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1. Citation: Pennick MO, Kalia A, Harris O, Barker D, Jois RHS, Audisio RA. Ultrasound Characteristics of Triple
Negative Breast Cancer - A Case Series and Review of the Literature. Austin J Clin Diag Res. 2016; 1(1): 1001.
Austin J Clin Diag Res - Volume 1 Issue 1 - 2016
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Austin Journal of Clinical & Diagnostic
Research
Open Access
Abstract
Purpose: Breast cancers are subdivided according to biological sub-types
and commonly with reference to their expression (or lack thereof) of specific
receptors - Oestrogen (ER), Progesterone (PR) and Her2-neu (HER2). Their
behavior is influenced by receptor subtype, with triple negative status (TRN)
conferring the worst overall prognosis. It is beneficial to recognize the malignant
features of breast change, but appropriate treatment cannot be initiated based
on Ultrasound (US) scan findings. The purpose of this study was to evaluate
our own series of TRN cancers, their ultrasound characteristics and perform a
literature review pertaining to this topic.
Results: Our series included sixty patients with TRN breast cancer. We
found that shape was not a reliable predictor of TRN status. We found the
majority of TRN cancers were of non-parallel lie (83%), had irregular margins
(68%), were hypoechoic (70%) and showed posterior enhancement (65%).
None of the cases in our series showed surrounding’s tissue change. Micro-
calcifications were absent in 92%. Eleven articles and one book chapter were
reviewed after a literature search (total of 582 patients). We found little consensus
between authors regarding US characteristics in TRN breast cancer. There was
a predilection for irregular shape, abrupt lesion boundary, hypoechoic features
and posterior enhancement. Micro-calcifications were absent in the majority of
cases.
Conclusions: We found little evidence supporting the claims of previous
authors that TRN cancers can be identified by specific ultrasound characteristics.
Tissue diagnosis cannot be replaced by imaging investigations; for any kind of
cancer treatment histology is and will be mandatory.
Keywords: Triple Negative; Breast Cancer; Ultrasound; Imaging
the statistical analysis of questionable value.
In this study, we have reviewed the literature and report our
experience with ultrasonic features of TRN tumour type at our
institute.
Materials and Methods
Patients selection
A consecutive series of patients who had triple negative breast
cancer were identified from our institutional database in between
2008-2012. Two dedicated breast radiologists analyzed their image
characteristics. Any correlation between ultrasonographical features
was compared against the findings highlighted by the published
relevant literature.
Immunohistochemical analysis
Hormonal (Oestrogen & Progesterone) and Her-2 status of the
cancers were analyzed on core biopsy using standard available kits
and were retested when negative on excision specimen.
Ultrasound analysis
The ultrasound scans were performed using Voluson 730 Expert,
GEwithahighresolution12MHzlinearprobe.Theultrasoundimages
were then analyzed retrospectively by a single breast radiologist with
Abbreviations
TRN: Triple Negative; USS: Ultrasound; DCIS: Ductal Carcinoma
in Situ; ER: Oestrogen Receptor; PR: Progesterone Receptor; HER2:
Human Epidermal Growth Factor 2; FNA: Fine Needle Aspiration
Introduction
The management of breast cancer and its prognosis is dependent
on numerous biological and molecular variables. Cancers which
do not express receptors for Oestrogen (ER), progesterone (PR) or
human epidermal growth factor 2 (HER2, previously ERBB2) are
termed triple negative (TRN). TRN cancers tend to occur in younger
women and confer a worse prognosis than the other breast cancer
subtypes. Early identification of these TRN subtypes could facilitate
aggressive therapy and hence better outcomes.
Some recent publications have looked at image characteristics
of TRN cancers and the diagnostic accuracy of different imaging
modalities in predicting triple negative status. Literature reports TRN
cancers exhibit certain specific morphological features, which could
assist quicker TRN tumour type diagnosis before the histology reports
are available. However, there is a lack of consensus amongst authors
regarding which features that are typical of TRN disease. Moreover
the studies have tended to be of small sample size, which has made
Research Article
Ultrasound Characteristics of Triple Negative Breast
Cancer - A Case Series and Review of the Literature
Pennick MO1
*, Kalia A2
, Harris O3
, Barker D4
, Jois
RHS1
, Audisio RA1,5
1
Department of Surgery, St Helens & Knowsley NHS
Trust, St Helens Hospital, England
2
Department of Surgery, Southport & Ormskirk NHS
Trust, Southport District General Hospital, England
3
Department of Radiology, St Helens & Knowsley NHS
Trust, Whiston Hospital, England
4
Department of Pathology, St Helens & Knowlsey NHS
Trust, Whiston Hospital, England
5
University of Liverpool, England
*Corresponding author: Mandana O Pennick,
Department of Surgery, St Helens & Knowsley NHS
Trust, St Helens Hospital, England
Received: July 20, 2016; Accepted: August 19, 2016;
Published: August 23, 2016

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more than 10 years experience in accordance with the Breast Imaging
Reporting and Data System (Bi-RADS) criteria.
Data were collected pertaining to the shape, orientation, margins,
lesion boundary, and echo pattern, posterior features, surrounding
tissue changes and the presence or absence of micro calcifications.
These characteristics were chosen based on previously published
reports so as to facilitate comparison of our data with existing
literature. The results of histological analysis from Fine Needle
Aspiration (FNA) of the ultrasound abnormality were also reviewed.
Statistical analysis
Lack of heterogeneity in the available data rendered complex
statistical analysis of no value, hence data were simply analyzed using
percentages of the total numbers. Our own institutional data were
included in the analysis. For example, 10 out of 11 studies included
information on the shape of TRN cancers and included 423 cases.
Shape was subdivided in 4 categories - Irregular, Lobulated, Oval and
Round. The number of patient’s expressing each characteristic was
simply expressed as a percentage of the total available for analysis, in
this case, 423.
Literature search
A literature search was applied to PubMed and to Google Scholar
including the terms ‘triple negative’ ‘breast cancer’ ‘ultrasound’
‘imaging’. Abstracts were reviewed and relevant English language
papers were then collected.
Results
Our series
Tables 1 and 2 outlines the results from our series.
We identified 60 patients with triple negative breast cancer
over the study period. We recorded data pertaining to patient
demographics, tumour histological information and pre-operative
features on ultrasound. The ultra-sound features recorded are
described in section 2.3. We also recorded results from Fine Needle
Aspiration Cytology (FNAC) in our series.
Ninety-two percent of the cases presented as a mass on USS. The
median age of patients included in the series was 58 years (47-76
years). The median tumour size was 24mm (17-32 mm).
The majority of TRN tumours in our study were poorly
differentiated (43 cases, 72%). Sixteen cases (27%) were moderately
differentiated and only 1 case was well differentiated. Lymphovascular
invasion was present in 21 cases (35%) and absent in 39 (65%).
We did not find shape to be a reliable predictor of TRN status
with 28 patients (41%) showing irregular shape, 9 (15%) oval and 23
(38%) round. In terms of orientation, we found that the majority were
non-parallel (50 patients, 83%). There was a predilection for irregular
margins in our series (41 patients, 68%) as compared to 13 (22%) with
microlobulated margins, 4 (7%) spiculated and 2 (3%) with ill defined
margins.
We found an abrupt lesion boundary in 40 patients (67%), an
echogenic halo in 19 (32%) and no halo in 1 patient (2%). The echo
pattern was hypo-echoic in 42 patients (70%), markedly hypo-echoic
in 17 patients (28%) and complex in 1 patient (2%). In terms of
posterior features on ultrasound we saw enhancement in 39 patients
(65%), posterior shadow in 17 patients (28%) and mixed features or
no features in 2 patients each (3%).
Surrounding tissue change was absent in 100% of our case series.
Micro-calcifications were present in only 5 patients (8%). Cytological
assessment revealed C4 (probably malignant) in 7 patients (12%) and
C5 (defined malignant) in 53 patients (88%).
Characteristic Number (%)
Mass on Ultrasound
Present 55 92
Absent 5 8
Shape
Irregular 28 47
Lobulated 0 0
Oval 9 15
Round 23 38
Orientation
Parallel 10 17
Non parallel 50 83
Margins
Ill defined 2 3
Irregular 41 68
Microlobulated 13 22
Spiculated 4 7
Lesion boundary
Abrupt 40 67
Echo Halo Present 19 32
Echo Halo Absent 1 2
Echo Pattern
Hypoechoic 42 70
Complex 1 2
Markedly Hypoechoic 17 28
Posterior features
Enhancement 39 65
Mixed 2 3
Shadow 17 28
None 2 3
Surrounding tissue changes
Present 0 0
Absent 60 100
Microcalcification
Present 5 8
Absent 55 92
Cytological Findings
C4 7 12
C5 53 88
Table 1: Ultrasonic and Cytological characteristics of trn tumors in our series
(n=60).
Number %
Median Age 58 yrs (range 47-76 yrs)
Median Tumour Size 24 mm (range 17-32mm)
Tumour Differentiation
Well Differentiated 1 2
Moderately Differentiated 16 27
Poorly Differentiated 43 72
Lymphovascular Invasion
Present 21 35
Absent 39 65
Table 2: Demographics and tumor characteristics from our series.

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Literature review
Fifty-nine articles were identified in PubMed after a keyword
search, with no time limits. Abstracts were re-viewed and fourteen
articles were selected as being relevant to the study. One was excluded
due to lack of an english language translation. Following an online
search using the same keywords, one book chapter was identified for
review (Table 3).
Comparisons between the various studies
Table 4 shows the ultrasonographic features described in the
different studies.
Shape: Ten authors commented on the shape of TRN tumours
on US (n=423). The majority reported shape to be irregular (47%)
(Figure 1).
Orientation: Six authors recorded orientation as either parallel
(52%) or non-parallel (48%) (n=269). The terms relate to the lie of the
tumour in relation to the horizontal axis. Orientation appears to be
an unreliable indicator of TRN status (Figure 2).
Margins: Eight authors examined the margins in TRN tumours
(n=386). Again, no reliable predictors were identified (Figure 3).
Lesion boundary: Six authors (n=298) recorded the lesion
boundary as abrupt (61%) with an echogenic halo present in 39%
(Figure 4).
Echo pattern: Echo patterns were examined by 7 authors (n=330).
It would be fair to day that these tumours do tend to be hypoechoic
or markedly hypoechoic with these categories making up 88% of the
Author Year Number of Cases
Wang 2008 19
Ko 2010 75
Dogan 2010 44
Choi 2011 41
Kojima 2011 80
Boisserie-Lacroix 2012 73
Irshad 2012 22
Kojima 2012 90
Wojcinski 2012 33
Kim 2013 45
Our Series 2013 60
Total 582
Table 3: Articles included in the review.
Ultrasonic
Characteristics
Choi
2011
Boisserie Ko
Kojima
2012
Kojima
2011
Dogan Wang
Choi
2013
Wojcinski
Our
Series
Irshad Total
SHAPE
Irregular 24 24 22 17 22 0 12 31 20 28 200
Lobulated 0 0 0 0 40 0 3 0 0 0 43
Oval 15 15 31 24 12 6 2 13 2 9 129
Round 2 2 10 0 0 0 2 1 11 23 51
Orientation
Parallel 22 53 13 31 12 10 141
Non Parallel 19 22 2 14 21 50 128
Margins
Ill Defined 18 9 7 6 8 26 2 76
Irregular 12 12 7 4 41 76
Microlobulated 25 7 42 5 21 17 13 130
Spiculated 21 3 4 1 7 4 40
Circumscribed 5 43 8 4 4 64
Lesion Boundary
Abrupt 19 45 63 15 40 182
Echogenic Halo 22 19 12 30 13 19 115
No Halo 1 1
Echo Pattern
Hypoechoic 17 31 12 38 29 42 169
Complex 20 8 3 8 1 1 41
Markedly
Hypoechoic
4 64 36 17 121
Posterior Features
Enhancement 7 23 37 43 33 9 24 12 39 18 245
Mixed 0 14 0 8 7 1 0 2 32
Shadow 4 0 4 0 0 3 9 17 37
None 30 27 34 46 40 17 12 2 208
Surrounding Tissue
Changes
Present 24 24
Absent 17 60 77
Microcalcification
Present 9 0 0 2 0 7 5 23
Absent 32 97 80 42 19 38 55 363
Table 4: Ultrasonic characteristics as described by different authors.

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total (Figure 5).
Posterior features: Ten authors recorded the posterior features
seen on US in TRN cancers (n=522). No reliable indicators of
TRN status were identified with almost as many authors reporting,
enhancing features as those re-porting no features at all (Figure 6).
Figure 1: Analysis of Shape to TRN Status (n=423, 10/11 studies included,
values expressed as % of total number of cases).
Figure 2: Analysis of Orientation to TRN Status (n=269, 6/11 studies
included, values expressed as % of total number of cases).
Figure 3: Analysis of Margins to TRN Status (N=386, 8/11 studies included,
values expressed as % of total number of cases).
Figure 4: Analysis of Lesion Boundary to TRN Status (n=298, 6/11 studies
included, values ex-pressed as % of total number of cases).
Figure 5: Analysis of Echo Pattern to TRN Status (n=330, 7/11 studies
included, values expressed as % of the total number of cases).
Surrounding tissue change: Only 2 authors looked at this feature
(n=101) which was defined as present in 24% or absent in 76% of
cases. (Figure 7).
Micro calcifications: Seven authors recorded information
regarding micro calcifications (n=386) which were most commonly
absent (Figure 8).
Discussion
Triple negative breast cancer (ER -ve, PR -ve and Her2/neu -ve)
is an aggressive subtype often occurring in younger women, being
biologically aggressive (grade III), and carrying a poorer prognosis.
It has been reported to occur more frequently in African American
women [1].
To date, nine publications have looked into various image
characteristics of the TRN tumours analyzing a total of 522 TRN
patients. Various features of TRN; shape, orientation, margins, Echo
pattern, lesions boundaries, posterior features, surrounding tissue
changes and the presence or absence of micro-calcifications have
been studied. Our experience has been with 60 TRN patients during
2008 and 2012.
Irregularshapehasbeenmostfrequentlyobservedtobeassociated
with TRN cancers (47%, 423 pts). Other shapes - oval (31%), round
(12%) and lobulated (10%) were also associated with TRN lesions.
Figure 6: Analysis of Posterior Features to TRN Status (n=522, 10/11 studies
included, values expressed as % of the total number of cases).
Figure 7: Analysis of Surrounding Tissue Change to TRN Status (n=101,
2/11 studies included, values expressed as % of the total number of cases).
Figure 8: Analysis of Microcalcifications to TRN Status (n=386, 7/11 studies
included, values ex-pressed as % of the total number of cases).

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Nonparallel orientation was observed in the vast majority in our
patient series (83%) was similar to the findings observed by Wojcinski
et al. [2]. However, this was contrary to the literature published by
many (48% - 269pts) authors [3-6]. Therefore, no consensus is seen
with non parallel orientation and its association with TRN cancers.
There appeared to be a lack of consensus regarding the margins
in TRN breast cancer studied in 386 pts. We found the majority to
have irregular margins; however, there was much variation in the
margin description from other authors, one in particular finding
that a circumscribed margin predicted TRN status [7]. Furthermore,
we found a lack of continuity in margin description (terms such as
‘indistinct’. ‘Ill defined’ and ‘Irregular’ used by different authors)
which may have been a contributing factor. An agreed list of
descriptors may go some way to address this issue.
Five authors totaling in 330 pts examined the echo pattern on
ultrasound. Hypoechoicity is one finding that has correlated with
TRN status in the published literature and was also a dominant
feature of TRN cancers from a Japanese book chapter [9]. This feature,
however cannot distinguish TRN from other types of breast cancer.
It has been suggested that TRN cancers show ‘marked hypoechoic’
features rather than simply hypoechoic, which may not be been seen
in other breast cancers. Indeed, in this literature review ‘marked
hypoechoicity’ appeared in 38% of cases. This feature may therefore
alert clinicians to TRN status (Figure 9).
The presence of posterior enhancement in breast cancers has been
thought to be related to the degree of associated tissue desmoplastic
reaction. A slow growing tumour is thought to create a stromal
reaction, which can alter the acoustic properties such that a posterior
shadow may be seen behind the tumour. The majority of TRN cancer
is fast growing cellular tumours with a higher mitotic rate. These are
thought to lead to a brighter signal posterior to the tumour, which is
termed posterior enhancement. As this has been previously described,
all authors studied the relationship between TRN cancers and
posterior enhancement (522 pts), with varying results. The majority
of TRN cancers (65%) in our study showed posterior enhancement,
similar to the findings of Kim [3], and Irshad [8]. However, this
feature was not found to be related to triple negative status in the work
published by at least 8 other authors [1,2,4,5,6,10,11,12]. Hence there
is a lack of consensus on the association with posterior enhancement
features and TRN cancers, which challenges previously held beliefs.
The lesion boundary was studied by four authors (258pts). An
abrupt lesion boundary was noted in the majority (60%) similar to
our series (67%) that was in agreement with the Boisserie-Lacroix
[10] and Ko [6] (62% and 80%). An echogenic-halo was observed in
just over a third (38%) in the rest as in our series (32%). Therefore, an
abrupt boundary, although studied only in a half of the TRN cancers,
seems to correlate with TRN tumours among the majority.
Whilst we also looked for surrounding tissue change in our series
we did not find it to be present in any cases. Only one other author
examined this feature and conversely found it to be present in 59% of
their study population [5].
There appears to be a negative correlation between the presence
of micro-calcifications and TRN status in both our own series and
the published literature micro-calcifications were absent in over 92%
of cases. This supports the notion that TRN cancers tend to be fast
growing without a preceding in situ stage that may lead to gradual cell
death and calcium deposition.
Although ultrasound has been reported to have a much higher
sensitivity than mammography for predicting TRN status [13], it is
clear from this review that imaging alone cannot reliably ascertain
this breast cancer subtype.
Limitations of the Study
Previous authors have speculated that TRN cancers are associated
with a low incidence of DCIS, reflecting the hypothesis that TRN
Echo Pattern
This described whether the mass seen on ultrasound is dark or light. A dark mass is termed ‘echo poor’ or ‘hypoechoic’. This is the typical
finding of a breast cancer on ultrasound although TRN cancers have also been found to be ‘profoundly hypoechoic’.
Echogenic Halo This is a bright or ‘hyperechoic’ rim that is found around some cancers on ultrasound.
Posterior
Enhancement
This refers to the magnification or brightening of echoes, which is usually seen behind breast cysts but can also be a feature or very cellular
cancers such as the TRN subtype.
Posterior Shadowing
The opposite of posterior enhancement. This is the darkening of the echoes behind the lesion that is more common in lower grade fibrotic
tumours.
Table 5: Ultrasound Terminology Explained.
Figures 9: Examples of Ultrasound Appearances of triple negative cancers in our series. Note the irregular shape, hypo echoic nature and abrupt lesion boundaryRN
Status (n=386, 7/11 studies included, values ex-pressed as % of the total number of cases).

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cancers are a distinct pathological entity when compared to other
breast cancer subtypes and that they progress rapidly to invasive
disease without a preceding in-situ stage. We have not looked at
associations with DCIS in this study. Furthermore, we have not
compared TRN cancers with those that are ER negative, PR negative
and HER2 positive, either in our own data series or in our literature
review as we wished to focus entirely on the TRN group. We have
not looked at the stage of disease at time of presentation, as this
information was not available from the published literature.
We have tried to overcome the issue of small sample size by
combining the results of the available studies. This does however
introduce the issue of inter-observer variability in terms of ultrasound
interpretation. At times, where data published were percentages, we
extrapolated to calculate numbers of patients that could have led to
sources of error.
Conclusions
In conclusion, there is little consensus regarding ultrasonic image
characteristics of TRN tumours. The series of TRN patients studied
appears to be small and needs further evaluation. However, in our
consolidated published information, we have compared our sixty
patient series for ultrasonic features of TRN tumours, and it has been
difficult to identify any one or more features which could predict the
TRN status of the lesion prior to pathological evaluation. However,
it is our observation that a lesion that is irregularly shaped, with an
abrupt boundary, which demonstrates hypoechoicity (‘marked’ or
otherwise) and is not associated with micro-calcifications could be a
TRN cancer. We did not find a correlation with other characteristics
such as orientation of the lesion, margins of the lesion, posterior
enhancement and surrounding tissue change. It is important to note
that only the pathological assessment of the tumour can confirm
the triple negative status and it is upon this that the management
is determined. It is an interesting effort to try to categorize these
tumours on image characteristics and a larger volume study may give
further clarity on this issue.
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Citation: Pennick MO, Kalia A, Harris O, Barker D, Jois RHS, Audisio RA. Ultrasound Characteristics of Triple
Negative Breast Cancer - A Case Series and Review of the Literature. Austin J Clin Diag Res. 2016; 1(1): 1001.
Austin J Clin Diag Res - Volume 1 Issue 1 - 2016
Submit your Manuscript | www.austinpublishinggroup.com
Pennick et al. © All rights are reserved