Bethany L. Niell

Is Excisional Biopsy Required After a Breast Core Biopsy Yields Lobular Neoplasia

OBJECTIVE The management of lobular neoplasia (LN) on percutaneous core breast biopsies remains controversial. Published upgrade rates after surgical excision vary widely. This study aims to determine the frequency of malignancy following excision in patients with LN found on core biopsy. SUBJECTS AND METHODS Our study identified patients from December 2005 through December 2010 with LN as the highest-risk lesion on core biopsy. Patients with flat epithelial atypia on core biopsy were not excluded. Per institutional policy, excision was routinely recommended. An upgrade from the core biopsy of LN was defined as excisional biopsy pathology that revealed ductal carcinoma in situ (DCIS), invasive ductal carcinoma (IDC), or invasive lobular carcinoma (ILC). RESULTS Between December 2005 and December 2010, 4472 percutaneous breast biopsies were performed, with 71 patients (1.5%) having LN as the highest-risk lesion on core biopsy. Sixty-seven patients (94%) underwent excision. The upgrade rate on excisional biopsy was 16% (11/67 patients), with the type of malignancy on excisional biopsy pathology as follows: DCIS, 36% (4/11); IDC, 18% (2/11); and ILC, 45% (5/11). All patients with pleomorphic lobular carcinoma in situ on core biopsy who proceeded to excision were upgraded to malignancy. After excluding patients with discordant results, patients with pleomorphic lobular carcinoma in situ, and patients with flat epithelial atypia on core biopsy, the upgrade rate of pure LN on excisional biopsy was 9%. CONCLUSION LN on core biopsy warrants excisional biopsy given the upgrade rate to malignancy.

Preoperative Tomosynthesis-guided Needle Localization of Mammographically and Sonographically Occult Breast Lesions.

PURPOSE To assess the feasibility and accuracy of digital breast tomosynthesis (DBT)-guided needle localization for DBT-detected suspicious abnormalities not visualized with other modalities and to analyze the imaging and pathologic characteristics of abnormalities detected only with DBT to determine the positive predictive value for malignancy. MATERIALS AND METHODS This HIPAA-compliant study was approved by the institutional review board, and the requirement to obtain informed consent was waived. A retrospective query of the imaging database identified 34 consecutive women (average age, 55 years; age range, 28-84 years) with 36 lesions who underwent DBT-guided needle localization between April 2011 and January 2013 with use of commercially available equipment. Imaging findings and medical records were reviewed. Findings that were attributable to previous surgical changes were classified as benign or probably benign and excluded from analysis because the lesions did not proceed to localization. RESULTS Architectural distortion was the imaging finding identified in all 36 abnormalities (100%). Findings from pathologic examination after the first attempt at localization were concordant with those from imaging in 35 of the 36 lesions (97%), which is suggestive of appropriate sampling. Histologic findings were malignant in 17 of the 36 lesions (47%; 95% confidence interval: 30.4%, 64.5%). Thirteen of the 17 lesions (76%; 95% confidence interval: 50.1%, 93.1%) were invasive malignancies. Twenty-two of the 36 abnormalities (61%) were either malignant or high-risk lesions (atypical ductal hyperplasia, lobular carcinoma in situ, atypical lobular hyperplasia). CONCLUSION DBT-guided needle localization is an accurate and feasible method with which to biopsy DBT-detected suspicious architectural distortions not visualized at mammography or sonography. The high risk of malignancy in abnormalities detected only with DBT (47%) confirms that routine biopsy is required for histologic analysis.

How old is this mutation? - a study of three Ashkenazi Jewish founder mutations

BackgroundSeveral founder mutations leading to increased risk of cancer among Ashkenazi Jewish individuals have been identified, and some estimates of the age of the mutations have been published. A variety of different methods have been used previously to estimate the age of the mutations. Here three datasets containing genotype information near known founder mutations are reanalyzed in order to compare three approaches for estimating the age of a mutation. The methods are: (a) the single marker method used by Risch et al., (1995); (b) the intra-allelic coalescent model known as DMLE, and (c) the Goldgar method proposed in Neuhausen et al. (1996), and modified slightly by our group. The three mutations analyzed were MSH2*1906 G->C, APC*I1307K, and BRCA2*6174delT.ResultsAll methods depend on accurate estimates of inter-marker recombination rates. The modified Goldgar method allows for marker mutation as well as recombination, but requires prior estimates of the possible haplotypes carrying the mutation for each individual. It does not incorporate population growth rates. The DMLE method simultaneously estimates the haplotypes with the mutation age, and builds in the population growth rate. The single marker estimates, however, are more sensitive to the recombination rates and are unstable. Mutation age estimates based on DMLE are 16.8 generations for MSH2 (95% credible interval (13, 23)), 106 generations for I1037K (86-129), and 90 generations for 6174delT (71-114).ConclusionsFor recent founder mutations where marker mutations are unlikely to have occurred, both DMLE and the Goldgar method can give good results. Caution is necessary for older mutations, especially if the effective population size may have remained small for a long period of time.

Patient Outcomes in Canceled MRI-Guided Breast Biopsies

OBJECTIVE The reported frequency of aborted MRI-guided breast biopsies ranges from 8% to 17%, usually secondary to nonvisualization at attempted biopsy. Our study examines the frequency of MRI-guided breast biopsies aborted because of lesion nonvisualization and the subsequent risk of malignancy. MATERIALS AND METHODS We identified 350 patients and 445 lesions scheduled for MRI-guided biopsy between January 1, 2007, and December 31, 2009. Medical records and imaging studies were reviewed to ascertain patient demographics, lesion and imaging characteristics, and subsequent pathology results. Chi-square statistics were calculated for patient level analyses. RESULTS MRI-guided biopsies were aborted in 13% (56/445) of lesions and 15% (53/350; 95% CI, 11.6-19.3%) of patients because of nonvisualization of the biopsy target at the time of attempted biopsy. Of these 53 patients, 50 patients had follow-up data available. Malignancy was subsequently diagnosed in five of those 50 patients (10%; 95% CI, 3.3-21.8%), three with invasive ductal carcinomas and two with ductal carcinoma in situ. The mean time to malignant diagnosis from the date of aborted biopsy was 2.6 months (range, 1.1-6.9 months). CONCLUSION Informed consent for MRI-guided breast biopsies should include discussion of biopsy cancellation because of nonvisualization of the target lesion. The low yet significant risk of malignancy in patients subsequent to an aborted MRI-guided breast biopsy warrants short-term follow-up MRI after a canceled biopsy.

Extramammary Findings on Breast MR Examinations: Frequency, Clinical Relevance, and Patient Outcomes

PURPOSE To evaluate the frequency of extramammary findings on breast magnetic resonance (MR) images, recommendations for further imaging evaluation of each finding, and the subsequent effect on patient outcomes and health care expenditures. MATERIALS AND METHODS Institutional review board approval was acquired for this HIPAA-compliant study. Informed consent was waived. Review of the institutional database identified 2324 breast MR examinations performed in women from January 1, 2010, to December 31, 2010. Breast MR imaging reports were reviewed for extramammary findings. Extramammary findings were categorized by using the computed tomography (CT) colonography reporting and data system (C-RADS). The electronic medical record was reviewed for each patient with a C-RADS category E3 and E4 finding to assess clinical relevance and pathologic outcome. If an E3 or E4 finding was previously described and evaluated, the finding was downgraded and assigned a final C-RADS E2 category. The cost of additional imaging was estimated by using the Medicare physician fee schedule. Statistical significance was assessed by using χ(2) statistics. A P value less than .05 indicated statistical significance, and 95% exact confidence intervals (CIs) were constructed. RESULTS Extramammary findings were identified in 391 of 2324 breast MR examinations (16.8%), which included 105 patients (4.5%) with E3 or E4 findings. Of the 2324 patients, 86 patients (3.7% [95% CI: 3.0%, 4.5%]) were recommended to undergo further imaging. After undergoing evaluation for additional imaging, a clinically important finding was found in nine patients (0.4% [95% CI: 0.2%, 0.7%]). Most frequently, hepatic lesions were the indication for additional imaging. Abdominal MR examinations accounted for 55% of costs related to additional imaging. Averaged across the entire cohort, further imaging evaluation and follow-up of incidental findings contributed an additional

Breast Cancer Screening in Women at Higher-Than-Average Risk: Recommendations From the ACR

16 to each breast MR imaging performed. CONCLUSION Additional imaging evaluation for E3 and E4 extramammary findings at breast MR imaging can identify clinically important disease without substantially increasing cost. .

Breast reconstruction with a deep inferior epigastric perforator flap: imaging appearances of the normal flap and common complications.

Early detection decreases breast cancer mortality. The ACR recommends annual mammographic screening beginning at age 40 for women of average risk. Higher-risk women should start mammographic screening earlier and may benefit from supplemental screening modalities. For women with genetics-based increased risk (and their untested first-degree relatives), with a calculated lifetime risk of 20% or more or a history of chest or mantle radiation therapy at a young age, supplemental screening with contrast-enhanced breast MRI is recommended. Breast MRI is also recommended for women with personal histories of breast cancer and dense tissue, or those diagnosed by age 50. Others with histories of breast cancer and those with atypia at biopsy should consider additional surveillance with MRI, especially if other risk factors are present. Ultrasound can be considered for those who qualify for but cannot undergo MRI. All women, especially black women and those of Ashkenazi Jewish descent, should be evaluated for breast cancer risk no later than age 30, so that those at higher risk can be identified and can benefit from supplemental screening.

Screening for Breast Cancer

OBJECTIVE The purpose of this essay is to illustrate the normal imaging appearance of deep inferior epigastric perforator (DIEP) flap breast reconstruction and common postoperative complications. CONCLUSION Familiarity with the anatomy and normal imaging appearance of a DIEP flap reconstruction will help the breast imager recognize normal postsurgical findings and common postoperative complications.

ACR Appropriateness Criteria® Evaluation of Nipple Discharge

The goal of screening is to detect breast cancers when still curable to decrease breast cancer-specific mortality. Breast cancer screening in the United States is routinely performed with mammography, supplemental digital breast tomosynthesis, ultrasound, and/or MR imaging. This article aims to review the most commonly used breast imaging modalities for screening, discuss how often and when to begin screening with specific imaging modalities, and examine the pros and cons of screening. By the articles end, the reader will be better equipped to have informed discussions with patients and medical professionals regarding the benefits and disadvantages of breast cancer screening.

Screening for Breast Cancer in Women Age 75 Years and Older

Appropriate imaging evaluation of nipple discharge depends the nature of the discharge. Imaging is not indicated for women with physiologic nipple discharge. For evaluation of pathologic nipple discharge, multiple breast imaging modalities are rated for evidence-based appropriateness under various scenarios. For women age 40 or older, mammography or digital breast tomosynthesis (DBT) should be the initial examination. Ultrasound is usually added as a complementary examination, with some exceptions. For women age 30 to 39, either mammogram or ultrasound may be used as the initial examination on the basis of institutional preference. For women age 30 or younger, ultrasound should be the initial examination, with mammography/DBT added when ultrasound shows suspicious findings or if the patient is predisposed to developing breast cancer. For men age 25 or older, mammography/DBT should be performed initially, with ultrasound added as indicated, given the high incidence of breast cancer in men with pathologic nipple discharge. Although MRI and ductography are not usually appropriate as initial examinations, each may be useful when the initial standard imaging evaluation is negative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.