E. Regini

Role of sonoelastography in characterising breast nodules. Preliminary experience with 120 lesions

PurposeThis study was performed to evaluate the diagnostic accuracy of sonoelastography in differentiating and characterising nodular breast lesions.Materials and methodsA total of 120 nodular lesions diagnosed on mammography and/or ultrasonography in 110 women (mean age 51.27 years) were evaluated with sonoelastography and classified according to elasticity score (S1–S5). Needle biopsy was performed in 104/120 cases, whereas 16/120 were sent for follow-up. Sensitivity and specificity of sonoelastography were determined by taking biopsy findings as the gold standard.ResultsBiopsy yielded the following results: 66 benign, three equivocal and 35 malignant lesions. Sensitivity and specificity of sonoelastography were, respectively, 88.5% and 92.7%. All nodules with an elasticity score of 5 were malignant, and those with a score ≤3 were benign, with the exception of four cases of invasive carcinoma with atypical elasticity (two lobular and two ductal with liquefaction necrosis). Twenty-two lesions were scored 4: 17 were malignant, two equivocal (columnar cell hyperplasia and complex sclerosing lesion) and three benign (sclerotic fibroadenomas).ConclusionsThe use of sonoelastography to complement mammography and ultrasonography could help in the differential diagnosis of nodular breast lesions, especially in Breast Imaging Reporting Data System (BI-RADS) 3 lesions with marked elasticity (S≤3). In these cases, the high concordance between elastography and cytology or histology in diagnosing benign lesions could reduce the number of needle biopsies and guide women at low radiological risk towards follow-up.RiassuntoObiettivoValutare l’accuratezza dell’elastosonografia nella differenziazione e caratterizzazione dei noduli mammari.Materiali e metodiValutazione con elastosonografia di 120 lesioni nodulari (classificate con score elastico (S1–S5) diagnosticate mammograficamente e/o ecograficamente in 110 donne (età media 51,27 anni). Sono state sottoposte ad agobiopsia 104/120 lesioni, mentre in 16/120 casi e stato scelto il follow-up. La sensibilità e la specificità dell’elastosonografia sono state calcolate assumendo i risultati anatomopatologici come gold standard.RisultatiL’esito dei 104 prelievi è stato: 66 benigni, 3 dubbi, 35 maligni. La sensibilità e specificità dell’elastosonografia sono risultate rispettivamente del 88,5% e del 92,7%. Tutti i noduli S5 sono risultati maligni mentre quelli con S≤3 sono tutti risultati benigni, eccetto quattro casi di carcinomi infiltranti con elasticità atipica (2 lobulari e 2 duttali con necrosi colliquativa). Le 22 lesioni S4 sono risultate: 17 maligne, 2 dubbie (iperplasia a cellule colonnari e lesione sclerosante complessa), 3 benigne (fibroadenomi sclerotici).ConclusioniL’elastosonografia utilizzata come metodica complementare alla mammografia ed all’ecografia consente un’accurata diagnosi differenziale dei noduli mammari, specialmente nelle lesioni Breast Imaging Reporting Data System (BI-RADS) 3 dotate di elevata elasticità (S≤3). L’alta concordanza tra le caratteristiche elastiche ed il riscontro anatomopatologico di benignità potrebbe evitare il prelievo agobioptico indirizzando verso il follow-up nei casi con basso rischio radiologico.

Digital breast tomosynthesis as an adjunct to digital mammography for detecting and characterising invasive lobular cancers: a multi-reader study

AIM To examine the interpretive performance of digital breast tomosynthesis (DBT) as an adjunct to digital mammography (DM) compared to DM alone in a series of invasive lobular carcinomas (ILCs) and to assess whether DBT can be used to characterise ILC. MATERIALS AND METHODS A retrospective, multi-reader study was conducted of 83 mammographic examinations of women with 107 newly diagnosed ILCs ascertained at histology. Consenting women underwent both DM and DBT acquisitions. Twelve radiologists, with varying mammography experience, interpreted DM images alone, reporting lesion location, mammographic features, and malignancy probability using the Breast Imaging-Reporting and Data System (BI-RADS) categories 1-5; they then reviewed DBT images in addition to DM, and reported the same parameters. Statistical analyses compared sensitivity, false-positive rates (FPR), and interpretive performance using the receiver operating characteristics (ROC) curve and the area under the curve (AUC), for reading with DM versus DM plus DBT. RESULTS Multi-reader pooled ROC analysis for DM plus DBT yielded AUC=0.89 (95% confidence interval [CI]: 0.88-0.91), which was significantly higher (p<0.0001) than DM alone with AUC=0.84 (95% CI: 0.82-0.86). DBT plus DM significantly increased pooled sensitivity (85%) compared to DM alone (70%; p<0.0001). FPR did not vary significantly with the addition of DBT to DM. Interpreting with DBT (compared to DM alone) increased the correct identification of ILCs depicted as architectural distortions (84% versus 65%, respectively) or as masses (89% versus 70%), increasing interpretive performance for both experienced and less-experienced readers; larger gains in AUC were shown for less-experienced radiologists. Multifocal and/or multicentric and bilateral disease was more frequently identified on DM with DBT. CONCLUSION Adding DBT to DM significantly improved the accuracy of mammographic interpretation for ILCs and contributed to characterising disease extent.

Efficacy and cost-effectiveness of stereotactic vacuum-assisted core biopsy of nonpalpable breast lesions: analysis of 602 biopsies performed over 5 years

PurposeThe authors sought to evaluate the diagnostic accuracy and cost-effectiveness of vacuum-assisted core biopsy (VACB) in comparison with diagnostic surgical excision for characterisation of nonpalpable breast lesions classified as Breast Imaging Reporting and Data System (BI-RADS) categories R3 and R4.Materials and methodsFrom January 2004 to December 2008, we conducted 602 stereotactic, 11-gauge, VACB procedures on 243 nonpalpable breast lesions categorised as BI-RADS R3, 346 categorised as BI-RADS R4 and 13 categorised as BI-RADS R5. We calculated the diagnostic accuracy and cost savings of VACB by subtracting the cost of the stereotactic biopsy from that of the diagnostic surgical procedure.ResultsA total of 56% of the lesions were benign and required no further assessment. Lesions of uncertain malignant potential (B3) (23.6%) were debated at multidisciplinary meetings, and diagnostic surgical biopsy was recommended for 83.1% of them. All malignant lesions (B4 and B5) underwent surgical excision. VACB had a sensitivity of 94.9%, specificity of 98.3% and diagnostic accuracy of 97.7%. The cost savings per VACB procedure were 464.00 euro; by obviating 335 surgical biopsies, the overall cost savings was 155,440.00 euro over 5 years.ConclusionsVACB proved to have high diagnostic accuracy for characterising abnormalities at low to intermediate risk of malignancy and obviated surgical excision in about half of the cases, allowing for considerable cost savings.RiassuntoObiettivoValutare l’accuratezza diagnostica ed il vantaggio economico della biopsia percutanea vacuum assistita (VACB) rispetto alla biopsia diagnostica chirurgica nella caratterizzazione di lesioni non palpabili classificate in base al Breast Imaging Reporting and Data System (BI-RADS) come R3 e R4.Materiali e metodiTra gennaio 2004 e dicembre 2008, sono state eseguite 602 VACB con ago da 11 G, sotto guida stereotassica, su 243 lesioni classificate come BI-RADS R3, 346 come BI-RADS R4 e 13 come BI-RADS R5. Sono stati calcolati l’accuratezza diagnostica ed il risparmio effettivo derivante dalla procedura, sottraendo al costo del rimborso della biopsia chirurgica quello per la VACB.RisultatiIl 56% delle lesioni sono risultate benigne e non hanno richiesto ulteriori interventi. Le lesioni B3 (23,6%) sono state discusse in sessioni multidisciplinari; di queste l’83,1% è stato sottoposto a verifica chirurgica, come tutte le lesioni risultate B4 e B5. La sensibilità della VACB è stata del 94,9%, la specificità 98,3% e l’accuratezza diagnostica 97,7%. La VACB ha consentito un risparmio di 464,00 euro a procedura; essendo state evitate 335 biopsie chirurgiche, il risparmio complessivo in cinque anni è risultato di 155440,00 euro.ConclusioniLa VACB è risultata metodica accurata nella caratterizzazione di lesioni a basso e medio rischio, evitando l’intervento chirurgico in oltre la metà dei casi con un effettivo risparmio economico.

Breast calciphylaxis following coronary artery bypass grafting completely resolved with total parathyroidectomy

A 58-year-old woman arrived at our institution complaining of progressive increase of local inflammatory symptoms at her left breast, unresponsive to a 10-day antibiotic treatment. Her clinical history included: subtotal thyroidectomy for goiter, diabetes mellitus, obesity, cardiovascular diseases and a 10-year haemodialitic treatment for chronic kidney disease. Recently, she had undergone coronary artery bypass grafting using left internal mammary artery, complicated with mediastinitis. On physical examination, the left breast presented an erythematous skin aspect, with slight ‘‘peau d’orange’’ in the internal regions, bordering the areola. A lump (about 2 cm of diameter), with intermediatehard consistence, was palpable at the inferior-internal quadrant of the breast. No nipple discharge was detected and the right breast was normal. The patient denied any other symptom. Mammography showed no specific changes, except for multiple and diffuse bilateral calcifications with dystrophic or vascular morphology (Fig. 1a–d). Ultrasound examination evidenced only echostructural changes indicative of tissue edema (Fig. 1e) rather than an inflammatory carcinoma in the area of the palpable mass and no pathologic lymph node in the axilla. At color-power Doppler, the vascular pattern of the region showed no significant alteration. After a week, the patient developed an ulceration and necrosis of the contours of the breast mass (Fig. 2) and other multiple cutaneous plaques of necrosis on her left leg, associated with intolerable pain (unresponsive to standard analgesics), normal white blood cell count, an upper limit serum levels of C-reactive protein and increased levels of calcium (5.54 mEq ⁄ L), phosphorus (5 mg ⁄ dL) and parathyroid hormone (774 pg ⁄ mL). Ultrasound-guided core-needle biopsy (14 G) was performed to differentiate the breast mass from a malignant lesion and to take a small skin fragment. The histological examination, revealing extensive foci of recent fat necrosis and fibrosis, resulted in calciphylaxis. Numerous calcium deposits in the vessel walls and calcifications of non-vascular tissues were associated. A subsequent total parathyroidectomy normalized rapidly the secondary hyperparathyroidism and led to a significant reduction of the pain. A complete healing of the cutaneous breast lesion occurred in a 2-month period (Fig. 3). Two years later the follow-up confirmed the good outcome of the treatment: the residual scar in the breast is smooth and the surrounding skin has normal aspect (Fig. 4). Mammography demonstrated vascular and dystrophic calcifications not significantly modified from the previous control; the left breast only presents a structural retraction in correspondence of the cutaneous scar (Fig. 5). Address correspondence and reprint requests to: Dott. Pier Paolo Campanino, Istituto di Radiologia Diagnostica ed Interventistica, Università di Torino, ASOU San Giovanni Battista di Torino, Sede Molinette, Via Genova 3 – 10126 Torino, Italy, or e-mail: piercamp66@alice.it.

Breast cancer surveillance in patients treated by radiotherapy for Hodgkin’s lymphoma

PurposeThe authors evaluated the relative risk of developing radiation-induced breast cancer (BC) in women treated with radiotherapy for Hodgkin’s disease (HD) and analysed the imaging features of these breast neoplasms.Materials and methodsWe retrospectively studied 54 women who had all undergone radiotherapy between 1980 and 2010 (median age, 36.6 years). Women aged ≤30 years were screened with clinical breast examination, ultrasound (US) and, if necessary, mammography; women >30 years had clinical breast examination, US and mammography. Three women underwent magnetic resonance (MR) imaging as well.ResultsMammography detected seven invasive breast cancers in 6/54 women (11.1%). Median age at diagnosis was 26.1 years for HD and 42.4 for breast cancer. Breast cancer was diagnosed following a median latent period from radiotherapy of 15.1 years. Mean radiation dose was 37.6 Gy in women who developed breast cancer and 31.3 Gy in the other women.ConclusionsIn our study, women who were exposed to radiation for HD had a 6.2-fold higher risk of developing breast cancer than the general population. In consideration of the young age and high breast density, women aged ≤30 years should be monitored by US and MR imaging; women aged >30 years should be monitored by US, mammography and, when necessary, MR imaging.RiassuntoObiettivoScopo del presente lavoro è stato valutare il rischio relativo di sviluppare neoplasie mammarie in donne radiotrattate per linfoma di Hodgkin (LH) e la presentazione all’imaging convenzionale dei tumori mammari radioindotti.Materiali e metodiIl presente è uno studio retrospettivo condotto su 54 donne che tra il 1980 e il 2010 sono state sottoposte a radioterapia per LH (età media 36,6 anni). Le pazienti con meno di 30 anni hanno effettuato visita clinica, ecografia e mammografia quando indicata, quelle con più di 30 anni visita clinica, ecografia e mammografia. Sono state sottoposte a risonanza magnetica (RM) 3 pazienti.RisultatiSono stati rilevati 7 carcinomi infiltranti della mammella mediante mammografia in 6/54 donne (11,1%). L’età media alla diagnosi è stata di 26,1 anni per LH e di 42,4 per tumore mammario. L’intervallo medio intercorso tra trattamento radioterapico e sviluppo di neoplasia mammaria è stato 15,1 anni. La dose media di radiazioni somministrata nelle donne che hanno sviluppato neoplasia mammaria è stata di 37,6 Gy, nelle altre 31,3 Gy.ConclusioniNel nostro studio, una donna radiotrattata per LH presenta un rischio 6,2 volte superiore rispetto alla popolazione generale di sviluppare un carcinoma mammario. Considerando giovane età e densità mammaria, le pazienti con meno di 30 anni dovrebbero essere sottoposte ad ecografia e RM, mentre quelle con più di 30 anni a mammografia ed ecografia, con eventuale RM, quando necessaria.

B3 core biopsies should be assumed as positive findings for accuracy purposes

The paper by Luparia et al. [1] recently published in “La Radiologia Medica” and dealing with vacuum-assisted breast core biopsy (VAB) suggested me some comments. Apart from uncommon pathological fi gures, such as B3 high prevalence (23.6% as compared to 9-10% average literature fi gures) and a subsequent low positive predictive value (PPV, 4.2% as compared to 25-30% average literature fi gures), or a null PPV for a few B4 cases, I would like to comment on the criteria adopted to assess VAB accuracy. In particular, assuming B3 fi ndings as “negative” is uncommon, as they are currently assumed as “positive” in the literature [2, 3] and usually referred for surgical confi rmation [3]. I admit that a debate is still ongoing on which, if any, subset of B3 cases might be simply followed-up, such as special histological subtypes (e.g. papillary lesions and radial scars) and/ or B3 without atypias, and I understand that the authors, due to the low PPV of their B3 cases, chose for collegial discussion to decide upon surgical confi rmation. However, since they still referred to surgery 83% of B3 cases, it seems confi rmed that B3 were dealt with as “suspicious” cases, that means “positive” for accuracy assessment purposes. Thus it would be more comparable with the current literature (as the authors do in a specifi c Table) if actual results would report 100% sensitivity and 70.2% specifi city. Of course the authors may also comment on a hipotetical scenario where B3 are not sent for surgery, consistent with 94.9% sensitivity and 98.3 specifi city. B3 core biopsies should be assumed as positive fi ndings for accuracy purposes