Symptomatic Breast Research Articles

Evaluation of core-needle biopsy in Breast Imaging Reporting and Data System 3 breast mass

Background/aim A crucial approach for finding breast cancer sooner is the triple examination of breast diseases. Our goal was to determine if ultrasound-guided core biopsies were required to investigate clinically ambiguous breast tumors that lacked imaging features suspicious for malignancy in Breast Imaging Reporting and Data System 3. Patients and methods A prospective study was performed on 50 patients fulfilling our eligibility criteria who presented with symptomatic indeterminate breast masses chosen according to our selection criteria and underwent an ultrasonography-guided core biopsy in the period from January 2021 to March 2022. Results A total of 50 clinically ambiguous breast masses were investigated, of which 47 (94%) were benign lesions, including 34 (68%) lesions were fibroadenomas, six (12%) lesions were fibrocystic disorder without ductal hyperplasia, one (2%) lesion was fibrocystic disease with ductal hyperplasia with no atypia, and six (12%) lesions showed periductal mastitis. Two (4%) lesions were proliferative breast lesions with focal atypia. One (2%) lesion was infiltrating duct carcinoma grade 2. Conclusion Ultrasound-guided core biopsy is necessary for investigating clinically indeterminate breast mass in symptomatic patients with Breast Imaging Reporting and Data System 3 finding on imaging, for early detection of malignancy and atypical hyperplastic changes.

Blue flag clinics – a Quality Improvement project to reduce referral pressure on breast surgery 2 week wait service

Introduction: The breast cancer urgent suspected cancer referral pathway is under unprecedented pressures. A Quality Improvement project implemented a new triaging criterion of 2 pathways; red flag (suspected breast cancer referral; same day triple assessment within 2 weeks) and blue flag (symptomatic breast referral; clinical assessment within 2 weeks and uncoupled imaging if required). This evaluation assesses whether the blue flag clinic reduces imaging and its safety.

Assessment of Spinal Metastases Surgery Risk Stratification Tools in Breast Cancer by Molecular Subtype.

Breast cancer molecular features and modern therapies are not included in spine metastasis prediction algorithms. To examine molecular differences and the impact of postoperative systemic therapy to improve prognosis prediction for spinal metastases surgery and aid surgical decision making. This is a retrospective multi-institutional study of patients who underwent spine surgery for symptomatic breast cancer spine metastases from 2008 to 2021 at the Massachusetts General Hospital and Brigham and Women's Hospital. We studied overall survival, stratified by breast cancer molecular subtype, and calculated hazard ratios (HRs) adjusting for demographics, tumor characteristics, treatments, and laboratory values. We tested the performance of established models (Tokuhashi, Bauer, Skeletal Oncology Research Group, New England Spinal Metastases Score) to predict and compare all-cause. A total of 98 patients surgically treated for breast cancer spine metastases were identified (100% female sex; median age, 56 years [IQR, 36-84 years]). The 1-year probabilities of survival for hormone receptor positive, hormone receptor positive/human epidermal growth factor receptor 2+, human epidermal growth factor receptor 2+, and triple-negative breast cancer were 63% (45 of 71), 83% (10 of 12), 0% (0 of 3), and 12% (1 of 8), respectively ( P < .001). Patients with triple-negative breast cancer had a higher proportion of visceral metastases, brain metastases, and poor physical activity at baseline. Postoperative chemotherapy and endocrine therapy were associated with prolonged survival. The Skeletal Oncology Research Group prognostic model had the highest discrimination (area under the receiver operating characteristic, 0.77 [95% CI, 0.73-0.81]). The performance of all prognostic scores improved when preoperative molecular data and postoperative systemic treatment plans was considered. Spine metastases risk tools were able to predict prognosis at a significantly higher degree after accounting for molecular features which guide treatment response.

Trajectories to a cancer diagnosis: Why and when women seek help for breast symptoms in Vietnam.

Women in low- and middle-income countries where the prevalence and mortality of breast cancer are growing rapidly are more likely to be diagnosed at advanced stages, which negatively affects their treatment outcomes and chance of survival. The current literature in those settings tends to focus largely on explaining patient delay in seeking medical attention for breast symptoms. Meanwhile, little is known as to what prompts women to attend screening and diagnostic services after discovering symptomatic breasts. Drawn upon the data from in-depth interviews with 33 breast cancer patients in Central Vietnam conducted in 2019, this paper examines the context of women's decisions about breast screening and how the practice of seeking cancer diagnosis occurred. Our findings reveal an absence of a national screening program and that seeking medical advice was conducted on an ad hoc basis after self-detection of breast symptoms. Women's interpretations of symptomatic breasts as suspicious signs of cancer, the co-occurrence of important life events, or encouragement by people in their social network motivated women to seek medical attention at different public and private health facilities. Their encounters with the health sector often involved multiple visits across time and space in which they experienced various forms of diagnosis delay produced by the health system. Our study carries implications for interventions to encourage women's awareness of early cancer symptoms and prompt medical presentation after self-discovery of symptomatic breasts.

Delayed diagnostic evaluation of symptomatic breast cancer in sub-Saharan Africa: A qualitative study of Tanzanian women.

BackgroundWomen with breast cancer in sub-Saharan Africa are commonly diagnosed at advanced stages. In Tanzania, more than 80% of women are diagnosed with stage III or IV disease, and mortality rates are high. This study explored factors contributing to delayed diagnostic evaluation among women with breast cancer in Tanzania.MethodsA qualitative study was performed at Muhimbili National Hospital in Dar es Salaam, Tanzania. Twelve women with symptomatic pathologically proven breast cancer were recruited. In-depth, semi-structured interviews were conducted in Swahili. Interviews explored the women’s journey from symptom recognition to diagnosis, including the influence of breast cancer knowledge and pre-conceptions, health seeking behaviors, psychosocial factors, preference for alternative treatments, and the contribution of culture and norms. Audio-recorded interviews were transcribed and translated into English. Thematic analysis was facilitated by a cloud-based qualitative analysis software.ResultsAll women reported that their first breast symptom was a self-identified lump or swelling. Major themes for factors contributing to delayed diagnostic presentation of breast cancer included lack of basic knowledge and awareness of breast cancer and misconceptions about the disease. Participants faced barriers with their local primary healthcare providers, including symptom mismanagement and delayed referrals for diagnostic evaluation. Other barriers included financial hardships, fear and stigma of cancer, and use of traditional medicine. The advice and influence of family members and friends played key roles in healthcare-seeking behaviors, serving as both facilitators and barriers.ConclusionLack of basic knowledge and awareness of breast cancer, stigma, financial barriers, and local healthcare system barriers were common factors contributing to delayed diagnostic presentation of breast cancer. The influence of friends and family also played key roles as both facilitators and barriers. This information will inform the development of educational intervention strategies to address these barriers and improve earlier diagnosis of symptomatic breast cancer in Tanzania.

872 The Role of Clinical Core Biopsy in Palpable Breast Lumps with Normal Imaging: 10 Year Experience of a Tertiary Symptomatic Breast Service

Abstract Aim Patients presenting with a palpable breast lump with normal imaging presents an investigative challenge. While the reported sensitivity of US and mammogram is high, radiologically occult cancers do occur. Traditionally these patients have undergone clinical core biopsy. The aim of our study was to examine the use of clinical core biopsy in our department over a 10-year period and assess its efficacy in diagnosing radiographically occult malignancies. Method We performed a retrospective review of a prospectively maintained database of all clinical core biopsies performed from 2010–2019 in a symptomatic tertiary breast cancer unit. Patients who underwent fine needle aspiration or skin punch biopsy without breast clinical core biopsy were excluded. A number of patients underwent clinical core biopsy despite abnormal radiological findings for clinical reasons, these patients were excluded from the final analysis. Clinical examination findings, radiological findings and ultimate pathological findings were reviewed. Results 370 clinical core breast biopsies were performed over the study period. 11 patients were excluded as they underwent clinical biopsies despite abnormal imaging. Of the remaining 359 biopsies, 349 (97.21%) were benign and 9 (2.51%) required further investigation. Of these patients, 6 underwent excisional biopsy with one patient being diagnosed with DCIS. The remaining excisional biopsies were benign. 1 patient (0.29%) with normal imaging was diagnosed with a malignancy on clinical core biopsy. Conclusions The management of patients with palpable breast lumps despite normal imaging is challenging. Clinical core biopsy, in the context of normal imaging, has a low rate of detection of malignancy.

267 Axillary Recurrence Following Negative Sentinel Lymph Node Biopsy for Symptomatic Invasive Breast Cancer: A Ten-Year Review

Abstract Aim Sentinel node biopsy (SNB) became established as the standard approach (versus axillary clearance) for axillary staging in the 2000s. This was based on studies showing reductions in short-term morbidity. Symptomatic cancers are biologically more aggressive than screen-detected cancers and are more susceptible to late loco-regional recurrence. Few studies have examined long-term axillary recurrence following SNBs in this subgroup. Method A retrospective case-note review was performed on 82 symptomatic breast cancer patients who had a negative SNB between 2009 and 2010. Clinicopathological data was collected on cancers, axillary nodal pathology, recurrence, and survival. Results Median age was 57 years (range 23–87). Mean tumour size was 20mm (range: 5–50). Fourteen cancers (17%) were ER negative, 11 (19.3%) HER2 positive and 30 (36.3%) were grade 3. Sixty-one (74%) patients had breast-conserving surgery and 21 patients (26%) underwent a mastectomy. After a median follow up of 11.8 years, 3 (3.7%) local, 1 (1.2%) axillary and 10 (12.2%) distant recurrences were seen. Twenty patients (25%) died. The median OS was 11.64 years (range: 1.20–12.47) and median DFS was 11.50 years (range: 1.14–12.47). Axillary recurrence rates were comparable to other studies that contained predominantly screening cancers (0.7–1.6%). Conclusion The risk of axillary recurrence and remains low at 10-year follow up after a negative SNB in symptomatic patients. This is comparable to that of follow up studies in mixed (screening and symptomatic) cohorts demonstrating equivalent long-term oncological safety in this biologically more aggressive cohort.

Prognosis of asymptomatic versus symptomatic metastatic breast cancer: a multicenter retrospective study

In Japan, asymptomatic metastatic breast cancer (MBC) is often detected using tumor markers or imaging tests. We aimed to investigate differences in clinicopathological features, prognosis, and treatment between asymptomatic and symptomatic MBCs. Patients with MBC were retrospectively divided into asymptomatic and symptomatic groups to compare their prognosis by breast cancer subtype: luminal, human epidermal growth factor receptor 2 positive, and triple negative. Of 204 patients with MBC (114 asymptomatic, 90 symptomatic), the symptomatic group had a higher frequency of multiple metastatic sites and TN subtype. All cohorts in the asymptomatic group tended to or had longer post-recurrence survival (PRS) than those in the symptomatic group. In contrast, all cohorts and TN patients in the asymptomatic group tended to have or had longer overall survival (OS) than those in the symptomatic group, although no significant difference was observed in the luminal and HER2 subtypes. In the multivariate analysis, TN, recurrence-free survival, multiple metastatic sites, and symptomatic MBC were independently predictive of PRS. Regarding the luminal subtype, the asymptomatic group had longer chemotherapy duration than the symptomatic group, with no significant difference in OS between the groups. Asymptomatic and symptomatic MBCs differ in terms of subtypes and prognosis, and whether they require different treatment strategies for each subtype warrants further investigation.

TH1.7 Patterns of care of male breast cancer in clinical practice: A five-year single institution experience

Abstract Aims Only 1% of all diagnosed breast cancers are in male patients. Overwhelmingly, current literature addresses breast cancer in female patients. This study aims to analyse the investigation and management of male breast cancers in a busy Symptomatic Breast Unit. Methods We conducted a single-centre review of male breast cancers diagnosed in our institution between January 2016 and December 2020. Initial presenting symptoms, imaging findings, histology and follow-up data were collected via a prospectively maintained database. Results The most common presenting symptom was a palpable breast lump (69%). Other symptoms included nipple bleeding/discharge (15%) and skin ulceration (8%). 62% of cases were located centrally behind, or involved, the nipple. The most common pathology was invasive ductal carcinoma (77%). One patient was diagnosed with invasive papillary carcinoma, while two patients were diagnosed with different cancers (spindle cell sarcoma and metastasis of medullary carcinoma of the thyroid). 77% of patients were managed operatively, with all undergoing a simple mastectomy. A sentinel lymph node biopsy or axillary clearance was performed in 62% and 8% of cases respectively. Several patients underwent adjuvant radiotherapy (62%) and chemotherapy (54%). 77% of patients were ER/PR positive, with 15% HER2+ positive. 100% of these patients received appropriate endocrine therapy. Conclusions Although female breast cancer commonly presents in the upper outer quadrant of the breast this study found that more male breast cancers occur centrally and involved the nipple. As breast cancer in male patients is rare, larger cohorts are required to confirm the findings of this study.

TH1.4 Indication for clinical biopsy in symptomatic breast disease- A closed loop audit

Abstract Aims Royal College of Radiologists states core biopsy is indicated where imaging is normal, but clinical assessment is P3 and above. However, many clinicians opt for clinical biopsy following normal imaging results despite clinical assessment under P3. We recommended: reserving clinical biopsies following normal imaging for women &amp;gt;50 year; performing ultrasound and mammogram in women &amp;lt;40 years with clinically (P3-P5) or ultrasonically (U3-U5) findings. Here we look at the impact of our recommendations on clinical practice and patient diagnosis. Methods All patients who had clinical biopsies were analysed within a six-month time period in 2019 and 2020. 43 patients were included in 2019. 78 patients were identified in 2020. 14 were excluded as they had history of breast malignancy, or a biopsy diagnosis of non-breast malignancy. Results 64 patients were included in our analysis. Improvements in the 2020 audit cycle compared to 2019 included: Lesser women &amp;lt;40 years with P3/U3 not getting MMG prior to clinical breast biopsy (15.4% compared to 80.0%); higher rates of both MMG and targeted US were performed in women 340 years with score 3U3 (86.8% compared to 41.9%). Only 6 (9.4%) patients returned with malignant biopsy results. No patients (compared to 1) who underwent clinical biopsy for symptomatic breast disease following normal imaging showed malignant biopsy results. Conclusion Our findings indicate a low test positivity rate for clinical biopsies performed following normal imaging. Being prudent and selective in the type of patients clinical biopsies are carried out have a positive impact on clinical practice and patient diagnosis.

O051 Incidence and management of axillary lymphadenopathy post COVID-19 vaccination in a symptomatic breast unit

Abstract Introduction Following the mass rollout of COVID-19 vaccination, regional lymphadenopathy presents as a diagnostic dilemma for clinicians. The aim of this study explores the incidence and management of unilateral axillary lymphadenopathy following vaccination at a symptomatic tertiary breast unit. Methods This is a retrospective review of a prospectively maintained database of all patients who underwent axillary imaging for symptomatic or incidental axillary lymphadenopathy detected on imaging following COVID-19 vaccination between January 2021 – December 2021. Radiological and histological information were obtained from the hospital s NIMIS radiology and PIPE histology system. Additional patient and clinical information was obtained from patient's clinical notes. Results A total of 253 patients underwent axillary ultrasounds during the twelve-month interval. Of these 24 (9.4%) of patients underwent investigation for axillary lymphadenopathy related to recent COVID vaccination. Of these, 21 patients had image consistent reactive nodes while the remaining 3 patients had normal radiological investigation. Only 6 patients underwent ultrasound guided biopsy of these nodes which confirmed reactive notes. Conclusion Patient and clinician education is required to raise awareness in COVID-19 related axillary lymphadenopathy. Standardization in the management including the timing of breast screening and radiological investigation in relation to COVID vaccination is required, in order to minimize over investigation in this patient cohort. Take-home message COVID-19 vaccine related axillary lymphadenopathy is being seen in tertiary symptomatic breast clinic. Patient and clinician education is necessary to raise awareness of this and contribute to a standardised approach of investigation and management of this phenomenon.

A Single-Center Audit of Symptomatic Breast Cancer Patient Referrals During COVID-19 Pandemic Restrictions.

BackgroundRecommendations to balance cancer care with patient and hospital staff safety have been issued to hospitals during the coronavirus disease (COVID-19) pandemic. Concerns have been raised that service restrictions could jeopardize effective cancer management. Thus, this study aimed to conduct an audit to verify this proposition.MethodsWe conducted an audit comparing two-week wait (2ww) breast cancer referrals in our center between May and July 2019 and 2020. The primary endpoints were changes in the overall referral rates, differences in the waiting time, and breast cancer diagnosis rates between the two cohorts. Group differences were evaluated using the chi-square test (χ2). A p-value of <0.05 at 95% CI was considered significant.ResultsThe 2ww referrals decreased by 442 (28.3%) in 2020 (2019 N=1564 vs. 2020, N=1122). Referrals in 2020 were associated with a higher rate of two-week specialist consultation than referrals in 2019 (p<0.05). The 2020 patient cohort was associated with a higher rate of breast cancer diagnosis than the 2019 cohort (6.9% vs. 4.9%, p<0.05). Of the 521 patients who had telephone consultations, 29.2% were discharged, and 367 (70.4%) had post-telephone one-stop clinic visits, of which 9.0% had breast cancer.ConclusionsThe audit provided evidence of effective breast cancer services during the COVID-19 pandemic restrictions. The study results could inform patients and the general public at large that the waiting time and breast cancer diagnosis are not compromised during COVID-19 pandemic management. The high rates of post-telephone one-stop clinic visits and cancer diagnosis may indicate weakness in triage and difficulties in diagnosing nonspecific presentation of cancer over the telephone.

Post-recurrence survival in asymptomatic compared with symptomatic metastatic breast cancer: A multicenter retrospective study.

1049 Background: Asymptomatic metastatic breast cancer (mBC) is often detected using tumor marker or imaging tests in Japan. At the ASCO 2019, we reported on mBC detection, the distribution of symptomatic and asymptomatic disease by subtype (abstract e12568). We aimed to determine whether there are differences in post-recurrence survival (PRS), and treatment between asymptomatic and symptomatic MBCs, and identify factors associated with PRS. Methods: We performed a multicenter, retrospective analysis of patients with mBC treated in our hospitals from 2008 to 2018. Patients were divided into asymptomatic and symptomatic MBCs to compare their prognosis by breast cancer (BC) subtypes: luminal (hormone receptor positive/human epidermal growth factor 2 [HER2] negative), HER2 (any hormone receptor/HER2 positive), and triple-negative (TN) (hormone receptor negative/HER2 negative). Results: Of 204 patients with mBC (114 asymptomatic, 90 symptomatic), PRS was longer in asymptomatic mBC than in symptomatic mBC (median survival: 55 months vs. 29 months; p &lt; 0.001) and tended to have longer overall survival (OS) (110 months vs 72 months, respectively; p = 0.09). In multivariate analysis, TN, recurrence-free survival (RFS), multiple metastasis sites, and symptomatic disease were independently predictive of PRS (Table). In luminal and HER2, PRS trended higher in the asymptomatic group than in the symptomatic group (luminal: 54 months vs. 41 months; p = 0.08, HER2: 71 months vs. 27 months; p = 0.09), but without significant difference in OS (luminal: 112 months vs. 124 months; p = 0.91, HER2: 113 months vs. 72 months; p = 0.40). In the luminal group, 13 patients (11%) were treated with cyclin-dependent kinase 4/6 (CDK4/6) inhibitors. The median PRS was 80 months for luminal patients with three factors — longer than 4 years of RFS, a single metastasis site, and asymptomatic disease. The duration of endocrine therapy did not differ between groups; however, the patients with luminal BC in the asymptomatic group had longer chemotherapy than those in the symptomatic group. In TN, PRS was very short (asymptomatic, 28 months; symptomatic, 10.5 months; p = 0.01). Conclusions: We demonstrated that asymptomatic MBC and symptomatic MBC differed in terms of subtypes, prognosis, and duration of chemotherapy in the luminal group. Therefore, unique treatment strategy for asymptomatic or symptomatic MBC should be developed. [Table: see text]

Artificial intelligence improves efficiency in the one stop symptomatic breast clinic

Introduction: Research to date has focused on the role of Artificial Intelligence (AI) in breast cancer diagnosis as an alternative to conventional mammographic reporting by radiologists. This project assessed the role of AI in supporting conventional radiological assessment of symptomatic breast patients with a view to improving the efficiency of the triple assessment process and reducing waiting times.

Reducing imaging of the symptomatic male breast - Audit of compliance with national guidelines

Introduction: Male breast imaging is often over-utilised, especially in the absence of suspicious presentation. Local practice was audited against the Royal College of Radiologists (RCR) 2019 guidelines.

Axillary recurrence following negative sentinel lymph node biopsy for symptomatic invasive breast cancer: A ten-year review

Aims: Sentinel node biopsy (SNB) became established as the standard approach (versus axillary clearance) for axillary staging in the 2000s. This was based on studies showing reductions in short-term morbidity. Symptomatic cancers are biologically more aggressive than screen-detected cancers and are more susceptible to late loco-regional recurrence. Few studies have examined long-term axillary recurrence following SNBs in this subgroup.

A multivariable triage model to support direct access of symptomatic breast patients to specialist breast units?

Background: Patients with breast symptoms access specialist care when referred by their General Practitioner (GP). The One-Stop Clinics (OSCs) remain the standard of specialist breast care but are resource-dependent, and OSCs are inundated with low specificity referrals, more so, since the Covid-19 crisis. Direct Patient Access (DPA) is theoretically more efficient and avoids delayed diagnoses. However, DPA can potentially further overwhelm breast units with self-referrals unless a reliable triage model that enables risk-based resource allocation is adopted.

Breast pain: Releasing capacity on the 2WW symptomatic service

Introduction: In the UK there are 560,000 symptomatic breast referrals annually, and this is continuing to rise. Approximately 20% of all referrals to one-stop breast clinic in the UK are related to breast pain. We investigated whether a 'Non-urgent Mastalgia Clinic' would be a safe and feasible option to relieve the pressure on the symptomatic service.

Referral patterns of male patients to a symptomatic breast clinic

Introduction: In 2021, the Association of Breast Surgery (ABS) published guidelines for the assessment, referral, and investigation of men with breast symptoms consistent with gynaecomastia. This retrospective study assesses the appropriateness of referrals made to a DGH during a one-year period.

AB170. SOH22ABS197. Streamlining the family history service in a symptomatic breast clinic: a quality improvement project

AB170. SOH22ABS197. Streamlining the family history service in a symptomatic breast clinic: a quality improvement project