Triple Negative Breast Cancer: Clinical Presentation and Multimodality Imaging Characteristics Poster No.: R-0141 Congress: RANZCR-AOCR 2012 Type: Scientific Exhibit Authors: O. H. Woo, S. Jang, K. R. Cho, B. K. Seo, H. S. Yong, E.-Y. Kang Keywords: Breast, MR, Mammography, Ultrasound, Diagnostic procedure, Pathology DOI: 10.1594/ranzcraocr2012/R-0141 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 20
Purpose Triple negative breast cancer(tnbc) is defined as tumors lacking the expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER 2)\ 10-17% of all breast cancers TNBC shows a basal-like phenotype with poor prognosis. Younger women (<50yrs) Aggressive clinical behavior whicn currently lacks effective targeted therapy The purpose of this scientific exhibit is 1. To evaluate the clinical presentations and multimodal imaging findings of triple negative breast cancer 2. To assess radiologic differentiation points, if any, to assist in surgical planning and future treatment Page 2 of 20
Images for this section: Fig. 1: TNBCs typically have a higher histological grade, elevated mitotic count and scant stromal content. Page 3 of 20
Methods and Materials 1. Patients IRB approved From Jan 2009 to March 2012, patients who underwent surgery for primary breast cancer with mammography at the time of diagnosis. A total of 390 patients with primary breast cancer were evaluated, and 58 turned out to be triple negative breast cancers. We reviewed patients' clinical, imaging and histologic features. 2. Multimodality Imaging Patients received mammography(mg, n=58),breast ultrasound(us, n=58) or contrast enhanced dynamic magnetic resonance imaging(cemr, n=38) A-1. Mammography MG was performed using a General Electic Seno digital MG(Milwaukee, WI) or a a Lorad M3 digital MG unit(hologic, Inc., Boston,MA) Standard two-view MG was performed, with additional views if deemed necessary Two breast radiologist reviewed all MG by consensus A-2. Mammographic analysis Breast parenchymal density Mass: size, shape, margin, density Calcification Asymmetry, architectural distortion Associated features such as skin thickening and retraction, nipple retraction and axillary lymphadenopathy Final assessment according to BI-RADS B-1. Breast Ultrasound Ultrasound was performed using a Logiq 9 US unit (General Electronic Medical System, Milwaukee, WI) or a IU-22 US unit (Philips, Bothell, WA) with a high frequency linear array transducer (5-17 MHz) We routinely scanned whole breasts and obtained transverse, longitudinal and radial views of each lesion. An expert breast radiologist retrospectively evaluated breast US images. B-2. Ultrasonographic analysis Page 4 of 20
Mass: size, shape, margin, orientation, boundary, echogenecity Calcification Ductal changes Final assessment according to BI-RADS C-1. CEMR imaging MR imaging of both breasts was performed with a 3.0T system (Siemens Medical System, Erlangen, Germany) The paitent was imaged in the prone position using a bilateral breast coil. Pre-contrast T1 and dynamic enhancement study C-2. CEMR imaging analysis Morphology assessment: size, shape, margin, internal enhancement Dynamic enhancement pattern Final assessment according to BI-RADS 3. Histologic assessment Histologic classification Nottingham combined histologic grade Immunohistochemical analysis Immunohistochemical scoring Page 5 of 20
Results 1. 2. 3. 4. 58(15%) patients identified as triple negative breast cancers on immunohistochemical assay Mean size: 3.7cm (range, 1.1-10.7cm) 47/58(81%) symptomatic group : Palpalbe mass (43/47), Ski retraction and skin redness (2/47), nipple discharge (1/47) and axillary lymphadenopathy (1/47) 11/58 (19%) screrening-detected group: MG only (6/11) and combined US (5/11) Page 6 of 20
Images for this section: Table 1: Mammography findings in 58 patients with TNBC Page 7 of 20
Table 2: Mammography findings in 46 patients with mass-forming TNBC Page 8 of 20
Table 3: US findings in 58 patients with TNBC Page 9 of 20
Table 4: MRI findings in 38 patients with TNBC Page 10 of 20
Table 5: Pathologic findings in 58 patients with TNBC Page 11 of 20
Fig. 2: A 45 year-old woman was found with abnormal microcalcifications in the left breast on screening MG. The lesion was not apparent in US apart from calcific foci. CEMR imaging shows rapid enhancement with gradual continuous increasing enhancement with time. This lesion was confirmed as DCIS, concordant with MR findings. Page 12 of 20
Fig. 3: Our second case is a 41-year-old patient with pleomorphic microcalcifications in the left breast.us revealed a associated small nodule with microcalcifications. It was confirms as DCIS with negative CK5/6 Page 13 of 20
Fig. 4: 48-year-old patient presented with a palpable mass. This 2cm sized mass had circumscribed or lobular margins on US. Page 14 of 20
Fig. 5: MR reveals a type 3 wash out pattern with rim enhancement. The lesion was confirmed to be invasive ductal carcinoma. Page 15 of 20
Fig. 6: A 44 year old woman with a 5cm sized large palpable mass lesion in the left breast was evaluated. You can notice an associated enlarged axillary lymph node. In US,the oval shaped mass has smooth distinct margins. Page 16 of 20
Fig. 7: This T2 high signal intensity lesion did not show any abnormal enhancement probably due to internal necrosis. You can also notice the enlarged axillary LNs which turned out to be invasive ductal carcinoma with LN involvement. Page 17 of 20
Conclusion 1. 2. 3. Triple negative breast cancers (TNBC) more often present as a large mass that show benign morphologic appearances on multimodality imaging. Especially, MRI demonstrates rim enhancement pattern and type III washout enhancement patterns in the majority of tumors, leading to a high positive predictive value for malignancy. Knowledge of the characteristics of TNBC may provide earlier detection and proper diagnosis. Page 18 of 20
Personal Information Page 19 of 20
References 1. Dogan BE, Gonzalez-Angulo AM, Gilcrease M, Dryden MJ, Yang WT. Multimodality Imaging of Tripile Receptor-Negative Tumors With Mammography, Ultrasound, and MRI. AJR 2010;194:1160-1166 2. Kim MJ, Ro JY, Ahn SH, Kim HH, Kim SB, Gong G. Clinicopathologic significance of the basal-like subtype of breast cancer: a comparison with hormone receptor and Her2/ neu-overexpressing phenotypes. Hum Pathol 2006;37:1217-1226 3. Yang WT, Dryden M, Broglio K, Gilcrease M, Dawood S, Dempsey PJ. Mammographic features of triple receptor-negative primary breast cancers in young premenopausal women. Breast CAncer REs TReat 2008;111:405-410 Page 20 of 20