Viviana Londero

Locally advanced breast cancer: comparison of mammography, sonography and MR imaging in evaluation of residual disease in women receiving neoadjuvant chemotherapy

The accuracy of mammography, sonography and magnetic resonance imaging (MRI) in identifying residual disease after neoadjuvant chemotherapy is evaluated and imaging findings are correlated with pathologic findings. Fifteen patients enrolled in an experimental protocol of preoperative neoadjuvant chemotherapy underwent clinical examination, mammography, sonography and dynamic MRI, performed in this order, before and respectively after 2 and 4 cycles of neoadjuvant chemotherapy. Four radiologists, two for mammography, one for sonography and one for MR, examined the images, blinded to the results of the other examinations. All patients underwent radical or conservative surgery, and imaging findings were compared with pathologic findings. MRI identified 2/15 (13.3.%) clinically complete response (CR), 9/15 (60%) partial response (PR), 3/15 (20%) stable disease (SD) and 1/15 (6.7%) progressive disease. Mammography identified 1/15 (6.7%) clinically CR, 8/15 (53.3%) PR and 4/15 (27%) SD, and was not able to evaluate the disease in 2/15 (13%) cases. Sonography presented the same results as MRI. Therefore, MRI and sonography compared to mammography correctly identified residual disease in 100 vs. 86%. MRI resulted in two false-negative results because of the presence of microfoci of in situ ductal carcinoma (DCIS) and invasive lobular carcinoma (LCI). MRI was superior to mammography in cases of multifocal or multicentric disease (83 vs. 33%). Sonography performed after MRI improves the accuracy in evaluation of uncertain foci of multifocal disease seen on MR images with an increase of diagnostic accuracy from 73 to 84.5%. MRI assesses response to neoadjuvant chemotherapy better than traditional methods of physical examination and mammography.

Role of Mammography, Ultrasound and Large Core Biopsy in the Diagnostic Evaluation of Papillary Breast Lesions

Background: It is well recognized that distinguishing benign from malignant papillary lesions of the breast may pose challenging diagnostic problems. To prospectively evaluate the potential role of mammography, ultrasound and image-guided core biopsy in the diagnosis of papillary lesions of the breast. Methods: 1,442 women consecutively underwent 14-gauge core biopsy and in 51 cases (3.5%) a diagnosis of papillary lesion was formulated. Both radiologists and pathologists independently expressed their degree of suspicion of malignancy (not suspicious, low, moderate, high) on the basis of radiological and core biopsy findings, respectively. Surgical excision of the lesion was used as gold standard and diagnostic agreement was assessed by the kappa statistic. Results: At surgery, 19 of the 49 (38.7%) resected cases had a diagnosis of malignancy. A poor agreement was found between mammography and core biopsy results in the categorization of suspicion of malignancy (k = 0.03). Similar data were obtained between ultrasound and core biopsy (k = 0.07). A poor agreement was also observed between radiological and surgical results (k < 0.20). In contrast, a good agreement was found between core biopsy and surgical samples (k > 0.70). However, 5 (26%) out of the 19 malignant cases at surgery were judged as benign or probably benign on core biopsy. Depending on how the categories of suspicion on core biopsy were set up, the range of sensitivity was 74–89%, whereas specificity ranged from 91 to 97%. Conclusions: Image-guided large core biopsy allows for a correct diagnosis in the majority of papillary lesions. However, its sensitivity is not good enough for surgical excision to be avoided.

Radial Scars Without Atypia Diagnosed at Imaging-Guided Needle Biopsy: How Often Is Associated Malignancy Found at Subsequent Surgical Excision, and Do Mammography and Sonography Predict Which Lesions Are Malignant?

OBJECTIVE The purposes of our study were to evaluate the surgical outcome of cases of radial scar without atypia diagnosed at imaging-guided percutaneous needle biopsy and to determine whether the mammographic and sonographic features are able to predict which lesions will be upgraded to malignancy at surgical excision. MATERIALS AND METHODS The records of 4,458 consecutive imaging-guided biopsies were retrospectively reviewed. Surgical excision results were available in 62 cases in which radial scar was the highest-risk lesion at stereotactically guided or sonographically guided biopsy. The mammographic and sonographic images and surgical findings were reviewed. The underestimation rate of malignancy of percutaneous biopsy was calculated. Differences in mammographic and sonographic appearances between radial scars with and without associated malignancy were evaluated using the Fishers exact test. RESULTS The percutaneous malignancy underestimation rate was 8% (5/62): 9% (4/43) for sonography guided 14-gauge biopsies and 5% (1/19) for stereotactically guided 11-gauge vacuum-assisted biopsies (p = 1.000). Mammographic and sonographic appearances were not significantly different between radial scars with and those without associated malignancy. CONCLUSION A percutaneous diagnosis of a radial scar does not exclude associated malignancy at surgical excision. Mammographic and sonographic features of a lesion diagnosed as a radial scar at percutaneous imaging-guided biopsy do not predict which lesions will have associated malignancy at surgery. Therefore, all patients with percutaneous diagnosis of a radial scar should undergo surgical excision regardless of mammographic and sonographic appearances, until further criteria can be determined.

Nonsurgical Management of High-Risk Lesions Diagnosed at Core Needle Biopsy: Can Malignancy Be Ruled Out Safely With Breast MRI?

OBJECTIVE The purpose of this study was to investigate whether breast MRI can be used to rule out malignancy in patients with high-risk lesions diagnosed at imaging-guided core needle biopsy. SUBJECTS AND METHODS The subjects were women consecutively registered between October 2004 and April 2010 who had high-risk lesions diagnosed at mammographically or sonographically guided core needle biopsy and subsequently underwent MRI and surgical excision. MR images were reviewed by two experienced breast radiologists. Lesions assessed as BI-RADS category 1-3 were considered negative for malignancy, and BI-RADS 4 and 5 lesions were considered malignant. Histologic findings at surgical excision were the reference standard. The sensitivity, specificity, and positive and negative predictive values of MRI in the detection of associated malignancy were calculated for the entire set of lesions and for each histologic subtype. RESULTS The final sample consisted of 169 high-risk lesions in 166 patients. At MRI analysis, 116 (68.6%) lesions were considered negative for malignancy, and the other 53 (31.4%) malignant. At surgical excision, 22 malignant lesions were found. The overall sensitivity, specificity, and positive and negative predictive values of MRI were 72.7% (16/22), 74.8% (110/147), 30.2% (16/53), and 94.8% (110/116). The negative predictive values for papilloma, radial scar, lobular neoplasia, and atypical ductal hyperplasia were 97.4% (38/39), 97.6% (41/42), 88.0% (22/25), and 90.0% (9/10). CONCLUSION Patients with high-risk lesions associated with the lowest likelihood of malignancy (papilloma and radial scar) and without suspicious MRI findings can safely undergo follow-up instead of surgery. Because of the low negative predictive value, however, MRI is not helpful in cases of lobular neoplasia and atypical ductal hyperplasia, and all these lesions should be excised.

Lobular neoplasia: core needle breast biopsy underestimation of malignancy in relation to radiologic and pathologic features.

The purpose of this study is to assess the positive predictive value (PPV) for malignancy of core needle biopsy (CNB) demonstrating lobular neoplasia (LN). From 3920 CNBs, 35 (0.89%) LNs (14 atypical lobular hyperplasia - ALH - and 21 lobular carcinoma in situ - LCIS) were identified. Twenty-eight patients underwent surgical excision and seven radiologic follow-up. We describe the imaging findings and excision histology outcomes. We report the PPV for malignancy based on excision histology (n=28) and on excision or follow-up (n=35), and according to the histologic type, biopsy probe and guidance, lesion diameter, and BI-RADS category. PPV for malignancy (based on excision histology) was 46.4% (13/28) and PPV (based on excision or follow-up) was 37.1% (13/35). The overall rate of malignancy for LN was 37.1% (13/35), with a PPV for malignancy of ALH and LCIS of 7.1% (1/14) and 57.1% (12/21), respectively (p=0.003). Estimates of the PPV for malignancy were: stereotactic-guided vacuum-assisted biopsy (22.7%) versus ultrasound-guided automated CNB (61.5%), p=0.053; lesions<20mm (31.2%) versus lesions>20mm (100%), p=0.043; lesions classified as BI-RADS 3 (16.7%) versus BI-RADS 4 or 5 (41.4%), p=0.377. Underestimation of malignancy was therefore more likely in cases of LCIS, US-guided CNB, and lesions that were large and suspicious on imaging. Nevertheless, the absence of these features does not spare the need for surgical excision in lobular neoplasia diagnosed on CNB.

High-Risk Breast Lesions at Imaging-Guided Needle Biopsy: Usefulness of MRI for Treatment Decision

OBJECTIVE The purpose of this study is to evaluate the role of MRI for characterization of high-risk breast lesions diagnosed at imaging-guided needle biopsy. MATERIALS AND METHODS In this retrospective analysis of 220 patients, 227 high-risk lesions (94 papillomas, 64 radial sclerosing lesions, 46 lobular neoplasias, and 23 atypical ductal hyperplasias) found at 11-gauge vacuum-assisted or 14-gauge needle biopsy were studied with dynamic MRI (time resolution, 84 or 88 seconds; gadopentetate dimeglumine or gadobenate dimeglumine, 0.1 mmol/kg). When lesions showed contrast enhancement on subtracted images, they were considered suspicious for malignancy. The reference standard was histopathologic examination after surgical excision in 190 of 227 (84%) lesions and negative follow-up (≥ 24 months) in 37 of 227 (16%) lesions. Predictive values and likelihood ratios were calculated. RESULTS Of 227 lesions, 155 (68%) were contrast enhancing and 72 (32%) were not. Of 155 contrast-enhancing lesions, 28 (18%) were upgraded to malignancy after surgical excision (nine papillomas, one radial sclerosing lesion, 11 lobular neoplasias, and seven atypical ductal hyperplasias); there were 11 invasive carcinomas and 17 ductal carcinomas in situ, four of the latter being G3. Of 72 non-contrast-enhancing lesions, two (3%) were upgraded to malignancy after surgical excision (one radial sclerosing lesion and one lobular neoplasia), both of which were G1 ductal carcinoma in situ. Cancer probability was significantly higher for contrast-enhancing (18%) than for non-contrast-enhancing (3%) lesions (p = 0.001) and for nonmasslike (43%) than for masslike (14%) lesions (p = 0.005). The positive predictive value was 18% (28/155; 95% CI, 13-24%), the negative predictive value was 97% (70/72; 95% CI, 94-99%), the positive likelihood ratio was 1.448 (95% CI, 1.172-1.788), and the negative likelihood ratio was 0.188 (95% CI, 0.152-0.232). CONCLUSION The absence of enhancement at dynamic MRI allowed reliable exclusion of invasive cancers among high-risk lesions diagnosed at needle biopsy.

Assessment of breast cancer response to neoadjuvant chemotherapy: Is volumetric MRI a reliable tool?

The purpose of this study was to evaluate the reliability of volumetric magnetic resonance imaging (MRI) in breast cancer size assessment before, during and after neoadjuvant chemotherapy (NAC). Volumetric MRI measures performed on 15 patients with breast cancer were compared with volumes reckoned upon mean lesional diameters, using the same MRI data. Concordance correlation coefficient (CCC), Bland & Altman plots, RECIST evaluation and Cohens Kappa were assessed, to evaluate the agreement between the two methods. CCC was computed before (0.9357), during (0.8053) and after (0.7499) NAC, in all examinations pooled together (0.8617), and on final tumor volume as a percentage of baseline volume (0.9224). In 2/15 (13.3%) cases RECIST assessment was different. Cohens Kappa was 0.787 (CI(95%)=0.513-1.062). In summary, volumetric MRI is a reliable tool to assess breast cancer size before, during and after NAC. Further investigations are needed to understand whether improvements in surgical planning are feasible.

Role of ultrasound and sonographically guided core biopsy in the diagnostic evaluation of ductal carcinoma in situ (DCIS) of the breast

PurposeThe aim of this study was to evaluate the role of ultrasound (US)-guided core biopsy in the diagnosis of ductal carcinoma in situ (DCIS) and to correlate the histological results on percutaneous biopsy and surgical excision.Materials and methodsOut of 2,423 consecutive core biopsies performed under US guidance, we evaluated 65 lesions with a histological diagnosis of DCIS. All patients underwent mammography, high-frequency broadband US and percutaneous breast biopsy with a 14-gauge needle and a mean number of five samples (range 4–7 passes). Surgical excision was performed in all cases, and the histological results on the surgical specimen were correlated with those on core biopsy samples. The sonographic features of DCIS lesions were described, comparing pure DCIS (those confirmed by definitive histology) and DCIS with invasive component at surgical excision.ResultsTwenty-seven out of 65 DCIS at core biopsy were found to have an invasive or microinvasive component at surgical excision, leading to rate of histological underestimation of core biopsy of 41.5%. The most frequent sonographic appearances were: (a) mass without microcalcifications (47.4% of pure DCIS, 63% of DCIS with invasive component); (b) mass with microcalcifications (23.7% of pure DCIS, 22% of DCIS with invasive component); (c) isolated microcalcifications (10.5% of pure DCIS); (d) ductal abnormalities (18.4% of pure DCIS, 15% of DCIS with invasive component).ConclusionsDue to the high underestimation rate of core biopsy, caution is mandatory in the case of DCIS diagnosis on core biopsy. Although some histological features (such as stromal fibrosis, periductal inflammatory infiltrate, high nuclear grade) can suggest the presence of an invasive component, the sonographic appearance of DCIS cannot be used to predict the cases that are underestimated on US-guided core biopsy. Nevertheless, a sonographically detectable solid component, either inside dilatated ducts or associated with microcalcifications, and a size greater than 20 mm are frequently associated with the presence of an invasive component.RiassuntoObiettiviValutare l’apporto della biopsia percutanea ecoguidata nella diagnosi del carcinoma duttale in situ, correlando i risultati della biopsia percutanea con l’esame istologico definitivo sul pezzo chirurgico.Materiali e metodiSu 2423 core biopsy consecutive sono state valutate 65 lesioni con diagnosi istologica percutanea di carcinoma duttale in situ (CDIS). Tutte le pazienti hanno eseguito l’esame mammografico e successivamente ecografico con sonda ad alta frequenza a larga banda, e la biopsia percutanea con aghi da 14 G con un numero medio di 5 frustoli (range 4–7). Tutte le pazienti sono state sottoposte a intervento chirurgico; la diagnosi istologica definitiva (sul pezzo operatorio) è stata confrontata con la diagnosi bioptica percutanea. Sono stati descritti gli aspetti ecografici dei CDIS confrontando i CDIS puri (confermati cioè al successivo esame istologico definitivo) e i CDIS con componente invasiva alla verifica istologica definitiva dopo l’escissione chirurgica.RisultatiVentisette/65 lesioni con diagnosi bioptica percutanea di CDIS sono risultate associate a una componente infiltrante o microinfiltrante all’esame istologico definitivo, ottenendo pertanto una “sottostima istologica” della core-biopsy pari al 41,5%. Gli aspetti ecografici principali riscontrati più frequentemente sono stati: (a) massa senza microcalcificazioni (47,4% dei CDIS puri, 63% dei CDIS con componente invasiva); (b) massa con microcalcificazioni (23,7% dei CDIS puri, 22% dei CDIS con componente invasiva); (c) microcalcificazioni isolate (10,5% dei CDIS puri); (d) alterazioni duttali (18,4% dei CDIS puri, 15% dei CDIS con componente invasiva).ConclusioniL’elevata incidenza di sottostime istologiche alla core-biopsy impone un atteggiamento oltremodo prudente di fronte a una diagnosi di CDIS effettuata con la core-biopsy stessa. Sebbene alcune caratteristiche istologiche presenti nei frustoli bioptici prelevati (quali la fibrosi stromale, l’infiltrato infiammatorio periduttale, l’alto grado nucleare) possano suggerire la presenza di una componente invasiva, le caratteristiche ecografiche dei CDIS non possono essere utilizzate per predire i casi che vengono sottostimati alla biopsia percutanea eco-guidata. Tuttavia la presenza di una componente solida visibile ecograficamente, all’interno di immagini duttali o associata a calcificazioni, e le dimensioni superiori ai 20 mm possono talvolta far sospettare la presenza di una componente invasiva.

Stereotactic vacuum-assisted breast biopsy: results, follow-up and correlation with radiological suspicion.

Purpose.The purpose of this study was to assess the accuracy and clinical usefulness of stereotactic vacuum-assisted biopsy (VAB) for diagnosing suspicious, nonpalpable, only mammographically detectable breast lesions.Materials and methods.We retrospectively evaluated the results of percutaneous stereotactic VAB with 11-gauge needles performed over a period of 34 months on 228 nonpalpable suspicious breast lesions detectable on mammography only [Breast Imaging Reporting and Data System (BI-RADS) 3: 25.9%; BI-RADS 4: 67.1%; BI-RADS 5: 7%]. The imaginghistological concordance was ascertained for each lesion. In cases of discordance, repeat biopsy or surgical excision were recommended; in cases of benign lesions, we urged a follow-up of at least 6 months and for borderline and malignant lesions a surgical excision. We also evaluated concordance between VAB results and subsequent examinations (surgical excision or followup).Results.VAB demonstrated 123 (54%) benign lesions (with six cases of imaging–histological discordance), 26 (11.4%) borderline lesions and 79 (34.6%) malignant lesions. We obtained a suitable post-VAB mammographic or histological evaluation for 78 benign lesions, 17 borderline lesions and 76 malignant lesions, with one (1.3%) false negative (FN) case, two (11.8%) underestimations of borderline lesions, 14 (18.4%) underestimations of malignant lesions and no (0%) false positive cases. We did not observe any postbiopsy complications or scars.Conclusions.Percutaneous histological VAB with an 11-gauge needle proved to be, as reported in previous studies, a reliable method for diagnosing nonpalpable, mammographically detectable only breast lesions, with an underestimation rate lower than core biopsy and a FN rate similar to that of surgical biopsy, without any significant complications.

Unusual malignant tumors of the breast: MRI features and pathologic correlation.

Unusual malignant breast tumors are well-differentiated subtypes of invasive ductal carcinoma, including mucinous, tubular, medullary and papillary carcinomas, and account for about 10% of malignant breast tumors. They are increasingly being encountered during magnetic resonance imaging (MRI) examinations of the breast. Therefore, breast radiologists should be aware of their appearance on MRI. This review provides an overview of MRI characteristics of a range of unusual tumors (mucinous carcinoma, medullary carcinoma, tubular carcinoma, intraductal papillary carcinoma, intracystic papillary carcinoma and invasive papillary carcinoma), highlighting specific clues for diagnosis and correlating MRI and pathologic features. Many unusual breast tumors exhibit MRI features similar to those of benign or low suspicious lesions (oval shape, well-defined margins, high signal intensity on T2-weighted images, continuous increase kinetics, i.e. type I dynamic curve), leading to a possible misdiagnosis. Nevertheless, an understanding of pathologic features of these tumors, especially tissue content (mucinous, fibrous) and growth pattern, can help to define some specific clues for their diagnosis.