Determination of Factors Associated with Upstage in Atypical Ductal Hyperplasia to Identify Low-Risk Patients Where Active Surveillance May be an Alternative.

BACKGROUND: Excision is routinely recommended for atypical ductal hyperplasia (ADH) found on core biopsy given cancer upstage rates of near 20%. Identifying a cohort at low-risk for upstage may avoid low-value surgery. Objectives were to elucidate factors predictive of upstage in ADH, specifically near-complete core sampling, to potentially define a group at low upstage risk. PATIENTS AND METHODS: This retrospective, cross-sectional, multi-institutional study from 2015 to 2019 of 221 ADH lesions in 216 patients who underwent excision or active observation (≥ 12 months imaging surveillance, mean follow-up 32.6 months) evaluated clinical, radiologic, pathologic, and procedural factors for association with upstage. Radiologists prospectively examined imaging for lesional size and sampling proportion. RESULTS: Upstage occurred in 37 (16.7%) lesions, 25 (67.6%) to ductal carcinoma in situ (DCIS) and 12 (32.4%) to invasive cancer. Factors independently predictive of upstage were lesion size ≥ 10 mm (OR 5.47, 95% CI 2.03-14.77, p < 0.001), pathologic suspicion for DCIS (OR 12.29, 95% CI 3.24-46.56, p < 0.001), and calcification distribution pattern (OR 8.08, 95% CI 2.04-32.00, p = 0.003, "regional"; OR 19.28, 95% CI 3.47-106.97, p < 0.001, "linear"). Near-complete sampling was not correlated with upstage (p = 0.64). All three significant predictors were absent in 65 (29.4%) cases, with a 1.5% upstage rate. CONCLUSIONS: The upstage rate among 221 ADH lesions was 16.7%, highest in lesions ≥ 10 mm, with pathologic suspicion of DCIS, and linear/regional calcifications on mammography. Conversely, 30% of the cohort exhibited all low-risk factors, with an upstage rate < 2%, suggesting that active surveillance may be permissible in lieu of surgery.

Does diagnostic mammography need to be a routine component of the initial evaluation of a breast symptom in women 30-39 years of age?

Diagnostic mammography is routinely ordered, along with targeted breast ultrasound, to evaluate breast symptoms in women 30-39 years of age. However, in this age group, mammography is often limited by breast density and the probability of detecting an occult malignancy is low. We sought to evaluate whether diagnostic mammography detected any new incidental malignancies in women aged 30-39 years presenting with focal breast symptoms. This retrospective study included women 30-39 years of age who had a diagnostic mammogram performed for focal breast symptoms at a single institution from 2002 to 2017. Descriptive analyses were performed to determine the rate of incidental mammographic findings outside of the region of the presenting symptom that 1) led to additional imaging and/or biopsies and 2) were found to be malignant. During the 16-year study period, 1770 evaluations were performed, of which 249 (14.1%) were found to have an additional incidental mammographic abnormality. Further diagnostic imaging was required in 211 (11.3%), core biopsy in 67 (3.8%), and excisional biopsy in 8 (0.5%). None of the mammographically detected incidental findings resulted in a new diagnosis of breast cancer. In the evaluation of focal benign breast symptoms in women 30-39 years of age, diagnostic mammography did not detect any new incidental malignancies outside of the area of interest, but instead led to additional unavailing imaging and biopsy procedures. The mammography component of the diagnostic evaluation of younger average-risk women may potentially be omitted if the presenting symptom is determined to be benign with ultrasound alone.

Squamous Cell Carcinoma Arising in Breast Implant Capsules.

ABSTRACT: Breast augmentation and reconstruction utilizing implants are among the most common plastic surgery procedures performed in the United States. A small proportion of these implants are removed each year. We report 2 cases where routine pathologic evaluation of capsulectomy specimens revealed squamous cell carcinoma associated with the breast implant capsule and discuss the possible pathogenesis of this unusual entity. Both patients had long-standing implants (>10 years) and presented with acute unilateral breast erythema and swelling. Intraoperatively, the capsules for both cases appeared thickened and calcified, containing extensive granulomatosis and keratinaceous debris invading into the chest wall. Extensive workup failed to find an occult primary. One patient died from a malignant pleural effusion secondary to tumor invasion during chemotherapy, and the second patient obtained stabilization of the mass after 5 weeks of chemotherapy but subsequently declined further surgical intervention. A thorough literature review was performed, and 5 similar reports were identified, involving 6 patients. All patients presented with similar clinical presentations as ours and had poor outcomes. The mean reporting age at diagnosis was 60 years, and the average time from initial implant to diagnosis was 25 years. Due to the small numbers of squamous cell carcinomas associated with breast implant capsules, the true association between the 2 is unknown. It is postulated that chronic inflammation/irritation from the breast implant and epithelialization of the capsule play a significant role in the disease process. This may represent a new entity of "chronic inflammatory capsular malignancies." Increased awareness of this entity may allow for earlier suspicion, diagnosis, and management.

Utility of short-interval follow-up mammography after a benign-concordant stereotactic breast biopsy result.

BACKGROUND: There is currently no clear consensus recommendation for the use of short-interval follow-up mammography after a benign-concordant breast biopsy (BCBB), and practice patterns vary widely. The objectives of this study were to evaluate whether a short-interval follow-up mammogram provided clinical utility after stereotactic BCBB and to examine the costs associated with this surveillance strategy. METHODS: A retrospective review of women who underwent a stereotactic breast biopsy yielding benign-concordant results between January 2005 and October 2014 was performed to evaluate findings on subsequent imaging, to calculate compliance with recommended short-interval imaging, and to examine whether subsequent imaging revealed an abnormality at the site of the initial stereotactic BCBB. A cost analysis was performed utilizing Medicare reimbursement rates to calculate projected and actual costs of short-interval follow-up imaging after stereotactic BCBB. RESULTS: Of the 470 stereotactic BCBB performed, a short-interval mammogram was completed in 207 (44.0%), 9 (4.3%) of which had suspicious mammographic findings at the initial biopsy site, and 6 subsequently underwent biopsy, with none resulting in malignant or high-risk pathology. The cost of short-interval mammographic follow-up (n = 207) was calculated at $28,541.16. CONCLUSIONS: This study provides evidence that 6-month follow-up mammography has low clinical utility and unnecessarily increases costs after stereotactic BCBB. A safe and more cost-effective strategy may be resumption of routine mammography at 12 months post-biopsy.

Lymphoepithelioma-like carcinoma of the breast.

Lymphoepithelioma-like carcinoma of the breast is a rare malignancy, with fewer than 20 cases documented in the literature. Given the paucity of reported cases, there is limited information available to guide the diagnosis and management of patients with this tumor. We present a case of a 39-year-old woman with a palpable right breast mass that was initially diagnosed by core needle biopsy as infiltrating carcinoma with prominent lymphoplasmacytic stroma. Subsequent neoadjuvant chemotherapy with docetaxel, doxorubicin, and cyclophosphamide resulted in a marked decrease in the size of the mass. After wide local surgical excision, pathology revealed a lymphoepithelioma-like carcinoma of the breast. Given the excellent treatment response, our experience may help clinicians determine future therapeutic strategies for this rare breast tumor.

Neuroimaging of tuberous sclerosis: spectrum of pathologic findings and frontiers in imaging.

OBJECTIVE: The purpose of this article is to present neuroimaging findings in tuberous sclerosis complex, including recently developed imaging techniques that have demonstrated clinical benefit to this patient population. CONCLUSION: Neuroimaging advances have improved the diagnosis of tuberous sclerosis complex and the treatment of children with this condition. Superimposition of functional information from PET onto MRI allows accurate and noninvasive identification of epileptogenic tubers, improving surgical cure rates. Magnetic source imaging can also be used to localize epileptiform activity arising from tubers.

Peripancreatic vascular abnormalities complicating acute pancreatitis: contrast-enhanced helical CT findings.

OBJECTIVE: To determine the prevalence and morphologic helical computed tomography (CT) features of peripancreatic vascular abnormalities in patients with acute pancreatic inflammatory disease in correlation with the severity of the pancreatitis. MATERIALS AND METHODS: One hundred and fifty-nine contrast-enhanced helical CT scans of 100 consecutive patients with acute pancreatitis were retrospectively and independently reviewed by three observers. CT scans were scored using the CT severity index (CTSI): pancreatitis was graded as mild (0-2 points), moderate (3-6 points), and severe (7-10 points). Interobserver agreement for both the CT severity index and the presence of peripancreatic vascular abnormalities was calculated (K-statistic). Correlation between the prevalence of complications and the degree of pancreatitis was estimated using Fisher's exact test. RESULTS: The severity of pancreatitis was graded as mild (n = 59 scans), moderate (n = 82 scans), and severe (n = 18 scans). Venous abnormalities detected included splenic vein (SV) thrombosis (31 scans, 19 patients), superior mesenteric vein (SMV) thrombosis (20 scans, 14 patients), and portal vein (PV) thrombosis (17 scans, 13 patients). Arterial hemorrhage occurred in five patients (6 scans). In our series, no cases of arterial pseudoaneurysm formation were detected. The interobserver agreement range for scoring the degree of pancreatitis and the overall presence of major vascular abnormalities was 75.5-79.2 and 86.2-98.8%, respectively. The presence of the vascular abnormalities in correlation with the severity of pancreatitis was variable. CONCLUSION: Vascular abnormalities are relatively common CT findings in association with acute pancreatitis. The CT severity index is insufficiently accurate in predicting some of these complications since no statistically significant correlation between their prevalence and the severity of pancreatitis could be established.

CT features with pathologic correlation of acute gastrointestinal graft-versus-host disease after bone marrow transplantation in adults.

OBJECTIVE: This study was conducted to describe the CT features of acute gastrointestinal graft-versus-host disease in adults and to correlate these findings with the pathologic grades of disease severity. MATERIALS AND METHODS: Patients (n = 22) with a history of allogeneic bone marrow transplantation and pathologically confirmed acute gastrointestinal graft-versus-host disease underwent contrast-enhanced (n = 13) and unenhanced (n = 9) CT. CT scans were retrospectively evaluated for intestinal and extraintestinal abnormalities by two radiologists who were unaware of the biopsy results. The CT findings were correlated with the pathologic grade of disease severity using the Pearson's correlation coefficient and the two-tailed nonparametric Spearman's rank correlation coefficient. RESULTS: CT features included small-bowel wall thickening (22/22), engorgement of the vasa recta adjacent to affected bowel segments (20/22), stranding of the mesenteric fat (16/22), large-bowel wall thickening (13/22), bowel dilatation proximal to thickened wall segments (5/22), ascites (10/22), periportal edema (8/22), mucosal enhancement (7/13), and serosal enhancement (4/13). The wall thickening had a discontinuous distribution in nine patients (41%). Bowel wall thickening was associated with high-grade graft-versus-host disease in patients in whom the distal esophagus (p = 0.015), ileum (p = 0.034), or ascending colon (p = 0.05) was involved. Increasing numbers of thickened bowel segments correlated with high-grade graft-versus-host disease (r = 0.548, p = 0.008). Increasing numbers of abnormal CT findings did not correlate with high-grade graft-versus-host disease (r = 0.117, p = 0.604). CONCLUSION: A variety of bowel abnormalities can be seen on CT in patients with acute graft-versus-host disease. CT findings associated with high-grade graft-versus-host disease are thickening of the distal esophagus, ileum, or ascending colon, as well as increasing numbers of thickened bowel wall segments.

Vaginal metastasis from uterine leiomyosarcoma. Magnetic resonance imaging features with pathological correlation.

Vaginal metastases, though more frequent than primary vaginal tumors, are rare. Except for isolated reports of metastatic disease arising from extragenital organs, the vagina is typically a site for metastatic disease from genitourinary tract sites, especially cervix, endometrium, and kidney. We present herein a case of a 68-year-old woman presenting with a vaginal metastasis as the first manifestation of a uterine leiomyosarcoma. The magnetic resonance imaging features are described and correlated with the pathological findings. To the best of our knowledge, this is the first case of vaginal metastasis from uterine leiomyosarcoma described in the literature.