Breast conservation for mammographically occult carcinoma

Occult primary breast cancer at a comprehensive cancer center

BACKGROUND

Management of occult primary breast cancer (OPBC), that is, breast cancer that first presents through regional nodal or distant disease without clinical or mammographic evidence of disease in the breast, has been controversial and inconsistent. Here, we review OPBC patients treated at our institution.

METHODS

We conducted a retrospective review of women diagnosed with a first primary breast cancer between March 1999 and September 2010 to identify patients who presented with isolated axillary lymphadenopathy proven to be histologically consistent with primary breast malignancy but had no evidence of a breast mass on physical examination, mammography, or ultrasound. Descriptions of treatments received, recurrence, morbidity, and mortality as of October 2012 are reported.

RESULTS

Of 5533 patients reviewed, seven (0.1%) patients were identified. The median age was 65 y old (range, 40-72), and the median length of follow-up was 86 mo (range, 42-124). Four patients underwent modified radical mastectomy, one patient had a lumpectomy and axillary lymph node dissection, and two patients had axillary lymph node dissection without breast surgery. Four patients received adjuvant radiation therapy. All seven patients received chemotherapy. Three patients received endocrine therapy, and two patients received anti-HER2 therapy. At the last follow-up, all seven patients were alive with no evidence of disease.

CONCLUSIONS

Although there was some variation in the management of OPBC at our institution, our patients had excellent outcomes after multimodal treatment. Our results support a curative intent approach to the treatment of OPBC and illustrate the need for individualized treatment algorithms based on tumor biology and extent of the disease at diagnosis.

Imaging-assisted large-format breast pathology: program rationale and development in a nonprofit health system in the United States

Modern breast imaging, including magnetic resonance imaging, provides an increasingly clear depiction of breast cancer extent, often with suboptimal pathologic confirmation. Pathologic findings guide management decisions, and small increments in reported tumor characteristics may rationalize significant changes in therapy and staging. Pathologic techniques to grossly examine resected breast tissue have changed little during this era of improved breast imaging and still rely primarily on the techniques of gross inspection and specimen palpation. Only limited imaging information is typically conveyed to pathologists, typically in the form of wire-localization images from breast-conserving procedures. Conventional techniques of specimen dissection and section submission destroy the three-dimensional integrity of the breast anatomy and tumor distribution. These traditional methods of breast specimen examination impose unnecessary limitations on correlation with imaging studies, measurement of cancer extent, multifocality, and margin distance. Improvements in pathologic diagnosis, reporting, and correlation of breast cancer characteristics can be achieved by integrating breast imagers into the specimen examination process and the use of large-format sections which preserve local anatomy. This paper describes the successful creation of a large-format pathology program to routinely serve all patients in a busy interdisciplinary breast center associated with a community-based nonprofit health system in the United States.

Prognosis for mammographically occult, early-stage breast cancer patients treated with breast-conservation therapy

PURPOSE

To compare mammographically occult (MamOcc) and mammographically positive (MamPos) early-stage breast cancer patients treated with breast-conservation therapy (BCT), to analyze differences between the two cohorts.

METHODS AND MATERIALS

Our two cohorts consisted of 214 MamOcc and 2168 MamPos patients treated with BCT. Chart reviews were conducted to assess mammogram reports and method of detection. All clinical-pathologic and outcome parameters were analyzed to detect differences between the two cohorts.

RESULTS

Median follow-up was 7 years. There were no differences in final margins, T stage, nodal status, estrogen/progesterone receptor status, or "triple-negative" status. Significant differences included younger age at diagnosis (p < 0.0001), more positive family history (p = 0.0033), less HER-2+ disease (p = 0.0294), and 1 degrees histology (p < 0.0001). At 10 years, the differences in overall survival, cause-specific survival, and distant relapse between the two groups did not differ significantly. The MamOcc cohort had more breast relapses (15% vs. 8%; p = 0.0357), but on multivariate analysis this difference was not significant (hazard ratio 1.0, 95% confidence interval 0.993-1.007, p = 0.9296). Breast relapses were mammographically occult in 32% of the MamOcc and 12% of the MamPos cohorts (p = 0.0136).

CONCLUSIONS

Although our study suggests that there are clinical-pathologic variations for the MamOcc cohort vs. MamPos patients that may ultimately affect management, breast relapse after BCT was not significantly different. Breast recurrences were more often mammographically occult in the MamOcc cohort; consideration should be given to closer follow-up and alternative imaging strategies (ultrasound, breast MRI) for routine posttreatment examination. To our knowledge, this represents the largest series addressing the prognostic significance of MamOcc cancers treated with BCT.

Prognosis of Occult Breast Carcinoma Presenting as Isolated Axillary Nodal Metastasis

Axillary metastasis from an occult breast carcinoma is an uncommon presentation and presents a therapeutic dilemma. The objective of this study is to describe the presenting clinical features, management approach and treatment outcomes for occult breast carcinoma. We conducted a retrospective review of patients who presented with axillary nodal metastases from an occult breast carcinoma between 1997 and 2004 at the Roswell Park Cancer Institute; 2,150 patients were diagnosed and treated for breast cancer during this period. After excluding stage I and IV patients, we identified 642 who had disease metastatic to lymph nodes, 10 of these had no primary tumor in the breast despite a thorough evaluation including bilateral mammography and breast ultrasound. Of these, 7 had undergone breast magnetic resonance imaging as well. All patients underwent axillary nodal dissection. The breast was managed with radiotherapy alone in 8 patients, wide local excision with radiation therapy in 1 patient and 1 patient underwent mastectomy. No patient had a recurrence with a median 57 months of follow-up. Breast conservation with radiation therapy alone can be considered as a management option for women with occult breast cancer presenting with axillary nodal metastasis.

A Clinical Oncology Perspective on the Use of Breast MR

MR imaging of the breast detects additional carcinoma in as many as 30% of women thought to have localized disease by clinical examination and mammography. This has led some to advocate its routine use in the preoperative evaluation of breast cancer patients. However, local failure rates in patients selected for breast conservation by conventional methods are less than 5% at 10 years, suggesting that he majority of this disease is controlled with radiotherapy. The potential role of MR in the preoperative evaluation and postoperative follow-up of patients with early-stage breast cancer is discussed.

Palpable breast cancer which is mammographically invisible

We have evaluated tumour characteristics, local recurrence rates and prognostic markers in 40 women with symptomatic palpable breast cancer proven by cytology, but in whom routine two-view mammography failed to detect a radiological abnormality. False negative mammograms were identified by cross-referencing all negative mammograms performed at the Royal Victoria Infirmary during the period 1995-1999, with pathological records at the same institution. The average age was 48 years. The majority of the tumours were invasive ductal carcinomas, 35 with an average size of 24 mm. There were 16 Grade II and 15 Grade III tumours. Lymphovascular invasion was seen in 18 on histology and six patients had distant metastases. Of those patients treated by conservation therapy there has been only one local recurrence, with a median follow-up of 18 months. We conclude that mammographically invisible tumours are of common histological type, are frequently high grade and node positive and occur mainly in the younger age group. However, BCT remains a viable option in the treatment of these tumours.

Cancer from an unknown primary site

Cancer from an unknown primary site (CUP) is frequently encountered in clinical practice. This review is designed to help physicians identify those patients with CUP that benefit from specific therapeutic approaches. The utility of pathologic and diagnostic tests in patients with CUP will also be discussed, as will the prognosis and appropriate treatment of these patients.

Impact of immediate reconstruction on the local recurrence of breast cancer after mastectomy

The incidence of local recurrence of breast cancer in women who underwent mastectomy with or without reconstruction was examined. All female mastectomy patients were followed-up in a 10-year retrospective review. Groups consisted of patients who had mastectomy, mastectomy with immediate reconstruction, or delayed reconstruction. Reconstruction was performed using prostheses, latissimus dorsi musculocutaneous flaps with or without implants, or transverse rectus abdominis musculocutaneous flaps. Charts were reviewed for local breast cancer recurrence. Statistical analysis was performed using Pearson's chi-square and analysis of variance. Of the 1,444 mastectomies performed from 1988 to 1997, 1,262 breasts (87%) were not reconstructed, 182 (13%) were reconstructed, 158 (87%) were immediately reconstructed, and 24 (13%) were reconstructed later. There were no recurrences in the delayed reconstruction group, two recurrences (1.3%) in the immediate reconstruction group, and nine recurrences (0.7%) in the mastectomy without reconstruction group (p=0.746). Analyses of an additional time period from 1992 to 2000 yielded similar results. There is little relationship between local recurrence of breast cancer after mastectomy and reconstruction.

Feasibility of breast preservation in the treatment of occult primary carcinoma presenting with axillary metastases

BACKGROUND

The objective of the study was to compare the treatment outcomes in patients with occult primary carcinoma with axillary lymph node metastasis who were treated with mastectomy or with intent to preserve the breast.

METHODS

From 1951 to 1998, 479 female patients were registered with axillary lymph node metastasis from an unknown primary. After clinical workup, including mammography, 45 patients retained this diagnosis and received treatment for T0 N1-2 M0 carcinoma of the breast. Clinical and pathological data were collected retrospectively, and survival was calculated from the date of initial diagnosis using the Kaplan-Meier method. Median follow-up time was 7 years.

RESULTS

Median age was 54 years (range, 32-79). Clinical nodal status was N1 in 71% and N2 in 29% of the patients. Surgical treatment was mastectomy in 29% and an intent to preserve the breast in 71% of the patients. Locoregional radiotherapy was used in 71% and systemic chemoendocrine therapy was used in 73% of the patients. Of the 13 mastectomy patients, only one had a primary tumor discovered in the specimen. Two patients (4%) were ultimately diagnosed with lung cancer and neuroendocrine tumor. No significant difference was detected between mastectomy and breast preservation in locoregional recurrence (15% versus 13%), distant metastases (31% versus 22%), or 5-year survival (75% vs. 79%). Regardless of surgical therapy, the most important determinant of survival was the number of positive nodes. Five-year overall survival was 87% with 1-3 positive nodes compared with 42% with > or =4 positive nodes (P < .0001).

CONCLUSIONS

Occult primary carcinoma with axillary metastases can be treated with preservation of the breast without a negative impact on local control or survival.

Pre-operative MR-mammography in breast cancer patients

AIMS

Pre-operatively, to exclude multiple invasive tumours not discovered by mammography and sonography in patients referred for breast conservation surgery.

METHODS

A supplementary MR-mammography was offered to all patients with mammographic and/or sonographic ascertained tumours less than 2 cm in diameter.

RESULTS

Forty patients were offered this additional examination. In accordance with the MR diagnosis, 51% of the planned surgical procedures were changed. Nine patients had more than one invasive tumour, and in four patients the tumour was >2cm in diameter. One patient had no tumour at all, and in four patients the MR-mammography suggested benign fibroadenomas, which resulted in small excisions. One patient with a suspect MR-mammography presented sclerosing adenosis at surgery. Three patients had to be excluded due to MR problems. Ten patients preferred mastectomy, although the MR-mammography had shown only a single invasive tumour.

CONCLUSION

MR-mammography is recommended as a pre-surgical diagnostic procedure in patients allocated to breast conservation surgery.

The evaluation of breast masses in women younger than forty years of age

BACKGROUND

Breast masses in young women are common, but carcinoma is rare. This study was undertaken to determine how often a complaint of mass was found to represent a dominant mass and to define the role of breast imaging and fine-needle aspiration cytology (FNA) in the evaluation of clinically nonworrisome masses.

METHODS

A retrospective review was made of 605 patients younger than 40 years of age with a breast mass between February 1994 and February 1996.

RESULTS

Dominant masses were confirmed by surgeon examination in 36% of 484 self-detected masses compared with 29% of physician-detected masses (difference not significant). With pathologic confirmation, 29% of self-detected masses had a dominant mass compared with 19% of physician-detected masses (P = .02). Carcinoma was present in 5% of both groups and not predicted by family history. Imaging studies were not useful in patients with normal examinations but were more likely to identify dominant masses in patients with an examination described as benign (P < .001). FNA did not identify any cancers in normal or benign examinations.

CONCLUSIONS

Self-examination is as reliable as a general physician examination in detecting breast masses. When an examination by an experienced surgeon is normal, imaging studies and FNA are low yield. When the examination is equivocal, directed ultrasonography is a useful adjunct.