Axillary Nodal Metastases from Carcinoma of Unknown Primary (CUPAx): Role of Contrast-Enhanced Spectral Mammography (CESM) in Detecting Occult Breast Cancer

Shifting from axillary dissection to targeted axillary surgery after neoadjuvant treatment: the evolving management of occult breast cancer in a monoinstitutional series of 114 patients

PURPOSE

The use of neoadjuvant systemic therapy for primary breast cancer can achieve tumor shrinkage, enabling less invasive surgical treatments, such as breast-conserving surgery instead of mastectomy, and sentinel node biopsy instead of axillary dissection. In recent years, an increasing number of studies have explored the use of primary systemic therapy for occult breast cancer with axillary presentation. These studies suggest that a more conservative approach, involving targeted axillary surgery could be cautiously proposed for occult breast cancer after neoadjuvant chemotherapy in selected patients. In cases where a complete pathological response in the lymph nodes is achieved, there may also be the possibility to omit radiotherapy.

METHODS

We retrospectively reviewed surgical interventions for carcinoma of unknown primary (CUP) syndrome with axillary presentation at the European Institute of Oncology from April 2004 to October 2022. Demographic and clinicopathological characteristics of the patients were collected and follow-up information has been updated.

RESULTS

A total of 114 patients who underwent axillary surgery for occult breast cancer were included. The 5-year disease-free survival was 74.5%, while overall survival was 88.5%. A total of 22.8% of patients underwent neoadjuvant treatment. Complete pathological response was achieved in 38.5%. Patients with complete nodal pathological response showed fewer events compared to patients with no complete pathological response after neoadjuvant treatment.

CONCLUSION

Although the sample size is limited, recent advances in breast cancer multimodal treatment indicate that targeted axillary surgery may be considered for the rare clinical presentation of occult breast cancer after neoadjuvant treatment.

TRIAL REGISTRY

Trial registration number UID 4184 24/07/2024 "retrospectively registered".

Contrast-enhanced mammography improves patient access to functional breast imaging

Imaging research pathways focus increasingly on the development of individualised approaches to breast cancer detection, diagnosis and management. Detection of breast cancer with X-ray mammography may fail in some cancer subtypes with limited changes in morphology/tissue density and in women with dense breasts. International organisations offer recommendations for contrast-enhanced breast imaging, as it provides superior sensitivity for screening, local staging and assessment of neoadjuvant treatment response, when compared with standard X-ray mammography (including tomosynthesis) and breast ultrasound. Arguably, the evidence base is stronger for contrast-enhanced MRI (CE-MRI). Unfortunately, patient access to breast MRI in rural and remote areas is limited by practical limitations and equipment licensing restrictions. Moreover, breast MRI is an expensive test, likely to be out of reach for many women. Contrast-enhanced mammography (CEM) offers an attractive alternative to improve patient access to functional breast imaging. It is a new type of digital, dual energy X-ray mammography that can be performed on most modern units, following a relatively inexpensive hard- and software upgrade. In this paper, we review the rapidly accumulating evidence that CEM can provide similar diagnostic accuracy to CE-MRI, though at a significantly lower cost and offering greater comfort to the patient. The adoption of CEM can help meet the anticipated increased demand for CE-MRI.

Axillary Lymph Node Metastasis from Ovarian Carcinoma: A Systematic Review of the Literature

BACKGROUND

Axillary lymph node metastasis is a rare stage IV ovarian carcinoma manifestation. This manuscript aims to systematically review the literature regarding axillary lymph node metastasis from ovarian carcinoma.

METHODS

We searched three medical internet databases (PubMed, Scopus, and Web of Science) for relevant articles published until 22 July 2023. Cases describing supraclavicular or intramammary lymph node metastases and concurrent metastasis to the breast were excluded.

RESULTS

After applying eligibility/inclusion and exclusion criteria, twenty-one manuscripts describing twenty-five cases were included from the English literature. Data were collected and analyzed regarding demographic, clinical, laboratory, radiological, histopathological, and oncological characteristics.

CONCLUSIONS

We analyzed the clinical and oncological characteristics of patients with axillary lymph node metastasis from ovarian carcinoma, presented either as an initial diagnosis of the disease or as a recurrent disease. The analysis we performed showed a significant difference only in the serum CA-125 level (p = 0.004) between the two groups. There was no observed difference in womens' survival.

[Breast-like cancer of unknow primary : Implications for radiological diagnostics]

BACKGROUND

Cancer of unknown primary (CUP) is defined by the presence of metastatic disease with an undetectable primary tumor at the time of presentation despite standard-of-care imaging. Although the prognosis of most CUP patients is poor, certain subgroups with more favorable prognosis have been defined.

DIAGNOSTICS

Women with isolated axillary lymph node metastases and confirmed histologic adenocarcinoma or poorly differentiated subtype, no other distant metastases, and no evidence of a primary cancer including primary breast carcinoma evaluated by clinical examination, computed tomography of thorax and abdomen, mammography, breast ultrasound, and breast magnetic resonance imaging (MRI) represent a potentially curable subgroup of patients with CUP. Breast MRI is the most important radiological modality in the diagnostic workup of breast-like CUP to exclude a primary cancer in the breast.

THERAPY

Breast-like CUP patients are treated according to guidelines for patients with node-positive breast cancer. Standard-of-care adjuvant systemic therapy should be given. Axillary lymph node dissection (ALND) is indicated. If no primary cancer in the breast is detected, surgery of the ipsilateral breast should not be performed. Radiotherapy of the ipsilateral breast and supra-/infraclavicular lymph nodes should be discussed.

Personalized Approaches for the Prevention and Treatment of Breast Cancer

Breast cancer (BC) remains a major public health issue worldwide [...]

Contrast-Enhanced Spectral Mammography-Based Prediction of Non-Sentinel Lymph Node Metastasis and Axillary Tumor Burden in Patients With Breast Cancer

Purpose

To establish and evaluate non-invasive models for estimating the risk of non-sentinel lymph node (NSLN) metastasis and axillary tumor burden among breast cancer patients with 1–2 positive sentinel lymph nodes (SLNs).

Materials and Methods

Breast cancer patients with 1–2 positive SLNs who underwent axillary lymph node dissection (ALND) and contrast-enhanced spectral mammography (CESM) examination were enrolled between 2018 and 2021. CESM-based radiomics and deep learning features of tumors were extracted. The correlation analysis, least absolute shrinkage and selection operator (LASSO), and analysis of variance (ANOVA) were used for further feature selection. Models based on the selected features and clinical risk factors were constructed with multivariate logistic regression. Finally, two radiomics nomograms were proposed for predicting NSLN metastasis and the probability of high axillary tumor burden.

Results

A total of 182 patients [53.13 years ± 10.03 (standard deviation)] were included. For predicting the NSLN metastasis status, the radiomics nomogram built by 5 selected radiomics features and 3 clinical risk factors including the number of positive SLNs, ratio of positive SLNs, and lymphovascular invasion (LVI), achieved the area under the receiver operating characteristic curve (AUC) of 0.85 [95% confidence interval (CI): 0.71–0.99] in the testing set and 0.82 (95% CI: 0.67–0.97) in the temporal validation cohort. For predicting the high axillary tumor burden, the AUC values of the developed radiomics nomogram are 0.82 (95% CI: 0.66–0.97) in the testing set and 0.77 (95% CI: 0.62–0.93) in the temporal validation cohort.

Discussion

CESM images contain useful information for predicting NSLN metastasis and axillary tumor burden of breast cancer patients. Radiomics can inspire the potential of CESM images to identify lymph node metastasis and improve predictive performance.