Jonathan James

Diagnosis of axillary nodal metastases by ultrasound-guided core biopsy in primary operable breast cancer

The purpose of this study was to examine the use of ultrasound (US)-guided core biopsy of axillary nodes in patients with operable breast cancer. The ipsilateral axillae of 187 patients with suspected primary operable breast cancer were scanned. Nodes were classified based on their shape and cortical morphology. Abnormal nodes underwent US-guided core biopsy/fine needle aspiration (FNA), and the results correlated with subsequent axillary surgery. The nodes were identified on US in 103 of 166 axillae of patients with confirmed invasive carcinoma. In total, 54 (52%) met the criteria for biopsy: 48 core biopsies (26 malignant, 20 benign node, two normal) and six FNA were performed. On subsequent definitive histological examination, 64 of 166 (39%) had axillary metastases. Of the 64 patients with involved nodes at surgery, preoperative US identified nodes in 46 patients (72%), of which 35 (55%) met the criteria for biopsy and 27 (42%) of these were diagnosed preoperatively by US-guided biopsy. In conclusion, US can identify abnormal nodes in patients presenting with primary operable breast cancer. In all, 65% of these nodes are malignant and this can often be confirmed with US-guided core biopsy.

Prognostic factors for patients with hepatic metastases from breast cancer

Median survival from liver metastases secondary to breast cancer is only a few months, with very rare 5-year survival. This study reviewed 145 patients with liver metastases from breast cancer to determine factors that may influence survival. Data were analysed using Kaplan–Meier survival curves, univariate and multivariate analysis. Median survival was 4.23 months (range 0.16–51), with a 27.6% 1-year survival. Factors that significantly predicted a poor prognosis on univariate analysis included symptomatic liver disease, deranged liver function tests, the presence of ascites, histological grade 3 disease at primary presentation, advanced age, oestrogen receptor (ER) negative tumours, carcinoembryonic antigen of over 1000 ng ml−1 and multiple vs single liver metastases. Response to treatment was also a significant predictor of survival with patients responding to chemo- or endocrine therapy surviving for a median of 13 and 13.9 months, respectively. Multivariate analysis of pretreatment variables identified a low albumin, advanced age and ER negativity as independent predictors of poor survival. The time interval between primary and metastatic disease, metastases at extrahepatic sites, histological subtype and nodal stage at primary presentation did not predict prognosis. Awareness of the prognostic implications of the above factors may assist in selecting the most appropriate treatment for these patients.

Bone metastases from breast carcinoma: histopathological – radiological correlations and prognostic features

The aim of this study was to identify factors that may be associated with the development of bone metastases in patients with metastatic breast carcinoma and to see if any of these factors had a bearing on subsequent survival. In total, 492 patients presented to the Nottingham City Hospital with metastatic breast carcinoma between July 1997 and December 2001. Of these, 267 patients had bone metastases at presentation with metastatic disease, 91 patients in this group had bone as their only site of metastatic disease. Sites of first presentation of metastatic disease were prospectively recorded, as were histological features of the primary tumour (tumour type, histological grade, lymph node stage, tumour size and oestrogen receptor (ER) status). The radiological features of the bone metastases, the metastasis-free interval and serological tumour marker levels at presentation with metastases were all recorded. There was a significant association between the development of bone metastases and lower grade tumours (P=0.019), ER-positive tumours (P<0.0001) and the lymph node stage of the primary tumour (P=0.047). A multivariate analysis found that metastasis-free interval, additional sites of metastatic disease other than bone, ER status and serological tumour marker levels all independently contributed to survival from time of presentation with bone metastases.

Influence of Mammographic Parenchymal Pattern in Screening-Detected and Interval Invasive Breast Cancers on Pathologic Features, Mammographic Features, and Patient Survival

OBJECTIVE The aim of our study was to assess the effect of mammographic parenchymal pattern on patient survival, mammographic features, and pathologic features of breast cancer in a screened population. MATERIALS AND METHODS We classified the parenchymal pattern (according to BI-RADS) of 759 screened women who presented with a screening-detected (n = 455) or interval (n = 304) invasive breast cancer. Pathologic details (tumor size, histologic grade, lymph node stage, vascular invasion, and histologic type) and mammographic appearances were recorded. Breast cancer-specific survival was ascertained, with a median follow-up of 9.0 years. RESULTS An excess of interval cancers was seen in women with dense breasts (p < 0.0001). Screening-detected (but not interval) tumors were significantly smaller in fatty breasts (p = 0.014). Tumor grade, lymph node stage, vascular invasion, and histologic type did not vary significantly with mammographic parenchymal pattern in screening-detected or interval cancers. Screening-detected cancers in fatty breasts were more likely to appear as indistinct (p = 0.003) or spiculated (p = 0.002) masses in contrast to cancers in dense breasts, which more commonly appeared as architectural distortions (p < 0.0001). No significant breast cancer-specific survival difference was seen by mammographic parenchymal pattern for screening-detected cancers (p = 0.75), interval cancers (p = 0.82), or both groups combined (p = 0.12). CONCLUSION The prognosis of screened women presenting with breast cancer is unrelated to dense mammographic parenchymal pattern despite an excess of interval cancers and larger screening-detected tumors in this group. These data support the mammographic screening of women with dense parenchymal patterns.

Is Mammographic Spiculation an Independent, Good Prognostic Factor in Screening-Detected Invasive Breast Cancer?

OBJECTIVE The aim of this study was to review the prognostic significance of pathologic and radiologic factors for screening-detected invasive breast cancers of any size. MATERIALS AND METHODS The patient group was a consecutive series of 470 screening-detected invasive breast cancers that were diagnosed between 1988 and 1998. Data regarding tumor type, grade, maximum invasive diameter, lymph node status, and the presence or absence of vascular invasion were recorded, as were the mammographic features of the lesion. Survival was ascertained from hospital records and a cancer registry. Differences in survival were assessed using Kaplan-Meier survival curves with a log-rank test for difference. The significance of any correlations was assessed using the chi-square test and the chi-square test for trend. Multivariate analysis used a Cox proportional hazards model. RESULTS At univariate analysis, large invasive size, the presence of definite vascular invasion, high histologic grade, and nodal involvement were associated with poorer breast-cancer-specific survival. Mammographic spiculation (the presence of either a spiculated mass or distortion) was associated with more prolonged breast-cancer-specific survival. The presence or absence of mammographic comedo calcification did not influence breast-cancer-specific survival. In a Cox multivariate analysis that included those factors significant in univariate analysis, size, grade, nodal stage, and mammographic spiculation maintained their prognostic significance. CONCLUSION Mammographic spiculation is an independent, good prognostic factor for screening-detected invasive breast cancer. The mechanism of how mammographic spiculation confers a beneficial prognostic effect is not clear.

Vacuum-assisted excision of breast lesions of uncertain malignant potential (B3) - an alternative to surgery in selected cases

To assess whether vacuum-assisted excision (VAE) is a safe alternative to surgery in the treatment of breast lesions of uncertain malignant potential (B3) in which no atypia is present on needle core biopsy (NCB). Forty two VAE procedures were performed for B3 lesions. Twenty four (57%) were papillary lesions. Eighteen (43%) were radial scars. Two patients (4.7%) were upgraded to carcinoma at VAE. Two patients with papillary lesions went on to develop cancer in the same breast (at 24 and 41 months post VAE). No cancer developed in the radial scar group. Eight patients (19%) had surgery - four for carcinoma, two for radial scars missed at VAE excision and two for symptomatic papillomatosis. Follow-up mammography after VAE of radial scars often showed residual distortion. VAE can be a safe alternative to surgery in the treatment of B3 lesions without atypia, providing thorough multidisciplinary discussion has taken place.

Accuracy of GE digital breast tomosynthesis versus supplementary mammographic views for diagnosis of screen-detected soft tissue breast lesions

Objective: To compare the accuracy of standard supplementary views and GE digital breast tomosynthesis (DBT) for assessment of soft-tissue mammographic abnormalities. Methods: Women recalled for further assessment of soft-tissue abnormalities were recruited and received standard supplementary views (typically spot compression views) and two-view GE DBT. The added value of DBT in the assessment process was determined by analysing data collected prospectively by radiologists working up the cases. Following anonymization of cases, there was also a retrospective multireader review. The readers first read bilateral standard two-view digital mammography (DM) together with the supplementary mammographic views and gave a combined score for suspicion of malignancy on a five-point scale. The same readers then read bilateral standard two-view DM together with two-view DBT. Pathology data were obtained. Differences were assessed using receiver operating characteristic analysis. Results: The study population was 342 lesions in 322 patients. The final diagnosis was malignant in 113 cases (33%) and benign/normal in 229 cases (67%). In the prospective analysis, the performance of two-view DM plus DBT was at least equivalent to the performance of two-view DM and standard mammographic supplementary views—the area under the curve (AUC) was 0.946 and 0.922, respectively, which did not reach statistical significance. Similar results were obtained for the retrospective review—AUC was 0.900 (DBT) and 0.873 (supplementary views), which did not reach statistical significance. Conclusion: The accuracy of GE DBT in the assessment of screen detected soft-tissue abnormalities is equivalent to the use of standard supplementary mammographic views. Advances in knowledge: The vast majority of evidence relating to the use of DBT has been gathered from research using Hologic equipment. This study provides evidence for the use of the commercially available GE DBT system demonstrating that it is at least equivalent to supplementary mammographic views in the assessment of soft-tissue screen-detected abnormalities.

Breast Carcinoma with Basal Phenotype: Mammographic Findings

OBJECTIVE Basal phenotype has been found to be an independent poor prognostic factor for breast cancer. The aim of this study was to assess the mammographic appearance of screening-detected breast carcinoma with the basal phenotype. MATERIALS AND METHODS A series of 1,944 consecutively enrolled patients with operable invasive breast cancer underwent immunohistochemical analysis with cytokeratin 5/6 and cytokeratin 14 markers to identify tumors exhibiting basal phenotype characteristics. Among those patients, 356 women with breast cancer were common to a prospectively collected database of screening-detected cases of breast cancer. The predominant mammographic appearance and any associated features were reported by experienced image readers blinded to phenotype status. A chi-square test was used to assess difference between the mammographic appearances of a group of tumors with the basal phenotype and those of a group with the nonbasal phenotype. RESULTS Forty-one (12%) of the screening-detected tumors had basal phenotypic expression, and these were compared with 309 (88%) nonbasal tumors. Basal-phenotype tumors were significantly more likely to manifest as an ill-defined mass (basal phenotype, 25 [61%] of 41 tumors; nonbasal phenotype, 75 [24%] of 309 tumors; p < 0.001) or with comedo calcification (basal phenotype, nine [22%] of 41 tumors; nonbasal phenotype, 30 [10%] of 309 tumors; p = 0.019). Nonbasal-phenotype tumors were more likely to manifest as a spiculated mass (nonbasal phenotype, 150 [49%] of 309 tumors; basal phenotype, eight [20%] of 41 tumors; p < 0.001). The low rate of spiculation in basal tumors was independent of histologic grade. CONCLUSION Screening-detected breast tumors with a basal phenotype have a mammographic appearance different from that of nonbasal tumors. This finding may explain the good prognostic value of mammographic spiculation reported in previous studies.

Outcome of pure mucocele‐like lesions diagnosed on breast core biopsy

Current guidelines recommend that mucocele‐like lesions (MLL) of the breast diagnosed on needle core biopsy (NCB) should be categorized as a lesion of uncertain malignant potential (B3). However, data on the outcome of MLL diagnosed on NCB remains limited due to the rarity of this lesion. The aim of this study was to assess the outcome of pure MLL without atypia diagnosed on NCB using a large series of cases and a review of the literature to provide evidence that can guide management.

Patient satisfaction and efficacy of vacuum-assisted excision biopsy of fibroadenomas

AIM To establish the efficacy, complications, and patient satisfaction for vacuum-assisted biopsy (VAB) excision of fibroadenomas. MATERIALS AND METHODS All patients referred for VAB of benign lesions from 11 December 2002 to 30 November 2006 were identified prospectively, and the following data were recorded: age, histology, lesion size, and completeness of excision. A questionnaire was sent at least a year after the procedure to assess pain, complications, residual palpable lesions, and cosmetic result. RESULTS One hundred and thirty-four patients were referred for VAB, 81 had fibroadenomas. Fifty-nine percent replied to the questionnaire. Fifty-four percent of patients reported no pain during the procedure, 8% rated their pain at > or =3/10. Thirty-two percent had no pain the week after the procedure, 55% had pain > or =3/10. Seventy-nine percent had no palpable mass at the site of the original lesion. Ninety-four percent would recommend the procedure to others and would prefer further VAB to surgery. Bruising was common, one patient required aspiration of a haematoma. Six percent developed infections, all resolved with antibiotic therapy. Eighty-five percent of patients were completely satisfied with the cosmetic result. Interval ultrasound was performed in 36 patients. A palpable mass was present in 11%, a non-palpable mass in 19%, and no mass in 70%. CONCLUSION VAB excision is well-tolerated, safe, and popular with a high initial success rate for fibroadenomas. Bruising and pain are common the week after the procedure.