The distance between breast cancer and the skin is associated with axillary nodal metastasis

Investigating the role of tumour-to-skin proximity in predicting nodal metastasis in breast cancer

BACKGROUND

Understanding the factors influencing nodal status in breast cancer is vital for axillary staging, therapy, and patient survival. The nodal stage remains a crucial factor in prognostication indices. This study investigates the relationship between tumour-to-skin distance (in T1-T3 tumours where the skin is not clinically involved) and the risk of nodal metastasis.

METHODS

We retrospectively reviewed data from 100 patients who underwent neoadjuvant chemotherapy (NACT). Besides patient demographics and tumour variables, a radiologist retrospectively reviewed pre-operative MRI to measure tumour-to-skin distance. R core packages were used for univariate (χ2 and T-Wilcoxon tests) and bivariate logistic regression statistical analysis.

RESULTS

Of 95 analysable datasets, patients' median age was 51 years (IQR: 42-61), 97% were symptomatic (rest screen detected), and the median tumour size was 43 mm (IQR, 26-52). On multivariate analysis, increasing invasive tumour size (p = 0.02), ER positivity (p = 0.007) and shorter tumour-to-skin distance (p = 0.05) correlated with nodal metastasis.  HER2 was not included in multivariate analysis as there was no association with nodal status on univariate analysis. In node-positive tumours, as tumour size increased, the tumour-to-skin distance decreased (r = - 0.34, p = 0.026). In node-negative tumours, there was no correlation (r = + 0.18, p = 0.23).

CONCLUSION

This study shows that non-locally advanced cancers closer to the skin (and consequent proximity to subdermal lymphatics) are associated with a greater risk of nodal metastasis. Pre-operative identification of those more likely to be node positive may suggest the need for a second-look USS since a higher nodal stage may lead to a change in therapeutic strategies, such as upfront systemic therapy, node marking, and axillary clearance without the need to return to theatre following sentinel node biopsy.

Use of imaging prediction model for omission of axillary surgery in early-stage breast cancer patients

PURPOSE

To develop a prediction model incorporating clinicopathological information, US, and MRI to diagnose axillary lymph node (LN) metastasis with acceptable false negative rate (FNR) in patients with early stage, clinically node-negative breast cancers.

METHODS

In this single center retrospective study, the inclusion criteria comprised women with clinical T1 or T2 and N0 breast cancers who underwent preoperative US and MRI between January 2017 and July 2018. Patients were temporally divided into the development and validation cohorts. Clinicopathological information, US, and MRI findings were collected. Two prediction models (US model and combined US and MRI model) were created using logistic regression analysis from the development cohort. FNRs of the two models were compared using the McNemar test.

RESULTS

A total of 964 women comprised the development (603 women, 54 ± 11 years) and validation (361 women, 53 ± 10 years) cohorts with 107 (18%) and 77 (21%) axillary LN metastases in each cohort, respectively. The US model consisted of tumor size and morphology of LN on US. The combined US and MRI model consisted of asymmetry of LN number, long diameter of LN, tumor type, and multiplicity of breast cancers on MRI, in addition to tumor size and morphology of LN on US. The combined model showed significantly lower FNR than the US model in both development (5% vs. 32%, P < .001) and validation (9% vs. 35%, P < .001) cohorts.

CONCLUSION

Our prediction model combining US and MRI characteristics of index cancer and LN lowered FNR compared to using US alone, and could potentially lead to avoid unnecessary SLNB in early stage, clinically node-negative breast cancers.

The Advantage of Using an Optical See-Through Head-Mounted Display in Ultrasonography-Guided Needle Biopsy Procedures: A Prospective Randomized Study

An optical see-through head-mounted display (OST-HMD) can potentially improve the safety and accuracy of ultrasonography (US)-guided fine-needle aspiration. We aimed to evaluate the usefulness of an OST-HMD in US-guided needle-puncture procedures. We conducted a prospective randomized controlled study in which we compared the accuracy and safety of the US-guided needle puncture procedure and the stress on the practitioner when using OST-HMD versus standard US display (SUD). Inexperienced medical students were enrolled and randomly divided into two groups. A breast phantom was used to evaluate the required time and accuracy of the US-guided needle puncture. Practitioner stress was quantified using a visual analog scale (VAS). When the procedure was performed for the first time, the time required to reach the target lesion at a shallow depth was significantly shorter in the OST-HMD group (39.8 ± 39.9 s) than in the SUD group (71.0 ± 81.0 s) (p = 0.01). Using the OST-HMD significantly reduced the unintentional puncture of a non-target lesion (p = 0.01). Furthermore, the stress felt by the practitioners when capturing the image of the target lesion (p < 0.001), inserting and advancing the needle more deeply (p < 0.001), and puncturing the target lesion (p < 0.001) was significantly reduced in the OST-HMD group compared with that in the SUD group. Use of OST-HMD may improve the accuracy and safety of US-guided needle puncture procedures and may reduce practitioner stress during the procedure.

The effect of the tumor-to-skin distance on axillary lymph node metastasis in breast cancer

OBJECTIVE

Tumor-to-skin distance is known to have an effect on axillary lymph node metastasis but has no clinical use with nomograms. This study aimed to investigate the effect of tumor-to-skin distance on axillary lymph node metastasis alone and in combination with nomogram for clinical use.

METHODS

A total of 145 patients who underwent surgery for breast cancer (T1-T2 stage) and whose axillary lymph nodes were evaluated (axillary dissection or sentinel lymph node biopsy) between January 2010 and December 2020 were included in the study. Tumor-to-skin distance and other pathological data of the patients were evaluated.

RESULTS

Of the 145 patients, 83 (57.2%) had metastatic lymph nodes in the axilla. Tumor-to-skin distance was different in terms of lymph node metastasis (p=0.045). In the receiver operating characteristic curve for tumor-to-skin distance, area under curve was 0.597 (95%CI 0.513-0.678, p=0.046), area under curve of the nomogram was 0.740 (95%CI 0.660-0.809), p<0.001) and nomogram+tumor-to-skin distance was 0.753 (95%CI 0.674-0.820), p<0.001). No statistical difference was found for axillary lymph node metastasis between the nomogram+tumor-to-skin distance and the nomogram alone (p=0.433).

CONCLUSION

Although tumor-to-skin distance demonstrated a significant difference in axillary lymph node metastasis, it had a poor association with an area under curve value of 0.597 and did not produce a significant improvement in predicting lymph node metastasis when combined with the nomogram. The tumor-to-skin distance may be unlikely to enter clinical practice.

The value of prognostic ultrasound features of breast cancer in different molecular subtypes with a focus on triple negative disease

The ultrasound (US) features of breast cancer have recently been shown to have prognostic significance. We aim to assess these features according to molecular subtype. 1140 consecutive US visible invasive breast cancers had US size and mean stiffness by shearwave elastography (SWE) recorded prospectively. Skin thickening (> 2.5 mm) overlying the cancer on US and the presence of posterior echo enhancement were assessed retrospectively while blinded to outcomes. Cancers were classified as luminal, triple negative (TN) or HER2 + ve based on immunohistochemistry and florescent in-situ hybridization. The relationship between US parameters and breast cancer specific survival (BCSS) was ascertained using Kaplan–Meier survival curves and ROC analysis. At median follow-up 6.3 year, there were 117 breast cancer (10%) and 132 non-breast deaths (12%). US size was significantly associated with BCSS all groups (area under the curve (AUC) 0.74 in luminal cancers, 0.64 for TN and 0.65 for HER2 + ve cancers). US skin thickening was associated most strongly with poor prognosis in TN cancers (53% vs. 80% 6 year survival, p = 0.0004). Posterior echo enhancement was associated with a poor BCSS in TN cancers (63% vs. 82% 6 year survival, p = 0.02). Mean stiffness at SWE was prognostic in the luminal and HER2 positive groups (AUC 0.69 and 0.63, respectively). In the subgroup of patients with TN cancers receiving neo-adjuvant chemotherapy posterior enhancement and skin thickening were not associated with response. US skin thickening is a poor prognostic indicator is all 3 subtypes studied, while posterior enhancement was associated with poor outcome in TN cancers

Oncological safety of immediate breast reconstruction with skin- or nipple-sparing mastectomy: the value of tumor-to-dermis distance measured by preoperative ultrasonography

Background

Immediate breast reconstruction with skin-sparing (SSM) or nipple-sparing mastectomy (NSM) has become a common procedure. In this study, we evaluated the distance between breast tumor and skin in a series of patients undergoing IBR as it relates to oncologic safety, namely, the incidence of recurrence.

Methods

The distance of the tumor to the dermis, rather than the outer layer of skin, was the key parameter of our preoperative ultrasound measurements. Our data set comprised the cases of 171 patients and 181 breasts with breast cancer that had undergone two-stage breast reconstruction by expander. The median age of the patients was 47 years (25–75 years). The overall median follow-up period was 47.1 months (8.8–125.3 months). Eighty-five breasts underwent IBR with SSM/NSM; the others underwent conventional mastectomy.

Results

Among the total of 181 reconstructed breast mounds, the locoregional recurrence rate was 1.1% (2 breasts) with no cases of skin flap recurrence or skin flap necrosis. The tumor-to-dermis distance of cases with skin preservation (NSM/SSM) was significantly less than that of cases with conventional mastectomy (3.8 ± 2.7 mm vs 5.2 ± 2.4 mm). In cases with invasive carcinoma, all cases whose tumor-to-dermis distance was less than 2 mm underwent resection of the skin immediately overlying the tumor.

Conclusions

Our results suggested that a 2-mm distance between the dermis and tumor on ultrasound evaluation is sufficient for the use of this tissue as a skin flap in SSM/NSM procedures. Our study indicated that immediate breast reconstruction with SSM/NSM can be an oncologically safe surgical option for breast cancer. However, we recommend that resection of the skin overlying the tumor be performed in cases with invasive breast cancer in which the tumor-to-dermis distance is less than 2 mm.

Trial registration

Patients in this study were retrospectively registered. This study design was approved by our Clinical Ethics Committee (No 1297) (http://ciru.dept.showa.gunma-u.ac.jp/guidance/storage-sample/list.html).

Distance Between the Tumour and Nipple as a Predictor of Axillary Lymph Node Involvement in Breast Cancer

Purpose

The possibility of axillary node metastasis via the lymphatics might be related to a cancer’s location within the breast. Previous studies of this topic had small sample sizes, inaccuracies because of subjective differences, and the inability to depict the entire three-dimensional structure of the breast. Here, we aimed to improve upon these existing drawbacks by retrospectively analysing whether tumour location (quadrants) and tumour–nipple distance can predict axillary node positivity.

Patients and Methods

We identified 961 patients with invasive breast cancer between January 2000 and April 2016. The tumour–nipple distance was objectively measured intraoperatively and clinicopathological information was extracted from hospital database. The distance was measured radially from the nipple to the epicentre rather than the edge of tumour to obviate confounders resulting from tumour size variations.

Results

A total of 847 breast cancers (839 patients) met the eligibility criteria and were included in the statistical analysis. The tumour–nipple distance was smaller in node-positive patients (n = 307; 2.76 ± 2.07 cm) than in node-negative patients (n = 297; 3.41 ± 2.18 cm) (p < 0.001). Tumour–nipple distance was an independent predictor of axillary involvement on logistic regression analysis. However, no statistically significant relationship was detected between node positivity and breast quadrant tumour location.

Conclusion

Tumour–nipple distance can be used to predict axillary lymph node metastasis and assist in surgical decision-making and therapy planning. However, exploratory studies are required to increase our understanding of the mechanism.

Associations between the ultrasound features of invasive breast cancer and breast cancer specific survival

AIM

To assess whether ultrasound features of breast cancer are associated with breast cancer specific survival (BCSS).

MATERIALS AND METHODS

Within a single breast service, data was collected prospectively (April 2010-April 2012) from 319 consecutive women (mean age 63 years) with 335 ultrasound-visible invasive breast cancers. Ultrasound features were evaluated retrospectively from the recorded images according to the Breast Imaging Reporting and Data System (BI-RADS) lexicon by a radiologist blinded to outcomes. Survival and cause of death were ascertained from local and national sources. Kaplan-Meier survival curves were generated, and statistical significance tested using the log-rank test.

RESULTS

Mean follow-up in those alive was 80.9 months. Thirty breast cancer deaths and 45 non-breast cancer deaths occurred. Five-year BCSS in the presence of distal acoustic enhancement was 76% compared to 88%, 96%, and 100% for those with distal shadowing, no distal effect or combined effect respectively (p<0.0002). Patients with sonographic skin involvement had 73% 5-year BCSS compared to 92% for no skin involvement (p<0.0001). Focal oedema was associated with 56% 5-year BCSS compared to 89% for those without (p=0.0002). A significant association was demonstrated between ultrasound tumour size and BCSS (p<0.0001). At multivariate analysis, skin changes, distal enhancement, and focal oedema maintained prognostic significance.

CONCLUSION

Distal enhancement, focal oedema, and skin involvement have strong associations with breast cancer death. These factors could be taken into account, along with lesion size and other commonly used preoperative prognostic features, when considering management of women with breast cancer.

Distance between tumor and nipple as a prognostic factor in breast cancers: Opposite effects in young and old patients

The present study aimed to investigate the prognostic implication of distance from tumor to nipple according to clinicopathological factors with known prognostic value.We retrospectively identified 961 patients of invasive breast cancer from January 2000 to April 2016. Clinicopathological information was extracted from hospital database and distance from tumor to nipple was objectively measured during surgeries. Overall survival (OS) and disease-free survival (DFS) were compared among patients with tumor-nipple distance ≤2, 2 to 5, and >5 cm. Subgroup analyses were performed according to age at diagnosis (≤35 vs >35), tumor size, histological features, treatment, axillary nodal metastasis and lymphovascular invasion.A total of 627 cases were included in statistical analysis. There was no difference detected in OS or DFS among patients with different tumor-nipple distance. Better OS was associated with greater tumor-nipple distance in old patients (HR = 0.582, 95%CI: 0.345-0.982, P = 0.042), while the association between OS and tumor-nipple distance was not observed in young patients. DFS was influenced by tumor-nipple distance in both young (HR = 5.321, 95%CI: 1.151-24.595, P = 0.032) and old (HR = 0.593, 95%CI: 0.385-0.913, P = 0.018) patients with opposite effects.Tumor-nipple distance can be adopted as a prognostic factor of breast cancer and it functions oppositely in young and old patients. Multicenter prospective studies with larger sample size are needed to validate the result.

Cutaneous metastasis of ascending colon cancer harboring a BRAF V600E mutation: A rare case report

RATIONALE

Cutaneous metastases from colorectal cancer are extremely rare and generally appear several years after diagnosis or resection of the primary colorectal tumor. Although cutaneous metastasis is unusual, it often indicates a poor prognosis.

PATIENT CONCERNS

We treated a 62-year-old woman with multiple cutaneous metastatic nodules on the chest, back, and armpit 7 months after resection of ascending colon cancer.

DIAGNOSES

The patient was diagnosed with cutaneous metastasis of ascending colon cancer with BRAF V600E mutation.

INTERVENTIONS

After 6 cycles of fluorouracil, leucovorin, oxaliplatin, cetuximab, and emurafenib, most of the metastatic lesions had begun to shrink, and no new metastases were observed. Serum tests showed that the levels of several tumor markers were decreased.

OUTCOMES

The patient responded well to treatment and survived for 6.5 months after presentation with skin metastasis.

LESSONS

Cutaneous metastasis of colorectal cancer with BRAF V600E mutation is a rare but important phenomenon that should not be ignored. Cutaneous metastasis of colorectal cancer frequently indicates advanced disease and poor prognosis. The SWOG 1406 program is one of the treatment options, but this needs further exploration.

Mode of presentation and skin thickening on ultrasound may predict nodal burden in breast cancer patients with a positive axillary core biopsy

OBJECTIVE

A number of pre-operative factors predicting nodal burden in females with breast cancer have recently been identified. The aim of this study is to assess if these factors independently influence nodal burden in females with a positive axillary core biopsy.

METHODS

All node positive patients detected on axillary core biopsy were identified in our cancer audit database. Mode of presentation, age, core tumour grade, core tumour type, ER and HER2 status were evaluated. Tumours were assessed for ultrasound size, distance of tumour-to-skin, presence of invasion of skin and diffuse skin thickening. Axillary lymph nodes were assessed for cortical thickness and presence of ultrasound replaced nodes. Statistical significance was ascertained using univariate logistic regression. A predictive model was produced following a multiple logistic regression model incorporating cross-validation and assessed using receiving operating characteristic curve.

RESULTS

115 patients' data were analysed. Patients referred because of symptoms (70% vs 38%, p = 0.005), and those with ultrasound skin thickening (87% vs 59%, p = 0.055) have higher nodal burden than those referred from screening or without skin thickening. These factors were significant after multivariate analysis. The final predictive model included mode of presentation, ultrasound tumour size, cortical thickness and presence of ultrasound skin thickening. The area under curve is 0.77.

CONCLUSION

We have shown that mode of presentation and ultrasound skin thickening are independent predictors of high nodal burden at surgery. A model has been developed to predict nodal burden pre-operatively, which may lead to avoidance of axillary node clearance in patients with lower nodal burden.

ADVANCES IN KNOWLEDGE

Method of presentation and skin involvement/proximity to skin by the primary tumour are known to influence outcome and nodal involvement respectively but have not been studied with regard to nodal burden. We have shown that mode of presentation and skin thickening at ultrasound are independent predictors of high nodal burden at surgery.

Distance of Tumor to Skin as a Predictive Marker for Axillary Lymph Node Metastasis in Cases of Breast Carcinoma - A Retrospective Study

Background: Breast cancer is arising as the most common cancer among women. Axillary lymph node status is considered as one of the most important predictors of survival in breast cancer and a very important component to the staging system. The tumors under the skin have abundant access to the dermal lymphatic and have an increased chance of metastasizing to draining lymph nodes. Aim of the Study: To evaluate whether distance of tumor to skin can be considered as a predictor for lymph node metastasis. Materials and Methods: This was a retrospective study on all operated cases of infiltrating mammary carcinoma from January 2013 to December 2016. Both lumpectomy and mastectomy specimens with invasive carcinoma component were included in the study. The distance of the tumor was measured from the base of the epidermis of the skin to the anterior margin of the tumor on gross examination or microscopically the closest invasive carcinoma component. The distance was measured, tabulated, and correlated with the nodal status on axillary node dissection. Also, compared are the other parameters such as size, site, and grade of the tumor. Results:: Out of 200 patients enrolled, positive nodes were seen in 67.5% (135) of cases, of which tumor with distance from skin <0.3 cm show maximum nodal positivity (64.4%) and maximum cases with N2 and N3 disease (48.8%). Most important and significant finding was that 100% cases with tumor size corresponding in T2 size with skin invasion either grossly or microscopically and T3 size tumor with microscopically involving epidermis was positive for metastatic deposits in axillary nodes and 10/11 cases (90%) in T4 stage were positive. Conclusion: The distance of tumor from skin is an important predictor for Axillary lymph nodal metastasis in invasive breast cancers. Closer the tumor, the incidence of axillary nodal metastasis increases. Hence, distance of tumor from skin should be considered while evaluating a breast cancer patient.

Nipple-Invasive Primary Carcinomas: Clinical, Imaging, and Pathologic Features of Breast Carcinomas Originating in the Nipple

Context Patients choosing to retain the nipple when undergoing therapeutic or prophylactic mastectomy are at risk for cancers arising at that site. Objective To identify cases of invasive carcinoma arising within the nipple and to investigate their clinical, imaging, biologic, and staging features. Design Carcinomas were identified by prospective review of surgical and consult cases at 4 hospitals. Results The 24 patients identified presented with symptoms related to the nipple. Mammography did not detect the cancer in most cases. Ten patients (42%) had skin changes from ductal carcinoma in situ involving nipple skin (Paget disease), with small foci of invasion into the dermis, and 6 of those 10 carcinomas (60%) stained positive for human epidermal growth factor receptor 2 (HER2). The remaining 14 patients (58%) presented with a nipple mass or with skin changes. These were larger invasive carcinomas of both ductal and lobular types. Only 2 of those 14 carcinomas (14%) were HER2⁺. Three of 15 patients (20%) undergoing lymph node biopsy had a single metastasis. No patients have had recurrent disease. Conclusions Rare, invasive, primary nipple carcinomas typically present as subtle nipple thickening or an exudative crust on the skin. Imaging studies are often nonrevealing. A variety of histologic and biologic types of carcinomas occur, similar to cancers arising deeper in the breast. Although the carcinomas invaded into the dermis, some with skin ulceration, the likelihood of lymph node metastasis was no higher than carcinomas of similar sizes. Patients who choose to preserve their nipple(s) should be aware of the possibility of breast cancer arising at that site and to bring any observed changes to the attention of their health care providers.

Feasibility of spatial frequency-domain imaging for monitoring palpable breast lesions

In breast cancer diagnosis and therapy monitoring, there is a need for frequent, noninvasive disease progression evaluation. Breast tumors differ from healthy tissue in mechanical stiffness as well as optical properties, which allows optical methods to detect and monitor breast lesions noninvasively. Spatial frequency-domain imaging (SFDI) is a reflectance-based diffuse optical method that can yield two-dimensional images of absolute optical properties of tissue with an inexpensive and portable system, although depth penetration is limited. Since the absorption coefficient of breast tissue is relatively low and the tissue is quite flexible, there is an opportunity for compression of tissue to bring stiff, palpable breast lesions within the detection range of SFDI. Sixteen breast tissue-mimicking phantoms were fabricated containing stiffer, more highly absorbing tumor-mimicking inclusions of varying absorption contrast and depth. These phantoms were imaged with an SFDI system at five levels of compression. An increase in absorption contrast was observed with compression, and reliable detection of each inclusion was achieved when compression was sufficient to bring the inclusion center within ∼12  mm of the phantom surface. At highest compression level, contrasts achieved with this system were comparable to those measured with single source-detector near-infrared spectroscopy.