Outcome of Imaging and Biopsy of BI-RADS Category 3 Lesions: Follow-Up Compliance, Biopsy, and Malignancy Rates in a Large Patient Cohort.

OBJECTIVES: To identify biopsy rates and indications for BI-RADS 3 lesions in a large cohort of patients and compare with follow-up compliance and malignancy outcomes. METHODS: We retrospectively reviewed all BI-RADS category-3 lesions seen on mammography and/or ultrasound between 2013 and 2015. Patient age, lesion size, follow-up rates at 6-, 12-, and 24-months were collected. Biopsy timing, indication, and outcomes (malignant vs benign) were recorded using at least 2-year follow-up or biopsy pathology as endpoint. RESULTS: Of 2319 BI-RADS 3 lesions in 2075 women analyzed, biopsy was performed in 173 (7.5%). Most biopsies were performed upfront (99, 57.2%), followed by at 6 (44, 25.4%), 12 (21, 12.1%), and 24-month follow-up (9, 5.2%; P < .001). Palpable (P < .001) and larger (median 1.4 vs 1.0 cm, P < .001) lesions in women <40 years (15.2% vs 4.8%, P < .001) were more likely to undergo biopsy. Most biopsies were prompted by patient/physician desire (64.5%, P < .001). Of 783 lesions with available endpoint, 5 (0.6%) were cancer. All cancers were identified either at presentation (in 0-5 months, n = 1) or 6-month follow-up (in 5-9 months, n = 4) with biopsy prompted by either morphology change (n = 3) or lesion growth (n = 2). Of the 1855 lesions which were expected for follow up, only 310 (16.7%) underwent all follow-ups, while 482 (26.1%) had two, 489 (26.5%) one, and 565 (30.6%) had no follow-up. CONCLUSIONS: In our cohort, BI-RADS category 3 lesions had significantly higher biopsy rates compared with the small malignancy rate, all of which were identified at baseline or first follow-up. Overall patient follow-up compliance low. Imaging follow-up, especially at first 6-month time point, should be encouraged in BI-RADS 3 lesions, instead of upfront biopsies.

Radiologic-Pathologic Correlation of Fibroepithelial Lesions: A Pictorial Review.

Fibroepithelial lesions (FEL) of the breast encompass a spectrum of masses ranging from benign to malignant. Although these lesions are on the same biologic spectrum, differences in their clinical behaviors necessitate different management approaches. While imaging features are nonspecific, small size (less than 3 cm), oval shape, circumscribed margins, growth in diameter less than 20% in six months, and homogeneous echotexture on US favor fibroadenoma (FA). Conversely, larger size (3 cm or larger), rapid growth, irregular shape, noncircumscribed margins, and heterogeneous echotexture suggest possible phyllodes tumor (PT). Histopathologically, increased stromal cellularity, stromal atypia, and mitotic activity characterize PT, while FA typically lack these features. In this review, we summarize the imaging and pathology characteristics of nonmalignant FEL, including simple, juvenile, and complex FA, and benign and borderline PT and highlight the collaborative role of radiologists and pathologists in informing diagnosis and clinical management.

Pilot Clinical Study Investigating the Thermal Physiology of Breast Cancer via High-Resolution Infrared Imaging.

This descriptive study investigates breast thermal characteristics in females histologically diagnosed with unilateral breast cancer and in their contralateral normal breasts. The multi-institutional clinical pilot study was reviewed and approved by the Institutional Review Boards (IRBs) at participating institutions. Eleven female subjects with radiologic breast abnormalities were enrolled in the study between June 2019 and September 2019 after informed consent was obtained. Static infrared images were recorded for each subject. The Wilcoxon signed rank test was used to conduct paired comparisons in temperature data between breasts among the eight histologically diagnosed breast cancer subjects (n = 8). Localized temperatures of cancerous breast lesions were significantly warmer than corresponding regions in contralateral breasts (34.0 ± 0.9 °C vs. 33.2 ± 0.5 °C, p = 0.0142, 95% CI 0.25-1.5 °C). Generalized temperatures over cancerous breasts, in contrast, were not significantly warmer than corresponding regions in contralateral breasts (33.9 ± 0.8 °C vs. 33.4 ± 0.4 °C, p = 0.0625, 95% CI -0.05-1.45 °C). Among the breast cancers enrolled, breast cancers elevated temperatures locally at the site of the lesion (localized hyperthermia), but not over the entire breast (generalized hyperthermia).

ACR BI-RADS Category 3 Lesions in Women Younger Than 30: Follow-up Outcomes and Factors Associated With Biopsy.

OBJECTIVE: Investigate imaging follow-up patterns and assessment of malignancy rate of BI-RADS 3 lesions in women younger than 30 years. METHODS: We retrospectively reviewed consecutive studies between January 1, 2013 and January 1, 2015 with BI-RADS 3 assessment in women <30 years. Lesion size, follow-up rate, and biopsy rate were recorded. Completion of 24-month imaging follow-up or biopsy determined the endpoint. Statistical analysis of follow-up rates and biopsy timing was performed. RESULTS: Of 2525 BI-RADS 3 lesions, 278 were identified in 215 women <30 years. Fifty-two (24%) women underwent a biopsy which was more frequently done at patient request than for lesion growth [33 (63.4%) versus 19 (36.5%), P <.01]. The odds of having biopsy upfront was significantly higher in lesions >2 cm in diameter (OR: 4.4 [95% CI 2.1-9.4], P <.01). The malignancy rate in our cohort was 0% (95% CI 0-1.7%). Of the 188 women expected for follow-up imaging, 58 (30%) were lost to follow-up, while 103 (55%) had 6-month follow-up, 74 (39%) 12-month follow-up, and 56 (30%) 24-month follow-up. CONCLUSIONS: BI-RADS 3 lesions identified in our cohort had high biopsy rates and low compliance with no cancers. Our findings suggest that probable fibroadenomas in young women may only warrant abbreviated short-term follow-up at 6-months.

Stereotactic Vacuum-Assisted Needle Biopsy Outcomes of Non-calcified Mammographic Lesions.

RATIONALE AND OBJECTIVES: To identify the outcomes of stereotactic vacuum-assisted large bore biopsies performed on sonographically-occult non-calcified mammographic lesions (NCL). MATERIALS AND METHODS: In an IRB-approved retrospective study, we reviewed all NCL that underwent stereotactic biopsy from January 1, 2014 to December 31, 2017 at our institution, comparing patient age, lesion type, size and location with pathology outcome (benign, high-risk or malignant) using Wilcoxon-Mann-Whitney or Fisher's exact tests as appropriate. Multivariable logistic regression models were developed to decrease benign biopsies in our cohort with diagnostic performance assessed using receiver operating characteristic curve and area under the curve (AUC). RESULTS: Of 222 biopsied lesions in 213 patients, 79.3% (176/222) were benign, 5.9% (13/222) malignant, and 14.9% (33/222) high-risk. NCL were less likely to be malignant compared to calcifications biopsied in the same period [5.9% vs 19.0% (243/1279), p < 0.001]. All 42 asymmetries and 33 architectural distortions were benign, while 8.7% (4/46) of masses and 8.9% (9/101) of focal asymmetries were malignant. Cancers were associated with older age (mean 65.2 vs 52.7 years, p < 0.001), smaller size (mean 9.5 mm vs 15.5 mm, p < 0.01), and concurrent breast cancer (p < 0.01) compared to benign/high-risk lesions. Multivariable logistic regression model using patient age >50 years, lesion type, and size <15 mm had a high diagnostic performance [AUC=0.89, 95%CI (0.83, 0.94)], and yielded the highest PPV [0.24; 95%CI (0.13, 0.38)], and highest number of avoided, unnecessary biopsies (172/209, 82%). CONCLUSION: NCL biopsied under stereotactic guidance have low cancer yield (5.9%). A multivariate model integrating age, lesion size and type could potentially help avoid unwarranted biopsies in our cohort.

Determining the thermal characteristics of breast cancer based on high-resolution infrared imaging, 3D breast scans, and magnetic resonance imaging.

For over the three decades, various researchers have aimed to construct a thermal (or bioheat) model of breast cancer, but these models have mostly lacked clinical data. The present study developed a computational thermal model of breast cancer based on high-resolution infrared (IR) images, real three-dimensional (3D) breast surface geometries, and internal tumor definition of a female subject histologically diagnosed with breast cancer. A state-of-the-art IR camera recorded IR images of the subject's breasts, a 3D scanner recorded surface geometries, and standard diagnostic imaging procedures provided tumor sizes and spatial locations within the breast. The study estimated the thermal characteristics of the subject's triple negative breast cancer by calibrating the model to the subject's clinical data. Constrained by empirical blood perfusion rates, metabolic heat generation rates reached as high as 2.0E04 W/m3 for normal breast tissue and ranged between 1.0E05-1.2E06 W/m3 for cancerous breast tissue. Results were specific to the subject's unique breast cancer molecular subtype, stage, and lesion size and may be applicable to similar aggressive cases. Prior modeling efforts are briefly surveyed, clinical data collected are presented, and finally thermal modeling results are presented and discussed.

Breast Lesions in Women Aged Younger than 30 Years: Clinical Presentation, Diagnosis, and Management.

Women aged younger than 30 years frequently present with palpable breast lesions, breast pain, and nipple discharge. Diagnostic work-up often results in benign findings, including a variety of benign solid masses, infectious or inflammatory conditions, pregnancy- or lactation-related abnormalities, and normal variants. While rare, breast cancer can occur within this demographic, and it is often more advanced and aggressive than in older women. Other rare tumors can present within this patient demographic, including primary sarcoma of the breast and granular cell tumors. A knowledge of the clinical presentation, diagnostic approach, and management of this spectrum of pathologic entities is crucial to ensure optimal and cost-effective care within this patient demographic.

Lymphangitic spread of invasive lobular carcinoma to the contralateral breast.

Breast cancer typically spreads primarily to regional lymph nodes and subsequently to distant sites via hematogenous routes. Occasionally metastasis can occur through lymphangitic spread, usually to the lungs, resulting in lymphangitic carcinomatosis. Lymphangitic spread of several malignancies have been reported at other sites in the body with varying degrees of clinical significance. In this case report, we describe a rare case of lymphangitic spread of invasive lobular carcinoma to the contralateral breast identified on imaging as significant background enhancement without a discrete suspicious mass.

Breast ultrasound utilization in a safety net emergency department.

PURPOSE: The purpose of this study is to (1) assess the diagnostic yield of ultrasounds performed in the emergency department for suspected breast abscess and determine the rates of reimaging, discordance, and emergent intervention in a large, busy safety net hospital and (2) determine clinical factors significantly associated with abscess as a way to improve patient selection for emergent breast ultrasounds. METHODS: A total of 581 consecutive breast ultrasounds performed in the emergency department for suspected abscess over 15 months were retrospectively reviewed for imaging, demographics, laboratory data, and physical exam findings. Breast abscess was confirmed by combining imaging, clinical, and laboratory data. Linear logistic regression analysis estimated the likelihood of abscess, and the cross-validated area under the receiver operating characteristic curve (AUC) evaluated diagnostic performance. RESULTS: Final diagnoses included abscess (153/581, 26%), cancer (29/581, 5%), granulomatous mastitis (41/581, 7%), normal (120/581, 21%), and other/indeterminate (238/581, 41%). Factors associated with abscess included induration, fluctuance, erythema, drainage, smoking, diabetes, and Black race. Based on these factors, the AUC of the characteristics predictive of abscess was 0.77 (CI, 0.72-0.81). Six breast cancers were not diagnosed on ultrasound. 40% of ultrasounds (231/581) were considered incomplete/inadequate. CONCLUSION: 74% (428/581) of emergent breast ultrasounds in our population were negative for abscess, while 21% (6/29) of cancers were not diagnosed, and 40% (231/581) of exams were incomplete/inadequate. Patient selection for emergent ultrasounds can be improved, allowing patients with a low likelihood of abscess to be imaged in a more optimal setting.