Correlation Between Mammographic Features And Clinicopathological Characteristics In Breast Cancer

BACKGROUNDWorldwide, it is estimated that more than one million women are diagnosed with breast cancer every year, and it accounts for about410,000deaths per year. Breast cancer is already the leading cause of cancer in Southeast Asian women, and is second only to gastric cancer in East Asian women. In some areas of China, the incidence of breast cancer was recorded to be increasing by5%per year, an increase greater than that worldwide.The application of mammography benefits more and more patients by leading to earlier detection and management because the introduction of mammography screening has led to an increased detection of smaller invasive tumors without local or distant metastasis. Breast cancer often exhibits intratumoral heterogeneity, so that mammographic patterns of breast cancer have a wide range of variation. Recently, we reported that mammographically occult breast cancer had a worse prognosis compared with mammographically positive breast cancer. At the same time, the insufficient of mammography is revealed. Mammography may increase the risk of breast cancer if received frequently. The sensitivity of breast cancer in dense breast is low, which needing other iconography examination to avoid missing of diagnosis. Some invasive breast cancer are not visible on mammogram, and the prognosis of them is poorer than that of visible on mammogram. Although an increased detection of ductal carcinoma in situ due to the high mammography sensitivity for calcification is observed, unnecessary stereoscopic core needle biopsy of suspicious calcification increased also。 In addition, it has been reported that some particular histological types of breast carcinomas have certain specific mammographic features. Mucinous carcinoma of the breast usually presents as a mass with a well-defined margin rather than a spiculated one, and is associated with the absence of calcifications, while tubular carcinoma of the breast usually manifests as a small spiculated mass. Both of these types have more favorable prognosis than common invasive ductal carcinoma. To our knowledge, there are few articles reporting the mammographic features of invasive ductal carcinomas (IDC). The aim of the current study was to evaluate the different types of mammographic tumoral appearances for their relationships with clinical, pathological and biological characteristics in a series of patients with IDC.Nipple discharge is a common complaint of women. The spontaneous, unilateral, single-duct nipple discharge is defined as pathological nipple discharge. Although most of pathological nipple discharge is caused by benign diseases, such as intraductal papilloma, about5～15%of patients with nipple discharge have cancer. Ultrasonography and exfoliative cytology are useful in the diagnosis of spontaneous pathological nipple discharge but are not reliable enough both. Galactography, also known as ductography, plays an important role in the management of spontaneous pathological nipple discharge. The purpose of this study is to illustrate the role of galactography in the management of nipple discharge and to assess the diagnostic value of preoperative galactography in women with nipple discharge.PART1Mammography features are correlated with clinicopathological characteristics in breast invasive ductal carcinomaOBJECTTo assess the correlation between mammographic features and clinicopathologic characteristics of invasive breast carcinoma. To evaluate if mammographic appearance can predict the therapy and prognosis of breast cancer.METHODSThe mammographic appearance and clinicopathological data of108patients with invasive ductal carcinoma were retrospectively analyzed.1.The collection of clinicopathological informations of invasive ductal carcinomasThe histological type of all the108patients was invasive ductal carcinoma, no matter companied by component of ductal carcinoma in situ or not, with infiltrative peculiar carcinomas excluded. The clinical information, including age, menopausal status, tumor size, grade, stage, and axillary lymph node status, were collected from our database.2.Immunohistostaining analysisThe immunohistostaining analysis was performed with PV-9000Polymer Detection System for Immuno-Histological Staining (GBI, USA). Estrogen recptor (ER), progesterone receptor (PR), human epidermal growth factor receptor2(Her2) and Ki67were successfully detected in all the paraffin sections. ER and PR were considered positive if nuclear staining was present in≥10%of the cells, and Ki67expression was considered positive in cases of a substantial percentage of positively stained nuclei(>30%). Her2expression was graded as recommended by the HercepTestTM scoring guidelines. Her2was considered to be positive if the score was2+or3+.3.Assessment of mammograms according to BI-RADSEvery patient received mammography screening bilaterally before the surgery with the use of a Mammomat Novation DR system (Simmens AG, Germany). Craniocaudal view (CC) and mediolateral view (ML) were performed routinely for all patients, and mediolateral oblique view (MLO) was obtained when necessary. All the mammograms were assessed according to the analytic criteria of Breast Imaging Reporting and Data System (BI-RADS) in which the mammographic features mass, calcification, architectural distortion and asymmetric density were recorded. 4.Statistical analysisAll data were analyzed using Statistical Package for the Social Sciences statistical software (version19.0; SPSS Inc., Chicago, IL, USA). Correlations between mammographic appearance and clinicopathological parameters of IDC were also evaluated by chi-square test. All statistical tests were two-sided. Ap-value of<0.05was considered as being significant.RESULTS1.Nineteen samples were invasive ductal carcinoma accompanied by ductal carcinoma in situ. The positive rates of ER and PR were76%and67%respectively, that of Her2was27%, and that of Ki67was56%. Sixty three patients manifested mammographic mass, and48had visible calcification on the mammogram. Twenty five patients showed evident mass accompanied with calcification. Twenty seven masses had a spiculated margin.2.The mammographically visible mass was frequently observed in histologically pure IDC, while mammographic calcification was significantly associated with IDC accompanied with DCIS (p<0.01).3.Mammographic calcification accompanied by evident mass was correlated with axillary lymph node metastasis (p<0.05). The tumor size was usually larger than2cm when the mammographic mass was accompanied by calcification (p<0.01).4.Tumors from patients presenting with spiculated mass had a significantly higher ER-positive and PR-positive rates than those from patients presenting with non-spiculated mass (p<0.01). Tumors from patients presenting with spiculated mass had Her2negativity (p<0.05) and lower proliferative activity as labeled by Ki67compared with those from patients presenting with non-spiculated mass (p<0.01). PART2Correlation between clinicopathological characteristics and galactographic features of breast cancer with nipple dischargeOBJECTThe purpose of this study was to illustrate the role of galactography in the management of nipple discharge and to assess the diagnostic value of preoperative galactography in women with nipple discharge. The histopathological and molecular biological characteristics of breast cancer manifesting nipple discharge were analyzed also.METHODS1.The collection of clinicopathological informations of patients with pathological nipple dischargeTwenty four breast cancer and38benign leisons manifested as pathological nipple discharge were involved in this study. The clinical information, including age, menopausal status, colour of fluid, tumor size, histopathological category, grade, stage, and axillary lymph node status, were collected from our database.2.Immunohistostaining analysisThe immunohistostaining analysis was performed with PV-9000Polymer Detection System for Immuno-Histological Staining (GBI, USA). Estrogen recptor (ER), progesterone receptor (PR), human epidermal growth factor receptor2(Her2) and Ki67were successfully detected in all the paraffin sections. ER and PR were considered positive if nuclear staining was present in≥10%of the cells, and Ki67expression was considered positive in cases of a substantial percentage of positively stained nuclei(>30%). Her2expression was graded as recommended by the HercepTestTM scoring guidelines. Her2was considered to be positive if the score was2+or3+. 3.The implemention of galactographyGastrografin, a water soluble contrast medium, was injected into the duct system with nipple discharge. Then, mammography was performed with craniocaudal view (CC) and mediolateral view(ML).4.Assessment of galactogramsAll the mammograms were assessed according to the analytic criteria of Breast Imaging Reporting and Data System (BI-RADS) in which the mammographic features mass, calcification, architectural distortion and asymmetric density were recorded. Assessment of duct system developed by gastrografin:the localization of duct system with nipple discharge, the common galactographic findings including complete ductal obstruction, multiple irregular filling defects in the nondilated peripheral ducts, ductal wall irregularities, periductal contrast extravasation.5.Statistical analysisAll data were analyzed using Statistical Package for the Social Sciences statistical software (version19.0; SPSS Inc., Chicago, IL, USA). Correlations between galactographic appearance and histological category were also evaluated by chi-square test. All statistical tests were two-sided. Ap-value of <0.05was considered as being significant.RESULTSI.The twenty four breast cancers were all ductal carcinoma, with11ductal carcinoma in situ,9invasive ductal carcinoma accompanied by DCIS,2invasive ductal carcinoma,2intraductal papillocarcinoma.2.The source of discharge can be localized approximately by galactography with the injection of contrast medium, and the change of duct wall or lumen can be displayed clearly.3.Common galactographic findings included completely obstruction of duct, intraductal filling defect, ductal dilatation, ductal wall irregularity, stenosis and periductal contrast extravasation.4.The positive predictive value of ductal wall irregularity for breast cancer was higher, and ductal wall irregularity was significantly associated with breast cancer.5.DCIS with pathological nipple discharge usually showed the absence of calcification on the mammogram, and was significantly associated with Her2negativity. The positive rates of ER and PR were usually higher.CONCLUSION1.Common mammographic appearances of invasive ductal carcinoma include mass, calcification, architectural distortion and mass accompanied by calcification. Some invasive ductal carcinomas are invisible on mammogram. Mammographic features are correlated with clinicopathological characteristics.2.If the mass is accompanied by calcifications on the mammogram, the tumor size is frequently larger than2cm. Axillary lymph node metastasis is also significantly related to mammographic mass accompanied by calcification. The spiculated margin of mammographic mass is significantly associated with high positive rate of ER and PR. Spiculated mass is also correlated with low proliferative activity and negative expression of Her2.3.Some common signs, such as completely obstruction of duct, intraductal filling defect, ductal dilatation and periductal contrast extravasation, have scarcely any of value to differential diagnosis. But completely obstruction of duct and intraductal filling defect were correlated with intraductal space occupying lesion.4.Ductal wall irregularity is significantly associated with breast cancer.SIGNIFICANCE1.Mammographic features are correlated with clinicopathological characteristics in invasive ductal carcinomas. Mammographic mass accompanied by calcification maybe act as a factor that predict the likely presence of axillary lymph node metastasis. And it can be regarded as a bad prognostic factor of breast cancer.2.Spiculated margin of mammographic mass can act as a good prognosis factor, or may be a predictive factor of endocrine therapy. 3.There is no normative evaluation criteria for galactography. We redefined the appearance "ductal wall irregularity" as the loss of flatness and uniform diameter of the calibre. It can manifest as segmental stenosis, inflexible, or alternative with duct dilatation. This galactographic feature was significantly associated with breast cancer.4.The major advantage of galactography is the precisely location of the source of discharge, thus enabling the surgeon to adopt an appropriate procedure that removes all diseased tissue and structures as is essential for histological success.