Gian Marco Giuseppetti

Contrast-Enhanced Breast MRI in Patients with Suspicious Microcalcifications on Mammography: Results of a Multicenter Trial

OBJECTIVE The objective of our study was to test dynamic MRI in evaluating mammographically detected suspicious microcalcifications. MATERIALS AND METHODS One hundred twelve patients with mammographically detected microcalcifications with BI-RADS category 5 (n = 78) or 4 (n = 34) lesions were studied at 17 centers a using 3D gradient-echo dynamic coronal technique (< or = 3 mm thickness) and 0.1 mmol/kg of gadoteridol. A pathologic sample was obtained in all cases. Agreement between the major diameter measured on mammography, MRI, or both and the major diameter measured at pathologic examination was calculated in 62 cases. RESULTS Of the 112 lesions, pathologic examination revealed 37 benign lesions, 33 ductal carcinoma in situ (DCIS), and 42 invasive carcinomas. The specificity of MRI for benign lesions was 68%. Considering the subgroups of calcifications alone and calcifications associated with masses, the specificity values became 79% and 33%, respectively. The sensitivity of MRI for DCIS was 79%. Analysis of the two subgroups showed sensitivity values of 68% for calcifications alone and of 1% for calcifications associated with masses. The sensitivity for invasive carcinomas was 93%. Analysis of the two subgroups showed sensitivity values to be 92% for calcifications alone and 94% for calcifications associated with masses. Considering the overall results, the sensitivity of MRI was 87%; specificity, 68%; positive predictive value, 84%; negative predictive value, 71%; and accuracy, 80%. Considering the subgroups of calcifications alone and calcifications associated with masses, the sensitivity values became 80% and 97%; the positive predictive values, 86% and 82%; the negative predictive values, 71% and 75% (95% confidence interval [CI], 0.19-0.99); and the accuracy values, 80% and 82% (95% CI, 0.66-0.92), respectively. An odds ratio (OR) of 13.54 (95% CI, 5.20-35.28) showed a raised risk of malignant breast tumor in subjects with positive MR examination of mammographically detected suspicious clusters of microcalcifications. The statistical analysis on each subgroup showed an OR of 15.07 (95% CI, 4.73-48.08) for calcifications alone and an OR of 14.00 (95% CI, 1.23-158.84) for calcifications associated with masses. Any significant improvement in the predictive ability of dynamic MRI depending on the extent of calcifications on mammography was not proved. Considering the 62 cases of proved malignancy with measured maximal diameter at pathologic examination, both mammography and MR examination seem to overestimate tumor extent. CONCLUSION The not-perfect sensitivity of MRI (87%), when applying our interpretation criteria and imaging sequences, is a crucial point that prevents us from clinical use of MRI in the diagnosis of mammographically detected microcalcifications.

Comparative study of breast implant rupture using mammography, sonography, and magnetic resonance imaging: correlation with surgical findings.

Abstract:  Purpose of this study was to evaluate the accuracy of mammography, ultrasonography, and magnetic resonance imaging (MRI), in the detection of breast implant rupture and to make a correlation with findings at explantation. The study population consisted of 63 women with 82 implants, undergoing surgical explantation. Implant rupture status was blindly determined obtaining diagnosis of rupture, possible rupture, or intact implant. Strictly predetermined rupture criteria were applied and compared with findings at surgery, which were considered the gold standard. False‐positives and false‐negatives were retrospectively evaluated to identify pitfalls in the investigation. All associations between imaging signs and surgical findings were evaluated by using chi‐square test. The respective sensitivity and specificity of investigations are reported. Our experience suggests that MRI is the more accurate method for identification of breast implant rupture, even if it should be performed following the diagnostic algorithm proposed.

Color Doppler sonography

The authors report the results obtained with color Doppler sonography in the study of breast conditions. Color Doppler allows to detect the following main features in breast conditions: the presence of blood flow, vessel arrangement, vascularization extent, the number of vascular poles. To investigate slow flows, it is better to use low PRF values (not above 1 KHz) and low filters, while amplification should be set immediately above the systems noise threshold; the size of color Doppler box should be adjusted as small as possible to maximize sensitivity and minimize flash artifacts. In May 1992 to September 1997, 252 patients with solid breast masses were examined with mammography, B-mode, color Doppler and power Doppler sonography (only 57 cases). We identified histologically (176 cases) or cytologically (77 cases) 141 carcinomas and 112 benign solid lesions. The diameter of the 141 carcinomas ranged 0.4-4 cm (mean 1.7), while the diameter of benign lesions ranged 0.7-3 cm (mean 1.5). The malignancy pattern was characterized by hypervascularity (92.9%), irregular and abundant (54.2%) vascularization and more than one vascular pole. Benign lesions were avascular (43.4%) with poor and peripheral vascularity (90%) and mostly showed only one vascular pole. The avascular cancers (10 cases) were three mucoid, five in situ and two small (0.7 and 0.9 cm) invasive ductal carcinomas. The six benign lesions with irregular and abundant vascularization and more than one vascular pole were proved to be two proliferating and three juvenile fibroadenomas and one phylloid tumor. These results are encouraging and suggest that this technique can be a useful adjunct to mammography and sonography in the differential, diagnosis of breast nodules.

Indications for breast magnetic resonance imaging. Consensus document “Attualità in senologia”, Florence 2007

The clinical use of breast magnetic resonance (MR) imaging is increasing, especially for applications requiring paramagnetic contrast-agent injection. This document presents a synthetic list of acceptable indications with potential advantages for women according to evidence from the literature and the expert opinion of the panel that developed this statement. We generally recommend that breast MR imaging be performed in centres with experience in conventional breast imaging [mammography and ultrasonography (US)] and needle-biopsy procedures (under stereotactic or US guidance) as well as in breast MR imaging and second-look US for findings not revealed by conventional imaging performed before MR imaging. In our opinion, there is no evidence in favour of breast MR imaging as a diagnostic tool to characterise equivocal findings at conventional imaging when needle-biopsy procedures can be performed, nor for the study of asymptomatic, non-high-risk women with negative conventional imaging. After a description of technical and methodological requirements, we define the indications and limitations of breast MR imaging for surveillance of high-risk women, local staging before surgery, evaluation of the effect of neoadjuvant chemotherapy, breast previously treated for carcinoma, carcinoma of unknown primary syndrome, nipple discharge and breast implants.RiassuntoLa RM mammaria è in fase di crescente utilizzo clinico, soprattutto per le applicazioni che richiedono la somministrazione di mezzo di contrasto (MdC) paramagnetico. Il presente documento propone una codificazione sintetica delle indicazioni accettabili con potenziale vantaggio per le donne, secondo la valutazione delle evidenze presenti in letteratura e l’opinione del gruppo di esperti estensori del documento. In generale si raccomanda che l’indagine sia eseguita presso centri che siano in grado di combinare l’esperienza senologica relativa all’imaging convenzionale e ai prelievi agobioptici con quella specifica in RM mammaria e che garantiscano l’esecuzione del second look ecografico per i reperti non rilevati all’imaging convenzionale pre-RM. Non si ritiene che vi siano evidenze in favore dell’utilizzo della RM quale approccio diagnostico nella caratterizzazione di reperti equivoci all’imaging convenzionale in tutte le situazioni nelle quali sia praticabile il prelievo agobioptico sotto guida ecografica o stereotassica né in favore dello studio di donne non ad alto rischio asintomatiche e con imaging convenzionale negativo. Sono qui definiti i requisiti tecnici e metodologici di esecuzione dell’indagine e indicazioni e limiti relativi a: sorveglianza delle donne ad alto rischio di tumore mammario; stadiazione locale pretrattamento chirurgico; valutazione dell’effetto della chemioterapia neoadiuvante; mammella trattata per carcinoma; carcinoma unknown primary syndrome; mammella secernente; protesi mammarie.

What is the sensitivity of mammography and dynamic MR imaging for DCIS if the whole-breast histopathology is used as a reference standard?

Purpose. Our purpose was to compare mammography and dynamic contrast-enhanced magnetic resonance imaging (MRI) in the detection of ductal carcinoma in situ (DCIS)Materials and methods. Ninety patients (aged 58.6±16.1 years) who were candidates for unilateral (n=81) or bilateral (n=9) mastectomy underwent mammography and dynamic contrast-enhanced breast MRI using a coronal three-dimensional gradient-echo sequence with slice thickness ≤3 mm before and after intravenous injection of gadoteridol (0.1 mmol/kg). Mammographic and MR images were evaluated by two offsite readers working in consensus. Pathological examination performed on 5-mm sections covering the whole breast was used as a reference standardResults. Out of 99 breasts, pathology revealed 26 DCIS in 14 breasts of 14 patients, aged 52.0+_9.6 years. Lesion diameter at pathology was <5 mm (n=4); ≥5 and <10 mm (n=7); ≥10 and <20 mm (n=3); ≥20 mm (n=2); not assessed (n=10). Sensitivity was 35% (9/26) for mammography and 38% (10/26) for MRI (not significant difference, McNemar test). Both mammography and MRI provided a true positive result in seven cases (four of them measured at pathology, with a diameter of 20.0±12.9 mm; median 20 mm) and a false negative result in 14 cases (10 of them measured at pathology, with a diameter of 4.2±1.9 mm; median 4.6 mm) (p=0.024, Mann-Whitney U test). Only 46% (12/26) of DCIS were detected at mammography and/or MRI; the remaining 54% (14/26) were diagnosed only at pathological examinationConclusions. When the whole breast is used as the histopathological reference standard, both mammography and MRI show low sensitivity for DCISRiassuntoObiettivo . Confrontare la sensibilità per il carcinoma duttale in situ (DCIS) della mammografia e della risonanza magnetica (RM) con mezzo di contrastoMateriali e metodi . Novanta pazienti (età 58.6±16.1 anni) candidate alla mastectomia monolaterale (n=81) o bilaterale (n=9) sono state sottoposte a mammografia e RM a contrasto dinamico mediante sequenza tridimensionale coronale gradient-echo con spessore di strato ≤3 mm, prima e dopo iniezione endovenosa di gadoteridolo (0.1 mmol/kg). Mammografia e RM sono state valutate da due lettori off-site, in consenso. L’;esame istologico dell’;intera mammella (strati di 5 mm di spessore) ha rappresentato lo standard di riferimentoRisultati . L’esame istologico delle 99 mammelle ha evidenziato 26 DCIS in 14 mammelle di 14 pazienti (età 52.0±9.6 anni). All’esame istologico il diametro della lesione è risultato <5 mm (n=4); ≥5 e <10 mm (n=7); ≥10 e <20 mm (n=3); ≥20 mm (n=2); non valutato (n=10). La sensibilità è risultata del 35% (9/26) per la mammografia e del 38% (10/26) per la RM (differenza non significativa, test di McNemar). Mammografia e RM sono risultate entrambe vere positive in 7 casi (4 dei quali con diametro misurato istologicamente, pari a 20.0±12.9 mm, mediana 20 mm) ed entrambe false negative in 14 casi (10 dei quali con diametro misurato istologicamente, pari a 4.2±1.9 mm, mediana 4.6) (p=0.024, test U di Mann-Whitney). Solo il 46% (12/26) dei DCIS sono stati identificati alla mammografia e/o alla RM mentre il rimanente 54% (14/26) è stato riconosciuto solo all’esame istologicoConclusioni . Allorquando l’intera mammella è assunta come standard di riferimento istologico, sia la mammografia che la RM mostrano ridotta sensibilità per il DCIS

Chromium Exposure and Germinal Embryonal Carcinoma: First Two Cases and Review of the Literature

The aim of the study was to determine the potential role of occupational exposures to chromium (Cr) in the onset of extragonadal germinal embryonal carcinoma. The first two cases of workers in a company with Cr exposure are reported. The published scientific literature regarding the topic in peer-reviewed journals including MEDLINE and CancerLit databases was extensively reviewed. Two young patients who were coworkers in the same company, exposed to Cr, developed extragonadal germinal embryonal carcinomas. One of them also developed angiosarcoma of the mediastinum. To the best of our knowledge these are the first two cases of germinal embryonal carcinoma in patients with occupational exposure to Cr.

“CADEAT”: considerations on the use of CAD (computer-aided diagnosis) in mammography

Computer-aided diagnosis (CAD) has been extensively reported to increase sensitivity by about 10% when added to a single reading while increasing recall rate by 12%, and its current use can be safely recommended in clinical practice. CAD has been suggested as a possible alternative to conventional double reading in screening. Uncontrolled comparison is consistent and suggests that CAD is comparable to double reading in incremental cancer detection rate (CAD +10.6%, double reading +9.1%) and possibly better in recall rate (CAD +12.5%, double reading +28.8%). However, controlled studies comparing single reading + CAD to conventional double reading are not consistent and on average suggest a lower cancer detection rate (−5.1%) and a lower recall rate (−9.8%) for CAD. Scientific evidence is not sufficient for a safe recommendation of single reading + CAD as a current alternative to conventional double reading.RiassuntoEsiste consistente evidenza scientifica che la computer aided diagnosis (CAD), aggiunta alla lettura singola, consenta un aumento della sensibilità di circa il 10%, con un aumento del tasso di richiamo di circa il 12%: l’uso corrente di CAD nella pratica clinica è pertanto raccomandabile. La singola lettura insieme a CAD è stata suggerita come una possibile alternativa alla doppia lettura convenzionale nello screening. Confronti tra studi non controllati suggeriscono consistentemente che CAD sia comparabile alla doppia lettura quanto a tasso diagnostico incrementale di carcinoma (CAD +10,6%, doppia lettura +9,1%) e possibilmente superiore quanto a tasso di richiamo (CAD +12,5%, doppia lettura +28,8%). Al contrario, un numero limitato di studi controllati che confrontano la singola lettura+CAD con la doppia lettura non mostra risultati consistenti e in media riporta per CAD un minor tasso diagnostico incrementale di cancro (−5,1%) e un minor tasso di richiamo (−9,8%). L’evidenza scientifica disponibile non è sufficiente per raccomandare la lettura singola + CAD come alternativa corrente alla doppia lettura convenzionale.

Role of Contrast-Enhanced Sonography in the Evaluation of Axillary Lymph Nodes in Breast Carcinoma: A Monocentric Study.

To evaluate the diagnostic performance of contrast‐enhanced sonography for characterization of the lymph node status (metastatic or not) in patients with breast carcinomas by comparison with sentinel lymph node biopsy.

Evaluation of Multifocality and Multicentricity with Breast Magnetic Resonance Imaging in each breast cancer subtype

Introduction: The purpose of this study was to evaluate whether diagnostic performance of breast magnetic resonance imaging (MRI) for detection of multifocality and multicentricity (MFMC) of breast cancer (BC) can be influenced by different histotypes or immunophenotypes in newly diagnosed patients with breast cancer. Materials and Methods: In this institutional review board‐approved retrospective study, 289 patients who underwent both preoperative breast MRI and radical or modified mastectomy in our institution because of primary BCs were selected. Patients were stratified based on the pathologic report in 2 main histotypes and 5 immunophenotypes. By matching the radiologic report with the corresponding pathologic report for each patient, breast MRI performance for detection of MFMC were obtained in each histotype and immunophenotype and subsequently compared. Results: Overall breast MRI sensitivity for MFMC detection was 88.1%, specificity was 80.0%, positive predictive value 82.1%, negative predictive value 85.8%, diagnostic accuracy 83.7%, and area under the curve 0.835. Breast MRI sensitivity for MFMC detection in triple‐negative BC was 84.6% (P = .88), specificity 70.8% (P = .63), positive predictive value 61.1% (P = .02), negative predictive value 89.5% (P = .20), diagnostic accuracy 75.7% (P = .65), and area under the curve 0.777 (P = .87). Conclusion: Performance of breast MRI for the detection of MFMC are not influenced by the BC histotypes, in accordance with published literature. Conversely, the triple‐negative immunophenotypes demonstrated lower performance, statistically significant only for positive predictive value (P = .02), for the detection of MFMC.

Role of DCE-MR in predicting breast cancer subtypes

ObjectiveThe purpose of this retrospective study is to find a correlation between dynamic contrast-enhanced MR features with histological, immunohistochemical and loco-regional characteristics of breast cancer.Materials and methodsA total of 149 patients with histopathologically confirmed invasive breast carcinoma underwent MR imaging. Histological analysis included: histological features (histological type, necrosis, vascular invasion and Mib-1), immunohistochemical characterization (immunophenotype, receptor status, HER2-neu and grading) and loco-regional characteristics (T and N). The kinetic MR features analyzed were: curve type, maximum enhancement, time to peak, wash-in and wash-out rate, brevity of enhancement and area under curve.ResultsMRI kinetic parameters and immunohistological features were compared using chi square test, two-tailed student t test and Anova test, with p = 0.05 level of significance. Vascular invasion was shown to be significantly related to time to peak (p = 0.02). The immunohistotype was shown to be significantly related with maximum enhancement (p = 0.05), time to peak (p = 0.04) and wash-in rate (p = 0.01). ER status correlates with maximum and relative enhancement (p = 0.004 and p = 0.028), wash-in rate (p = 0.0018) and area under curve (p = 0.006). PR status was significantly related to time to peak (p = 0.048) and wash-in rate (p = 0.05).ConclusionMaximum enhancement absolute and relative, time to peak, wash-in rate and area under the curve significantly correlate with several prognostic factors, like ER status, immune profile and tumoral vascular invasion, and may predict the aggressiveness of the tumor.