Cecilia L. Mercado

Is Surgical Excision Necessary for the Management of Atypical Lobular Hyperplasia and Lobular Carcinoma In Situ Diagnosed on Core Needle Biopsy?: A Report of 38 Cases and Review of the Literature

CONTEXT Both atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS) have traditionally been considered to be risk factors for the development of invasive carcinoma and are followed by close observation. Recent studies have suggested that these lesions may represent true precursors with progression to invasive carcinoma. Due to the debate over the significance of these lesions and the small number of cases reported in the literature, the treatment for lobular neoplasia diagnosed by percutaneous core biopsy (PCB) remains controversial. OBJECTIVE To review our experience with pure LCIS or ALH diagnosed by PCB and correlate the radiologic findings and surgical excision diagnoses to develop management guidelines for lobular neoplasia diagnosed by PCB. DESIGN We searched the pathology database for patients who underwent PCB with a diagnosis of either pure LCIS or ALH and had subsequent surgical excision. We compared the core diagnoses with the surgical excision diagnoses and the radiologic findings. RESULTS Thirty-eight PCBs with a diagnosis of ALH (18 cases) or LCIS (20 cases) were identified. Carcinoma was present at excision in 1 (6%) of the ALH cases and in 2 (10%) of the LCIS cases. In summary, 8% (3/38) of PCBs diagnosed as lobular neoplasia (ALH or LCIS) were upgraded to carcinoma (invasive carcinoma or ductal carcinoma in situ) at excision. CONCLUSIONS Surgical excision is indicated for all PCBs diagnosed as ALH or LCIS, as a significant percentage will show carcinoma at excision.

Is breast MRI helpful in the evaluation of inconclusive mammographic findings

OBJECTIVE The purpose of this study was to evaluate the usefulness of MRI of the breast in cases in which mammographic or sonographic findings are inconclusive. MATERIALS AND METHODS We retrospectively reviewed images from 115 MRI examinations of the breast performed from 1999 to 2005 for the indication of problem-solving for inconclusive findings on a mammogram. Forty-eight of the 115 women (41.8%) were at high risk. We discerned whether sonography or MRI was used as an adjunctive tool and correlated the findings with those in the pathology database. RESULTS The equivocal findings most frequently leading to MRI were asymmetry and architectural distortion. No suspicious MRI correlate was found in 100 of 115 cases (87%). These cases were found stable at follow-up mammography or MRI after a mean of 34 months. Fifteen enhancing masses (13%) that corresponded to the mammographic abnormality were seen on MR images. All masses identified at MRI were accurately localized for biopsy, and six malignant lesions were identified. Four of six malignant tumors were seen in one mammographic view only; two were seen on second-look ultrasound images. MRI had a sensitivity of 100% and compared with mammography had significantly higher specificity (91.7% vs 80.7%, p = 0.029), positive predictive value (40% vs 8.7%, p = 0.032), and overall accuracy (92.2% vs 78.3%, p = 0.0052). Eighteen incidental lesions (15.7%) were detected at MRI, and all were subsequently found benign. CONCLUSION We found breast MRI to be a useful adjunctive tool when findings at conventional imaging were equivocal. Strict patient selection criteria should be used because of the high frequency of incidental lesions seen on MR images.

Pseudoangiomatous stromal hyperplasia of the breast: sonographic features with histopathologic correlation.

Abstract:  The objective of this study was to evaluate the spectrum of sonographic findings in pseudoangiomatous stromal hyperplasia (PASH) of the breast when it presents as a tumoral mass with pathologic correlation. Breast sonogram studies of 13 patients with 13 pathologically proven PASH lesions were retrospectively reviewed. The morphologic characteristics of the lesions as seen on ultrasound were evaluated and correlated with histopathologic findings. Sonography demonstrated most lesions, 11 of 13, to be hypoechoic in echotexture. One lesion was isoechoic in echotexture, also demonstrating small internal cysts, and one was predominantly hyperechoic. Two of the 11 hypoechoic lesions also demonstrated a complex heterogeneous pattern with a central hypoechoic area and a peripheral echogenic rim. All lesions were oval in shape with the long axis of the lesion parallel to the chest wall. None of the lesions demonstrated posterior acoustic shadowing. PASH lesions of the breast have a varied sonographic appearance. Knowledge of the spectrum of morphologic features shown on sonography can be helpful in the diagnosis of this entity. 

Outcome of High-Risk Lesions at MRI-Guided 9-Gauge Vacuum- Assisted Breast Biopsy

OBJECTIVE The purposes of this study were to determine the frequency of underestimation of high-risk lesions at MRI-guided 9-gauge vacuum-assisted breast biopsy and to determine the imaging and demographic characteristics predictive of lesion upgrade after surgery. MATERIALS AND METHODS We retrospectively reviewed consecutively detected lesions that were found only at MRI and biopsied under MRI guidance from May 2007 to April 2012. Imaging indications, imaging features, and histologic findings were reviewed. The Fisher exact test was used to assess the association between characteristics and lesion upgrade. Patients lost to follow-up or who underwent mastectomy were excluded, making the final study cohort 140 women with 151 high-risk lesions, 147 of which were excised. RESULTS A database search yielded the records of 1145 lesions in 1003 women. Biopsy yielded 252 (22.0%) malignant tumors, 184 (16.1%) high-risk lesions, and 709 (61.9%) benign lesions. Thirty of the 147 (20.4%) excised high-risk lesions were upgraded to malignancy. The upgrade rate was highest for atypical ductal hyperplasia, lobular carcinoma in situ, and radial scar. No imaging features were predictive of upgrade. However, there was a significantly higher risk that a high-risk lesion would be upgraded to malignancy if the current MRI-detected high-risk lesion was in the same breast as a malignant tumor previously identified in the remote history, a recently diagnosed malignant tumor, or a high-risk lesion previously identified in the remote history (p = 0.0001). The upgrade rate was significantly higher for women with a personal cancer history than for other indications combined (p = 0.0114). CONCLUSION The rate of underestimation of malignancy in our series was 20%. No specific imaging features were seen in upgraded cases. Surgical excision is recommended for high-risk lesions found at MRI biopsy and may be particularly warranted for women with a personal history of breast cancer.

Microinvasive Breast Cancer and the Role of Sentinel Node Biopsy: An Institutional Experience and Review of the Literature

Abstract:  Ductal carcinoma in situ with microinvasion (DCISM) is a distinct clinicopathologic entity. Its true metastatic potential has been unclear, due in part to historical differences in the definition of microinvasion. The role of routine axillary staging for DCISM is controversial, given the reportedly low incidence of axillary metastases. We describe our institutional experience with DCISM, and define the role of axillary staging. A retrospective analysis was made of patients with DCISM. Forty‐four patients underwent axillary staging (24 axillary lymph node dissection [ALND], 22 sentinel node biopsy [SNB]). Macrometastatic disease was present in three patients (7%), and two patients had isolated tumor cells (itc) in the sentinel node. Patients with axillary metastases tended to be younger. Comedonecrosis, nuclear grade, multifocal microinvasion or presentation as a clinical mass was not associated with a higher rate of axillary metastases. In this series, 7% of patients had macrometastatic disease, and two patients (5%) had itc only. Axillary staging is indicated, and SNB is appropriate for the identification of axillary metastatic disease.

Sonographic Appearances of Benign and Malignant Male Breast Disease With Mammographic and Pathologic Correlation

Objective. Imaging of the male breast is most often performed for the evaluation of a clinical abnormality such as breast enlargement or tenderness, a palpable mass, nipple skin changes, or nipple discharge. Most breast lesions encountered in men are benign. Malignant breast lesions are less frequent; breast cancer accounts for less than 1% of all male cancers in the United States. The initial imaging evaluation of a finding in the male breast is performed with mammography. Sonography is frequently used as an adjunct to mammography but is less often used as the primary imaging modality. The objective of this article is to provide readers with a thorough review of the sonographic appearances of benign and malignant male breast disease. Methods. We reviewed our institutions case database to identify male patients who underwent mammography, sonography, and subsequent biopsy of a breast lesion. These cases were collected and reviewed to select the best imaging examples. Results. A spectrum of benign and malignant male breast disease is presented with corresponding sonographic, mammographic, and pathologic imaging. For each entity, the salient imaging findings and typical clinical presentation are discussed. Conclusions. Most studies in the literature have reported on the mammographic and sonographic imaging features of primary breast carcinoma in men. However, very little has been reported on the sonographic appearance of benign and malignant male breast conditions. Recognition and correct identification of pathologic male breast entities on sonography is essential to determine appropriate management recommendations and avoid unnecessary biopsies.

An Unusual Presentation of Neurofibromatosis of the Breast

Abstract: Patients with neurofibromatosis type I or von Recklinghausen disease develop neurofibromas in the subcutaneous tissues, including the breast. There are two German reports of massive neurofibromatosis of the breast, but few reports of massive neurofibromatosis of the breast in the English literature. We present an unusual case of neurofibromatosis of the breast with large neurofibromas predominantly noted protruding from both nipple‐areolar complexes.

Abbreviated MRI Protocols: Wave of the Future for Breast Cancer Screening

OBJECTIVE The purpose of this article is to describe the use of abbreviated breast MRI protocols for improving access to screening for women at intermediate risk. CONCLUSION Breast MRI is not a cost-effective modality for screening women at intermediate risk, including those with dense breast tissue as the only risk. Abbreviated breast MRI protocols have been proposed as a way of achieving efficiency and rapid throughput. Use of these abbreviated protocols may increase availability and provide women with greater access to breast MRI.

Acquired arteriovenous fistula of the breast.

P ercutaneous biopsies have become a valuable tool for the evaluation of masses in the breast. For nonpalpable masses, ultrasound core biopsy has become particularly useful not only for tissue diagnosis, but for treatment planning as well. Despite the widespread adoption of this useful tool, it is not without serious adverse sequelae, albeit rare. We present the first reported case of an acquired arteriovenous fistula (AVF) of the breast. A 34-year-old woman presented to the ColumbiaPresbyterian Comprehensive Medical Center with a 1-week history of breast discomfort. Three days prior to presenting to the center, the patient, a dialysis nurse, palpated a thrill on the medial aspect of her right breast. The patient had undergone an ultrasound-guided core biopsy of a 0.4 cm mass in the right breast 4 months earlier. At the end of the procedure, a marking clip was placed at the biopsy site (Fig. 1). The procedure was technically uneventful and was performed without incident. The patient remained asymptomatic until her presentation. She denied any history of recent trauma. Her past medical history was noncontributory, notable only for a strong family history of breast cancer. She had undergone a right breast excisional biopsy in 1998 that revealed fibrocystic changes. Clinical examination revealed symmetric breasts, without distortion or masses, and a palpable thrill over the medial aspect of her right breast at 3 o’clock. A bruit could be appreciated by auscultation. There was no breast or arm swelling on the

Free Silicone Injection Causing Polyarthropathy and Septic Shock

A 29-year-old man with transgender identity disorder presented with progressive, worsening pain in both breasts over a 2-week period. He had received breast “augmentation injections” as an inexpensive alternative to conventional augmentation mammaplasty. He was febrile and hypotensive. Both breasts had areas of erythema as well as multiple bullae. He also had bilateral tender, swollen ankles, knees, and wrists. Pathology from operative incision and drainage showed a florid histiocytic and giant cell response (Fig. 1A) and evidence of cellular response to infection (Fig. 1B). A magnetic resonance imaging (MRI) study was performed that showed multiple areas of foreign body in both breasts (Fig. 2). This necessitated return to the operating room for further debridement of the loculated abscesses. The polyarthropathy resolved completely with the resolution of the infectious process in the breasts. Local complications are well described in silicone gel extravasation from implant envelopes. Some described complications include extravasation of the gel transcutaneously, expression from the nipple, migration to the axillary lymph nodes, and even spread along tissue planes to the hand, causing a compartment syndrome-like phenomenon. In the diagnosis of silicone extravasation, there is no clear consensus as to the dominant study. Ultrasound, mammography, and MRI have all been favored by different studies. There is no controversy, however, that physical examination is inadequate in