Chiara Adriana Pistolese

Small Breast Cancers: In Vivo Percutaneous US-guided Radiofrequency Ablation with Dedicated Cool-Tip Radiofrequency System

PURPOSE To evaluate in vivo the efficacy of a newly developed breast radiofrequency (RF) ablation system in human small invasive breast carcinomas in terms of induction of complete tumor necrosis, reproducibility of ablation lesion size and shape, and cosmetic outcome. MATERIALS AND METHODS This study had institutional review board approval, and written informed consent was obtained. Thirty-four postmenopausal women (mean age, 53 years +/- 5 [standard deviation]; range, 49-62 years) with small (< or = 2 cm) biopsy-proved invasive ductal breast carcinomas were enrolled. RF energy was delivered through a 25-mm 15-gauge monopolar cool-tip needle electrode by using the temperature-controlled mode. Patients were divided into three groups according to their breast pattern as assessed at mammography. The volumetric size and geometry of the coagulation zone, together with ablation time, were determined. Histopathologic data were compared with postprocedural 3.0-T contrast material-enhanced magnetic resonance (MR) images. Cosmesis after RF ablation was assessed. Four weeks after RF ablation, patients underwent definitive surgery. RESULTS All ablation procedures were performed successfully. For 97% of the procedures, nicotinamide adenine dinucleotide in its reduced form-diaphorase staining showed no evidence of viable cells. The mean induced ablation volume, as assessed with histologic analysis, was 12.50 cm(3) +/- 0.8. Tumor ablation volume on the postablation MR images showed good correlation with results of histopathologic analysis (r = 0.823, P < .005). No differences were observed in terms of duration of the procedure or ablation volume with respect to the glandular pattern of the breast (P > .05 for both). The general shape of the induced necrosis was close to a sphere in all cases. Cosmesis was excellent in 28 patients. CONCLUSION A dedicated breast cool-tip RF ablation system can induce complete tumor necrosis and reproducible ablation volumes independently of breast glandular pattern, providing excellent cosmesis. Postablation MR images are a reliable tool in predicting histologic findings.

Microcalcifications in breast cancer: an active phenomenon mediated by epithelial cells with mesenchymal characteristics

BackgroundMammary microcalcifications have a crucial role in breast cancer detection, but the processes that induce their formation are unknown. Moreover, recent studies have described the occurrence of the epithelial–mesenchymal transition (EMT) in breast cancer, but its role is not defined. In this study, we hypothesized that epithelial cells acquire mesenchymal characteristics and become capable of producing breast microcalcifications.MethodsBreast sample biopsies with microcalcifications underwent energy dispersive X-ray microanalysis to better define the elemental composition of the microcalcifications. Breast sample biopsies without microcalcifications were used as controls. The ultrastructural phenotype of breast cells near to calcium deposits was also investigated to verify EMT in relation to breast microcalcifications. The mesenchymal phenotype and tissue mineralization were studied by immunostaining for vimentin, BMP-2, β2-microglobulin, β-catenin and osteopontin (OPN).ResultsThe complex formation of calcium hydroxyapatite was strictly associated with malignant lesions whereas calcium-oxalate is mainly reported in benign lesions. Notably, for the first time, we observed the presence of magnesium-substituted hydroxyapatite, which was frequently noted in breast cancer but never found in benign lesions. Morphological studies demonstrated that epithelial cells with mesenchymal characteristics were significantly increased in infiltrating carcinomas with microcalcifications and in cells with ultrastructural features typical of osteoblasts close to microcalcifications. These data were strengthened by the rate of cells expressing molecules typically involved during physiological mineralization (i.e. BMP-2, OPN) that discriminated infiltrating carcinomas with microcalcifications from those without microcalcifications.ConclusionsWe found significant differences in the elemental composition of calcifications between benign and malignant lesions. Observations of cell phenotype led us to hypothesize that under specific stimuli, mammary cells, which despite retaining a minimal epithelial phenotype (confirmed by cytokeratin expression), may acquire some mesenchymal characteristics transforming themselves into cells with an osteoblast-like phenotype, and are able to contribute to the production of breast microcalcifications.

MR imaging-guided 10-gauge vacuum-assisted breast biopsy: histological characterisation

PurposeThe aim of this study was to evaluate a handheld vacuum-assisted device for magnetic resonance imaging (MRI)-guided breast biopsy.Materials and methodsIn 47 patients, a total of 47 suspicious breast lesions (mean maximum diameter 9 mm) seen with MRI (no suspicious changes on breast ultrasound or mammography) were sampled using a 10-gauge vacuum-assisted breast biopsy (VAB) device under MRI guidance. Histology of biopsy specimens was compared with final histology after surgery or with follow-up in benign lesions.ResultsTechnical success was achieved in all biopsies. Histological results from VAB revealed malignancy in 15 lesions (32%), atypical ductal hyperplasia in four lesions (8%) and benign findings in 28 lesions (60%). One of four lesions with atypical ductal hyperplasia was upgraded to ductal carcinoma in situ after surgery. One of seven lesions showing ductal carcinoma was upgraded to invasive carcinoma after surgery. Two lesions diagnosed as infiltrating carcinoma by VAB were not validated at excisional biopsy due to complete removal of the lesion during the procedure. During the follow-up (mean 18 months) of histologically benign lesions, we observed no cases of breast cancer development. Because of morphological changes on follow-up MRI scans, two lesions underwent surgical excision, which confirmed their benign nature. Besides minor complications (massive bleeding, n=1) requiring no further therapeutic intervention, no complications occurred.ConclusionsMRI-guided biopsy of breast lesions using a handheld vacuum-assisted device is a safe and effective method for the workup of suspicious lesions seen on breast MRI alone.RiassuntoObiettivoValutare l’accuratezza diagnostica dei prelievi con sistema portatile ad aspirazione retroazionata (VAB) 10 gauge sotto-guida RM nella caratterizzazione delle lesioni mammarie visibili unicamente alla RM.Materiali e metodi47 lesioni (diametro massimo 9 mm) visibili unicamente all’esame RM, sono state caratterizzate usando un sistema portatile ad aspirazione retroazionata (VAB) con ago da 10 Gauge, sotto guida RM. L’istologia delle biopsie VAB è stata confrontata con l’istologia definitiva dopo l’escissione chirurgica o con i reperti di follow-up.RisultatiIl successo tecnico è stato ottenuto in tutti i casi. I risultati istologici della biopsia VAB hanno mostrato 15 lesioni maligne (32%), 4 lesioni classificabili come iperplasia duttale atipica (ADH) (8%), e 28 lesioni come benigne (60%). Alla istologia definitiva una delle quattro lesioni classificate come ADH è stata riclassificata come carcinoma duttale in situ (DCIS), mentre una delle lesioni classificate come DCIS è stata riclassificata come carcinoma invasivo. Due lesioni diagnosticate al VAB come carcinoma infiltrante non sono state riscontrate alla istologia definitiva, probabilmente a causa della totale rimozione durante la procedura VAB. Il follow-up delle lesioni benigne ha confermato la benignità delle lesioni. Due lesioni benigne che all’Imaging RM hanno mostrato una modificazione della morfologia, sono andate incontro ad intervento chirurgico che ha confermato la benignità della lesione. Ad eccezione di un massivo sanguinamento in 1 caso, non si sono osservate complicanze.ConclusioniI prelievi VAB sotto-guida RM sono una mammetodica sicura ed efficace per la caratterizzazione delle lesioni mammarie visibili unicamente all’RM.

Subclinical Breast Cancer: Minimally Invasive Approaches. Our Experience with Percutaneous Radiofrequency Ablation vs. Cryotherapy

Background: The aim of this study was to compare the efficacy of radiofrequency ablation vs. cryoablation in the treatment of early breast cancer. Patients and Methods: 80 women (mean age 73 ± 5 years) with early breast cancer were retrospectively evaluated. 40 patients underwent cryoablation and 40 patients underwent radiofrequency ablation, both with sentinel lymph node excision. Tumor volume and histopatological data were compared by means of postprocedural 3.0-T magnetic resonance imaging (MRI). 30-45 days after the percutaneous ablation, all patients underwent surgical resection of the tumor. The mean follow-up was 18 months without any local recurrences. Results: Both techniques allow good correlation with histopathological data. In 75 patients (93.8%) we observed complete necrosis; in 5 cases there was residual disease in the postprocedural MRI and postoperative histological examination. There was a good correlation between MRI volume and histologic samples. Cosmetic results were good in all patients but 2. Conclusion: Both percutaneous radiofrequency ablation and cryotherapy are minimally invasive techniques with a good clinical and cosmetic outcome in selected cases. MRI examination is an ideal method to assess breast neoplasms in terms of quality and quantity as well as residual tumor extent after percutaneous ablation. Cryotherapy is the preferred method because of the analgesic effect of freezing with better patients compliance.

Cost-effectiveness analysis of two vacuum-assisted breast biopsy systems: Mammotome and Vacora

PurposeThis study was undertaken to compare the cost effectiveness of two vacuum-assisted breast biopsy devices, the Mammotome and Vacora systems.Materials and methodsBetween January and June 2006, 238 vacuum-assisted breast biopsies were performed at our radiology department. Five out of 238 lesions were excluded because of inadequate sampling. The Mammotome system was used in 108/233 lesions and the Vacora system in 125/233. Fifty-eight lesions underwent ultrasound-guided breast biopsy, and 50 lesions underwent mammography-guided biopsy with both Mammotome and Vacora devices. Magnetic-resonance-guided biopsy was possible with the Vacora system only (17/125 lesions).ResultsAll procedures were successfully completed. No significant differences were found between the results of the Mammotome and Vacora biopsies in terms of effectiveness: sensitivity was 84.4% and 86.2%, respectively, and specificity 100%. In terms of cost, the Mammotome system has higher costs per procedure compared with the Vacora.ConclusionsOur clinical results confirm the diagnostic accuracy of both the Mammotome and Vacora systems, whereas our cost analysis shows that there is a considerable difference, mostly related to the initial investment.RiassuntoScopoConfrontare costi ed efficacia di due sistemi di biopsia mammaria ad aspirazione forzata: Mammotome e Vacora.Materiali e metodiPresso il nostro Centro, dal gennaio a giugno 2006 sono state sottoposte a caratterizzazione istologica mediante prelievo VAB 238 lesioni mammarie. Di queste 5/238 sono state escluse dalla nostra casistica per numero insufficiente di frustoli prelevati. In 108/233 lesioni è stato utilizzato il sistema Mammotome ed in 125/233 il Vacora. Con entrambi i sistemi sono state sottoposte a prelievo 58 lesioni sotto guida ecografica e 50 sotto guida mammografica. Per la guida RM è stato utilizzato unicamente il sistema Vacora (17/125 lesioni).RisultatiTutte le procedure considerate sono state portate a termine con successo. L’efficacia diagnostica dei due sistemi è risultata sovrapponibile: sensibilità 84,4%–86,2%, specificità 100%. I costi unitari delle singole procedure risultano maggiori per il sistema Mammotome, rispetto al Vacora.ConclusioniI risultati clinici confermano l’accuratezza diagnostica di entrambi i sistemi mentre, ai fini della valutazione economica delle procedure, il fattore determinante è l’investimento iniziale.

A Phyllodes Tumor in a Child

Phyllodes tumor of the breast is a rare neoplasm, particularly in adolescent girls and young women. It is usually presented as a unilateral palpable mass. We are reporting the case of an 11-year-old adolescent girl who came to our Diagnostical Imaging Department with non-hematic nipple discharge. Ultrasound, mammography, and magnetic resonance imaging were performed. The histological examination showed a phyllodes tumor. The management and the biological behavior of this uncommon tumor are discussed with particular regard to the very unusual clinical presentation in this patient.

Breast Osteoblast-like Cells: A Reliable Early Marker for Bone Metastases From Breast Cancer

&NA; The development of bone metastasis from breast cancer results from a functional interaction between tumor cells and osteoclasts or osteoblasts. The finding of breast osteoblast‐like cells in primary breast lesions could represent a precursor (and hence an early predictor) of the formation of osteolytic bone metastasis. The identification of breast cancer cells with high affinity for bone environment opens new perspectives on prevention and therapy of bone metastases from breast. Background: The development of bone metastasis from breast cancer results from a functional interaction between tumor cells and osteoclasts or osteoblasts. The main aim of this study was therefore to test the hypothesis that the appearance of breast osteoblast‐like cells (BOLCs) in primary mammary lesions is a precursor (and hence an early predictor) of the formation of breast cancer metastases to bone. Patients and Methods: In this study, we collected 64 breast infiltrating carcinomas, 50 breast benignant lesions, and 10 biopsies of bone metastasis selected from patients with infiltrated carcinoma. Immunohistochemical, western blot, and ultrastructural analysis allowed us to investigate the presence of BOLCs in breast cancer lesions and metastatic sites. Results: We established the presence of a high amount of breast cancer cells that underwent mesenchymal transformation in infiltrating carcinomas. In addition, our results demonstrated that the microenvironment of breast cancer is very similar to the microenvironment of bone. We noted a significantly higher expression of BMP‐2/4 and PTX3 in breast‐infiltrating carcinomas compared with benign lesions. Moreover, we also identified numerous BOLCs positive to RANKL and Vitamin D receptor. Thanks to ultrastructural analysis, we also revealed the presence of BOLCs at the metastatic site. Conclusions: The identification of breast cancer cells with high affinity for a bone environment opens new perspectives on prevention and therapy of bone metastases from breast.

Value of the correct diagnostic pathway through conventional imaging (mammography and ultrasound) in evaluating breast disease

PurposeThis study evaluated the role of the correct diagnostic pathway through conventional imaging in evaluating breast disease.Materials and methodsSix hundred patients aged between 35 and 75 years were enrolled in the study. All patients underwent detailed history and clinical examination, ultrasound (US) and mammography. US scans were repeated after mammography. All suspicious lesions were studied by cytological and histological characterisation and magnetic resonance (MR) imaging.ResultsThe first US scan showed 147 solid lesions, 67 lesions characterised by posterior acoustic shadowing and 193 areas of heterogeneous echostructure. The second US scan, performed after mammography, confirmed 123/147 solid nodular lesions, 53/67 lesions characterised by posterior acoustic shadowing and 183/193 areas of heterogeneous echostructure; it also showed 13 nodular lesions not seen on the first scan and two cases of nodular lesions with irregular calcifications.ConclusionsOur experience suggests that US not performed in conjunction with mammography gives rise to incorrect diagnostic interpretations (either false positive or false negative results). The detection rate of the US scan performed after mammography increases from 4.16% to5.5%.RiassuntoObiettivoScopo del nostro lavoro è stato valutare il ruolo del corretto iter diagnostico nell’imaging convenzionale nello studio della patologia mammaria.Materiali e metodiSono state esaminate 600 pazienti (35–75 anni) sottoposte ad anamnesi, esame clinico, ecografia e mammografia. È stata effettuata successivamente una rivalutazione ecografica, alla luce della mammografia. Tutte le pazienti con lesioni sospette hanno proseguito il loro iter diagnostico mediante esame cito-istologico e/o risonanza magnetica.RisultatiLa prima ecografia ha documentato 147 lesioni nodulari solide, 67 casi di sbarramento del fascio ultrasonoro e 193 aree di disomogeneità ecostrutturale. Il secondo esame ecografico, eseguito successivamente alla mammografia, ha confermato 123/147 lesioni nodulari solide, 53/67 casi di sbarramento del fascio ultrasonoro e 183/193 aree di disomogeneità ecostrutturale. Sono state inoltre individuate 13 ulteriori lesioni nodulari non evidenziate alla preliminare ecografia ed in due casi abbiamo riscontrato la presenza di substrato nella sede del reperto mammografico di microcalcificazioni.ConclusioniDal nostro studio è emerso che l’ecografia effettuata senza la possibilità di riscontro mammografico, ha dato luogo ad erronee interpretazioni diagnostiche intese sia come falsi positivi che come falsi negativi e secondo i nostri dati, qualora eseguita successivamente alla mammografia, ha consentito di incrementare il valore della detection rate dell’indagine ecografica da 4,16% a 5,5%.

Radiological, Histological and Chemical Analysis of Breast Microcalcifications: Diagnostic Value and Biological Significance

Classification of mammary microcalcifications is based on radiological and histological characteristics that are routinely evaluated during the diagnostic path for the identification of breast cancer, or in patients at risk of developing breast cancer. The main aim of this study was to explore the relationship between the imaging parameters most commonly used for the study of mammary microcalcifications and the corresponding histological and chemical properties. To this end, we matched the radiographic characteristics of microcalcifications to breast lesion type, histology of microcalcifications and elemental composition of microcalcifications as obtained by energy dispersive x ray (EDX)-microanalysis. In addition, we investigated the properties of breast cancer microenvironment, under the hypothesis that microcalcification formation could result from a mineralization process similar to that occurring during bone osteogenesis. In this context, breast lesions with and without microcalcifications were compared in terms of the expression of the main molecules detected during bone mineralization (BMP-2, BMP-4, PTX3, RANKL OPN and RUNX2). Our data indicate that microcalcifications classified by mammography as “casting type” are prevalently made of hydroxyapatite magnesium substituted and are associated with breast cancer types with the poorest prognosis. Moreover, breast cancer cells close to microcalcifications expressed higher levels of bone mineralization markers as compared to cells found in breast lesions without microcalcifications. Notably, breast lesions with microcalcifications were characterized by the presence of breast-osteoblast-like cells. In depth studies of microcalcifications characteristics could support a new interpretation about the genesis of ectopic calcification in mammary tissue. Candidating this phenomenon as an integral part of the tumorigenic process therefore has the potential to improve the clinical management of patients early during their diagnostic path.

Inappropriateness of breast imaging: cost analysis

PurposeThe aim of this study was to assess how an incorrect indication for an examination may affect the diagnostic workup and diagnosis as well as healthcare expenditure.Materials and methodsWe considered all the requests for breast imaging (mammography, ultrasound and magnetic resonance imaging) received by our radiology department between October 2010 and December 2010, and assessed their appropriateness based on the patient’s age and the clinical question, if present. We then analysed the unnecessary costs resulting from inappropriate requests.ResultsOut of a total of 1500 requests for ultrasound examination, the request was appropriate in 855 (57%) cases; out of a total of 2350 requests for mammography, the request was appropriate in 493 (21%) cases; out of a total of 100 requests for magnetic resonance imaging, the request was appropriate in 83 (83%) cases. The cost deriving from inappropriate requests was 51,235.04 Euros.ConclusionsImproving the timeliness of diagnosis is an important goal to be pursued by enhancing the available health services, improving communication and coordination of the different professionals involved and optimising diagnostic pathways in order to reduce healthcare spending.RiassuntoObiettivoScopo del presente lavoro è stato valutare come, nella diagnostica senologica, una non corretta indicazione ad un esame possa influire sul percorso diagnostico, sulla diagnosi e sulla spesa sanitaria che ne deriva.Materiali e metodiAbbiamo preso in considerazione tutte le richieste di esami di diagnostica senologica [mammografia, ecografia e risonanza magnetica (RM)], giunte presso il Dipartimento di Diagnostica per Immagini dello IRCS, Policlinico Universitario di Tor Vergata, Roma, nel periodo compreso tra ottobre 2010 e dicembre 2010, valutandone la loro appropriatezza in base all’età delle pazienti ed al quesito clinico, quando presente: abbiamo quindi analizzato i costi inutili che ne sono derivati.RisultatiPer quanto concerne l’ecografia mammaria, abbiamo riscontrato che, su un totale di 1500 esami richiesti, in 855 casi (57%) la richiesta risultava inappropriata; delle 2350 richieste di mammografie il 21% (493 esami) è risultato inappropriato ed infine per gli esami di RM, delle 100 richieste ricevute, l’83% risultavano inappropriate. La spesa globale relativa all’inappropriatezza delle richieste prese in esame è stata di 51235,04 Euro.ConclusioniIl miglioramento della tempestività della diagnosi è un obiettivo rilevante da perseguire attraverso un potenziamento dei servizi sanitari a disposizione, tale da migliorare la comunicazione ed il coordinamento tra le diverse figure professionali specialistiche interessate, al fine di ottimizzare i percorsi diagnostici con conseguente diminuzione della spesa sanitaria.