Sung Eun Song

Undiagnosed Breast Cancer: Features at Supplemental Screening US

PURPOSE To retrospectively investigate the reasons for and features of undiagnosed cancers at previous supplemental screening ultrasonography (US) in women who subsequently received a diagnosis of breast cancer. MATERIALS AND METHODS The institutional review board approved this retrospective study and waived the requirement to obtain informed patient consent. The study consisted of 230 women (median age, 49 years; age range, 29-81 years) with 230 pairs of US examinations (prior and subsequent examinations) performed between December 2003 and August 2013 who were found to have cancer (median interval, 12 months; range, 2-24 months). The authors compared the clinical-pathologic features of patients with negative findings on prior images with those of patients with visible findings on prior images. Findings visible at prior US were classified as actionable or underthreshold by means of a blinded review by five radiologists. Lesions classified as Breast Imaging Reporting and Data System category 4 or 5 by fewer than three readers were determined to be underthreshold. Reasons for undiagnosed cancers and their imaging features were analyzed. RESULTS Among the 230 prior US examinations, 72 (31.3%) showed visible findings and 158 (68.7%) showed negative findings. High-nuclear-grade cancers and triple-negative cancers were more common in patients with negative findings than in those with visible findings (P = .023 and P = .006, respectively). Blinded review revealed that 57 of the 72 visible findings (79%) were actionable. Misinterpretation (39% [28 of 72 lesions]) and multiple distracting lesions (17% [12 of 72 lesions]) were the two most common reasons for missing these actionable findings, which showed more noncircumscribed margins than did underthreshold findings (P = .028). CONCLUSION At supplemental screening breast US, close attention should be paid to the presence of a margin that is not circumscribed, and multiple lesions should be separately assessed to reduce the number of missed breast cancers.

Additional value of diffusion-weighted imaging to evaluate multifocal and multicentric breast cancer detected using pre-operative breast MRI

ObjectivesTo investigate whether diffusion-weighted imaging (DWI) aids pre-operative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to evaluate additional lesions in breast cancer patients.MethodsDCE-MRI and DWI were performed on 131 lesions, with available histopathological results. The apparent diffusion coefficient (ADC) of each lesion was measured, and the cut-off value for differentiation between malignant and benign lesions was calculated. A protocol combining the ADC cut-off value with DCE-MRI was validated in a cohort of 107 lesions in 77 patients.ResultsWhen an ADC cut-off value of 1.11 × 10-3 mm2/s from the development cohort was applied to the additional lesions in the validation cohort, the specificity increased from 18.9% to 67.6% (P < 0.001), and the diagnostic accuracy increased from 61.7% to 82.2% (P = 0.05), without significant loss of sensitivity (98.6% vs. 90.0%, P = 0.07). The negative predictive values of lesions in the same quadrant had decreased, as had those of lesions ≥1 cm in diameter. The ADC cut-off value in the validation cohort was 1.05 × 10-3 mm2/s.ConclusionsAdditional implementation of DWI for breast lesions in pre-operative MRI can help to obviate unnecessary biopsies by increasing specificity. However, to avoid missing cancers, clinicians should closely monitor lesions located in the same quadrant or lesions ≥1 cm.Key Points• DWI can be used to further differentiate lesions during pre-operative cancer staging.• ADC cut-off values were similar in the development and validation cohorts.• DWI improves both PPV and NPV in cases of multicentric lesions.• DWI improves both PPV and NPV in lesions <1 in diameter.• NPVs are decreased in multifocal lesions and lesions ≥1 cm in diameter.

Association between US features of primary tumor and axillary lymph node metastasis in patients with clinical T1–T2N0 breast cancer

Background Most patients with early-stage breast cancer have clinically negative lymph nodes (LNs). However, 15–20% of patients have axillary nodal metastasis based on the sentinel LN biopsy. Purpose To assess whether ultrasound (US) features of a primary tumor are associated with axillary LN metastasis in patients with clinical T1–T2N0 breast cancer. Material and Methods This retrospective study included 138 consecutive patients (median age = 51 years; age range = 27–78 years) who underwent breast surgery with axillary LN evaluation for clinically node-negative T1–T2 breast cancer. Three radiologists blinded to the axillary surgery results independently reviewed the US images. Tumor distance from the skin and distance from the nipple were determined based on the US report. Association between US features of a breast tumor and axillary LN metastasis was assessed using a multivariate logistic regression model after controlling for clinicopathologic variables. Results Of the 138 patients, 28 (20.3%) had nodal metastasis. At univariate analysis, tumor distance from the skin (P = 0.019), tumor size on US (P = 0.023), calcifications (P = 0.036), architectural distortion (P = 0.001), and lymphovascular invasion (P = 0.049) were associated with axillary LN metastasis. At multivariate analysis, shorter skin-to-tumor distance (odds ratio [OR] = 4.15; 95% confidence interval [CI] = 1.01–16.19; P = 0.040) and masses with associated architectural distortion (OR = 3.80; 95% CI = 1.57–9.19; P = 0.003) were independent predictors of axillary LN metastasis. Conclusion US features of breast cancer can be promising factors associated with axillary LN metastasis in patients with clinically node-negative early-stage breast cancer.

Extensive silicone lymphadenopathy after breast implant insertion mimicking malignant lymphadenopathy

Silicone implants are widely used in aesthetic and reconstructive breast surgery. Silicone lymphadenopathy is a well-known rare complication of implant insertion. Silicone leakage from a rupture or silicone bleeding can accumulate in lymph nodes. Foreign body reactions in the affected lymph nodes may be misdiagnosed as metastasis or malignant lymphadeno pathy upon initial presentation if silicone lymphadenopathy is not considered in the initial diagnosis. We report a case of siliconoma with extensive involvement of multiple lymph nodes mimicking malignant features to emphasize that clinicians should carefully evaluate each patients medical history and disease status during differential diagnosis.

Intravoxel Incoherent Motion Diffusion-Weighted MRI of Invasive Breast Cancer: Correlation With Prognostic Factors and Kinetic Features Acquired With Computer-Aided Diagnosis: Correlation of IVIM Marker and Kinetic Feature

As both intravoxel incoherent motion (IVIM) modeling and dynamic contrast‐enhanced magnetic resonance imaging (DCE‐MRI) provide perfusion parameters, IVIM‐derived perfusion parameters might be expected to correlate with the kinetic features from DCE‐MRI.

Significance of microvascular evaluation of ductal lesions on breast ultrasonography: Influence on diagnostic performance

We aim to investigate the significance of microvascular ultrasonography in breast ductal lesions for distinguishing benign from malignant lesions. Sixty-two ductal lesions were evaluated with gray-scale and three Doppler techniques before biopsy, Superb Microvascular Imaging (SMI), color Doppler (CDI), and power Doppler imaging (PDI). We evaluated number, distribution, and morphology of vessels. The area under the ROC curve of combined use of Doppler imaging was greater than that of gray-scale only and SMI had higher value than CDI and PDI (p < 0.05). Microvascular ultrasonography improves diagnostic performance that distinguishes benign from malignant breast ductal lesions, and SMI is superior to CDI and PDI.

Diagnostic performances of supplemental breast ultrasound screening in women with personal history of breast cancer

Background Supplemental breast ultrasonography (US) has been used as a surveillance imaging method in women with personal history of breast cancer (PHBC). However, there have been limited data regarding diagnostic performances. Purpose To evaluate diagnostic performances of supplemental breast US screening for women with PHBC and to compare with those for women without PHBC. Material and Methods Between 2011 and 2012, 12,230 supplemental US exams were performed in 12,230 women with negative mammograms: 6584 women with PHBC and 5646 women without PHBC. Cancer detection rate, interval cancer rate, abnormal interpretation rate, positive predictive values (PPVs), sensitivity, and specificity were calculated and compared. Results Overall cancer detection rate and first-year interval cancer rate were 1.80/1000 exams and 0.91/1000 negative exams, both of which were higher in women with PHBC than in women without PHBC (2.88 vs. 0.53 per 1000, P = 0.003; 1.50 vs. 0.20 per 1000, P = 0.027). Abnormal interpretation rate was lower in the women with PHBC than in women without PHBC (9.1% vs. 12.1%, P < 0.001). Sensitivity was not different (67.9% vs. 75.0%, P = 1.000), whereas specificity and PPV3 were higher in women with PHBC than in women without PHBC (91.2% vs. 88.0%, P < 0.001; 22.6% vs. 3.1%, P < 0.001). The majority of detected cancers in women with PHBC (78.9%, 15/19) were stage 0 or 1. Conclusion Supplemental breast US screening increases early stage second breast cancers with high specificity and PPV3 in women with PHBC, however, high interval cancer rate in younger women with PHBC should be noted.