V. Girardi

Branch duct IPMTs: value of cross-sectional imaging in the assessment of biological behavior and follow-up.

Branch duct intraductal papillary mucinous tumors (IPMTs) are increasingly being described and represent a challenge for the physician. Recent imaging modalities, especially computed tomography and magnetic resonance, allow for a correct diagnosis, but IPMTs can manifest with different degrees of cellular atypia so it is very important to be able to establish the biological behavior of the lesion. Sixty-five patients were included in this study: 29 of them underwent surgery, and the other 36 were followed with cross-sectional imaging. Among patients who underwent surgery, 11 had benign lesions and 18 had malignant lesions. Overall sensitivity, specificity, and accuracy in the diagnosis of malignancy for all the cross-sectional imaging techniques were 61%, 81%, and 69%, respectively. Among patients who were followed and had a magnetic resonance cholangiopancreatographic diagnosis of branch duct IPMT with imaging features indicative of benignity, only two showed modifications over the follow-up period. Even considering some important biases (small number of patients and relatively short follow-up), interesting conclusions can be drawn: the imaging diagnosis of malignancy can be trusted, whereas that of benignity cannot be relied upon, but if the signs of malignancy are absent, the slow growth of the lesions justifies watchful follow-up in the correct clinical setting.

Autoimmune pancreatitis: imaging findings on contrast-enhanced MR, MRCP and dynamic secretin-enhanced MRCP.

PurposeThis study retrospectively determined magnetic resonance (MR), MR cholangiopancreatography (MRCP) and secretin-MRCP findings in patients with autoimmune pancreatitis (AIP).Materials and methodsThe MR examinations of 28 patients with histopathologically proven AIP were reviewed. In 14 cases, secretin-enhanced MRCP was performed. The observers evaluated pancreatic parenchymal enlargement, signal intensity abnormalities, enhancement, vascular involvement, bile-duct diameter and main pancreatic duct (MPD) narrowing (diffuse/focal/segmental). After secretin administration, the presence of the “duct-penetrating” sign was evaluated.ResultsMR imaging showed diffuse pancreatic enlargement in 8/28(29%) cases, focal pancreatic enlargement in 16/28 (57%) cases and no enlargement in 4/28 (14%) cases. The alteration of pancreatic signal intensity was diffuse in 8/28 (29%) cases (eight diffuse AIP) and focal in 20/28 (71%) cases (20 focal AIP). Delayed pancreatic enhancement was present in all AIP, with peripheral rim of enhancement in 8/28 (29%) AIP (1/8 diffuse, 7/20 focal); vascular encasement was present in 7/28 (25%) AIP (1/8 diffuse, 6/20 focal); distal common bile duct narrowing was present in 12/28(43%) AIP (5/8 diffuse, 7/20 focal). MRCP showed MPD narrowing in 17/28 (61%) AIP (4/8 diffuse, 15/20 focal), MPD dilation in 8/28(29%) AIP (3/8 diffuse, 5/20 focal) and normal MPD in1/8 diffuse AIP. Secretin-MRCP showed the duct-penetrating sign in 6/14(43%) AIP (one diffuse AIP with MPD segmental narrowing, five focal AIP with MPD focal narrowing), demonstrating integrity of the MPD.ConclusionsDelayed enhancement and MPD stenosis are suggestive for AIP on MR and MRCP imaging. Secretin-enhanced MRCP is a problem-solving tool in the differential diagnosis between focal AIP and ductal adenocarcinoma.RiassuntoObiettivoScopo di questo lavoro è stato valutare i rilievi di pancreatite autoimmune (AIP) nella revisione retrospettiva delle immagini di risonanza magnetica (RM), colangiopancreatografia-RM (CPRM) e CPRM con secretina.Materiali e metodiÈ stata valutata l’indagine RM di 28 pazienti con diagnosi patologica di AIP; in 14 casi è stato espletato l’esame CPRM con somministrazione di secretina. Le immagini sono state analizzate considerando i seguenti parametri: volume del pancreas, alterazioni dell’intensità di segnale del parenchima, impregnazione del pancreas, coinvolgimento vascolare, calibro delle vie biliari e restringimento (diffuso/focale/segmentale) del dotto pancreatico principale (DPP). Dopo somministrazione di secretina, è stata verificata la presenza del segno del “dotto penetrante”.RisultatiL’esame RM ha evidenziato un incremento dimensionale diffuso del pancreas in 8/28 (29%) casi, un ingrandimento di una parte del pancreas - focale - in 16/28 (57%) casi e pancreas di regolare dimensione in 4/28 (14%) casi. L’alterazione dell’intensità di segnale del pancreas era diffusa in 8/28 (29%) casi (8 AIP di tipo diffuso) e focale in 20/28 (71%) casi (20 AIP di tipo focale). Impregnazione pancreatica tardiva con “cercine” periferico iperintenso si è rilevata in 8/28 (29%) AIP (1/8 AIP di tipo diffuso, 7/20 AIP di tipo focale); “encasement” vascolare è stato dimostrato in 7/28 (25%) AIP (1/8 AIP di tipo diffuso, 6/20 AIP di tipo focale); restringimento del dotto biliare comune è stato rilevato in 12/28 (43%) AIP (5/8 AIP di tipo diffuso, 7/20 AIP di tipo focale). L’esame CPRM ha mostrato restringimento del DPP in 17/28 (61%) AIP (4/8 AIP di tipo diffuso, 15/20 AIP di tipo focale), dilatazione del DPP in 8/28 (29%) AIP (3/8 AIP di tipo diffuso, 5/20 AIP di tipo focale), e DPP normale in 1 AIP di tipo diffuso. L’esame CPRM con secretina ha fatto rilevare il segno del “dotto penetrante” in 6/14 (43%) AIP (1 caso di AIP diffusa con restringimento segmentale del DPP, 5 casi di AIP focale con restringimento focale del DPP) dimostrano l’integrità del DPP.ConclusioniAll’indagine RM e CPRM, il pattern di impregnazione tardivo e l’assotigliamento del DPP sono reperti suggestivi di AIP. La somministrazione di secretina durante l’esame CPRM è uno strumento utile nella diagnosi differenziale tra AIP di tipo focale e adenocarcinoma duttale.

Utility of second-look ultrasound in the management of incidental enhancing lesions detected by breast MR imaging

PurposeTo assess the utility of second-look ultrasound (US) for identifying and characterising incidental enhancing lesions detected by breast magnetic resonance imaging (MRI).Materials and methodsFrom among 655 consecutive breast MRI studies, 62 lesions (MRI visible, nonpalpable, occult at first-look US and mammography) were recommended for second-look US. MRI enhancement of lesions was mass-like in 59 cases (95%) and non-mass-like in three (5%). Forty-two lesions (68%) were ≤10 mm; only three lesions (5%) were >20 mm. Of all lesions, the Breast Imaging Reporting and Data System (BI-RADS) MRI category was highly suggestive of malignancy in six cases (10%), suspicious abnormality in 33 (53%) and probably benign in 23 (37%). The correlation between MRI lesion appearance, lesion size, histopathology findings and detection rate at second-look US were analysed. The reference standard was histopathology and/or follow-up (range 18–24 months). Statistical analysis was performed with the Fisher exact test.ResultsSecond-look US identified 44 out of 62 (71%) lesions depicted at MRI. The detection rate at second-look US was higher for mass-like MRI lesions (75%) than nonmass-like lesions (0%), for lesion size >10mm (90%) and for BI-RADS 4 lesions (88%). Second-look US-guided biopsy detected 12 out of 17 (71%) malignant lesions. There was no correlation between the likelihood of carcinoma and the presence of a sonographic correlate.ConclusionsSecond-look US is a reliable problemsolving tool in identifying and characterising most incidental MRI findings. It contributes to accurately selecting the cases in which MRI-guided biopsy is required.RiassuntoObiettivoLo scopo del lavoro è stato verificare l’utilità del second look ecografico nella identificazione e nella tipizzazione delle lesioni incidentali alla risonanza magnetica (RM) mammaria.Materiali e metodiÈ stata effettuata un’analisi retrospettiva di 62 lesioni identificate incidentalmente dalla RM, non palpabili e occulte alla mammografia ed ecografia espletate prima della RM. L’impregnazione delle lesioni era tipo massa in 59 casi (95%) e non massa in 3 casi (5%). Quarantadue lesioni (68%) erano ≤10 mm; solo 3 lesioni (5%) erano >20 mm. Il grado di sospetto RM era alla classificazione breast imaging reporting and data system (BI-RADS) 5 in 6 casi (10%), BI-RADS 4 in 33 casi (53%), BI-RADS 3 in 23 casi (37%). Le lesioni RM con corrispettivo reperto al second look ecografico sono state analizzate riguardo: aspetto RM, dimensioni, sospetto radiologico, diagnosi istologica. Il gold standard è stato l’esame patologico o il follow-up clinico e strumentale a 24 mesi. I risultati sono stati analizzati con il test statistico di Fisher (significatività: p<0,05).RisultatiIl second look ecografico ha identificato 44/62 (71%) lesioni incidentali alla RM mammaria. Il numero di lesioni identificate con il second-look è stato superiore in caso di impregnazione di tipo massa (75%), lesioni con dimensioni >10 mm (90%) e con BI-RADS 4 (88%). Dodici/44 (27%) lesioni identificate dal second look ecografico erano maligne e 5/18 (27%) lesioni prive di traduzione ecografica erano maligne. Il prelievo guidato dal second look ecografico ha caratterizato 12/17 (71%) lesioni maligne.ConclusioniIl second look ecografico è una valida metodica nel management delle lesioni identificate incidentalmente dalla RM mammaria in quanto consente l’identificazione e la caratterizzazione della maggioranza di esse e l’accurata selezione di quelle da avviare a procedure RM-guidate.

Collateral branches IPMTs: secretin-enhanced MRCP

Recently, the fantastic evolution of imaging modalities (especially MR, MDCT, EUS) has raised many issues regarding the correct classification of smaller and smaller lesions, their preoperative evaluations, and indications of most appropriate treatment. However, it is still debated which technique should be employed for the diagnosis and the follow-up of intraductal papillary mucinous tumours (IPMTs). Despite the superb spatial resolution of MDCT, nowadays most of the authors agree on considering MR with magnetic resonance cholangiopancreatography (MRCP) the imaging modality of choice in studying IPMTs. In particular, MRCP is rapid, non-invasive, and accurate in detecting, localizing, and correctly classifying IPMT. The diagnostic performance of MRCP is even improved after the introduction of secretin stimulation. In fact, dynamic MRCP studies after secretin administration, besides facilitating the depiction of the structural characteristics of the lesions, make easier the detection of the communicating duct of branch duct IPMTs with the main pancreatic duct, especially if the newest high resolution 3D heavily T2-weighted sequences are utilized. Secretin stimulation is also useful in the demonstration of early changes of associated chronic pancreatitis. Consequently, we believe that secretin-enhanced MRCP is the most suitable imaging modality in the diagnosis and follow-up of IPMTs of the collateral branches.

Assessment of pelvic endometriosis: correlation of US and MRI with laparoscopic findings.

Purpose.The purpose of this study was to evaluate the contribution of ultrasound (US) and magnetic resonance (MR) imaging in the diagnosis and local staging of endometriosis by comparing results with laparoscopic findings.Materials and methods.We evaluated 36 consecutive women with suspected or clinically diagnosed endometriosis. Thirty–two out of 36 patients met the following inclusion criteria: transabdominal and endocavitary (US) examination and MR imaging, followed by laparoscopy performed within 2 weeks. US and MR findings were classified based on location, number and morphology (small nodules, large nodules, laminar lesions, cystic lesions, complex lesions, adhesions, cul–de–sac obliteration).Results.Laparoscopy, considered the gold standard, identified 143 lesions in 32 patients. US detected 101 lesions, and MR detected 92 lesions, which were subsequently divided by morphologic appearance. Sensitivity and specificity of the two imaging techniques in the recognition of the different locations were 58% and 25%, respectively, for US and 56% and 50%, respectively, for MR imaging. Results of the two techniques in the different locations examined were similar, with the exception of lesions in the rectovaginal septum, which were better detected by US, and for adhesions and cul–de–sac obliteration, which were more easily detected by MR.Conclusions.Both US and MR are accurate in the diagnosis of endometriosis. There are no significant differences in staging of pelvic endometriosis between US and MR. US examination is the primary evaluation in cases of suspected disease and for the rectovaginal septum. MR examination is recommended for correct classification in doubtful cases and in cases of suspected extrapelvic lesions and adhesions.

Multifocal, multicentric and contralateral breast cancers: breast MR imaging in the preoperative evaluation of patients with newly diagnosed breast cancer

PurposeThis study was done to verify the usefulness of preoperative breast magnetic resonance (MR) imaging in patients with newly diagnosed breast cancer.Materials and methodsA retrospective analysis of 291 patients with invasive breast cancer newly diagnosed with conventional breast imaging (mammography and ultrasound) was performed. All patients underwent MR imaging prior to surgery. The MR imaging detection rate of additional malignant cancers occult to mammography and ultrasound was calculated. Data were analysed with Fisher’s exact test (p<0.05) according to the following parameters: histopathological features of the index tumour (histological type and size) and mammographic density [according to the Breast Imaging Reporting and Data System (BI-RADS) classification from 1 fatty to 4 dense). The gold standard was the histological examination on the surgical specimen.ResultsMR imaging identified 40 mammographically and sonographically occult malignant lesions other than the index cancer in 27/291 patients (9%). These additional cancers were located in the same quadrant as the index cancer in 13 women (4%), in a different quadrant in 12 (4%) and in the contralateral breast in the remaining two (1%). The cancer detection rate in the subgroup of index cancers with lobular histological type was 25%, significantly higher (p=0.03) than the detection rate of 11% recorded in the subgroup of ductal cancers. The cancer detection rate in the subgroup of index cancers >2 cm was 27%, significantly higher (p=0.001) than the rate of 8% found in the subgroup of index cancers <2 cm. Mammographic density was not correlated (p=0.48) with MR detection of additional cancer, with 14% of additional malignancies being detected in both dense and fatty breasts.ConclusionsIn patients with newly diagnosed invasive breast cancer, preoperative MR imaging is useful for detecting additional synchronous malignancies that are not detected on conventional breast imaging. The cancer detection rate is 9%. The use of preoperative MR imaging as an adjunct to conventional breast imaging in women with an infiltrating lobular index cancer and an index cancer >2 cm is especially beneficial.RiassuntoObiettivoVerificare l’utilità dell’esecuzione della risonanza magnetica (RM) mammaria preoperatoria in pazienti con carcinoma invasivo della mammella.Materiali e metodiSono state analizzate retrospettivamente 291 pazienti con carcinoma invasivo della mammella sottoposte a mammografia, ecografia e RM prima di intervento chirurgico. È stato calcolato il tasso diagnostico aggiuntivo di lesioni maligne sincrone rispetto al tumore principale identificate dalla sola RM, occulte alla mammografia e all’ecografia. I dati sono stati analizzati con il test esatto di Fisher (p<0,05) secondo i seguenti parametri: caratteri istologici della lesione principale (istotipo tumorale e dimensione), densità mammografica (classificazione Breast Imaging Reporting and Data System [BI-RADS] in categorie da 1=adiposa a 4=densa). Il gold standard è stato l’esame istologico del pezzo operatorio.RisultatiL’indagine RM ha diagnosticato 40 lesioni maligne sincrone in 27/291 Pazienti (tasso diagnostico: 9%). Le lesioni maligne identificate dalla RM erano nello stesso quadrante rispetto alla lesione principale in 13 pazienti (4%), interessavano un altro quadrante in 12 pazienti (4%) e la mammella controlaterale nei rimanenti 2 pazienti (1%). Una correlazione significativa positiva (p=0,03) è emersa tra il tasso di identificazione RM di lesione maligna e istotipo lobulare del carcinoma principale (lesioni maligne sincrone sono state rilevate nel 25% dei tumori lobulari vs 11% dei tumori duttali). Una correlazione significativa (p=0,001) è stata osservata tra identificazione RM di lesione maligne e dimensione della lesione principale superiore a 2 cm (lesioni maligne sincrone sono state diagnosticate dalla RM nel 27% dei tumori superiori a 2 cm vs 8% dei tumori inferiori a 2 cm). L’aspetto radiologico della densità mammaria non è risultato correlato (p=0,48) con l’incidenza di malignità, in quanto lesioni maligne sincrone sono state trovate nel 14% dei casi sia con seno denso che adiposo.ConclusioniIn pazienti con neoplasia mammaria infiltrante, l’indagine RM preoperatoria è utile nella ricerca di lesioni occulte e identifica foci multipli sincroni alla lesione principale nel 9% delle Pazienti. Il tasso diagnostico è superiore quando la neoplasia principale ha istotipo lobulare e dimensioni >2 cm.

Breast ultrasound in 22,131 asymptomatic women with negative mammography.

PURPOSE To evaluate increment cancer detection rate generated by ultrasound (US). MATERIALS AND METHODS US only detected cancers were assessed for 22,131 self-referring asymptomatic women with negative mammography and subgroups by age, previous cancer, breast density. Invasive assessment and surgical biopsy rate were evaluated. RESULTS The overall US detection was 1.85 per thousand (41/22,131). In the subgroups it was: 1.95 per thousand (22/11,274) in women <50 years vs 1.75 per thousand (19/10,857) in women ≥ 50 years (p = 0.42), 5.49 per thousand (12/2183) in women with previous cancer vs 1.45 per thousand (29/19,948) in women without cancer history (p = 0.0004), 2.21 per thousand (22/9960) in dense breasts (p = 0.17) vs 1.56 per thousand (19/12,171) in fatty breasts. The US generated invasive assessment was 1.9% (422/22,131). The benign to malignant open surgical biopsy ratio was 0.17 (7/41). CONCLUSION Adding US to negative mammography allowed for substantial incremental cancer detection rate (1.85 per thousand), particularly at age <50 years, in women with previous breast cancer and in dense breasts.

Combined radiofrequency and kyphoplasty in painful osteolytic metastases to vertebral bodies

PurposeThe aim of this study was to assess retrospectively the safety and efficacy of combined radiofrequency (RF) and kyphoplasty (KP) in managing painful osteolytic metastases to vertebral bodies resistant to conservative treatments.Materials and methodsEleven patients (9 women and 2 men; mean age 68 years; age range 58–82) with painful osteolytic vertebral body metastases unresponsive to conservative treatments underwent RF combined with KP under general anaesthesia. Primary neoplasms were kidney carcinoma (n=1), breast carcinoma (n=1), thyroid carcinoma (n=2) and multiple myeloma (n=7). Lesion levels were cervical (n=1), thoracic (n=9) and lumbar (n=1). Combined RF and KP was well-tolerated by all patients. The procedures were performed using fluoroscopic guidance and intraoperative neurophysiology monitoring. Pain relief with the visual analogue scale (VAS) pain score and analgaesic consumption were evaluated before and after treatment.ResultsNo complication occurred. In one case, we observed an asymptomatic cement leakage. Pain significantly decreased after treatment: the mean VAS pain score before treatment was 8 (range 7–10) vs. 1.8 (range 0–3) and 1.9 (range 1–3), respectively, 72 h and 6 weeks after the treatment. Analgaesic reduction was achieved in all patients.ConclusionsRF combined with KP represents a potential alternative method for palliation of painful spinal osteolytic metastases in selected patients. The procedures are safe and provide pain relief with bone augmentation and improvement in quality of life.RiassuntoObiettivoScopo di questo studio è stato valutare retrospettivamente la sicurezza e l’efficacia dell’utilizzo combinato di radiofrequenza (RF) e cifoplastica (CP) per il trattamento del dolore correlato a lesioni osteolitiche metastatiche del corpo vertebrale resistente ai trattamenti conservativi standard.Materiali e metodiUndici pazienti (9 donne e 2 uomini), con età media di 68 anni (range 58–82), affetti da metastasi osteolitiche del soma vertebrale associate a dolore resistente ai trattamenti conservativi standard, sono stati sottoposti all’utilizzo combinato di RF e CP in anestesia generale. Le neoplasie primitive erano di origine renale (n=1), mammaria (n=1), tiroidea (n=2), e mielomatosa (n=7). Il livello della lesione era cervicale (n=1), toracico (n=9) e lombare (n=1). La procedura combinata di RF e CP è stata ben tollerata da tutti i pazienti. Le procedure sono state eseguite con l’ausilio dell’amplificatore di brillanza e del monitoraggio neurofisiologico intraoperatorio. La riduzione del dolore, considerata secondo la scala analogica del dolore (VAS), e l’assunzione di farmaci analgesici, sono stati valutati prima del trattamento, dopo 72 ore e a 6 settimane dalla procedura.RisultatiNon si sono verificate complicazioni. Il dolore è significativamente diminuito dopo il trattamento: il valore medio era di 8 (range 7–10) prima del trattamento, passando a 1,8 (range 0–3) 72 ore dopo il trattamento e quindi a 1,9 (range 1–3) a 6 settimane dalla procedura. La riduzione nell’assunzione di farmaci analgesici è stata documentata in tutti i pazienti.ConclusioniL’utilizzo combinato di RF e CP rappresenta una potenziale alternativa di trattamento palliativo per le lesioni osteolitiche metastatiche del corpo vertebrale in pazienti selezionati. La procedura si dimostra sicura, permettendo di ottenere una significativa riduzione del dolore, un effetto di stabilizzazione del corpo vertebrale ed un miglioramento della qualità di vita.

Inflammatory breast carcinoma and locally advanced breast carcinoma: characterisation with MR imaging

PurposeThis study was done to identify the typical magnetic resonance (MR) imaging findings of inflammatory breast carcinoma (IBC) in comparison with noninflammatory locally advanced breast carcinoma (LABC).Materials and methodsMR images of 30 patients with IBC (T4d) were compared with those of a cohort of 30 patients with LABC (T3/T4a–c). The age distribution was approximately equal in the two groups. MR images were assessed for the following features: skin thickening (>4 mm), skin oedema, architectural distortion, enhancement pattern (mass-like/non-mass-like), time-signal intensity curve (continuous-persistent type/wash-out type), skin enhancement. Fisher’s exact text was used to compare MR imaging appearances of IBC and LABC (significant p value <0.05).ResultsSkin involvement and enhancement pattern differed between groups: skin thickening was present in 16/30 IBC (53%) vs 8/30 LABC cases (27%, p=0.06), skin oedema was present in 26/30 IBC (87%) vs 8/30 LABC (27%, p < 0.0001), and skin enhancement in 10/30 IBC (33%) vs 2/30 LABC (7%, p=0.02); non-mass-like enhancement was present in 22/30 IBC (73%) vs 12/30 LABC (40%, p=0.02).ConclusionsIBC is a distinct clinical and pathological entity resulting in typical MR imaging features. Skin changes (thickening, oedema, enhancement) related to neoplastic involvement of the dermal lymphatics are suggestive of IBC and should prompt a skin biopsy to confirm or rule out the diagnosis.RiassuntoObiettivoObiettivo di questo lavoro è stato verificare l’esistenza di rilievi in risonanza magnetica (RM) specifici di carcinoma infiammatorio e dimostrarne l’accuratezza nella differenziazione del carcinoma infiammatorio (IBC) rispetto al tumore mammario localmente avanzato (LABC).Materiali e metodiLe indagini RM mammarie di 30 pazienti con carcinoma infiammatorio (T4d) sono state esaminate confrontandole con quelle del gruppo di controllo costituito da 30 pazienti con carcinoma localmente avanzato non infiammatorio T3/T4a–c). L’età delle pazienti era distribuita in maniera analoga nei due gruppi. Gli aspetti RM analizzati sono stati: ispessimento della cute (>4 mm), edema cutaneo, distorsione architetturale, pattern di impregnazione (tipo massa/tipo non-massa), curva dell’intensità di segnale nel tempo (tipo continuativo/persistente/tipo wash-out), impregnazione della cute. Il test esatto di Fischer è stato utilizzato per confrontare i rilievi RM nei casi di carcinoma infiammatorio rispetto a quelli di carcinoma localmente avanzato (significatività p<0,05).RisultatiComparando i rilievi RM nel carcinoma infiammatorio rispetto al tumore localmente avanzato sono state osservate significative differenze per quanto riguarda le alterazioni cutanee — più frequenti nel carcinoma infiammatorio — e il pattern di impregnazione. In particolare, ispessimento cutaneo si è rilevato in 16/30 (53%) IBC vs 8/30 (27%) LABC (p=0,06), edema cutaneo era presente in 26/30 (87%) IBC vs 8/30 (27%) LABC (p<0,0001), impregnazione della cute in 10/30 (33%) IBC vs 2/30 (7%) LABC (p=0,02); impregnazione diffusa tipo non-massa in 22/30 (73%) IBC vs 12/30 (40%) LABC (p=0,02).ConclusioniIl carcinoma infiammatorio rappresenta un’entità clinica e biologica distinta dal carcinoma localmente avanzato risultante in peculiari rilievi RM. Le alterazioni della cute (ispessimento, edema, impregnazione) sostenute dall’infiltrazione neoplastica dei linfatici del derma sono segni suggestivi di carcinoma infiammatorio e devono guidare al controllo bioptico della cute per confermare o escluderne la diagnosi.

Fischer’s score criteria correlating with histopathological prognostic factors in invasive breast cancer

PurposeThis study aimed to evaluate whether the Fischer score criteria on contrast-enhanced magnetic resonance (CE-MR) imaging could correlate with histopathological prognostic factors in invasive breast cancer.Materials and methodsSeventy-two women with histologically proven invasive breast cancer underwent preoperative CE-MR imaging. Images were assessed for the following parameters, according to the scoring system described by Fischer in 1999: tumour shape, margins, internal enhancement, signal intensity increase, signal intensity course and overall Fischer score. Evaluated histopathological prognostic factors included histological type, associated extensive intraductal component, diameter, lymph node metastasis, tumour grade, and oestrogen receptor (ER), progesterone receptor (PgR), Ki67 proliferation, oncogene c-erbB-2 (HER2/neu) expression. Fisher’s exact test was used to correlate the CE-MR imaging parameters and histopathological findings (with significance set a p < 0.05).ResultsFischer’s score was 0–4 in 14/72 (19%) cases, >4 in 58/72 (81%) and 3 in 5/72 (7%; false negative), with a sensitivity of 93%. A significant correlation (p=0.02) was found between stellate-dendritic shape and the presence of an associated extensive intraductal component (EIC), which was found in 78% of stellate tumours vs. 49% of round-oval tumours. A significant correlation (p=0.039) was found between Ki67 expression and signal intensity course (Ki67 overexpression was present in 81% of tumours with washout course vs. 21% with plateau course).ConclusionsThe CE-MR imaging findings that correlate with prognostic factors are shape and signal intensity curve. Fischer’s multifactorial analysis was helpful in the interpretation of CE-MR images, showing a sensitivity of 93% for invasive breast cancer.RiassuntoObiettivoScopo di questo studio è verificare se esiste una correlazione fra aspetti morfologici e dinamici della risonanza magnetica (RM) descritti dal sistema di Fischer e fattori istologici prognostici del carcinoma invasivo della mammella.Materiali e metodiSettantadue pazienti con diagnosi istologica su pezzo operatorio di carcinoma infiltrante sono state sottoposte a RM pre-operatoria. Le immagini RM sono state analizzate secondo i seguenti criteri descritti nel 1999 dal sistema di Fischer: forma, margini, pattern di impregnazione, incremento e andamento del segnale, e punteggio di Fischer complessivo. I fattori prognostici patologici considerati sono stati: istotipo tumorale, estesa componente intraduttale, diametro di infiltrazione, stato linfonodale ascellare, grado, espressione di recettori per gli estrogeni (ER), dei recettori per il progesterone (PgR), dell’indice di proliferazione Ki67 e dell’oncogene c-erbB-2 (HER2/neu). L’associazione fra i rilievi RM e i fattori patologici è stata verificata con Fisher’s exact test (valore di p significativo<0,05).RisultatiIl punteggio di Fischer è risultato 0–4 in 14/72 (19%) casi, >4 in 58/72 (81%) casi e pari a 3 in 5/72 (7%; falsi negativi) mostrando una sensibilità del 93%. Una correlazione significativa (p=0,02) è emersa fra l’aspetto morfologico spiculato-dendritico e la presenza di estesa componente intraduttale (ECI) (è stata rilevata nel 78% dei tumori spiculati vs 49% dei tumori con morfologia rotonda-ovale). Altra correlazione significativa (p=0,039) è risultata fra la curva del segnale e Ki67 (sovraespressione del Ki67 è stata osservata nel 81% dei tumori con curva a washout vs 21% dei tumori con curva continua-plateau).ConclusioniI reperti RM che correlano significativamente con i fattori patologici prognostici del tumore mammario sono la morfologia e l’andamento della curva del segnale. Il sistema di Fischer è un utile modello interpretativo dei reperti RM, presentando una sensibilità del 93%.