Local staging of ipsilateral breast tumor recurrence: mammography, ultrasound, or MRI?

BACKGROUND: Despite increasingly effective curative breast-conserving treatment (BCT) regimens for primary breast cancer, patients remain at risk for an ipsilateral breast tumor recurrence (IBTR). With increasing interest for repeat BCT in selected patients with IBTR, a reliable assessment of the size of IBTR is important for surgical planning. AIM: The primary aim of this study is to establish the performance in size estimation of XMG, US, and breast MRI in patients with IBTR. The secondary aim is to compare the detection of multifocality and contralateral lesions between XMG and MRI. PATIENTS AND METHODS: The sizes of IBTR on mammography (XMG), ultrasound (US), and magnetic resonance imaging (MRI) in 159 patients were compared to the sizes at final histopathology. The accuracy of the size estimates was addressed using Pearson's coefficient and Bland-Altman plots. Secondary outcomes were the detection of multifocality and contralateral lesions between XMG and MRI. RESULTS: Both XMG and US significantly underestimated the tumor size by 3.5 and 4.8 mm, respectively, while MRI provided accurate tumor size estimation with a mean underestimation of 1.1 mm. The sensitivity for the detection of multifocality was significantly higher for MRI compared to XMG (25.5% vs. 5.5%). A contralateral malignancy was found in 4.4% of patients, and in 1.9%, it was detected by MRI only. CONCLUSION: The addition of breast MRI to XMG and US in the preoperative workup of IBTR allows for more accurate size estimation. MRI provides a higher sensitivity for the detection of multifocality compared to XMG.

The clinical significance of HER2 expression in DCIS.

HER2 is an established prognostic and predictive marker for patients with invasive breast cancer. The clinical and biological significance of HER2 overexpression in patients with ductal carcinoma in situ (DCIS) remains poorly defined. DCIS is a heterogeneous disease and some patients with DCIS will not progress to invasive breast cancer. However, clinically significant recurrence rates have been reported after breast-conserving surgery for DCIS and approximately half of these cases will be life-threatening invasive recurrences. Since the incidence of DCIS is rising due to the widespread use of screening mammography, there is robust interest in selecting high-risk DCIS patients that may benefit from adjuvant therapies. Molecular prognostic and predictive models in early invasive breast cancer help clinicians identify patients that will benefit from chemotherapy. Molecular subtyping and profiling could also be useful in treating DCIS patients. According to current practice guidelines, HER2 testing is not recommended in DCIS patients. Nevertheless, evidence suggests that HER2-positive DCIS cases may be associated with adverse clinicopathological parameters and increased recurrence rates. This review summarizes the existing body of evidence linking HER2 expression and ipsilateral breast cancer recurrence in DCIS. HER2, as well as its correlation with other clinicopathological markers might be a useful prognostic and predictive marker, helping clinical decision-making in DCIS patients.

Multifocality in ipsilateral breast tumor recurrence - A study in ablative specimens.

BACKGROUND: The incidence and clinical significance of multifocality in ipsilateral breast tumor recurrence (IBTR) after breast-conserving therapy (BCT) are unclear. With growing interest in repeat BCT, this information has become of importance. This study aimed to gain insight in the incidence of multifocality in IBTR, to identify patient- and tumor-related predicting factors and to investigate the prognostic significance of multifocality. METHODS: Two hundred and fifteen patients were included in this analysis. All had an IBTR after BCT and were treated by salvage mastectomy and appropriate adjuvant therapy. Predictive tumor- and patient-related factors for multifocality in IBTR were identified using X2 test and univariate logistic regression analyses. Prognostic outcomes were calculated using Kaplan Meier analysis and compared using the log rank test. RESULTS: Multifocality was present in 50 (22.9%) of IBTR mastectomy specimens. Axillary positivity in IBTR was significantly associated with multifocality in IBTR. Chest wall re-recurrences occurred more often after multifocal IBTR (14% versus 7% after unifocal IBTR, p = 0.120). Regional re-recurrences did not differ significantly between unifocal and multifocal IBTR (8% vs. 6%, p = 0.773). Distant metastasis after salvage surgery occurred more frequently after multifocal IBTR (15% vs. 24%, p = 0.122). Overall survival was 132 months after unifocal IBTR and 112 months after multifocal IBTR (p = 0.197). CONCLUSION: The prevalence of multifocality in IBTR is higher than in primary breast cancer. Axillary positivity in IBTR was associated with a multifocal IBTR. Chest wall re-recurrences and distant metastasis were, although not statistically significant, more prevalent after multifocal IBTR.

HER2 overexpression in ductal carcinoma in situ is associated with ipsilateral breast cancer recurrence after conservative surgery.

BACKGROUND: A few patients with ductal carcinoma in situ (DCIS) after breast conservative surgery would develop ipsilateral breast cancer recurrence (IBTR), either invasive or non-invasive. Study of accurate predictive biomarkers for IBTR risk are warranted. We analyzed the association of human epidermal growth factor receptor 2 (HER2) status with IBTR after conservative surgery. METHODS: We chose 213 cases of DCIS diagnosed between 2005 and 2010. Immunohistochemistry was performed for ER, PR, and HER2. The primary endpoint was IBTR. Kaplan-Meier plot was used for univariate survival analysis with log-rank test. Cox proportional hazards model was used for multivariate analysis. Hazard ratio (HR) and 95% confidence interval (CI) were calculated. RESULTS: With a median follow-up 80 months, there were 29 IBTR events. In univariate analysis, patients with high grade, ER-negative, and HER2-positive breast cancers tended to have an increased risk of IBTR. In multivariate analysis, grade III and HER2-positivity were independent predictive factors for IBTR. HER2-positive DCIS had a 2.6-time risk of recurrence compared with those with HER2-negative tumors (HR=2.60; 95% CI, 1.02-6.98; P=0.044). For HER2-equivocal cases, the HR was 1.59 (95% CI, 0.40-6.34; P=0.50) compared with HER2-negative cases. Moreover, annual recurrence pattern according to HER2 status showed that HER2-positive DCIS had a recurrence peak at 3-5 years (0.3% per annum) while the annual recurrence rate of HER2-negative DCIS was very low (less than 0.1% per annum). CONCLUSIONS: This study suggests that of HER2-overexpression might contribute to IBTR in DCIS after breast conservation.