Mireille Van Goethem

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.

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.

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.

A rare cause of mastitis: Idiopathic Granulomatous Mastitis

A 26-year-old female patient was referred by her gynecologist to the radiology department for evaluation of the right breast. The patient did not have a relevant medical (gynecological) history. During the last five months, she suffered from recurrent breast abscesses. She was treated several times with broad-spectrum antibiotics and surgical drainage, but without clinical improvement. Physical examination revealed a very tender, inflamed breast during palpation. Routine blood tests were normal. Ultrasonography of the right breast demonstrated a large heterogeneous echoic mass (Figure A). Although not shown in the figure, peripheral hypervascularity and a fistula to the skin in the medial retroareolar region were seen. In addition, multiple smaller collections were seen throughout the right breast. The overlying skin was thickened, and several enlarged axillary lymph nodes were present. Subsequent contrast-enhanced magnetic resonance imaging (MRI) confirmed multiple peripheral-enhancing collections (Figure B1) with diffusion restriction (Figure B2) and corresponding low ADC values (Figure B3) in the right breast. Also, global asymmetric enhancement of the right breast tissue and overlying skin compared to the left side was observed (Figure B1). To exclude an underlying carcinoma, a breast biopsy was performed. Malignancy was definitely excluded, but histopathological examination (Figure C) revealed a chronic inflammatory lymphocytic infiltrate (arrow) interspersed with histiocytes (arrowhead) and giant cells (double arrow). No specific aetiological factor could be detected clinically. The patient was treated with corticosteroids, with definite clinical improvement. Based on the clinical history, the imaging features, the histopathology, and good therapeutic response to corticosteroids, the diagnosis of idiopathic granulomatous mastitis (IGM) was made. IGM is a very rare chronic inflammatory breast disease. The etiology has not yet been fully elucidated but may be due to an autoimmune process, infection, a chemical Figure A.

Guidelines and recommendations for MRI in breast cancer follow-up: A review

OBJECTIVE Present article will perform a review regarding the current recommendations of Magnetic resonance imaging (MRI) in routine follow-up after successfully treated breast cancer by surgery, radiation and/or systemic therapy. METHODS For this review, a literature review search was done with the MeSH-terms: Magnetic Resonance Imaging, breast neoplasm, post-operative period and follow-up, according to PRISMA. The literature published between 2006 and 2016 in MedBase, PubMed and Embase was consulted. RESULTS The 10 articles and 8 guidelines were analysed for their recommendations regarding MRI use in routine follow-up for breast cancer. One article concluded that MRI could influence further policy, all others did not find superiority of MRI over mammography or were inconclusive. One guideline recommended annual MRI for patients with a positive personal history (PPH) for breast cancer without further risk factors, one guideline offered no MRI to these patients and all other guidelines were inconclusive. CONCLUSION There is insufficient evidence regarding superiority of MRI versus mammography in routine follow-up for patients with a PPH of breast cancer. MRI does not improve survival in all patients and should therefore not be offered to patients in follow-up without increased risk for recurrences.

International Day of Radiology: Breast Imaging

November 8, 2016, is the International Day of Radiology (IDoR), which is dedicated to breast imaging and the essential role that radiology plays in the detection, diagnosis, and management of diseases of the breast (http://www.internationaldayofradiology.com). On the website, you can find the book to honour the International Day of Radiology, Screening & Beyond, which provides an amazing overview of breast imaging, with contributions from many of the world’s top breast radiologists.

The fibrotic focus in MR-mammography.

A fibrotic focus (FF) is defined as a scar-like area, consisting mainly of fibroblasts and collagen fibres, that occupies various percentages of the centre of an invasive ductal carcinoma of the breast [1]. It shows many similarities with granulation tissue and subsequent scar-formation in wound repair and can be regarded as a focus of exaggerated reactive vascular stroma formation in a tumor [2]. It was first proposed in 1996 by Hasebe et al. as an indicator of tumor aggressiveness and subsequently confirmed as an independent prognostic factor in a prospective study of 439 patients [3]. It is correlated with tumor size, higher histological grade, higher frequency of tumor necrosis, c-erbB-2 overexpression, higher pathological stage, higher frequency of cases with more than three positive lymph node metastases and decreased shortand longterm survival [4,5]. FF characteristics can be the most important histologic factors for predicting metastasis to the bone [6]. Colpaert et al. have confirmed the independent prognostic significance of the FF, especially in early stage breast cancer [7]. Additionally they showed that the relative size (fibrotic focus/tumor ratio) of the FF is important for patient’s outcome and they emphasized the possible use of FF as a surrogate for quantifying angiogenesis [8]. FF is mentioned as a prognostic parameter in the WHO book on breast pathology [9]. Therefore, pre-operative detection of an FF could be important in planning the type of therapy in patients who will receive neoadjuvant therapy. Jitsuiki et al. reported that the presence of an FF was associated with a high microvessel density in both central and peripheral areas of the tumor and that microvessel count (MVC) significantly increased from the central to the peripheral zones in invasive ductal carcinoma [10]. In dynamic MR-mammography, lesion detection is based on enhancement of lesions after contrast injection. Degree of enhancement and enhancement pattern (homogeneous, non homogeneous or peripheral enhancement) largely depend on microvascular amount, density and distribution [11,12].

Axillary lymphadenopathy as a first symptom of diabetic mastopathy.

Diabetic mastopathy is an unusual fibroinflammatory breast lesion that characteristically presents in premenopausal women with long-standing type 1 diabetes mellitus. Patients present with clinically suspicious breast masses or axillary lymph nodes with imaging characteristics indistinguishable from malignancy. Fine needle aspiration is often inadequate and a core biopsy should be performed. Excisional biopsy is not necessary, and annual follow-up is recommended. Recognition of diabetic mastopathy should lead to better care of patients with breast nodules or axillary masses who are diabetic, avoiding surgery for this benign condition.

A logit model to evaluate the performance of diagnosis of solid palpable breast tumours

The applicability of log-linear (logit) analysis has been tested with preoperative data of 303 consecutive patients with a solid palpable breast tumour. The log-linear routine of the SPSS-package provides for the selection of appropriate diagnostic tests, which can be suitably judged in a given situation. The histologic diagnosis (benign or malignant) has been chosen as dependent variable. The independent variables are: (1) the patients age (less than 50 years or greater than or equal to 50 years), (2) the size of the lesion (diameter less than 2 cm or greater than or equal to 2 cm) and the test results (benign or malignant) of (3) physical examination, (4) mammography, (5) ultrasound scanning and (6) thermography. Of the tested models with one independent variable, the best model uses ultrasonography test results (H = 0.35). Physical examination and mammography also have good predictive power (H, respectively: 0.23 and 0.25). The combination of two independent variables augments accuracy. Models combining ultrasonography with age, physical examination or mammography are shown to be most successful (H respectively: 0.41, 0.42 and 0.39).