectively). The most common cause of indeterminate findings was small liver nodules, including liver cysts and liver hemangiomas. Human epidermal growth factor receptor2 (HER2) status and tumor stage are most significant predictors for positive results of staging APCT scans with high ORs (3.9 and 3.7, respectively).

CONCLUSION

Staging APCT is associated with a high incidence of FPRs and low yield, especially among EBCs. It is desirable to choose this investigation more selectively according to HER2 status and tumor stage.

Epidemiology of De Novo Metastatic Breast Cancer

Most cases of metastatic breast cancer (MBC) arise as a recurrence of a previously treated early breast cancer. Distinct from recurrent MBC is de novo MBC (dnMBC), which describes patients who present with distant sites of disease at initial diagnosis and is reviewed here. dnMBC represents approximately 3% to 6% of new breast cancer diagnoses in high-income countries. This incidence has not declined despite decades of widespread use of population-based mammography screening. Overrepresentation of both biologically aggressive tumors and patients negatively impacted by social determinants of health are characteristics of dnMBC. Survival has generally been superior for patients with dnMBC compared with those with recurrent MBC, although it is similar to that for patients with recurrent MBC with long disease-free intervals. Subgroups of patients with dnMBC who experience prolonged survival include those with human epidermal growth factor receptor-2-positive disease or hormone receptor-positive bone-only disease. Opportunities to decrease dnMBC presentation may include novel screening modalities suited for biologically aggressive breast tumors and improved access to health care. Recognizing that there will remain some women diagnosed with dnMBC, refining our ability to identify those likely to be long-term survivors could allow for appropriate escalation or de-escalation of care. Finally, evaluation of tumor genomics in robust sample sizes has the potential to advance our knowledge of the biology of dnMBC as an entity distinct from recurrent MBC.

Risk and prognostic factors of breast cancer with liver metastases

Background

Liver metastasis is a significant adverse predictor of overall survival (OS) among breast cancer patients. The purpose of this study was to determine the risk and prognostic factors of breast cancer with liver metastases (BCLM).

Methods

Data on 311,573 breast cancer patients from the Surveillance, Epidemiology, and End Results (SEER) database and 1728 BCLM patients from Fudan University Shanghai Cancer Center (FUSCC) were included. Logistic regression was used to identify risk factors for liver metastasis. Cox proportional hazards regression model was adopted to determine independent prognostic factors in BCLM patients.

Results

Young age, invasive ductal carcinoma, higher pathological grade, and subtype of triple-negative and human epidermal growth factor receptor 2 positive (HER2+) were risk factors for developing liver metastasis. The median OS after liver metastasis was 20.0 months in the SEER database and 27.3 months in the FUSCC dataset. Molecular subtypes also played a critical role in the survival of BCLM patients. We observed that hormone receptor-positive (HR+)/HER2+ patients had the longest median OS (38.0 for SEER vs. 34.0 months for FUSCC), whereas triple-negative breast cancer had the shortest OS (9.0 vs. 15.6 months) in both SEER and FUSCC. According to the results from the FUSCC, the subtype of HR+/HER2+ (hazard ratio (HR) = 2.62; 95% confidence interval (CI) = 1.88–3.66; P < 0.001) and HR−/HER2+ (HR = 3.43; 95% CI = 2.28–5.15; P < 0.001) were associated with a significantly increased death risk in comparison with HR+/HER2- patients if these patients did not receive HER2-targeted therapy. For those who underwent HER2-targeted therapy, however, HR+/HER2+ subtype reduced death risk compared with HR+/HER2- subtype (HR = 0.74; 95% CI = 0.58–0.95; P < 0.001).

Conclusions

Breast cancer patients at a high risk for developing liver metastasis deserve more attention during the follow-up. BCLM patients with HR+/HER2+ subtype displayed the longest median survival than HR+/HER2- and triple-negative patients due to the introduction of HER2-targeted therapy and therefore it should be recommended for HER2+ BCLM patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07968-5.

Usefulness of Staging Chest CT in Breast Cancer: Evaluating Diagnostic Yield of Chest CT According to the Molecular Subtype and Clinical Stage

The aim of this study is to investigate the clinical utility of staging chest CT in breast cancer by evaluating diagnostic yield (DY) of chest CT in detection of metastasis, according to the molecular subtype and clinical stage. This retrospective study included 840 patients with 855 breast cancers from January 2017 to December 2018. The number of patients in clinical stage 0/I, II, III and IV were 457 (53.5%), 298 (34.9%), 92 (10.8%) and 8 (0.9%), respectively. Molecular subtype was identified in 841 cancers and there were 709 (84.3%) luminal type, 55 (6.5%) human epidermal growth factor receptor 2 (HER2)-enriched type and 77 (9.2%) triple-negative (TN) type. The DYs in clinical stage 0/I, cII, cIII and cIV were 0.2% (1/457), 1.7% (5/298), 4.3% (4/92) and 100.0% (8/8), respectively. The DYs in luminal type, HER2-enriched type and TN type were 1.7% (12/709), 3.6% (2/55) and 2.6% (2/77), respectively. Clinical stage was associated with the DY (p = 0.000). However, molecular subtype was not related to the DY (p = 0.343). Molecular subtype could not provide useful information to determine whether staging chest CT should be performed in early-stage breast cancer. However, chest CT should be considered in advanced breast cancer.

Incidental radiologic findings in breast cancer patients who undergo staging prior to neo-adjuvant chemotherapy

NCCN guidelines discourage the use of staging imaging for newly diagnosed patients with early breast cancer (BC). When performed, incidental radiologic findings of uncertain significance are often encountered. The purpose of this study was to compare incidental findings seen on staging imaging with distant recurrence in patients undergoing neo-adjuvant chemotherapy (NAC). 396 patients with BC who had NAC from 2008 to 2016 were identified from a prospectively maintained data base. Staging imaging was reviewed. Of 396 patients with BC treated with NAC, patients with a positive PET/CT for metastatic disease (n = 36, 9.1%), those that did not undergo staging imaging (n = 49, 12.4%), or those that did not have a reported incidental finding (n = 49, 12.4%) were excluded from analysis. Of the 262 patients who met criteria, mean age was 50 years (range: 26-88). 201 (76.7%) patients had stage I-II cancer, and 61 (23.3%) patients had stage III cancer. Overall, 146 (55.7%) patients had an incidental finding on imaging. 90 (34.4%) patients had one finding, 42 (16.0%) patients had two, and 14 (5.3%) patients had three or more findings. The majority of incidental findings were seen in the ovary/uterus (29.7%), followed by lung (18.4%), liver (10.3%), and bone (9.0%). 5 (3.4%) patients had additional imaging performed. At mean follow-up of 3.7 years (range: 0.7-10.8), 43 (15.6%) patients had a distant recurrence. Of these patients, only 5 (1.9%) patients had distant metastasis in the same organ that was initially thought to be an incidental finding. Our results suggest that breast cancer patients with incidental findings on preoperative staging imaging are unlikely to be indicative of sites for future metastasis.

Diagnostic workup of early-stage breast cancer: can we choose more wisely?

INTRODUCTION

Current international guidelines, including the Choosing Wisely Initiative, recommends against the routine use of systemic imaging studies or tumor markers in early-stage breast cancer. Accumulating data suggests that adherence to these guidelines is low. We aimed to investigate the execution of unnecessary diagnostic tests among Israeli breast cancer patients and identify factors associated with their performance.

METHODS

A retrospective analysis was conducted involving a database of early breast cancer patients treated at Tel Aviv Sourasky Medical Center. A survey was distributed among Israeli surgeons and oncologists specializing in breast cancer treatment.

RESULTS

The study included early breast cancer patients (n = 178), who have no indication for completing systemic evaluation. Nearly half of the patients (76, 42%) were referred to 128 unjustified diagnostic studies, with the most common referral comprising a PET-CT (n = 39 30.5%). As expected, none of the tests led to any change in either disease staging or alteration in clinical management. Variables associated with systemic evaluation included younger age (61.8% for < 50 years vs 38.9% for > 50 years, p = 0.02), diagnosis by palpable mass compared to screening mammography (26.9% vs 52.9% p = 0.043, respectively) and higher tumor grade (33.7% vs 52.2% p = 0.02, respectively). In concordance with the findings of the database, the physicians' survey revealed low adherence to guidelines and a role of the treating physicians' subjective feelings. Doctors were more likely to recommend unnecessary studies when presented with a clinical case as an image, than to an informative question.

CONCLUSIONS

Our data indicate a high rate of non-adherence to guidelines, physicians recommending extensive systemic evaluation for women with early breast cancer. These deviations from the guidelines are associated with subjective factors, some of them being physician-dependent. Initiatives aimed at improving adherence to guidelines, and specifically to guidelines recommending "doing less" should therefore include not just knowledge-based education but also encourage conversation about what is appropriate and necessary.

PET-CT for Evaluating Breast Cancer Yields Incidental Finding in the Lung

BACKGROUND

A woman aged 75 years presented with a palpable left axillary lymph node. Mammography showed a spiculated mass in the left breast, demonstrated by biopsy to be triple-negative breast cancer. A positron emission tomography-computed tomography (PET-CT) scan was performed to evaluate the extent of the cancer and revealed an unrelated nonmetastatic, synchronous carcinoid in the left lung. The patient was a nonsmoker and presented with no symptoms of lung disease.

DISCUSSION

Advanced imaging modalities used to evaluate the extent of locally advanced breast cancer have been a keystone in decreasing cancer mortality rates. Mammography is considered the gold standard for breast disease evaluation, but sonography is a valuable modality for correlating suspicious findings and evaluating lesions that might not be visible on mammograms. When a breast biopsy confirms metastasis to the axillary lymph nodes, PET-CT is the modality of choice for cancer staging and ruling out distant metastases.

CONCLUSION

Imaging tools used to evaluate breast cancer can help determine whether distant metastasis has occurred and in rare cases can help discover other primary cancers. The patient in this case study was 1 of the few patients with an incidental finding of a second nonmetastatic primary malignancy in the lung detected using PET-CT. The risks associated with advanced imaging include exposing patients to additional tests and potentially invasive procedures based on the results. However, in some instances, imaging results can alter the treatment plan and increase survival rates. Further empirical research and case studies are needed to identify clinical outcomes for patients with a second primary cancer.

Adherence to guidelines for baseline staging in newly diagnosed localized breast cancer

RATIONALE, AIMS, AND OBJECTIVES

Different health agencies in Canada including Cancer Care Ontario (CCO) have developed guidelines for the baseline staging of newly diagnosed breast cancer patients but adherence to them is unknown. We sought to investigate adherence to CCO staging guidelines in a single cancer center in addition to the factors that influence this adherence.

METHOD

A retrospective chart review was conducted on 212 newly diagnosed breast cancer patients between 2015 and 2017. Baseline patient demographic and disease characteristics as well as radiologic staging studies and subsequent treatments were recorded. The group of patients in whom the guidelines were observed was compared to the group of patients in whom the guidelines were not followed.

RESULTS

Staging guidelines were not followed in 46.7% of the patients in the cohort (99 of 212 patients). In most cases, deviations from the guidelines consisted of performing more than the recommended baseline screening, most commonly in the form of a computerized tomography (CT) scan or a bone scan and chest x-ray (CXR)/ ultrasound (US) of the liver. Less commonly, a recommended staging evaluation was omitted or the suggested timing of the staging procedure (i.e., pre-operatively versus post-operatively) was not followed. Higher stage and grade of the disease and subsequent chemotherapy administration were associated with higher guideline non-adherence.

CONCLUSIONS

Low adherence to staging guidelines for newly diagnosed breast cancer according to CCO is shown in a community cancer center. Incorporation of arising prognostic factors to staging procedure determination may increase acceptance and adherence to guidelines in the future.

Variation in the use of advanced imaging at the time of breast cancer diagnosis in a statewide registry

BACKGROUND

Although national guidelines do not recommend extent of disease imaging for patients with newly diagnosed early stage breast cancer given that the harm outweighs the benefits, high rates of testing have been documented. The 2012 Choosing Wisely guidelines specifically addressed this issue. We examined the change over time in imaging use across a statewide collaborative, as well as the reasons for performing imaging and the impact on cost of care.

METHODS

Clinicopathologic data and use of advanced imaging tests (positron emission tomography, computed tomography, and bone scan) were abstracted from the medical records of patients treated at 25 participating sites in the Michigan Breast Oncology Quality Initiative (MiBOQI). For patients diagnosed in 2014 and 2015, reasons for testing were abstracted from the medical record.

RESULTS

Of the 34,078 patients diagnosed with stage 0-II breast cancer between 2008 and 2015 in MiBOQI, 6853 (20.1%) underwent testing with at least 1 imaging modality in the 90 days after diagnosis. There was considerable variability in rates of testing across the 25 sites for all stages of disease. Between 2008 and 2015, testing decreased over time for patients with stage 0-IIA disease (all P < .001) and remained stable for stage IIB disease (P = .10). This decrease in testing over time resulted in a cost savings, especially for patients with stage I disease.

CONCLUSION

Use of advanced imaging at the time of diagnosis decreased over time in a large statewide collaborative. Additional interventions are warranted to further reduce rates of unnecessary imaging to improve quality of care for patients with breast cancer. Cancer 2017;123:2975-83. © 2017 American Cancer Society.