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ABSTRACT |
Hsu J.Y.1; Tran T.M.1; Loh S.1; Roth C.G.1,2; 1. Radiology, Lahey Clinic, Burlington, MA; 2. MRI, Beaches Open MRI of Palm Beach Gardens, LLC, Palm Beach Gardens, FL.
Address correspondence to J.Y. Hsu (joe_yo_hsu{at}lahey.org)
Background: Breast MRI is a powerful modality for detection, evaluation, and characterization of breast pathology. Its strength lies in its ability to detect angiogenesis and characterize blood flow using dynamic techniques. In so doing, the enhancement features unique to tumor neovascularity are distinguished from benign lesions and background normal breast parenchyma. The sensitivity and negative predictive values for breast cancer are exceedingly high — reportedly nearly 100%. However, the specificity has been much less impressive. A thorough understanding of malignant lesion characteristics and appreciation of the potential pitfalls can increase the specificity.
Key Issues: Although there is institutional variability in MR protocols, there are published guidelines for minimal requirements. The cornerstone of the examination is the pre- and post-gadolinium dynamic examination, in which certain parameters have been established. Imaging protocol at our institution will be presented and the indications for breast MRI will be discussed. Dynamic enhancement characteristics of common breast cancer such as invasive ductal and lobular cancer will be emphasized. Limitations of detecting ductal carcinoma in situ (DCIS) will be explored. Where appropriate, pitfalls will be discussed and alternative diagnosis such as radial scar, mastitis, fibroadenoma, hormone / post radiation / chemotherapy changes will be presented.
Format: This is a didactic exhibit with an introductory section dedicated to the technique and indications for breast MRI followed by a thorough treatment of the various malignant lesions and potentially confounding benign mimickers. When available, correlating mammographic, sonographic, and pathologic findings will be presented.
Teaching Points: 1. Understand indications for beast MRI and common techniques. 2. Recognize the imaging characteristics of common breast pathology such as ductal carcinoma in situ (DCIS), invasive ductal carcinoma including less common sub-types, inflammatory cancer, invasive lobular carcinoma, radial scar, mastitis. 3. Appreciate common pitfalls and recognize benign entity such as fibroadenoma, hormonal, post radiation changes.
E002. High-Spatial-Resolution MR Imaging using the VIBE Sequence: Interpretation Model of Non-Mass-Like Breast Lesions
Tozaki M.; Igarashi T.; Fukuda K.; Department of Radiology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan.
Address correspondence to M. Tozaki (e-tozaki{at}keh.biglobe.ne.jp)
Objective: The purpose of this study was to assess an interpretation model based on BI-RADS-MRI descriptors and high-spatial-resolution MR images in lesions showing non-mass-like enhancement.
Materials and Methods: Retrospective review was performed of 65 consecutive lesions showing non-mass-like enhancement (29 benign and 36 malignant). MR imaging was performed on a 1.5-Tesla system using the volumetric interpolated breath-hold examination sequence (mean partition thickness, 1.2 mm; and time of acquisition, 35 sec). The affected single breast was examined on the first- and third-phase dynamic images, acquired at 60 sec and 4 min, respectively, and both the breasts were examined on images obtained in the second phase at 100 sec. If incidental suspicious enhancement was detected in the contralateral breast during the second phase, additional images of both the breasts were obtained immediately during the subsequent third phase. First, the distribution patterns were classified into three categories as follows: Single quadrant/Solitary lesion (linear), Single quadrant/Grouped lesion (focal, regional, segmental), and Multiquadrant lesion (multiple regions, diffuse). Second, the presence of a "ductal pattern" was assessed in the enhancing lesions (linear-nonspecific, linear-ductal, branching-ductal, non-branching). Third, internal enhancement (homogeneous, heterogeneous, stippled, clumped, reticular) was evaluated. Fourth, in addition to the BI-RADS-MRI descriptors, the presence of "clustered ring enhancement" was also assessed in heterogeneous enhancing lesions. The distribution of the lesion was analyzed on coronal images. The presence of a "ductal pattern" was evaluated on transverse and sagittal multiplanar reformations.
Results: The most frequent morphological finding among the benign lesions was Multiquadrant distribution (34%), followed by a linear-ductal pattern (24%); on the other hand, clustered ring enhancement (58%), and a segmental pattern (53%) (p < 0.001) were the most frequent findings in malignant lesions. The features with the highest positive predictive value for carcinoma were a segmental distribution (100%), a branching-ductal pattern (100%), clustered ring enhancement (100%), and clumped internal architecture (70%). Using this interpretation model, the positive predictive value for carcinoma was 92% (34/37).
Conclusion: A combination of BI-RADS-MRI descriptors and clustered ring enhancement criteria is useful for the differential diagnosis of lesions showing non-mass-like enhancement.
E003. The Diagnostic Value of Breast MRI in Patients with Intraductal Papillomas of the Breast: Can the MRI Replace Other Imaging Modalities?
Son E.J.; Kim E.K.; Oh K.K.; Ko K.; Department of Diagnostic Radiology, Yong Dong Severance Hospital, Yonsei University, Seoul, South Korea.
Address correspondence to E.J. Son (ejsonrd{at}yumc.yonsei.ac.kr)
Background: To evaluate the value of breast MRI in diagnosis of intraductal papillomas of the breast.
Key Issues: 26 intraductal papilloma cases were evaluated with 3D FLASH dynamic breast MRI. Nine masses were palpable and 17 of 26 patients had nipple discharge. We analyzed the location, size of the lesions and shape, margin of the masses, multiplicity and ductal relation. The pattern of enhancement and associated findings were also evaluated. On dynamic enhanced images, 2 cases showed multiple foci, 21 cases revealed mass and 3 cases showed non-mass like enhancement. The shape of the masses were round (n = 5), oval (n = 6), lobulated (n = 6), irregular (n = 4) and shapes were smooth (n = 14), irregular (n = 5), spiculated (n = 2). Six cases showed multiple lesions and 3 cases showed cystic portion within the mass. In case of non-mass like enhancement, 2 cases showed ductal enhancement and 1 case showed segmental enhancement. Those 2 cases of ductal enhancement revealed negative findings in ultrasonogram. The kinetic curve of initial phase showed persistent enhancement in delayed phase. The contrast enhanced dynamic breast MRI had lower false negative rate than US and more accurate in detection of multiple papillomas.
Format: didactic by MRI imaging findings The point of this presentation is: The contrast enhanced dynamic breast MRI had lower false negative rate than US and more accurate in detection of multiple papillomas. MRI could play a key role in the pre-operative work-up for intraductal papilloma and could be replacing the other imaging modalities.
Teaching Points: 1. To learn about breast MRI lexicon according to BI-RADS system. 2. To review the MRI findings of breast intraductal papillomas. 3. To evaluate the value of breast MRI in diagnosis of intraductal papillomas of the breast.
E004. Spectrum of Normal Breast MRI Appearances Post Radiation Treatment
Coll D.M.; Radiology, Mt Sinai Hospital, New York, NY.
Address correspondence to D.M. Coll (deirdre.coll{at}gmail.com)
Background: Breast MRI is increasingly used both for diagnosis and follow up of patients with breast carcinoma. Whole and partial breast radiation is an accepted treatment for patients post lumpectomy to decrease the chance of local recurrence. It is important for the radiologist to be aware of the normal appearance of the breast post irradiation both in the early and late stages. This will avoid unnecessary interventions and follow up.
Key Issues: To explain the differences between partial breast and whole breast radiation Spectrum of normal appearance on Breast MRI post radiation with correlation with mammography, sonography and pathology. Spectrum of normal appearance of local structures which lie within the irradiated area e.g. pectoral muscle, ribs, etc.
Format: Didactic presentation Multiplanar breast MRI, subtraction, time kinetic analysis and 3D illustration. Correlation with mammography, sonography and pathology to illustrate teaching points.
Teaching Points: Understanding of the techniques of breast irradiation Normal appearance of the breast post irradiation Correlation of MRI appearances with mammography, sonography and pathology. Normal appearance of surrounding structures post radiation.
E005. Spectrum of Extra-mammary Findings on Breast MRI: What You Can Find
Rausch D.R.; Department of Radiology, Mount Sinai Medical Center, New York, NY.
Address correspondence to D.R. Rausch (danarausch{at}hotmail.com)
Background: Breast MRI can be a powerful and useful adjunctive tool in breast imaging. Although breast MRI is tailored to the evaluation of the breast parenchyma, there is a gratuitous view of a portion of the upper abdomen, chest and osseous structures. Radiologists should be familiar with the wide range of abnormalities which can be incidentally noted as their potential impact on patient care is significant, particularly in those patients with a recent or remote history of breast cancer.
Key Issues: A spectrum of clinically relevant extra-mammary findings noted on breast MRI of hepatic, renal, osseous, pulmonary, cardiac, nodal and dermal origin will be presented as will the more complete and tailored correlative imaging studies.
Format: Examples of extra-mammary findings on breast MRI will be presented in an interactive, quiz format by organ system.
Teaching Points: 1. To present a spectrum of extra-mammary findings on breast MRI as well as the corresponding definitive imaging study findings. 2. To outline strategies to optimize detection of these findings.
E006. Multidetector Computed Tomography Assessment of Tumor Size and Nodal Status in Advanced Breast Cancer Before and After Neoadjuvant Chemotherapy
Cheung Yun-Chung.1,4; Chen Shin-Cheh.2,4; Hseuh Swei.3,4; 1. Department of Radiology, Chang Gung Memorial Hospital, Tao Yuan, Taiwan; 2. Department of Surgery, Chang Gung Memorial Hospital, Tao Yuan, Taiwan; 3. Department of Pathology, Chang Gung Memorial Hospital, Tao Yuan, Taiwan; 4. College of Medicine and School of Medical Technology, Chang Gung University, Tao Yuan, Taiwan.
Address correspondence to Yun-Chung Cheung (alex2143{at}adm.cgmh.org.tw)
Objective: We evaluated the utility of multidetector computed tomography (MCT) in assessing tumor size and nodal status in patients with advanced breast cancers before and after the neoadjuvant chemotherapy.
Materials and Methods: Twenty-eight advanced breast cancer patients with 30 tumors were enrolled in this study. MCT was used to assess tumor size and axillary lymph nodes before and after the neoadjuvant chemotherapy. The correlation between tumor size on MCT and tumor size on pathology was tested. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the axillary nodal status prediction were analyzed.
Results: On MCT, the largest axial diameter of 11 (36.6%) of 30 breast cancers decreased more than 50%. MCT findings were concordant with pathologic findings in 2 of the 3 complete responders. The mean tumor diameter on pathology and post-chemotherapy MCT were 3.6 cm (S.D.= ± 2.9 cm) and 3.1 cm (S.D.= ± 2.6), respectively. The Pearson correlation coefficient was 0.76 (p < 0.001). The accuracy of nodal evaluation using MCT was higher before 83.4% (95% CI= 66.3-92.5) than after 66.7% (95% CI= 48.6-80.8) chemotherapy. The false negative rate of nodal metastasis after chemotherapy was 77.7%. At all the 5 axillary statuses downstaged from node-positive to node-negative on MCT, cancer cells were microscopically revealed within the lymph nodes after chemotherapy. The accuracies at all axilla levels were similar before chemotherapy, but the accuracy at level 3 was highest after chemotherapy.
Conclusion: MCT can be used to evaluate tumor size and nodal status in advanced breast cancer. MCT before chemotherapy is essential to improve the diagnostic accuracy of nodal staging.
E007. Disorders of the Breast: CT Diagnosis
Belfi L.; Wax B.; Levin G.; Fuchs S.; Kranz A.; Rausch D.; Katz D.S.; Radiology Department, Winthrop-University Hospital, Mineola, NY.
Address correspondence to B. Wax (bwax{at}winthrop.org)
Background: A wide variety of disorders of the breast may be identified on CT of the chest and/or abdomen, whether intentionally or not. With the advent of multidetector CT, and the use of increasingly thinner slices for routine thoracic imaging, we have increasingly noted findings, usually incidental, in the breasts on a minority of these CT examinations. Such findings may be easily missed if the interpreting radiologist does not include the breasts in their routine search pattern. Portions of the breasts are also included on the top of abdominal CT examinations, and similarly breast findings may be identified. Alternatively and less commonly, CT may specifically be ordered for evaluation of local or regional evaluation of known or suspected breast pathology.
Key Issues: The purpose of this educational exhibit is to review our experience with the identification of breast pathology at one institution, over the past decade, with CT examinations performed usually for other reasons, but also specifically for the evaluation and staging of known or suspected breast pathology. We have now prospectively identified several incidental and previously unknown breast carcinomas on CT, which will be demonstrated. Examples of benign breast pathology, including asymmetric tissue, gynecomastia, cysts, fibroadenomas, and parenchymal and vascular calcifications, will be shown, as will breast implant rupture. Infectious and traumatic processes will also be shown (cellulitis, abscess, and hematoma), as will post-surgical changes including findings related to recent percutaneous biopsy or open surgical procedures, as well as breast reconstruction. Regionally advanced breast cancer will also be demonstrated, as will lymphoma involving the breasts. Axillary adenopathy, due to a variety of benign and malignant etiologies, will also be shown. Radiologists need to be aware that a wide variety of breast findings may be seen on thoracic and abdominal CT.
Format: CT cases will be demonstrated, along with brief patient histories and, where appropriate, mammographic correlation will be provided. The relevant current literature will be reviewed. Additionally, dedicated breast CT techniques and experimental CT units will be briefly covered.
Teaching Points: CT of the chest, as well as of the abdomen and pelvis, often includes substantial portions of both breasts, and a variety of findings, most frequently benign, but occasionally of potential consequence to the patient, may be revealed.
E008. Radiographic Pathologic Correlation of Breast Biopsy Markers
Da Costa D.1; d'Almeida M.1; Gerson D.2; Poppiti Jr. R.2; Esserman L.E.1; 1. Radiology, Mount Sinai Comprehensive Breast Center, Miami Beach, FL; 2. Pathology, Mount Sinai Medical Center, Miami Beach, FL.
Address correspondence to D. Da Costa (dpcosta{at}bellsouth.net)
Background: The purpose of this exhibit is to show the different radiographic and pathologic appearances of the breast biopsy markers that are currently available. The advantages or disadvantages of each type will be discussed in order to help the radiologist decide which clip to use during a particular biopsy. Since there are many different types available, different clips can be used to mark separate biopsy sites so that each lesion can be separately identified on both views. The majority of the clips are made of titanium, however some are accompanied by biodegradable material that will aid in ultrasound visualization and that also have varied appearances on pathologic examination. Breast biopsy markers, initially used to identify mammographic biopsy sites, can also help the pathologist to accurately localize the targeted lesion in the specimen. The clip can be visualized on the specimen radiograph. Auxiliary materials that accompany the clip (e.g., collagen, and re-absorbable pellets) can be recognized on visual inspection which can help the surgeon confirm that the appropriate tissue has been removed. The pathologic appearance of a foreign body in the specimen can provide further confirmation of the biopsy site. This is especially important when the initial lesion is small and may have been partially or completely removed on core biopsy.
Key Issues: Using mammogram, ultrasound and MRI, the varied appearance of the different clips and accompanying materials that are currently available will be shown with pathologic correlation.
Format: Didactic exhibit with radiographic and pathologic correlation of different clips available and a final quiz.
Teaching Points: Recognize the various biopsy markers available. Understand the advantages of each so that the radiologist can make an informed decision as to which clip would be best used during a particular biopsy. Be able to inform the pathologist of the varied materials that may be seen in the specimen.
E009. Foreign Bodies of the Breast: Imaging Findings
Moraes P.C.; Chala L.F.; Rudner M.; Castro F.S.; Kim S.J.; Endo E.; de Barros N.; Radiology, General Hospital of the University of São Paulo Medical School, São Paulo, SP, Brazil.
Address correspondence to P.C. Moraes (moraespc{at}terra.com.br)
Background: Foreign bodies can be defined as non-self objects that are inserted in the body in an intentionally, iatrogenic or traumatic manner. This broad definition, which includes biological medical devices, will be the one adopted in this work. Breast foreign bodies are relatively uncommon. Most of them are not associated with complications, don't require any particular treatment and can be correctly diagnosed by correlating clinical background and imaging findings. However, in rare circumstances, the foreign body may be associated with complications, infection being a major issue to be considered. In an atypical presentation, foreign bodies may simulate malignant lesions on imaging methods. Therefore, prompt and correct recognition of foreign bodies prevents false-positive diagnosis and helps making adequate decisions towards removing them or treating associated complications.
Key Issues: The authors illustrate the spectrum of imaging findings in patients with foreign bodies of the breast, including mammographic, sonographic and magnetic resonance imaging examinations.
Format: Didactic review electronic poster.
Teaching Points: Demonstrate the wide spectrum of presentation of breast foreign bodies - Show their typical and atypical appearances on different imaging methods, especially on mammography—Illustrate potential complications related to them.
E010. Incidence and Features of Upgraded Lesions in Discordant Percutaneous Breast Biopsies
Hain K.S.1; Burnside E.S.1; Sisney G.A.1; Van Buren R.2; 1. Radiology, University of Wisconsin, Madison, WI; 2. Pathology, University of Wisconsin, Madison, WI.
Address correspondence to K.S. Hain (kskingsbury{at}wisc.edu)
Objective: The purpose of this study was to assess the frequency of imaging-histologic discordance after percutaneous breast biopsy and examine the features of the discordant lesions upgraded to malignancy.
Materials and Methods: Percutaneous imaging guided breast biopsies were performed on 1,448 consecutive lesions from November 11, 2001 to July 31, 2004 under stereotactic (n = 789), ultrasound (n = 624), or vacuum-assisted ultrasound guidance (n = 35). Imaging-histologic discordance was defined as a histologic diagnosis that was insufficient explanation for the mammographic findings. Biopsy records, computerized medical records, mammographic studies, and histologic findings were reviewed to determine discordant studies. Exclusion criteria included: 1) less than 12 months follow-up, or 2) films unavailable for review. Mammograms obtained prior to biopsy were reviewed by two subspecialty trained breast imagers who were blinded to the mammographic findings and the pathologic results. They were provided information on the age, hormone replacement status, family history, and previous breast cancer history of the subjects, and they recorded BI-RADS descriptors, BI-RADS assessment, and a probability of malignancy for each case.
Results: Imaging-histologic discordance meeting the criteria of the study was present in 40 of 1,448 lesions (2.8%). Six of the discordant lesions were upgraded to malignancy (15%). The major features of case 1 and 2 were calcifications. The core biopsy result for case 1 was no breast tissue. Excisional biopsy revealed infiltrating lobular carcinoma. The core biopsy result for case 2 was fibrocystic change and excisional biopsy diagnosed DCIS. Case 3 and 4 were described as architectural distortion. The core biopsy result from case 3 was benign breast tissue and excisional biopsy diagnosed infiltrating ductal carcinoma. Case 4 had atypia on core biopsy and infiltrating lobular carcinoma was found at excisional biopsy. The major feature of case 5 and 6 was a mass. Core biopsy of case 5 was benign breast tissue and excisional biopsy revealed tubular carcinoma. Case 6 had LCIS diagnosed on core biopsy and was upgraded to infiltrating lobular carcinoma after excisional biopsy.
Conclusion: The incidence of imaging-histologic discordance was 2.8%. Infiltrating lobular carcinoma was the final pathologic diagnosis for 50% of the discordant lesions upgraded to malignancy. This disproportionate representation of infiltrating lobular carcinoma warrants further study.
E011. Follow-up of Patients with Atypical Lobular Hyperplasia Diagnosed at Core Needle Biopsy
Herman C.R.; Dove C.K.; Radiology, Vanderbilt University, Nashville, TN.
Address correspondence to C.K. Dove (christine.dove{at}vanderbilt.edu)
Objective: It remains unclear whether mammographic follow up or surgical excision is necessary when there is a result of atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) on core needle biopsy of the breast. Our purpose is to retrospectively determine the occurrence of ductal carcinoma in situ (DCIS) or invasive mammary carcinoma (IMC) in patients who have undergone percutaneous core needle biopsy (CNBX) with ALH or LCIS as a result.
Materials and Methods: We reviewed pathology results from 2,371 consecutive percutaneous imaging-guided core breast needle biopsies over a 3 year period (from 2002 thru 2004), performed in 2,031 patients. The rate of ALH/LCIS on CNBX was determined and follow up was characterized as mammographic 6 month exam or surgical excision. The results of excision were grouped as: 1. residual/regressing ALH, 2. No residual ALH, 3. Upgrade to malignancy (DCIS or IMC). Patients with coincident malignancy with ALH diagnosed on CNBX were not studied at this time.
Results: Seventy three pathology results revealed ALH/LCIS, yielding a rate of 3%. Nineteen of the 73 (26%) had coincident malignancy of either DCIS or IMC and 54 of the 73 (74%) had ALH/LCIS only or ALH/LCIS with a benign pathology. Since all biopsies resulting in ALH with coincident malignancy will ultimately go to excision, and because malignancy is already present, they were not studied at this time. Of the remaining 54 results, 20 (37%) received mammographic 6 month follow up, with one (5%) case developing new calcifications which underwent CNBX with a diagnosis of ALH. All other mammographic follow up has remained negative for malignancy over 6 to 18 months of follow up, 15 (28%) had residual or regressing ALH on excision, 4 (7%) had residual ALH with DCIS or IMC on excision, 7 (13%) had no residual ALH on excision, and 7 (13%) were lost to follow up.
Conclusion: Our findings revealed a lower rate (7%) of malignancy at excision in patients with ALH/LCIS on core biopsy when compared to published rates. Mammographic assessment is a viable alternative to surgical excision in the management of ALH/LCIS is established at CNBX.
E012. Pseudocystic Lesions and Clustered Cysts: Radiologists Beware
El Khoury M.; Khetani K.; Kao E.; Mujoomdar A.; Phancao J.P.; Mesurolle B.; Cedar Breast Clinic, McGill University Health Centre, Montreal, QC, Canada.
Address correspondence to M. El Khoury (elkhourymona{at}yahoo.fr)
Background: Varied types of cystic and pseudocystic lesions of the breast can be encountered on sonographic examination, the spectrum of which extends from simple cysts, definitely benign, to complex cystic lesions that might be malignant necessitating biopsy.
Key Issues: The aspect of minimally complicated cysts (cysts with internal echoes) and the clustered microcysts are usually benign, consistent with fibrocystic disease. However, noncalcified ductal carcinoma in situ and high grade invasive ductal carcinoma may present as a deeply hypoechoic nodule or lobulated mass and thus be mistaken for fibrocystic disease. Respect of the BIRADS lexicon and the use of Doppler can help rectify the diagnosis.
Format: Interactive presentation of cases with mammographic, MRI, and pathologic correlations are presented illustrating these findings.
Teaching Points: To be able to identify the tricks enabling recognition of malignant `pseudocystic' lesions. To know how to manage clustered microcysts.
E013. Initial Data of Screen Detected Cancers from India
Ramani S.K.; Merchant N.H.; Radiodiagnosis, Tata Memorial Hospital, Mumbai, India.
Address correspondence to S.K. Ramani (dr.ramani{at}gmail.com)
Objective: With more women in India undergoing screening mammography for early detection of breast cancer a study was undertaken to: 1. Determine cancers detected per 1,000 screens. 2. Age group of screen detected cancers. 3. Give recommendations for screening mammography in India.
Materials and Methods: This was a retrospective study of 2,994 asymptomatic women who underwent screening mammography at a tertiary cancer care centre during a five year period from August 2000 to July 2005. All mammograms were reported by a single radiologist specializing in Breast Imaging. The age group of patients ranged from 30 to 78 years. All patients underwent standard film screen mammography. All mammograms were reported as per the ACR-BIRADS format.
Results: Eighteen (18) of 2,994 (0.60%) patients in the age group 41-71 years underwent biopsies resulting in the detection of seven (7) cancers. There were five (5) ductal carcinoma in situ (D.C.I.S) in 52-66 years age group, and two (2) invasive ductal carcinomas in the 50-71 years age group. Seven cancers were detected out of 2,994 screening mammograms.
Conclusion: In our patient population 2.33 cancers are detected per 1,000 screens. The age group of screen detected cancers was 50-71 years. Maximum (71.42%) cancers were detected in the 50-59 years age group (5/7). Majority of screen detected cancers were D.C.I.S. Unlike developed countries where screening mammography is widespread, India has no breast cancer screening programme resulting in the low numbers in our study. In our patient population the number of screen detected cancers is low. More studies with larger numbers are needed to confirm our findings. We recommend that screening mammography in India can be considered for women age 50 and above.
E014. Pictorial Review of the Manifestations of Systemic Diseases on Mammogram
d'Almeida M.1; Da Costa D.1; Soaita M.M.2; Weisberg S.1; Esserman L.E.1; Poppiti Jr R.2; 1. Radiology, Mount Sinai Comprehensive Breast Cancer, Miami Beach, FL; 2. Pathology, Mount Sinai Medical Center, Miami Beach, FL.
Address correspondence to M. d'Almeida (mariadalmeida{at}aol.com)
Background: The purpose of this exhibit is to demonstrate how systemic disease can manifest as breast lesions radiographically. Representative examples of lesions from various categories of diseases will be shown. Systemic diseases of the axillary lymph nodes include rheumatoid arthritis, psoriatic arthritis, sarcoidosis, cat scratch fever, HIV, lymphoma, and metastatic malignancy. Diseases in the skin will include scleroderma, neurofibromatosis, and anasarca. In the vascular category, diseases such as atherosclerosis, diabetes, renal failure and venous obstruction will be included. Examples of diabetic mastophaty and metastasis to the breast will be shown. In certain instances, image guided breast biopsy can be utilized to diagnose the specific systemic disease. Histopathologic correlation will be shown.
Key Issues: Mammographic and sonographic examples of the appearance of lesions of underlying systemic disease will be shown.
Format: Didactic exhibit with imaging and pathologic illustration.
Teaching Points: Recognize various manifestations of systemic disease seen on breast imaging studies. Become familiar with the different categories of lesions that can be indicative of systemic disease. Understand how image guided biopsy can be used to diagnose systemic disease.
E015. Breast Diseases During Pregnancy and Lactation—A Pictorial Review
Tzeng Y.H.1,2; Hesley G.K.1; Glazebrook K.N.1; 1. Radiology, Mayo Clinic, Rochester, MN; 2. Radiology, Cheng-Hsin General Hospital, Taipei, Taiwan.
Address correspondence to Y.H. Tzeng (Tzeng.YunHsuan{at}mayo.edu)
Background: During pregnancy and lactation, the breasts undergo profound changes as a result of the influence of various placental and maternal hormones. Some unique breast problems are prone to occur in this period, including inflammatory and infectious process, galactoceles, enlargement of certain benign breast tumors, breast hypertrophy, and nipple discharge. Although most breast lesions encountered during pregnancy and lactation are benign, any of the other breast problems seen in the non pregnant female populations may develop including malignancy. The physiologic changes of the breasts in pregnant women make the diagnosis of neoplasm a challenge. In this exhibition, we will discuss the clinical and imaging findings of both benign and malignant breast problems during pregnancy and provide a self quiz after the discussions.
Key Issues: We will demonstrate the clinical, mammographic, and sonographic features of the benign breast diseases prone to occur in the pregnant women, including puerperal mastitis, abscess, galactocele, fibroadenoma, hamartoma, lactating adenoma, and gigantomastia. We will also illustrate the diagnosis of breast cancer during pregnancy.
Format: Quiz following didactic presentation.
Teaching Points: To present the normal physiologic changes of breasts in pregnant woman. To demonstrate the clinical and imaging features of unique breast problems in gestation. To discuss the diagnostic challenge of breast cancer during pregnancy. To provide a self quiz after the discussions.
E016. Cortical Morphology of Axillary Lymph Nodes as a Predictor of Metastatic Disease in Breast Cancer: an in-vitro Ultrasound Study
Bedi D.G.1; Krishnamurthy R.2; Krishnamurthy S.1; Edeiken B.1; Hunt K.1; Feig B.W.1; Singletary S.E.1; Ross M.I.1; Ames F.C.1; Bedrosian I.1; Kuerer H.M.1; Fornage B.D.1; 1. Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX; 2. Radiology, Texas Children's Hospital, Houston, TX.
Address correspondence to D.G. Bedi (dbedi{at}di.mdacc.tmc.edu)
Objective: To determine if cortical morphology of axillary lymph nodes, on high-resolution in-vitro ultrasonography, accurately predicts metastatic involvement in patients with early stage breast cancer.
Materials and Methods: 171 lymph nodes from 19 patients, undergoing axillary dissection for early breast cancer, were examined in-vitro by high-resolution ultrasonography. The studies were evaluated in blinded fashion by two observers, with discordant readings referred to a third blinded observer. Each lymph node was classified as types 1 through 6, based on cortical morphology. Types 1-4 represented benign morphology (ranging from fatty replacement of the cortex, to thickened nodular cortex with normal echogenicity). Type 5 (focal hypoechoic cortical nodule[s]) and type 6 (hypoechoic node with absent hilum) nodes were considered suspicious for metastatic involvement. The gold standard for metastatic disease was histopathological evaluation of the sectioned nodes by a single pathologist, blinded to the ultrasound findings.
Results: The inter-observer agreement was 77% for classifying the type of nodal morphology (types 1-6) and 88% for characterizing the node as benign (types 1-4) or malignant (types 5-6). The sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of cortical morphology in predicting metastatic involvement of the axillary nodes were 77%, 80%, 36%, 96%, and 80% respectively. False positives contributing to the low positive predictive value were encountered only in node types 5 and 6.
Conclusion: Existing conventional sonographic criteria for nodal malignancy include size, shape and echogenicity; these are limited because they do not address earlier stages of metastatic deposit when the nodal cortex only may be affected. Since afferent lymphatic channels enter the nodal cortex peripherally, early metastatic deposits alter cortical morphology first, eventually leading to overall nodal changes of size, shape and echogenicity. Although there is some overlap in sonographic findings of benign and malignant nodes, negative predictive values are excellent using this classification. The presence of asymmetric, hypoechoic cortical lobulation or a completely hypoechoic node may serve as a guideline for performing fine needle aspiration in the pre-operative staging of breast cancer. Axillary lymph nodes can be classified based on cortical morphology, with a better reflection on prognosis than existing criteria based on nodal size or shape.
E017. Ultrasound Evaluation of Axillary Lymph Node Morphology following Breast Cancer Neoadjuvant Chemotherapy as Marker for Treatment Response
Obaldo R.; McCrary B.S.; Smith W.P.; Radiology, University of Kansas Medical Center, Kansas City, KS.
Address correspondence to R. Obaldo (robaldo{at}kumc.edu)
Background: Many women at our institution receive dose dense neoadjuvant chemotherapy prior to restaging and/or surgery in newing diagnosed invasive ductal carcinoma. Tumor response is primarily monitored evaluating primary breast lesion morphology with ultrasound, mammography and physical exam. The breast lesion morphology may be an unreliable marker if the tumor response to chemotherapy is atypical, i.e., tumor scarring with minimal volume change, or tumor edema with increased size. We purpose that additional evaluation of axillary lymph node morphology and geometrics may be a valid option in gauging breast cancer response.
Key Issues: Selected women at our institution with biopsy proven intraductal invasive carcinoma with lesions greater than 2 cm are treated with dense neoadjuvant chemotherapy prior to restaging and/or surgery. Breast and axillary ultrasonography is performed prior to, during and following neoadjuvant chemotherapy to evaluate morphology and volumetrics of both primary breast lesions and axillary lymph nodes as a gauge of treatment effectiveness. Women receiving neoadjuvant chemotherapy following newing diagnosed invasive ductal breast carcinoma had both the primary breast lesion and the associated ipsilateral axillary lymph nodes monitored with ultrasonography before, during and following neoadjuvant chemotherapy. Special attention was paid to nodal geometry, morphology and particularly hilar fat content and distribution during sonographic evaluation. Our preliminary results show parallel responses between index breast tumors and ipsilateral axillary nodes.
Format: We provide specific examples, insights and experience correlated with biopsy data from axillary lymph nodes to aid our understanding of the morphologic and geometric evolution of lymph nodes with neoadjuvant chemotherapy. We describe our approach providing insights and detailing our experience utilizing this additional marker in tracking breast cancer response to neoadjuvant chemotherapy.
Teaching Points: By utilizing ultrasonography in evaluating both the primary breast lesions and axillary lymph node morphology, we provide additional markers, that maybe useful in evaluating breast lesions with an atypical morphologic response.
E018. Benign and Malignant Mimickers on Breast Ultrasound
El Khoury M.; Khetani K.; Mujoomdar A.; Le H.; Mesurolle B.; Cedar Breast Clinic, McGill University Health Centre, Montreal, QC, Canada.
Address correspondence to M. El Khoury (elkhourymona{at}yahoo.fr)
Background: Respecting the BIRADS Lexicon in the description of breast lesions is the best guarantee for a correct diagnosis and management. Nevertheless, unusual sonographic features of either benign or malignant lesions are encountered.
Key Issues: While hyperechoic echotexture, smooth well circumscribed margins, posterior enhancement and wider-than-tall aspect are typically benign, they can be found in malignant lesions such as, mucinous, high grade invasive and hyperechoic carcinomas. As well, the malignant features including ill defined margins, taller-than-wide aspect and posterior shadowing can be rarely encountered with benign lesions such as fibrosis, fibroadenomas and fat necrosis.
Format: A number of cases are presented to illustrate this assertion, with mammographic, sonographic and pathologic correlations.
Teaching Points: To help radiologists identify misleading manifestations of malignant lesions.
E019. Breast Sonography in Children and Adolescents with Breast Symptomatology
Lafita V.S.; Vade A.; Lin-Dunnham J.; Bova D.; Radiology, Loyola University Health Center, Maywood, IL.
Address correspondence to V.S. Lafita (vlafita{at}lumc.edu)
Objective: This study was done to identify the spectrum of sonographic findings in children and adolescents with breast symptomatology. Pathologic correlation is discussed for the patients who underwent tissue biopsy.
Materials and Methods: This retrospective study of breast sonograms included a total of 33 children and adolescents with breast symptomatology. The age range of the patients was 7 weeks to 20 years with mean age of 14.9 years. All but 5 patients were females. 26 children presented with breast mass, 3 with asymmetric breast enlargement, 2 with nipple discharge, 1 with fullness/tenderness, and 1 with breast pain.
Results: Sonograms showed normal breast tissue in 17 patients. Of these 11 presented with a palpable breast mass, 3 with asymmetric breast enlargement and 3 with localized tenderness. Sonograms showed solid masses in 16 patients. Of the solid masses, 1 was a subcutaneous lesion with sonographic features of lymph node. In 14 patients, the solid mass had benign features and was wider than taller with maximum width ranging from 1 to 7 cm. Tissue biopsy was obtained in 9 of these patients revealing fibroadenoma in 5 patients, benign cystic phylloides tumor in 2 patients and benign breast tissue in 2 patients. Excisional biopsy of one of the solid palpable mass withsuggestion of malignancy including focal calcifications revealed benign breast tissue with fibrocystic changes and sclerosing adenosis. 6 of the 16 patients were managed conservatively. All 5 males with breast symptomatology showed normal breast tissue. One of these patients had partial mastectomy for gynecomastia. Cystic masses were seen in 2 patients. One resolved after aspiration of clear fluid and the other was followed conservatively.
Conclusion: Breast sonography in our pediatric population with breast symptomatology showed benign imaging features in all but one of the 33 patients. There was no malignancy diagnosed in our patients. With strict application of the previously described sonographic criteria for generally benign solid masses of the breast, high resolution ultrasonography of the breast promises to be a valuable imaging tool by obviating tissue diagnosis in the symptomatic pediatric breast.
E020. Quality Criteria and Training Systems for Hand-held Real-time Ultrasound Strain Imaging of Breast Lesions
Meixner D.D.1; Tzeng Y.1,2; Hangiandreou N.J.1; Hesley G.K.1; 1. Radiology, Mayo Clinic, Rochester, MN; 2. Radiology, Cheng-Hsin General Hospital, Taipei, Taiwan.
Address correspondence to D.D. Meixner (meixner.duane{at}mayo.edu)
Background: Ultrasound strain imaging (USSI) has emerged as a promising modality for assessing many disease processes. USSI compares the RF echo data before and after slight axial tissue displacement and calculates the relative stiffness of the tissues. Free-hand real-time USSI is a feasible and effective method of acquiring sequences of strain images of breast lesions. Evaluation of breast lesions with this method, including assessing lesion conspicuity in USSI sequences, has shown promise in differentiating benign from malignant processes.
Key Issues: Free-hand real-time USSI requires precise manipulation of the ultrasound transducer to effect axial-only tissue displacement. Generation of high-quality strain images is essential to assessing lesion conspicuity. We establish criteria for evaluating the quality of strain images, for training users, and for assessing users' proficiency in producing and recognizing highest-quality strain images.
Format: This didactic presentation will include a) rationale for quality criteria, b) specific quality criteria and method of calculating a quality index, c) user training system for recognizing high-quality strain images, d) user training system for generating high-quality strain images, e) evaluation method for testing users' proficiency and e) ramifications of applying the system to lesion conspicuity analysis.
Teaching Points: The teaching points of this exhibit are a) generation of high-quality ultrasound strain images is essential to accurately assessing breast lesions with USSI, b) consistent training of users of USSI results in consistent ability to generate and recognize high-quality USSI sequences and c) the ability to generate and recognize high-quality USSI sequences enhances the accuracy of breast lesion conspicuity analysis.
E021. Breast Intervention: A Review
Betel C.; Medical Imaging, Sunnybrook and Women's College Health Science Center, Toronto, ON, Canada.
Address correspondence to C. Betel (cara.betel{at}utoronto.ca)
Background: Breast intervention is an essential component of breast imaging, and it is therefore imperative for breast imaging radiologists to have strong intervention skills. In addition to the widespread use of many established intervention procedures, there are a number of new and emerging techniques that provide the potential for improved patient care and increased diagnostic accuracy. This includes using MRI guidance for biopsy or wire localization, and the insertion of post-biopsy surgical clips. This exhibit is designed to serve as a review of breast intervention and to provide instruction for those interested in expanding their breast intervention armamentarium.
Key Issues: This exhibit will provide a comprehensive review of breast intervention. The legal issues relating to obtaining consent and potential complications will be out-lined. The indications and technical step by step instructions will be provided for all forms of intervention, including aspiration, biopsy, wire localization, and abscess management. All techniques will be illustrated with imaging examples. Special emphasis will be placed on problem solving skills and troubleshooting. Finally, new and emerging techniques will be described, including the use and importance of MRI guidance, and the utility and practicality of post biopsy clip insertion.
Format: The format will be didactic and organized by imaging technique.
Teaching Points: (1) Breast intervention: Consent and Complications (2) Breast intervention: Indications (3) Breast intervention: Techniques (4) Breast intervention: Troubleshooting (5) Breast intervention: Special Cases.
E022. Initial Experience with Radiofrequency Assisted Stereotactic Breast Biopsies
Speece P.R.; Phillips S.W.; Morton M.J.; Radiology, Mayo Clinic, Rochester, MN.
Address correspondence to P.R. Speece (Speece.Paul{at}mayo.edu)
Objective: Recently a new percutaneous breast biopsy device has been developed that combines the advantages of stereotactic guidance with the ability to obtain intact tissue specimens. This new device, approved by the FDA for commercial use, utilizes radiofrequency (RF) and a unique capture mechanism that allows the breast radiologist to obtain a single large intact specimen rather than multiple small individual tissue samples. It is the purpose of our study to retrospectively evaluate our initial 200 RF biopsy procedures performed with stereotactic guidance. We will evaluate this technology in terms of technical success, efficiency, patient acceptance, diagnostic accuracy and mammographic and pathologic correlation.
Materials and Methods: As stated above, the initial part of the study is to evaluate the technical success and patient satisfaction regarding the new technology. We will determine whether there were any device failures, biopsy errors or patient complications. We will review the patients' radiologic studies and compare the radiographic diagnosis with the biopsy results.
Results: The initial results from the first 100 patients undergoing the RF assisted percutaneous biopsies are as follows; 109 biopsies were performed on 100 patients. 35 of these patients went on to undergo surgical biopsy. Out of those 35 patients, 23 had DCIS as the final diagnosis, 8 had a type of infiltrating carcinoma and 5 had no residual tumor identified. Of the 8 with infiltrating carcinoma, 4 of those were correctly identified at their initial biopsy. There were 5 upgrades from the initial biopsy (3 were DCIS to infiltrating ductal carcinoma (IDC), 1 atypical ductal hyperplasia (ADH) to IDC, 1 ADH to DCIS). Only 1 of the biopsies missed the target lesion due to targeting error. Patients rated the procedure an average of 2.2 (out of 10) on a pain scale compared to a 3 (out of 10) given for table comfort. To date, no significant patient complications have been identified.
Conclusion: Our initial results suggest that use of the RF biopsy device for stereotactic biopsy of the breast is an accurate method of obtaining a representative sample from the target area for histopathological analysis. If the entire targeted lesion is excised, the intact architecture of the specimen may eventually obviate the necessity for surgical excision of lesions such as papilloma and radial scar as more experience with the RF biopsy device is acquired and future larger devices are developed.
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