Axillary Metastases Research Articles

A Diagnostic Revelation: Case of a Mucinous Carcinoma of the Breast.

Mucinous or colloid cancers are a rare subtype of invasive ductal carcinoma, making up only 2-3% of infiltrating carcinomas. Prevalence of pure mucinous breast cancer(PMBC) among infiltrating duct carcinomas in less than 60year olds is 2-7%, and in less than 35year olds, it is 1%. Mucinous carcinoma of the breast is divided into 2 subtypes, the pure type and mixed type. PMBC is characterized by a lower incidence of nodal involvement, favourable histological grade, and higher ER/PR expression. Axillary metastases are rare, though found in 12-14%. It has a better prognosis than infiltrative ductal cancer with 10-year survival being more than 90%. Here is the case of a 70-year-old female who presented with lump in the left breast since 3years. On examination, we detected a left breast lump occupying the whole breast except lower outer quadrant, measuring 10 × 8cm with overlying skin stretched with puckering and engorged veins seen, nipple displaced laterally and higher by 1cm, firm to hard in consistency, and mobile with breast tissue. Sonomammography, mammography, FNAC and biopsy were suggestive of benign phyllodes tumour. Patient was hence posted for simple mastectomy on the left side with removal of attached lymph nodes (near axillary tail). Histopathological examination revealed pure mucinous breast carcinoma with nine lymph nodes, free from tumour and showing reactive hyperplasia. Immunohistochemistry studies demonstrated ER + , PR + , HER-2-NEU-. The patient was started on hormonal therapy. Therefore, mucinous carcinoma of the breast is a rare entity with imaging features sometimes mimicking a benign tumour such as Phyllodes tumour, hence making it important to include it as a differential diagnosis in our daily practice. It is especially important in the subtyping of carcinoma of the breast since it carries a favourable risk profile with less chances of lymph node involvement, higher hormone receptor positivity and good response to endocrine treatment.

A Prospective Multi-Institutional Observational Study on ER, PR, HER2/NEU, and Ki-67 Expression and Discordance Pattern in Primary and Metastatic and Recurrent Carcinoma Breast and Its Therapeutic Implications and Prognostic Outcome.

Only few studies reported in literature that has elucidated in detail the implications of molecular typing in metastatic and recurrent breast cancer. In this prospective study, we have analysed in depth the pattern of expression, discordances of molecular markers in various metastatic sites, and recurrent cases and their response to chemotherapy/targeted agents and the prognostic outcome. The primary aim of the study was to determine ER, PR, HER2/NEU, and Ki-67 from recurrent and metastatic carcinoma breast to study the expression pattern and discordance and also to study the degree of discordance in relation to the site of metastasis and pattern of metastasis (synchronous vs metachronous) and discordance pattern with the response to chemotherapy and median overall survival rates in months in available subset of patients. Prospective open-label study done at the Government Rajaji Hospital, Madurai Medical College, and Government Royapettah Hospital, Kilpauk Medical College, India, from November 2014 to August 2021. All breast carcinoma patients with recurrence or oligo metastasis (defined as one organ with less than 5 metastases in our study) with known receptor status were eligible and 110 patients were enrolled in the study. ER (ER + to ER -) discordance was seen in 19 (26.38%) cases. PR (PR + to PR -Ve) discordance was seen in 14 (19.17%) cases. HER2/NEU (HER2/NEU + Ve to -Ve) discordance was seen in 3 (16.6%) cases. Ki-67 discordance was seen in 54 (49.09%) cases. High Ki-67 as a proliferative marker has increased response to chemotherapy but earlier relapse and disease progression especially in Luminal B type. In further subset analysis, ER, PR, and HER2/NEU discordance is higher for lung metastasis (ER, PR 61.1%, p value .001, HER2/NEU 5.5%), followed by liver metastasis (ER, PR 50%, p value .0023, 1 case turning ER -ve to + ve, HER2/NEU 1 (10%)). In lung, discordance is more for metachronous metastasis. In liver, discordance is 100% for synchronous metastasis. Synchronous metastasis with discordance in ER and PR is associated with rapid disease progression. High Ki-67 subset of Luminal B-like tumors progressed rapidly than triple negative and HER2/NEU positive subset. Complete clinical response rate in contralateral axillary node metastasis group was 87.8%, followed by local only recurrence with high Ki-67 where chemotherapy had response rate of 81% and 2years DFS of 93.12% after excision. Certain subsets like contralateral axillary nodes and supraclavicular nodes which present as oligo metastatic disease with discordance and high Ki-67 respond well to chemotherapeutics and targeted agents improving the OS in this subset of patients. Molecular markers and their expression and discordance pattern determine the therapeutic outcome and prognosis of the disease. Early identification and targeting the discordance would go a long way in improving the outcome and DFS and OS of breast cancer patients.

Radiomics model based on features of axillary lymphatic nodes to predict axillary lymphatic node metastasis in breast cancer.

Breast cancer (BC) is among the most common cancers worldwide. Machine learning-based radiomics model could predict axillary lymph node metastasis (ALNM) of BC accurately. The purpose is to develop a machine learning model to predict ALNM of BC by focusing on the radiomics features of axillary lymphatic node (ALN). A group of 398 BC patients with 800 ALNs were retrospectively collected. A set of patient characteristics were obtained to form clinical factors. Three hundred and twenty-six radiomics features were extracted from each region of interest for ALN in contrast-enhanced computed tomography (CECT) image. A framework composed of four feature selection methods and 14 machine learning classification algorithms was systematically applied. A clinical model, a radiomics model, and a combined model were developed using a cross-validation approach and compared. Metrics of the area under the curve (AUC), accuracy, sensitivity, and specificity were calculated to evaluate the performance of these models in the prediction of ALNM in BC. Among the 800 cases of ALNs, there were 388 cases of positive metastasis (48.50%) and 412 cases of negative metastasis (51.50%). The baseline clinical model achieved the performance with an AUC = 0.8998 (95% CI [0.8540, 0.9457]). The radiomics model achieved an AUC = 0.9081 (95% CI [0.8640, 0.9523]). The combined model using the clinical factors and radiomics features achieved the best results with an AUC = 0.9305 (95% CI [0.8928, 0.9682]). Combinations of feature selection methods and machine learning-based classification algorithms can develop promising predictive models to predict ALNM in BC using CECT features. The combined model of clinical factors and radiomics features outperforms both the clinical model and the radiomic model.

Extranodal extension, an international survey on its evaluation and reporting in breast cancer patients

Lymph node metastasis is the most important prognostic factor for breast cancer patients. In addition to the number of nodes involved and the largest metastatic focus, extranodal extension (ENE) is also used to subclassify breast cancer patients into different risk groups. More recently, pathologists are required to report the size/extent of ENE per the new CAP guideline, as it seems to be associated with more axillary nodal burden and/or a worse prognosis. Although the definition of ENE is largely understood and agreed upon among pathologists around the world, evaluation and reporting for the size of ENE are not. To understand current practice, we conducted an international survey among pathologists who are interested in breast pathology. A total of 70 pathologists responded. The results showed that (1) 98% of the participants reported the presence or absence of ENE and 61% also reported the size of ENE in millimeter (mm). (2) There was no uniform method of measuring the size of ENE; 47% measured the largest dimension regardless of orientation, while 30% measured the largest perpendicular distance from the capsule. (3) The most common factors affecting the accuracy in diagnosis of ENE are the presence of lymphovascular invasion (LVI), lack of capsule integrity, and the presence of fatty hilar or fatty replacement of a lymph node. (4) 71% felt that the H&E stain is adequate to evaluate ENE, deeper levels and IHC analysis for vascular and cytokeratin markers can be helpful if needed. (5) 75% agreed that there is an urgent need to standardize the measurement and reporting for ENE. Our survey highlights the variation in ENE evaluation and the need for its standardization in breast cancer patients with axillary node metastasis.

Correlation of dynamic contrast-enhanced MRI and diffusion-weighted MR imaging with prognostic factors and subtypes of breast cancers.

ObjectiveTo determine the preoperative magnetic resonance imaging (MRI) findings of breast cancer on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and diffusion-weighted magnetic resonance imaging (DWI) in different molecular subtypes.Materials and methodsA retrospective study was conducted on 116 breast cancer subjects who underwent preoperative MRI and surgery or biopsy. Three radiologists retrospectively assessed the morphological and kinetic characteristics on DCE-MRI and tumor detectability on DWI, by using apparent diffusion coefficient (ADC) values of lesions. The clinicopathologic and MRI features of four subtypes were compared. The correlation between clinical and MRI findings with molecular subtypes was evaluated using the chi-square and ANOVA tests, while the Mann–Whitney test was used to analyze the relationship between ADC and prognostic factors.ResultsOne hundred and sixteen women diagnosed with breast cancer confirmed by surgery or biopsy had the following subtypes of breast cancer: luminal A (27, 23.3%), luminal B (56, 48.2%), HER2 positive (14, 12.1%), and triple-negative breast cancer (TNBC) (19, 16.4%), respectively. Among the subtypes, significant differences were found in axillary node metastasis, histological grade, tumor shape, rim enhancement, margin, lesion type, intratumoral T2 signal intensity, Ki-67 index, and paratumoral enhancement (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, and p = 0.02, respectively). On DWI, the mean ADC value of TNBC (0.910 × 10−3 mm2/s) was the lowest compared to luminal A (1.477×10−3 mm2/s), luminal B (0.955 × 10−3 mm2/s), and HER2 positive (0.996 × 10−3 mm2/s) (p < 0.001). Analysis of the correlation between different prognostic factors and ADC value showed that only axillary lymph node status and ADC value had a statistically significant difference (p = 0.009).ConclusionThe morphologic features of MRI can be used as imaging biomarkers to identify the molecular subtypes of breast cancer. In addition, quantitative assessments of ADC values on DWI may also provide biological clues about molecular subtypes.

Diffusion-weighted Breast MRI in Prediction of Upstaging in Women with Biopsy-proven Ductal Carcinoma in Situ.

Background Accurate preoperative prediction of upstaging in women with biopsy-proven ductal carcinoma in situ (DCIS) is important for surgical planning, but published models using predictive MRI features remain lacking. Purpose To develop and validate a predictive model based on preoperative breast MRI to predict upstaging in women with biopsy-proven DCIS and to select high-risk women who may benefit from sentinel lymph node biopsy at initial surgery. Materials and methods Consecutive women with biopsy-proven DCIS who underwent preoperative 3.0-T breast MRI including dynamic contrast-enhanced (DCE) MRI and diffusion-weighted imaging (DWI) and who underwent surgery between June 2019 and March 2020 were retrospectively identified (development set) from an academic medical center. The apparent diffusion coefficients of lesions from DWI, lesion size and morphologic features on DCE MRI scans, mammographic findings, age, symptoms, biopsy method, and DCIS grade at biopsy were collected. The presence of invasive cancer and axillary metastases was determined with surgical pathology. A predictive model for upstaging was developed by using multivariable logistic regression and validated in a subsequent prospective internal validation set recruited between July 2020 and April 2021. Results Fifty-seven (41%) of 140 women (mean age, 53 years ± 11 [SD]) in the development set and 43 (41%) of 105 women (mean age, 53 years ± 10) in the validation set were upstaged after surgery. The predictive model combining DWI and clinical-pathologic factors showed the areas under the receiver operating characteristic curve at 0.87 (95% CI: 0.80, 0.92) in the development set and 0.76 (95% CI: 0.67, 0.84) in the validation set. The predicted probability of invasive cancer showed good interobserver agreement (intraclass correlation coefficient, 0.79); the positive predictive value was 85% (28 of 33), and the negative predictive value was 92% (22 of 24). Conclusion A predictive model based on diffusion-weighted breast MRI identified women at high risk of upstaging. © RSNA, 2022 Online supplemental material is available for this article See also the editorial by Baltzer in this issue. An earlier incorrect version appeared online. This article was corrected on July 7, 2022.

Predictive Factors for Unnecessary Axillary Dissection According to SLN Metastasis in T1, T2 Stage Breast Cancer.

The axillary nodes' status is essential in determining the treatment algorithm according to complete clinical staging. Unnecessary axillary lymph node dissection (ALND) has been prevented after sentinel lymph node biopsy (SLNB) has occurred in current practice. However, approximately half of patients with positive SLNB do not have axillary metastatic lymph nodes. Our study aims to predict unnecessary ALND in patients with SLN metastases by evaluating the patients' clinicopathological data. In total, 221 patients with macrometastasis in SLNB who underwent completion ALND were evaluated retrospectively. Patients were divided into two groups: patients with metastases only in the sentinel lymph node and additional axillary lymph nodes. Univariate and multivariate logistic regression analyses were used to analyze the correlation between SLN metastasis and axillary lymph node metastasis; clinicopathological characteristics, including patient age, menopause status, tumor size and grade, receptor status proliferative marker status, and molecular subtypes of the tumor. In the evaluation of T1-2, cN0 breast cancer patients with SLNB in the form of macrometastasis, only SLNB metastasis was found in 118 (53.4%) patients. In 103 (46.6%) patients, additional axillary node metastasis was observed. The risk of additional nodal spread correlated with patient age older than fertility age (age of 49) (p = 0.015, OR: 1.96, 95% CI: 1.14-3.39) and the number of increased metastatic sentinel nodes (p < 0.001). In line with the data shown by our study, the rate of axillary metastases increases in patients over the age of fertility and as the number of metastatic SLNs increases.

Effectiveness of Quantitative Shear Wave Elastography for the Prediction of Axillary Lymph Node Metastasis

Objective Invasive breast cancer can be metastasized through axillary lymph nodes (LNs). This study was to evaluate the effectiveness of quantitative shear wave elastography (SWE) to predict axillary LN metastasis, which also provides prognostic implication of SWE as a histopathologic element of invasive breast cancer. Methods 72 prospectively enrolled patients received B-mode ultrasound (BUS) and SWE, and the elasticity index (EI) of SWE at the stiffest part of lymph nodes (LNs) was measured. EI of SWE was closely associated with pathologic results and the histopathologic elements. The receiver operating characteristics (ROC) curve was drawn to evaluate the optimal cut-off value for the assessment of disease severity. Results A significantly longer short-axis diameter and a larger maximal cortex were observed in malignant LNs than that in healthy LNs. The absence of the hilum was associated with metastatic LNs. The EI of SWE varied markedly between the benign and malignant LNs. The combination of Emax and BUS showed higher area under the curve (AUC) than BUS alone to predict metastatic LNs (0.7762 vs. 0.7230). EI of SWE in malignant lymph nodes those with extranodal extension are higher than those without extranodal extension. Conclusions Quantitative SWE provides a viable alternative for the assessment of axillary LN and shows great potential to predict pathological prognostic elements of metastatic axillary LNs in invasive breast cancer. Joint use of SWE and BUS allows examination of the predictive outcome of BUS for axillary lymph node metastasis in invasive breast cancer.

Oncological Safety of Skin-Sparing Mastectomy and Immediate Breast Reconstruction in Extensive Ductal Carcinoma In Situ

IntroductionSkin-sparing mastectomy (SSM) with immediate breast reconstruction is the ideal treatment for interested and suitable patients with extensive ductal carcinoma in situ (DCIS). There is no guideline to indicate on how large DCIS the procedure can be performed safely. The primary target of this study was to define the oncological safety of SSM in extensive pure DCIS. The secondary target was to find predictive factors for DCIS upstaging to invasive disease. Materials and methodsA total of 71 consecutive patients with extensive pure DCIS and undergoing SSM with immediate latissimus dorsi (LD) breast reconstruction were retrospectively evaluated. ResultsThe median size of DCIS lesion in preoperative imaging was 60 mm, the median weight of mastectomy specimen was 350 g, and the median resection margin (RM) was 2.0 mm. A total of 20 patients (28%) had an RM less than 0.5 mm and nine patients (13%) had ink positive margins. Six patients having positive RM underwent reoperation. A total of 29 patients (41%) presented invasive cancer foci in final histopathological assessment and nine patients (13%) had an axillary metastasis. Adjuvant therapy was given to 23 patients presenting invasive cancer. There were no local recurrences or distant metastases (0%, 95% confidence interval 0-0.051) during the mean follow-up of 71 mo. None of the factors evaluated predicted upstaging to invasive disease. ConclusionsSSM with immediate breast reconstruction in patients with extensive DCIS is oncologically safe even when the margins are close or positive. Additional invasive foci and solitary axillary lymph node metastases are frequent but do not worsen the outcome.

Predictive value of combining clinicopathological, multimodal ultrasonic characteristics in axillary lymph nodal metastasis burden of patients with cT1-2N0 breast cancer.

To improving diagnosis of axillary lymph node metastasis (ALNM), we assessed the value of combining clinicopathological, conventional ultrasound, SWE features in the cT1-2N0 breast cancer patients. Retrospective analysis of 285 patients with cT1-2N0 breast cancer who underwent preoperative ultrasound examination of the lesion and axillary, with shear wave elastography (SWE) of the lesions. According to the postoperative pathological results, they were divided into ≤2 metastatic ALNs group (low nodal burden, LNB) and > 2 metastatic ALNs group (high nodal burden, HNB). Binary logistic regression analysis was used to screen independent risk factors and establish prediction models. The best cut-off value of continuous variables is determined by the receiver operating characteristic curve, and the performance of the prediction model is evaluated. Presence of lymphovascular invasion (OR = 7.966, P = 0.010), tumor size (OR = 2.485, P = 0.019), Emean of intratumor (OR = 0.939, P = 0.002) and cortical thickness of lymph node (OR = 9.277, P < 0.001) were independent risk predictors for HNB of cT1-2N0 Group. The predictive model of combined method had better performance in predicting HNB of cT1-2N0 compared with models based on SWE and conventional ultrasound alone (area under the curve: 0.824 vs 0.658, P < 0.001; 0.824 vs 0.789, P = 0.035). The predictive models of combined method obtained from significant clinicopathological and ultrasonographic features can potentially improve the diagnosis and individual treatment of ALNM in patients with cT1-2N0 breast cancer.

A Convolutional Neural Network Based on Ultrasound Images of Primary Breast Masses: Prediction of Lymph-Node Metastasis in Collaboration With Classification of Benign and Malignant Tumors.

Purpose: A convolutional neural network (CNN) can perform well in either of two independent tasks [classification and axillary lymph-node metastasis (ALNM) prediction] based on breast ultrasound (US) images. This study is aimed to investigate the feasibility of performing the two tasks simultaneously. Methods: We developed a multi-task CNN model based on a self-built dataset containing 5911 breast US images from 2131 patients. A hierarchical loss (HL) function was designed to relate the two tasks. Sensitivity, specificity, accuracy, precision, F1-score, and analyses of receiver operating characteristic (ROC) curves and heatmaps were calculated. A radiomics model was built by the PyRadiomics package. Results: The sensitivity, specificity and area under the ROC curve (AUC) of our CNN model for classification and ALNM tasks were 83.5%, 71.6%, 0.878 and 76.9%, 78.3%, 0.836, respectively. The inconsistency error of ALNM prediction corrected by HL function decreased from 7.5% to 4.2%. Predictive ability of the CNN model for ALNM burden (≥3 or ≥4) was 77.3%, 62.7%, and 0.752, and 66.6%, 76.8%, and 0.768, respectively, for sensitivity, specificity and AUC. Conclusion: The proposed multi-task CNN model highlights its novelty in simultaneously distinguishing breast lesions and indicating nodal burden through US, which is valuable for “personalized” treatment.

Clinicopathologic characteristics and patient outcomes of malignant phyllodes tumors: A multi-institution experience.

e23528 Background: Phyllodes tumors (PT) are rare fibroepithelial neoplasm that start in the connective tissue of the breast. PTs are classified by their histologic features into benign, borderline, and malignant. Malignant PTs account for about 1 in 4 PTs and are most likely to come back after treatment and metastasize. This study was conducted to investigate the incidence, clinical presentation, pathological characteristics, treatment and outcome of malignant PTs in the Abu Dhabi Health Services Company (SEHA) institutions in the United Arab Emirates. This will provide a better insight on factors that influences outcome in these patients. Methods: We retrospectively analyzed data of malignant PT treated at Tawam Hospital, Sheikh Khalifa Medical City and Sheikh Shakbout Medical City between 2000 and 2020. Information was obtained from the SEHA Cancer Registry and analyzed using excel software. Results: A total of 36 patients with malignant PT were identified. All were females. The median age at diagnosis was 38 (17-60). Median BMI at diagnosis was 27 (21-47). Out of the 36 patients, 3 were diagnosed during pregnancy, 16 (44%) had a history of fibroadenoma and 8 had a family history of first degree relative with breast cancer. Initial symptom at presentation was breast mass in 30 patients and fungating breast mass in 6 patients. Out of the 26 patients, 4 (11%) had tumor &lt; 5 cm, 10 (28%) had tumor ≥5 cm and &lt; 10 cm, 22 (61%) had tumor ≥10 cm, 2 patients had heterogenous tumor with component of invasive ductal carcinoma, no patient had metastatic ipsilateral axillary adenopathy at diagnosis and 5 (14%) presented with de-novo metastatic disease (4 in the lung and 1 in the contralateral breast as the first metastatic site). Of the 31 patients with non-metastatic disease at presentation, 17 underwent mastectomy, 14 underwent lumpectomy, 14 had axillary lymph node dissection, 8 had no axillary surgery, 9 had sentinel lymph node biopsy, 16 had adjuvant radiation therapy and 2 had adjuvant chemotherapy. Of the 31 patients, 13 patients developed locoregional recurrence of which 9 had positive margin on initial surgery and 4 had negative closet margin of ≤1 cm, 7 patients developed metastatic disease of which lung and/or the chest are the main sites. Of the total population to date, 7 patients passed away from the disease. Conclusions: Malignant PT patients are a unique population with limited characterization to date. Our study demonstrates the clinical and pathological characteristics and the treatment pattern of these patients. Further analysis is underway to assess risks associated with surgical and survival outcome of this disease.

COVID-19 Vaccination in Patients with Cancer.

Simple SummaryPatients with cancer are concerned about the effects of the COVID-19 vaccination while authorities search for ways to encourage vaccination; however, many points are still unclear. To remedy this situation, we conducted an online survey of 1182 female patients with cancer. The results showed that 768 were concerned about the vaccine, and 726 consulted with their attending physicians about the vaccination. The results also showed significantly higher vaccination rates among the patients who had consulted with their physicians. We found that consulting with attending physicians appeared to be linked to reduced anxiety, decisions about the timing of the vaccination, and higher vaccination rates. This was corroborated by the result of the cross-analysis of vaccination status and information sources about the vaccination. Therefore, we concluded that consulting with a physician about vaccination alleviates the concerns of patients with cancer and encourages them to get vaccinated.Patients with cancer are concerned about the effects of the COVID-19 vaccination. We conducted an online survey on the COVID-19 vaccination status and side effects among patients with cancer in Japan between 8 and 14 August 2021. We included 1182 female patients with cancer aged 20–70 years and registered on an online patient website. Of the patients, 944 had breast cancer, 216 had gynecological cancer, 798 were undergoing drug/radiation therapy, and 370 were in follow-up. At the time of the survey, 885 patients had already received at least one dose. Of these, 580 had also received their second dose. The incidence rate of side effects was equivalent to previous reports. In patients with breast cancer, problems such as the onset or worsening of lymphedema or axillary lymphadenopathy metastasis requiring differential diagnosis were encountered following vaccination. A total of 768 patients were concerned about the vaccine at some point, and 726 consulted with their attending physicians about the timing or side effects of the vaccination. Of the 110 patients undergoing chemotherapy or radiation therapy, 75 adjusted the timing of the vaccination based on their therapy. The cross-analysis revealed that 81% of those who consulted their physician had received at least one dose of the COVID-19 vaccination compared with 65% of those who had not consulted their physician. Consulting with a physician about the COVID-19 vaccination was found to alleviate the concerns of patients with cancer and encourage them to get vaccinated.

Intraoperative Lymph Node Assessment (Touch Preparation Only) for Metastatic Breast Carcinoma in Neoadjuvant and Non-neoadjuvant Settings.

Touch preparation (TP) alone is discouraged for intraoperative lymph node (LN) assessment in the neoadjuvant setting (NAS) owing to overall low sensitivity in detecting metastatic breast cancer. To compare the sensitivity, specificity, and negative predictive value of intraoperative LN assessment via TP and examine potential causes of discrepancies along with the clinical, radiologic, and pathologic parameters in the NAS and non-neoadjuvant setting (NNAS). A total of 99 LNs from 47 neoadjuvant patients and 108 LNs from 56 non-neoadjuvant patients were identified. Discordant cases were reviewed retrospectively to reveal the discrepancy reasons. Clinical, radiologic, and pathologic data were obtained from chart review and the pathology CoPath database. The sensitivity, specificity, and negative predictive value of TP in NAS and NNAS were 34.2% versus 37.5%, 100% versus 100%, and 70.9% versus 90.2%, respectively. In NAS, discrepancy reasons were interpretation challenge due to lobular histotype, poor TP quality secondary to therapy-induced histomorphologic changes, and undersampling due to small tumor deposits (≤2 mm); the latter was the major reason in NNAS. More cases with macrometastasis were missed in NAS compared to NNAS (14 of 25 versus 1 of 10). The parameters associated with discrepancy were lobular histotype, histologic grade 2, estrogen receptor positivity, HER2 human epidermal growth factor receptor 2 negativity, multifocality, and pathologic tumor size greater than 10 mm in NAS; and lymphovascular space involvement and pathologic tumor size greater than 20 mm in NNAS. In NAS, intraoperative TP alone should be used very cautiously owing to a high false-negative rate of macrometastasis, especially for patients with invasive lobular carcinoma and known axillary LN metastasis before neoadjuvant therapy.

De-escalation of axillary surgery post neoadjuvant therapy in hormone-positive breast cancer: Feasible or futile

A proportion of patients with breast cancer presenting with nodal metastases will undergo an axillary pathological complete response (pCR) following neoadjuvant chemotherapy (NACT). The probability of an axillary pCR is highly dependent on tumour subtype with the lowest probability in patients with estrogen receptor (ER) positive disease. A retrospective review was conducted of patients with symptomatic breast cancer who received neoadjuvant chemotherapy from 2013 to 2021. Inclusion criteria comprised newly diagnosed ER positive breast cancer patients with histologically proven axillary metastasis, undergoing treatment with curative intent. Univariate and multivariate analysis was performed to identify predictors of axillary pCR. Statistical analyses were performed with SPSS v.26.0. During the study period, 154 patients with biopsy confirmed axillary nodal disease and ER positive breast cancer were treated with neoadjuvant chemotherapy. Of these 35% (n=54) were also HER2 positive. Axillary pCR was significantly more likely in the patients with ER positive and HER2 positive breast cancer (pCR in 59%). In patients with HER2 negative disease only 19% attained an axillary pCR (p<0.001). On multivariate analysis of the HER2 negative cohort the only factor significantly associated with axillary pCR was a complete radiological response of the primary tumour (p=0.004). In patients without a radiological complete response, the axillary pCR rate was 16%. In patients with ER positive, HER2 negative breast cancer, the rate of axillary pCR remains low and in those without a radiological complete response in the breast primary, axillary lymph node dissection should still be considered the standard of care.

Metastatic nonhematopoietic neoplasms to the breast: a study of 238 cases

The aim of this study was to review the clinicopathologic characteristics of metastatic nonhematopoietic malignancies to the breast, in order to identify salient features for practicing pathologists that are useful in distinguishing metastatic lesions from primary breast neoplasms. A total of 238 cases were identified during the period from January 2005 to January 2015. Clinicopathologic features of these cases were retrospectively reviewed. Primary tumors included melanoma (99, 42%), serous carcinoma (35, 15%), neuroendocrine neoplasm (32, 13%), sarcoma (23, 10%), and adenocarcinoma from various organs (47, 20%), and 2 others. Most metastases were unilateral (223, 94%) and unifocal (206, 87%)and were detected radiographically (167, 70%). Concurrent ipsilateral axillary metastasis occurred in 33 (14%) patients. Among 238 cases, 41 had metastatic disease to the breast concurrently or preceding the primary cancer diagnosis. Notably, in 39 (16%) cases, breast metastasis was the first clinical presentation of disease, and 16 (41%) of these cases were initially misdiagnosed as breast primaries. In contrast, with a known history of nonmammary primary tumors, only 4 of 197 (2%) cases were misdiagnosed (p<0.0001). Metastatic tumors share many overlapping features with breast primary carcinomas. However, cases with a well-circumscribed tumor, lack of in situ component, estrogen receptor/progesterone receptor negativity, and unusual morphologic features should raise the consideration of metastatic disease. While clinical history is paramount for correct diagnosis, metastasis to the breast as the first clinical presentation is not uncommon.

Unknown Case: Unilateral Fluorodeoxyglucose Avid Axillary Lymphadenopathy in a Woman With History of Mastectomy and Implant Reconstruction.

A 67-year-old female presented with a history of right breast invasive ductal carcinoma and right axillary metastasis five years ago, status post bilateral mastectomies and right axillary lymph node dissection. Three years ago, she underwent implant reconstruction. She was diagnosed with metastasis to mediastinal lymph nodes one year ago after abnormal PET-CT and bronchoscopy. Fluorodeoxyglucose (FDG) PET-CT was performed for surveillance as she is currently on endocrine therapy. Fluorodeoxyglucose PET-CT demonstrated interval increase in size and hypermetabolic activity of a left axillary lymph node when compared to the prior year (Figure 1). Subsequent targeted left axillary US was performed for biopsy of this lymph node (Figure 2). On the biopsy images, the lymph node demonstrates a well-defined anterior margin with hyperechogenicity and echogenic noise. The differential diagnosis for unilateral lymphadenopathy includes benign and malignant etiologies (1,2). Benign etiologies include reactive...

Combining conventional ultrasound and sonoelastography to predict axillary status after neoadjuvant chemotherapy for breast cancer.

To determine the ability of conventional ultrasound (US) combined with shear wave elastography (SWE) to reveal axillary status after neoadjuvant chemotherapy (NAC) in breast cancer patients. From September 2016 to December 2021, 201 patients with node-positive breast cancer who underwent NAC were enrolled in this prospective study. Conventional US features of axillary lymph nodes and SWE characteristics of breast lesions after NAC were analyzed. The diagnostic performances of US, SWE, and their combination were assessed using multivariate logistic regression and receiver operator characteristic curve (ROC) analyses. The area under the ROC curve (AUC) for the ability of conventional US features to determine axillary status after NAC was 0.82, with a sensitivity of 85.23%, a specificity of 67.39%, and an accuracy of 76.11%. Shear wave velocity (SWV) displayed moderate performance for predicting axilla status after NAC with SWVmean demonstrating an AUC of 0.85. Cortical thickness and shape of axillary nodes and SWVmean of breast tumors were independently associated with axillary nodal metastasis after NAC. Compared to conventional US, the combination of conventional US of axillary lymph nodes with SWE of breast lesions achieved a significantly higher AUC (0.90 vs 0.82, p < 0.01, Delong's test) with a sensitivity of 87.50%, improved specificity of 82.61% and accuracy of 85.00%. BreastSWE was independently associated with residual metastasis of axillary node after NAC in patients with initially diagnosed positive axilla. Combining SWE with conventional US showed good diagnostic performance for axillary node disease after NAC. • Breast SWE can serve as a supplement to axilla US for the evaluation of the axilla after NAC. • The combination of axilla US with breast SWE may be a promising method to facilitate less-invasive treatment in patients receiving NAC.

CORRELATION OF RECEPTOR STATUS WITH AXILLARY NODAL METASTASIS AND OTHER PROGNOSTIC FACTORS IN CARCINOMA BREAST : INDIAN PERSPECTIVE

Background- nd Breast cancer is the 2 most common cancer globally and it ranks rst in India. The predictive value of various components like hormone receptor status, tumor size, grade to axillary lymph nodal metastasis has been studied previously. Our aim is to study the correlation of receptor status and axillary lymph nodal metastasis in breast cancer patients. Methods- This is a retrospective study carried out in single surgical unit. 104 biopsy proven unilateral breast cancer patients who underwent modied radical mastectomy has been reviewed. The clinicopathological data has been collected from hospital records. Results- The mean age of presentation is 42.2years. Most common age group is 30-49years with clinical stage III(65.38%) with inltrating ductal carcinoma(99.03%). Although axillary lymph node was palpable in 75%, nodal metastasis is present in 63.46% of patients. Positive estrogen receptor, progesterone receptor and Her2 receptors are seen in 45.19%, 34.6% and 59.61% patients respectively. TNBC patients has least while triple positive has maximum nodal metastasis in our study group. Perineural invasion and extra capsular extension is seen in 15.38% each and lymphovascular invasion is seen in 38.4% patient. Although LVI, PNI and ECE is predominant in Her2-enriched subtypes, most patients belonging to HR+/Her2+ subtypes has LVI, PNI and ECE. TNBC and HR+/Her2- subtypes has least LVI, PNI and ECE. Conclusion- Receptor status has signicant role in predicting nodal metastasis. TNBC, although considered most aggressive, has least axillary nodal metastasis suggesting less lymphatic involvement and less LVI, PNI and ECE. Also Her2 over-expression seems to be related to nodal metastasis, LVI, PNI and ECE, suggesting there may be some pathway which is still unrevealed. Thus Her2 receptor positivity can be considered as an independent poor prognostic factor.

Recaídas locorregionales tras mastectomías preservadoras y reconstrucción inmediata en mujeres con cáncer de mama

IntroductionIn recent years, cultural changes in today's society and improved risk assessment have increased the indication for mastectomies in women with breast cancer. Various studies have confirmed the oncological safety of sparing mastectomies and immediate reconstruction. The objective of this study is to analyze the incidence of locoregional relapses of this procedure and its impact on reconstruction and overall survival. Patients and methodsProspective study of patients with breast carcinoma who underwent a sparing mastectomy and immediate reconstruction. Locoregional relapses and their treatment and their impact on survival were analyzed. ResultsThe study group is made up of 271 women with breast carcinoma treated with a skin-sparing mastectomy and immediate reconstruction. The mean follow-up was 7.98 years and during the same 18 locoregional relapses (6.6%) were diagnosed: 72.2% in the mastectomy flap and 27.8% lymph node. There were no significant differences in the pathological characteristics of the primary tumor between patients with and without locoregional relapse, although the percentage of women with hormone-sensitive tumors was higher in the group without relapse. Patients with lymph node relapse had larger tumors (80% T2–T3) and 60% had axillary metastases at diagnosis, compared to 7.7% of women with skin relapse (p = 0.047). All patients operated on for locoregional relapse preserved their reconstruction. The incidence of metastases and deaths was significantly higher in patients with a relapse, causing a non-significant decrease in overall survival. ConclusionLocoregional relapses are a rare event in women with a sparing mastectomy and immediate reconstruction. Most patients with locoregional relapse can preserve their initial reconstruction through local resection of the tumor and adjuvant and/or neoadjuvant therapies.