Tsun-Hou Chang

Incidentally Detected Enhancing Breast Lesions on Chest Computed Tomography

Objective To evaluate the nature and imaging appearance of incidental enhancing breast lesions detected on a routine contrast-enhanced chest CT. Materials and Methods Twenty-three patients with incidental enhancing breast lesions on contrast-enhanced chest CT were retrospectively reviewed. The breast lesions were reviewed by unenhanced and enhanced CT, and evaluated by observing the shapes, margins, enhancement patterns and backgrounds of breast lesions. A histopathologic diagnosis or long-term follow-up served as reference standard. Results Sixteen (70%) patients had malignant breast lesions and seven (30%) had benign lesions. In 10 patients, the breast lesions were exclusively detected on contrast-enhanced CT. Using unenhanced CT, breast lesions with fibroglandular backgrounds were prone to be obscured (p < 0.001). Incidental primary breast cancer showed an non-significant trend of a higher percentage irregular margin (p = 0.056). All of the four incidental breast lesions with non-mass-like enhancement were proven to be malignant. Conclusion Routine contrast-enhanced chest CT can reveal sufficient details to allow for the detection of unsuspected breast lesions, in which some cases may be proven as malignant. An irregular margin of incidental enhancing breast lesion can be considered a suggestive sign of malignancy.

Non-mass-like breast lesions at ultrasonography: Feature analysis and BI-RADS assessment ☆

OBJECTIVE To analyze the features of non-mass-like (NML) breast lesions on ultrasound (US) and determine their corresponding malignancy rate and to stratify these lesion patterns according to US BI-RADS categories. MATERIALS AND METHODS One hundred sixty-four consecutive lesions were retrospectively classified into four types according to the US features, the corresponding positive predictive values (PPVs) were obtained. Clinical, imaging, and histopathological findings were reviewed. RESULTS Among the 164 lesions, 39 (24%) were classified as type Ia, 14 (8%) as type Ib, 39 (24%) as type IIa, 19 (12%) as type IIb, 19 (12%) as type III, and 34 (21%) as type IV. The PPVs for malignancy were 21% for type Ia, 79% for type Ib, 10% for type IIa, 58% for type IIb, 16% for type III, and 21% for type IV. All NML lesions were classified as BI-RADS category 4a (type IIa), 4b (type Ia, III and IV) and 4c (type Ib and IIb) according to their PPVs. There was a significantly higher frequency of malignancy among lesions of type Ib and type IIb compared with the other types (P<0.01 for each). Lesions with associated calcifications, presence of abnormal axillary nodes, or a mammographic finding of suspected malignancy had a higher probability of malignancy (P<0.05 for each). CONCLUSION US is useful in clarifying the indication for biopsy of NML lesions. The types of US classifications used in our study establish reliable references for the NML patterns when stratified according to the BI-RADS categories.

Underestimation of invasive lesions in patients with ductal carcinoma in situ of the breast diagnosed by ultrasound-guided biopsy: A comparison between patients with and without HER2/neu overexpression☆

PURPOSE To determine the rate of underestimation of ductal carcinoma in situ (DCIS) diagnosed at imaging-guided biopsy and to analyze its association with HER2/neu oncogene, an important biomarker in assessing the tumour aggressiveness and guiding hormone therapy for breast cancer. METHODS We retrospectively reviewed 162 patients with DCIS diagnosed by imaging-guided core needle biopsy between January 2008 and March 2013. All of these patients received surgical excision, and in 25, the diagnosis was upgraded to invasive breast cancer. In this study, we examined the ultrasound, mammographic features and histopathological results for each patient, and compared these parameters between those with and without HER2/neu overexpression. RESULTS Of the 162 DCIS lesions, 110 (67.9%) overexpressed HER2/neu. Nineteen patients with HER2/neu overexpressing DCIS (n=19/110, 17.3%) were upgraded after surgery to a diagnosis of invasive breast cancer. In this group, the upgrade rate was highest in patients with a dilated mammary duct pattern (42.1%, n=8/19, p=0.02) and the presence of abnormal axillary nodes (40.0%, n=12/30, p<0.01) at ultrasound and was significantly associated with comedo tumour type on pathology. CONCLUSIONS Biopsy may underestimate the invasive component in DCIS patients. Sonographic findings of dilated mammary ducts and presence of abnormal axillary lymph nodes may help predicting the invasive components and possibly driving more targeted biopsy procedures.

Breast Nonmass Enhancement Detected with MRI: Uility and Lesion Characterization with Second-Look Ultrasonography.

The purpose of this study was to verify the utility of second‐look ultrasonography (US) in evaluating nonmass enhancement (NME) lesions detected on breast magnetic resonance imaging (MRI) by analysing its correlation and imaging features. From July 2008 to June 2012, 102 consecutive MRI‐detected NME lesions were subsequently evaluated with US. Lesions were evaluated according to the established Breast Imaging Reporting and Data System (BI‐RADS) lexicon. The correlation between MRI‐detected NME lesion characteristics, lesion size, histopathological findings and features at second‐look US were analysed. Second‐look US identified 44/102 (43%) of the NME lesions revealed by MRI. A US correlate was seen in 34/45 (76%) malignant lesions compared with 10/57 (18%) benign lesions (p < 0.0001). The likelihood of malignancy was significantly higher for NME lesions with a US correlate than lesions without: 34/44 (77%) versus 11/58 (19%) (p < 0.0001). The malignancy of the 44 (43%) MRI‐detected NME lesions with a US correlate was significantly associated with US lesion margins and BI‐RADS categories (p = 0.001 and 0.002 respectively). Second‐look US of MRI‐detected NME lesions is useful for decision‐making as part of the diagnostic workup. Familiarity with the US features associated with malignancy improves the utility of US in the workup of these NME abnormalities.

Atypical Pulmonary Metastases from a True Malignant Mixed Tumor of the Parotid Gland

A 58-year-old male patient presented with a recurrent true malignant mixed tumor of the parotid gland. Patchy pulmonary opacities were identified with a chest radiograph. Subsequently, a CT scan of the chest showed pulmonary parenchymal consolidation with amorphous calcifications. This abnormality was confirmed to be the result of a metastatic true malignant mixed tumor by using CT-guided biopsy. The current case demonstrated an extremely rare example of atypical pulmonary metastases from a true malignant mixed tumor of the parotid gland showing an air-space pattern and calcification.

Differentiation of Malignant and Benign Incidental Breast Lesions Detected by Chest Multidetector-Row Computed Tomography: Added Value of Quantitative Enhancement Analysis

To retrospectively determine the association between breast lesion morphology and malignancy and to determine the optimal value of lesion enhancement (HU, Hounsfield units) to improve the diagnostic accuracy of breast cancer in patients with incidental breast lesions (IBLs). A total of 97 patients with 102 IBLs detected from July 2009 to December 2012 were enrolled in this study. Two radiologists analyzed CT images for the presence of malignancy based on the morphology of the lesions alone and in combination with an enhancement value (HU) analysis. There were 36 malignant and 66 benign IBLs. When the morphology and enhancement values were combined, the sensitivity, specificity, and accuracy were 92%, 97%, and 95%, respectively, for reader 1 and 89%, 94%, and 92%, respectively, for reader 2. The addition of HU values led to correct changes in the diagnosis; specifically, the accuracy of the diagnosis of reader 1 and reader 2 improved by 6.9% and 11.8%, respectively. The addition of the enhancement value (HU) to the CT morphology improved the diagnostic accuracy in the differentiation of malignant from benign IBLs by using the region of interest (ROI) to measure the HU within the most suspicious part of the lesion.

The Values of Combined and Sub-Stratified Imaging Scores with Ultrasonography and Mammography in Breast Cancer Subtypes

Background and Objectives The Breast Imaging Reporting and Data System (BI-RADS) of Mammography (MG) and Ultrasonography (US) were equivalent to the “5-point score” and applied for combined and sub-stratified imaging assessments. This study evaluated the value of combined and sub-stratified imaging assessments with MG and US over breast cancer subtypes (BCS). Materials and Methods Medical records of 5,037 cases having imaging-guided core biopsy, performed from 2009 to 2012, were retrospectively reviewed. This study selected 1,995 cases (1,457 benign and 538 invasive cancer) having both MG and US before biopsy. These cases were categorized with the “5-point score” for their MG and US, and applied for combined and sub-stratified imaging assessments. Invasive cancers were classified on the basis of BCS, and correlated with combined and sub-stratified imaging assessments. Results These selected cases were evaluated by the “5-point score.” MG, US, and combined and sub-stratified imaging assessments all revealed statistically significant (P < 0.001) incidence of malignancy. The sensitivity was increased in the combined imaging score (99.8%), and the specificity was increased in the sub-stratified combined score (75.4%). In the sub-stratified combined imaging assessment, all BCS can be classified with higher scores (abnormality hierarchy), and luminal B subtype showed the most salient result (hierarchy: higher, 95%; lower, 5%). Conclusions Combined and sub-stratified imaging assessments can increase sensitivity and specificity of breast cancer diagnosis, respectively, and Luminal B subtype shows the best identification by sub-stratified combined imaging scoring.

Value of sonographically guided needle sampling of cystic versus solid components in the diagnosis of complex cystic breast masses

Background: The common practice for diagnosis of complex cystic breast masses (CCBM) may be imaging-guided aspiration or biopsy of cystic or solid components. Purpose: To assess the diagnostic value of sonographically guided needle sampling of cystic and solid components for CCBM. Material and Methods: Twenty patients with 20 CCBM underwent sonographically guided fine-needle aspiration biopsy (FNAB) for cystic components, followed by core needle biopsy (CNB) for residual solid components. The diagnostic results of each were evaluated. Excisional biopsy or mastectomy served as a reference standard. Results: Fourteen (70%) masses were malignant. Needle sampling for cystic components of the 14 malignant tumors showed malignancy in one (7%), atypia in four (29%), benign findings in four (29%), and insufficient samples in five (36%). Needle sampling for residual solid components showed malignancy in 11 (79%), atypia in two (14%), and insufficient sample in one (7%). The diagnostic yield of needle sampling of solid components was significantly higher than that of cystic components for malignant CCBM (P<0.05). Sixteen (80%) of 20 CCBMs showed bloody fine-needle aspirates. There was no significant difference between the rates of bloody aspirates of malignant and benign CCBM (86% vs. 67%, P=0.55). Conclusion: Sonographically guided needle sampling of solid components may help to identify most malignant CCBMs, and the aspirated fluid may be discarded due to low diagnostic value.

T1-Weighted Dynamic Contrast-Enhanced Magnetic Resonance Imaging (DCE-MRI) to Distinguish Between Concurrent Cholesterol Granuloma and Invasive Ductal Carcinoma of the Breast: A Case Report

Patient: Female, 52 Final Diagnosis: Cholesterol granuloma of the breast Symptoms: Follow up Medication: — Clinical Procedure: Surgical excision Specialty: Radiology Objective: Rare disease Background: Cholesterol granuloma is a benign condition that can be misdiagnosed as breast cancer on mammographic and ultrasound imaging. A case of concomitant cholesterol granuloma with invasive ductal carcinoma of the left breast was imaged with ultrasound elastography and magnetic resonance imaging (MRI) methods, including T1-weighted dynamic contrast-enhanced MRI (DCE-MRI), before biopsy and histopathology. Case Report: A 52-year-old woman, with a previous history of intraduct papillomas in both breasts, underwent six-monthly follow-up breast imaging. The most recent breast mammogram showed a progressively enlarging oval mass in the upper inner quadrant (UIQ) of the left breast, and an adjacent irregular mass with microcalcifications. Virtual Touch IQ (VTIQ) shear wave elastography was used with ultrasound of the breast lesions. T1-weighted fat saturation (T1WFS) MRI, T2-weighted short-tau inversion recovery (STIR) MRI, and T1-weighted DCE-MRI were used to image the left breast. T1-weighted DCE-MRI showed that the oval lesion had a high T1-weighted signal and mild progressive enhancement, with a Type I (benign) time-signal intensity curve; the second, irregular, mass showed rapid, intense enhancement with a washout pattern or Type III (malignant) time-signal intensity curve. Histopathology confirmed that the oval mass was a cholesterol granuloma, and the irregular mass was an invasive ductal carcinoma. Conclusions: A case of concomitant cholesterol granuloma with invasive ductal carcinoma of the left breast, showed that ultrasound with shear wave elastography and T1-weighted DCE-MRI could distinguish between cholesterol granuloma and invasive ductal carcinoma.