Improving resource utilization: Axillary lymph node core biopsy triaging for lymphoma

OBJECTIVES

To evaluate the utilization of hematopathology resources within our enterprise on axillary lymph node core biopsy (AxLNCB) specimens, particularly those obtained in the context of breast cancer screening.

METHODS

The utilization of hematopathology resources was determined for all AxLNCB specimens over a 30-month period from across our enterprise, and chart review was performed for select patient demographics and radiographic features. The AxLNCB cases with benign histology were reviewed for subtyping of histologic patterns.

RESULTS

Of the total 594 AxLNCB specimens, 61.6% were benign and 38.6% malignant. Of malignant cases, only 9.3% contained any hematologic malignancy, yet 94% of all cases received tissue triage for lymphoma, and 81% were reviewed at least in part by a hematopathologist. Six clinical parameters were found to independently predict risk of hematologic malignancy: male sex (P = .041), bilateral lymphadenopathy (P = .004), diffuse cortical thickening (P = .005), lack of breast cancer (P = .001), older age (P < .001), and history of hematologic malignancy (P < .001).

CONCLUSIONS

Our enterprise overused hematopathology resources in the evaluation of AxLNCB performed in the study period. Our process could improve from the application of a simple tool generated from this cohort to predict percent risk of the specimen containing hematologic malignancy using patient characteristics easily found via routine chart review.

Architectural Distortion on Screening Digital Breast Tomosynthesis: Pathologic Outcomes and Indicators of Malignancy

OBJECTIVE

Digital breast tomosynthesis (DBT) has significantly improved cancer detection capabilities through its identification of subtle findings often imperceptible on 2D digital mammography, particularly architectural distortion (AD). The purpose of this study was to analyze of suspicious AD detected on screening DBT to evaluate the incidence of malignancy and to determine other patient or imaging characteristics in these cases as possible predictors of malignancy.

METHODS

This was an IRB approved retrospective analysis of subjects with AD detected on DBT screening mammography who were given a biopsy recommendation between January 1, 2016, and June 30, 2018. Univariate analysis of various imaging characteristics and patient high-risk factors was performed for statistical correlation with diagnosis of malignancy.

RESULTS

In the 218 DBT-detected AD findings with a final BI-RADS assessment of 4 or 5 on diagnostic workup, 94 (43.1%) yielded malignancy, 57 (26.2%) were classified as high-risk, and 67 (30.7%) were benign. There was a strong statistically significant association with malignancy in the cases with an US correlate (P < 0.0001). There was a statistically significant inverse correlation between malignancy and one-view findings (P = 0.0002). The presence of AD on 2D (P = 0.005) or synthetic 2D views (P = 0.002) showed statistically significant correlations with malignancy, whereas breast density or high-risk factors (P = 0.316) did not.

CONCLUSION

AD detected on DBT that persists on further workup and has no explainable cause should be considered suspicious for malignancy. Identification of the AD on both standard mammographic views and the presence of an US correlate significantly increase the probability of malignancy.

A high mitotic score in breast cancer after neoadjuvant chemotherapy is predictive of outcome and associated with a distinct morphology

AIMS

Neoadjuvant chemotherapy (NAC) is frequently used for the treatment of breast cancer. We sought to analyse the clinical, morphological and immunohistochemical features of tumours from patients who did not achieve pathological complete response following NAC.

METHODS AND RESULTS

We identified stage I-III post-NAC breast cancers from surgical resections (2000-2016) with evaluable residual invasive carcinoma [ypT1a(m) or greater and ≥15% tumour cellularity]. One hundred and forty-three tumours from 142 patients were included. On univariable analysis, a high (score 3) post-NAC mitotic score (as compared with 1 or 2) was significantly associated with invasive ductal carcinoma (IDC) subtype (P = 0.023), high grade, pushing borders with zones of necrosis, hormone receptor and triple-negative status, lack of hormonal therapy, higher cellularity (P < 0.001), and a higher percentage of tumour-infiltrating lymphocytes (P = 0.016). Multivariable analysis showed a high post-NAC mitotic score to be significantly associated with recurrence, distant metastasis, and shortened survival (hazard ratios of 5.73, 4.49, and 3.68, respectively). High post-NAC mitotic score tumours (n = 32) were IDC and had a high Ki67 proliferation index (median, 55%). Of these, 24 (75%) had pushing borders with zones of necrosis; 19 (79.2%) of these had necrosis on preoperative imaging, and 24 (75%), 15 (46.9%) and four (12.5%) lacked androgen receptor, GATA-3 and cytokeratin 18 expression, respectively.

CONCLUSIONS

High post-NAC mitotic score breast cancers cause high morbidity and mortality, frequently have pushing borders and zones of necrosis, and may show loss of common 'breast cancer markers'. Our findings support that necrosis in pretreatment studies and post-NAC mitotic score should be routinely reported, as they offer significant additional prognostic information to guide management.