Experience with opposite breast biopsy in patients with operable breast cancer

Synchronous bilateral breast cancer with different histology

Synchronous bilateral breast cancer is a rare clinical entity. And due to both an improved prognosis and growing life expectancy on early detection, we have brought interest in case of patient with synchronous breast cancer. This study reports a case of synchronous bilateral breast cancer in an asymptomatic 70-year-old woman with a positive family history of breast cancer. This woman was diagnosed through radiological screenings, including mammograms, ultrasonography, and magnetic resonance imaging (MRI). On histopathologic examination of the core biopsy, the left breast mass was a Nottingham grade I invasive carcinoma of no particular type. The right breast mass was a Nottingham grade I invasive carcinoma with a mucinous component. After lumpectomies ultrasonography of the surgical specimens confirmed a small biopsy-proven invasive ductal cancer hypoechoic mass in the left breast, with an irregular margins and proven mucinous cancer mass in the right breast. The case was finally diagnosed as synchronous bilateral breast cancer of different pathologic types (ductal and mucinous).

Dynamic helical CT mammography of breast cancer

PURPOSE

The purpose of this study was to determine whether dynamic helical computed tomography (CT)-mammography could assist in selecting the most appropriate surgical method in women with breast cancer.

MATERIALS AND METHODS

Preoperative contrast-enhanced helical CT scanning of the breast was performed on 133 female patients with suspicion of breast cancer at the same time as clinical, mammographic, and/or ultrasonographic examinations. The patients were scanned in the prone position with a specially designed CT-compatible device. A helical scan was made with rapid intravenous bolus injection (3 ml/s) of 100 ml of iodine contrast material. Three-dimensional maximum intensity projection (MIP) images were reconstructed, and CT findings were correlated with surgical and histopathological findings.

RESULTS

Histopathological analysis revealed 84 malignant lesions and seven benign lesions. The sensitivity, specificity, and accuracy levels of the CT scanning were 94.6%, 58.6%, and 78.9%. Helical scanning alone revealed additional contralateral carcinomas in three of four patients and additional ipsilateral carcinomas in three of five patients. However, the technique gave false-positive readings in 24 patients. The preoperative CT-mammogram altered the surgical method in six patients.

CONCLUSION

Dynamic helical CT-mammography in the prone position may be one of the choices of adjunct imaging in patients with suspected breast cancer scheduled for surgery.

Bilateral synchronous breast cancer: mode of detection and comparison of histologic features between the 2 breasts

BACKGROUND

Bilateral synchronous breast cancer is uncommon (accounting for 1.0%-2.6% of all patients with breast cancer), and most physicians do not accumulate a large personal experience of patients with this disease. We reviewed our experience with patients with bilateral synchronous breast cancer, focusing on the mode of detection and histologic features in the 2 breasts.

METHODS

The charts of patients who were treated at this institution for bilateral synchronous breast cancer during the 15-year period of 1984 through 1999 were reviewed. Information regarding age, mode of detection, histopathologic features, treatment, and overall survival were analyzed.

RESULTS

During the study period, 51 patients (all women) were treated at our institution for bilateral synchronous breast cancer. This comprised 2.1% of all patients (n = 2382 patients) treated for breast cancer during the same period of time. The first cancer was detected by palpation in 81% and by mammography in 14%. The corresponding figures for the contralateral cancer were 24% and 54%, respectively. The histologic type of cancer was identical in the 2 breasts in 29 patients (57%) and was different between the 2 breasts in 22 patients (43%). The overall 10-year survival rate was 63%.

CONCLUSIONS

Bilateral synchronous breast cancer is often detected by mammography and is frequently of the same histologic type as the index cancer. A better awareness of the risk for this disease may help detect bilateral breast cancer earlier.

Breast carcinoma: effect of preoperative contrast-enhanced MR imaging on the therapeutic approach

PURPOSE

To determine if magnetic resonance (MR) imaging can help determine the therapeutic approach in women with breast cancer.

MATERIALS AND METHODS

Preoperative contrast-enhanced MR imaging of the breast was performed in 463 patients with probably benign lesions (n = 63), suspicious lesions (n = 230), or lesions highly suggestive of malignancy (n = 170) per established clinical, mammographic, and/or ultrasonographic (US) criteria. T1-weighted fast low-angle shot MR imaging was performed before and after administration of gadopenetetate dimeglumine. MR imaging findings were correlated with other imaging results and histopathologic findings. Special attention was paid to multifocality and multicentricity.

RESULTS

Histopathologic analysis revealed 143 benign and 405 malignant lesions. The sensitivity, specificity, and accuracy were 58%, 76%, and 62% for clinical examination; 86%, 32%, and 72% for conventional mammography; 75%, 80%, and 76% for US; and 93%, 65%, and 85% for contrast-enhanced MR imaging. Multifocality in 30 of 42 patients, multicentricity in 24 of 50 patients, and additional contralateral carcinomas in 15 of 19 patients were depicted with MR imaging alone. Due to the MR imaging findings, therapy was changed correctly in 66 patients (14.3%); unnecessary open biopsy was performed in 16 patients (3.5%).

CONCLUSION

Contrast-enhanced MR imaging of the breast is highly sensitive for invasive breast cancer. MR imaging may reveal unsuspected multifocal, multicentric, or contralateral breast carcinoma and result in therapy changes.

Evolving perspectives in contralateral breast cancer

Despite extensive publications reviewing contralateral breast cancer (CBC), the role of screening and preventative measures for contralateral tumours is controversial and optimal clinical management remains undefined. This paper addresses the incidence, the predisposing factors, the prevention and the treatment of bilateral breast cancer based on a review of the literature. Risk factors for CBC include young age at primary breast cancer diagnosis, hereditary breast cancer (due to a germline mutation), familial breast cancer (one or more affected relatives), radiation exposure at a young age, lobular carcinoma in situ (LCIS), lobular invasive carcinoma and multicentricity. Retrospective studies suggest that contralateral mammographic surveillance results in the early detection of breast cancer, but no clear survival benefit has been demonstrated. Trials of adjuvant tamoxifen in breast cancer patients have shown a reduction in the incidence of CBC in both pre- and postmenopausal women. In addition, breast cancer patients treated with ovarian ablation and prednisone have significantly reduced CBC versus controls. In patients with primary breast cancer there is no evidence that contralateral breast biopsies or contralateral prophylactic mastectomy reduce mortality. Randomised, prospective trials to determine optimal surveillance, prevention and treatment strategies for the contralateral breast in breast cancer patients have not been conducted. Based on the published literature, contralateral breast surveillance in breast cancer patients reasonably includes breast self-examination, regular physical examinations and annual mammography. In women who have no evidence of distant metastasis at the time of CBC diagnosis, we recommend that the CBC be treated in the same manner as a first breast cancer, taking into account prior local and systemic therapy.

MRI of histologically confirmed mammary carcinoma: clinical relevance of diagnostic procedures for detection of multifocal or contralateral secondary carcinoma

PURPOSE

MR mammography (MRM) is a sensitive diagnostic method for the detection of mammary carcinomas. The present study evaluates whether MRM can yield additional relevant data in cases of histologically confirmed mammary carcinoma.

METHOD

Thirty-four patients with histologically confirmed mammary carcinoma were examined at MRM using a T1-weighted GE sequence and a T2-weighted SE sequence. Morphologic criteria and the dynamic contrast medium behavior of the tumors were evaluated.

RESULTS

MRM showed a 100% sensitivity and diagnostic accuracy in the detection of mammary carcinomas. Additionally, three unexpected contralateral carcinomas were discovered. In 26 patients, there was a multifocal or multicentric tumor process. In 24 patients, peritumoral edema was visualized, which corresponded histologically in 21 patients with lymphangiosis and in 3 with an inflammatory peritumoral reaction.

CONCLUSION

Because of its high sensitivity in the diagnosis of multifocal disease and of contralateral carcinomas, MRM would seem to represent a useful addition to preoperative diagnostic procedures. The potential benefit to the patient and its cost efficiency, however, remain to be clarified.

Routine contralateral breast biopsy: helpful or irrelevant? Experience in 871 patients, 1979-1993

OBJECTIVE

Is routine contralateral biopsy in the breast cancer patient justified, and by which parameters can the result be predicted in advance?

SUMMARY BACKGROUND DATA

Routine contralateral biopsy remains controversial, and with the possible exception of an invasive lobular primary, little used by most surgeons. Previous series are biased by small sample size, by interpreting lobular carcinoma in situ (LCIS) as a positive result, by selection on the basis of tumor type, and by the inclusion of patients with clinical or mammographic abnormalities.

METHODS

Among 1113 consecutive patients with breast cancer treated in the author's practice between 1979 and 1993 (excluding 77 patients who had a previous mastectomy, 131 who declined biopsy, and 34 with suspicious clinical or mammographic findings), 871 had a routine contralateral biopsy.

RESULTS

Invasive cancers were found in 1.6%, duct carcinoma in situ in 1.4%, LCIS in 3.2%, and atypical hyperplasia in 6.9% of all random biopsies. If LCIS was excluded as a positive result, invasive lobular carcinoma was not significantly more bilateral than invasive duct (5.2% vs. 2.9%, p = 0.32), nor were in situ tumors more bilateral than invasive (2.5% vs. 3.0%, p = 0.76). Tumor size, axillary node status, and young age were not predictive of a positive result. A positive biopsy result was significantly more frequent in patients older than 50 years of age (4% vs. 1%, p = 0.016), and with a first-degree family history of breast cancer (6.3% vs. 2.2%, p = 0.004).

CONCLUSIONS

The following conclusions can be made: 1. If LCIS was excluded as a positive biopsy result, invasive lobular was not significantly more bilateral than invasive duct cancer. 2. Family history and older age significantly predicted a positive biopsy, whereas young age, tumor size, and axillary node status did not. 3. Routine contralateral biopsy identified conditions (invasive cancer or duct carcinoma in situ) requiring immediate further management in 3.0% of patients, and markers of risk (LCIS or atypia) with the potential to influence future decisions in another 10.1%. 4. As a screening device applied in a high-risk population, with low cost and little morbidity, contralateral biopsy deserves wider consideration in an era of ever-earlier breast cancer diagnosis.

Evaluation of the contralateral breast. The role of biopsy at the time of treatment of primary breast cancer

Ninety-five women who underwent blind contralateral breast biopsy during surgical treatment of a known breast cancer primary were studied prospectively. All biopsies were performed between 1981 and 1989. Patients with palpable or mammographic abnormalities prompting the contralateral biopsy were excluded so that the study sample included only truly blind contralateral biopsies. Only two infiltrating carcinomas were found, resulting in a positive biopsy rate of 2.1% for invasive disease. Three additional biopsies showed only lobular carcinoma in situ, a finding that usually does not alter clinical management. One patient with a negative contralateral biopsy developed invasive carcinoma in that breast within 2 years of the biopsy. The authors were unable to identify any subgroup of patients at increased risk of a positive contralateral biopsy. These results suggest that blind biopsy of the contralateral breast performed at the time of the initial treatment of breast carcinoma is not an efficient method of cancer detection. Alternative management strategies are discussed.

Bilateral breast cancer

A second primary breast cancer in the opposite breast can be either synchronous or metachronous. The majority are metachronous. A woman who has had breast cancer has a fivefold increase in risk for a second breast cancer. Additional risk factors include multifocal cancer, lobular carcinoma in situ, and an original cancer at an early age with long survival. Lobular carcinoma in situ is predominantly a marker for the subsequent development of a second primary breast cancer. The incidence of synchronous bilateral cancer is approximately 1% to 2% and that of metachronous cancer 5% to 6%. The cancer can be invasive or noninvasive. Mammography has increased the number of synchronous cancers found but not the overall incidence. The incidence of invasive cancer detected by random biopsy of the opposite breast is not high enough to justify routine adoption of this procedure. The remaining breast must be followed for the remainder of the patient's life by physical examination and annual mammography. The treatment of the secondary primary breast cancer should be that appropriate for the stage of the disease. The prognosis for the woman with a second primary breast cancer is quite favorable and is dependent on the stage of both the first and the second cancer.

Bilateral breast carcinoma: 28 years' experience

From 1959 to 1987, a total of 1,182 histologically proven breast cancer patients were followed. Of these, 48 (4.06%) with bilateral breast carcinoma were reviewed. Eight patients (0.68%) had simultaneous breast carcinomas and the remaining 40 (3.38%) had nonsimultaneous breast carcinomas. The period between the development of the first and second primary carcinoma ranged from 17 to 200 months (mean, 86 months). The second primary carcinoma was found symmetrically located with the first primary carcinoma in only 34.5% of the cases. No significant differences were observed between the bilateral carcinoma patients and the unilateral carcinoma patients with respect to pregnancy, delivery, family history, and the size and localization of the carcinomas. Axillary metastasis was seen in a higher percentage of the second primary carcinomas (48% versus 37.5%). It was observed that the shorter the time interval between the presentation of the carcinomas, the shorter the survival.

Selective biopsy of the opposite breast

The bilaterality of breast cancer detected by performing a contralateral biopsy has been reported to be 14%. Since the majority of cancers detected were noninfiltrating, a mastectomy was not always performed because of either the advanced stage of the presenting carcinoma or the age of the patient. This study was undertaken to determine the yield of contralateral cancers in younger patients with a better prognosis. Patients younger than 65 years with clinical Stage I and II initial breast cancers were selected for biopsy of the opposite breast between September 1978 and December 1984. Of 651 consecutive patients treated for breast cancer, 610 had an initial breast cancer and 258 (42%) met the criteria. Forty-three contralateral primary breast cancers were detected, for an incidence of 16.7%. In 11 of these 43 patients there was suspicion that a malignancy might be present; these were all infiltrating carcinomas. In 32 patients a truly random biopsy was performed, and the yield was 14.2%. Four (12.5%) of these were infiltrating cancers, and 28 (87.5%) were in situ carcinomas. By selecting patients for biopsy of the opposite breast, a 16.7% incidence of cancers can be detected. Since these patients were younger than 65 years and have a good prognosis in terms of their initial breast cancer, biopsy of the opposite breast is a worthwhile procedure and should be performed with the hope of improving these patients' ultimate outcome.

Bilateral breast cancer. Risk reduction by contralateral biopsy

Although survival from primary breast cancer has improved with earlier diagnosis and treatment, the management of the opposite breast is still in question. The risk factors for bilaterality are known, and preoperative mammography is occasionally helpful, but identification of early second breast cancer is very limited. Contralateral biopsy may provide a reasonable answer to the problem. During a 5-year period, 62 elective contralateral biopsies were performed in patients having mastectomies for primary breast cancer. This consisted of either a mirror image biopsy or, more commonly, a biopsy of the upper outer quadrant. Thirteen patients had simultaneous contralateral cancers, of whom two had clinically overt bilateral cancers and 11 (18%) had clinically occult malignancy. Seven of these 11 had both radiologically and clinically normal breasts. Thus, 11.3% had radiologically and clinically occult cancer demonstrated by biopsy. Surgical management consisted of total mastectomy with low axillary dissection for noninvasive cancers and modified radical mastectomy for invasive cancers. Pathologic findings of the dominant breast cancer and the contralateral lesion were: bilateral, noninvasive: three patients; invasive, noninvasive: (seven patients), and invasive, invasive: three patients. Although follow-up is short (median of 40 months), 82% of the patients who had clinically occult second-breast cancer remain free of disease. During a previous 8-year period, 37 of 500 primary breast cancer patients (7.4%) developed metachronous (33) or synchronous (4) second-breast primary cancers primarily diagnosed clinically or radiologically. Of these, 35 were invasive and two noninvasive cancers; 41% had nodal metastases. A selected "favorable group," 28 of these patients who were free of disease 3 years after their first cancer, was analyzed. The analysis showed that only 10 (36%) were surviving free of disease at 7 years; 25% were free of disease at 10 years. Although the incidence of clinically-recognized, second-primary breast cancer is relatively low, development of a second invasive cancer severely impairs patient survival. Contralateral biopsy would appear useful to identify patients with early invasive or preinvasive cancer in the second breast, which appears normal after clinical observation or mammography. It provides opportunity to reduce the risk of invasive cancer in that breast, as well as to provide important diagnostic and prognostic information.

Pathologic findings from the National Surgical Adjuvant Breast Project (Protocol No. 4). XI. Bilateral breast cancer

Sixty-six confirmed instances of clinically metachronous second breast cancers were encountered over a 10-year period in 1578 women with invasive breast cancer enrolled in Protocol 4 of the National Surgical Adjuvant Breast Project (NSABP). Seven of the second cancers were in situ, yielding an incidence of 3.7% invasive and 0.5% noninvasive cancers. Except for a peak of 1.75% in the second postoperative year, the annual incidence based on patients at risk was constant and less than 1%. Ninety-three percent of the second cancers occurred within 7 years and 80% within 5 years following mastectomy for the initial primary. All of the second cancers were regarded as being primarily of mammary origin exhibiting either: (1) an in situ component; (2) dissimilar but well-recognized patterns of primary breast cancers; or (3) the appearance of scar cancer, a recently described morphologic feature characteristically observed in some primary breast cancers. A search for factors that might be predictive of bilaterality was performed. Thirty-eight pathologic and eight clinical factors were assessed, including family history. Although the latter was 1.5 to 2 times more frequent in patients with bilateral disease, this estimate was not statistically significant. On the other hand, a statistically significant association with bilateral disease was found when the initial tumor measured more than 2.0 cm, was associated with invasive cancer or proliferative fibrocystic disease, nipple involvement, absent nodal sinus histiocytosis, lobular carcinoma in situ in the vicinity of the dominant mass, or was of the lobular invasive or tubular types. However, the degree of risk of these discriminants was no greater than 2 to 3:1. Despite the clinical scrutiny imposed by the NSABP protocol second tumors measured only 1 cm less than the first, measuring on average 2.4 cm, which reflects the difficulty attendant on the clinical detection of so-called early breast cancers. Yet, no significant difference in pathologic nodal status was noted between the first and second cancers or that of patients with unilateral disease. Furthermore, there was no difference in survival rate between patients who developed a second cancer and those with unilateral disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Breast cancer in association with lobular carcinoma in situ. Clinicopathologic review and treatment recommendation

A 6 year follow-up study of 80 women with coexisting lobular carcinoma in situ and infiltrating breast cancer has been conducted to emphasize the natural history and management of these cancers. Treatment of the contralateral breast is of utmost importance as lobular carcinoma in situ is a multicentric neoplasm associated with a subsequent high occurrence of invasive cancer. This series has documented a high incidence of bilateral cancer. Six patients (7.5 percent) had simultaneous bilateral tumors and eight patients (10 percent) had the subsequent development of a second primary tumor, representing approximately four times the expected rate. Despite a well structured out-patient department, follow-up was suboptimal. Six of eight metachronous tumors were detected at a late stage (T2 and greater).

Bilateral breast cancer

The true incidence of bilateral breast cancer, both simultaneous and subsequent, is higher than older statistics indicate, and the frequency can be expected to increase as more efficient methods of detection and treatment become commonplace. Furthermore, there is a subgroup of patients who have an especially high risk for having a second primary cancer in the other breast; if such a cancer develops it deleteriously influences the survival of the patient. A rational approach to the management of the other breast is presented using contralateral biopsy as an added modality for detection and reserving prophylatic matectomy of the other breast for those patients who ar at high risk for developing cancer in it.