Elisabetta Giannotti

Radial scar without associated atypical epithelial proliferation on image-guided 14-gauge needle core biopsy: Analysis of 49 cases from a single-centre and review of the literature

The purpose of this study was to evaluate the reliability of image-guided 14-gauge needle core biopsy in the diagnosis of radial scar without associated atypical epithelial proliferation, by comparison with definitive histological diagnosis on surgical excision. The records of 8792 consecutive image-guided 14-gauge needle core biopsy of the breast performed from January 1996 to December 2009 were reviewed. Forty-nine cases of radial scar without associated atypical epithelial proliferation were identified and compared with definitive histological diagnosis on surgical excision. The definitive histological diagnosis on surgical excision confirmed the results of image-guided 14-gauge needle core biopsy in 36 of 49 cases (73.5%), in 9 cases (18.3%) radial scar was associated with atypical epithelial proliferation, while 4 cases out of 49 cases were upgraded to carcinoma (3 cases of ductal carcinoma in situ and one case of invasive lobular carcinoma), with an underestimation rate of 8.2%. A diagnosis of radial scar without associated atypical epithelial proliferation on image-guided 14-gauge needle core biopsy does not exclude a malignancy on surgical excision; consequently during the multidisciplinary discussion further assessment by surgical excision or vacuum-assisted excision, as recently reported, needs to be considered to obtain a definitive histological diagnosis.

Role of preoperative breast MRI in ductal carcinoma in situ for prediction of the presence and assessment of the extent of occult invasive component

Ductal carcinoma in situ (DCIS) is a common neoplasm that may be associated with focal invasive breast cancer lesions. The aim of our study was to evaluate the role of preoperative magnetic resonance imaging (MRI) in determining occult invasive presence and disease extent in patients with preoperative diagnosis of pure DCIS. We analyzed 125 patients with postoperative pure DCIS (n = 91) and DCIS plus invasive component (n = 34). Diagnostic mammography (MRX) showed a size underestimation rate of 30.4% while MRI showed an overestimation rate of 28.6%. Comparing the mean absolute error between preoperative MRI and MRX evaluations and final disease extent, MRI showed an improved accuracy of 51.2%. In our analysis preoperative breast MRI showed a better accuracy in predicting postoperative pathologic extent of disease, adding strength to the growing evidences that preoperative MRI can lead to a more appropriate management of DCIS patients.

Influence of region of interest size and ultrasound lesion size on the performance of 2D shear wave elastography (SWE) in solid breast masses

AIM To evaluate the influence of the region of interest (ROI) size and lesion diameter on the diagnostic performance of 2D shear wave elastography (SWE) of solid breast lesions. MATERIALS AND METHODS A study group of 206 consecutive patients (age range 21-92 years) with 210 solid breast lesions (70 benign, 140 malignant) who underwent core biopsy or surgical excision was evaluated. Lesions were divided into small (diameter <15 mm, n=112) and large lesions (diameter ≥15 mm, n=98). An ROI with a diameter of 1, 2, and 3 mm was positioned over the stiffest part of the lesion. The maximum elasticity (Emax), mean elasticity (Emean) and standard deviation (SD) for each ROI size were compared to the pathological outcome. Statistical analysis was undertaken using the chi-square test and receiver operating characteristic (ROC) analysis. RESULTS The ROI size used has a significant impact on the performance of Emean and SD but not on Emax. Youdens indices show a correlation with the ROI size and lesion size: generally, the benign/malignant threshold is lower with increasing ROI size but higher with increasing lesion size. CONCLUSIONS No single SWE parameter has superior performance. Lesion size and ROI size influence diagnostic performance.

Anisotropy of Solid Breast Lesions in 2D Shear Wave Elastography is an Indicator of Malignancy.

RATIONALE AND OBJECTIVES To investigate if anisotropy at two-dimensional shear wave elastography (SWE) suggests malignancy and whether it correlates with prognostic and predictive factors in breast cancer. MATERIALS AND METHODS Study group A of 244 solid breast lesions was imaged with SWE between April 2013 and May 2014. Each lesion was imaged in radial and in antiradial planes, and the maximum elasticity, mean elasticity, and standard deviation were recorded and correlated with benign/malignant status, and if malignant, correlated with conventional predictive and prognostic factors. The results were compared to a study group B of 968 solid breast lesions, which were imaged in sagittal and in axial planes between 2010 and 2013. RESULTS Neither benign nor malignant lesion anisotropy is plane dependent. However, malignant lesions are more anisotropic than benign lesions (P ≤ 0.001). Anisotropy correlates with increasing elasticity parameters, breast imaging-reporting and data system categories, core biopsy result, and tumor grade. Large cancers are significantly more anisotropic than small cancers (P ≤ 0.001). The optimal anisotropy cutoff threshold for benign/malignant differentiation of 150 kPa(2) achieves the best sensitivity (74%) with a reasonable specificity (63%). CONCLUSIONS Anisotropy may be useful during benign/malignant differentiation of solid breast masses using SWE. Anisotropy also correlates with some prognostic factors in breast cancer.

Phyllodes tumours of the breast diagnosed as B3 category on image-guided 14-gauge core biopsy: analysis of 51 cases from a single institution and review of the literature.

AIMS Image-guided 14-gauge (G) core biopsy (CB) has been shown to be an accurate method providing histological diagnosis of breast lesions. The purpose of this study was to evaluate the reliability of image-guided 14-G CB in the diagnosis of phyllodes tumours (PT) reported as B3 category and its accuracy in distinguishing this lesion from fibroadenomas (FA). MATERIALS AND METHODS The records of 10 000 image-guided 14-G CB of the breast performed from January 2001 to August 2011 at the Diagnostic Senology Unit of Careggi University Hospital were reviewed; 2554 (25.5%) were fibroepithelial lesions: 56 of them (2%) were diagnosed as PT and reported as B3 category. The database of the Pathological Anatomy Unit of Careggi University Hospital was then searched to verify the histological diagnosis after surgical excision. Fifty-one cases of PT diagnosed as B3 category in 51 women were included in the present study. RESULTS Of the 51 cases of PT diagnosed as B3 category on 14-G CB, 39 (76.5%) lesions were confirmed as PT on SE (30, 4 and 5 as benign, borderline and malignant PT respectively) with a PPV of 76.5%. Twelve lesions (23.5%) were diagnosed as FA after surgical excision. CONCLUSIONS Our study shows that 14-G CB is a valuable tool, in a preoperative setting, in diagnosing PT.

Shear-wave elastography and greyscale assessment of palpable probably benign masses: is biopsy always required?

OBJECTIVE To establish if palpable breast masses with benign greyscale ultrasound features that are soft on shear-wave elastography (SWE) (mean stiffness <50 kPa) have a low enough likelihood of malignancy to negate the need for biopsy or follow-up. METHODS The study group comprised 694 lesions in 682 females (age range 17-95 years, mean age 56 years) presenting consecutively to our institution with palpable lesions corresponding to discrete masses at ultrasound. All underwent ultrasound, SWE and needle core biopsy. Static greyscale images were retrospectively assigned Breast Imaging Reporting and Data System (BI-RADS) scores by two readers blinded to the SWE and pathology findings, but aware of the patients age. A mean stiffness of 50 kPa was used as the SWE cut-off for calling a lesion soft or stiff. Histological findings were used to establish ground truth. RESULTS No cancer had benign characteristics on both modalities. 466 (99.8%) of the 467 cancers were classified BI-RADS 4a or above. The one malignant lesion classified as BI-RADS 3 was stiff on SWE. 446 (96%) of the 467 malignancies were stiff on SWE. No cancer in females under 40 years had benign SWE features. 74 (32.6%) of the 227 benign lesions were BI-RADS 3 and soft on SWE; so, biopsy could potentially have been avoided in this group. CONCLUSION Lesions which appear benign on greyscale ultrasound and SWE do not require percutaneous biopsy or short-term follow-up, particularly in females under 40 years. ADVANCES IN KNOWLEDGE None of the cancers had benign characteristics on both greyscale ultrasound and SWE, and 32% of benign lesions were BI-RADS 3 and soft on SWE; lesions that are benign on both ultrasound and SWE may not require percutaneous biopsy or short-term follow-up.

Pilomatrixoma of the breast, a rare lesion simulating breast cancer: a case report.

Pilomatrixoma or calcifying epithelioma of Malherbe is a rare, benign, skin tumour originating from piliferous follicles; breast localization is considered to be very rare. These lesions can origin from the peri-areolar piliferous bulbs and, due to the clinical and imaging features, be easily misdiagnosed as a breast neoplasm. We present a case of pilomatrixoma of the left breast in a woman of 43 years appearing as a firm, deep nodule in the external quadrants. The lesion had mammographic and sonographic malignant features, but histological analysis on core-needle biopsy and surgical specimens revealed this unusual benign lesion.

Fourier domain and high frame rate based elastography for breast nodules investigation

The malignant/benign characterization of breast nodules represents a main concern in current senology diagnostic practice. Investigation through manual palpation and B-mode imaging plays a major role, but the attainable specificity is still too low. Several studies show that elastography could help reducing false positive cases. In freehand elastography the probe is manually moved to produce an axial compression in the tissue to be investigated. The axial strain tensor is then estimated by calculating the gradient of the produced displacement. A new elastography method, based on a Fourier domain displacement estimator and a high frame-rate averaging technique, has been recently shown to produce robust strain estimates on phantoms compressed with computer control. In this study we extend the test of this method to in-vivo investigation on breast. Results of the investigation of 6 malignant and 10 benign lesions in 11 patients aged between 30 and 84 are reported.

The Evolving Role of Ultrasound Guided Percutaneous Laser Ablation in Elderly Unresectable Breast Cancer Patients: A Feasibility Pilot Study

Background and Objectives Breast-conserving surgery represents the standard of care for the treatment of small breast cancers. However, there is a population of patients who cannot undergo the standard surgical procedures due to several reasons such as age, performance status, or comorbidity. Our aim was to investigate the feasibility and safety of percutaneous US-guided laser ablation for unresectable unifocal breast cancer (BC). Methods Between December 2012 and March 2017, 12 consecutive patients underwent percutaneous US-guided laser ablation as radical treatment of primary inoperable unifocal BC. Results At median follow-up of 28.5 months (range 6-51), no residual disease or progression occurred; the overall success rate for complete tumor ablation was therefore 100%. No significant operative side effects were observed, with only 2 (13.3%) experiencing slight to mild pain during the procedure, and all patients complained of a mild dull aching pain in the first week after procedure. Conclusions Laser ablation promises to be a safe and feasible approach in those patients who are not eligible to the standard surgical approach. However, longer follow-up results and larger studies are strongly needed.

Radiological anatomy of the breast

Breast cancer is the most frequent cancer site in women (28.8% of all cancer sites), the seconc most common in the world with an estimated 1.67 million new cases diagnosed in 2012 (25% of all cancers) and an estimated lifetime risk of 1/9 women. It is the fifth cause of tumor death overall (7.5%) and the first in women. Diagnostic senology has the purpose of the early diagno sis of breast cancer. The aim of this paper is to evaluate the role of all imaging techniques in studying the norma morphological anatomy of the breast. Knowing the normal anatomy of the breast is essentia to integrate all available imaging techniques in order to distinguish normal from pathologica structures.