Primary Breast Malignancy Research Articles

PLASMA CELL NEOPLASM IN BREAST: A RARE CASE REPORT

Abstract Introduction/Objective Breast carcinoma continues to be the most common malignancy in women however plasma cell neoplasms are rare in breast tissue. Most of these recorded cases are from patients with Multiple myeloma (1). We present a rare case of a new breast lesion in a 69 year female incidentally found on imaging. She had a history of adenocarcinoma of lung with brain metastasis undergoing treatment. Methods/Case Report The patient’s breast lesion presentation was unusual without any pain or associated symptoms, but a new right breast mass was incidentally discovered on CT-Chest Abdomen-Pelvis. Mammogram revealed a 1.4 cm circumscribed mass in lower, outer breast with scattered calcifications. With the suspicion for a primary breast malignancy or metastatic disease from her lung cancer the patient’s breast lesion was biopsied. On histology, abnormal proliferation of cells with ovoid nuclei, vesicular chromatin and variable cytoplasm was noted with a background of mature adipose tissue. Immunohistochemistry showed neoplastic cells positive for plasma cell associated markers including CD38 (patchy), CD56, CD138, and MUM1 with a kappa restriction on ISH. The Ki67 showed 20% proliferation index. EBER was negative and SMARC4 and INI were preserved. Other immunohistochemical stains were performed to rule out differentials and were all negative. The morphology and IHCs were consistent with the diagnosis of Plasma cell neoplasm with kappa-restriction. Subsequently this patient developed a shoulder lesion which on biopsy showed a plasma cell neoplasm expressing plasma cell markers and kappa light chain overexpression. Results (if a Case Study enter NA) NA Conclusion It is critical to distinguish a breast plasma cell neoplasm from other primary and metastatic breast lesions in order to avoid unnecessary surgery and cytotoxic chemotherapy. Rarely, plasma cell neoplasm can manifests as a breast lesion, which in this case turned out to be the early manifestation of multiple myeloma.

EP496 - Metastatic Invasive Lobular Carcinoma of the Breast mimicking healed Gastric Ulcer: A Case Report

Abstract Introduction Breast cancer metastasizing to the stomach as a new presentation is highly unusual. We report a 77-year-old female with such presentation. Case Presentation A 77-year-old female investigated for significant weight loss. She denied any upper or lower gastrointestinal symptoms. She had bidirectional scopes. Colonoscopy showed only diverticulosis. Two gastroscopies revealed non-specific stellar shaped areas in the anterior antrum wall mimicking a healed gastric ulcer. Biopsies confirmed metastatic lobular carcinoma of the breast, ER+ve, HER2 negative. On further clinical examination she had large mass upper outer quadrant with palpable enlarged nodes. Staging CT scan showed couple of hyper enhancing foci in the right breast which may be potential candidates for primary tumour and enlarged right axillary nodes. Subsequently she had an ultrasound guided biopsy of the breast lesion confirmed invasive lobular cancer. Patient has been referred to the breast MDT for breast and lymph node biopsy. Discussion The incidence of GI metastatic disease from a primary breast cancer is less than 1%. It is more common to diagnose in patients with prior history and treatment for primary breast malignancy. However, occasionally it can be encountered prior to the diagnosis of the primary tumour. Hence, index of high suspicion is required as the endoscopic findings are non-specific.

Caveolin-1 knockout mitigates breast cancer metastasis to the lungs via integrin α3 dysregulation in 4T1-induced syngeneic breast cancer model

Caveolin-1 (Cav-1) is a critical lipid raft protein playing dual roles as both a tumor suppressor and promoter. While its role in tumorigenesis, progression, and metastasis has been recognized, the explicit contribution of Cav-1 to the onset of lung metastasis from primary breast malignancies remains unclear. Here, we present the first evidence that Cav-1 knockout in mammary epithelial cells significantly reduces lung metastasis in syngeneic breast cancer mouse models. In vitro, Cav-1 knockout in 4T1 cells suppressed extracellular vesicle secretion, cellular motility, and MMP secretion compared to controls. Complementing this, in vivo analyses demonstrated a marked reduction in lung metastatic foci in mice injected with Cav-1 knockout 4T1 cells as compared to wild-type cells, which was further corroborated by mRNA profiling of the primary tumor. We identified 21 epithelial cell migration genes exhibiting varied expression in tumors derived from Cav-1 knockout and wild-type 4T1 cells. Correlation analysis and immunoblotting further revealed that Cav-1 might regulate metastasis via integrin α3 (ITGα3). In silico protein docking predicted an interaction between Cav-1 and ITGα3, which was confirmed by co-immunoprecipitation. Furthermore, Cav-1 and ITGα3 knockdown corroborated its role in metastasis in the cell migration assay.

Abstract PO5-20-11: Synchronous Breast Cancer and Pheochromocytoma: A Case Series

Abstract Background: Pheochromocytomas are rare, although literature suggests a rising incidence due to the widespread use of sensitive imaging modalities. Synchronous presentation of breast cancer with a pheochromocytoma is exceedingly rare with only one case documented in the literature. We present two cases of malignancy in the breast in which pheochromocytomas were incidentally detected during workup and management with vastly different presentations. Case Presentation: Two patients presented with breast cancer and were secondarily diagnosed with pheochromocytoma. Patient 1 is a 48-year-old postmenopausal female with a history of intraductal papilloma four years prior, who presented with right breast nipple discharge. Diagnostic mammogram showed a right breast mass and biopsy confirmed an intraductal papilloma with intermediate-grade DCIS, ER+/PR-. She had no family history of cancer or PGL/PPC. During a scheduled lumpectomy, she developed hypoxia, hypotension, and flash pulmonary edema requiring intubation and ECMO with prolonged ICU stay and long recovery with tracheostomy for four months. Contrast-enhanced CT of her abdomen showed a 9 cm right adrenal mass. Serum and urine metanephrines were markedly elevated, and it was determined that she had an adrenal crisis secondary to undiagnosed pheochromocytoma. She completed treatment for DCIS with lumpectomy and radiation and is currently on adjuvant anastrozole. She additionally had an adrenalectomy for pheochromocytoma, which was found to be stage PASS 2. Subsequent genetic testing confirmed the absence of germline mutations associated with hereditary PGL/PPC or breast cancer. Patient 2 is a 57-year-old female presenting with a history of left breast mass she first noted a year ago, with newly found nipple retraction and skin changes. Biopsy showed invasive ductal carcinoma of the breast, G3, Stage IIIA, pT3N2aM0, ER 95%/PR-/Her2- (IHC 0). Staging PET scan showed a 3.4 cm hypermetabolic left adrenal mass in addition to the breast mass and left axillary adenopathy. Serum and urine metanephrines were elevated, and pheochromocytoma was diagnosed. Family history was positive only for pancreatic cancer in a maternal aunt. Comprehensive genotype testing was negative for hereditary breast cancer and PGL/PCC syndromes. She was concomitantly treated with a radical mastectomy for breast cancer and a left adrenalectomy and tolerated the procedure well as she received perioperative alpha-adrenergic blockade with doxazosin. She has received chemotherapy and radiation for breast cancer treatment and is currently on adjuvant anastrozole. The adrenal mass was confirmed to be a pheochromocytoma PASS 2-3. Discussion: We present two unique cases of breast cancer and pheochromocytomas discovered in tandem with variable clinical manifestations. It is extremely uncommon to have a presentation of primary breast malignancy concomitantly with pheochromocytoma, and we demonstrate two cases that occurred within months of one another at our facility. During the first case, metastatic workup was not indicated for DCIS. However, during the seemingly benign lumpectomy procedure, the patient experienced significant complications, leading to intense ICU management, intubation, and tracheostomy. In the second case, a metastatic workup was completed due to locally advanced breast cancer where the adrenal mass was detected and a pheochromocytoma was diagnosed prior to surgery. This allowed both cancers to be resected simultaneously and safely. This series demonstrates the importance of keeping pheochromocytomas in the differential during the workup of adrenal masses prior to surgical interventions. Additionally, they demonstrate how the usual workup and management of breast cancer does not take into account these rare but significant diagnoses, and that can result in fatal consequences. Citation Format: Nikita Dahake, Abhimanyu Tushir, Aruna Padmanabhan. Synchronous Breast Cancer and Pheochromocytoma: A Case Series [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-20-11.

Axillary node evaluation and biopsy: Predictors of malignancy based on sonographic morphology and mode of detection

PurposeThe purpose of this study was to evaluate various morphologic features of axillary nodes on ultrasound (US) in predicting malignancy and estimate the incidence of malignancy in axillary nodes based on their imaging mode of detection. Methods and materialsA retrospective review of all percutaneous US-guided biopsies on axillary nodes performed at our institution between 1/1/2019–09/30/2021 was performed. Sonographic morphologic features of the biopsied node, imaging mode of detection and size of primary breast malignancy were correlated with malignancy. ResultsThere were 224 malignancies detected in a total of 594 patients who underwent an axillary node biopsy. The positive predictive value (PPV) was significantly associated with the extent of nodal cortical thickening (p < 0.0001). The PPV of malignancy was significantly higher in nodes which lacked a normal hilum (0.61 vs 0.23). The PPV of malignancy in nodes detected on screening mammography (18.8%) or MRI (15.8%) was much lower than those detected on diagnostic imaging, by palpation or on CT/PET (48.4%, 43.8% and 65.3% respectively). Of all screening detected nodes in patients with no history of malignancy and mild cortical thickening, only 2 (4.3%) demonstrated malignancy. ConclusionsMorphology of axillary nodes on sonography is vital in predicting nodal metastasis. Cortical thickness > 5 mm and/or absence of a normal hilum had the highest PPV for metastatic disease. Using clinical history in conjunction with imaging findings will help improve accuracy of axillary nodal biopsies, especially for incidental nodes detected on screening.

Imaging Challenges in Diagnosing Triple-Negative Breast Cancer.

Triple-negative breast cancer (TNBC) refers to a heterogeneous group of carcinomas that have more aggressive biologic features, faster growth, and a propensity for early distant metastasis and recurrence compared with other breast cancer subtypes. Due to the aggressiveness and rapid growth of TNBCs, there are specific imaging challenges associated with their timely and accurate diagnosis. TNBCs commonly manifest initially as circumscribed masses and therefore lack the typical features of a primary breast malignancy, such as irregular shape, spiculated margins, and desmoplastic reaction. Given the potential for misinterpretation, review of the multimodality imaging appearances of TNBCs is important for guiding the radiologist in distinguishing TNBCs from benign conditions. Rather than manifesting as a screening-detected cancer, TNBC typically appears clinically as a palpable area of concern that most commonly corresponds to a discrete mass at mammography, US, and MRI. The combination of circumscribed margins and hypoechoic to anechoic echogenicity may lead to TNBC being misinterpreted as a benign fibroadenoma or cyst. Therefore, careful mammographic and sonographic evaluation with US image optimization can help avoid misinterpretation. Radiologists should recognize the characteristics of TNBCs that can mimic benign entities, as well as the subtle features of TNBCs that should raise concern for malignancy and aid in timely and accurate diagnosis. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Risk of developing glioblastoma following non-CNS primary cancer: a SEER analysis between 2000 and 2018.

Patients with a prior malignancy are at elevated risk of developing subsequent primary malignancies (SPMs). However, the risk of developing subsequent primary glioblastoma (SPGBM) in patients with a prior cancer history is poorly understood. We used the Surveillance, Epidemiology, and End Results (SEER) database and identified patients diagnosed with non-CNS malignancy between 2000 and 2018. We calculated a modified standardized incidence ratio (M-SIR), defined as the ratio of the incidence of SPGBM among patients with initial non-CNS malignancy to the incidence of GBM in the general population, stratified by sex latency, and initial tumor location. Of the 5,326,172 patients diagnosed with a primary non-CNS malignancy, 3559 patients developed SPGBM (0.07%). Among patients with SPGBM, 2312 (65.0%) were men, compared to 2,706,933 (50.8%) men in the total primary non-CNS malignancy cohort. The median age at diagnosis of SPGBM was 65years. The mean latency between a prior non-CNS malignancy and developing a SPGBM was 67.3months (interquartile range [IQR] 27-100). Overall, patients with a primary non-CNS malignancy had a significantly elevated M-SIR (1.13, 95% CI 1.09-1.16), with a 13% increased incidence of SPGBM when compared to the incidence of developing GBM in the age-matched general population. When stratified by non-CNS tumor location, patients diagnosed with primary melanoma, lymphoma, prostate, breast, renal, or endocrine malignancies had a higher M-SIR (M-SIR ranges: 1.09-2.15). Patients with lung cancers (M-SIR 0.82, 95% CI 0.68-0.99), or stomach cancers (M-SIR 0.47, 95% CI 0.24-0.82) demonstrated a lower M-SIR. Patients with a history of prior non-CNS malignancy are at an overall increased risk of developing SPGBM relative to the incidence of developing GBM in the general population. However, the incidence of SPGBM after prior non-CNS malignancy varies by primary tumor location, with some non-CNS malignancies demonstrating either increased or decreased predisposition for SPGBM depending on tumor origin. These findings merit future investigation into whether these relationships represent treatment effects or a previously unknown shared predisposition for glioblastoma and non-CNS malignancy.

Landscape of germline pathogenic variants in patients with dual primary breast and lung cancer

BackgroundCancer predisposition is most often studied in the context of single cancers. However, inherited cancer predispositions can also give rise to multiple primary cancers. Yet, there is a paucity of studies on genetic predisposition in multiple primary cancers, especially those outside of well-defined cancer predisposition syndromes. This study aimed to identify germline variants associated with dual primary cancers of the breast and lung.MethodsExome sequencing was performed on germline DNA from 55 Singapore patients (52 [95%] never-smokers) with dual primaries in the breast and lung, confirmed by histopathology. Using two large control cohorts: the local SG10K_Health (n = 9770) and gnomAD non-cancer East Asians (n = 9626); and two additional local case cohorts of early-onset or familial breast cancer (n = 290), and lung cancer (n = 209), variants were assessed for pathogenicity in accordance with ACMG/AMP guidelines. In particular, comparisons were made with known pathogenic or likely pathogenic variants in the ClinVar database, pathogenicity predictions were obtained from in silico prediction software, and case–control association analyses were performed.ResultsAltogether, we identified 19 pathogenic or likely pathogenic variants from 16 genes, detected in 17 of 55 (31%) patients. Six of the 19 variants were identified using ClinVar, while 13 variants were classified pathogenic or likely pathogenic using ACMG/AMP guidelines. The 16 genes include well-known cancer predisposition genes such as BRCA2, TP53, and RAD51D; but also lesser known cancer genes EXT2, WWOX, GATA2, and GPC3. Most of these genes are involved in DNA damage repair, reaffirming the role of impaired DNA repair mechanisms in the development of multiple malignancies. These variants warrant further investigations in additional populations.ConclusionsWe have identified both known and novel variants significantly enriched in patients with primary breast and lung malignancies, expanding the body of known cancer predisposition variants for both breast and lung cancer. These variants are mostly from genes involved in DNA repair, affirming the role of impaired DNA repair in the predisposition and development of multiple cancers.

Breast malignancy after radioactive iodine ablation for thyroid pathology: A systematic review of the literature.

e22511 Background: Radioactive Iodine Ablation (RAI) is a procedure in which the administration of radioactive iodine is utilized to eradicate pathologic thyroid tissue. RAI is commonly used for thyroid malignancy and hyperthyroidism. Although RAI has been a mainstay of treatment for these diseases, there has been some controversy regarding the development of secondary primary malignancy after RAI. Breast cancer is a particular concern. As breast cancer is the second most common cancer for women in the United States, understanding its risk factors is a key component of public health. Methods: A systematic review was conducted following PRISMA guidelines. Inclusion criteria consisted of English language studies that evaluated the association between radioactive iodine ablation and secondary primary breast malignancy. The study was conducted from January 2023 until February 2023. Two independent researchers conducted the literature search utilizing PubMed, SCOPUS, JSTOR, and Wiley Library using standardized search terms. The titles and abstracts of these studies were independently screened, and further evaluated for relevancy. Qualitative data was then extracted and summarized. Results: Of the 386 manuscripts retrieved, 27 met inclusion criteria. These studies were published between 1983 – 2022. Of these, 15 articles reported no association between RAI and the development of secondary primary breast malignancy. Of the manuscripts which reported no association, 6 examined RAI for hyperthyroidism, and 9 examined RAI for thyroid malignancy. 12 studies reported an association between RAI and the development of secondary primary breast malignancy. Of the studies reporting an association, 1 examined RAI for hyperthyroidism, and the remaining 11 examined RAI for thyroid malignancy. For the single study that found an association in the case of hyperthyroidism, the researchers found a dose-dependent relationship. Conclusions: The literature surrounding secondary primary breast malignancy after RAI is controversial. This systematic review resulted in conflicting data regarding the association between radioactive iodine ablation for thyroid pathology and the development of secondary primary breast malignancy. The studies that suggested an association between RAI and secondary primary breast malignancy were overwhelmingly studies in which RAI was used for the treatment of thyroid malignancy. Some studies suggest a possible dose-dependent relationship between RAI and secondary primary breast malignancy, however this data is limited. Additional studies would be beneficial to address this gap in the literature.

Pure Mucinous Carcinoma of the Breast: Radiologic-Pathologic Correlation.

Mucinous carcinoma (MC) of the breast is a rare, specialized subtype of invasive breast carcinoma (IBC) accounting for approximately 1% to 4% of all primary breast malignancies. Mucinous carcinoma occurs predominantly in patients who are postmenopausal or elderly. It is usually detected on screening mammography, but occasionally the patient may present with a palpable mass. The most common mammographic appearance is an equal to high density, oval or round mass with circumscribed or indistinct margins; MC can mimic a benign lesion. Histologically, MC is a well-differentiated cancer characterized by pools of mucin around neoplastic cells. Depending on mucin content, the tumor is classified as pure (≥90% mucin) or mixed (>10% and <90% mucin). Pure MCs (PMCs) are of low or intermediate nuclear grade, and the vast majority are hormone receptor-positive and human epidermal growth factor-2 receptor-negative (luminal A subtype). Pure MCs may be classified as hypocellular (type A) or hypercellular (type B) and have a lower rate of axillary lymph node involvement and more favorable prognosis than IBCs, no special type. The purpose of this article is to review the clinical features, imaging appearances, associated histopathology, and management of PMC.

Primary Breast Sarcoma: A Two-Centre Analysis and Review of Literature.

Primary breast sarcoma is a very rare malignant type of breast tumours with an incidence of 0.1% of all primary breast malignancies. We present a retrospective analysis of the case series from two hospitals in the Czech Republic with a review of the diagnostic and treatment approach to primary breast sarcomas with an analysis of published prognostic factors. Eleven patients were included in the study, 9 women and 2 men. Statistical evaluation revealed that tumour size (p = 0.1964), grade (p = 0.1667), margin distance (p = 0.5403), mitotic activity (p = 0.8577), or age (p = 0.7822) were not prognostic factors in our cohort. The analysis did not prove any of the factors, such as age, tumour size, grade, or mitotic activity, to be statistically significant prognostic factors. Based on the literature review, the most common published prognostic factors are tumour size, margin status, and grade, but the results are ambiguous.

S2269 Malignant Dysphagia in Latent Triple Negative Metastatic Breast Cancer

Introduction: Luminal gastrointestinal metastasis of breast cancer is rare and esophageal metastasis from breast cancer is reported in less than 100 cases. We present a unique case of metastatic esophageal cancer from a primary breast malignancy, 20 years post initial diagnosis. Case Description/Methods: A 79-year-old African American female with past medical history of triple negative metastatic breast cancer, COPD, HTN, & T2DM presented to the hospital with 3 weeks of progressive dysphagia to liquids & solids, regurgitation and 10kg weight loss. No heartburn, nausea/vomiting or change in bowel habits. No prior EGD and colonoscopy many years ago showed 2 benign polyps. She was diagnosed with breast cancer in early 2000s and underwent right mastectomy; recurrence was discovered in 2014, which led to lumpectomy, chemotherapy/radiation. Vital signs stable on arrival. Physical examination notable for cachectic female; no lymphadenopathy, abdominal distension/tenderness or edema. Labs showed: WBC 7.9, Hb 11, MCV 82, Plt 291. EGD, showed severe stenosis in the mid-esophagus – dilation was attempted, but unsuccessful; biopsies were negative. Esophogram revealed severe stenosis of the mid-esophagus. CT thorax demonstrated a focal density in the mid-esophagus & multiple hepatic lesions concerning for metastasis. Endoscopic ultrasound (EUS) revealed severe stenosis of mid-esophagus; dilation, fine needle aspiration (FNA) and stent placement were performed. Pathology demonstrated metastatic triple negative breast cancer. The patient planned to start paclitaxel but was placed on hospice (Figure). Discussion: Esophageal metastasis of breast cancer has a prevalence of 0.59-5.9%. The most common presenting symptom is dysphagia. Studies describe a latency period between the diagnosis of breast cancer and symptoms of esophageal metastasis. Diagnosis is difficult as mucosal involvement is rare and most cases will present with stricture and normal mucosa. EUS with FNA is necessary to confirm diagnosis. Some success has been shown with expandable stents for symptomatic relief as dilation is limited by high risk of perforation. As in our case, esophageal metastasis is usually part of multi-organ metastasis, so treatment aimed at the primary malignancy, but palliative in most cases. Concern for malignant dysphagia must be included in the differential for breast cancer patients presenting with dysphagia. Due to difficult diagnosis and latency period, more routine screening with EUS may be beneficial.Figure 1.: Repeat EGD with EUS & Fluoroscopic guided stent placement.

PET-CT in Clinical Adult Oncology: II. Primary Thoracic and Breast Malignancies.

Simple SummaryPositron emission tomography (PET), typically combined with computed tomography (CT), has become a critical advanced imaging technique in oncology. With PET-CT, a radioactive molecule (radiotracer) is injected in the bloodstream and localizes to sites of tumor because of specific cellular features of the tumor that accumulate the targeting radiotracer. The CT scan, performed at the same time, provides information to facilitate assessment of the amount of radioactivity from deep or dense structures, and to provide detailed anatomic information. PET-CT has a variety of applications in oncology, including staging, therapeutic response assessment, restaging, and surveillance. This series of six review articles provides an overview of the value, applications, and imaging and interpretive strategies of PET-CT in the more common adult malignancies. The second article in this series addresses the use of PET-CT in breast cancer and other primary thoracic malignancies.Positron emission tomography combined with x-ray computed tomography (PET-CT) is an advanced imaging modality with oncologic applications that include staging, therapy assessment, restaging, and surveillance. This six-part series of review articles provides practical information to providers and imaging professionals regarding the best use of PET-CT for the more common adult malignancies. The second article of this series addresses primary thoracic malignancy and breast cancer. For primary thoracic malignancy, the focus will be on lung cancer, malignant pleural mesothelioma, thymoma, and thymic carcinoma, with an emphasis on the use of FDG PET-CT. For breast cancer, the various histologic subtypes will be addressed, and will include 18F fluorodeoxyglucose (FDG), recently Food and Drug Administration (FDA)-approved 18F-fluoroestradiol (FES), and 18F sodium fluoride (NaF). The pitfalls and nuances of PET-CT in breast and primary thoracic malignancies and the imaging features that distinguish between subcategories of these tumors are addressed. This review will serve as a resource for the appropriate roles and limitations of PET-CT in the clinical management of patients with breast and primary thoracic malignancies for healthcare professionals caring for adult patients with these cancers. It also serves as a practical guide for imaging providers, including radiologists, nuclear medicine physicians, and their trainees.

Bilateral Myeloid Sarcoma of the Breast: A Case Report With Radiological and Pathological Correlation

Myeloid sarcoma is a solid extramedullary mass of immature myeloid cells, often in patients with myeloid leukemia. Myeloid sarcoma of the breast is extremely uncommon, and bilateral involvement is even rarer. Myeloid sarcoma of the breast can mimic primary breast cancer, lymphoma, and other neoplasms. Differentiation between myeloid sarcoma and primary breast malignancy is imperative, as management and treatment are drastically different. We present a case of myeloid sarcoma of both breasts in a 63-year-old female with relapsed acute myelogenous leukemia (AML), a personal history of ovarian cancer, and a family history of both leukemia and breast cancer. This report highlights the need for high clinical, radiological, and pathological suspicion to diagnose myeloid sarcoma of the breast.

Clinical and Molecular Insights of Radiation-Induced Breast Sarcomas: Is There Hope on the Horizon for Effective Treatment of This Aggressive Disease?

Radiation-induced breast sarcomas (RIBS) are rare entities representing <1% of all primary breast malignancies, limiting most reports to small retrospective case series. They constitute a heterogeneous group of neoplasms, with high-grade angiosarcoma being the most common subtype. Other sarcoma histotypes, such as undifferentiated pleomorphic sarcoma and leiomyosarcoma, can also be identified. Radiation-induced breast angiosarcoma (RIBA) has an incidence of approximately 0.1% after breast-conserving therapy and arises mainly from the dermis of the irradiated breast. MYC gene amplification is highly indicative of secondary breast angiosarcomas. Their clinical presentation often mimics benign port-radiation lesions, leading to a delay in diagnosis and a lost window of opportunity for cure. Surgery with negative margins is the mainstay of treatment of localized RIBS. In the case of angiosarcoma, technical difficulties, including multifocality, infiltrative margins, and difficulty in assessing tumor margins, render surgical treatment quite challenging. A limited number of studies showed that adjuvant radiation therapy reduces local recurrences; therefore, it is proposed by many groups for large, high-grade tumors. Chemotherapy has been evaluated retrospectively in a small subset of patients, with some evidence supporting its use in angiosarcoma patients. Approximately half of patients with RIBA will show local recurrence. In the advanced setting, different therapeutic options are discussed in the review, including chemotherapy, antiangiogenic therapy, and immunotherapy, whereas the need for further research on molecular therapeutic targets is pointed out.

Yield of flow cytometry in addition to cytology for lymph node sampling in patients with incidental axillary adenopathy without a concurrent diagnosis of primary breast malignancy.

PurposeNon-specific lymphadenopathy is increasingly being reported especially given the COVID-19 vaccination campaign and is a diagnostic dilemma especially in oncology patients. The purpose of this study was to evaluate the diagnostic accuracy and discordance rate between fine-needle aspiration (FNA) cytology and flow cytometry (FC) immunophenotyping in axillary FNA in patients with morphologically abnormal axillary lymph nodes on imaging and no concurrent diagnosis of primary breast malignancy.MethodsThis retrospective study included 222 patients who underwent screening or diagnostic axillary ultrasound that yielded suspicious lymphadenopathy without concurrent or recent prior diagnosis of breast cancer and who had subsequent image-guided axillary FNA and FC. Diagnostic accuracy, sensitivity, specificity, and positive and negative predictive value (PPV and NPV) were reported for FNA with cytology alone, and FC alone, and in combination. Discordance rate between FNA cytology and FC was assessed. Discordant cases were evaluated with histology or clinical and imaging follow-up.ResultsDiagnostic sensitivity, specificity, PPV, NPV, and diagnostic accuracy were 88%, 92%, 77%, 96%, and 91%, for FNA alone, 98%, 98%, 92%, 99%, and 98% for FC alone, and 100%, 92%, 79%, 100%, and 94% when combined. The overall discordance rate between FNA and FC was 7% (16/222). 7/16 (44%) patients with discordant results were diagnosed with lymphoma, while 9/16 (56%) patients with discordant results had benign findings.ConclusionWith a diagnostic accuracy of 91%, FNA with cytology is sufficient to screen patients with indeterminate and incidental lymphadenopathy. Flow cytometry could be initially deferred in patients with low pretest probability of lymphoma.

Assessment of response of neoadjuvant chemotherapy in carcinoma breast patients by high-frequency ultrasound.

To assess the response of neoadjuvant chemotherapy in carcinoma breast patients by high-frequency ultrasound. The current single blind, observational study was conducted at rural tertiary healthcare center of Acharya Vinoba Bhave Rural Hospital from October 2018 to Sept 2020. We incorporated breast cancer patients with TNM stages IIIA and IIIB who received neoadjuvant chemotherapy with Cyclophosphamide/Adriamycin/5 FU and Paclitaxel respectively followed by standard surgical procedure modified radical mastectomy. Successive ultrasound examination of the breast malignancy and the axilla was done after 21 days of either of any neoadjuvant chemotherapy for 3 cycles. Assessment of response to neoadjuvant chemotherapy was applied in terms of reduction in the breast tumour volume on ultrasound and percentage of tumour response calculated by Response Evaluation Criteria for Solid Tumours (RECIST). Data were analysed using SPSS version 24.0. Higher frequency of patients was invasive ductal breast cancer. In our study, Paclitaxel group showed better response in terms of CR and PR than CAF group. Our study noticed a consistent decrement in tumour volume after every cycle of either CAF or Paclitaxel NACT. Axillary ultrasound was able to predict the response of axillary lymph nodes in terms of increase or decrease in number and morphological changes after 3 cycles of NACT with similarity on final histopathology. It can be concluded from the results of the present study that high-frequency ultrasound is appropriate tool for assessment of response of primary breast malignancy and lymphnode metastasis in the axilla after neoadjuvant chemotherapy.

Trucut biopsy as a first line diagnostic modality for equivocal or suspicious breast masses: an experience from a teaching hospital in Khyber Pukhtunkhwa

&lt;p&gt;&lt;strong&gt;Background and Objective:&lt;/strong&gt; Trucut biopsy (TCB) is a commonly used technique for histopathological diagnosis of a clinically and radiologically equivocal or suspicious breast mass. This study aimed to determine the sensitivity and specificity of TCB in the diagnosis of equivocal or suspicious breast masses at local tertiary care hospital in Khyber Pukhtunkhwa.&lt;/p&gt;&#x0D; &lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This descriptive cross-sectional study was conducted at the surgical unit of Mufti Mehmood Memorial Teaching Hospital, Dera Ismail Khan, Pakistan. The study included 80 patients who presented with equivocal or suspicious breast masses from September, 2015 to December, 2020. The patients underwent TCB and after the histopathology report, they were followed by a definitive surgical procedure. The histopathology diagnosis following TCB was compared with the histopathology report of postsurgical specimen to determine the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of TCB taking post-surgery histopathology as a gold standard for diagnosis.&lt;/p&gt;&#x0D; &lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; Out of the 80 patients, 68 (85%) were found to have a primary breast malignancy, while 12 (15%) patients were diagnosed with non-malignant lesions. There were only two false negative cases. The specificity and PPV of TCB were found to be 100%, while a sensitivity of 97% and a NPV of 85.7% was calculated.&lt;/p&gt;&#x0D; &lt;p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; TCB is a valid, reliable, and simple first line minimally invasive method to determine the diagnosis of breast masses that are clinically and radiologically (breast imaging-reporting and data system 3 to 5) equivocal or suspicious.&lt;/p&gt;

Simultaneous FAPI PET/MRI Targeting the Fibroblast-Activation Protein for Breast Cancer.

Background Integrated PET/MRI is a promising modality for breast assessment. The most frequently used tracer, fluorine 18 (18F) fluorodeoxyglucose (FDG), is applied for whole-body staging in advanced breast cancer but has limited accuracy in evaluating primary breast lesions. The fibroblast-activation protein (FAP) is abundantly expressed in invasive breast cancer. FAP-directed PET tracers have recently become available, but results in primary breast tumors remain lacking. Purpose To evaluate the use of FAP inhibitor (FAPI) breast PET/MRI in assessing breast lesions and of FAPI whole-body scanning for lymph node (LN) and distant staging using the ligand gallium 68 (68Ga)-FAPI-46. Materials and Methods In women with histologically confirmed invasive breast cancer, all primary 68Ga-FAPI-46 breast and whole-body PET/MRI and PET/CT examinations conducted at the authors' center between October 2019 and December 2020 were retrospectively analyzed. MRI lesion characteristics and standardized uptake values (SUVs) were quantified with dedicated software. Mann-Whitney U tests were used to compare tumor SUVs across different tumor types. The Pearson correlation coefficient was calculated between SUV and measures of MRI morphologic characteristics. Results Nineteen women (mean age, 49 years ± 9 [standard deviation]) were evaluated-18 to complement initial staging and one for restaging after therapy for distant metastases. Strong tracer accumulation was observed in all 18 untreated primary breast malignancies (mean maximum SUV [SUVmax] = 13.9 [range, 7.9-29.9]; median lesion diameter = 26 mm [range, 9-155 mm]), resulting in clear tumor delineation across different gradings, receptors, and histologic types. All preoperatively verified LN metastases in 13 women showed strong tracer accumulation (mean SUVmax= 12.2 [range, 3.3-22.4]; mean diameter = 21 mm [range, 14-35 mm]). Tracer uptake established or supported extra-axillary LN involvement in seven women and affected therapy decisions in three women. Conclusion This retrospective analysis indicates use of 68Ga fibroblast-activation protein inhibitor tracers for breast cancer diagnosis and staging. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Mankoff and Sellmyer in this issue.

Metaplastic carcinoma breast: Three year histopathological analysis at a tertiary care centre of Kashmir

Background: Metaplastic breast carcinomas (MBCs) comprise a rare but aggressive subtype of breast cancer and represent less than 5% of invasive breast carcinomas. Histologically, metaplastic breast carcinoma is characterized by the presence of divergent cellular differentiation and heterologous elements, including squamous, spindled, sarcomatoid /pleomorphic, chondroid, and osseous differentiation. Material and Methods: Histopathologic characteristics of 11 cases of metaplastic carcinoma of breast encountered over a period of three years from May 2016 to May 2019 in our institute. Results: We encountered 11 cases of metaplastic breast cancers out of 226 primary breast malignancies. Two were breast conservation surgeries and the rest were modified radical mastectomies. The histopathological patterns encountered included squamous, chondroid, sarcomatoid and mixed histologic subtypes. Median tumor size was 3.5 cm, majority were triple-negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2. All except two patients had lymph nodal metastasis. Conclusion: Metaplastic breast carcinoma is a rare type of breast cancer associated with a poor prognosis. Most patients in this series had high-grade, triple-negative tumors and were treated with optimal therapy.