Giovanna Mariscotti

A first evaluation of breast radiological density assessment by QUANTRA software as compared to visual classification

Breast radiological density is a determinant of breast cancer risk and of mammography sensitivity and may be used to personalize screening approach. We first analyzed the reproducibility of visual density assessment by eleven experienced radiologists classifying a set of 418 digital mammograms: reproducibility was satisfactory on a four (BI-RADS D1-2-3-4: weighted kappa = 0.694-0.844) and on a two grade (D1-2 vs D3-4: kappa = 0.620-0.851), but subjects classified as with dense breast would range between 25.1 and 50.5% depending on the classifying reader. Breast density was then assessed by computer using the QUANTRA software which provided systematically lower density percentage values as compared to visual classification. In order to predict visual classification results in discriminating dense and non-dense breast subjects on a two grade scale (D3-4 vs, D1-2) the best fitting cut off value observed for QUANTRA was ≤22.0%, which correctly predicted 88.6% of D1-2, 89.8% of D3-4, and 89.0% of total cases. Computer assessed breast density is absolutely reproducible, and thus to be preferred to visual classification. Thus far few studies have addressed the issue of adjusting computer assessed density to reproduce visual classification, and more similar comparative studies are needed.

Columnar cell lesions associated with breast calcifications on vacuum-assisted core biopsies: clinical, radiographic, and histological correlations.

Columnar cell lesions of the breast are increasingly recognized at mammography for their tendency to calcify. We studied 392 vacuum-assisted core biopsies performed solely for calcifications to evaluate the frequency of columnar cell lesions, their relationship with radiological risk, appearance of calcifications, and clinical data. Management and follow-up of columnar cell lesions without and with atypia (flat epithelial atypia) was analyzed. Cases with architectural atypia (cribriform spaces and/or micropapillae) were excluded from flat epithelial atypia. Calcifications were within the lumen of acini affected by columnar cell lesions in 137 out of 156 biopsies diagnosed with some columnar cell lesions. These represented 37% of vacuum-assisted core biopsies and 62% of low radiological risk (BI-RADS3) calcifications. High-risk (BI-RADS5) calcifications were never associated with columnar cell lesions. Age and menopausal status were comparable in columnar and in not-columnar cell lesions. Atypia was associated with long-term hormone replacement therapy in both lesions. Surgical biopsy was recommended for all cases with atypia. Flat epithelial atypia, as the only histological findings on vacuum-assisted core biopsies, was never associated with malignancy at surgery. In conclusion, we suggest that surgical excision is not mandatory when flat epithelial atypia is found as the most advanced lesion on vacuum-assisted core biopsy performed for low radiological risk calcifications, and that women should be advised of the possible hormone dependency of this entity.

Accuracy of tumour size assessment in the preoperative staging of breast cancer: comparison of digital mammography, tomosynthesis, ultrasound and MRI

PurposeAccurate measurement of breast tumour size is fundamental for treatment planning. We compared the accuracy of digital mammography (DM), digital breast tomosynthesis (DBT), ultrasound (US) and magnetic resonance imaging (MRI) for the preoperative evaluation of breast cancer size.Materials and methodsWe retrospectively reviewed 149 breast cancers in 110 patients who underwent DM, DBT, US and MRI between January 2010 and December 2011, before definitive surgery. The lesions were measured by two radiologists, without knowledge of the final histological examination, considered the gold standard. For each imaging modality, the maximum tumour size was measured to the nearest millimetre; the measurements were considered concordant if they were within ±5 mm. Pearson’s correlation coefficient was calculated for each imaging modality.ResultsThe median pathological tumour size was 22.3 mm. MRI and DBT had a level of concordance with pathology of 70% and 66%, respectively, which was higher than that of DM (54%). DBT and MRI measurements had a better correlation with pathological tumour size (R:0.89 and R:0.92, respectively) compared to DM (R:0.83) and US (R:0.77).ConclusionsDBT and MRI are superior to DM and US in the preoperative assessment of breast tumour size. DBT seems to improve the accuracy of DM, although MRI remains the most accurate imaging modality for breast cancer extension.RiassuntoObiettivoLa corretta valutazione pre-operatoria dell’estensione del carcinoma mammario è fondamentale nella pianificazione chirurgica-terapeutica. Scopo dello studio è stato confrontare l’accuratezza di mammografia digitale (DM), tomosintesi (DBT), ecografia (US) e risonanza magnetica (RM) nella valutazione preoperatoria delle dimensioni del tumore mammario rispetto all’istologia definitiva.Materiali e metodiSono stati valutati retrospettivamente 149 carcinomi in 110 pazienti, sottoposte a DM, DBT, US e RM prima dell’intervento chirurgico tra gennaio 2010 e dicembre 2011. Le lesioni sono state rivalutate e misurate da due radiologi non a conoscenza dell’estensione istologica. Le dimensioni valutate all’esame istologico sono state utilizzate come gold standard. Per ogni metodica, è stata valutata l’estensione massima tumorale; le misurazioni sono state considerate concordanti con l’istologia se comprese nei ±5 mm. è stato calcolato il coefficiente di correlazione di Pearson rispetto all’estensione istologica per ciascuna metodica.RisultatiIl diametro medio delle lesioni è stato 22,3 mm. RM e DBT hanno avuto rispettivamente una concordanza del 70% e 66% con l’istologia, superiore alla DM (54%). La DBT e l’RM hanno avuto un coefficiente di correlazione di Pearson con l’istologico definitivo(R: 0,89 e R: 0,92 rispettivamente) più elevato rispetto a DM (R: 0,83) e US (R: 0,77).ConclusioniDBT e RM sono risultate superiori a DM e US nella valutazione pre-operatoria dell’estensione tumorale. L’impiego della DBT sembra implementare i risultati della DM, sebbene l’RM rimanga la metodica di riferimento.

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.

Efficiency of a preoperative axillary ultrasound and fine-needle aspiration cytology to detect patients with extensive axillary lymph node involvement.

Background Recent studies have demonstrated that axillary lymph node dissection (ALND) does not affect patient survival, even in those with one or two positive sentinel lymph nodes (SLNs). On the other hand, patients with 3 or more metastatic lymph nodes are eligible for chemotherapy. Therefore, it is crucial to identify a priori patients at risk of having a high number of metastatic axillary lymph nodes for their surgical and/or clinical management. Ultrasound (US) guided Fine-Needle Aspiration (FNA) has been proven to be a useful and highly specific method for detecting metastatic axillary lymph nodes. However, only one recent study has evaluated the efficiency of this method in identifying patients with high metastatic nodal involvement. Our aim was to validate US-guided FNA as a reliable method to discriminate a priori patients with >3 metastatic lymph nodes. Methods A retrospective series of 1287 breast cancer patients who underwent a simultaneous preoperative breast and axillary US to stage their axilla was collected. A total of 365 patients, with either positive SLNs (278) or positive axillary lymph nodes detected via US-guided FNA (87), underwent ALND. In these two subgroups, we compared the number of metastatic lymph nodes in the axilla. Results The number of metastatic axillary lymph nodes in patients who underwent US-guided FNA was significantly higher (63% had >3 metastatic lymph nodes) than that in patients with SLNs positive for micro- or macrometastases (3% and 27%, respectively) (P<0.001, χ 2 = 117.897). Conclusions Preoperative axillary US-guided FNA could act as a reliable tool in identifying breast cancer patients with extensive nodal involvement.

Breast Cancer: Computer-aided Detection with Digital Breast Tomosynthesis.

PURPOSE To evaluate a commercial tomosynthesis computer-aided detection (CAD) system in an independent, multicenter dataset. MATERIALS AND METHODS Diagnostic and screening tomosynthesis mammographic examinations (n = 175; cranial caudal and mediolateral oblique) were randomly selected from a previous institutional review board-approved trial. All subjects gave informed consent. Examinations were performed in three centers and included 123 patients, with 132 biopsy-proven screening-detected cancers, and 52 examinations with negative results at 1-year follow-up. One hundred eleven lesions were masses and/or microcalcifications (72 masses, 22 microcalcifications, 17 masses with microcalcifications) and 21 were architectural distortions. Lesions were annotated by radiologists who were aware of all available reports. CAD performance was assessed as per-lesion sensitivity and false-positive results per volume in patients with negative results. RESULTS Use of the CAD system showed per-lesion sensitivity of 89% (99 of 111; 95% confidence interval: 81%, 94%), with 2.7 ± 1.8 false-positive rate per view, 62 of 72 lesions detected were masses, 20 of 22 were microcalcification clusters, and 17 of 17 were masses with microcalcifications. Overall, 37 of 39 microcalcification clusters (95% sensitivity, 95% confidence interval: 81%, 99%) and 79 of 89 masses (89% sensitivity, 95% confidence interval: 80%, 94%) were detected with the CAD system. On average, 0.5 false-positive rate per view were microcalcification clusters, 2.1 were masses, and 0.1 were masses and microcalcifications. CONCLUSION A digital breast tomosynthesis CAD system can allow detection of a large percentage (89%, 99 of 111) of breast cancers manifesting as masses and microcalcification clusters, with an acceptable false-positive rate (2.7 per breast view). Further studies with larger datasets acquired with equipment from multiple vendors are needed to replicate the findings and to study the interaction of radiologists and CAD systems.

Role of axillary ultrasound in the preoperative diagnosis of lymph node metastases in patients affected by breast carcinoma

PurposeThis study was conducted to evaluate the diagnostic accuracy of axillary ultrasound (US) alone or in combination with fine-needle-aspiration cytology (FNAC) in patients with breast carcinoma, in comparison with the final histological examination (sentinel node biopsy and/or axillary dissection).Materials and methodsBetween January 2005 and June 2008, we evaluated 427 breast cancer patients with axillary US. The findings were classified according to the following criteria: hilum and cortex morphology, ratio between longitudinal and transverse diameter and ratio between hilar and longitudinal diameter of the lymph node. Patients with breast lesions ≤3 cm (n=147) underwent FNAC of the most suspicious lymph node.ResultsOverall concordance between axillary US and final histological examination was 85%, sensitivity was 72.3% and specificity was 93.4%. Concordance between FNAC and final histological examination was 93%, sensitivity was 88.1% and specificity was 100%.ConclusionsIn 48.3% of patients, the combination of axillary US and FNAC guided treatment decisions towards immediate axillary dissection, thus sparing the patients sentinel node biopsy, with a significant reduction of costs and hospitalization time.RiassuntoObiettivoScopo del nostro lavoro è stato valutare, in pazienti affette da carcinoma mammario, l’accuratezza diagnostica dell’ecografia (US) del cavo ascellare da sola oppure associata ad agoaspirato con ago sottile (FNAC) assumendo come parametro di confronto l’esame istologico definitivo (biopsia del linfonodo sentinella e/o dissezione ascellare).Materiali e metodiTra gennaio 2005 e giugno 2008 in 427 pazienti affette da neoplasia mammaria è stato eseguito lo studio ecografico del cavo ascellare. Per la classificazione dei reperti ecografici sono stati valutati: la morfologia dell’ilo e della corticale, il rapporto tra diametro longitudinale e trasversale e il rapporto tra diametro della regione ilare e longitudinale del linfonodo. In 147 pazienti, con neoplasia mammaria≤3 cm, è stata eseguita l’US-FNAC del linfonodo più sospetto.RisultatiSi è evidenziata una concordanza complessiva tra US del cavo ascellare e istologico definitivo dell’85%, una sensibilità del 72,3% ed una specificità del 93,4%. La concordanza dell’US-FNAC con l’istologico definitivo è risultata del 93%, la sensibilità dell’88,1% e la specificità del 100%.ConclusioniL’ecografia del cavo ascellare associata alla FNAC nel 48,3% dei casi ha permesso di evitare la biopsia del linfonodo sentinella, orientando il trattamento chirurgico verso una dissezione ascellare immediata, con sensibile riduzione dei costi e del tempo di ospedalizzazione.

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.

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.

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.