Evaluation of Breast Edema Findings at T2-weighted Breast MRI Is Useful for Diagnosing Occult Inflammatory Breast Cancer and Can Predict Prognosis after Neoadjuvant Chemotherapy.

Background Prediction of occult inflammatory breast cancer (IBC) and breast cancer prognosis based on breast edema findings on T2-weighted MRI scans, even for patients without clinical signs of IBC, would be useful in both pretreatment planning and prognosis and may elucidate the underlying biologic mechanisms. Purpose To evaluate whether classification of breast edema on T2-weighted MRI scans is useful for predicting the prognosis of patients with breast cancer treated with neoadjuvant chemotherapy (NAC). Materials and Methods A retrospective evaluation was performed of women with breast cancer who underwent breast MRI and were treated with NAC between January 2011 and December 2018. Breast edema on T2-weighted images was scored on a scale of 1 to 4, as follows: (a) breast edema score (BES) 1, no edema; (b) BES 2, peritumoral edema; (c) BES 3, prepectoral edema; and (d) BES 4, subcutaneous edema (suspicious for occult IBC). Clinically evident IBC was classified as BES 5 (without MRI). The log-rank test was performed, and hazard ratios were calculated using the Cox hazard model to evaluate associations between BES and progression-free survival (PFS) and overall survival (OS). PFS rate at 100 months after initiation of therapy was also evaluated. Results Of 408 patients (median age, 53 years; range, 28-80 years), 65 (16%) had a recurrence and 27 (7%) died. The log-rank test revealed differences in PFS for BES 4 versus 1, BES 5 versus 1, BES 5 versus 2, and BES 5 versus 3 (adjusted P < .05 for all). PFS rates for BES 1-5 were 0.92, 0.85, 0.80, 0.62, and 0.58, respectively, and the corresponding OS rates at 100 months were 0.98, 0.91, 0.92, 0.77, 0.86, respectively. Conclusion Classification of breast edema findings on T2-weighted MRI scans using a breast edema score was related to the prognosis of patients after neoadjuvant chemotherapy. © RSNA, 2021 Online supplemental material is available for this article.

Large Plaque-type Blue Nevus with GNAQ Q209P Mutation, Involving Mammary Gland Tissue: Under-Recognized Mammary Condition as an Origin of Primary Mammary Melanocytic Tumors.

ABSTRACT: Plaque-type blue nevus is a rare variant of blue nevi that was first described in 1954. This article presents clinical, macroscopic, histopathological, and genetic findings for a case of large plaque-type blue nevus expanding into the mammary gland tissue as well as the skin of the right breast. A 63-year-old woman presented with a congenital, large, blue-colored macule limited to the hypochondriac area of the right breast. A nodule 8 mm in diameter was also present in the mammary gland tissue. Magnetic resonance imaging was unable to detect diffuse melanin deposition in the mammary gland tissue, but pigmentation in the whole mammary parenchyma was observed in the cut surfaces of the mastectomy specimen. Histopathology revealed a sparse distribution of dendritic melanocytes in whole sections of the mammary fibrous tissue and partial sections of the dermis. The histopathological criteria for atypical cellular blue nevus were fulfilled for the mammary tumor. Nodal blue nevus was diagnosed in the sentinel lymph node. Sanger sequencing confirmed the GNAQ Q209P mutation, which was also identified in all 4 literature cases of plaque-type blue nevus, but rarely in conventional blue nevi and uveal melanoma. It should be noted that plaque-type blue nevus can expand into the mammary gland tissue, even if the pigmented lesion does not exist on the overlying breast skin. The mammary condition can be the origin of primary mammary melanocytic tumors. Mosaicism of the GNAQ Q209P mutation can be a characteristic genetic alteration to extensive blue nevi, including plaque-type blue nevus.

Is the presence of edema and necrosis on T2WI pretreatment breast MRI the key to predict pCR of triple negative breast cancer?

PURPOSE: Given that a pathological complete response (pCR) after neoadjuvant chemotherapy (NAC) is an important prognostic factor, evaluating pretreatment imaging findings is important. Outcomes for triple negative breast cancer (TNBC) vary with the histological classification, indicating that this classification is clinically significant. In this study, we focus on the most common histological subtype of TNBC, invasive carcinoma of no special type (NST), to evaluate whether intramammary edema (intra-E) and intratumoral necrosis (intra-N) on T2-weighted magnetic resonance imaging (T2WI) is a useful predictor of pCR. METHOD: We retrospectively included patients with biopsy-diagnosed TNBC-NST who received NAC between January 2014 and December 2017. Intra-E and intra-N were evaluated on T2WI before NAC. We grouped intra-E into no edema, peritumoral edema, prepectoral edema, and subcutaneous edema, and we defined intra-N as water-like signal intensity without enhancement on T2WI. We also evaluated tumor size, Ki-67 expression, and histological/nuclear grade, as well as their correlation with intra-E and intra-N. RESULTS: Fifty-seven patients with TNBC-NST were enrolled. There was no correlation with the rate of pCR and the presence of either intra-E or intra-N before NAC. Only intra-E and tumor size showed a positive correlation. CONCLUSIONS: In patients with TNBC-NST, intra-E and intra-N did not correlate with pCR, but intra-E did positively correlate with tumor size. NST may exhibit a greater response to NAC, regardless of whether intra-E or intra-N is present or not on the pretreatment MRI. KEY POINTS: • Pathological complete response in TNBC-NST had no correlation with intramammary edema or intratumoral necrosis. • NAC may be justified in TNBC-NST even in the presence of edema or necrosis. • The extension of edema correlated with tumor size of TNBC-NST.

T2-hypointense rim of breast mass lesions on magnetic resonance images: Radiologic-pathologic correlation.

We investigated the radiologic-pathologic correlation of a strong hypointense rim on T2-weighted images (T2-hypo-rim) surrounding breast mass lesions and evaluated its clinical significance. We retrospectively reviewed 3503 consecutive breast magnetic resonance imaging (MRI) examinations. The T2-hypo-rim was defined as a border of strong hypointensity compared with the fat signal on fat-suppressed T2-weighted images. Detected lesions with T2-hypo-rim were classified as a solid or cystic mass with MRI and correlated with histopathologic findings. Sixty-two masses (2%; 34 solid, 28 cystic) with T2-hypo-rim were detected [44 breast cancers, 18 benign lesions, including 15 (24%) papillary tumors]. Patients with cancer were significantly older than those with benign lesions (P = .002). Breast cancers were significantly larger than benign masses (P = .023). In 49 of 62 lesions (24 solid and 16 cystic cancers; three solid and six cystic benign masses), the rims were accurately correlated with the histopathologic findings. All malignant and benign cystic masses exhibited hemosiderin deposits in the cyst walls. However, 22 of 24 solid cancers and no solid benign masses exhibited hemosiderin at the tumor periphery (92% and 0%, respectively, P < .001). In addition, a thick fibrous capsule was present in nine (38%) of 24 solid cancers and none of the solid benign lesions. Strong T2-hypo-rims mostly correlated with hemosiderin deposits and/or sometimes fibrous capsules. Although the rims could not distinguish malignant from benign cystic lesions, they indicated malignancy in solid mass lesions on MRI. Additionally, the rims often indicated papillary tumors.

Comparison of visibility of circumscribed masses on Digital Breast Tomosynthesis (DBT) and 2D mammography: are circumscribed masses better visualized and assured of being benign on DBT?

OBJECTIVE: To compare the visibility of circumscribed masses on digital breast tomosynthesis (DBT) images and 2D mammograms and determine the usefulness of DBT for differentiation between benign and malignant circumscribed masses. METHODS: Seventy-one (19 malignant and 52 benign) mammographic well-circumscribed masses were included. Visibility of the masses and halo signs on DBT images were retrospectively compared with 2D mammograms. The effects of mammographic breast density on mass visibility were also evaluated. RESULTS: For DBT, 83% were superior and 17% were equivalent in visibility of the masses to that of 2D, and superiority of DBT was significantly enhanced in the high breast density group compared with the low breast density group (91% vs 68%, respectively, p = 0.016). Three lesions were only detected on DBT. There was no significant difference in the superiority of DBT for lesion visibility between malignant and benign masses. The halo sign was detected in 58% lesions on DBT and in 4% on 2D (p < 0.001). CONCLUSION: Circumscribed masses were better visualized on DBT than on 2D mammograms, particularly in high-density breasts. The halo sign often appeared on DBT and gave a clearer mass margin. However, circumscribed masses on DBT are not assured of being benign. KEY POINTS: • Circumscribed masses were better visualized on breast tomosynthesis than on 2D mammography. • Tomosynthesis visualized circumscribed masses better than 2D for all breast density categories. • Halo signs often appeared on tomosynthesis and contributed to detect circumscribed margins. • Circumscribed masses on tomosynthesis images are not assured of being benign lesions.

Diagnostic performance of CT findings for bowel ischemia and necrosis in closed-loop small-bowel obstruction.

PURPOSE: The aim of this study was to investigate the diagnostic performance of contrast-enhanced CT (CECT) findings for bowel ischemia and necrosis in closed-loop small-bowel obstruction (CL-SBO). MATERIALS AND METHODS: Thirty-five patients with CL-SBO confirmed by laparotomy (n = 34) or multiplanar reconstruction of thin slice CT images (n = 1) were included. Based on the surgical and clinical findings, these patients were classified into three groups: necrosis group (n = 16), ischemia without necrosis group (n = 11), and no-ischemia group (n = 8). Two blinded radiologists retrospectively reviewed CECT including multiplanar reconstruction images and evaluated 12 CT findings. The sensitivity and specificity of each finding were compared among the three groups, and logistic regression analysis was performed. RESULTS: High attenuation of the bowel wall, intraperitoneal air, reduced enhancement of the mesenteric arteries, and small-bowel feces signs showed high specificities of 100%, 100%, 89%, and 89% but low sensitivities of 31%, 25%, 44%, and 31%, respectively, for the prediction of bowel necrosis in CL-SBO. According to multivariate logistic regression analysis, reduced bowel-wall enhancement, reduced enhancement of the mesenteric veins, and a lack of engorgement of the mesenteric veins were significant for predicting bowel ischemia or necrosis (P < 0.05). CONCLUSIONS: Reduced enhancements of bowel wall and mesenteric veins were good indicators of bowel ischemia or necrosis. On the contrary, engorgement of the mesenteric veins was a predictor of a viable bowel.

Local recurrence after chemoembolization of hepatocellular carcinoma: uptake of gadoxetic acid as a new prognostic factor.

OBJECTIVE: The purpose of this article is to investigate whether there is a difference in susceptibility to transcatheter arterial chemoembolization between hepatocellular carcinomas (HCCs) showing high uptake and those showing low uptake of gadoxetic acid in the hepatobiliary phase of MRI. MATERIALS AND METHODS: One hundred HCCs that achieved optimal chemoembolization, as assessed by immediate CT in 60 patients, were classified as having high (n = 19) or low (n = 81) uptake of gadoxetic acid on MRI performed before chemoembolization. The local recurrence rates were estimated using the Kaplan-Meier method, and differences between the groups were compared using the log-rank test. The following factors were also correlated with the local recurrence rate using the Cox proportional hazards model for a univariate analysis: high uptake of gadoxetic acid, number of feeding arteries, extrahepatic arterial supply, Child-Pugh class, clinical tumor stage, size, location, and iodized oil accumulation in the noncancerous tissue surrounding the lesion. Parameters that were significant at p < 0.05 were entered into a multivariate model. RESULTS: The 1- and 3-year local recurrence-free rates were 95% in high-uptake HCCs and 66% and 54%, respectively, in low-uptake HCCs (log-rank test, p < 0.01). The low uptake of gadoxetic acid was the only significant predictor of early local recurrence (hazard ratio = 9.24; p = 0.03) by multivariate analysis. CONCLUSION: HCCs showing high uptake of gadoxetic acid appear to be susceptible to chemoembolization.

Preliminary study of standardized semiquantitative method for ultrasonographic breast composition assessment.

PURPOSE: To develop a classification tree via semiquantitative analysis for ultrasonographic breast composition assessment using routine breast ultrasonography examination images. METHODS: This study retrospectively enrolled 100 consecutive normal women who underwent screening mammography and supplemental ultrasonography. Based on sonographic breast composition, the patients' breasts were classified as nondense or dense, which were correlated with mammographic breast composition. Ultrasonographic breast composition was classified based on the fibroglandular tissue (FGT) thickness-to-subcutaneous fat and retromammary fat (FAT) thickness ratio. In addition, the presence of a high glandular tissue component (GTC) in FGT or the presence of evident fat lobules in FGT was investigated. The cutoff point between the nondense and dense breasts was calculated from the area under the curve (AUC). RESULTS: All cases with a high GTC were dense breasts, and all cases with evident fat lobules in the FGT were nondense breasts. The AUC of the FGT thickness-to-FAT ratio of all cases, the group without a high GTC, the group without evident fat lobules in the FGT, and the group without a high GTC or evident fat lobules in the FGT were 0.93, 0.94, 0.99, and 1, respectively. CONCLUSION: The presence of a high GTC indicated dense breasts, and the presence of evident fat lobules in the FGT represented nondense breasts. For the remaining cases, the cutoff point of the FGT thickness-to-FAT thickness ratio was 0.93 for ultrasonographic two-grade scale breast composition assessment with 100% accuracy.

Non-contrast-enhanced breast MRI for evaluation of tumor volume change after neoadjuvant chemotherapy.

PURPOSE: Three-dimensional contrast-enhanced magnetic resonance imaging (3D-Ce-MRI) is a most powerful tool for evaluation of neoadjuvant chemotherapy (NAC). However, the use of contrast agent is invasive, expensive, and time consuming, Thus, contrast agent-free imaging is preferable. We aimed to investigate the tumor volume change after NAC using maximum intensity projection diffusion-weighted image (MIP-DWI) and 3D-Ce-MRI. METHOD: We finally enrolled 55 breast cancer patients who underwent NAC in 2018. All MRI analyses were performed using SYNAPSE VINCENT® medical imaging system (Fujifilm Medical, Tokyo, Japan). We evaluated the tumor volumes before, during, and after NAC. Tumor volume before NAC on 3D-Ce-MRI was termed Pre-CE and those during and after NAC were termed Post-CE. The observer raised the lower end of the window width until the tumor was clearly visible and then manually deleted the non-tumor tissues. A month thereafter, the same observer who was blinded to the 3D-Ce-MRI results randomly evaluated the tumor volumes (Pre-DWI and Post-DWI) using MIP-DWI with the same method. Tumor volume change between ΔCE (Pre-CE - Post-CE/Pre-CE) and ΔDWI (Pre-DWI - Post-DWI/Pre-DWI) and the processing time for both methods (Time-DWI and Time-CE) were compared. RESULTS: We enrolled 55 patients. Spearman's rho between ΔDWI and ΔCE for pure mass lesions, and non-mass enhancement (NME) was 0.89 (p < 0.01), 0.63(p < 0.01) respectively. Time-DWI was significantly shorter than Time-CE (41.3 ± 21.2 and 199.5 ± 98.3 respectively, p < 0.01). CONCLUSIONS: Non-contrast-enhanced Breast MRI enables appropriate and faster evaluation of tumor volume change after NAC than 3D-Ce-MRI especially for mass lesions.

The Japanese breast cancer society clinical practice guidelines for breast cancer screening and diagnosis, 2022 edition.

This article provides updates to readers based on the newly published Japanese Breast Cancer Society Clinical Practice Guidelines for Breast Cancer Screening and Diagnosis, 2022 Edition. These guidelines incorporate the latest evaluation of evidence from studies of diagnostic accuracy. For each clinical question, outcomes for benefits and harms were established, and qualitative or quantitative systematic reviews were conducted. Recommendations were determined through voting by a multidisciplinary group, and guidelines were documented to facilitate shared decision-making among patients and medical professionals. The guidelines address screening, surveillance, and pre- and postoperative diagnosis of breast cancer. In an environment that demands an integrated approach, decisions are needed on how to utilize modalities, such as mammography, ultrasound, MRI, and PET/CT. Additionally, it is vital to understand the appropriate use of new technologies, such as tomosynthesis, elastography, and contrast-enhanced ultrasound, and to consider how best to adapt these methods for individual patients.

A Japanese Family Meeting the Clinical Diagnostic Criteria for MEN1 with a MEN1 Variant of Uncertain Significance.

Multiple gastroenteric, pancreatic, and pituitary neuroendocrine neoplasms (NENs) were diagnosed in a 74-year-old man with a history of primary hyperparathyroidism (PHPT). Germline testing demonstrated a variant of MEN1 (c.1694T>A, p.L565Q), whose pathogenicity was classified as a variant of uncertain significance (VUS) according to the ACMG/AMP guidelines. The same germline variant was detected in the patient's son and daughter, who also showed PHPT or hypercalcemia and met the clinical diagnostic criteria for multiple endocrine neoplasia type 1 (MEN1). During surveillance of the son, multiple pancreatic tumors suggestive of NENs were detected. The pathogenicity of the current MEN1 variant was re-evaluated as likely pathogenic, based on additional family data.

Inter- and intra-observer variability of qualitative visual breast-composition assessment in mammography among Japanese physicians: a first multi-institutional observer performance study in Japan.

BACKGROUND: Visual assessment of mammographic breast composition remains the most common worldwide, although subjective variability limits its reproducibility. This study aimed to investigate the inter- and intra-observer variability in qualitative visual assessment of mammographic breast composition through a multi-institutional observer performance study for the first time in Japan. METHODS: This study enrolled 10 Japanese physicians from five different institutions. They used the new Japanese breast-composition classification system 4th edition to subjectively evaluate the breast composition in 200 pairs of right and left normal mediolateral oblique mammograms (number determined using precise sample size calculations) twice, with a 1-month interval (median patient age: 59 years [range 40-69 years]). The primary endpoint of this study was the inter-observer variability using kappa (κ) value. RESULTS: Inter-observer variability for the four and two classes of breast-composition assessment revealed moderate agreement (Fleiss' κ: first and second reading = 0.553 and 0.587, respectively) and substantial agreement (Fleiss' κ: first and second reading = 0.689 and 0.70, respectively). Intra-observer variability for the four and two classes of breast-composition assessment demonstrated substantial agreement (Cohen's κ, median = 0.758) and almost perfect agreement (Cohen's κ, median = 0.813). Assessments of consensus between the 10 physicians and the automated software Volpara® revealed slight agreement (Cohen's κ; first and second reading: 0.104 and 0.075, respectively). CONCLUSIONS: Qualitative visual assessment of mammographic breast composition using the new Japanese classification revealed excellent intra-observer reproducibility. However, persistent inter-observer variability, presenting a challenge in establishing it as the gold standard in Japan.

Peri-stent aneurysm formation following a stent implant for stenotic intracranial vertebral artery dissection: a technical report of two cases successfully treated with coil embolization.

INTRODUCTION: Although stenting for stenotic vertebral artery dissection (VAD) improves compromised blood flow, subsequent peri-stent aneurysm (PSA) formation is not well-known. We report two cases with PSA successfully treated with coil embolization. METHODS: Three patients with stenotic intracranial VAD underwent endovascular angioplasty at our institution because they had acute infarction in posterior circulation territory and clinical evidence of hemodynamic insufficiency. In two of three patients balloon angioplasty at first session failed to relieve the stenosis, and a coronary stent was implanted. Angiography immediately after stenting showed no abnormality in case 1 and minimal slit-like projection at proximal portion of the stent in case 2. RESULTS: Angiography obtained 16 months after the stenting revealed PSA in case 1. In case 2, angiography performed 3 months later showed that the projection at proximal portion enlarged and formed an aneurysm outside the stent. Because follow-up angiographies showed growth of the aneurysm in both cases, endovascular aneurysmal embolization was performed. We advanced a microcatheter into the aneurysm through the strut of existing stent and delivered detachable coils into the aneurysm lumen successfully in both cases. The post-procedural course was uneventful, and complete obliteration of aneurysm was confirmed on angiography in both cases. CONCLUSION: Stenting for stenotic intracranial VAD may result in delayed PSA; therefore, follow-up angiographies would be necessary after stenting for stenotic intracranial arterial dissection. Coil embolization through the stent strut would be a solution for enlarging PSA.

Comparisons between artificial intelligence computer-aided detection synthesized mammograms and digital mammograms when used alone and in combination with tomosynthesis images in a virtual screening setting.

PURPOSE: To compare the reader performance of artificial intelligence computer-aided detection synthesized mammograms (AI CAD SM) with that of digital mammograms (DM) when used alone or in combination with digital breast tomosynthesis (DBT) images. MATERIALS AND METHODS: This retrospective multireader (n = 4) study compared the reader performances in 388 cases (84 cancer, 83 benign, and 221 normal or benign cases). The overall accuracy of the breast-based assessment was determined by four radiologists using two sequential reading modes: DM followed by DM + DBT; and AI CAD SM followed by AI CAD SM + DBT. Each breast was rated by each reader using five-category ratings, where 3 or higher was considered positive. The area under the receiver-operating characteristic curve (AUC) and reading time were evaluated. RESULTS: The mean AUC values for DM, AI CAD SM, DM + DBT, and AI CAD SM + DBT were 0.863, 0.895, 0.886, and 0.902, respectively. The mean AUC of AI CAD SM was significantly higher (P < 0.0001) than that of DM. The mean AUC of AI CAD SM + DBT was higher than that of DM + DBT (P = 0.094). A significant reduction in the reading time was observed after using AI CAD SM + DBT when compared with that after using DM + DBT (P < 0.001). CONCLUSION: AI CAD SM + DBT might prove more effective than DM + DBT in a screening setting because of its lower radiation dose, noninferiority, and shorter reading time compared to DM + DBT.

Artificial intelligence computer-aided detection enhances synthesized mammograms: comparison with original digital mammograms alone and in combination with tomosynthesis images in an experimental setting.

BACKGROUND: It remains unclear whether original full-field digital mammograms (DMs) can be replaced with synthesized mammograms in both screening and diagnostic settings. To compare reader performance of artificial intelligence computer-aided detection synthesized mammograms (AI CAD SMs) with that of DM alone or in combination with digital breast tomosynthesis (DBT) images in an experimental setting. METHODS: We compared the performance of multireader (n = 4) and reading multicase (n = 388), in 84 cancers, 83 biopsy-proven benign lesions, and 221 normal or benign cases with negative results after 1-year follow-up. Each reading was independently interpreted with four reading modes: DM, AI CAD SM, DM + DBT, and AI CAD SM + DBT. The accuracy of probability of malignancy (POM) and five-category ratings were evaluated using areas under the receiver operating characteristic curve (AUC) in the random-reader analysis. RESULTS: The mean AUC values based on POM for DM, AI CAD SM, DM + DBT, and AI CAD SM + DBT were 0.871, 0.902, 0.895, and 0.909, respectively. The mean AUC of AI CAD SM was significantly higher (P = 0.002) than that of DM. For calcification lesions, the sensitivity of SM and DM did not differ significantly (P = 0.204). The mean AUC for AI CAD SM + DBT was higher than that of DM + DBT (P = 0.082). ROC curves based on the five-category ratings showed similar proximity of the overall performance levels. CONCLUSIONS: AI CAD SM alone was superior to DM alone. Also, AI CAD SM + DBT was superior to DM + DBT but not statistically significant.

Computed tomographic pulmonary angiography: Three cases of low-tube-voltage acquisition with a slow injection of contrast medium.

Acute pulmonary thromboembolism occurring during cancer treatment has been increasing with the number of cancer patients and chemotherapy cases. Computed tomographic pulmonary angiography (CTPA) for evaluating the pulmonary artery is generally performed using rapid injection of contrast medium. However, intravenous catheters for contrast medium injection might cause extravasation due to rapid injection. This case series describes three patients who underwent contrast-enhanced computed tomography combined with low-tube-voltage imaging and slow injection. Low-tube-voltage slow-injection CTPA can be an effective technique for obtaining high contrast enhancement while accommodating fragile veins and low injection rates.

A case of lupus-associated pancreatitis with ruptured pseudoaneurysms.

Pancreatitis is a relatively rare complication in systemic lupus erythematosus (SLE). Herein we report a case of SLE with the initial development of acute pancreatitis, subsequently complicated by bleeding pseudoaneurysms. A 55-year-old Japanese woman was admitted to our hospital for the treatment of SLE. During the course of treatment, she complained of upper abdominal pain. An abdominal computed tomography (CT) scan showed that the pancreas was diffusely enlarged, and she was diagnosed with acute pancreatitis. Her pancreatitis was resistant to glucocorticoid therapy and was subsequently associated with pancreatic pseudocysts and recurrent rupture of the pseudoaneurysms. After surgical drainage of the hemorrhagic pseudocysts, the patient's clinical condition gradually improved with intensive therapies. Our case indicates that lupus pancreatitis can be associated with the potentially fatal complication of recurrent bleeding of pseudoaneurysms.

Can breast MRI and adjunctive Doppler ultrasound improve the accuracy of predicting pathological complete response after neoadjuvant chemotherapy?

BACKGROUND: To examine the accuracy of MRI and Doppler ultrasound (US) for detecting residual tumor after neoadjuvant chemotherapy (NAC) for breast cancer and evaluate whether adjunctive Doppler US improves the MRI accuracy. METHODS: We reviewed 276 invasive breast cancer cases treated with NAC. Tumors were classified into four subtypes based on estrogen receptor and HER2 status. Response to NAC was evaluated using contrast-enhanced MRI and Doppler US. Residual Doppler flow was assumed to indicate a residual tumor. MRI and Doppler findings were compared with the histopathological findings of resected specimens. Pathological complete response (pCR) was defined as neither in situ nor invasive cancer left. RESULTS: Of the 276 tumors, imaging complete responses were observed using MRI and Doppler US in 62 (22%) and 111 (40%), respectively, whereas pCR was achieved in 44 (16%). MRI and Doppler US predicted residual tumor with 88% and 69% sensitivity, 80% and 91% specificity, 87% and 73% accuracy, 96% and 98% PPV, and 56% and 36% NPV, respectively. The accuracies of MRI and Doppler US were significantly higher for HER2-negative than HER2-positive tumors (p < 0.001 and p = 0.043, respectively). Seven (26%) of 27 false-negative cases identified by MRI were correctly diagnosed as positives with adjunctive Doppler US. CONCLUSIONS: Although MRI accurately detected residual tumor with 87% accuracy, this was still not sufficient to meet clinical demands and differed with tumor subtype. Adjunctive Doppler US in cases that appear to show a complete response on MRI might reduce chances of false negatives and increase the NPV of MRI for predicting residual tumor.

FLAIR hyperintensity along the brainstem surface in leptomeningeal metastases: a case series and literature review.

BACKGROUND: The incidence of leptomeningeal metastasis (LM) is underestimated because of its non-specific signs and the low sensitivity of clinical diagnostic modalities. Cerebrospinal magnetic resonance (MR) imaging with and without contrast enhancement (CE) is a gold standard for the neuroradiological assessment of patients with suspected LM. Previous studies suggested that some LM cases show changes of the brainstem surface on non-contrast MR images without or before the appearance of abnormalities on CE images. We assessed the features of this non-contrast MR finding in a cohort of LM patients in this retrospective single-institution study. METHODS: We reviewed head MR images and clinical data of 142 consecutive patients in whom the final diagnosis was LM. RESULTS: We found that 11 of these 142 patients (7.7%) with LM had band-like hyperintensity on the brainstem surface on non-enhanced FLAIR images, which looked like bloomy rind on cheese. Three of seven patients who were examined using diffusion-weighted imaging showed restricted diffusion in the corresponding lesion site. The above-mentioned 11 patients included 10 women and 1 man, with a median age of 61 years. All 11 patients had primary lung adenocarcinoma. Seven patients had symptomatic hydrocephalus. Ten patients had EGFR-mutated and one had ALK-rearrangement adenocarcinomas. Before the diagnosis of LM, 10 patients had undergone systemic therapy with EGFR-TKI or pemetrexed, and 1 patient with ALK inhibitor and bevacizumab. CONCLUSIONS: We present a series of patients with bloomy rind sign that is non-enhancing LM reliably detected by FLAIR hyperintensity on the brainstem surface. This finding is rare, but may reflect the spread of cancer cells in both the leptomeningeal membrane and the surface of the brain parenchyma specifically in patients with lung adenocarcinomas. Further study is needed to determine the clinical significance of this sign, and the pathophysiological factors associated with it may be clarified by analyzing serial MR images in a larger cohort of patients treated for LM.

A practical predictor of the growth potential of benign meningiomas: Hypointensity of surface layer in T2-weighted magnetic resonance imaging.

BACKGROUND: Accurate evaluation of proliferative potential is particularly important in the clinical management of individual patients with meningiomas. We introduce a new feature in the parenchyma of meningioma, namely, hypointensity of the surface layer (HSL), on T2-weighted MR images and compare it with a cellular proliferation index and growth speed. MATERIALS AND METHODS: We retrospectively analyzed the records of consecutive patients with WHO grade I meningiomas in two institutes: an operated group with 124 meningiomas resected in one institute, and an observed group with 89 meningiomas monitored without surgery in the other. Proliferative potential was evaluated using the MIB-1 labeling index (MIB-1 LI) for the operated group and using the relative growth rate on serial MR images for the observed group. RESULTS: In the operated group, 60 (48.4%) meningiomas exhibited HSL. HSL-positive meningiomas were significantly smaller in size and more often calcified than HSL-negative ones. Univariate analysis showed that HSL negativity, large size, no calcification, and surrounding brain edema were significantly associated with high MIB-1 LI (p < 0.05). Multivariate analysis demonstrated that only HSL was significantly related to MIB-1 LI (p = 0.001). HSL did not correlate with tumor recurrence after resection. In the observed group, 43 (48.3%) meningiomas exhibited HSL and they presented a significantly slow relative growth rate. CONCLUSIONS: HSL is a simple and new radiological feature indicative of low proliferative potential and a low risk of enlargement of meningiomas. The presence or absence of HSL may serve as a key parameter for the selection of aggressive treatment or active observation.