Hiroko Tsunoda

Mammography and ultrasound features of triple-negative breast cancer

BackgroundTriple-negative breast cancer is characterized as a cancer with a high malignancy potential and a poor prognosis. Therefore, early detection of this subtype of breast cancer is vital. In this paper, we describe the mammography and ultrasound findings of triple-negative breast cancer in a large population and investigate the specific features of this subtype.MethodsFrom January 2007 to April 2010, mammography and ultrasound findings of 88 patients with triple-negative breast cancer were retrospectively reviewed. In this cohort, 52 patients underwent neoadjuvant chemotherapy. We compared the pathological chemotherapy effects and radiological findings among these patients. Mammograms were reviewed according to the Japanese mammography guideline. Ultrasound findings were classified as masses, low echoic area, distortions, and calcifications. Noted features included shapes, patterns of internal echoes, posterior echoes, vascularity, and elasticity scores.ResultsOn mammography, triple-negative breast cancers frequently presented with a mass (62.4%). Masses with microlobulated margins were the most frequent (39.6%), indistinct (32.0%) and circumscribed (20.8%) were commonly observed, but spiculated margins were rare (4.7%). On ultrasound, cancers were more likely to present as a mass (92.5%), and less likely to show attenuating posterior echoes (8.8%). Of the 40 cases obtained via elasticity imaging, 35 (87.5%) lesions were scored as 4 or 5. There were no significant differences in the mammography or ultrasound findings between the chemotherapy effects.ConclusionMammography and ultrasound imaging together revealed that the morphological features of triple-negative breast cancer include a lobulated mass, with less attenuating posterior echoes, some vascularity, and low elasticity.

Elastographic evaluation of mucinous carcinoma of the breast

BackgroundElastography is widely used as a diagnostic tool for the diagnosis of invasive breast cancer. However, no study has yet shown if elastography for diagnosing mucinous carcinoma is as useful as that for diagnosing the usual invasive carcinoma. Mucinous carcinoma is considered as a soft tumor. In this study, we used elastography to evaluate the elasticity of mucinous carcinoma.MethodsAmong 1,015 patients who underwent surgery for primary breast cancer between February 2007 and August 2008 in our facility, the final pathological diagnosis showed only 32 mucinous carcinomas. We evaluated 16 of the 32 mucinous carcinoma patients who underwent preoperative elastography.ResultsThere were 13 cases of the pure-type and 3 cases of the mixed-type mucinous carcinoma. B-mode ultrasound (US) imaging showed mass formation in 16 patients. The elasticity score was 2 in 1 case (8%), 3 in 3 cases (23%), 4 in 7 cases (54%), and 5 in 2 cases (15%). The fat-to-lesion ratio (FLR) was evaluated in 7 cases. The mean value of the FLR was 12 (range 3–30).ConclusionTwelve of the 16 (75%) cases had an elastography score of 4 or 5. Although mucinous carcinoma had an elastography score similar to that of usual invasive carcinoma, elastography may be useful for distinguishing mucinous carcinoma from benign fibroadenoma.

High prevalence of neuroendocrine carcinoma in breast lesions detected by the clinical symptom of bloody nipple discharge.

AIM Bloody nipple discharge (BND) is an important clinical symptom in breast disorders, especially cancers. However, the association between this symptom and breast neuroendocrine carcinomas (NECs) has not been sufficiently investigated or well understood. METHODS We clinicopathologically studied 89 cases using biopsy and/or resection in 144 patients who came to the hospital for a thorough examination of symptomatic BND. RESULTS Of these 89 cases examined histologically, 24 (27%) were neuroendocrine carcinomas (NECs) in which >50% of cells immuno-expressed chromogranin A and/or synaptophysin. Moreover, NECs made up 44% (24/55) of the mammary cancers found because of the BND. The frequency of diagnosing malignancy preoperatively in 24 NECs was 4% by nipple discharge cytology, 40% by fine needle aspiration cytology, 62% by core needle biopsy and 67% by mammotome biopsy. There were neither postoperative recurrences nor metastases in the NEC cases during a mean follow-up of 83.7 months. The 24 NECs were subclassified into neuroendocrine ductal carcinoma in situ (NE-DCIS) (9 cases) and microinvasive (7 cases) and invasive (8 cases) NECs with extensive NE-DCIS components. Most NECs had early-stage and low-grade pathological parameters: pTis or pT1 (96%), pN0 (96%), low nuclear grade (83%), absence of necrosis (88%), immuno-positivity of estrogen and progesterone receptors (100%) and absence of HER2 protein overexpression (100%). CONCLUSIONS NECs predominantly with NE-DCIS lesions, often under-diagnosed preoperatively, accounted for an important share of breast conditions associated with BND. It is, therefore, worth keeping this type of breast cancer in mind when performing medical examinations on patients with BND.

Neuroendocrine cells associated with neuroendocrine carcinoma of the breast: nature and significance

Background The developmental mechanisms of breast neuroendocrine carcinoma (B-NEC) have not been sufficiently analysed and are not well understood. Aims To investigate NE cells in the background tissues surrounding B-NECs. Methods Three cases (four breasts) having many NE cells in the background tissues of multifocal B-NECs were identified at the University of Yamanashi Hospital and St Lukes International Hospital, Japan. These patients were, respectively, 28-, 31- and 38-year-old women with no familial history of NE tumour. The totally-resected breasts were serially studied by immunohistochemistry for specific NE markers (chromogranin A/synaptophysin) and the morphologies and/or localisation of NE cells were investigated. Results Immunohistochemical examination showed extensively-distributed NE cells in the background mammary ducts/lobules of the NECs in all breasts. These NE cells were classifiable into three emerging patterns: isolated/scattered, clustered and circumferential. Their distributions were intermingled and were not clearly related to B-NEC foci. NE cells were morphologically polygonal, oval or columnar with sometimes eosinophilic and/or fine-granular cytoplasm and round-to-ovoid nuclei lacking atypia. Some cells were located between epithelial and myoepithelial cells. Apical snouts were occasionally observed in NE cells forming luminal structures. Conclusions Benign-appearing NE cells in the parenchyma of a breast with NEC could be regarded as hyperplastic from their emerging patterns and distribution; this NE cell hyperplasia may be associated with the histogenesis of B-NEC as a precancerous condition. These observations might raise questions about the treatment for B-NEC.

A nomogram for predicting locoregional recurrence in primary breast cancer patients who received breast-conserving surgery after neoadjuvant chemotherapy

We sought to develop and validate a predictive model of locoregional recurrence (LRR) in patients who underwent breast‐conserving therapy (BCT) after neoadjuvant chemotherapy (NAC).

Role of Breast Tomosynthesis in Diagnosis of Breast Cancer for Japanese Women

INTRODUCTION Mammography is the most basic modality in breast cancer imaging. However, the overlap of breast tissue depicted on conventional two-dimensional mammography (2DMMG) may create significant obstacles to detecting abnormalities, especially in dense or heterogeneously dense breasts. In three-dimensional digital breast tomosynthesis (3DBT), tomographic images of the breast are reconstructed from multiple projections acquired at different angles. It has reported that this technology allows the generation of 3D data, therefore overcoming the limitations of conventional 2DMMG for Western women. We assessed the detectability of lesions by conventional 2DMMG and 3DBT in diagnosis of breast cancer for Japanese women. METHODS The subjects were 195 breasts of 99 patients (median age of 48 years, range 34~82 years) that had been pathologically diagnosed with breast cancer from December 20, 2010 through March 31, 2011. Both conventional 2DMMG and 3DBT imaging were performed for all patients. Detectability of lesions was assessed based on differences in category class. RESULTS Of the affected breasts, 77 (75.5%) had lesions assigned to the same categories by 2DMMG and 3DBT. For 24 (23.5%) lesions, the category increased in 3DBT indicating improvement in diagnostic performance compared to 2DMMG. 3DBT improved diagnostic sensitivity for patients with mass, focal asymmetric density (FAD), and architectural distortion. However, 3DBT was not statistically superior in diagnosis of the presence or absence of calcification. CONCLUSIONS In this study, 3DBT was superior in diagnosing lesions in form of mass, FAD, and/or architectural distortion. 3DBT is a novel technique that may provide a breakthrough in solving the difficulties of diagnosis caused by parenchyma overlap for Japanese women.

Ductal Carcinoma In Situ That Involves Sclerosing Adenosis: High Frequency of Bilateral Breast Cancer Occurrence

BACKGROUND The radiologic and pathologic characteristics of ductal carcinoma in situ (DCIS) that involves sclerosing adenosis (SA) (SA DCIS) resemble those of invasive carcinoma. However, differences in the clinical features of these conditions remain unclear. This study was designed to clarify the clinicopathologic characteristics of SA DCIS compared with those of DCIS not involving SA (non,-SA DCIS). METHODS We retrospectively studied 1309 patients who underwent breast surgery at our hospital between January 2007 and December 2008. A total of 205 cases of DCIS were diagnosed in 198 patients, and 28 (13.7%) cases of breast SA DCIS were diagnosed in 24 patients. We compared clinical characteristics as well as radiologic and pathologic findings between SA DCIS and non-SA DCIS. RESULTS Synchronous and metachronous bilateral breast cancer was detected at a significantly higher rate in SA DCIS (9 [38%] of 24 patients) than in non-SA DCIS (22 [13%] of 174 patients; P < .01). As for radiologic findings, architectural distortion was more frequent in patients with SA DCIS than in those with non-SA DCIS (15 [54%] of 28 cases vs. 5 [2%] of 177 cases on mammography; P < .01; and 14 [50%] of 28 cases vs. 4 [2%] of 177 cases on ultrasound; P < .01). The rate of negativity for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 was significantly higher in SA DCIS than in non-SA DCIS (5 [18%] of 28 cases vs. 5 [3%] of 177 cases, P = .005) with immunohistochemical studies. CONCLUSIONS The rate of bilateral breast cancer and of architectural distortion on radiologic studies was higher in patients with SA DCIS than in those with non-SA DCIS. Our findings suggest that patients with SA DCIS should be closely monitored by radiologic and pathologic examinations to detect the presence of contralateral lesions.

A model to predict upstaging to invasive carcinoma in patients preoperatively diagnosed with ductal carcinoma in situ of the breast

The aims of this study were to determine clinicopathological factors associated with postoperative upstaging to invasive carcinoma in patients preoperatively diagnosed with ductal carcinoma in situ (DCIS) and to develop a model to predict the risk of upstaging.

Frequency and Clinical Significance of Previously Undetected Incidental Findings Detected on Computed Tomography Simulation Scans for Breast Cancer Patients

PURPOSE To determine the frequency and clinical significance of previously undetected incidental findings found on computed tomography (CT) simulation images for breast cancer patients. METHODS AND MATERIALS All CT simulation images were first interpreted prospectively by radiation oncologists and then double-checked by diagnostic radiologists. The official reports of CT simulation images for 881 consecutive postoperative breast cancer patients from 2009 to 2010 were retrospectively reviewed. Potentially important incidental findings (PIIFs) were defined as any previously undetected benign or malignancy-related findings requiring further medical follow-up or investigation. For all patients in whom a PIIF was detected, we reviewed the clinical records to determine the clinical significance of the PIIF. If the findings from the additional studies prompted by a PIIF required a change in management, the PIIF was also recorded as a clinically important incidental finding (CIIF). RESULTS There were a total of 57 (6%) PIIFs. The 57 patients in whom a PIIF was detected were followed for a median of 17 months (range, 3-26). Six cases of CIIFs (0.7% of total) were detected. Of the six CIIFs, three (50%) cases had not been noted by the radiation oncologist until the diagnostic radiologist detected the finding. On multivariate analysis, previous CT examination was an independent predictor for PIIF (p = 0.04). Patients who had not previously received chest CT examinations within 1 year had a statistically significantly higher risk of PIIF than those who had received CT examinations within 6 months (odds ratio, 3.54; 95% confidence interval, 1.32-9.50; p = 0.01). CONCLUSIONS The rate of incidental findings prompting a change in management was low. However, radiation oncologists appear to have some difficulty in detecting incidental findings that require a change in management. Considering cost, it may be reasonable that routine interpretations are given to those who have not received previous chest CT examinations within 1 year.

Well-differentiated neuroendocrine tumour of the breast showing peculiar endovascular spread.

Sir: Spread of an intravascular tumour embolus from a primary lesion can be found in some cancers: intraportal spread of hepatocellular carcinoma, postcaval spread of renal cell carcinoma, and so on. However, to the best of our knowledge, such a finding in breast cancers has not previously been reported in the English literature. The WHO classifies mammary carcinomas with neuroendocrine (NE) features as a special tumour entity, representing <1% of invasive breast carcinomas, and recognises three subtypes: (i) NE tumor (NET), well differentiated; (ii) NE carcinoma, poorly differentiated; and (iii) invasive carcinoma with NE differentiation. Herein, we describe the first case of a well-differentiated mammary NET with extensive intravenous spread. The patient, a 42-year-old premenopausal Thai woman, presented with a palpable mass in the subareolar portion of the left breast. Ultrasonography revealed a sharply marginated, hypoechoic left breast tumour showing heterogeneous internal echoes, with a cranially extending lumen-like structure filled with solid tumour with similar echoic findings (Figure 1A). On MRI, these lesions appeared as an oval-shaped mass and a continuous intravenous occupying lesion, respectively, both of which were strongly enhanced during the early phases of the dynamic study (Figure 1B). These images suggested an invasive cancer with a tumour thrombus. Systemic CT and bone scintigraphy detected no other suspicious lesions. Ultrasound-guided, fine needle aspiration of the breast mass yielded a cytological diagnosis of carcinoma. The cut surface of the lumpectomy specimen contained well-circumscribed, mixed brownish-red and grey-whitish, solid tumour nodules, measuring up to 17 9 15 mm in size. Histopathologically, the tumour was composed of a solid invasive growth of carcinoma cells with a peripheral palisading arrangement and a highly vascular stroma (Figure 2A,B). Haemorrhage was marked in the lesions. Carcinoma cells were polygonal or, occasionally, spindle-shaped with finely granular, slightly eosinophilic cytoplasm (Figure 2B). Their nuclei had ovoid or irregular shapes, a finely granular chromatin pattern, and small nucleoli. Mitotic figures were seen in seven of 10 high-power fields. An in-situ component composed of carcinoma cells with the same histological features was locally observed near the invasive cancer nests (Figure 2C). Massive tumour embolization within prominently dilated veins, spreading from the primary focus, was confirmed by the elastic Van Gieson method (Figure 2A,D). Focal lymphatic permeation