Performance of CT scan of abdomen and pelvis in detecting asymptomatic synchronous metastasis in breast cancer

Utility of systemic staging in breast cancer patients with a positive sentinel lymph node biopsy

BACKGROUND

CT thorax, abdomen and pelvis (CT-TAP) remains the standard in the identification of metastatic disease in patients with newly diagnosed breast cancer. In patients with proven micro and macro axillary nodal metastasis, the optimal radiological technique remains controversial. A consensus on which patients with axillary nodal disease should receive radiological staging for distant disease and how this should be performed is not currently available. The aim of this study was to evaluate the yield from CT staging of the thorax, abdomen and pelvis (CT-TAP) in patients with proven nodal disease.

METHODS

Patients diagnosed with invasive breast cancer with a positive sentinel lymph node biopsy (SLNB) and subsequent staging CT-TAP between 2013 and 2017 were identified. Patient demographics, clinicopathological characteristics, CT-TAP findings and further imaging requirements were documented.

RESULTS

A total of 234 patients were identified. Of these, 164 (70%) were found to have macrometastasis and 70 (30%) to have micrometastasis or isolated tumour cells on SLNB. Within the macrometastasis cohort, abnormalities were noted on staging CT-TAP for 100 (61%) patients. Eighty of the 100 received follow-up assessment of abnormalities with 3 (2%) patients being diagnosed with distant metastatic disease. Within the micrometastasis group, abnormalities on CT-TAP staging were noted in 36 (52.1%) patients. Twenty-eight (40%) patients required further investigation and follow-up. No patient was found to have metastatic disease within this group.

CONCLUSION

Patients diagnosed with micrometastatic disease of the axilla following a sentinel lymph node biopsy do not require systemic staging as it fails to detect metastatic disease.

Can Ki-67 serve as a suitable marker to indicate the necessity of staging diagnostics in cases of low-risk breast cancer?

BACKGROUND

For many years, staging tests have not been routinely employed for low-risk early breast cancer (EBC). However, the role of Ki-67 in determining the need for staging tests in low-risk EBC remains unclear. Our study aimed to assess the number and types of staging diagnostics, additional imaging, false-positive results, and rate of distant metastases in low-risk EBC with low and high Ki-67 (< / ≥ 25%).

METHODS

This is a retrospective, single institution cohort study. All patients with newly diagnosed low-risk breast cancer at the University Medical Center in Freiburg in 2017 and 2021 were included. Low-risk was defined as clinical tumor stage T1/2, node negative (N0), hormone receptor positive, HER2 negative, asymptomatic EBC. Information on demographics, clinical and pathological characteristics, as well as number and type of performed staging diagnostics was obtained. Rate and type of additional imaging or follow-up diagnostics due to suspicious findings was analyzed. The patients were divided into two groups (Ki-67 < and ≥ 25%) and rates of distant metastases, performed staging diagnostics and false positive rates were compared.

RESULTS

A total of 189 patients with low-risk EBC were identified, with 54% (n = 102) having Ki-67 < 25% and 46% (n = 87) having Ki-67 ≥ 25%. Risk for distant metastases was 0% in Ki-67 < 25% and 1.1% in patients with Ki-67 ≥ 25% (p = 0.46). Due to suspicious findings in the initial staging diagnostic, additional imaging was required for 11.8% (n = 12) of patients with Ki-67 < 25% compared to 19.5% (n = 17) of patients with Ki-67 ≥ 25% (p = 0.16). False positive rates did not differ significantly between the two groups (7.6% in Ki-67 < 25% vs. 9.8% in Ki-67 ≥ 25%; p = 0.55).

CONCLUSION

Distant metastases are rare in low-risk EBC. All in all, staging diagnostics should not be routinely employed in this patient population. Only patients with high Ki-67 developed distant metastases. In these cases, staging diagnostics may be discussed with the patient.

Predictive models and biomarkers for survival in stage III breast cancer: a review of clinical applications and future directions

Stage III breast cancer, characterized by locally advanced tumors and potential regional lymph node involvement, presents a formidable challenge to both patients and healthcare professionals. Accurate prediction of survival outcomes is crucial for guiding treatment decisions and optimizing patient care. This publication explores the potential clinical utility of predictive tools, encompassing genetic markers, imaging techniques, and clinical parameters, to improve survival outcome predictions in stage III breast cancer. Multimodal approaches, integrating these tools, hold the promise of delivering more precise and personalized predictions. Despite the inherent challenges, such as data standardization and genetic heterogeneity, the future offers opportunities for refinement, driven by precision medicine, artificial intelligence, and global collaboration. The goal is to empower healthcare providers to make informed treatment decisions, ultimately leading to improved survival outcomes and a brighter horizon for individuals facing this challenging disease.

Current Role and Future Prospects of Positron Emission Tomography (PET)/Computed Tomography (CT) in the Management of Breast Cancer

Breast cancer has become the most diagnosed cancer in women globally, with 2.3 million new diagnoses each year. Accurate early staging is essential for improving survival rates with metastatic spread from loco regional to distant metastasis, decreasing mortality rates by 50%. Current guidelines do not advice the routine use of positron emission tomography (PET)-computed tomography (CT) in the staging of early breast cancer in the absence of symptoms. However, there is a growing body of evidence to suggest that the use of PET-CT in this early stage can benefit the patient by improving staging and as a result treatment and outcomes, as well as psychological burden, without increasing costs to the health service. Ongoing research in PET radiomics and artificial intelligence is showing promising future prospects in its use in diagnosis, staging, prognostication, and assessment of responses to the treatment of breast cancer. Furthermore, ongoing research to address current limitations of PET-CT by improving techniques and tracers is encouraging. In this narrative review, we aim to evaluate the current evidence of the usefulness of PET-CT in the management of breast cancer in different settings along with its future prospects, including the use of artificial intelligence (AI), radiomics, and novel tracers.

Radiologic patterns of distant organ metastasis in advanced breast cancer patients: Prospective review of computed tomography images

BACKGROUND

Breast cancer (BC) metastases to the abdomen and pelvis affect the liver, mesentery, retroperitoneum, peritoneum, bladder, kidney, ovary, and uterus. The study documented the radiological pattern and features of the chest, bone, abdominal and pelvic (AP) metastases among advanced BC patients.

AIM

The aim is to document the radiological pattern and features of breast cancer metastasis in the chest, abdomen, pelvis and bones.

MATERIALS AND RESULTS

Chest, abdominal, and pelvic computed tomography scan images of 36 patients with advanced BC were collated from Cape Coast Teaching Hospital and RAAJ Diagnostics. The images were prospectively assessed for metastasis to the organs of the chest, AP soft tissues, and bones. Radiologic features of metastasis of the lungs, liver, lymph nodes (LNs), and bones were documented. Patients' demographics, clinical data, and histopathology reports were also collected. The data were captured using UVOSYO and exported to Microsoft Excel templates. The data obtained were descriptively analyzed. Only 2.8% of BCs exhibited metaplastic BC, whereas 97.2% had invasive ductal BC. Triple-negative cases were 55.6%. Of 36 patients, 31 (86.1%), 21 (58.3%), and 14(38.8%) were diagnosed of chest, AP, and bone tissues metastasis, respectively. LN involvement was reported in 26 (72.2%) patients. Majority, 21 (58.3%) were diagnosed of multiple sites metastasis with 15 (41.7%) showing single site. Lungs (77.4%, 24/31) and liver (47.6%, 10/21) were the most affected distant organs. Most bone metastases were lytic lesions (92.9%, 13/14) with the vertebrae (85.7%, 12/14) been the most affected.

CONCLUSION

According to the study, advanced BC patients have a higher-than-average radiologic incidence of lung, liver, bone, and LN metastases.

Diagnostic yield of contrast-enhanced abdominal staging CT in patients with initially diagnosed breast cancer

PURPOSE

To estimate the diagnostic yield (DY) of abdominal staging CT for detecting breast cancer liver metastasis (BCLM) in patients with initially diagnosed breast cancer and to determine the indications for abdominal staging CT.

METHODS

Patients with newly diagnosed breast cancer who underwent abdominal CT as an initial staging work-up between January 2019 and December 2020 were retrospectively analyzed. DY was calculated and analyzed according to patient age, type of treatments, histologic type, histologic grade, lymphovascular invasion, Ki-67 status, hormone receptor status, subtype, and the American Joint Committee on Cancer anatomical staging.

RESULTS

A total of 2056 patients (mean age, 51 ± 11 years) were included. The DY of abdominal staging CT for detecting BCLM was 1.1 % (22 of 2056). DY was significantly higher in stage III than in stage I or II cancers (3.9 % [18 of 467] vs. 0 % [0 of 412] or 0.4 % [4 of 1158], respectively, p < .001), and in human epidermal growth factor receptor-2 (HER2)-enriched cancers than in luminal or triple negative cancers (2.9 % [16 of 560] vs. 0.4 % [4 of 1090] or 0.5 % [2 of 406], respectively, p < .001).

CONCLUSIONS

The DY of abdominal staging CT for detecting BCLM was low among all patients with initially diagnosed breast cancer. However, although abdominal staging CT for detecting BCLM is probably unnecessary in all patients, it can be clinically useful in patients with stage III or human epidermal growth factor receptor-2-enriched breast cancers.

Effect of High-Versus Low-Frequency of Abdominopelvic Computed Tomography Follow-Up Testing on Overall Survival in Patients With Stage II Or III Colon Cancer

BACKGROUND

Intensive surveillance of colon cancer by using the abdominopelvic computed tomography (AP-CT) is common in real world practice; however, it is still unclear whether high-frequency surveillance using AP-CT in patients with these risk factors is superior to that in the low-frequency surveillance.

PATIENTS AND METHODS

We retrospectively reviewed 1803 patients with stage II-III colon cancer receiving curative surgery between January 1, 2005 to December 31, 2015. We evaluated the average scan-to-scan intervals of postoperative AP-CT testing and assigned patients with an interval of 5 to 8 and 9 to 13 months to the high-frequency (HF) and low-frequency (LF) groups, respectively. The cutoff value of preoperative and postoperative CEA levels was 5 ng/mL. We also applied propensity score matching (PSM) and inverse probability of treatment weighting to adjust clinicopathologic differences between the 2 groups.

RESULTS

We matched 1:1 for each surveillance group yielding a cohort of 776 matched patients. After PSM, Baseline demographics were overall well balanced between 2 groups. Stage III (OR, 2.00; 95% Confidence interval [CI], 1.21-3.30) and postoperative CEA elevation (OR, 2.30; 95% CI, 1.08-4.92) were independent risk factors of recurrence in multivariate analyses. Patient in the HF group had more surgery plus chemo- or radiotherapy as postrecurrence treatment than patient in the LF group (46.2% vs. 23.1%, P = .017). This trend was retained after PSM, although it is not significant (44.4% vs. 23.1%, P = .060). However, survival outcomes of high-frequency AP-CT surveillance were not superior to those of low-frequency surveillance in all subgroups, including stage III (HR 0.99, 95% CI 0.40-2.47) and postoperative CEA elevation (HR 1.36, 95% CI 0.45-4.11).

CONCLUSION

High-frequency AP-CT testing is associated with a higher proportion of surgery plus chemo- or radiotherapy as postrecurrence treatment, without improvement in 5-year overall survival.

Clinical Impact of ASCO Choosing Wisely Guidelines on Staging Imaging for Early-Stage Breast Cancers: A Time Series Analysis Using SEER-Medicare Data

PURPOSE

American Society for Clinical Oncology released the Choosing Wisely list in 2012, highlighting low-value procedures that lack evidence, advising against the use of positron emission tomography, computerized tomography, and radionuclide bone scans for the staging of early-stage breast cancer at low risk for metastasis. The objective of the study was to assess the impact of the American Society of Clinical Oncology Choosing Wisely guidelines on inappropriate staging imaging among early-stage breast cancers.

METHODS

The Surveillance, Epidemiology, and End Results Program-Medicare data set was used to identify 50,004 women age 66 years and older with new incident diagnosis of early-stage breast cancer (stage 0 through stage 2a; T < 4, N = 0, and M = 0). The primary outcome was the incidence of patients with inappropriate imaging following an early-stage breast cancer diagnosis. The primary outcome was identified within 6 months of the first diagnosis. An interrupted time series analysis using negative binomial regression was performed for outpatient claims for these diagnostic studies versus the two interruptions of guidelines release and guidelines reinforcement. Mean images per patient, percent change for the study period, and rate of change per year were calculated.

RESULTS

Imaging rates fell by a modest 2.32% following guidelines release in April 2012 (point estimate = -2.32%; 95% CI, -6.34% to 1.88%). By contrast, imaging rates fell by a four-fold larger amount (point estimate = -9.36%; 95% CI, -13.20% to -5.35%) following guidelines published reminders in journals (or reinforcement) in October 2013. Mean imaging studies per patient (95% CI) declined from 1.80 (1.76 to 1.84) in January 2012 to 1.50 (1.48 to 1.53) by January 2015, representing a 16% decline in imaging overuse in 2015 compared with 3 years earlier. The rate of change (95% CI) in images per patient was initially small at -0.47% (-4.27% to 3.33%) per year between April 2012 and October 2013, but almost eight times faster at -3.70% (-5.81% to -1.60%) per year after October 2013.

CONCLUSION

This analysis demonstrates a substantial decrease in the prevalence of imaging overuse in early-stage breast cancers correlating with the 2013 reinforcement of American Society of Clinical Oncology's 2012 Choosing Wisely guidelines. The creation and dissemination of such resources serves as a powerful tool to improve clinical practice, cost-effectiveness, and patient safety from secondary malignancies, anxiety, and overdiagnosis.

Le-Petross HT, Slanetz PJ, Lewin AA, Bao J, Dibble EH, Golshan M, Hayward JH, Kubicky CD, Leitch AM, Newell MS, Prifti C, Sanford MF, Scheel JR, Sharpe RE, Weinstein SP, Moy L. ACR Appropriateness Criteria® Imaging of the Axilla

This publication reviews the current evidence supporting the imaging approach of the axilla in various scenarios with broad differential diagnosis ranging from inflammatory to malignant etiologies. Controversies on the management of axillary adenopathy results in disagreement on the appropriate axillary imaging tests. Ultrasound is often the appropriate initial imaging test in several clinical scenarios. Clinical information (such as age, physical examinations, risk factors) and concurrent complete breast evaluation with mammogram, tomosynthesis, or MRI impact the type of initial imaging test for the axilla. Several impactful clinical trials demonstrated that selected patient's population can received sentinel lymph node biopsy instead of axillary lymph node dissection with similar overall survival, and axillary lymph node dissection is a safe alternative as the nodal staging procedure for clinically node negative patients or even for some node positive patients with limited nodal tumor burden. This approach is not universally accepted, which adversely affect the type of imaging tests considered appropriate for axilla. This document is focused on the initial imaging of the axilla in various scenarios, with the understanding that concurrent or subsequent additional tests may also be performed for the breast. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Performance, clinical utility, and cost-effectiveness of selective use of staging investigations in early breast cancers

BACKGROUND

International guidelines do not recommend routine staging of EBCs. However, most clinicians still perform staging investigations (SI) selectively for several reasons. We examined our practice of selective use of SI to determine its performance, clinical utility, and cost-effectiveness.

METHODS

We performed this retrospective study on patients who had treatment for AJCC stage I or stage II breast cancer through Eastern health Breast and cancer centre, Melbourne, for 50 months from January 2012.

RESULT

Our practice of selective use resulted in SI in 41% of all EBCs (95% CI 37-46%). Overall yield was 3% (95% CI 0.4-5.4%) with a false positive rate of 22% (95% CI 1628%) and a false-negative rate of 45% (95% CI 11-79%). The sensitivity of SI is 55% (95% CI 21-89%) with a negative predictive value of 97% (95% CI 94.8-99.9%). None of the treatment components was found to be significantly changed based on findings on SI. There was no significant difference in all-cause mortality or new distant recurrence in the staged and non-staged groups. Identification of six new metastases cost at least 422 021 AUD. The approximate cost to stage one EBC is 2069 AUD. 'Number needed to scan' to detect one new metastasis is 34 at the expense of 70337AUD.

CONCLUSION

Selective use of SI results in better yield. However, the clinical utility of these results is not significant. It is debatable if this level of expenditure is cost-effective. Our results point to a need for change in practice.

A critical review of abdominopelvic computed tomography for the detection of asymptomatic metastasis in new and recurrent breast cancers

AIM

Abdominopelvic computed tomography (APCT) is a commonly used staging investigation to detect asymptomatic metastasis in breast cancer including early breast cancer (EBC). This study aimed to assess the usefulness of APCT in breast cancers at each clinical stage.

METHODS

Patients with new or recurrent invasive breast cancer between January 2009 and December 2014 were included in the study. All staging APCT results were reviewed to evaluate its yield and false positive rate (FPR) and how many investigations are needed to confirm indeterminate results. Odds ratios (ORs) for positive APCT results were calculated for possible risk factors for asymptomatic metastasis.

RESULTS

Sixty-five asymptomatic metastases were detected from 1002 APCTs, giving an overall yield of 6.5%. The overall false-positive rate was 14.9 % due to 149 indeterminate findings that were found not to be metastases after further investigations or observation. Whereas the APCTs have a low yield of 3.1% in EBC, but advanced breast cancer and recurrent breast cancer have a high incidence of asymptomatic metastases (13.8% and 16.3%, respectively). The most common cause of indeterminate findings was small liver nodules, including liver cysts and liver hemangiomas. Human epidermal growth factor receptor2 (HER2) status and tumor stage are most significant predictors for positive results of staging APCT scans with high ORs (3.9 and 3.7, respectively).

CONCLUSION

Staging APCT is associated with a high incidence of FPRs and low yield, especially among EBCs. It is desirable to choose this investigation more selectively according to HER2 status and tumor stage.

Expanded criteria for pretreatment staging CT in breast cancer

Background

There is wide variation in the approach to staging for distant metastatic disease in breast cancer. This study sought to identify factors predictive of distant metastatic disease at presentation to enable appropriate selection of patients for pretreatment CT.

Methods

Data were collected retrospectively for all patients with newly diagnosed breast cancer (screening and symptomatic) over 3 years (2014–2017). Detailed demographic, pathological, biological, and management data were recorded at presentation, and outcome data were recorded after follow-up. Binomial logistic regression was used to identify variables independently associated with distant metastatic disease at presentation.

Results

A total of 1377 patients with newly diagnosed breast cancer were identified, of whom 1025 had complete data; 323 staging CT examinations were performed. Distant metastases were identified at presentation in 47 (4.6 per cent). Some 30 of 47 patients with metastatic disease met established criteria for staging (T4, recurrence, symptoms of possible distant metastases), leaving 17 patients with metastatic disease potentially missed by use of these criteria alone. Multivariable analysis showed that tumour size at least 3 cm combined with sonographically abnormal axillary lymph nodes predicted a high probability of distant metastatic disease at presentation (positive predictive value 18.8 per cent, odds ratio 4.83, P < 0.001). Addition of this criterion increased the positive CT rate to 17.1 per cent.

Conclusion

Selective pretreatment CT staging can be further optimized with the addition of tumour size at least 3 cm with abnormal axillary nodes to established staging criteria.

Trastuzumab with carboplatin/paclitaxel for treatment of advanced stage and recurrent uterine papillary serous carcinoma: A cost-effectiveness analysis

OBJECTIVE

Uterine papillary serous carcinoma (UPSC) is a variant of endometrial cancer that is aggressive and associated with poor outcomes. We sought to evaluate the cost effectiveness of carboplatin/paclitaxel alone versus carboplatin/paclitaxel with trastuzumab among patients with Her2/neu-positive advanced or recurrent UPSC.

METHODS

We designed a Markov model in TreeAge Pro 2019 software to simulate management of a theoretical cohort of 4000 patients with Her2/neu-positive advanced or recurrent uterine papillary serous carcinoma (UPSC) followed for four years. In the carboplatin/paclitaxel with trastuzumab strategy, we included the cost of testing for Her2/neu status. We obtained all model inputs from the literature and a societal perspective was assumed. Outcomes included progression-free survival, progression, UPSC-specific mortality, cost, and quality-adjusted life years (QALYs). The intervention was considered cost effective if the incremental cost-effectiveness ratio (ICER) was below the willingness-to-pay threshold of $100,000 per QALY. Sensitivity analyses were used to determine the robustness of the results.

RESULTS

In our theoretical cohort of 4000 women, treatment with the addition of trastuzumab resulted in 637 fewer deaths and 627 fewer cases of progression compared with treatment with carboplatin/paclitaxel alone. Treatment with trastuzumab was associated with an additional cost of $144,335,895, but was associated with an increase of 2065 QALYs. The ICER was $69,903 per QALY, which was below our willingness-to-pay threshold. Sensitivity analysis demonstrated that this treatment strategy was cost-effective until the cost of 6 months of treatment surpassed $38,505 (baseline input: $27,562).

CONCLUSION

We found that the addition of trastuzumab to carboplatin/paclitaxel was a cost-effective treatment strategy for patients with advanced/recurrent Her2/neu-positive UPSC.

A critical review of the chest CT scans performed to detect asymptomatic synchronous metastasis in new and recurrent breast cancers

Background

Chest computed tomography (CTC) has now replaced chest X-ray (CXR) as the first choice of investigation to stage breast cancers in most centers in Australia. Routine staging is not recommended in early breast cancers (EBCs). This recommendation is based largely on the use of conventional tests like CXR as staging investigations (SIs). We looked at our experience with CTC in detecting asymptomatic synchronous distant metastasis (ASM) in new and recurrent breast cancers (RBCs).

Materials and methods

Breast cancer patients from Eastern Health Breast Unit during the period from January 2012 to March 2016 were included in the study. Cases were grouped into early, advanced, and recurrent breast cancers, and outcome of CTC was assessed in each group. Relative risk of potential risk factors (tumor size, axillary nodal status, presence of lymphovascular invasion and estrogen, and HER2 receptor status) with a positive result in CTC was determined.

Results

Fourteen ASMs were detected from 335 CTCs giving an overall yield of 4% (95% CI 1.89–6.47). The overall false-positive rate was 10% due to 35 indeterminate findings that were found not to be metastases after further tests or observation. Even with selective use, CTCs have a low yield of 2% (95% CI − 0.19–4.19) in EBCs. Advanced breast cancers have a 9% incidence of ASMs. None of the clinically isolated locoregionally recurrent diseases were associated with detectable distant metastasis in CTC. The most common cause of indeterminate findings was small pulmonary nodules.

Conclusion

Even with selective use, CTC has a very low yield in EBCs. Advanced breast cancers can benefit from CTC in their initial evaluation due to the higher yield. Locoregional RBCs were not usually associated with detectable metastasis on CTC. The usefulness of CTC in all stages of breast cancer is further reduced by its high rate of false-positive results.