Eva C. Gombos

Brava and Autologous Fat Transfer Is a Safe and Effective Breast Augmentation Alternative: Results of a 6-year, 81-patient, Prospective Multicenter Study

Background: Breast augmentation by autologous fat transfer is an appealing alternative in need of scientific validation. Methods: In a prospective multicenter study, 81 women (age range, 17 to 63 years) wore the Brava device, a bra-like vacuum-based external tissue expander, for 4 weeks and then underwent autologous fat injection using 10 to 14 needle puncture sites into each breast in a three-dimensional fanning pattern (average, 277 ml volume injected per breast). Patients resumed Brava wear within 24 hours for 7 or more days. Pretreatment and posttreatment breast volumes were derived from three-dimensional volumetric reconstruction of magnetic resonance imaging scans, and outcomes were compared with a meta-analysis of six recent published reports on autologous fat transfer breast augmentation without expansion. Follow-up ranged from 12 months to 6 years (average, 3.7 years). Results: Breast volume was unchanged between 3 and 6 months. Seventy-one of the treated women were compliant with Brava wear and had a mean augmentation volume at 12 months of 233 ml per breast compared with 134 ml per breast in published series without Brava (p < 0.00001). Graft survival was 82 ± 18 percent compared with 55 ± 18 percent without Brava (p < 0.00001). There was a strong linear correlation (R 2 = 0.87) between pregrafting Brava expansion and the resultant breast augmentation. There were no suspicious breast masses or nodules. Magnetic resonance imaging recognized a 16 percent incidence of fat necrosis easily identified at 1-year mammographic evaluation. Conclusion: The addition of Brava expansion before autologous fat grafting leads to significantly larger breast augmentations, with more fat graft placement, higher graft survival rates, and minimal graft necrosis or complications, demonstrating high safety and efficacy for the procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Breast MRI in the Evaluation of Eligibility for Accelerated Partial Breast Irradiation

OBJECTIVE Eligibility for accelerated partial breast irradiation is generally determined by physical examination in conjunction with conventional imaging techniques such as mammography and breast sonography. MRI is recognized as a significant imaging tool in diagnosing breast cancer and has shown the ability to identify mammographically occult carcinoma. Our purpose was to retrospectively assess preoperative breast MRI examinations in women with early-stage breast cancer who were theoretically eligible for accelerated partial breast irradiation and to explore the use of MRI in selecting patients for this treatment. MATERIALS AND METHODS Seventy-nine patients with core needle biopsy-proven breast cancer, who were eligible candidates for breast-conserving surgery and accelerated partial breast irradiation, underwent bilateral breast MRI examinations. At review, the presence and location of occult tumor sites (detected on MRI only) were documented and subsequently correlated with pathology findings. RESULTS From 79 patients, a total of 126 suspicious areas, including the index tumors, were detected by MRI. Additional sites of cancer other than the index tumor were observed in 30 patients (38%). Of these, eight (10%) had an additional cancer in a different quadrant from the index tumor. CONCLUSION The treatment effect of whole-breast irradiation on microscopic tumor cells and on additional occult foci in other quadrants of the breast is lost with partial breast irradiation. Our results suggest that MRI before accelerated partial breast irradiation may be of benefit to patients to ensure they do not have multifocal or multicentric disease, remote from the lumpectomy bed.

Breast Focused Ultrasound Surgery With Magnetic Resonance Guidance

This paper will review the experience and current applications of magnetic resonance-guided focused ultrasound surgery (MRgFUS) for treatment of breast tumors. Because of the efficient screening mammography programs, most of the breast cancers diagnosed today in the United States and European Union are in early stage and are treated with limited surgery. The MRgFUS may offer an alternative treatment option to conventional surgical lumpectomy with the advantage of being a noninvasive procedure and potentially achieving a better cosmetic outcome. Selection of appropriate patients is of paramount importance. Additional studies are needed to determine the effectiveness of the MRgFUS tumor ablation and define its role as a replacement for surgical lumpectomy.

Factors That Impact the Duration of MRI-Guided Core Needle Biopsy

OBJECTIVE The purpose of our study was to determine which patient-related, target lesion-related, or procedure-related variables impact the duration of MRI-guided core needle breast biopsy. MATERIALS AND METHODS Between July 11, 2006, and September 26, 2007, data were collected for 75 single-target MRI-guided 9-gauge vacuum-assisted core needle biopsy procedures using a grid-guidance technique and performed at a single institution. The following variables were studied: MRI suite occupation time, number of operators, patient age and breast size, target morphology and location, approach to target, equipment used, number of image acquisitions and times the patient was moved in and out of the closed magnet, and occurrence of complications. Statistical analysis was performed using the Students t test, analysis of variance, and Pearsons correlation, with p values < 0.05 considered significant. RESULTS The mean duration was 57.9 minutes (SD, 17.2 minutes; range, 30-109 minutes). None of the patient- or target-related variables significantly impacted the duration, although lesions located in the anterior third of the breast showed a trend to prolong the procedure (p = 0.059). The time to complete a procedure was reduced when the operating radiologist was assisted by a breast imaging fellow-in-training (p = 0.01). Increasing numbers of image acquisitions and times the patient was moved in and out of the magnet significantly lengthened the procedure duration (p = 0.0001 for both). No major complications occurred. Biopsies yielded 16% (12/75) malignant and 84% (63/75) benign diagnoses. CONCLUSION Variables that minimized procedure duration were number of image acquisitions, number of patient insertions or removals from the magnet, and assistance of a breast imaging fellow-in-training. No patient-related or target-related variables impacted procedure time.

MR Imaging Assessment of the Breast after Breast Conservation Therapy: Distinguishing Benign from Malignant Lesions

Dynamic contrast material-enhanced magnetic resonance (MR) imaging has emerged as a valuable tool in evaluation of women who have undergone lumpectomy and whole-breast radiation therapy for breast cancer. Early diagnosis of local recurrence by means of close clinical and imaging follow-up is an important component of a breast-conserving strategy, as it may improve survival. In the post-breast conservation therapy (BCT) breast, resolving edema, fat necrosis, a small focal area of non-masslike enhancement (NMLE), and thin linear NMLE at the lumpectomy site can all be expected findings. In contrast, masslike enhancement or NMLE of ductal or segmental distribution can indicate recurrence. Therefore, at MR imaging of the post-BCT breast, it is important to identify lesions that are benign or appropriate for short-interval imaging surveillance to minimize unnecessary intervention, as well as to discern suspicious lesions and optimize the diagnosis of recurrence.

MRI Kinetics With Volumetric Analysis in Correlation With Hormonal Receptor Subtypes and Histologic Grade of Invasive Breast Cancers

OBJECTIVE. The aim of this study was to assess whether computer-assisted detection-processed MRI kinetics data can provide further information on the biologic aggressiveness of breast tumors. MATERIALS AND METHODS. We identified 194 newly diagnosed invasive breast cancers presenting as masses on contrast-enhanced MRI by a HIPAA-compliant pathology database search. Computer-assisted detection-derived data for the mean and median peak signal intensity percentage increase, most suspicious kinetic curve patterns, and volumetric analysis of the different kinetic patterns by mean percentage tumor volume were compared against the different hormonal receptor (estrogen-receptor [ER], progesterone-receptor [PR], ERRB2 (HER2/neu), and triple-receptor expressivity) and histologic grade subgroups, which were used as indicators of tumor aggressiveness. RESULTS. The means and medians of the peak signal intensity percentage increase were higher in ER-negative, PR-negative, and triple-negative (all p ≤ 0.001), and grade 3 tumors (p = 0.011). Volumetric analysis showed higher mean percentage volume of rapid initial enhancement in biologically more aggressive ER-negative, PR-negative, and triple-negative tumors compared with ER-positive (64% vs 53.6%, p = 0.013), PR-positive (65.4% vs 52.5%, p = 0.001), and nontriple-negative tumors (65.3% vs 54.6%, p = 0.028), respectively. A higher mean percentage volume of rapid washout component was seen in ERRB2-positive tumors compared with ERRB2-negative tumors (27.5% vs 17.9%, p = 0.020). CONCLUSION. Peak signal intensity percentage increase and volume analysis of the different kinetic patterns of breast tumors showed correlation with hormonal receptor and histologic grade indicators of cancer aggressiveness. Computer-assisted detection-derived MRI kinetics data have the potential to further characterize the aggressiveness of an invasive cancer.

Imaging Findings After Breast Brachytherapy

OBJECTIVE The purpose of this study was to determine whether there are imaging changes specific to partial breast radiation therapy with interstitial catheters or a single balloon. MATERIALS AND METHODS The records of 43 of 83 patients treated with partial breast irradiation at our institution from June 1996 to October 2003 were retrospectively reviewed. The images of 27 patients who had received radiation by interstitial catheters and 16 who had received radiation by a single balloon were reviewed. Patients were examined for the presence of skin thickening, diffuse and focal increased density, mass, lucency, and calcifications. Fifteen initial sonograms were ordered to evaluate pain or focal findings on mammograms. In addition, two patients underwent one and one patient underwent three follow-up sonographic examinations. RESULTS Mild to moderate skin thickening was present in 26 (60%) and no skin thickening in 17 (40%) of the 43 patients. Forty-one (95%) of the 43 patients had focal increased density. Diffuse increased density was seen in only one (2%) of the patients. There was no change in overall density in 2 (5%) of the patients. Fifteen (35%) of the 43 patients had mass or seroma at the first follow-up examination. Central lucency was present in 35 (81%) of 43 patients on at least one follow-up study. Calcification was present in 8 (19%) of 43 cases. CONCLUSION Imaging findings after breast brachytherapy include the spectrum of findings seen with external beam radiation but are more focal. The focal findings may be alarming both clinically and radiographically, but biopsy can be avoided in most instances if information from the history is correlated with findings from continued follow-up of the patients case.

MRI findings of radiation‐associated angiosarcoma of the breast (RAS)

To describe the magnetic resonance imaging (MRI) characteristics of radiation‐associated breast angiosarcomas (RAS).

Automatic segmentation of invasive breast carcinomas from dynamic contrast-enhanced MRI using time series analysis.

To accurately segment invasive ductal carcinomas (IDCs) from dynamic contrast‐enhanced MRI (DCE‐MRI) using time series analysis based on linear dynamic system (LDS) modeling.

Radiation-Associated Angiosarcoma of the Breast: What the Radiologist Needs to Know

OBJECTIVE The purpose of this article is to describe the diagnosis, treatment, and follow-up of radiation-associated angiosarcoma (RAS) of the breast. CONCLUSION Radiologists play an important role in the diagnosis of RAS, which may initially present clinically as erythema, ecchymosis, or skin thickening. Conventional imaging with mammography and ultrasound is less sensitive than MRI for the diagnosis of RAS. Follow-up CT is important to monitor treatment response.