Sona A. Chikarmane

BI-RADS 3, 4, and 5 Lesions: Value of US in Management—Follow-up and Outcome

PURPOSE To evaluate the use, final outcome, and positive biopsy rate of American College of Radiology ultrasonographic (US) Breast Imaging Reporting and Data System (BI-RADS) categories 3, 4, and 5 recommended for breast masses. MATERIALS AND METHODS At US, consecutive masses, palpable and nonpalpable, categorized as BI-RADS 3, 4, and 5 between January 1, 2003, and December 31, 2004, were retrospectively reviewed with institutional review board approval. Medical records provided imaging and histologic information. RESULTS After patients lost to follow-up were excluded, the study population was 767 patients with 926 masses (476 palpable, 450 nonpalpable). In BI-RADS 3 masses (n = 356), imaging follow-up of 252 masses documented stability for 6-24 months. Aspiration of 24 masses revealed cysts. Biopsy in 80 masses revealed three malignancies, all of which were diagnosed within 6 months of the index examination, were smaller than 1 cm, and were node negative (negative predictive value = 99.2%). In BI-RADS 4 masses (n = 524), aspiration results indicated 35 cysts; biopsy in 455 revealed 85 malignancies (positive predictive value [PPV] = 16.2%). Imaging follow-up only in 34 revealed no cancers 2 and more years later. Among BI-RADS 5 masses (n = 46), 43 were malignant and three benign (PPV = 93.4%). CONCLUSION Inconsistent use of BI-RADS category 3 occurred in 14.0% of cases when biopsy was recommended. Although biopsy was performed in almost equal numbers of palpable and nonpalpable masses, only 11% of palpable BI-RADS 3 and 4 masses were malignant, as compared with 22% of nonpalpable masses. Strict adherence to lexicon characteristics of probably benign lesions should improve specificity.

Using Real-time Tissue Elastography for Breast Lesion Evaluation: Our Initial Experience

Objective. The purpose of this study was to prospectively assess the performance of real‐time tissue elastography (RTE) in the evaluation of breast masses and correlate RTE and American College of Radiology Breast Imaging Reporting and Data System (BI‐RADS) assessments with pathologic findings. Methods. Informed consent was obtained from all patients for this Health Insurance Portability and Accountability Act–compliant, Institutional Review Board–approved study. Patients with sonographically visible breast lesions for which a biopsy was recommended were considered potential study participants. Between October 2006 and February 2008, 186 consecutive women with 200 lesions were enrolled. Twelve lesions in 11 patients were excluded, resulting in a study population of 188 lesions in 175 women. After routine B‐mode sonographic examination, RTE was performed using a manual free‐hand compression technique. Study lesions were assigned elasticity scores (ES) based on the system proposed by Itoh et al (Radiology 2006; 239:341–350), where 1 is normal and 5 represents abnormal strain. The lesion size on RTE and B‐mode imaging was compared. Results were correlated with BI‐RADS assessment and pathologic findings. Results. Pathologic examination revealed 61 of 188 malignancies (32.4%) and 127 of 188 benign lesions (67.6%). Of the malignant lesions, 84% had ES of 5 and 4, whereas 76% of benign lesions had ES of 1 and 2. The sensitivity of RTE was 92.7%, and specificity was 85.8%, with 4 false‐negative and 16 false‐positive results. Of the biopsy‐proven benign BI‐RADS 4A lesions, 63 of 76 (82.9%) had ES of 1 and 2, consistent with normal tissue. Conclusions. Real‐time tissue elastography may provide additional characterization of breast lesions, improving specificity, particularly for low‐suspicion lesions.

Pure Ductal Carcinoma in Situ : A Range of MRI Features

OBJECTIVE The purpose of this article is to describe and illustrate the variety of common morphologic features, enhancement patterns, and kinetics of pure ductal carcinoma in situ (DCIS) on dynamic contrast-enhanced MRI of the breast, using the American College of Radiology BI-RADS lexicon. CONCLUSION Breast MRI plays an important role in the detection of DCIS, which most often appears as nonmass clumped enhancement, in a ductal or segmental distribution, with variable enhancement kinetics.

Breast MRI in the Evaluation of Eligibility for Accelerated Partial Breast Irradiation

OBJECTIVE Eligibility for accelerated partial breast irradiation is generally determined by physical examination in conjunction with conventional imaging techniques such as mammography and breast sonography. MRI is recognized as a significant imaging tool in diagnosing breast cancer and has shown the ability to identify mammographically occult carcinoma. Our purpose was to retrospectively assess preoperative breast MRI examinations in women with early-stage breast cancer who were theoretically eligible for accelerated partial breast irradiation and to explore the use of MRI in selecting patients for this treatment. MATERIALS AND METHODS Seventy-nine patients with core needle biopsy-proven breast cancer, who were eligible candidates for breast-conserving surgery and accelerated partial breast irradiation, underwent bilateral breast MRI examinations. At review, the presence and location of occult tumor sites (detected on MRI only) were documented and subsequently correlated with pathology findings. RESULTS From 79 patients, a total of 126 suspicious areas, including the index tumors, were detected by MRI. Additional sites of cancer other than the index tumor were observed in 30 patients (38%). Of these, eight (10%) had an additional cancer in a different quadrant from the index tumor. CONCLUSION The treatment effect of whole-breast irradiation on microscopic tumor cells and on additional occult foci in other quadrants of the breast is lost with partial breast irradiation. Our results suggest that MRI before accelerated partial breast irradiation may be of benefit to patients to ensure they do not have multifocal or multicentric disease, remote from the lumpectomy bed.

US of Breast Masses Categorized as BI-RADS 3, 4, and 5: Pictorial Review of Factors Influencing Clinical Management

The Breast Imaging Reporting and Data System (BI-RADS) lexicon for ultrasonography (US) is based on the established lexicon used successfully in mammography and attempts to provide a common language to avoid ambiguity in interpreting, reporting, and teaching breast US. Proper and consistent use of the BI-RADS US lexicon has numerous advantages, including facilitating (a) communication of final assessment categories that clearly indicate management recommendations, (b) data tracking for self-audits, and (c) clinical review of outcome summaries. However, the literature to date does not include sufficient data on outcomes to validate clinical use of the BI-RADS US lexicon. In this article, a pictorial review of the BI-RADS US lexicon descriptors is provided, and specific cases from a retrospective review are used to highlight the challenges in using the BI-RADS US lexicon. With these examples, suggestions are offered for greater clarity in the use of this lexicon. The technical challenges in follow-up US imaging are described. The challenges in assigning final assessment categories are detailed, as well as the clinical factors that may influence decision making and the management of certain lesions.

Factors That Impact the Duration of MRI-Guided Core Needle Biopsy

OBJECTIVE The purpose of our study was to determine which patient-related, target lesion-related, or procedure-related variables impact the duration of MRI-guided core needle breast biopsy. MATERIALS AND METHODS Between July 11, 2006, and September 26, 2007, data were collected for 75 single-target MRI-guided 9-gauge vacuum-assisted core needle biopsy procedures using a grid-guidance technique and performed at a single institution. The following variables were studied: MRI suite occupation time, number of operators, patient age and breast size, target morphology and location, approach to target, equipment used, number of image acquisitions and times the patient was moved in and out of the closed magnet, and occurrence of complications. Statistical analysis was performed using the Students t test, analysis of variance, and Pearsons correlation, with p values < 0.05 considered significant. RESULTS The mean duration was 57.9 minutes (SD, 17.2 minutes; range, 30-109 minutes). None of the patient- or target-related variables significantly impacted the duration, although lesions located in the anterior third of the breast showed a trend to prolong the procedure (p = 0.059). The time to complete a procedure was reduced when the operating radiologist was assisted by a breast imaging fellow-in-training (p = 0.01). Increasing numbers of image acquisitions and times the patient was moved in and out of the magnet significantly lengthened the procedure duration (p = 0.0001 for both). No major complications occurred. Biopsies yielded 16% (12/75) malignant and 84% (63/75) benign diagnoses. CONCLUSION Variables that minimized procedure duration were number of image acquisitions, number of patient insertions or removals from the magnet, and assistance of a breast imaging fellow-in-training. No patient-related or target-related variables impacted procedure time.

MR Imaging Assessment of the Breast after Breast Conservation Therapy: Distinguishing Benign from Malignant Lesions

Dynamic contrast material-enhanced magnetic resonance (MR) imaging has emerged as a valuable tool in evaluation of women who have undergone lumpectomy and whole-breast radiation therapy for breast cancer. Early diagnosis of local recurrence by means of close clinical and imaging follow-up is an important component of a breast-conserving strategy, as it may improve survival. In the post-breast conservation therapy (BCT) breast, resolving edema, fat necrosis, a small focal area of non-masslike enhancement (NMLE), and thin linear NMLE at the lumpectomy site can all be expected findings. In contrast, masslike enhancement or NMLE of ductal or segmental distribution can indicate recurrence. Therefore, at MR imaging of the post-BCT breast, it is important to identify lesions that are benign or appropriate for short-interval imaging surveillance to minimize unnecessary intervention, as well as to discern suspicious lesions and optimize the diagnosis of recurrence.

Screening Breast MRI in Patients Previously Treated for Breast Cancer: Diagnostic Yield for Cancer and Abnormal Interpretation Rate.

RATIONALE AND OBJECTIVES To determine the cancer detection rate and abnormal interpretation rate of screening breast magnetic resonance imaging (MRI) in previously treated breast cancer patients. MATERIALS AND METHODS Institutional review board-approved retrospective review of the breast MRI database from 2009 to 2011 identified a total of 3297 screening examinations. After excluding genetic mutation carriers, untested first-degree relatives of known mutation carriers, and patients with a history of chest irradiation, there were 1194 (36.2%) examinations in 691 patients previously treated for breast cancer. MRI reports were reviewed to determine MRI findings and breast imaging reporting and data system (BI-RADS) assessments. The longitudinal medical record was reviewed to determine patient demographics and outcomes of imaging surveillance and biopsy. RESULTS Mean patient age at initial cancer diagnosis was 46.1 years, and mean patient age during the study interval was 52 years. Cancer detection rate was 10 per 1000 (1%; 95% confidence interval [CI], 0.5%-1.8%]; 12 of 1194 examinations). Overall 10.7% (128 of 1194) of examinations received an abnormal interpretation, including 5.4% (65 of 1194) BI-RADS 4 or 5 and 5.3% (63 of 1194) BI-RADS 3 assessments with a 9.4% positive predictive value (PPV1; 12 of 128 examinations) and a 17.9% PPV3 (12 malignancies per 67 biopsies). CONCLUSIONS Screening breast MRI in women previously treated for breast cancer detected cancer in 1.0% of examinations, with a 10.7% abnormal interpretation rate, and a PPV for malignancy of 17.9%.

Metastatic patterns of breast cancer subtypes: What radiologists should know in the era of personalized cancer medicine

There is accumulating evidence that molecular phenotyping of breast cancer determines the timing, pattern, and outcome of metastatic disease. The most clinically relevant subtypes are hormonal-positive [oestrogen and progesterone receptor (ER/PR) positive], HER2 expressing, and triple-negative breast cancers (TNBCs). ER/PR-positive breast cancers demonstrate the best prognosis; however, metastases, in particular osseous disease, may develop much later. HER2-expressing breast cancers, although aggressive, have improved outcomes due to the advent of HER2-targeted therapies, with increased risk of central nervous system (CNS) relapses later. Finally, TNBCs present in younger women, BRCA1 mutations carriers, and carry the worst overall prognosis, with high incidence of CNS metastases, especially during the first 5 years of diagnosis. It is important for radiologists to understand the nuances of these breast cancer subtypes to predict metastatic behaviours and guide possible imaging surveillance.

What the emergency radiologist needs to know about treatment-related complications from conventional chemotherapy and newer molecular targeted agents

Emergency departments (ED) are increasingly utilized by oncology patients for disease- and treatment-related issues. With the increased use of new molecular targeted therapy (MTT) and conventional chemotherapeutic regimens, oncology patients present with a range of adverse treatment effects, some of which reveal characteristic injury patterns and imaging appearances. Knowledge of these imaging findings is critically important for early detection and prompt management in oncology patients. In this article, we present a brief review of conventional chemotherapeutic and new MTT regimens as well as address adverse reactions that bring oncology patients to the ED.