Breast cancer in the very young patient: a multidisciplinary case presentation

Breast cancer in an 18-year-old female: A fatal case report and literature review

Breast cancer (BC) is the most frequent malignancy in both pre- and postmenopausal women. However, it is exceedingly rare in very young patients, and especially in adolescents. Herein, we report a case of an 18-year-old female diagnosed with invasive BC. The proband had been found to be negative for BC in close family members. A common BC genetic screening test for the Polish population did not detect any known founder mutations in the BRCA1 gene. Further evaluation identified a p.Ile157Thr (I157T) mutation in the CHEK2 gene, a p.Ala1991Val (A1991V) variant of unknown significance in the BRCA2 gene, p.Lys751Gln (K751Q) variant in the XPD (ERCC2) gene, and a homozygous p.Glu1008Ter (E1008*) mutation in the NOD2 gene. No other mutation had been found by next generation sequencing in major BC high-risk susceptibility genes BRCA1, BRCA2, as well as 92 other genes. To date, all these found alterations have been considered as low to moderate risk factors in the general population and moderate risk factors in younger women (<35 years of age). There are no previous articles relating low and moderate risk gene mutations to very young onset (below 20 years) BC with a fatal outcome. In our patient, a possible cumulative or synergistic risk effect for these 4 alterations, and a mutation in the NOD2 gene in particular, of which both presumably healthy parents were found to be carriers, is suggested.

A context-sensitive deep learning approach for microcalcification detection in mammograms

A challenging issue in computerized detection of clustered microcalcifications (MCs) is the frequent occurrence of false positives (FPs) caused by local image patterns that resemble MCs. We develop a context-sensitive deep neural network (DNN), aimed to take into account both the local image features of an MC and its surrounding tissue background, for MC detection. The DNN classifier is trained to automatically extract the relevant image features of an MC as well as its image context. The proposed approach was evaluated on a set of 292 mammograms using free-response receiver operating characteristic (FROC) analysis on the accuracy both in detecting individual MCs and in detecting MC clusters. The results demonstrate that the proposed approach could achieve significantly higher FROC curves when compared to two MC-based detectors. It indicates that incorporating image context information in MC detection can be beneficial for reducing the FPs in detections.

Breast cancer features in women under the age of 40 years

Summary Objective: To describe the clinical features, imaging findings and pathological aspects of breast cancer diagnosed in women under the age of 40 years. Method: A retrospective, descriptive study was performed through analysis of medical records between November 2008 and August 2012. One hundred and twenty (120) patients were included, of whom 112 underwent mammography, 113 underwent ultrasonography, and 105 underwent magnetic resonance imaging (MRI). The histopathological data was obtained in most cases from post-surgical analysis, which was available for 113 patients. Results: The mean age at diagnosis of primary breast cancer was 34 years. Only 11 patients (9.0%) had a family history of breast or ovarian cancer in first-degree relative. Ninety-two (92) patients sought medical attention after showing breast symptoms, and the presence of a palpable nodule was the main complaint. One hundred and twenty-two (122) primary tumors were diagnosed, of which 112 were invasive (95%). The most common histological type was invasive ductal carcinoma (73.8%). Luminal B was the predominant molecular subtype (42.6%). Ultrasonography was positive in 94.5% of the cases and the most common finding were nodules (94.8%). At mammography, the malignancy was observed in 92.8% and the presence of suggestive calcifications was the dominant feature. The MRI was positive in 98% of patients, and mass lesions were the most common. Conclusion: Most cases of breast cancer diagnosed in patients under the age of 40 years, in our population, had symptoms at diagnosis and tumor with more aggressive biological behavior. Despite the ultrasound has been the most widely used method, we found improved characterization of breast lesions when also used mammography and MRI.

Om.breast cancer in very young women aged 25 year-old or below in the center of Tunisia and review of the literature

Breast cancer in very young women under 40 or 35 years attracted a widespread attention. Few studies have focused on women aged below 25 years. The aim of this study was to evaluate the situation of breast cancer in women ≤25 years in the center of Tunisia. Retrospective review from 1993 to 2013. Clinical, histopathological, therapeutic and outcome data were recorded. Cases were classified into different molecular subtypes based on the immunohistochemistry-based definitions. The series included 25 patients. The mean duration of symptoms was 7.5 months. The most common presenting symptom was a palpable mass. Four patients had at least one relative diagnosed with breast cancer. Mammography combined with ultrasound was suggestive of malignancy in 60 % of cases. Curative surgical treatment could be offered in 19 cases. The mean tumor size was 39 mm. Nodal metastases were detected in 9/18 cases. Twenty cases could be classified into: luminal A (5 cases), luminal B (6 cases), Her-2 (1 case), triple negative (6 cases) and unclassified (2 cases). Two women experienced locoregional recurrence and 6 had distant recurrence. Asynchronous contralateral breast cancer occurred in one case. The overall survival at 5 and 10 years was 85 and 75 % respectively. The survival was significantly lower in grade III tumors (p = 0.04) and triple negative tumors (p = 0.03). Breast cancer in women ≤25 years is uncommon. An adequate medical education of young women and physicians is necessary.

Clinicopathologic characteristics of breast cancer in BRCA-carriers and non-carriers in women 35 years of age or less

PURPOSE

Breast cancer diagnosed in women 35 years of age or less accounts for <2% of all breast cancer cases. Clinical and pathologic characteristics of early onset breast cancer are not well defined in BRCA mutation carriers and non-carriers.

METHODS

194 women diagnosed with breast cancer at 35 years of age or less who had BRCA1/2 mutation testing were included in the study. Logistic regression models were fit to determine the associations between clinical variables and BRCA status.

RESULTS

Thirty-two (17%) and 12 (6%) patients had BRCA1 and BRCA2 mutations, respectively. BRCA1-carriers had a higher likelihood of a positive family history (FH) of breast and/or ovarian cancer (P = 0.001), or first-degree relatives diagnosed with breast cancer at <50 years old (P = 0.001) compared to non-carriers. BRCA2-carriers were more likely to have a FH of male breast cancer compared to noncarriers (P = 0.02). Among BRCA2-carriers, the age at first full-term pregnancy was younger in ER-negative cases compared with ERpositive cases (19.5 vs. 28.5 years old; P = 0.01). BRCA1-carriers with a later age at menarche were more likely to have a later stage at diagnosis (P = 0.04). Non-carriers with a lower BMI were more likely to have lymph node involvement (P = 0.03).

CONCLUSIONS

Several associations were identified between reproductive risk factors or BMI and disease characteristics. Further characterization may result in a better understanding of the trends in young onset breast cancer in BRCA-carriers and non-carriers.

Management of early invasive breast cancer in very young women (<35 years)

BACKGROUND

To give an overview about current treatment recommendations and special problems concerning the management of women <35 years with early breast cancer.

METHODS

We performed a selective systematic literature review. We discussed with reference to key studies and meta-analyses, current standards of care, and controversies regarding patient management.

RESULTS

Breast cancer in patients younger than 35 years is rare but associated with an unsatisfactory prognosis. Local treatment should not differ from general guidelines, but awareness of the high risk of local recurrence must be maintained. Adjuvant polychemotherapy is almost always indicated, standard endocrine therapy is tamoxifen. Before the start of systemic therapy, the patient must be offered different types of fertility preservation. Pregnancy related breast cancer is not associated with a worse prognosis, but with delayed diagnosis. Therefore, every suspicious lesion in the breast or axilla must be imaged and biopsied. The optimal time to delay pregnancy following the diagnosis is unknown. Hormonal contraceptives are contraindicated after breast cancer. Every woman <35 years diagnosed with breast cancer should be offered genetic counseling.

CONCLUSION

The management of breast cancer in very young women requires a multidisciplinary team to find the optimal treatment and to solve their specific problems.

Time for a re-evaluation of mammography in the young? Results of an audit of mammography in women younger than 40 in a resource restricted environment

Mammography in younger women is considered to be of limited value. In a resource restricted environment without access to magnetic resonance imaging (MRI) and with a high incidence of breast cancer in the young, mammography remains an important diagnostic tool. Recent technical advances and better regulation of mammography make a reassessment of its value in these conditions necessary. Data of all the mammograms performed at a tertiary hospital and private breast clinic between January 2003 and July 2009 in women less than 40 years of age were collected. Indications were the presence of a mass, follow-up after primary cancer therapy, and screening for patients perceived at high risk due to a family history or the presence of atypical hyperplasia. Data acquired were as follows: Demographics, prior breast surgery, indication for mammography, outcome of mammography, diagnostic procedures, and their results. Of 2,167 mammograms, 393 were performed for a palpable mass, diagnostic mammography. In these, the overall cancer detection rate was 40%. If the mammography was reported as breast imaging reporting and data system (BIRADS(®)) 5 versus BIRADS(®) 3 and 4 versus BIRADS(®) 1 and 2, a final diagnosis of malignancy was established in 96, 48, and 5%, respectively. Of 367 mammograms done for the follow-up after primary treatment of breast cancer, seven cancers were diagnosed for a detection rate of 1.9%. Of 1,312 mammograms performed for screening, the recall rate was 4%; the biopsy rate 2%, and the cancer diagnosis rate 3/1,000 examinations. In contrast to past series, this series has shown that recent advances in mammography have made it a useful tool in the management of breast problems in young women, notably in a resource-restricted environment. Women for screening should be selected carefully.

Development of breast cancer in a 21-year-old childhood Wilms' tumor survivor with a BRCA1 2634delC mutation

Breast cancer at age 21 is rare, even in individuals who have a genetic predisposition. These early diagnoses are usually the result of a hereditary cancer syndrome. Other contributing factors, such as chemotherapy and radiation for previous malignancies, can also increase the risk of secondary malignancies, including breast cancer. Here we present one of the youngest cases of breast cancer reported in the literature: a 21-year-old Wilms' tumor survivor (diagnosed at age 6), who was found to have a familial BRCA1 mutation and was diagnosed with ductal carcinoma in situ at age 21.

The need for breast cancer screening in women undergoing elective breast surgery: an assessment of risk and risk factors for breast cancer in young women

BACKGROUND

Given the 11% lifetime risk of breast cancer and increasing popularity of elective breast surgery, the role of preoperative screening begs further investigation. There are currently no guidelines that indicate which women younger than 40 years of age should be screened preoperatively.

OBJECTIVES

A meta-analysis of studies regarding the odds ratio (OR) and relative risk ratio for breast cancer risk factors in women younger than 40 was completed.

METHODS

Of a total of 240 results in the PubMed database for articles referencing breast cancer risk factors in young women, eight were selected for review. A total of 5381 patients were included in the studies in this meta-analysis; 26 risk factors were identified. A meta-analysis was performed to determine the OR of each specific risk factor, with a 95% confidence interval.

RESULTS

The most significant risk factors were having a sister with breast cancer (OR, 11.66), having a first-degree relative with breast cancer (OR, 2.66), having a mother with breast cancer (OR, 2.31), never having breastfed (OR, 1.77), and having undergone a breast biopsy (OR, 1.66). From these data, the authors developed a clinical questionnaire to estimate the risk of breast cancer in young women. In addition, an algorithm was developed for preoperative breast cancer screening for women of all ages undergoing elective breast procedures.

CONCLUSIONS

For women younger than 40, the preoperative risk assessment involves two steps. First, the possibility of existing breast cancer should be evaluated with a preoperative screening survey. Second, the patient's risk for future development of cancer should be assessed, with a focus on genetic mutations. Women older than 40 years of age should be stratified to receive either a preoperative mammogram or MRI. The clinical questionnaire and preoperative screening algorithm provide an evidence-based guideline on which to base the discussion with patients regarding preoperative breast cancer screening.

An integrated transcriptomic and computational analysis for biomarker identification in gastric cancer

This report describes an integrated study on identification of potential markers for gastric cancer in patients’ cancer tissues and sera based on: (i) genome-scale transcriptomic analyses of 80 paired gastric cancer/reference tissues and (ii) computational prediction of blood-secretory proteins supported by experimental validation. Our findings show that: (i) 715 and 150 genes exhibit significantly differential expressions in all cancers and early-stage cancers versus reference tissues, respectively; and a substantial percentage of the alteration is found to be influenced by age and/or by gender; (ii) 21 co-expressed gene clusters have been identified, some of which are specific to certain subtypes or stages of the cancer; (iii) the top-ranked gene signatures give better than 94% classification accuracy between cancer and the reference tissues, some of which are gender-specific; and (iv) 136 of the differentially expressed genes were predicted to have their proteins secreted into blood, 81 of which were detected experimentally in the sera of 13 validation samples and 29 found to have differential abundances in the sera of cancer patients versus controls. Overall, the novel information obtained in this study has led to identification of promising diagnostic markers for gastric cancer and can benefit further analyses of the key (early) abnormalities during its development.

Diagnosis of breast cancer in women age 40 and younger: delays in diagnosis result from underuse of genetic testing and breast imaging

BACKGROUND

The impact of newer breast imaging technologies and genetic testing on the detection of breast cancer in women age 40 and younger remains unknown.

METHODS

A records review identified 628 women age 40 and younger diagnosed with breast cancer from 1996 to 2008. Patient and tumor characteristics, means of diagnosis, imaging results, and genetic testing were examined.

RESULTS

Tumors were first detected by self-examination in 71%, with a median invasive tumor size of 2.0 cm. Imaging performed at or after diagnosis visualized most tumors; mammography visualized 86%, magnetic resonance imaging (MRI) visualized 96%, and mammography plus MRI visualized more than 98% of tumors. For 81% of patients, the mammogram at diagnosis was their first mammogram. Although 50% had a family history of breast or ovarian cancer, few underwent genetic testing before their cancer diagnosis; 61 of 247 (25%) ultimately tested had a BRCA mutation.

CONCLUSIONS

Better use of genetic testing, mammography, and MRI could improve breast cancer detection in young women.

Breast cancer in young women and its impact on reproductive function

BACKGROUND

Breast cancer is the most common cancer in women in developed countries, and 12% of breast cancer occurs in women 20-34 years. Survival from breast cancer has significantly improved, and the potential late effects of treatment and the impact on quality of life have become increasingly important. Young women constitute a minority of breast cancer patients, but commonly have distinct concerns and issues compared with older women, including queries regarding fertility, contraception and pregnancy. Further, they are more likely than older women to have questions regarding potential side effects of therapy and risk of relapse or a new primary. In addition, many will have symptoms associated with treatment and they present a management challenge. Reproductive medicine specialists and gynaecologists commonly see these women either shortly after initial diagnosis or following adjuvant therapy and should be aware of current management of breast cancer, the options for women at increased genetic risk, the prognosis of patients with early stage breast cancer and how adjuvant systemic treatments may impact reproductive function.

METHODS

No systematic literature search was done. The review focuses on the current management of breast cancer in young women and the impact of treatment on reproductive function and subsequent management. With reference to key studies and meta-analyses, we highlight controversies and current unanswered questions regarding patient management.

RESULTS

Chemotherapy for breast cancer is likely to negatively impact on reproductive function. A number of interventions are available which may increase the likelihood of future successful pregnancy, but the relative safety of these interventions is not well established. For those who do conceive following breast cancer, there is no good evidence that pregnancy is detrimental to survival. We review current treatment; effects on reproductive function; preservation of fertility; contraception; pregnancy; breastfeeding and management of menopausal symptoms following breast cancer.

CONCLUSION

This paper provides an update on the management of breast cancer in young women and is targeted at reproductive medicine specialists and gynaecologists.

Breast-feeding after breast cancer in childbearing women

According to the American Cancer Society in 2007, about 178,000 women are diagnosed with breast cancer each year in the United States. Of these, 25% have tumors in their childbearing years and may desire future opportunities for pregnancy and lactation. Although there is a multitude of options related to preserving fertility, little is known about the residual effects of breast cancer treatment and the ability to breast-feed afterward. This article describes the epidemiological relationship between breast cancer and pregnancy and lactation. Basic types of treatment for breast cancer including surgery, chemotherapy, and radiation are reviewed. Practical information on how to support breast-feeding after breast cancer is included.

Radiological features and pathological-biological correlations in 348 women with breast cancer under 35 years old

The aim of this study was to present mammography and ultrasound features, and accuracy, in 348 young women (under 35 years old) with breast cancer, and to determine whether such features could be correlated with pathological and biological factors. We performed a retrospective review of the radiological, pathological and biological features of women under 35 years old with breast cancer who were seen in our institute between January 2000 and December 2002. A total of 348 women were analysed. The sensitivity of mammography was 84.9% and that of ultrasound was 88%. There is a statistically significant positive correlation between the high sensitivity of ultrasound and the histology type (P=0.004) as well as the expression of PgR (P=0.01). Also, there is a correlation between the sensitivity of mammography and the histology type (P=0.004). Microcalcifications are associated with age (P=0.05) and overexpression of HER2/neu (P=0.007). Ultrasound may be the appropriate initial imaging test for symptomatic young women, and mammography may be useful in confirming the features, although there was no significant difference in the accuracy of the two tests. Histological and biological profiles may be correlated with imaging sensitivity.

Chemotherapy-Induced Amenorrhea from Adjuvant Breast Cancer Treatment: The Effect of the Addition of Taxanes

PURPOSE

Adjuvant chemotherapy for breast cancer can be associated with a variety of side effects, one of which is the induction of premature menopause in premenopausal patient. Although taxanes have increasingly been used in the adjuvant setting, there has been relatively little published on the frequency of amenorrhea related to their use.

PATIENTS AND METHODS

We review records of 159 premenopausal patients receiving adjuvant chemotherapy from our practice.

RESULTS

Altogether, 51% of all patients retained menstrual function after chemotherapy.

CONCLUSION

It was observed that patients receiving adjuvant anthracycline-based chemotherapy with sequential taxane therapy did not have a higher rate of amenorrhea than those not receiving a taxane.

Comments on the St. Gallen Consensus 2003 on the Primary Therapy of Early Breast Cancer

This final paper of the proceedings of the recent Eighth St. Gallen Conference 2003 on the Primary Therapy of Early Breast Cancer comments on the Consensus Paper put forth by the international expert panel and emphasizes new information, that has emerged during the 2 years since the seventh such meeting in 2001. More than 3200 breast cancer specialists from various medical fields-coming from 75 countries and all six continents-have attended the meeting and the process of scientific consensus development. Recommendations for patient care are so critically dependent on assessment of endocrine responsiveness that the importance of high-quality steroid hormone receptor determination and standardized quantitative reporting cannot be overemphasized. The Panel modified and simplified the risk categories so that only endocrine receptor-absent status was sufficient to reclassify an otherwise low-risk, node-negative disease into the category of average risk. Absence of steroid hormone receptors was also recognized as indicating endocrine non-responsiveness. Some important areas highlighted especially in the 2003 consensus include: recognition of the separate nature of endocrine non-responsive breast cancer, both invasive cancers and ductal carcinoma in situ (DCIS); improved understanding of the mechanisms of acquired endocrine resistance, offering exciting prospects for extending the impact of successful sequential endocrine therapies; presentation of high-quality evidence indicating that chemotherapy and tamoxifen should be used sequentially rather than concurrently; availability of a potential alternative to tamoxifen for treatment of postmenopausal women with endocrine responsive disease; promise of newly defined prognostic and predictive markers.

Potential exposure to PCBs, DDT, and PBDEs from sport-caught fish consumption in relation to breast cancer risk in Wisconsin

In Wisconsin, consumption of Great Lakes fish is an important source of exposure to polychlorinated biphenyls (PCBs), dichlorodiphenyltrichloroethane (DDT), polybrominated diphenyl ethers (PBDEs), and other halogenated hydrocarbons, all of which may act as potential risk factors for breast cancer. We examined the association between sport-caught fish consumption and breast cancer incidence as part of an ongoing population-based case-control study. We identified breast cancer cases 20-69 years of age who were diagnosed in 1998-2000 (n = 1,481) from the Wisconsin Cancer Reporting System. Female controls of similar age were randomly selected from population lists (n = 1,301). Information about all sport-caught (Great Lakes and other lakes) fish consumption and breast cancer risk factors was obtained through telephone interviews. After adjustment for known and suspected risk factors, the relative risk of breast cancer for women who had recently consumed sport-caught fish was similar to women who had never eaten sport-caught fish [relative risk (RR) = 1.00; 95% confidence interval (CI), 0.86-1.17]. Frequency of consumption and location of sport-caught fish were not associated with an increased risk of breast cancer. Recent consumption of Great Lakes fish was not associated with postmenopausal breast cancer (RR = 0.78; 95% CI, 0.57-1.07), whereas risk associated with premenopausal breast cancer was elevated (RR = 1.70; 95% CI, 1.16-2.50). In this study we found no overall association between recent consumption of sport-caught fish and breast cancer, although there may be an increased breast cancer risk for subgroups of women who are young and/or premenopausal.

Meeting highlights: updated international expert consensus on the primary therapy of early breast cancer

This account of the highlights of the eighth St Gallen (Switzerland) meeting in 2003 emphasizes new information that has emerged during the 2 years since the seventh meeting in 2001. This article should be read in conjunction with the report of that earlier meeting. Recommendations for patient care are so critically dependent on assessment of endocrine responsiveness that the importance of high-quality steroid hormone receptor determination and standardized quantitative reporting cannot be overemphasized. The International Consensus Panel modified the risk categories so that only endocrine receptor-absent status was sufficient to reclassify an otherwise low-risk, node-negative disease into the category of average risk. Absence of steroid hormone receptors also was recognized as indicating endocrine nonresponsiveness. Some important areas highlighted at the recent meeting include: (1) recognition of the separate nature of endocrine-nonresponsive breast cancer-both invasive cancers and ductal carcinoma-in-situ; (2) improved understanding of the mechanisms of acquired endocrine resistance, which offer exciting prospects for extending the impact of successful sequential endocrine therapies; (3) presentation of high-quality evidence indicating that chemotherapy and tamoxifen should be used sequentially rather than concurrently; (4) availability of a potential alternative to tamoxifen for treatment of postmenopausal women with endocrine-responsive disease; and (5) the promise of newly defined prognostic and predictive markers.