Detecting Metastatic Patterns of Oligometastatic Breast Cancer: A Comparative Analysis of 18F-FDG PET/CT and Conventional CT Imaging

Metastasis-directed therapy has the potential to improve progression-free and overall survival in oligometastatic disease (OMD). For breast cancer, however, randomized trials have failed so far to confirm this finding. Because the concept of metastasis-directed therapy in OMD is highly dependent on the accuracy of the imaging modality, we aimed to assess the impact of 18F-FDG PET/CT on the definition of OMD in breast cancer patients. Methods: Eighty patients with a total of 150 18F-FDG PET/CT images (between October 2006 and January 2022) were enrolled in this retrospective study at the Technical University of Munich. The inclusion criteria were OMD, defined as 1-5 distant metastases, at the time of 18F-FDG PET/CT. For the current study, we systemically compared the metastatic pattern on 18F-FDG PET/CT with conventional CT. Results: At the time of 18F-FDG PET/CT, 21.3% of patients (n = 32) had a first-time diagnosis of metastatic disease, 40.7% (n = 61) had a previous history of OMD, and 38% (n = 57) had a previous history of polymetastatic disease. In 45.3% of cases, the imaging modality (18F-FDG PET/CT vs. conventional CT) had an impact on the assessment of whether OMD was present. An identical metastatic pattern was observed in only 32% of cases.18F-FDG PET/CT detected additional metastases in 33.3% of cases, mostly in the nonregional lymph node system. Conclusion: The use of 18F-FDG PET/CT had a substantial impact on the definition of OMD and detection of metastatic pattern in breast cancer. Our results emphasize the importance of establishing a standardized definition for imaging modalities in future trials and clinical practices related to metastasis-directed therapy in breast cancer patients.

Contact of the Tumor with the Internal Mammary Perforator Vessels as Risk Factor for Internal Mammary Lymph Node Involvement Based on Dynamic Contrast Enhancing MRI Imaging in Breast Cancer Patients

PURPOSE/OBJECTIVE(S)

Distant metastasis free and overall survival of high-risk breast cancer patients can be improved with irradiation of the lymphatic system. However, inclusion of internal mammary region (IMN) markedly increases the dose to the heart. Hence, an estimation of the individual risk of subclinical involvement is necessary in order to balance the oncological benefit versus the cardiac toxicity. In randomized studies the risk stratification for IMN involvement is mainly based on the tumor location (medial, central vs. lateral). The aim of this study was to evaluate whether the contact of the tumor with the internal mammary perforator vessels (IMPV) is an additional risk factor for IMN involvement.

MATERIALS/METHODS

For this trial we retrospectively examined 104 sets of pre-treatment dynamic contrast enhanced magnetic resonance imaging (DE-MRI) scans of locally advanced breast cancer patients. All patients had ipsilateral clinical suspect lymph nodes in the axillary region and either positive (n = 52) or negative lymph nodes (n = 52) in the internal mammary region. Based on the DE-MRI we assessed the tumor location as well as contact to the internal mammary perforating vessels (IMPV). Contact between tumor and IMPV was classified into either predominant, minor or no contact. Criteria for a predominant IMPV contact was defined as: main vessel contact or contact to multiple (> = 5) side branches.

RESULTS

The tumor location of IMN+ patients were medial in 19.2% (10/52), central in 26.9% (14/52), lateral in 28.8% (15/52) and multicentric in 25.0% (13/52) of. In IMN- patients, tumor location was medial in 9.6% (5/52), central in 26.9% (14/52), lateral in 42.3% (22/52) and multicentric in 21.2% (11/52) in IMN- patients. The tumor size ranged from T1-T4 with most patients staged as T2 (48.1% (IMN+) vs. 38.5% IMN-). Most patients had hormone receptor positive / Her2neu negative disease (36.5% (IMN+) vs. 46.2% (IMN-). 100 % of tumors in IMN+ patients had contact with IMPV: in 94.2% (49/52) criteria for predominant IMPV contact was fulfilled; in the remaining 3 cases (5.8%) the tumor had minor IMPV contact. In IMN- patients however, 36/52 of cases (69.2%) had direct IMPV contact. Predominant contact was found in only 23.1% (12/52), minor IMPV contact in 46.2% (24/52).

CONCLUSION

Predominant contact of the tumor with IMPV appears to be a potential risk factor for IMN involvement in breast cancer patients and could be used for stratification for IMN-irradiation in future trials.

Best Practice Guideline - DEGUM Recommendations on Breast Ultrasound

For many years, breast ultrasound has been used in addition to mammography as an important method for clarifying breast findings. However, differences in the interpretation of findings continue to be problematic 1 2. These differences decrease the diagnostic accuracy of ultrasound after detection of a finding and complicate interdisciplinary communication and the comparison of scientific studies 3. In 1999, the American College of Radiology (ACR) created a working group (International Expert Working Group) that developed a classification system for ultrasound examinations based on the established BI-RADS classification of mammographic findings under consideration of literature data 4. Due to differences in content, the German Society for Ultrasound in Medicine (DEGUM) published its own BI-RADS-analogue criteria catalog in 2006 3. In addition to the persistence of differences in content, there is also an issue with formal licensing with the current 5th edition of the ACR BI-RADS catalog, even though the content is recognized by the DEGUM as another system for describing and documenting findings. The goal of the Best Practice Guideline of the Breast Ultrasound Working Group of the DEGUM is to provide colleagues specialized in senology with a current catalog of ultrasound criteria and assessment categories as well as best practice recommendations for the various ultrasound modalities.

AGO Recommendations for the Surgical Therapy of Breast Cancer: Update 2022

The recommendations of the AGO Breast Committee on the surgical therapy of breast cancer were last updated in March 2022 (www.ago-online.de). Since surgical therapy is one of several partial steps in the treatment of breast cancer, extensive diagnostic and oncological expertise of a breast surgeon and good interdisciplinary cooperation with diagnostic radiologists is of great importance. The most important changes concern localization techniques, resection margins, axillary management in the neoadjuvant setting and the evaluation of the meshes in reconstructive surgery. Based on meta-analyses of randomized studies, the level of recommendation of an intraoperative breast ultrasound for the localization of non-palpable lesions was elevated to "++". Thus, the technique is considered to be equivalent to wire localization, provided that it is a lesion which can be well represented by sonography, the surgeon has extensive experience in breast ultrasound and has access to a suitable ultrasound device during the operation. In invasive breast cancer, the aim is to reach negative resection margins ("no tumor on ink"), regardless of whether an extensive intraductal component is present or not. Oncoplastic operations can also replace a mastectomy in selected cases due to the large number of existing techniques, and are equivalent to segmental resection in terms of oncological safety at comparable rates of complications. Sentinel node excision is recommended for patients with cN0 status receiving neoadjuvant chemotherapy after completion of chemotherapy. Minimally invasive biopsy is recommended for initially suspect lymph nodes. After neoadjuvant chemotherapy, patients with initially 1 - 3 suspicious lymph nodes and a good response (ycN0) can receive the targeted axillary dissection and the axillary dissection as equivalent options.

Interdisciplinary Screening, Diagnosis, Therapy and Follow-up of Breast Cancer. Guideline of the DGGG and the DKG (S3-Level, AWMF Registry Number 032/045OL, December 2017) - Part 2 with Recommendations for the Therapy of Primary, Recurrent and Advanced Breast Cancer

Purpose The aim of this official guideline coordinated and published by the German Society for Gynecology and Obstetrics (DGGG) and the German Cancer Society (DKG) was to optimize the screening, diagnosis, therapy and follow-up care of breast cancer. Method The process of updating the S3 guideline published in 2012 was based on the adaptation of identified source guidelines. They were combined with reviews of evidence compiled using PICO (Patients/Interventions/Control/Outcome) questions and with the results of a systematic search of literature databases followed by the selection and evaluation of the identified literature. The interdisciplinary working groups took the identified materials as their starting point and used them to develop suggestions for recommendations and statements, which were then modified and graded in a structured consensus process procedure. Recommendations Part 2 of this short version of the guideline presents recommendations for the therapy of primary, recurrent and metastatic breast cancer. Loco-regional therapies are de-escalated in the current guideline. In addition to reducing the safety margins for surgical procedures, the guideline also recommends reducing the radicality of axillary surgery. The choice and extent of systemic therapy depends on the respective tumor biology. New substances are becoming available, particularly to treat metastatic breast cancer.

Interdisciplinary Screening, Diagnosis, Therapy and Follow-up of Breast Cancer. Guideline of the DGGG and the DKG (S3-Level, AWMF Registry Number 032/045OL, December 2017) - Part 1 with Recommendations for the Screening, Diagnosis and Therapy of Breast Cancer

Purpose The aim of this official guideline coordinated and published by the German Society for Gynecology and Obstetrics (DGGG) and the German Cancer Society (DKG) was to optimize the screening, diagnosis, therapy and follow-up care of breast cancer. Methods The process of updating the S3 guideline dating from 2012 was based on the adaptation of identified source guidelines which were combined with reviews of evidence compiled using PICO (Patients/Interventions/Control/Outcome) questions and the results of a systematic search of literature databases and the selection and evaluation of the identified literature. The interdisciplinary working groups took the identified materials as their starting point to develop recommendations and statements which were modified and graded in a structured consensus procedure. Recommendations Part 1 of this short version of the guideline presents recommendations for the screening, diagnosis and follow-up care of breast cancer. The importance of mammography for screening is confirmed in this updated version of the guideline and forms the basis for all screening. In addition to the conventional methods used to diagnose breast cancer, computed tomography (CT) is recommended for staging in women with a higher risk of recurrence. The follow-up concept includes suggested intervals between physical, ultrasound and mammography examinations, additional high-tech diagnostic procedures, and the determination of tumor markers for the evaluation of metastatic disease.

Breast MRI: EUSOBI recommendations for women's information

This paper summarizes information about breast MRI to be provided to women and referring physicians. After listing contraindications, procedure details are described, stressing the need for correct scheduling and not moving during the examination. The structured report including BI-RADS® categories and further actions after a breast MRI examination are discussed. Breast MRI is a very sensitive modality, significantly improving screening in high-risk women. It also has a role in clinical diagnosis, problem solving, and staging, impacting on patient management. However, it is not a perfect test, and occasionally breast cancers can be missed. Therefore, clinical and other imaging findings (from mammography/ultrasound) should also be considered. Conversely, MRI may detect lesions not visible on other imaging modalities turning out to be benign (false positives). These risks should be discussed with women before a breast MRI is requested/performed. Because breast MRI drawbacks depend upon the indication for the examination, basic information for the most important breast MRI indications is presented. Seventeen notes and five frequently asked questions formulated for use as direct communication to women are provided. The text was reviewed by Europa Donna-The European Breast Cancer Coalition to ensure that it can be easily understood by women undergoing MRI.

KEY POINTS

• Information on breast MRI concerns advantages/disadvantages and preparation to the examination • Claustrophobia, implantable devices, allergic predisposition, and renal function should be checked • Before menopause, scheduling on day 7-14 of the cycle is preferred • During the examination, it is highly important that the patient keeps still • Availability of prior examinations improves accuracy of breast MRI interpretation.

Use of an Additional Diagnostic Work-up Following a Treatment Recommendation from the Preoperative Conference of the Mammography Screening Units

Objective: If a focus of suspicion is classified as being B 3-5 by a punch biopsy as part of a mammography screening, a recommendation for further action to be taken will be given in the preoperative conference of the screening unit. As part of this investigation, these treatment recommendations were compared with the final therapeutic approach taken at a certified breast centre. Furthermore, it was investigated whether and which additional examinations were performed on patients, depending on compliance with the recommended treatment. Material and Method: The data from 272 breast cancer patients from the years 2007, 2008 and 2009 was analysed. The patients took part in the screening programmes of four screening units in the German mammography screening programme, in one federal state. In addition, the data from each patient from one screening unit was analysed in two further federal states. Results: In total, the most recently conducted intervention deviated from the treatment recommendation from the preoperative conference in the screening unit in 77 out of 272 patients (28.3 %). Of these, there were 50 recommendations for open biopsy which ultimately resulted in breast-conserving surgery, which is not to be evaluated as an error, as the bioptic result was supplemented by the open biopsy. Additional examinations were performed in patients with deviating treatment recommendation in 39 cases (50.6 %) and in patients without deviating treatment recommendation in 66 cases (34.0 %). The additional examinations carried out included additional punch biopsies (most frequent) and MRI scans, but also additional ultrasounds or a mammography. Conclusions: Additional examinations lead to a change in treatment in a higher percentage of patients in comparison with the initial screening including assessment. An exact reexamination of the findings obtained in the screening is therefore preoperatively necessary in order to guarantee optimum treatment.

Report of a metaplastic carcinoma of the breast with multi-directional differentiation: an adenoid cystic carcinoma, a spindle cell carcinoma and melanoma

Metaplastic carcinoma of the breast is a heterogeneous neoplasia, generally composed of both epithelial and mesenchymal components. We report an unusual case of mammary metaplastic carcinoma in a 51-year-old female patient. Needle core biopsy from the tumour mass showed malignant epithelial and sarcomatous features. The resection specimen revealed a multi-directional tumour differentiation consisting predominantly of: firstly, a poorly differentiated basaloid epithelial cell type, consistent with an adenoid cystic carcinoma; secondly, areas of a spindle cell carcinoma; and, thirdly, areas with a melanocytic differentiation. This is the first report on a metaplastic carcinoma of the breast presenting as an admixture of an adenoid cystic carcinoma and melanoma.