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CC BY-NC-ND 4.0 · Rev Bras Ginecol Obstet 2018; 40(07): 403-409
DOI: 10.1055/s-0038-1666997
Original Article
Thieme Revinter Publicações Ltda Rio de Janeiro, Brazil

Value of Systemic Staging in Asymptomatic Early Breast Cancer

Valor do estadiamento sistêmico no câncer de mama precoce assintomático
Gregório Pinheiro Soares
1   Faculty of Medicine, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, SP, Brazil
,
Allan Andresson Lima Pereira
1   Faculty of Medicine, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, SP, Brazil
,
Mariana Silva Vilas Boas
1   Faculty of Medicine, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, SP, Brazil
,
Victor Van Vaisberg
1   Faculty of Medicine, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, SP, Brazil
,
Maria Cristina Figueroa Magalhães
1   Faculty of Medicine, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, SP, Brazil
,
Rudinei Diogo Marques Linck
1   Faculty of Medicine, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, SP, Brazil
,
Max Senna Mano
1   Faculty of Medicine, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, SP, Brazil
› Author Affiliations
Further Information

Publication History

21 November 2017

17 May 2018

Publication Date:
10 July 2018 (online)

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Abstract

Objective Metastases are rare in early breast cancer (EBC), and international guidelines recommend against routine systemic staging for asymptomatic patients. However, imaging exams remain widely employed in the clinical practice. The aim of the present study is to evaluate the value of imaging for systemic staging in EBC.

Methods A retrospective analysis of newly-diagnosed breast cancer (BC) patients was performed. Clinical data including BC subtype, stage, presence of symptoms at diagnosis and instrumental procedures performed for staging were recorded.

Results A total of 753 patients were included, with a median age of 57 years. The majority of the patients underwent at least 1 imaging procedure (91%); had invasive ductal carcinoma (83.5%); histological grade 2 (51.4%); stage II (61.8%); and luminal subtype (67.9%). Among the 685 (91%) patients who underwent any radiologic staging, distant metastases (DMs) were detected in 32 (4.7%). In the univariate analyses, stage IIb and pathological lymph node involvement (pN1) showed a statistically significant association with the presence of DMs, versus only a trend for triple negative and human epidermal growth factor receptor 2 (Her2) positive subtype. In an exploratory analysis performed in this same subgroup, when unfavorable biology (triple negative or Her2 positive) was present, patients had a DM rate of 14.4%, one of the highest reported at this stage of the disease.

Conclusion Early breast cancer has a low prevalence of DM at the initial evaluation, and systemic staging of asymptomatic, unselected patients is not warranted as a routine practice. However, we have identified subgroups of patients to whom a full staging could be indicated.

Resumo

Objetivo Metástases são de ocorrência rara no câncer de mama precoce, e as diretrizes internacionais não recomendam o estadiamento sistêmico de rotina para pacientes assintomáticos. Apesar disso, exames de imagem continuam sendo largamente empregados na prática clínica. O objetivo do presente estudo é avaliar o valor do estadiamento por imagem no câncer de mama precoce.

Métodos Análise retrospectiva de pacientes recém-diagnosticados com câncer de mama. Foram registrados os dados clínicos dos pacientes, incluindo subtipo da neoplasia de mama, estadiamento, presença de sintomas no momento do diagnóstico e procedimentos de estadiamento.

Resultados Um total de 753 pacientes foram incluídos, com idade média de 57 anos. Grande parte deles se submeteu a pelo menos um exame de imagem (91%); tinha carcinoma ductal invasivo (83,5%); grau histológico 2 (51,4%); estádio II (61,8%); e subtipo luminal (67,9%). Entre os 685 (91%) pacientes que realizaram algum exame de imagem, metástases à distância foram detectadas em 32 (4,7%). Na análise univariada, estádio IIb e acometimento linfonodal (pN1) tiveram uma associação estatisticamente significativa com a presença de metástase, enquanto os subtipos triplo negativo e receptor tipo 2 do fator de crescimento epidérmico humano (Her2) positivo demonstraram apenas uma tendência para a identificação de metástases. Na análise exploratória deste mesmo subgrupo, diante da presença de biologia desfavorável (triplo negativo e Her2 positivo), os pacientes apresentaram uma taxa de metástase à distância de 14,4%, uma das mais altas relatadas nesse estádio.

Conclusão Neoplasia de mama precoce apresenta baixa baixa prevalência de metástase à distância no momento do diagnóstico, e o estadiamento sistêmico de rotina de pacientes assintomáticos e não selecionados não é justificável. Contudo, identificamos subgrupos de pacientes para os quais o estadiamento completo poderia ser indicado.

Keywords

breast neoplasms - metastases - neoplasm staging

Palavras-chave

neoplasia de mama - metástases - estadiamento de neoplasia

Contributors

Soares G. P., Pereira A. A. L., Boas M. S. V., Vaisberg V. V., Magalhães M. C. F., Linck R. D. M. and Mano M. S. contributed with the project and interpretation of data, writing of the article, critical review of the intellectual content and final approval of the version to be published.


 

  • References

  • 1 Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA Cancer J Clin 2015; 65 (01) 5-29 . Doi: 10.3322/caac.21254
    CrossrefPubMedGoogle Scholar
  • 2 Edge SB, Compton CC. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol 2010; 17 (06) 1471-1474
    CrossrefPubMedGoogle Scholar
  • 3 Ravaioli A, Pasini G, Polselli A. , et al. Staging of breast cancer: new recommended standard procedure. Breast Cancer Res Treat 2002; 72 (01) 53-60
    CrossrefPubMedGoogle Scholar
  • 4 Barrett T, Bowden DJ, Greenberg DC, Brown CH, Wishart GC, Britton PD. Radiological staging in breast cancer: which asymptomatic patients to image and how. Br J Cancer 2009; 101 (09) 1522-1528 . Doi: 10.1038/sj.bjc.6605323
    CrossrefPubMedGoogle Scholar
  • 5 Brennan ME, Houssami N. Evaluation of the evidence on staging imaging for detection of asymptomatic distant metastases in newly diagnosed breast cancer. Breast 2012; 21 (02) 112-123 . Doi: 10.1016/j.breast.2011.10.005
    CrossrefPubMedGoogle Scholar
  • 6 Chen X, Sun L, Cong Y. , et al. Baseline staging tests based on molecular subtype is necessary for newly diagnosed breast cancer. J Exp Clin Cancer Res 2014; 33: 28 . Doi: 10.1186/1756-9966-33-28
    CrossrefPubMedGoogle Scholar
  • 7 Linkugel A, Margenthaler J, Dull B, Cyr A. Staging studies have limited utility for newly diagnosed stage I-II breast cancer. J Surg Res 2015; 196 (01) 33-38 . Doi: 10.1016/j.jss.2015.02.065
    CrossrefPubMedGoogle Scholar
  • 8 Thavorn K, Wang Z, Fergusson D, van Katwyk S, Arnaout A, Clemons M. Cost implications of unwarranted imaging for distant metastasis in women with early-stage breast cancer in Ontario. Curr Oncol 2016; 23 (Suppl. 01) S52-S55 . Doi: 10.3747/co.23.2977
    CrossrefPubMedGoogle Scholar
  • 9 Senkus E, Kyriakides S, Ohno S. , et al; ESMO Guidelines Committee. Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2015; 26 (Suppl. 05) v8-v30 . Doi: 10.1093/annonc/mdv298
    CrossrefPubMedGoogle Scholar
  • 10 Anderson BO. Breast cancer--thinking globally. Science 2014; 343 (6178): 1403 . Doi: 10.1126/science.1253344
    CrossrefPubMedGoogle Scholar
  • 11 Schnipper LE, Smith TJ, Raghavan D. , et al. American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncology. J Clin Oncol 2012; 30 (14) 1715-1724 . Doi: 10.1200/JCO.2012.42.8375
    CrossrefPubMedGoogle Scholar
  • 12 Simos D, Hutton B, Clemons M. Are physicians choosing wisely when imaging for distant metastases in women with operable breast cancer?. J Oncol Pract 2015; 11 (01) 62-68 . Doi: 10.1200/JOP.2014.000125
    CrossrefPubMedGoogle Scholar
  • 13 Brothers JM, Kidwell KM, Brown RK, Henry NL. Incidental radiologic findings at breast cancer diagnosis and likelihood of disease recurrence. Breast Cancer Res Treat 2016; 155 (02) 395-403 . Doi: 10.1007/s10549-016-3687-1
    CrossrefPubMedGoogle Scholar
  • 14 Simos D, Hutton B, Graham ID. , et al. Patient perceptions and expectations regarding imaging for metastatic disease in early stage breast cancer. Springerplus 2014; 3: 176 . Doi: 10.1186/2193-1801-3-176
    CrossrefPubMedGoogle Scholar
  • 15 Myers RE, Johnston M, Pritchard K, Levine M, Oliver T. ; Breast Cancer Disease Site Group of the Cancer Care Ontario Practice Guidelines Initiative. Baseline staging tests in primary breast cancer: a practice guideline. CMAJ 2001; 164 (10) 1439-1444
    PubMedGoogle Scholar
  • 16 Badwe R, Hawaldar R, Nair N. , et al. Locoregional treatment versus no treatment of the primary tumour in metastatic breast cancer: an open-label randomised controlled trial. Lancet Oncol 2015; 16 (13) 1380-1388 . Doi: 10.1016/S1470-2045(15)00135-7
    CrossrefPubMedGoogle Scholar
  • 17 Mohammed TL, Chowdhry A, Reddy GP. , et al; Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria® screening for pulmonary metastases. J Thorac Imaging 2011; 26 (01) W1-W3 . Doi: 10.1097/RTI.0b013e3182010bf9
    CrossrefPubMedGoogle Scholar
  • 18 Cantisani V, Grazhdani H, Fioravanti C. , et al. Liver metastases: Contrast-enhanced ultrasound compared with computed tomography and magnetic resonance. World J Gastroenterol 2014; 20 (29) 9998-10007 . Doi: 10.3748/wjg.v20.i29.9998
    CrossrefPubMedGoogle Scholar
  • 19 Carter CL, Allen C, Henson DE. Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer 1989; 63 (01) 181-187 . Doi: 10.1002/1097-0142(19890101)63:1<181:AID-CNCR2820630129>3.0.CO;2-H
    CrossrefPubMedGoogle Scholar
  • 20 Andersson Y, Frisell J, Sylvan M, de Boniface J, Bergkvist L. Breast cancer survival in relation to the metastatic tumor burden in axillary lymph nodes. J Clin Oncol 2010; 28 (17) 2868-2873 . Doi: 10.1200/JCO.2009.24.5001
    CrossrefPubMedGoogle Scholar
  • 21 de Boer M, van Dijck JA, Bult P, Borm GF, Tjan-Heijnen VCG. Breast cancer prognosis and occult lymph node metastases, isolated tumor cells, and micrometastases. J Natl Cancer Inst 2010; 102 (06) 410-425 . Doi: 10.1093/jnci/djq008
    CrossrefPubMedGoogle Scholar
  • 22 Weaver DL, Ashikaga T, Krag DN. , et al. Effect of occult metastases on survival in node-negative breast cancer. N Engl J Med 2011; 364 (05) 412-421 . Doi: 10.1056/NEJMoa1008108
    CrossrefPubMedGoogle Scholar