Martine Boisserie-Lacroix

Triple-Negative Breast Cancers: Associations Between Imaging and Pathological Findings for Triple-Negative Tumors Compared With Hormone Receptor-Positive/Human Epidermal Growth Factor Receptor-2-Negative Breast Cancers

BACKGROUND Triple-negative (TN) breast cancers have high malignancy potential and are often characterized by early systemic relapse. Early detection is vital, but there are few comprehensive imaging reports. Here we describe mammography, ultrasound, and magnetic resonance imaging (MRI) findings of TN breast cancers, investigate the specific features of this subtype, and compare the characteristics of TN breast cancers with those of hormone receptor (HR)-positive/human epidermal growth factor receptor (HER)-2-negative breast cancers. MATERIALS AND METHODS From July 2009 to June 2011, mammography and ultrasound findings of 210 patients with pathologically confirmed TN (n = 105) and HR-positive/HER-2-negative breast cancers (n = 105) were retrospectively reviewed from our institutional database. Ultrasound vascularity was notified in 88 cases and elasticity scores were notified in 49 cases overall. Thirty-five patients underwent MRI (22 TN and 13 HR-positive/HER-2-negative). Mammograms, ultrasound, and MRI were reviewed according to the Breast Imaging-Reporting and Data System (BI-RADS) lexicon and classification. RESULTS TN breast cancers were more likely to show round, oval, or lobulated masses with indistinct margins on mammography than HR-positive/HER-2-negative breast cancers. On ultrasound, TN tumors were more likely than HR-positive/HER-2-negative breast cancers to show circumscribed or microlobulated margins and no posterior acoustic features or posterior enhancement-positive. On MRI, TN cancers exhibited suspicious aspects more often than HR-positive/HER-2-negative cancers, often with rim enhancement-positiveHER-2 (84.6% of masses were classified BI-RADS 5). CONCLUSION This study is the first to describe findings on mammography, ultrasound, and MRI for TN breast cancers with a matched HR-positive/HER-2-negative control group. Several distinctive morphological features of these aggressive tumors are identified that can be used for earlier diagnosis and treatment, and ultimately to improve outcomes.

Correlation between imaging and molecular classification of breast cancers.

The histological type of tumour according to the WHO: ductal, lobular, rare forms, is correlated with specific aspects of the imaging based on each type. This morphological classification was improved by knowledge of the molecular anomalies of breast cancers, resulting in the definition of cancer sub-groups with distinct prognoses and different responses to treatment: luminal A, luminal B, HER2 positive, basal-like, triple-negative. Studies are beginning to deal with the appearance of each sub-type in the imaging. It is now important for the radiologist to be familiar with them.

Imaging benign inflammatory syndromes

Benign mastitis is a rare disease and its management is difficult. The diagnostic challenge is to distinguish it from carcinomatous mastitis. We make a distinction between acute mastitis secondary to an infection, to inflammation around a benign structure or to superficial thrombophlebitis, and chronic, principally plasma cell and idiopathic granulomatous mastitis. Imaging is often non-specific but we need to know and look for certain ultrasound, mammogram or magnetic resonance imaging (MRI) signs to give a pointer as early as possible towards a benign aetiology. A biopsy should be undertaken systematically where there is the slightest diagnostic doubt, to avoid failing to recognise a carcinomatous mastitis.

Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF): benign breast tumors – short text

Screening with breast ultrasound in combination with mammography is needed to investigate a clinical breast mass (Grade B), colored single-pore breast nipple discharge (Grade C), or mastitis (Grade C). The BI-RADS system is recommended for describing and classifying abnormal breast imaging findings. For a breast abscess, a percutaneous biopsy is recommended in the case of a mass or persistent symptoms (Grade C). For mastalgia, when breast imaging is normal, no MRI or breast biopsy is recommended (Grade C). Percutaneous biopsy is recommended for a BI-RADS category 4-5 mass (Grade B). For persistent erythematous nipple or atypical eczema lesions, a nipple biopsy is recommended (Grade C). For distortion and asymmetry, a vacuum core-needle biopsy is recommended due to the risk of underestimation by simple core-needle biopsy (Grade C). For BI-RADS category 4-5 microcalcifications without any ultrasound signal, a minimum 11-G vacuum core-needle biopsy is recommended (Grade B). In the absence of microcalcifications on radiography cores additional samples are recommended (Grade B). For atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ, flat epithelial atypia, radial scar and mucocele with atypia, surgical excision is commonly recommended (Grade C). Expectant management is feasible after multidisciplinary consensus. For these lesions, when excision margins are not clear, no new excision is recommended except for LCIS characterized as pleomorphic or with necrosis (Grade C). For grade 1 phyllodes tumor, surgical resection with clear margins is recommended. For grade 2 phyllodes tumor, 10mm margins are recommended (Grade C). For papillary breast lesions without atypia, complete disappearance of the radiological signal is recommended (Grade C). For papillary breast lesions with atypia, complete surgical excision is recommended (Grade C).

Apport de l’IRM dans les écoulements mamelonnaires pathologiques : analyse de 50 cas

PURPOSE To determine the role of MRI in the evaluation and management of patients with suspicious nipple discharge and normal mammographic and US evaluation. PATIENTS AND METHODS A total of 50 patients with suspicious nipple discharge and normal mammographic and US evaluation prospectively underwent MRI. The first 16 patients underwent routine breast MRI, while MR-ductography with image fusion at the console was added for the last 34 patients. RESULTS In 22 of 25 high-risk and malignant lesions, MRI showed enhancement whereas it was normal in three cases. In 25 benign cases (resolution of discharge/benign non-proliferative breast disease), MRI was negative in 22 cases and falsely positive in three cases. CONCLUSION In this clinical setting, MRI shows excellent sensitivity, PPV and NPV. A negative result on MRI would support clinical follow-up as opposed to surgery.

Thérapeutiques hormonales de la ménopause : impact sur la densité mammographique

Resume Qu’elle soit evaluee qualitativement ou quantitativement, la densite mammographique constitutionnelle, qui peut subir des variations physiologiques, est desormais un facteur consensuel d’augmentation du risque relatif de cancer du sein. Le but de cette mise au point est de preciser l’impact des therapeutiques hormonales de la menopause sur la densite mammographique et les possibles consequences. Alors que ni la Tibolone, ni le Raloxifene ne semblent avoir d’effet defavorable, la prise d’un traitement hormonal substitutif œstroprogestatif peut, dans certains cas, s’accompagner d’un effet de densification susceptible de reduire la sensibilite et la specificite de la mammographie. L’adaptation du rythme des mammographies et son association avec l’examen clinique et l’echographie mammaire semblent la meilleure facon de reduire le nombre de cancers de l’intervalle dans les cas de forte densite mammographique.

The inflammatory breast: management, decision-making algorithms, therapeutic principles.

Inflammatory syndrome is one of the rare emergency breast situations. Its etiology is benign, infectious in most cases. The clinical examination is often self-evident and suggests the diagnosis. But alone it is insufficient, and diagnostic tests are necessary to guide therapy. As essential as it is, mammographys limitations reinforce the benefit of ultrasonography, which in all cases reveals an abscess and has greater sensitivity for detecting a malignant tumor. If the etiology is benign, clinical signs will disappear with medical treatment, with no need for further investigation. While it is legitimate to initiate a trial treatment, it must not delay oncologic management, because of the severity of inflammatory cancer.

Correlation between imaging and prognostic factors: Molecular classification of breast cancers

The new molecular classification of breast cancers defines cancer sub-groups with a distinct prognosis and response to treatment. Studies on the literature deal with the imaging of each tumour sub-type. The radiologist should be familiar with them in order to adapt the care of an aggressive sub-type. In view of the current knowledge, the following have been significantly more often observed: mammographical spiculated mass with echogenic halo in luminal A sub-type; architectural distortion in luminal B sub-type; an irregular mass with indistinct margin comprising microcalcifications, with an abrupt interface in the sonography, or non-sonographic mass in the HER2 sub-type; a very hypoechogenic, lobulated mass with indistinct or microlobulated margin, with an abrupt interface, sometimes pseudo-benign, in the triple-negative sub-type.

Establishment of a consultation to announce the results of a breast biopsy.

PURPOSE Establishment of post-breast biopsy consultations to announce the results. Evaluation of this system in order to help improve the practice. PATIENTS AND METHODS The radio-senologists benefited from continuing medical education for the in-house announcement. Fifty patients (with malignant results) received questionnaires comprising 13 items and the possibility of free and anonymous comments. RESULTS The authors present tools to help in the interview. Thirty-one questionnaires were returned by the patients and were analysed. Thirty patients (96.8%) considered the information provided as rather or fully sufficient, and only one considered that she did not have enough time to ask all of the questions she wanted to ask. Two patients (6.6%) found the scheduling of the subsequent appointments insufficient. The patients had a rather positive overall judgement about this consultation. CONCLUSION The radiologist may provide one of the consultations to announce the results, depending on their involvement in senology, their personal expertise and their integration in the care network.

Biopsias percutáneas de mama

La necesidad de obtener un diagnostico preoperatorio del cancer de mama (sobre todo antes de la introduccion de la tecnica del ganglio centinela) ha dado lugar a un importante desarrollo de la radiologia intervencionista y ha modificado las condiciones de anuncio del cancer y de su tratamiento. El radiologo es el responsable de la eleccion de la tecnica de biopsia, en funcion del tipo de imagen y de su accesibilidad. La microbiopsia guiada por ecografia es la tecnica mas rapida y la menos costosa, por lo que debe preferirse para el diagnostico de una masa. Las microcalcificaciones se biopsian por macrobiopsia bajo estereotaxia para superar las posibles subestimaciones de la microbiopsia. Aun no existe un consenso sobre las indicaciones de la macrobiopsia bajo ecografia; su interes radica en aumentar el tamano de la muestra para tener un diagnostico anatomopatologico mas fiable. Las biopsias bajo antena de resonancia magnetica estan dirigidas a imagenes no visibles en la radiologia convencional y sobre todo que no tienen traduccion en la ecografia dirigida de segunda intencion. Aunque las indicaciones son cada vez mas numerosas (por el desarrollo, entre otras, de las tecnicas de deteccion en las mujeres portadoras de mutacion), pocos equipos realizan esta tecnica, larga y dificil. Del resultado de la biopsia dependera la continuacion del tratamiento de la paciente: seguimiento simple, vigilancia expectante, exeresis quirurgica de la lesion. El equipo radiologo-patologo debe ser capaz de interpretar las informaciones transmitidas reciprocamente y debe conocer la traduccion radiologica y patologica de las diferentes imagenes detectadas y biopsiadas. La concordancia radiopatologica es esencial para poder validar la conducta practica; en los casos dificiles, se debe hacer en las reuniones multidisciplinarias de concertacion.