Outcome of breast-conserving treatment for axillary lymph node metastasis from occult breast cancer with negative breast MRI

Proteomic profiling reveals biological processes and biomarkers involved in the pathogenesis of occult breast cancer

BACKGROUND

Occult breast cancer (OBC) is defined as axillary lymph node metastasis without any evidence of a primary tumor in the breast. Because of the limited number of clinical cases, the clinicopathological features and treatment recommendations of OBC are still controversial. In addition, its natural history is poorly understood and its proteomic signature remains unknown.

MATERIALS AND METHODS

We compared the clinicopathological features and prognosis of OBC patients and Non-OBC patients from the Surveillance, Epidemiology, and End Results (SEER) database and analyzed the effects of local treatment on the survival outcomes of OBC patients. Additionally, we performed a quantitative proteomic analysis for tissue samples of metastatic lymph nodes from OBC patients (OBC-LN), and paired tissue samples of metastatic lymph nodes (Non-OBC-LN) and primary tumors (Non-OBC-PT) from Non-OBC patients. We identified differentially expressed proteins in different comparable groups using Student's t test. Functional enrichment and protein-protein interaction network analyses were used to interpret the functions and interactions of the differentially expressed proteins in the comparison of OBC-LN vs Non-OBC-LN. Immunohistochemistry was used for the validation of the hub proteins.

RESULTS

Analysis of data from the SEER database demonstrated that OBC patients had a better prognosis than Non-OBC patients did and that either mastectomy or radiation therapy improved the outcomes of OBC patients. A total of 7208 comparable proteins were successfully quantified. Compared with those of the Non-OBC-LN samples, the OBC-LN protein profiles exhibited an active extracellular matrix and a thoroughly upregulated epithelial-mesenchymal transition phenotype. COL1A1, COL1A2, COL3A1, MMP2 and LUM were overexpressed in the OBC-LN samples and were identified as hub proteins. Immunohistochemical staining demonstrated that the five hub proteins were overexpressed in OBC-LN samples.

CONCLUSION

Our results provide insights for the clinical management of OBC and the proteomic signature of OBC offers molecular basis for further biological research.

Clinicopathological features, psychological status, and prognosis of 33 patients with occult breast cancer

BACKGROUND

Occult breast cancer (OBC) has traditionally been considered to be a carcinoma of unknown primary origin with a favorable prognosis and can be treated as stage II-III breast cancer. Due to the small number of cases and limited clinical ex-perience, treatments vary greatly around the world and no standardized treat-ment has yet been established.

AIM

To investigate the clinicopathological features, psychological status and prog-nostic features of patients with OBC.

METHODS

The clinicopathological data of 33 OBC patients diagnosed and treated in the Affiliated Hospital of Xuzhou Medical University and Xuzhou Central Hospital from November 2015 to November 2022 were retrospectively analyzed. The psychological status of OBC patients was evaluated by the Self-rating Anxiety Scale and Self-rating Depression Scale. Patients' emotions, stress perception and psychological resilience were evaluated by the Positive and Negative Affect Schedule, the Chinese Perceived Stress Scale, and the Connor-Davidson Resilience Scale (CD-RISC), respectively. Patient survival was calculated using the Kaplan-Meier method, and survival curves were plotted for analysis with the log-rank test. Univariate and multivariate survival analyses were performed using the Cox regression model.

RESULTS

The 33 OBC patients included 32 females and 1 male. Of the 33 patients, 30 (91%) had axillary tumors, 3 (9%) had a neck mass as the primary symptom; 18 (54.5%) had estrogen receptor-positive tumors, 17 (51.5%) had progesterone receptor-positive tumors, and 18 (54.5%) had Her-2-positive tumors; 24 (72.7%) received surgical treatment, including 18 patients who underwent modified radical mastectomy, 1 patient who underwent breast-conserving surgery plus axillary lymph node dissection (ALND), and 5 patients who underwent ALND alone; 12 patients received preoperative neoadjuvant therapy. All 30 patients developed anxiety and depression, with low positive affect scores and high negative affect scores, accompanied by a high stress level and poor psychological resilience. There were no differences in the psychological status of patients according to age, body mass index, or menopausal status. The overall survival and disease-free survival (DFS) of all the patients were 83.3% and 55.7%, respectively. Univariate analysis demonstrated that the initial tumor site (P = 0.021) and node stage (P = 0.020) were factors that may affect patient prognosis. The 5-year DFS rate of OBC patients who received radiotherapy was greater (P < 0.001), while the use of different surgical methods (P = 0.687) had no statistically significant effect on patient outcomes. Multivariate analysis revealed that radiotherapy (P = 0.031) was an independent prognostic factor. Receiving radiotherapy had a significant effect on the CD-RISC score (P = 0.02).

CONCLUSION

OBC is a rare breast disease whose diagnosis and treatment are currently controversial. There was no significant difference in the efficacy of other less invasive surgical procedures compared to those of modified radical mastectomy. In addition, radiotherapy can significantly improve patient outcomes. We should pay attention to the psychological state of patients while they receive antitumor therapy.

Development of a Rare Earth Nanoprobe Enables In Vivo Real-Time Detection of Sentinel Lymph Node Metastasis of Breast Cancer Using NIR-IIb Imaging

Sentinel lymph node (SLN) biopsy plays a critical role in axillary staging of breast cancer. However, traditional SLN mapping does not accurately discern the presence or absence of metastatic disease. Detection of SLN metastasis largely hinges on examination of frozen sections or paraffin-embedded tissues post-SLN biopsy. To improve detection of SLN metastasis, we developed a second near-infrared (NIR-II) in vivo fluorescence imaging system, pairing erbium-based rare-earth nanoparticles (ErNP) with bright down-conversion fluorescence at 1,556 nm. To visualize SLNs bearing breast cancer, ErNPs were modified by balixafortide (ErNPs@POL6326), a peptide antagonist of the chemokine receptor CXCR4. The ErNPs@POL6326 probes readily drained into SLNs when delivered subcutaneously, entering metastatic breast tumor cells specifically via CXCR4-mediated endocytosis. NIR fluorescence signals increased significantly in tumor-positive versus tumor-negative SLNs, enabling accurate determination of SLN breast cancer metastasis. In a syngeneic mouse mammary tumor model and a human breast cancer xenograft model, sensitivity for SLN metastasis detection was 92.86% and 93.33%, respectively, and specificity was 96.15% and 96.08%, respectively. Of note, the probes accurately detected both macrometastases and micrometastases in SLNs. These results overall underscore the potential of ErNPs@POL6326 for real-time visualization of SLNs and in vivo screening for SLN metastasis.

SIGNIFICANCE

NIR-IIb imaging of a rare-earth nanoprobe that is specifically taken up by breast cancer cells can accurately detect breast cancer macrometastases and micrometastases in sentinel lymph nodes.

De-escalation of surgery for occult breast cancer with axillary metastasis

Occult breast cancer presenting as axillary metastasis is rare and remains a diagnostic and therapeutic challenge. Evidence to guide clinical management is limited, and locoregional treatment remains nonstandardized and highly varied nationally. Historically, occult breast cancer was managed with modified radical mastectomy ± radiotherapy; however, equivalent local control and survival are observed with breast preservation and adjuvant whole breast radiotherapy. Axillary lymph node dissection remains the standard surgical approach to the axilla for occult breast cancer patients. De-escalating axillary surgery in a subset of occult breast cancer patients treated with neoadjuvant chemotherapy with good response to treatment may be appropriate, similar to the management of clinically node-positive patients in a known primary setting. As in other clinically node-positive breast cancer cases, thoughtful integration and tailoring of axillary surgery and regional nodal radiotherapy (for the varying extent of nodal burden) is an area of continued controversy and active investigation.

Best treatment options for occult breast cancer: A meta-analysis

Objectives

Occult breast cancer (OBC) is a rare malignant breast tumor. Because of the rare cases and limited clinical experience, a huge therapeutic difference has existed all over the world and standardized treatments have yet been established.

Methods

A meta-analysis was conducted using MEDLINE and Embase databases to identify the choice of OBC surgical procedures in all studies: (1) patients undergoing axillary lymph node dissection (ALND) or sentinel lymph node biopsy (SLNB) only; (2) patients undergoing ALND with radiotherapy (RT); (3) patients undergoing ALND with breast surgery (BS); (4) patients undergoing ALND with RT and BS; and (5) patients undergoing observation or RT only. The primary endpoints were mortality rates, the second endpoints were distant metastasis and locoregional recurrence.

Results

Among the 3,476 patients, 493 (14.2%) undergo ALND or SLNB only; 632 (18.2%) undergo ALND with RT; 1483 (42.7%) undergo ALND with BS; 467 (13.4%) undergo ALND RT and BS, and 401 (11.5%) undergo observation or RT only. After comparing the multiple groups, both groups 1 and 3 have higher mortality rates than group 4 (30.7% vs. 18.6%, p < 0.0001; 25.1% vs. 18.6%, p = 0.007), and group 1 has higher mortality rates than groups 2 and 3 (30.7% vs.14.7%, p < 0.00001; 30.7 vs. 19.4%, p < 0.0001). Group (1 + 3) had a prognosis advantage over group 5 (21.4% vs. 31.0%, p < 0.00001). There was no significant difference both in the distant recurrence rates and locoregional rates between group (1 + 3) and group (2 + 4) (21.0% vs. 9.7%, p = 0.06; 12.3% vs. 6.5%, p = 0.26).

Conclusion

On the basis of this meta-analysis, our study indicates that BS including modified radical mastectomy (MRM) and breast-conserving surgery (BCS) combined RT may appear as the optimal surgical approach in patients with OBC. RT cannot prolong both the time of distant metastasis and the local recurrences.

Adenocarcinoma of the Breast Presenting as Occult Breast Cancer With Axillary and Supraclavicular Lymph Node Metastasis: A Case Report

Breast cancer is a leading cause of cancer-related mortality in women, with over 250,000 new cases diagnosed annually in the United States. Although mortality rates have decreased, breast cancer remains the second most common cause of cancer death in women. Occult breast cancer (OBC), a rare form of breath cancer that typically presents as axillary lymphadenopathy with no evidence of primary disease, accounts for less than 1% of all breath cancer diagnoses. To date, only three cases of OBC treated with radical mastectomy have been documented in the literature. This case presents a 76-year-old female with a benign left breast mass who was subsequently diagnosed with metastatic estrogen receptor/progesterone receptor (ER/PR)-positive ductal cell breast carcinoma after a visible axillary lymph node was detected on follow-up imaging. Due to the rarity of OBC, standardized treatment guidelines have not been established. Our patient underwent a left radical mastectomy with axillary and cervical lymph node dissection. Clinicians should maintain a high index of suspicion for biopsying axillary lymph nodes in females without evidence of breast malignancy, even though OBC has a low incidence rate. This case report aims to present a documented case of OBC and comprehensibly review the existing literature, discussing the available diagnostic and treatment approaches for this condition. We describe the case of a 76-year-old woman referred to surgery consultation due to a mammographic finding of a left superior lateral mass. The mass was biopsied and found to have no malignancy. On follow-up imaging, she was found to have a left axillary lymph node visible. Her only complaints at this time were breast tenderness and swelling. She underwent fine needle aspiration of the mass, which showed atypical cells that led to an excisional biopsy of the detected axillary node. The biopsy pathology report showed ER/PR-positive ductal cell breast carcinoma. The patient underwent left modified radical mastectomy with left axillary and cervical lymph node dissection. It was during this procedure that the pathology report revealed a 2 cm lesion on the left breast that showed ER/PR-positive infiltrating ductal carcinoma with 32 out of the 37 lymph nodes positive for metastatic disease. This case illustrates the importance of having a low imaging threshold in patients with vague breast symptoms. Surgeons should have a high level of suspicion when metastatic breast cancer is found, even if there is no clinical or radiographic evidence of a primary lesion. This includes conducting lymph node biopsies in patients who present with lymphadenopathy without the initial presence of primary breast cancer. Many studies agree that a modified radical mastectomy with lymph node recession is the treatment of choice for metastatic breast cancer without evidence of primary lesion. However, the efficacy of adjuvant treatments like radiation therapy or chemotherapy should be further studied.

Prognostic Models Using Machine Learning Algorithms and Treatment Outcomes of Occult Breast Cancer Patients

BACKGROUND

Occult breast cancer (OBC) is an uncommon malignant tumor and the prognosis and treatment of OBC remain controversial. Currently, there exists no accurate prognostic clinical model for OBC, and the treatment outcomes of chemotherapy and surgery in its different molecular subtypes are still unknown.

METHODS

The SEER database provided the data used for this study's analysis (2010-2019). To identify the prognostic variables for patients with ODC, we conducted Cox regression analysis and constructed prognostic models using six machine learning algorithms to predict overall survival (OS) of OBC patients. A series of validation methods, including calibration curve and area under the curve (AUC value) of receiver operating characteristic curve (ROC) were employed to validate the accuracy and reliability of the logistic regression (LR) models. The effectiveness of clinical application of the predictive models was validated using decision curve analysis (DCA). We also investigated the role of chemotherapy and surgery in OBC patients with different molecular subtypes, with the help of K-M survival analysis as well as propensity score matching, and these results were further validated by subgroup Cox analysis.

RESULTS

The LR models performed best, with high precision and applicability, and they were proved to predict the OS of OBC patients in the most accurate manner (test set: 1-year AUC = 0.851, 3-year AUC = 0.790 and 5-year survival AUC = 0.824). Interestingly, we found that the N1 and N2 stage OBC patients had more favorable prognosis than N0 stage patients, but the N3 stage was similar to the N0 stage (OS: N0 vs. N1, HR = 0.6602, 95%CI 0.4568-0.9542, p < 0.05; N0 vs. N2, HR = 0.4716, 95%CI 0.2351-0.9464, p < 0.05; N0 vs. N3, HR = 0.96, 95%CI 0.6176-1.5844, p = 0.96). Patients aged >80 and distant metastases were also independent prognostic factors for OBC. In terms of treatment, our multivariate Cox regression analysis discovered that surgery and radiotherapy were both independent protective variables for OBC patients, but chemotherapy was not. We also found that chemotherapy significantly improved both OS and breast cancer-specific survival (BCSS) only in the HR-/HER2+ molecular subtype (OS: HR = 0.15, 95%CI 0.037-0.57, p < 0.01; BCSS: HR = 0.027, 95%CI 0.027-0.81, p < 0.05). However, surgery could help only the HR-/HER2+ and HR+/HER2- subtypes improve prognosis.

CONCLUSIONS

We analyzed the clinical features and prognostic factors of OBC patients; meanwhile, machine learning prognostic models with high precision and applicability were constructed to predict their overall survival. The treatment results in different molecular subtypes suggested that primary surgery might improve the survival of HR+/HER2- and HR-/HER2+ subtypes, however, only the HR-/HER2+ subtype could benefit from chemotherapy. The necessity of surgery and chemotherapy needs to be carefully considered for OBC patients with other subtypes.

Survival analysis and nomogram for early-stage occult breast cancer with positive lymph nodes based on the SEER database

Background

Occult breast cancer (OBC) is a rare type of breast cancer, which accounts for 0.3-1.0% of all breast cancers. However, the treatment of OBC remains controversial, especially the local treatment. We aimed to analyze the impact of different treatment and N stage on survival in early-stage OBC patients, and construct a nomogram to predict the prognosis.

Methods

The data of patients with early-stage breast cancer were obtained from 17 registries in the Surveillance, Epidemiology, and End Results (SEER) database. Patient characteristics and breast cancer-specific survival (BCSS) were compared among the groups. Cox proportional risk models were used for both the univariate and multivariate analyses. Variables with a P value <0.07 in the univariate analysis were included in the multivariate analysis. The independent prognostic factors were included in the nomogram and validated internally.

Results

A total of 492 early-stage OBC patients were randomized at a 7:3 ratio into the training cohort (n=348) and the testing cohort (n=144). N2+ stage patients had a worse prognosis than N1 stage patients (P=0.0051). Triple-negative breast cancer (TNBC) patients had the worst prognosis. Early-stage OBC patients benefited from surgery (P=0.0093) and radiotherapy (P=0.0102), but not chemotherapy (P=0.4030). An analysis of OBC patients with different N stages showed that in terms of treatment, N1 stage patients benefited from surgery (P=0.023), but did not benefit significantly from radiotherapy (P=0.0793), whereas N2+ stage patients benefited from radiotherapy (P=0.0098), but the benefit from surgery was not significant (P=0.1005). In the multivariate analysis, N stage, surgery, and radiotherapy remained statistically significant. Based on the results of the multivariate analysis, we constructed a nomogram for estimating the 3- and 5-year BCSS of OBC patients. The concordance index and the calibration plots show that our nomogram had sufficient accuracy and good coordination.

Conclusions

N stage, surgery, and radiotherapy were identified as independent prognostic factors for OBC. We successfully constructed a nomogram using these independent risk factors and demonstrated that it could help predict the 3- and 5-year BCSS of OBC patients. Further data analyses need to be conducted to revise the treatment of early-stage OBC.

Occult breast cancer presenting as axillary lymphadenopathy - Case Report

INTRODUCTION

Occult breast carcinoma (OBC) is a rare entity and therefore generates discussion regarding diagnosis, approach, and prognosis. This article aims to present a case of OBC and reviews some concepts discussed in the literature.

PRESENTATION OF CASE

43-year-old woman with right axillary adenopathies, without further complaints, whose biopsy shows a lymph node metastasis from invasive ductal carcinoma of the breast. Breast study, breast RMI and FDG-PET did not identify the primary tumour. As decided by a multidisciplinary team, the patient underwent neoadjuvant chemotherapy, axillary surgery, breast radiotherapy and hormone therapy. Four years after surgery, the patient has no evidence of the primary tumour and no axillary recurrence.

DISCUSSION

OBC was described in 1907. Although the best therapeutic approach is widely discussed in the literature, it is consensual that as long as the existence of a primary tumour is excluded by breast MRI, the conservative approach (excision of axillary adenopathy and breast and axillary radiotherapy) is more advocated.

CONCLUSION

Breast cancer must be considered in the differential diagnosis of a patient with axillary lymphadenopathy. The conservative approach of OBC is the preferred since breast MRI does not identify any suspicious lumps.

Sensitive and specific detection of breast cancer lymph node metastasis through dual-modality magnetic particle imaging and fluorescence molecular imaging: a preclinical evaluation

PURPOSE

A sensitive and specific imaging method to detect metastatic cancer cells in lymph nodes to detect the early-stage breast cancer is still a challenge. The purpose of this study was to investigate a novel breast cancer-targeting and tumour microenvironment ATP-responsive superparamagnetic iron oxide nanoparticles (SPIOs) imaging probe (abbreviated as SPIOs@A-T) that was developed to detect lymph node metastasis through fluorescence molecular imaging (FMI) and magnetic particle imaging (MPI).

METHODS

The conjugation of the targeted peptide CREKA and SPIOs was via linker sulfo-SMCC, while the dsDNA-Cy5.5 was modified on SPIOs through the conjugation between maleimide group in sulfo-SMCC and sulfydryl group in dsDNA-Cy5.5. SPIOs@A-T was characterised for its imaging properties, targeting ability and toxicity in vitro. Mice with metastatic lymph node (MLN) of breast cancer were established to evaluate the FMI and MPI imaging strategy in vivo. Healthy mice with normal lymph node (NLN) were used as control group. Histological examination and biosafety evaluation were performed for further assessment.

RESULTS

After injection with SPIOs@A-T, the obvious high fluorescent intensity and MPI signal were observed in MLN group than those in NLN group. FMI can specifically light up MLN using an ATP-responsive fluorescence design. On the other hand, MPI could complement the limitation of imaging depth from FMI and could detect MLN more sensitively. Besides, the biosafety evaluation results showed SPIOs@A-T had no detectable biological toxicity.

CONCLUSION

SPIOs@A-T imaging probe in combination with FMI and MPI can provide a promising novel method for the precise detection of MLN in vivo.

Clinicopathological characteristics and treatment outcomes of occult breast cancer: a population-based study

BACKGROUND

Occult breast cancer (OBC) is a special type of breast cancer. Because of its rarity, clinicopathological information is still insufficient, causing a controversial condition about its treatment recommendation. Thus, we aimed to clarify major clinicopathological information, treatment strategies and prognosis of OBC based on a large population.

METHODS

We retrospectively collected adult female OBC population from Surveillance, Epidemiology, and End Results database. We divided the whole cohort into two groups based on surgical treatment in-breast. Descriptive analysis of 18 clinicopathological variables was conducted. Survival analysis was performed based on different clinicopathological factors. Univariate and multivariate Cox regression analysis was performed to identify potential independent predictor for prognosis of OBC.

RESULTS

1189 OBC patients were in final analysis and most of them were diagnosed as an early-stage carcinoma. Patients received breast-conserving treatment (BCT) was nearly two times of ones received mastectomy. Patients receiving radiotherapy in BCT group were significantly more than patients receiving radiotherapy in mastectomy group (61.76 vs. 50.9%, P  <   0.001). After a median follow-up period of 62 months, 5-year and 10-year overall survival (OS) of all subjects was 81.6% and 68.8%, respectively. No significant difference in OS and breast-cancer specific survival (BCSS) was found between mastectomy and local breast-conserving surgery. Older age and larger number of positive lymph nodes causes a worse prognosis whereas radiotherapy brought a better clinical outcome for OBC patients.

CONCLUSIONS

OBC has a generally good prognosis. Less-intensive surgery does not negatively impact clinical outcomes of OBC while additional radiotherapy is totally beneficial to prolong OS and BCSS.

Surgical treatment trends and identification of primary breast tumors after surgery in occult breast cancer: a study based on the Japanese National Clinical Database-Breast Cancer Registry

BACKGROUND

Occult breast cancer (OBC) is classified as carcinoma of an unknown primary site, and the adequate therapy for OBC remains controversial. This retrospective study aimed to reveal the transition in breast cancer therapy and the frequency of primary breast tumors after resection in clinical OBC (cT0N+) patients using the Japanese Breast Cancer Registry database.

METHODS

We enrolled OBC patients with cT0N+ from the registry between 2010 and 2018. On the basis of the period of diagnosis, OBC patients were divided into the following two groups: 2010-2014 and 2015-2018. We described the transition in treatments and tumor characteristics. After breast resection, the frequency of pathological identification of primary tumors and tumor sizes was assessed.

RESULTS

Of the 687,468 patients registered, we identified 148 cT0N+ patients with a median age of 61 years. Of these patients, 64.2% (n = 95) received breast surgery (2010-2014: 79.1%, 2015-2018: 50.0%). Axillary lymph node dissection was performed in 92.6% (n = 137, 2010-2014: 91.6%, 2015-2018: 93.4%). The breast tumor size in the resected breast was 0-7.0 cm (median: 0 cm, 2010-2014: 0-7.0 cm [median: 0 cm], 2015-2018: 0-6.2 cm [median: 0 cm]). The pathological identification rate of the primary tumor was 41.1% (n = 39, 2010-2014: 40.4%, 2015-2018: 42.1%).

CONCLUSIONS

Breast surgery for cT0N+ decreased between 2010 and 2018. Despite the high identification rate of primary tumors, most tumors were small, and there was no significant change in the identification rate or invasive diameter of the identified tumors after 2010.

Histologic Discordance Between Primary Tumor and Nodal Metastasis in Breast Cancer: Solving a Clinical Conundrum in the Era of Genomics

Next-generation sequencing (NGS) technologies have become increasingly used for managing breast cancer. In addition to the conventional use of NGS for predicting recurrence risk and identifying potential actionable mutations, NGS can also serve as a powerful tool to understand clonal origin and evolution of tumor pairs and play a unique role in clarifying complex clinical presentations. We report an unusual case of early-stage breast cancer in which the primary tumor and draining axillary node were histologically discordant. The primary tumor was invasive lobular carcinoma, whereas the nodal metastasis was invasive ductal carcinoma. This discordance led us to question whether the tumors had the same origin. NGS performed on both specimens identified no overlapping variants, leading us to conclude that the patient had two separate primary breast cancers, with the nodal tumor representing metastasis from an occult breast cancer. DNA sequencing of the primary tumor and the nodal metastasis allowed us to predict the patient's recurrence risk, and we initiated adjuvant chemotherapy and hormonal therapy based on these results. This case illustrates the utility of NGS for successfully managing a rare and challenging case. KEY POINTS: A degree of molecular concordance is expected for tumors originating from a common stem or progenitor cell. Histological discordance and absence of any genomic overlap should raise suspicion for two separate primary tumors. Paired DNA sequencing of the primary tumor and nodal metastasis can inform clinical decisions when primary breast tumor and axillary metastasis are histologically discordant. Molecular/Precision Oncology Tumor Board is the best setting to facilitate such decisions in these challenging cases. Paired DNA sequencing under these rare circumstances may suggest an occult breast tumor.

What's Hot in Breast MRI

Several articles in the literature have demonstrated a promising role for breast MRI techniques that are more economic in total exam time than others when used as supplement to mammography for detection and diagnosis of breast cancer. There are many technical factors that must be considered in the shortened breast MRI protocols to cut down time of standard ones, including using optimal fat suppression, gadolinium-chelates intravascular contrast administrations for dynamic imaging with post processing subtractions and maximum intensity projections (MIP) high spatial and temporal resolution among others. Multiparametric breast MRI that includes both gadolinium-dependent, i.e., dynamic contrast-enhanced (DCE-MRI) and gadolinium-free techniques, i.e., diffusion-weighted/diffusion-tensor magnetic resonance imaging (DWI/DTI) are shown by several investigators that can provide extremely high sensitivity and specificity for detection of breast cancer. This article provides an overview of the proven indications for breast MRI including breast cancer screening for higher than average risk, determining chemotherapy induced tumor response, detecting residual tumor after incomplete surgical excision, detecting occult cancer in patients presenting with axillary node metastasis, detecting residual tumor after incomplete breast cancer surgical excision, detecting cancer when results of conventional imaging are equivocal, as well patients suspicious of having breast implant rupture. Despite having the highest sensitivity for breast cancer detection, there are pitfalls, however, secondary to false positive and false negative contrast enhancement and contrast-free MRI techniques. Awareness of the strengths and limitations of different approaches to obtain state of the art MR images of the breast will facilitate the work-up of patients with suspicious breast lesions.

The role of ultrasound elastography and virtual touch tissue imaging in the personalized prediction of lymph node metastasis of breast cancer

Background

This study examined the effects of different ultrasound imaging technologies in the identification and prediction of axillary lymph node metastasis of breast cancer. It also investigated the relationship between human papilloma virus (HPV) infection and axillary lymph node metastasis.

Methods

Eighty-five female patients diagnosed with breast masses participated in this study. Each patient underwent a conventional ultrasound, ultrasonic elastography, and virtual touch tissue imaging quantification (VTIQ). The differential diagnosis efficiency of a conventional ultrasound, ultrasound elastography, VTIQ, and ultrasound elastography combined with VTIQ technology was compared with a pathological diagnosis, which represents the gold standard. 85 axillary lymph node tissues and 25 normal breast tissues were used to detect HPV positive infection rate differences in different tissues.

Results

The results showed that metastatic lymph nodes and reactive lymph node hyperplasia accounted for 54.12% and 45.88% of the 85 axillary lymph nodes of breast cancer, respectively. The conventional ultrasound, ultrasound elastography, and VTIQ scores of metastatic lymph nodes were significantly higher than those of reactive lymph node hyperplasia (P<0.05). The diagnostic sensitivity (Se) (91.30%), specificity (Sp) (92.31%), accuracy (Ac) (91.76%), positive predictive value (PPV) (93.33%), and negative predictive value (NPV) (90.00%) of ultrasound elastography combined with VTIQ technology were the highest among the diagnostic efficiency test results of different computer ultrasound imaging technologies. The positive infection rate of HPV in metastatic lymph node tissues was significantly higher than that in reactive lymph node hyperplasia and normal breast tissues (P<0.05).

Conclusions

Combining ultrasound elastography with VTIQ technology has high value in the differential diagnosis of axillary lymph nodes of breast cancer. Further, it appears that HPV infection may have an etiological role in lymph node metastasis in breast cancer patients.

Occult breast cancer: Where are we at?

Occult breast cancer (OBC) is described as an axillary metastatic carcinoma without detection of a primary breast lesion and is uncommon. Significant advances in breast imaging have occurred since its description, decreasing its incidence. However current management is based upon old studies, with variable clinical, radiological and pathological definitions of OBC. We suggest standardised definitions of OBC to facilitate more homogenous data representation in the literature. This review also discusses the conflicting heterogeneous data and its influence in determining the current management guidelines. We discuss whether the current significant surgical recommendations are necessary and postulate whether they could be safely substituted with less invasive management.

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Pathological occult breast cancer is defined as no lesion detectable on MRI or pathological breast lesion post-surgery when examined at 5mm slices

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NAC in OBC may result in the de-escalation of axillary surgery.

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Current evidence indicates that ALND with ipsilateral breast RT has equivalent outcomes compared to ALND with mastectomy