Incidental radiologic findings at breast cancer diagnosis and likelihood of disease recurrence

Abstract

Purpose Despite guidelines recommending against its routine use, perioperative imaging for distant metastases is frequently performed in newly diagnosed breast cancer patients, uncovering incidental findings of uncertain significance. We assessed the clinical significance of incidental findings by determining if their presence is associated with disease recurrence. Methods A retrospective review of staging imaging was performed in patients with stage II or III invasive breast cancer diagnosed 2008–2009 at a large academic medical center. Data related to perioperative imaging and disease recurrence were abstracted from the medical record. Kaplan Meier curves and Cox proportional hazards models were used to assess the association between incidental findings and time to disease recurrence. Results A total of 169 of 340 patients (49.7%) underwent staging evaluation for distant metastases (CT chest, abdomen, pelvis, bone scan, and/or PET-CT). Of these, 146 (86.4%) had at least one suspicious or indeterminate finding. Follow-up studies were performed in 73 (43.2%) patients. Nineteen patients were diagnosed with metastatic disease at diagnosis, 18 of whom had stage III disease. In patients without metastatic disease at diagnosis, 32 later developed recurrence. Non-calcified pulmonary nodules were associated with shorter time to disease recurrence (hazard ratio 2.51, 95% CI 1.13–5.57, p=0.02). Conclusions Imaging for distant metastases frequently reveals indeterminate findings, most of which are not associated with disease recurrence. The association between pulmonary nodules and recurrence warrants validation in an independent cohort. Overall, these findings support current guidelines recommending against routine extent of disease evaluation in patients with newly diagnosed stage II breast cancer.

Variation in the use of advanced imaging at the time of breast cancer diagnosis in a statewide registry

“…The likelihood of having metastatic disease in this setting has been demonstrated to be less than 2% in multiple studies. 14,15 Harm from performing unnecessary imaging can include the cost of testing to patients and society, radiation exposure from the imaging tests, and anxiety related to testing.…”

Invasive Breast Cancer Version 1.2016, NCCN Clinical Practice Guidelines in Oncology

“…50 These recommendations are based on studies showing no additional value of these tests in patients with early-stage disease. [51][52][53] In one study, metastases were identified by bone scan in 5.1%, 5.6%, and 14% of patients with stage I, II, and III disease, respectively, and no evidence of metastasis was detected by liver ultrasonography or chest radiography in patients with stage I or II disease. 51 For patients with stage III breast cancer, the prevalence of positive results on liver ultrasound and chest radiography was 6% and 7%, respectively.…”

Value of Systemic Staging in Asymptomatic Early Breast Cancer

“…However, only 12% were eventually diagnosed with DM. 13 Furthermore, this approach may lead to delays in the treatment delivery, have negative impact on the cost of care, and cause unnecessary psychological distress to patients. On the other hand, failure to properly diagnose DMs during the initial workup may also lead to an inappropriate treatment, such as unnecessary local surgery and/or radiation and adjuvant chemotherapy.…”