Predicting local recurrence by correlating pre-operative mammographic findings with pathological risk factors in patients with breast cancer

Recurrence Yield of Stereotactic Biopsy of Suspicious Calcifications After Breast Conservation Therapy

Aim To analyze the histopathological outcome of stereotactic biopsies of newly developed suspicious calcifications at lumpectomy scar site in patients with breast conservation surgery (BCS) to determine the incidence of malignancy and the association of mammographic appearance of recurrent microcalcification and their distribution. We also determined the association of disease recurrence with the presence of calcifications in original tumor and lumpectomy resection margins with the risk of recurrence. Materials and methods This study is a retrospective review of mammograms of patients with breast cancer from 2010 to 2021 who underwent stereotactic biopsy of newly developed suspicious calcifications at scar site appreciated on annual follow-up mammogram after breast conservation surgery (BCS) with no mass on correlative ultrasound. The radiological and pathological features of the patients' primary tumor and new calcifications were obtained from the hospital's electronic patient record system. Results A total of 84 patients with breast cancer developed suspicious microcalcifications at the lumpectomy scar site detected on follow-up mammograms after BCS, and 28.6% showed malignant histopathological outcomes. All malignant cases demonstrated pleomorphic morphology. All amorphous (9.5%) and coarse heterogeneous (54.8%) calcifications were benign. The distribution pattern of recurrent malignant calcifications was grouped in 9.5%, regional in 2.4%, linear in 9.5%, and segmental in 7.1%. Calcifications in primary tumors were found in 20.2% of cases. Positive margins were found in 7.1% of these malignant cases. Statistically, there was a strong association between calcification morphology, calcification distribution, presence of calcifications on baseline mammogram, and tumor resection margins. The presence of calcifications in primary tumors and positive resection margins were identified as significant independent risk factors of malignant recurrent calcifications in the logistic regression model and marginal statistical significance in the multivariable logistic regression (MLR) model. Conclusion The interval development of pleomorphic calcifications after BCS with either linear or segmental pattern, positive resection margins, and associated calcifications in primary tumors was related to the increase in the risk of recurrence. Although amorphous and coarse heterogeneous morphology with grouped distribution showed benign outcomes, stereotactic biopsy is recommended to exclude disease recurrence in this high-risk patient population.

The clinical value of detecting microcalcifications on a mammogram

Many breast lesions are associated with microcalcifications that are detectable by mammography. In most cases, radiologists are able to distinguish calcifications usually associated with benign diseases from those associated with malignancy. In addition to their value in the early detection of breast carcinoma and accurate radiological diagnosis, the presence of microcalcifications often affects the extent of surgical intervention. Certain types of microcalcifications are associated with negative genetic and molecular characteristics of the tumor and unfavorable prognosis. Microcalcifications localized in the larger ducts (duct-centric, casting-type microcalcifications) represent an independent negative prognostic marker compared to lesions containing other types of microcalcifications and to non-calcified lesions. In this review, we summarize the theoretical and methodological background for understanding the clinical impact and discuss the diagnostic and prognostic value of microcalcifications detected in the breast by mammography.

Mammographic calcification can predict outcome in women with breast cancer treated with breast-conserving surgery

The impact of calcification in patients with breast carcinoma treated with breast-conserving surgery (BCS) is unclear. The present study aimed to determine the outcome of breast cancer patients with calcification treated with BCS. The records of 409 patients with breast carcinoma treated with BCS from January 2005 to December 2008 were reviewed. Patients were categorized as those with calcification (on mammography or ultrasonography), or those without calcification (neither on mammography nor ultrasonography). The local relapse free survival time (LRFS), disease free survival time (DFS) and overall survival time (OS) were compared, and subgroup analysis was performed based on morphological types and distribution patterns of mammographic calcification. Survival analysis demonstrated that patients with calcification had a significantly increased risk of local recurrence, distant metastasis and mortality compared with those without calcification [relative risk (RR) and 95% confidence interval (CI): local recurrence, 2.46 and 1.11-5.44; distant metastasis, 2.24 and 1.19-4.24; mortality, 2.50 and 1.06-5.86]. Subgroup analysis revealed that the distribution patterns (rather than morphological types of calcification) accounted for the increased risk of recurrence following BCS. Patients with mammographic calcification of liner/segmental distribution had significantly decreased LRFS (RR=6.20; 95% CI, 2.26-16.98), DFS (RR=6.81; 95% CI, 2.86-16.20) and OS (RR=9.14; 95% CI, 2.53-33.00), while patients with mammographic calcification of clustered distribution did not have significantly decreased LRFS, DFS and OS (P>0.05), compared with those without calcification. In addition, the mammographic calcification spreading along the ducts was more likely to be accompanied by an extensive intraductal component (P<0.001). Finally, the outcome of patients with calcification on breast ultrasound was as good as those without calcification. Patients with mammographic calcification, particularly those with calcification spreading along the ducts, have a higher risk of recurrence following BCS, which has a negative impact on long-term survival. Calcification identified on breast ultrasonography does not affect the survival of patients treated with BCS.

Microcalcification-Associated Breast Cancer: Presentation, Successful First Excision, Long-Term Recurrence and Survival Rate

INTRODUCTION

In this study we evaluated mammographic, histological and immunohistochemical findings for microcalcification-associated breast cancer with regards to breast-conserving therapy, recurrence and survival rate.

PATIENTS AND METHODS

We retrospectively analyzed 99 consecutive, non-palpable and microcalcification-associated breast cancers (94 women) that were treated surgically between January 2002 and December 2003 at a national academic breast cancer center. Calcifications were classified according to the Breast Imaging Reporting and Data System (BI-RADS). Descriptors, surgical outcome and histological findings were assessed. Recurrences and survival rates were evaluated based on medical records, standardized patient questionnaires and/or contacting the physician.

RESULTS

42 of the 99 lesions (42.4%) were invasive carcinomas, 57 (57.6%) were pure ductal carcinoma in situ (DCIS). 6 out of 99 (6.1%) lesions were triple negative, and 29 (29.3%) were HER2/neu positive. Successful first excision rate was 76/99 lesions (76.8%). Breast conservation was achieved in 73.7% (73/99). 10 women showed local recurrences without negatively impacting survival. The recurrences included round/punctate, amorphous, fine pleomorphic, and fine linear or fine-linear branching descriptors. The breast cancer-specific long-term survival rate was 91/94 (96.8%) for a mean follow-up of 81.4 months. The 3 patients who died due to breast carcinoma showed fine pleomorphic calcifications, and had nodal-positive invasive carcinoma at diagnosis.

CONCLUSION

Microcalcification-associated breast cancers are frequently treated with breast-conserving therapy. Continuous clinical and mammographic follow-up is recommended for all descriptors.

Mammography casting-type calcification and risk of local recurrence in DCIS: analyses from a randomised study

BACKGROUND

We studied the association between mammographic calcifications and local recurrence in the ipsilateral breast.

METHODS

Case-cohort study within a randomised trial of radiotherapy in breast conservation for ductal cancer in situ of the breast (SweDCIS). We studied mammograms from cases with an ipsilateral breast event (IBE) and from a subcohort randomly sampled at baseline. Lesions were classified as a density without calcifications, architectural distortion, powdery, crushed stone-like or casting-type calcifications.

RESULTS

Calcifications representing necrosis were found predominantly in younger women. Women with crushed stone or casting-type microcalcifications had higher histopathological grade and more extensive disease. The relative risk (RR) of a new IBE comparing those with casting-type calcifications to those without calcifications was 2.10 (95% confidence interval (CI) 0.92-4.80). This risk was confined to in situ recurrences; the RR of an IBE associated with casting-type calcifications on the mammogram adjusted for age and disease extent was 16.4 (95% CI 2.20-140).

CONCLUSION

Mammographic appearance of ductal carcinoma in situ of the breast is prognostic for the risk of an in situ IBE and may also be an indicator of responsiveness to RT in younger women.

[Local control in breast cancer: constant importance, changing radiotherapy practice]

Local control is of primary importance when treating operable breast cancer. Local relapse serves as a secondary source of distant metastases, and compromises survival. Postoperative radiotherapy improves local control after mastectomy or breast conserving surgery, however, sometimes it leads to overtreatment. The risk of local relapse may be estimated based on different correlated factors, such as the type of the surgery, the size and stage of the tumor, the nodal status, the histological type, multifocality and biological features of the cancer, the margin status, the age and the mammographic appearance of the lesion. Late radiogenic sequelae appearing 5-10 years after radiotherapy are sometimes fatal, but may be prevented if radiotherapy is delivered at a high standard. Systemic therapies contribute to local control, and in some cases may substitute radiotherapy. In other low risk cases, radiotherapy may be either omitted or lessened. Local therapies in breast cancer should be tailored individually.

Casting-type calcifications on the mammogram suggest a higher probability of early relapse and death among high-risk breast cancer patients

INTRODUCTION

A retrospective analysis of the relation between the presence of casting-type calcifications on the mammogram and the prognosis of breast cancer was performed.

MATERIALS AND METHODS

The mammographic tumor features and other characteristics (invasive tumor size, histological tumor type, grade, nodal, hormone receptor and HER2 status, presence of lymphovascular invasion) of 55 high-risk breast cancers were studied.

RESULTS

After a median follow-up time of 29.1 months, the median relapse-free survival and overall survival times among breast cancer patients with tumors associated with casting calcifications were 26.6 and 29.6 months, respectively. The corresponding parameters among patients with tumors not accompanied by casting calcifications were 54.4 and > 58.5 months, respectively. Significant associations were found between the presence of casting calcifications and the risks of relapse (HR = 3.048, 95% CI: 1.116-8.323, p = 0.030) or death (HR = 3.504, 95% CI: 1.074-11.427, p = 0.038). Positive associations were found between casting calcifications and ER/PR negativity (p = 0.015 and p = 0.003, respectively) and HER2 overexpression (p = 0.019).

DISCUSSION

Our findings support the theory that breast tumors associated with casting-type calcifications at mammography comprise a disease entity which exhibits significantly more aggressive behavior and a poorer outcome than do cancers with other mammographic tumor features.

Intermediate to highly suspicious calcification in breast lesions: a radio-pathologic correlation

Breast calcification is an important feature in the radiological assessment of breast lesions. There are well established diagnostic criteria basing on the morphology and distribution of the calcifications radiologically with recommendation protocols. Pathologically, calcifications in breast lesions are of dystrophic type, and may occur in either the secretory materials or necrotic debris, with inflammation and osteopontin being plausible mediators. Detection of calcium phosphate (hydroyapaptite) is considerably easier than calcium oxalate. Radiologically amorphous calcification represents a borderline type of calcification, and occurs in both benign and malignant (low grade) lesions, and warrants careful follow up and investigation. Clustering of calcification alone may not be an accurate predictor for malignancy, but when there are associated features like pleomorphism, branching, architectural distortion, and associated mass or density, the predictive value for malignant increases. Adequate sampling of calcification in the biopsy is crucial in the management of patients; in general, needle core biopsy or mammotome biopsy achieve satisfactory calcification retrieval. In a benign biopsy that fails to identify the calcifications visible in the mammography, further evaluation or cutting of the histologic block is recommended to minimize the potential of a false negative investigation.

MARGINS AND OUTCOME OF SCREEN-DETECTED BREAST CANCER WITH EXTENSIVE IN SITU COMPONENT

BACKGROUND

In situ disease surrounding invasive tumours is an important consideration in the management of patients with early breast cancer. This study of screen-detected breast cancers assessed the influence of in situ disease including an extensive in situ component (defined as ductal carcinoma in situ involving more than 25% of the area within the invasive tumour) on surgical management, local recurrence and survival of a group of patients.

METHODS

A total of 595 cases of invasive breast cancer detected at St Vincent's BreastScreen were retrospectively reviewed to determine presence and extent of in situ disease, the surgical procedure and adequacy of excision. Outcome was examined in a cohort of 126 cases.

RESULTS

A total of 438 (74%) patients had in situ foci in or around the invasive tumour and 107 (18%) were defined as extensive in situ component (EIC)-positive. The initial procedure was mastectomy in 20% of the cases and breast-conserving surgery in 80% including 18% who underwent further surgery. Re-excision (P = 0.02) or mastectomy (P = 0.01) was more often required in patients with EIC. After definitive local excision, margins were close or involved with invasive disease in 3% but the patients with EIC were more likely to have margins close or involved with in situ disease (16 vs 2%; P = 0.001). There were seven deaths and one local invasive recurrence in the follow-up group and none of the deaths were in patients who were EIC-positive.

CONCLUSIONS

EIC predicts for a higher rate of re-excision and/or mastectomy. For patients with EIC, there is an acceptably low risk of local recurrence if margins are clear.

Predictive factors for local recurrence in 2006 patients with surgically resected small breast cancer

BACKGROUND

Analyses of predictive factors for local recurrences are important, as an increasing number of patients with early breast cancer opt for a breast-conserving procedure. This study investigates whether factors predictive of local recurrence differ between patients treated with conservative or radical surgery.

PATIENTS AND METHODS

Two thousands and six patients with invasive breast carcinoma (< or =25 mm) were included. Of these patients, 717 were treated conservatively (lumpectomy and breast irradiation) and 1289 were treated with total mastectomy. All patients had axillary dissection and received lymph node irradiation if axillary nodes were positive. Most patients did not receive adjuvant chemotherapy or additive hormonal treatments. The mean duration of follow-up was 20 years. The main end point was the total local recurrence rate. The risk factors of local recurrence were estimated by multivariate analyses and interaction tests were used for intergroup comparisons.

RESULTS

Statistically significant predictive factors for mastectomized patients were histological grade, extensive axillary node involvement (10 nodes or more), and inner quadrant tumors, which were of borderline significance. Young age, however, was not a prognostic indicator for local recurrence. The main statistically significant factor for patients treated with a conservative approach was young age (< or =40 years). These younger patients had a five-fold increased risk of developing a breast recurrence compared with patients older than 60 years.

CONCLUSIONS

Younger patients with early breast cancer treated with breast-conserving surgery should in particular be followed up at regular intervals so that any sign of local failure can be diagnosed early.

Preoperative mammographic features predict clinicopathological risk factors for the development of local recurrence in breast cancer

This study attempts to correlate preoperative mammographic features with established clinicopathological risk factors for local recurrence with a view to selecting patients who might be unsuitable for breast-conserving surgery. A total of 357 patients underwent surgery for invasive breast cancer. All patients' preoperative mammograms were reviewed by a single radiologist (LW) blinded to clinicopathological features. The independent sample t-test and chi-squared tests were used to correlate preoperative mammographic features with established clinicopathological risk factors for the development of local recurrence. The presence of extensive in situ disease within the tumour was associated with both casting calcification and absence of a mammographic nidus (P=0.0001 and 0.002 respectively) but not with mammographic density. Furthermore casting calcification (P=0.003), absence of a mammographic nidus (P=0.027) and maximum nidus size (P=0.014) were all predictors of tumour bed positivity. This study has demonstrated that preoperative mammograms can be used to identify those patients at risk of occult disease and help select those patients that may be unsuitable for breast-conserving surgery.

Indicators of loco-regional recurrence in breast cancer. The South East Swedish Breast Cancer Group

AIM

The aim of the investigation was to contribute to the identification of patients who have increased or decreased risk of loco-regional recurrence.

METHODS

Six hundred and twenty-nine consecutive patients with primary breast cancer diagnosed between 1988 and 1990 were studied. Two-thirds of the patients underwent mastectomy. Radiotherapy was administered if patients were node positive or breast conserved. The Nottingham histological grading protocol was used and presence of lymphovascular invasion was assessed. Investigated parameters were: age, size, grade, steroid receptor content, surgical radicality, vascular invasion and nodal status. Statistically significant risk factors for loco-regional recurrence using univariate or Cox proportional hazard analysis were grade and lymphovascular invasion.

RESULTS

Women with grade 1-2, node-negative tumours without vascular invasion had a very low loco-regional recurrence rate-3.1%. Seventeen percent of patients with grade 3 tumours and vessel invasion had loco-regional recurrence.

CONCLUSIONS

Our findings, and those of others, indicate that the use of adjuvant radiotherapy should be influenced to a greater extent by grade and lymphovascular invasion.

10-Year results after sector resection with or without postoperative radiotherapy for stage I breast cancer: a randomized trial

PURPOSE

To study the long-term effectiveness of postoperative radiotherapy after sector resection for breast cancer in a randomized trial in which mammography is a major pathway to diagnosis.

PATIENTS AND METHODS

Three hundred eighty-one women with a unifocal breast cancer < or = 20 mm in diameter on the preoperative mammogram and without histopathologic signs of axillary metastases were treated by sector resection plus axillary dissection. Of these patients, 184 women were randomized to receive postoperative radiotherapy to the breast (XRT group), and 197 women received no further treatment (non-XRT group).

RESULTS

The local recurrence rate was 8.5% (95% confidence interval [CI], 3.9% to 13.1%) in the XRT group and 24.0% (95% CI, 17.6% to 30.4%) in the non-XRT group (P =.0001). Survival free from regional and distant recurrence was 83. 3% in the XRT group (95% CI, 77.5% to 89.1%) and 80.0% in the non-XRT group (95% CI, 73.9% to 86.1%) (P =.23). Overall survival was 77.5% in the XRT group (95% CI, 70.9% to 84.1%) and 78% in the non-XRT group (95% CI, 71.7% to 84.3%) (P =.99). A subgroup analysis suggested that women older than 55 years of age without comedo or lobular carcinomas had a low risk of local recurrence of 6.1% (95% CI, 0.1% to 9.1%) in the XRT-group and 11.0% (4.0% to 18.0%) in the non-XRT group (P =.16).

CONCLUSION

Sector resection plus radiotherapy resulted in an absolute reduction in local recurrence of 16% at 10 years compared with surgery alone. Women older than 55 years of age without comedo or lobular carcinomas may have a low risk of local recurrence. Postoperative radiotherapy was not shown to reduce distant recurrences or improve overall survival.

Mammographic, pathologic, and treatment-related factors associated with local recurrence in patients with early-stage breast cancer treated with breast conserving therapy

BACKGROUND

We retrospectively reviewed our institution's experience treating early-stage breast cancer patients with breast conserving therapy (BCT) to determine clinical, pathologic, mammographic, and treatment-related factors associated with outcome.

METHODS

Between January 1980 and December 1987, 400 cases of Stage I and II breast cancer were managed with BCT at William Beaumont Hospital, Royal Oak, Michigan. All patients underwent at least an excisional biopsy. Radiation treatment consisted of delivering 45-50 Gy to the whole breast, followed by a boost to the tumor bed to at least 60 Gy in all patients. The median follow-up in the 292 surviving patients is 118 months. Multiple clinical, pathologic, mammographic, and treatment-related factors were analyzed for an association with local recurrence and survival.

RESULTS

A total of 37 local recurrences developed in the treated breast, for a 5- and 10-year actuarial rate of 4% and 10%, respectively. On univariate analysis, patient age < or =35 years (25% vs. 7%, p = 0.004), and positive surgical margins (17% vs. 6%, p = 0.018) were associated with an increased risk of local recurrence at 10 years. On multivariate analysis, only age < or = 35 years remained significant. A subset analysis of 214 patients with evaluable mammographic findings was performed. On univariate analysis, age < or = 35 years (38% vs. 8%, p = 0.0029) and the presence of calcifications on preoperative mammography (22% vs. 6%, p = 0.0016) were associated with an increased risk of local recurrence. On multivariate analysis, both of these factors remained significant. The presence of calcifications on preoperative mammography did not affect the rates of overall survival, disease-free survival, and cause-specific survival.

CONCLUSION

In patients with early-stage breast cancer treated with BCT, age < or = 35 years and calcifications on preoperative mammography appear to be associated with an increased risk of local recurrence.

Risk factors for local recurrence after conservative treatment in stage I breast cancer. Definition of a subgroup not requiring radiotherapy

BACKGROUND

Risk factors for local recurrence after breast-conserving treatment of early breast cancer have not previously been evaluated in settings where mammography has been a major pathway to diagnosis of both primary tumour and recurrences or in patients treated surgically by a formal sector resection.

PATIENTS AND METHODS

Three hundred eighty-one women with stage 1 primary breast cancer were randomised after a standardised sector resection to either a course of postoperative radiotherapy to 54 Gy to the breast (XRT group) or to surgery alone (non XRT group). At five years, 43 local recurrences, six of them in the XRT group, appeared. Patient characteristics collected from the medical records, histopathological characteristics determined by re-examination of slides, and mammographic characteristics from the pre-operative mammograms were evaluated as risk factors for recurrence by univariate and multivariate Cox proportional hazards models. Results are reported as relative hazards (RH) with 95% confidence intervals (95% CI).

RESULTS

In the univariate analysis comedo cancer, RH 3.5 (95%, CI 18 6.7), lobular cancers RH 2.8 (95% CI 1.1 7.1), mammographic appearance as circular/oval shaped density, RH 2.3 (95% CI 1.1 4.51, and mammographic appearance as a stellate lesion with microcalcifications inside the lesion, RH 3.8 (95% CI 1.1-13.0) were identified as risk factors for local recurrence. Age, with a RH of 0.97 (95% CI 0.94 0.99) for each increasing year was inversely associated with risk. A multivariate analysis, which also took postoperative radiotherapy into account, only showed comedo cancers with a RH 2.6 (95% CI 1.3-5.0) and mammographic appearance of a stellate lesion with microcalcification inside the lesion RH 4.5 (95% CI 1.1-17.6) to be statistically significant. The estimates for age RH 0.98 (95% CI 0.95 1.01 and lobular cancers RH 2.5 (95%, CI 0.98 6.6) were marginally changed, with widened CIs. Patients > 60 years of age, without comedo or lobular carcinomas were found to be at low risk 15.9% at five years in Kaplan Meyer estimate) of local recurrence, even without postoperative radiotherapy.

CONCLUSION

Low age, comedo and lobular cancers and mammographic appearance of the tumour as a stellate lesion with microcalcifications inside the lesion indicate an increased risk for local recurrence after sector resection in stage 1 tumours at five years. Patients > 60 years of age without comedo or lobular cancers are at low risk for local recurrence at five years even without postoperative radiotherapy.