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. A retrospective review of staging imaging was performed in patients with stage II or III invasive breast cancer diagnosed during 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. 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). 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.
Breast Cancer Incidental Findings Staging CT PET Bone Scan
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Dr. Henry was supported in part by an NCI Clinical Cancer Investigator Team Leadership Award (supplement to 3-P30-CA046592, PI M Wicha).
Compliance with ethical standards
Conflicts of interest
Dr. Henry has previously received research funding from BioMarin, Celldex, and Sanofi. No other authors have conflicts of interest to report.
Institutional Review Board approval was granted for this study and a waiver of informed consent was obtained.
Puglisi F, Follador A, Minisini AM et al (2005) Baseline staging tests after a new diagnosis of breast cancer: further evidence of their limited indications. Ann Oncol 16(2):263–266CrossRefPubMedGoogle Scholar
Kasem AR, Desai A, Daniell S, Sinha P (2006) Bone scan and liver ultrasound scan in the preoperative staging for primary breast cancer. Breast J 12(6):544–548CrossRefPubMedGoogle Scholar
Kim H, Han W, Moon HG et al (2011) The value of preoperative staging chest computed tomography to detect asymptomatic lung and liver metastasis in patients with primary breast carcinoma. Breast Cancer Res Treat 126(3):637–641CrossRefPubMedGoogle Scholar
Gerber B, Seitz E, Muller H et al (2003) Perioperative screening for metastatic disease is not indicated in patients with primary breast cancer and no clinical signs of tumor spread. Breast Cancer Res Treat 82(1):29–37CrossRefPubMedGoogle Scholar
Schnipper LE, Smith TJ, Raghavan D et al (2012) American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncology. J Clin Oncol 30(14):1715–1724CrossRefPubMedGoogle Scholar
Simos D, Hutton B, Clemons M (2015) Are physicians choosing wisely when imaging for distant metastases in women with operable breast cancer? J Oncol Pract 11(1):62–68CrossRefGoogle Scholar
Crivello ML, Ruth K, Sigurdson ER et al (2013) Advanced imaging modalities in early stage breast cancer: preoperative use in the United States Medicare population. Ann Surg Oncol 20(1):102–110PubMedCentralCrossRefPubMedGoogle Scholar
Han D, Hogeveen S, Sweet Goldstein M et al (2012) Is knowledge translation adequate? A quality assurance study of staging investigations in early stage breast cancer patients. Breast Cancer Res Treat 132(1):1–7CrossRefPubMedGoogle Scholar
James JJ, McMahon MA, Tennant SL, Cornford EJ (2012) CT staging for breast cancer patients with poor prognostic tumours. Breast 21(6):735–738CrossRefPubMedGoogle Scholar
Morris PG, O’Connor M, O’Rafferty C et al (2009) The excessive cost of baseline diagnostic imaging in early breast cancer. Ir Med J 102(5):149–152PubMedGoogle Scholar
Yeh KA, Fortunato L, Ridge JA, Hoffman JP, Eisenberg BL, Sigurdson ER (1995) Routine bone scanning in patients with T1 and T2 breast cancer: a waste of money. Ann Surg Oncol 2(4):319–324CrossRefPubMedGoogle Scholar
Truong MT, Ko JP, Rossi SE et al (2014) Update in the evaluation of the solitary pulmonary nodule. Radiographics 34(6):1658–1679CrossRefPubMedGoogle Scholar
MacMahon H, Austin JH, Gamsu G et al (2005) Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: a Statement from the Fleischner Society. Radiology 237(2):395–400CrossRefPubMedGoogle Scholar
Lee B, Lim A, Lalvani A et al (2008) The clinical significance of radiologically detected silent pulmonary nodules in early breast cancer. Ann Oncol 19(12):2001–2006PubMedCentralCrossRefPubMedGoogle Scholar
Hahn EE, Tang T, Lee JS et al (2015) Use of imaging for staging of early-stage breast cancer in two integrated health care systems: adherence with a choosing wisely recommendation. J Oncol Pract. 11(3):e320–e328CrossRefPubMedGoogle Scholar
Brennan ME, Houssami N (2012) Evaluation of the evidence on staging imaging for detection of asymptomatic distant metastases in newly diagnosed breast cancer. Breast 21(2):112–123CrossRefPubMedGoogle Scholar
Brennan M, Houssami N (2012) Newly diagnosed early breast cancer—an update on pre-operative assessment and staging. Aust Fam Physician 41(11):871–874PubMedGoogle Scholar
Daglar G, Yuksek YN, Gozalan U, Tutuncu T, Kama NA (2010) The significance of pulmonary nodule in breast cancer patients. Bratisl Lek Listy 111(5):280–283PubMedGoogle Scholar
Khatcheressian JL, Wolff AC, Smith TJ et al (2006) American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. J Clin Oncol 24(31):5091–5097CrossRefPubMedGoogle Scholar
Al-Mutairi A, Meyer AN, Chang P, Singh H (2015) Lack of timely follow-up of abnormal imaging results and radiologists’ recommendations. J Am College Radiol 12(4):385–389CrossRefGoogle Scholar
Blagev DP, Lloyd JF, Conner K et al (2014) Follow-up of incidental pulmonary nodules and the radiology report. J Am College Radiol 11(4):378–383CrossRefGoogle Scholar
Dutta S, Long WJ, Brown DF, Reisner AT (2013) Automated detection using natural language processing of radiologists recommendations for additional imaging of incidental findings. Ann Emerg Med 62(2):162–169CrossRefPubMedGoogle Scholar