Anna Linda

Early and late lung radiographic injury following stereotactic body radiation therapy (SBRT)

OBJECTIVE To describe early and late CT patterns of radiographic lung injury after SBRT for lung cancer, and to correlate radiological findings with patient and treatment characteristics. MATERIALS AND METHODS Follow-up CT scans of 68 patients with 70 tumors were divided into 4 periods: (1) 6 weeks; (2) 2-6 months; (3) 7-12 months and (4) 13-18 months after SBRT. Early (within 6 months) and late radiological injuries were evaluated according to Ikezoe and Koening, respectively. The correlation between CT findings and patient characteristics was evaluated. RESULTS Radiographic injury in periods 1 and 2 was: (1) diffuse consolidation 3 and 27%, (2) patchy consolidation and ground-glass opacity (GGO) 13.2 and 33%, (3) diffuse GGO 13.2 and 21%, (4) patchy GGO 16.2 and 6%, and (5) no findings 54.4 and 21%, respectively. Late injury in periods 3 and 4 were: (1) modified conventional pattern (consolidation, volume loss, bronchiectasis) 54 and 44%, (2) mass-like 20 and 28%, (3) scar-like 14 and 16% and (4) no findings 20 and 12%, respectively. The proportion of emphysema grades 2-4 was significantly higher in patients who had no radiological findings 6 weeks after treatment (p=0.021). Both patchy consolidation and GGO patterns resulted more frequently in patients who were not administered steroids (p=0.035). No relationship was found with smoking, tumor dimension and radiation dose. CONCLUSIONS The majority of patients had no evidence of radiographic lung injury 6 weeks after SBRT; the most prevalent findings were diffuse or patchy GGO. Patchy and diffuse consolidation develops 2-6 months after SBRT. Modified conventional pattern was the most prevalent in the late periods.

Radial Scars Without Atypia Diagnosed at Imaging-Guided Needle Biopsy: How Often Is Associated Malignancy Found at Subsequent Surgical Excision, and Do Mammography and Sonography Predict Which Lesions Are Malignant?

OBJECTIVE The purposes of our study were to evaluate the surgical outcome of cases of radial scar without atypia diagnosed at imaging-guided percutaneous needle biopsy and to determine whether the mammographic and sonographic features are able to predict which lesions will be upgraded to malignancy at surgical excision. MATERIALS AND METHODS The records of 4,458 consecutive imaging-guided biopsies were retrospectively reviewed. Surgical excision results were available in 62 cases in which radial scar was the highest-risk lesion at stereotactically guided or sonographically guided biopsy. The mammographic and sonographic images and surgical findings were reviewed. The underestimation rate of malignancy of percutaneous biopsy was calculated. Differences in mammographic and sonographic appearances between radial scars with and without associated malignancy were evaluated using the Fishers exact test. RESULTS The percutaneous malignancy underestimation rate was 8% (5/62): 9% (4/43) for sonography guided 14-gauge biopsies and 5% (1/19) for stereotactically guided 11-gauge vacuum-assisted biopsies (p = 1.000). Mammographic and sonographic appearances were not significantly different between radial scars with and those without associated malignancy. CONCLUSION A percutaneous diagnosis of a radial scar does not exclude associated malignancy at surgical excision. Mammographic and sonographic features of a lesion diagnosed as a radial scar at percutaneous imaging-guided biopsy do not predict which lesions will have associated malignancy at surgery. Therefore, all patients with percutaneous diagnosis of a radial scar should undergo surgical excision regardless of mammographic and sonographic appearances, until further criteria can be determined.

Nonsurgical Management of High-Risk Lesions Diagnosed at Core Needle Biopsy: Can Malignancy Be Ruled Out Safely With Breast MRI?

OBJECTIVE The purpose of this study was to investigate whether breast MRI can be used to rule out malignancy in patients with high-risk lesions diagnosed at imaging-guided core needle biopsy. SUBJECTS AND METHODS The subjects were women consecutively registered between October 2004 and April 2010 who had high-risk lesions diagnosed at mammographically or sonographically guided core needle biopsy and subsequently underwent MRI and surgical excision. MR images were reviewed by two experienced breast radiologists. Lesions assessed as BI-RADS category 1-3 were considered negative for malignancy, and BI-RADS 4 and 5 lesions were considered malignant. Histologic findings at surgical excision were the reference standard. The sensitivity, specificity, and positive and negative predictive values of MRI in the detection of associated malignancy were calculated for the entire set of lesions and for each histologic subtype. RESULTS The final sample consisted of 169 high-risk lesions in 166 patients. At MRI analysis, 116 (68.6%) lesions were considered negative for malignancy, and the other 53 (31.4%) malignant. At surgical excision, 22 malignant lesions were found. The overall sensitivity, specificity, and positive and negative predictive values of MRI were 72.7% (16/22), 74.8% (110/147), 30.2% (16/53), and 94.8% (110/116). The negative predictive values for papilloma, radial scar, lobular neoplasia, and atypical ductal hyperplasia were 97.4% (38/39), 97.6% (41/42), 88.0% (22/25), and 90.0% (9/10). CONCLUSION Patients with high-risk lesions associated with the lowest likelihood of malignancy (papilloma and radial scar) and without suspicious MRI findings can safely undergo follow-up instead of surgery. Because of the low negative predictive value, however, MRI is not helpful in cases of lobular neoplasia and atypical ductal hyperplasia, and all these lesions should be excised.

Lobular neoplasia: core needle breast biopsy underestimation of malignancy in relation to radiologic and pathologic features.

The purpose of this study is to assess the positive predictive value (PPV) for malignancy of core needle biopsy (CNB) demonstrating lobular neoplasia (LN). From 3920 CNBs, 35 (0.89%) LNs (14 atypical lobular hyperplasia - ALH - and 21 lobular carcinoma in situ - LCIS) were identified. Twenty-eight patients underwent surgical excision and seven radiologic follow-up. We describe the imaging findings and excision histology outcomes. We report the PPV for malignancy based on excision histology (n=28) and on excision or follow-up (n=35), and according to the histologic type, biopsy probe and guidance, lesion diameter, and BI-RADS category. PPV for malignancy (based on excision histology) was 46.4% (13/28) and PPV (based on excision or follow-up) was 37.1% (13/35). The overall rate of malignancy for LN was 37.1% (13/35), with a PPV for malignancy of ALH and LCIS of 7.1% (1/14) and 57.1% (12/21), respectively (p=0.003). Estimates of the PPV for malignancy were: stereotactic-guided vacuum-assisted biopsy (22.7%) versus ultrasound-guided automated CNB (61.5%), p=0.053; lesions<20mm (31.2%) versus lesions>20mm (100%), p=0.043; lesions classified as BI-RADS 3 (16.7%) versus BI-RADS 4 or 5 (41.4%), p=0.377. Underestimation of malignancy was therefore more likely in cases of LCIS, US-guided CNB, and lesions that were large and suspicious on imaging. Nevertheless, the absence of these features does not spare the need for surgical excision in lobular neoplasia diagnosed on CNB.

High-Risk Breast Lesions at Imaging-Guided Needle Biopsy: Usefulness of MRI for Treatment Decision

OBJECTIVE The purpose of this study is to evaluate the role of MRI for characterization of high-risk breast lesions diagnosed at imaging-guided needle biopsy. MATERIALS AND METHODS In this retrospective analysis of 220 patients, 227 high-risk lesions (94 papillomas, 64 radial sclerosing lesions, 46 lobular neoplasias, and 23 atypical ductal hyperplasias) found at 11-gauge vacuum-assisted or 14-gauge needle biopsy were studied with dynamic MRI (time resolution, 84 or 88 seconds; gadopentetate dimeglumine or gadobenate dimeglumine, 0.1 mmol/kg). When lesions showed contrast enhancement on subtracted images, they were considered suspicious for malignancy. The reference standard was histopathologic examination after surgical excision in 190 of 227 (84%) lesions and negative follow-up (≥ 24 months) in 37 of 227 (16%) lesions. Predictive values and likelihood ratios were calculated. RESULTS Of 227 lesions, 155 (68%) were contrast enhancing and 72 (32%) were not. Of 155 contrast-enhancing lesions, 28 (18%) were upgraded to malignancy after surgical excision (nine papillomas, one radial sclerosing lesion, 11 lobular neoplasias, and seven atypical ductal hyperplasias); there were 11 invasive carcinomas and 17 ductal carcinomas in situ, four of the latter being G3. Of 72 non-contrast-enhancing lesions, two (3%) were upgraded to malignancy after surgical excision (one radial sclerosing lesion and one lobular neoplasia), both of which were G1 ductal carcinoma in situ. Cancer probability was significantly higher for contrast-enhancing (18%) than for non-contrast-enhancing (3%) lesions (p = 0.001) and for nonmasslike (43%) than for masslike (14%) lesions (p = 0.005). The positive predictive value was 18% (28/155; 95% CI, 13-24%), the negative predictive value was 97% (70/72; 95% CI, 94-99%), the positive likelihood ratio was 1.448 (95% CI, 1.172-1.788), and the negative likelihood ratio was 0.188 (95% CI, 0.152-0.232). CONCLUSION The absence of enhancement at dynamic MRI allowed reliable exclusion of invasive cancers among high-risk lesions diagnosed at needle biopsy.

Assessment of breast cancer response to neoadjuvant chemotherapy: Is volumetric MRI a reliable tool?

The purpose of this study was to evaluate the reliability of volumetric magnetic resonance imaging (MRI) in breast cancer size assessment before, during and after neoadjuvant chemotherapy (NAC). Volumetric MRI measures performed on 15 patients with breast cancer were compared with volumes reckoned upon mean lesional diameters, using the same MRI data. Concordance correlation coefficient (CCC), Bland & Altman plots, RECIST evaluation and Cohens Kappa were assessed, to evaluate the agreement between the two methods. CCC was computed before (0.9357), during (0.8053) and after (0.7499) NAC, in all examinations pooled together (0.8617), and on final tumor volume as a percentage of baseline volume (0.9224). In 2/15 (13.3%) cases RECIST assessment was different. Cohens Kappa was 0.787 (CI(95%)=0.513-1.062). In summary, volumetric MRI is a reliable tool to assess breast cancer size before, during and after NAC. Further investigations are needed to understand whether improvements in surgical planning are feasible.

Stereotactic vacuum-assisted breast biopsy: results, follow-up and correlation with radiological suspicion.

Purpose.The purpose of this study was to assess the accuracy and clinical usefulness of stereotactic vacuum-assisted biopsy (VAB) for diagnosing suspicious, nonpalpable, only mammographically detectable breast lesions.Materials and methods.We retrospectively evaluated the results of percutaneous stereotactic VAB with 11-gauge needles performed over a period of 34 months on 228 nonpalpable suspicious breast lesions detectable on mammography only [Breast Imaging Reporting and Data System (BI-RADS) 3: 25.9%; BI-RADS 4: 67.1%; BI-RADS 5: 7%]. The imaginghistological concordance was ascertained for each lesion. In cases of discordance, repeat biopsy or surgical excision were recommended; in cases of benign lesions, we urged a follow-up of at least 6 months and for borderline and malignant lesions a surgical excision. We also evaluated concordance between VAB results and subsequent examinations (surgical excision or followup).Results.VAB demonstrated 123 (54%) benign lesions (with six cases of imaging–histological discordance), 26 (11.4%) borderline lesions and 79 (34.6%) malignant lesions. We obtained a suitable post-VAB mammographic or histological evaluation for 78 benign lesions, 17 borderline lesions and 76 malignant lesions, with one (1.3%) false negative (FN) case, two (11.8%) underestimations of borderline lesions, 14 (18.4%) underestimations of malignant lesions and no (0%) false positive cases. We did not observe any postbiopsy complications or scars.Conclusions.Percutaneous histological VAB with an 11-gauge needle proved to be, as reported in previous studies, a reliable method for diagnosing nonpalpable, mammographically detectable only breast lesions, with an underestimation rate lower than core biopsy and a FN rate similar to that of surgical biopsy, without any significant complications.

Unusual malignant tumors of the breast: MRI features and pathologic correlation.

Unusual malignant breast tumors are well-differentiated subtypes of invasive ductal carcinoma, including mucinous, tubular, medullary and papillary carcinomas, and account for about 10% of malignant breast tumors. They are increasingly being encountered during magnetic resonance imaging (MRI) examinations of the breast. Therefore, breast radiologists should be aware of their appearance on MRI. This review provides an overview of MRI characteristics of a range of unusual tumors (mucinous carcinoma, medullary carcinoma, tubular carcinoma, intraductal papillary carcinoma, intracystic papillary carcinoma and invasive papillary carcinoma), highlighting specific clues for diagnosis and correlating MRI and pathologic features. Many unusual breast tumors exhibit MRI features similar to those of benign or low suspicious lesions (oval shape, well-defined margins, high signal intensity on T2-weighted images, continuous increase kinetics, i.e. type I dynamic curve), leading to a possible misdiagnosis. Nevertheless, an understanding of pathologic features of these tumors, especially tissue content (mucinous, fibrous) and growth pattern, can help to define some specific clues for their diagnosis.

Surgical specimen ultrasound: Is it able to predict the status of resection margins after breast-conserving surgery?

PURPOSE To evaluate the accuracy of surgical specimen ultrasound in the assessment of the status of resection margins after breast-conserving surgery. METHODS AND MATERIALS Sonographic examination of 46 surgical specimens of US-detectable malignant tumors was performed. Distance of the lesion from the specimen margins in four radial directions was measured and compared with distances measured on pathologic examination. Positive pathologic margins were defined when invasive or intraductal carcinoma was found within 2 mm of the specimen margin. Sensitivity, specificity, positive(PPV) and negative predictive values(NPV) of US in predicting surgical margins were calculated, considering both a 10-mm and a 4-mm sonographic threshold. RESULTS Of 184 margins(4 per lesion), pathology demonstrated 28 positive and 156 negative margins. Considering the 10-mm cut-off, US identified 32 positive and 152 negative margins, showing the following sensitivity, specificity, PPV and NPV: 28.5%, 84.6%, 25% and 86.8%, respectively. Considering the 4-mm cut-off, US identified 7 positive and 177 negative margins, with a sensitivity of 7.1%, a specificity of 96.8%, a PPV of 28.2% and a NPV of 85.3%. False-negative results were more frequent in case of invasive lobular carcinoma (20%) and presence of intraductal component (60%). CONCLUSION Sonography demonstrated a poor performance in the evaluation of the status of resection margins in breast specimens; however, because of the high NPV -both with 10-mm and 4-mm thresholds- it might be helpful in confirming complete excision of a US-detected neoplasm and in ruling out the presence of macroscopic invasive ductal carcinoma at surgical margins.

Magnetic resonance imaging of radial sclerosing lesions (radial scars) of the breast.

PURPOSE To identify magnetic resonance (MR) imaging (MRI) features of radial sclerosing lesions (RSLs) of the breast. METHODS AND MATERIALS The radiologic and pathologic records for 4629 consecutive patients undergoing MR examinations of the breast were retrospectively reviewed. Patients who received a pathologic diagnosis of RSL without atypia or carcinoma at surgical excision were identified. The MR images were evaluated according to the BI-RADS-MRI lexicon by two experienced breast radiologists. The frequency of morphologic and kinetic patterns and of BI-RADS-MRI assessment categories was calculated. RESULTS Twenty-nine patients with 29 surgically excised RSL were identified. Nine (31%) RSL were MR-occult; the remaining 20 (69%) RSL presented as masses (10/20, 50%), architectural distortions (5/20, 25%), non-mass lesions (4/20, 20%), and focus (1/20, 5%). Kinetic analysis was performed in 18 RSL: enhancement features were benign in 9 (50%) cases, suspicious in 7 (39%) cases and indeterminate in 2 (11%) cases. Twelve (41%) MR examinations were assessed as suspicious (BI-RADS-MRI 4 and 5), and 17 (59%) as negative (BI-RADS-MRI 1) or benign (BI-RADS-MRI 2 and 3). CONCLUSION RSLs are often visualized on MR imaging. Just as in mammography and sonography, RSL can have variable morphologic and kinetic features, and not infrequently they can mimic invasive carcinoma of the breast.