Lucie Lalonde

Breast abscesses: evidence-based algorithms for diagnosis, management, and follow-up.

Radiologists who regularly perform breast ultrasonography will likely encounter patients with breast abscesses. Although the traditional approach of surgical incision and drainage is no longer the recommended treatment, there are no clear guidelines for management of this clinical condition. Breast abscesses that develop in the puerperal period generally have a better course than nonpuerperal abscesses, which tend to be associated with longer treatment times and a higher rate of recurrence. The available literature on treatment of breast abscesses is imperfect, with no clear consensus on drainage, antibiotic therapy, and follow-up. By synthesizing the data available from studies published in the past 20 years, an evidence-based algorithm for management of breast abscesses has been developed. The proposed algorithm is easy to follow and has been validated by a multidisciplinary team approach and applied successfully during the past 2 years. Breast abscesses are a challenging clinical condition, and radiologists have a pivotal role in evaluation and follow-up of these lesions.

Nonmasslike Enhancement at Breast MR Imaging: The Added Value of Mammography and US for Lesion Categorization

PURPOSE To determine the value of adding conventional imaging (mammography and ultrasonography [US]) to nonmasslike enhancement (NMLE) analysis with breast magnetic resonance (MR) imaging for predicting malignancy and for building an interpretation model incorporating all imaging modalities. MATERIALS AND METHODS The institutional ethics committees approved the study and granted a waiver of informed consent. In 115 women (mean age, 48.3 years; range, 21-76 years; 56 malignant, 12 high-risk, and 63 benign lesions), 131 NMLE lesions were analyzed. Two independent readers first classified MR images by using descriptive Breast Imaging Reporting and Data System (BI-RADS) criteria (BI-RADS classification with MR images alone [BI-RADS(MR)]) and later repeated this classification, adding information from conventional imaging (BI-RADS classification with combination of MR images and conventional images [BI-RADS(MR+Con)]). Lesion diagnosis was established with surgical histopathologic findings (n = 68), percutaneous biopsy results (n = 25), or 2 years of stability at MR imaging (n = 38). Receiver operating characteristic curves were built to compare BI-RADS(MR) with BI-RADS(MR+Con). A multivariate interpretation model was constructed and validated in a distinct cohort of 44 women. RESULTS Values for inter- and intraobserver agreement, respectively, were better for BI-RADS(MR+Con) (κ = 0.847 and 0.937) than for BI-RADS(MR) (κ = 0.748 and 0.861). For both readers, the areas under the receiver operating characteristic curve (AUCs) for diagnosis of malignancy were also superior when BI-RADS(MR+Con) (AUC = 0.91 [reader 1] and 0.93 [reader 2]) was compared with BI-RADS(MR) (AUC = 0.84 [reader 1] and 0.87 [reader 2]) (P < .05). An interpretation model combining conventional imaging with MR imaging criteria showed very good discrimination (AUC = 0.89 [training set] and 0.90 [validating set]). CONCLUSION Adding conventional imaging to NMLE lesion characterization at breast MR imaging improved the diagnostic performance of radiologists, and the interpretation model used offers good accuracy with the potential to optimize the reproducibility of NMLE analysis at MR imaging.

Chronic granulomatous mastitis: Imaging, pathology and management

PURPOSE The aim of this study is to describe the clinical and radiological presentation of chronic granulomatous mastitis. MATERIAL AND METHODS We retrospectively reviewed the clinical and radiological data of 11 women with histologically proven chronic granulomatous mastitis (CGM) diagnosed between March 2008 and September 2011. RESULTS The diagnosis of CGM is often a challenging one that can mimic infectious and malignant breast conditions. Clinically, CGM most commonly presents as a mass, occasionally with associated erythema. The most frequent mammographic presentation is an asymmetric density, while ultrasound most commonly reveals a hypoechoic mass with tubular extensions and a striated echotexture. On MRI, the most specific finding is peripherally enhancing fluid or solid masses with fistulous tract to the skin, although the latter is not commonly encountered. Diagnosis can be reliably obtained by needle core or vacuum-assisted biopsy, and is established pathologically by the identification of granulomatous inflammation without caseous necrosis. CGM is a diagnosis of exclusion after infectious and foreign body causes are ruled out. Treatment options include oral steroids or surgery; both options are associated with similar recurrence rates. The disease tends to burn itself out and the option of conservative management with observation is a valid one. CONCLUSION CGM is a rare benign disease with no specific features clinically or at imaging. There are no radiologic findings that are specific of CGM, but in the appropriate clinical setting, the diagnosis can be suggested by the radiologist.

A plea for the biopsy marker: how, why and why not clipping after breast biopsy?

In the last decade, percutaneous breast biopsies have become a standard for the management of breast diseases. Biopsy clips allow for precise lesion localization, thus minimizing the volume of breast to be resected at the time of surgery. With the development of many imaging techniques (including mammography, sonography, and breast magnetic resonance imaging), one of the challenges of the multidisciplinary became to synthesize all informations obtained from the various imaging procedures. The use of biopsy markers after percutaneous biopsy is one of the keys for optimal patient management, helping the radiologist to deal with multiple lesions, to insure correlation across different imaging modalities and to follow-up benign lesions, helping the oncologist by marking a tumor prior to neoadjuvant chemotherapy, helping the surgeon by facilitating preoperative needle localization, to precisely mark the margins of extensive disease and to guide intraoperative tumor resection, and helping the pathologist to insure the lesion of interest has been removed and to identify the region of interest in a mastectomy specimen. We believe biopsy clip markers should be deployed after all percutaneous interventions and present in this review the arguments to support this statement. Minimal indications for clip deployment will also be detailed.

Molecular classification of infiltrating breast cancer: toward personalized therapy.

Breast cancer is a heterogeneous disease, which comprises several molecular and genetic subtypes, each with characteristic clinicobiologic behavior and imaging patterns. Traditional classification of breast cancer is based on the histopathologic features but offers limited prognostic value. Novel molecular characterization of breast cancer with cellular markers has allowed a new classification that offers prognostic value, with predictive categories of disease aggressiveness. These molecular signatures also open the door to personalized therapeutic options, with new receptor-targeted therapies. For example, invasive cancer subtypes such as the luminal A and B subtypes show better prognosis and response to hormone receptor-targeted therapies compared with the triple-negative subtypes; on the other hand, triple-negative tumors respond better than luminal tumors to chemotherapy. Tumors that display amplification of the oncogene ERBB2 (also known as the HER2/neu oncogene) respond to drugs directed against this oncogene, such as trastuzumab. The imaging aspects of tumors correlate with molecular subgroups, as well as other pathologic features such as nuclear grade. Smooth tumor margins at mammography may be suggestive of a triple-negative breast cancer, and a human epidermal growth factor receptor 2 (HER2)-positive tumor is characteristically a spiculated mass with calcifications. Low-grade ductal carcinoma in situ (DCIS) is better detected with mammography, although magnetic resonance (MR) imaging may allow better characterization of high-grade DCIS. MR imaging diffusion sequences show higher values for the apparent diffusion coefficient for triple-negative and HER2-positive subtypes, compared with luminal A and B tumors. MR imaging is also a useful tool in the prediction of tumor response after chemotherapy, especially for triple-negative and HER2-positive subtypes.

Imaging findings of breast augmentation with injected hydrophilic polyacrylamide gel: patient reports and literature review.

Hydrophilic polyacrylamide gel (PAAG) is a nonresorbable soft tissue filler that has been used as implant material for breast augmentation in some countries, particularly from the Asian continent. Many complications associated with hydrogel use have been reported in the clinical literature including inflammation, persistent mastodynia, formation of multiple lumps, poor cosmetic results, glandular atrophy, and significant spread of hydrogel into the surrounding tissue. Data on long-term toxicity is currently unavailable. The radiologic features of PAAG injection mammoplasty frequently constitute a diagnostic challenge for radiologists. Indeed, the imaging appearances of uncomplicated PAAG implants may mimic conventional implants on mammography, sonography and MRI, with some distinguishing features. The location and local spread of the injected PAAG, and the eventual detection of local inflammation, are best evaluated by ultrasonography and especially MRI, considered the most sensitive technique for assessment of PAAG mammoplasty. MRI clearly depicts the volume and the distribution of gel within the breast; contrast medium enhancement allows delineation of areas of inflammation and infection. It is important to be familiar with the spectrum of imaging findings in order to make an accurate diagnosis and offer proper management. This paper aims to review the normal and abnormal mammographic, sonographic, and MR imaging characteristics of PAAG augmentation mammoplasty through presented patient reviews of three women having undergone direct PAAG injection.

Surgical Outcome of Biopsy-Proven Lobular Neoplasia: Is There Any Difference Between Lobular Carcinoma In Situ and Atypical Lobular Hyperplasia?

OBJECTIVE The aims of our study were to determine the frequency of malignancy after surgical excision of biopsy-proven lobular carcinoma in situ (LCIS) or atypical lobular hyperplasia (ALH) lesions, to assess any difference between pure LCIS and pure ALH lesions regarding their radiologic presentation and the malignancy upgrade rate after surgical excision, and to evaluate the outcome of lesions that were not excised surgically but were followed up. MATERIALS AND METHODS Radiologic and pathologic records of 14,435 imaging-guided needle biopsies of the breast performed between 2004 and 2008 in three different institutions were retrospectively reviewed. A total of 126 patients (0.9%) had biopsy-proven LCIS or ALH, or both, as the highest-risk lesion. Among the 126 patients, 89 (71%) continued to surgery, and 14 were followed up for more than 24 months. The Mantel-Haensel chi-square test was used for statistical analysis. RESULTS Cancer upgrade was documented in 17 of the 43 LCIS (40%), 11 of the 40 ALH (27%), and two of the six combined ALH and LCIS lesions (33%) surgically excised, for a total malignancy upgrade rate of 34% (30/89). Both LCIS and ALH lesions presented mammographically in most cases as microcalcifications (p = 0.078). None of the 14 patients followed up for a mean period of 51 months showed development of malignancy. CONCLUSION No statistically significant difference was found between mammographic presentation and postsurgical outcome of LCIS versus ALH lesions. Surgical excision of these lesions is recommended as long as no evident criteria are provided to differentiate those that might be associated with an underlying malignancy.

Breast Biopsies Under Magnetic Resonance Imaging Guidance: Challenges of an Essential but Imperfect Technique

Magnetic resonance imaging (MRI)-guided breast biopsy is an essential tool of a breast imager; yet, a decade after its introduction, this technique remains challenging and imperfect. This article presents the technique of MRI-guided biopsy, with an emphasis on challenges particular to the technique: technical considerations related to adequate lesion sampling and difficulties in confirming radiologic-pathologic correlation for enhancing lesions. Through clinical vignettes, challenges unique to MRI-guided biopsy are discussed and practical tips are offered. Prebiopsy planning including second-look targeted studies, patient preparation, and equipment is covered. Challenging situations pertaining to breast size, lesion location, or type of enhancement are illustrated, as well as the topic of performing multiple MRI-guided breast biopsies in a single session and biopsies of women with implants. Postbiopsy management is discussed. Success of MRI-guided biopsies requires careful prebiopsy planning, as well as appropriate choice of biopsy device, optimized for the specifics of breast shape and lesion size and location. Special features of biopsy systems (smaller apertures and blunt tips) facilitate the sampling of lesions in challenging locations. Vanishing lesions should undergo short-term follow-up, because malignancy cannot be excluded, as should lesions diagnosed as benign after pathologic analysis when the result is felt to be concordant with imaging features. To this end, radiologic-pathologic correlation is essential. Underestimation rates after MRI-guided breast biopsy are superior to those for vacuum-assisted stereotactic biopsy and ultrasound-guided biopsy. Close follow-up and rebiopsy should be considered when there is imaging-discordant histology. For benign and concordant histology, a first follow-up can be offered at 6 months.

Biopsie sous guidage IRM

Resume L’IRM mammaire occupe une place croissante en clinique. L’IRM offre l’avantage d’une sensibilite elevee, permettant une meilleure detection des lesions malignes, mais avec une moins grande specificite. Selon les etudes publiees a ce jour, la proportion de cancers visibles uniquement par l’IRM atteindrait 14 a 57 %. La biopsie sous guidage IRM permet de confirmer la nature des lesions detectees uniquement par IRM. D’autre part, comme toute lesion rehaussee n’est pas necessairement cancereuse, il est primordial d’obtenir une preuve histologique afin d’eviter le plus possible le recours injustifie a la chirurgie. Le taux eleve de detection par l’IRM serait nettement moins avantageux s’il se traduisait par un nombre accru de chirurgies pour des lesions benignes. Nous discuterons d’abord du role de l’echographie de seconde intention dans l’investigation des patientes presentant une lesion suspecte a l’IRM. Nous traiterons par la suite de la technique de biopsie sous IRM, ainsi que des complications, des contraintes et des defis qui y sont associes.

Tips and techniques in breast MRI.

The standard breast MRI protocol includes T2 sequences (anatomy and signal analysis), T1 gradient-echo sequences which can detect markers placed after biopsy, and injected dynamic 3D sequences for performing volume and multiplanar reconstructions, which are particularly useful for locating lesions well. Good patient positioning is essential and is obtained by using foam wedges for small breasts, ensuring there are no folds, and the correct position of the nipples. These aspects limit movement artefacts which alter subtraction sequences, so that it must always be possible for reading these sequences to be assisted by comparing them with the native sequences. New functional imaging sequences are now appearing in an attempt to increase the specificity of MRI, which is one of its main limitations. Of these, magnetic resonance spectroscopy appears to be the most promising, highlighting an abnormal choline peak in malignant lesions. This molecular signature provides early information (24 hours after beginning neoadjuvant treatment) on the chemosensitivity of a breast tumour.