Karla A. Sepulveda

Role of Imaging in the Era of Precision Medicine

Precision medicine is an emerging approach for treating medical disorders, which takes into account individual variability in genetic and environmental factors. Preventive or therapeutic interventions can then be directed to those who will benefit most from targeted interventions, thereby maximizing benefits and minimizing costs and complications. Precision medicine is gaining increasing recognition by clinicians, healthcare systems, pharmaceutical companies, patients, and the government. Imaging plays a critical role in precision medicine including screening, early diagnosis, guiding treatment, evaluating response to therapy, and assessing likelihood of disease recurrence. The Association of University Radiologists Radiology Research Alliance Precision Imaging Task Force convened to explore the current and future role of imaging in the era of precision medicine and summarized its finding in this article. We review the increasingly important role of imaging in various oncological and non-oncological disorders. We also highlight the challenges for radiology in the era of precision medicine.

Clinical Decision Support at the Point-of-Order Entry: An Education Simulation Pilot with Medical Students

RATIONALE AND OBJECTIVES We have been called to reform radiology undergraduate medical education (UME) curricula. Clinically available clinical decision support provides an opportunity to improve education regarding appropriate imaging utilization, patient safety, and cost-effective care. MATERIAL AND METHODS We created an education simulation portal utilizing integrated clinical decision support. The portal was then piloted with 34 volunteer medical students at our institution in a blended learning environment. A program assessment was performed utilizing the results from a qualitative survey, pre-test, and post-test. RESULTS The large majority of medical students felt this supplemental education resource should be included in our UME curriculum (85.29%). All students perceived value in the education simulation portal. The students performed significantly better on the post-test in multiple categories (overall P <.0001), including Choosing Wisely topics (P = .0207). CONCLUSIONS Based on our program assessment from this pilot program, we believe this innovative educational resource has significant potential to fill curricular gaps in radiology UME curricula. This platform is scalable and can be further customized to fill needs across the continuum of medical education.

BI-RADS update for breast cancer caregivers.

This review will discuss changes relevant to breast cancer caregivers in the fifth edition of the Breast Imaging Reporting and Data System.

Is breast magnetic resonance imaging (MRI) useful for diagnosis of additional sites of disease in patients recently diagnosed with pure ductal carcinoma in situ (DCIS)

PURPOSE To determine if breast MRI is useful for detecting additional or invasive sites of disease in patients initially diagnosed with pure DCIS. MATERIALS AND METHODS A retrospective review of women diagnosed with pure DCIS who underwent a breast MRI for evaluation of extent of disease was performed at a single institution from January 2013 to April 2015. Data analysis included imaging (mammography, ultrasound and MRI) and pathology characteristics (histology and biomarker status) of the primary DCIS as well as descriptors for the additional sites of disease incidentally found by breast MRI. RESULTS A total of 108 patients were diagnosed with pure DCIS during this time period. A breast MRI for staging was recommended for all patients. 76 patients had an MRI performed, ages ranging from 38 to 79 years old (median, 53 years); sizes ranging from 0.3 to 10cm (mean, 2.2cm). A total of 52 patients (68%) either had suspicious new finding(s) (n=27, 36%) or bigger tumor size than originally visualized on mammography (n=43, 57%). A total of twenty-seven patients (36%) had other MRI findings suspicious for additional sites of disease in either breast (four in the ipsilateral breast and twenty-three in the contralateral breast). From this group of patients, twenty-three (85%) patients underwent MRI-guided biopsy as recommended. The four patients who did not have the recommended MRI guided-biopsy either underwent total mastectomies or refused the biopsy. Six out of the twenty-three patients (26%) were diagnosed with an additional site of cancer (5 DCIS and 1 IDC) (7.9%, CI=3.7%, 16.2%). All of the six patients had contralateral disease (100%) and none had a second site of disease in the ipsilateral breast. The size of the additional sites of disease ranged from 0.4 to 8cm (mean, 3.1cm) and the size of the primary lesion in this selected group ranged from 0.1 to 10.9cm (mean, 5.6cm). Ages ranged from 44 to 63 years old (median, 52.5 years). Five out 6 patients (83%) presented with the first site of disease as pure DCIS with estrogen (ER) and progesterone (PR) receptors positive and one case (17%) was pure DCIS ER/PR- negative. The second incidental lesion found on MRI demonstrated 5 cases of contralateral pure DCIS and 1 case of contralateral invasive disease. From this group, we did not have the data for biomarker analysis for the second site of disease in 2 cases and 3 cases showed concordant biomarker status between the first and second sites of disease. The 1 case that presented with an invasive component in the contralateral side of the initially biopsy-proven pure DCIS had discordant biomarkers compared to the first site of disease: the first site of pure DCIS was ER/PR-negative and the second site of invasive ductal carcinoma (IDC) presented with ER/PR-positive status. CONCLUSION From a total of 76 patients with recent diagnosis of pure DCIS who underwent staging breast MRI examination for diagnosis of additional sites of disease, approximately 8% (95% confidence interval=3.7%, 16.2%) was diagnosed with an additional site of cancer and 1.3% (95% confidence interval=0.2%, 7%) of the total cases had invasive disease in the additional sites with different biomarker status; changing their management and prognosis.

Stereotactic Biopsy of Segmental Breast Calcifications: Is Sampling of Anterior and Posterior Components Necessary?

RATIONALE AND OBJECTIVES Core needle biopsy results of segmental calcifications on mammography can have direct impact on surgical management. Although dependent on breast size, cancer spanning greater than 5 cm is usually treated with mastectomy, and cancer less than 5 cm is managed with lumpectomy. Approach to stereotactic biopsy of morphologically similar segmental calcifications that span more than 5 cm on mammography varies geographically and is currently largely based on preference of the surgical or medical oncology colleagues. Some clinicians prefer biopsy of the anterior and posterior aspects of the abnormality, whereas others believe a single biopsy within the abnormality is adequate. There is insufficient data to support whether a single biopsy of calcifications is adequate to establish the need for mastectomy, or if pathology-proven cancer in the anterior and posterior components to define the extent of disease is required. This study aims to evaluate concordance rates of paired biopsies of suspicious segmental mammographic calcifications. MATERIALS AND METHODS From a 5-year review of our imaging database, 32 subjects were identified with breast imaging reporting and data system (BI-RADS) 4 or 5 segmental calcifications on mammography who underwent anterior and posterior stereotactic biopsies. The paired biopsy results were independently analyzed for concordance on benign, high-risk, or malignant pathology. RESULTS Of the 32 cases, there was perfect agreement (32/32 cases = 100% concordance, 95% confidence interval = 89.3-100%) in anterior and posterior pairs in benign, high-risk, or malignant findings (kappa = 1, P < 0.001). CONCLUSIONS The absence of data on pathological concordance in anterior and posterior aspects of suspicious, morphologically similar, segmental calcifications spanning 5 cm or more has led to a varied clinical approach to stereotactic biopsy. The 100% rate of pathological concordance in our study suggests that a single biopsy is adequate for diagnosis and representative of the whole mammographic abnormality. Implementation of this approach will potentially reduce unnecessary biopsies and surgeries, minimize healthcare costs, and decrease patient morbidity.

Spindle cell lesions of the breast: Multimodality imaging and clinical differentiation of pathologically similar neoplasms

Spindle cell lesions of the breast comprise a wide-range of entities including reactive, benign and malignant proliferations. They can be pathologically challenging to differentiate as there is often immunohistochemical and morphologic similarities with characteristic spindle shaped cellular patterns. Radiological and pathological correlation is essential. Radiology detects, defines the size and extent, and assists in localizing the lesions. Pathology confirms the diagnosis and provides prognostic parameters. Familiarity with the clinicoradiological features of these diagnostically challenging lesions helps to establish an accurate pathological diagnosis and subsequent clinical decision making.

The Postoperative Breast

Surgical interventions in the breast include excisional biopsy, lumpectomy, mastectomy, reduction, and augmentation. There are expected benign postsurgical changes following these interventions. These benign imaging findings may overlap with radiographic features of malignancy or obscure tumor recurrence. Awareness of normal postoperative imaging changes correlated with prior procedural history and time that has elapsed since those procedures is important for increasing accurate early detection of breast cancer or tumor recurrence in patients with history of breast cancer.

Dedifferentiated liposarcoma of the adult male breast.

A 66-year-old male presented with a right breast mass, enlarging insidiously over a one-year period after trauma to the site. After the findings were attributed to glandular injury and hematoma, the patient eventually underwent mammographic and ultrasonographic evaluation that demonstrated masses in the breast and the axilla. A subsequent ultrasound-guided biopsy of the breast mass yielded a diagnosis of fibromatosis. However, the imaging features were suggestive of malignancy. Surgical resection was performed and revealed dedifferentiated liposarcoma—a neoplasm with components of well- and poorly differentiated liposarcoma as well as nonlipomatous sarcoma. This tumor type is primarily described in the retroperitoneum and limbs and is especially rare in the breast. We report an unusual case of multifocal primary dedifferentiated liposarcoma involving the breast in a man.