I. Verslegers

MR mammography in the pre-operative staging of breast cancer in patients with dense breast tissue: comparison with mammography and ultrasound

The aim of this study was to determine whether pre-operative MR mammography could predict the extent of breast cancer in patients with dense breasts or whether dense parenchyma will lead to false-positive or inconclusive examinations. Sixty-seven patients with dense breasts with a malignant breast tumor planned for conservative surgery were reviewed. Detection rates of mammography, ultrasound, and MR mammography were studied, and the diameters of the lesions were measured and compared with pathological examination. Pathology revealed breast cancer in 65 patients. Sensitivity for detection of index lesions was 83% for mammography, 70.8% for ultrasound, and 98% for MR mammography. Mammography underestimated tumor extent in 37%, ultrasound in 40%, and MR in 12.5%. Of the 20 patients (31%) with multifocal or multicentric carcinoma, mammography detected the lesions in 35%, ultrasound in 30%, and MR in 100%, with a false-positive rate of 12.5, 14, and 23%. The MR mammography is more accurate in assessing tumor extent and multifocality in patients with dense breasts, but benign changes may lead to false-positive examinations.

Preoperative breast MRI in patients with invasive lobular breast cancer

To investigate the use of MRI in preoperative characterization of invasive lobular breast cancer (ILC) and in detection of multifocal/multicentric disease. We retrospectively reviewed T1-weighted FLASH 3D precontrast and postcontrast MR images together with subtraction images of 26 women with histopathologically proven invasive lobular cancer. Two experienced radiologists described tumor patterns of ILC independently. MR findings of unifocal, multifocal, single quadrant and multiquadrant disease were correlated with results of other imaging techniques and compared with histopathological findings as gold standard. Most ILC presented on MRI as a single spiculated/irregular, inhomogeneous mass (pattern 1, n=12) or as a dominant lesion surrounded by multiple small enhancing foci (pattern 2, n=8). Multiple small enhancing foci with interconnecting enhancing strands (pattern 3) and an architectural distortion (pattern 4) were both described in three cases. There was one case of a focal area of inhomogeneous enhancement (pattern 5) and one normal MR examination (pattern 6). Unifocal and multifocal lesions were identified on MRI in four patients with normal conventional imaging. In nine women, multiple additional lesions or more extensive multiquadrant disease were correctly identified only on MRI. MRI may play an important role in the evaluation of patients with ILC, which is often difficult to diagnose on clinical examination and conventional imaging and more likely occur in multiple sites and in both breasts. However, false-negative MR findings do occur in a small percentage of ILC.

Evaluation of the diagnostic value of a computed radiography system by comparison of digital hard copy images with screen–film mammography: results of a prospective clinical trial

The purpose of the study was to determine prospectively the diagnostic value of a computed radiography (CR) system by comparing mammographic hard copy images with screen–film mammography (SFM). A series of 100 patients, who came for diagnostic investigation, underwent two-view SFM (Lorad M-IV Platinum) and digital mammography with a CR system (AGFA CR system). The images were obtained by double exposure, i.e. same view without removing compression of the corresponding breast. The CR images were processed with dedicated processing for mammography. Six radiologists read sets of SFM and CR images. The primary efficacy parameter was the overall diagnostic value. The secondary efficacy parameters were lesion conspicuity and lesion details (for masses and micro-calcifications), tissue visibility at chest wall and at skin line, axillary details, overall density and sharpness impression and the overall noise impression. These parameters were scored by a 7-point scoring system. “CR non-inferior to SFM” was concluded if the lower confidence interval bound exceeded 80%. The confidence interval for the overall diagnostic value was between 96.4% and 100%. Pooled analysis of the ten features for image quality comparison demonstrated for all but one feature (lesion details of the calcifications) CR non-inferiority to SFM.

Invasive papillary carcinoma of the male breast

Abstract. Intracystic papillary carcinoma of the male breast is a very rare disease with only a few cases reported in the literature. A case is described and the additional value of MRI is discussed. To our knowledge, this is the first report regarding the MRI findings of an intracystic papillary carcinoma of the male breast.

Role of Mri of the breast in the evaluation of the symptomatic patient

Purpose of review The role of MRI in breast pathology is still controversial. The technique has a high sensitivity for detection of breast carcinoma, but specificity is low. Therefore, it is only useful for right indications. Recent findings Studies are still performed to define the role of MRI. For diagnosis of a breast lesion, image-guided percutaneous core biopsy is the method of choice, and MRI is not indicated. It has a place in the detection of carcinoma in patients with nipple discharge. MRI has a role in the search of an occult primary breast carcinoma in patients with metastasis and primary unknown cancer. MRI is the best technique for locoregional staging of breast carcinoma. Its role in detection of recurrence is controversial, as image-guided biopsy has to be done if a suspicious lesion is seen. In dense breasts or difficult scar formation, MRI is able to detect recurrence. MRI is sensitive in detection of implant rupture in symptomatic augmented patients. Summary MRI has a role in well defined indications, but its role is still controversial even in some of these indications. MRI is not indicated in diagnosis in which image-guided percutaneous biopsy is the method of choice. Further studies must be performed.

MR is/is not a useful diagnostic tool for breast cancer management.

Dynamic Magnetic Resonance Imaging (MRI) of the breast has become an important complementary examination in breast cancer management, thanks to its high sensitivity of 98% for invasive breast cancer and of 80% for ductal carcinoma in situ (DCIS) (1-2). MR mammography is based on the enhancement of lesions after contrast injection. Interpretation of MR images is based on the morphology and dynamics of enhancement. As benign lesions also may enhance, specificity is low, with variable reported rates of 37-97%. Therefore, it may only be performed for selected indications.

Suspicious nipple discharge and breast magnetic resonance imaging.

To the Editor: We read with great interest the article of WahnerRoedler et al. (1) regarding the management of high-risk patients with suspicious nipple discharge. Nipple discharge is a distressing symptom that accounts for roughly 3–5% of problems seen in the breast clinic. It is a frightening symptom for patients because of its association with breast cancer. However, it is only associated with a malignancy in 5–20% of cases (2). Discharge is considered suspicious for a malignancy when it arises from a single duct, is bloodstained, and associated with a mass in an elderly patient. The “classical” assessment of nipple discharge includes a complete physical examination with mammography and ultrasound. When no physical or imaging abnormalities are present, nipple discharge is still due to cancer in 32% of patients older than 60 years, in 10% of patients between 40 and 60 years, and in less than 3% of patients younger 40 years (3). Secreted fluid from a mammary duct can easily be smeared onto a glass slide for cytologic assessment of the cellular material (1). However, cytology is not useful because its sensitivity for malignancy is 34.6– 46.5% (2,4,5). Ductography has a sensitivity of 60% and is therefore also not useful in the evaluation (2,4,5). Ductal lavage or mammary ductoscopy are new interesting methods, but whether they are diagnostically helpful remains to be seen (1). Breast magnetic resonance imaging (MRI) is increasingly being used as a diagnostic modality, with sensitivity for invasive disease and intraductal disease of 91–100% and 40–100%, respectively (6–8). MRI is commonly used as an adjuvant tool for evaluation of patients with an equivocal mammogram (9). There is growing evidence that MRI could also be sensitive for the detection of intraductal, early invasive disease, occult multiple lesions, and occult contralateral breast cancer (6–11). In the literature there are two articles regarding MRI in patients with nipple discharge (9,12). The first report describes enhanced ducts on MRI, corresponding to areas of ductal carcinoma in situ (DCIS) and microinvasion (12). The second report was a prospective study of 23 patients who underwent MRI for the evaluation of nipple discharge (9). MRI demonstrated an abnormality in 12 patients (52%) and correlated with the histopathologic findings in 11 (73%) of the 15 patients who underwent an excisional biopsy. Of the seven (30%) malignant lesions found at the excisional biopsy, six (86%) were detected prospectively on MRI. The only patient who had a falsenegative finding of malignancy on MRI had an incidental single focus of DCIS that was identified at the margin of a resected papilloma. The papilloma was identified on MRI. Only one (40%) of the seven malignant lesions was detected on clinical or conventional imaging. These articles are of course liable to biases, such as patient selection, the fact that not all patients had a biopsy, and short follow-up. Nevertheless MRI may have a role in the evaluation of suspicious discharge or in high-risk patients with discharge. Prospective studies are necessary to define the possible additional value of MRI in patients with nipple discharge.

Preoperative ultrasound staging of the axilla make’s peroperative examination of the sentinel node redundant in breast cancer: saving tissue, time and money

OBJECTIVE To evaluate the role of preoperative axillary staging with ultrasound (US) and fine needle aspiration cytology (FNAC). Can we avoid intraoperative sentinel lymph node (SLN) examination, with an acceptable revision rate by preoperative staging? DESIGN This study is based on the retrospective data of 336 patients that underwent US evaluation of the axilla as part of their staging. A FNAC biopsy was performed when abnormal lymph nodes were visualized. Patients with normal appearing nodes on US or a benign diagnostic biopsy had removal of the SLNs without intraoperative pathological examination. We calculated the sensitivity, specificity and accuracy of US/FNAC in predicting the necessity of an axillary lymphadenectomy. Subsequently we looked at the total cost and the operating time of 3 models. Model A is our study protocol. Model B is a theoretical protocol based on the findings of the Z0011 trial with only clinical preoperative staging and in Model C preoperative staging and intraoperative pathological examination were both theoretically done. sentinel node, staging, ultrasound, preoperative axillary staging, FNAC, axilla RESULTS: The sensitivity, specificity and accuracy are respectively 0.75 (0.66-0.82), 1.00 (0.99-1.00) and 0.92 (0.88-0.94). Only 26 out of 317 (8.2%) patients that successfully underwent staging needed a revision. The total cost of Model A was 1.58% cheaper than Model C and resulted in a decrease in operation time by 9,46%. The benefits compared with Model B were much smaller. CONCLUSION Preoperative US/FNAC staging of the axillary lymph nodes can avoid intraoperative examination of the sentinel node with an acceptable revision rate. It saves tissue, reduces operating time and decreases healthcare costs in general.

Idiopathic ganulomatous mastitis

Idiopathic granulomatous mastitis (IGM) is a rare chronic benign disease of the breast. Histologically, the disease presents as an inflammatory reaction with non-caseating granulomas considered characteristic for IGM. IGM is often confused with breast cancer or mastitis with abcedations, and is treated with surgery which involves mutilation of the breast. Although no consensus exists on the best treatment modality, the use of low-dose oral and topical steroids has proven efficacy.

MR mammography of a primary squamous cell carcinoma of the breast: a case report

A case of a primary squamous cell carcinoma of the breast in a patient with synchronous contralateral invasive ductal adenocarcinoma is reported. To our knowledge, no dynamic MR mammography of this pathology is described in the literature. On MR, it presented as a mainly non-enhancing, partially cystic mass with an enhancing irregular peripheral rim. In the differential diagnosis of a mass with unsharp margins and an irregular border of the cystic or the non-enhancing area on MR mammography, a primary squamous cell carcinoma must be included.