Ann Aldis

Flat Epithelial Atypia of the Breast: Pathological-Radiological Correlation

OBJECTIVE This study was undertaken to determine the prevalence of flat epithelial atypia at ultrasound-guided and stereotactically guided needle biopsies, to describe the mammographic and sonographic features of flat epithelial atypia, and to determine the significance of lesions diagnosed as flat epithelial atypia at imaging-guided needle biopsies. MATERIALS AND METHODS Retrospective review of a database of 1369 consecutive sonographically and stereotactically guided needle biopsies performed during a 12-month period yielded 33 lesions with flat epithelial atypia as the most severe pathologic entity (32 patients). Two radiologists retrospectively reviewed the imaging presentation, by combined consensus, according to the BI-RADS lexicon. RESULTS Twenty-two of 33 flat epithelial atypia diagnoses (67%) were obtained under stereotactic guidance, and 11 (33%) were obtained under sonographic guidance. Six patients had synchronous breast cancer. Flat epithelial atypia lesions presented mammographically most often as microcalcifications (20/33 [61%]) distributed in a cluster (14/20 [70%]) with amorphous morphology (13/20 [65%]). Sonographically, flat epithelial atypia lesions appeared most often as masses (9/11 [82%]), with an irregular shape (6/9 [67%]), microlobulated margins (5/9 [56%]), and hypoechoic or complex echotexture (7/9 [78%]). Twenty-eight of 33 lesions (85%) were surgically excised, confirming the flat epithelial atypia diagnosis in 11 of the 28 lesions (39%), yielding carcinoma in four (14%) and atypical ductal hyperplasia in six (21%). Columnar cell changes without atypia were diagnosed in four lesions (14%), and lobular carcinoma in situ was diagnosed in three lesions (11%). CONCLUSION Mammographic and sonographic presentation of flat epithelial atypia is not specific (clustered amorphous microcalcifications and irregular, hypoechoic or complex masses). Given the underestimation rate of malignancy, surgical excision should be considered when imaging-guided biopsy yields flat epithelial atypia.

Atypical ductal hyperplasia diagnosed at sonographically guided core needle biopsy: frequency, final surgical outcome, and factors associated with underestimation.

OBJECTIVE The purposes of this article were to review the mammographic and sonographic features of breast masses yielding atypical ductal hyperplasia (ADH) at sonographically guided biopsy, evaluate the surgical pathology outcome of these lesions, and determine whether clinical or imaging features can be used to predict upgrade to malignancy. MATERIALS AND METHODS Among 6325 sonographically guided biopsies (2003- 2010) (14-gauge cores), 56 yielded the diagnosis of ADH (0.9%). Six patients were excluded (lost to follow-up). Fifty lesions were surgically excised in 45 patients. Mammographic and sonographic features were analyzed in consensus by two radiologists using the BI-RADS lexicon. RESULTS Forty-five patients (mean age, 56 years; 12 < 50 years; six with synchronous breast carcinoma) had 50 ADH lesions (median size, 0.6 cm). Surgical excision yielded malignancy in 28 cases (56% underestimation rate). Among 42 mammograms (47 lesions), 30 lesions were identified (30/47, 64%) as masses (12/30, 40%), asymmetric densities (10/30, 33%), microcalcifications (4/30, 13%), and architectural distortions (4/30, 13%). Sonographically, most lesions appeared as hypoechoic masses (64%, 30/47) with irregular shape (51%, 24/47), microlobulated margins (49%, 23/47), no posterior acoustic feature (25/47, 53%), abrupt interface (70%, 33/47), and parallel orientation (57%, 27/47). No mammographic and sonographic features were associated with malignant outcome, whereas age less than 50 years (p = 0.03) and synchronous malignancy (p = 0.03) were associated with malignant outcome. CONCLUSION ADH diagnosed at sonographically guided 14-gauge core needle biopsy shows a high underestimation rate. Synchronous carcinoma or age less than 50 years is associated with malignant outcome.

Value of pre-operative breast MRI for the size assessment of ductal carcinoma in situ.

OBJECTIVE To retrospectively evaluate the accuracy of pre-operative breast MRI and mammography in determining the size of ductal carcinoma in situ (DCIS) compared with the histopathological results. METHODS 79 patients [mean age: 56.5 (standard deviation 10.2) years] with pathologically proven DCIS (79 lesions) obtained a bilateral mammogram and a pre-operative contrast-enhanced MRI. The accuracy of MRI and mammography to detect tumour size were estimated and compared, using histopathological size as the gold standard, on the subjects with measurements with both modalities (n = 60). RESULTS MRI detected 67 (85%) lesions, mammography detected 72 (91%) and both modalities detected 60 (76%). Median DCIS size detected by mammography vs MRI was smaller (1.55 vs 1.65 cm). Out of these 60 cases, compared with the histopathological size, the accuracy of MRI and mammography was 0.66 and 0.56, respectively (p = 0.045). MRI showed better accuracy than mammography for younger patients (age ≤ 50 years, p = 0.003). For tumour nuclear grade, there was a statistically significant difference for the intermediate level, with higher accuracy for MRI (p = 0.03). CONCLUSION MRI was more accurate than mammography in DCIS size assessment when visible, particularly in lesions of intermediate grade and in patients less than 50 years of age. ADVANCES IN KNOWLEDGE Breast MRI may help in management of DCIS of intermediate grade and in females less than 50 years of age.

Retroareolar Carcinomas in Breast Ultrasound: Pearls and Pitfalls

Breast Ultrasound (US) is an important tool for both screening and diagnostic examinations. Although breast US has benefitted from significant recent technical improvements, its use for the retroareolar region is known to be more challenging than for other locations. The retroareolar location was defined by Giess et al. in 1998 as the region where any lesion is situated at less than two cm from the nipple and/or involves the nipple-areolar complex on mammogram. Understanding of the complex anatomy and physiology of the nipple-areolar region is important to avoid misinterpretation and misdiagnosis. The ability for the breast imager to manage difficulties related to the retroareolar area is paramount by adjusting settings (compounding, frequency, Doppler) and utilizing specific manoeuvers. Cases illustrating difficulties encountered in diagnosis of retroareolar carcinomas are presented.

Imaging features and conspicuity of invasive lobular carcinomas on digital breast tomosynthesis

OBJECTIVE To review the imaging features of invasive lobular carcinoma (ILC) seen on digital breast tomosynthesis (DBT) in comparison with invasive ductal carcinoma (IDC), and to evaluate whether DBT could improve conspicuity and tumour size assessment of ILC in comparison with digital mammography (DM). METHODS Institutional review board with waiver of informed consent was obtained for this retrospective study. Patients with ILC or IDC who underwent DBT and DM at the time of diagnosis were included. DM and DBT images were reviewed in consensus by two breast radiologists in order to assess imaging features, conspicuity and maximum tumour diameter of ILC and IDC. Pathology on the surgical specimen was considered the standard of reference for assessment of tumour size. RESULTS 43 patients (20 patients with ILC and 23 patients with IDC) were included. On DBT, compared with IDC, ILC presented less frequently as masses (40% vs 78%) (p = 0.01) and more frequently as isolated distortion (20% vs 0%) (p = 0.03). ILC presented more often as asymmetries (60%) than masses (20%) on DM (p = 0.02) but not on DBT (35% vs 40%; p = 1.00). Conspicuity of ILC was significantly higher on DBT than on DM (p = 0.002), while the difference between the two techniques was not significant for IDC (p = 0.2). Regarding ILC, concordance in tumour size measurement between DBT and pathology was fair (intraclass correlation coefficient = 0.24). CONCLUSION ILC rarely presented as dense masses but frequently demonstrated architectural distortion on DBT. DBT increased lesion conspicuity but failed to accurately assess tumour size of ILC. Advances in knowledge: (1) This study describes specific features of ILC on DBT. (2) It shows that DBT can improve conspicuity of ILC.

Differentiation of Fibroadenomas and Pure Mucinous Carcinomas on Dynamic Contrast-Enhanced MRI of the Breast Using Volume Segmentation for Kinetic Analysis: A Feasibility Study

OBJECTIVE The objective of this study was to retrospectively evaluate the diagnostic performance of volume-based kinetic analysis in dynamic contrast-enhanced MRI (DCE-MRI) of the breast for the differentiation of fibroadenomas (FAs) with high T2 signal intensity from pure mucinous carcinomas (PMCs). MATERIALS AND METHODS A review of records from 2007 to 2013 that were stored in the pathology department database at our institution identified nine patients with PMCs (defined as tumor cells with a mucinous component ≥ 90%) who underwent preoperative breast MRI. The PMCs were compared with 15 biopsy-proven FAs from 13 patients. Characteristics noted on DCE-MRI were evaluated using computer-assisted diagnosis software. For each mass, the proportion of progressive enhancement in the lesion at the delayed phase was quantified. Both groups of masses were compared using a Wilcoxon signed rank test. A ROC curve was used to define an appropriate cutoff point. RESULTS The median rate of progressive enhancement was 100% (range, 99-100%) for FAs and 97% (range, 87-99%) for PMCs (p = 0.0326). The AUC of the kinetic curve for progressive enhancement was 0.7519 (95% CI, 0.5258-0.9407). A more appropriate cutoff value to maximize sensitivity and specificity was 98.5%. With this cutoff, sensitivity was 66.7% (95% CI, 11.1-100%) and specificity was 80% (95% CI, 39.6-99.8%) for the diagnosis of PMCs. CONCLUSION Volume-based kinetic analysis may aid in differentiating FAs from PMCs on DCE-MRI studies of the breast.

Enhancement of breast cancer on pre-treatment dynamic contrast-enhanced MRI using computer-aided detection is associated with response to neo-adjuvant chemotherapy

PURPOSE To evaluate whether enhancement of breast cancer on pre-treatment dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) as evaluated semi-quantitatively using computer-aided detection (CAD) is associated with response to neo-adjuvant chemotherapy. MATERIALS AND METHODS A total of 84 women, (mean age, 51±10 [SD] years; range: 30-73 years) with 84 breast cancers who underwent MRI before neo-adjuvant chemotherapy were included in this retrospective study. The proportion of each type of signal intensity-time curve (SITC) (type 1: persistent; type 2: plateau; Type 3: washout) within the tumor volume was quantified semi-automatically using a CAD system (Aegis®, Sentinelle medical, Toronto, Canada) and was compared to histological features of the tumors and to pathological response to neo-adjuvant chemotherapy. RESULTS Pathological complete response was obtained in 29 patients (35%). Proportion of SITC type 1 was greater in non-responders (P=0.019) while proportion of SITC type 3 was greater in responders (P=0.04). Sensitivity, specificity, and accuracy of proportion of SITC type 1 for the identification of incomplete response on pathology were 42% (95% CI: 29%-56%), 90% (95% CI: 73%-98%), and 59% (95% CI: 48%-70%), respectively. CONCLUSION Proportion of SITC type 1 (persistent) in breast cancers on pre-treatment MRI as semi-automatically quantified using a CAD system is associated with absence of pathological complete response to neo-adjuvant chemotherapy with good specificity.

The Positive Outcome of MRI-Guided Vacuum Assisted Core Needle Breast Biopsies Is Not Influenced by a Prior Negative Targeted Second-Look Ultrasound

Purpose The study sought to investigate the outcome of breast magnetic resonance–guided biopsies as a function of the indication for magnetic resonance imaging (MRI), the MRI features of the lesions, and the performance or not of a targeted second-look ultrasound (SLUS) prior breast MRI-guided biopsy. Methods We identified 158 women with MRI-detected breast lesions scheduled for MRI-guided biopsy (2007-2013). Patient demographics, performance of targeted SLUS, imaging characteristics, and subsequent pathology results were reviewed. Results Three biopsies were deferred, and 155 lesions were biopsied under MRI guidance (155 women; median age 55.14 years; range 27-80 years). Ninety-eight women underwent a SLUS prior to the MRI-guided biopsy (63%). Of the 155 biopsied lesions, 23 (15%) were malignant, 106 (68%) were benign, and 26 (17%) were high risk. Four of 15 surgically excised high-risk lesions were upgraded to malignancy (27%). Most of the biopsied lesions corresponded to non–mass-like enhancement (81%, 126 of 155) and most of the biopsies (52%, 81 of 155) were performed in a screening context. No demographic or MRI features were associated with malignancy. No differences were noted between the 2 subgroups (prior SLUS vs no prior SLUS) except for the presence of a synchronous carcinoma associated with a likelihood of targeted SLUS before MRI-guided biopsy (P = .001). Conclusion A negative SLUS does not influence the pathology outcome of a suspicious lesion biopsied under MR guidance.

Values of pathological analysis of lost tissue fragments in the vacuum canister during a vacuum-assisted stereotactic biopsy of the breast

OBJECTIVE Determine values of pathological analysis of the canister content during a vacuum-assisted breast biopsy (VABB). METHODS Approval was obtained from the ethical committee. Prospective radiological and pathological analyses of the canister content collected during 231 VABBs performed on 231 patients were carried out. χ(2) test was used to determine predictors on canister pathology. RESULTS The canister pathology was reported separately in 212 cases. It showed only blood in 78/212 (37%) cases and benign (including high-risk lesions) and malignant results in, respectively, 113/212 (53%) and 21/212 (10%) cases. Respective specimen analysis was benign, including high-risk lesions in 162/212 cases (76%) and malignant in 50/212 (24%) cases. Microcalcifications were documented on canister X-ray in 70/231 (30%) cases. There was significant association between the canister and the specimen pathology (p<0.0001). In none of the cases was microcalcifications seen exclusively in the canister content or pathological upgrading found in the canister content compared with the specimen. CONCLUSION Small tissue fragments and microcalcifications may be lost in the canister during a VABB. Nevertheless, our results did not show any significant value for systematic analysis of the canister content. ADVANCES IN KNOWLEDGE There is no added diagnostic value to retrieval and analysis of tissue lost in the canister during a VABB.

SEIN-WP-2 Avez-vous dit sein dense unilateral ?

Objectifs Revisiter les etiologies d’un sein dense. Illustrer a travers des exemples cliniques et iconographiques. Rappeler les pathologies sous-jacentes. Points cles Un sein dense unilateral peut resulter de differentes conditions benignes, telles que chirurgicale, inflammatoire non specifique, trouble circulatoire comme une thrombose veineuse centrale ou lymphatique mais aussi et surtout de processus neoplasiques comme le cancer lobulaire invasif ou inflammatoire.