Current opinion on clip placement after breast biopsy: a survey of practising radiologists in France and Quebec.

AIM: To investigate current practice regarding clip placement after breast biopsy. MATERIALS AND METHODS: In June 2011, an online survey instrument was designed using an Internet-based survey site (www.surveymonkey.com) to assess practices and opinions of breast radiologists regarding clip placement after breast biopsy. Radiologists were asked to give personal practice data, describe their current practice regarding clip deployment under stereotactic, ultrasonographic, and magnetic resonance imaging (MRI) guidance, and describe what steps are taken to ensure quality control with regards to clip deployment. RESULTS: The response rate was 29.9% in France (131 respondents) and 46.7% in Quebec (50 respondents). The great majority of respondents used breast markers in their practice (92.1% in France and 96% in Quebec). In both countries, most reported deploying a clip after percutaneous biopsy under stereotactic or MRI guidance. Regarding clip deployment under ultrasonography, 38% of Quebec radiologists systematically placed a marker after each biopsy, whereas 30% of French radiologists never placed a marker in this situation, mainly due to its cost. Finally, 56.4% of radiologists in France and 54% in Quebec considered that their practice regarding clip deployment after breast percutaneous biopsy had changed in the last 5 years. CONCLUSION: There continues to be variations in the use of biopsy clips after imaging-guided biopsies, particularly with regards to sonographic techniques. These variations are likely to decrease over time, with the standardization of relatively new investigation protocols.

[Non-masslike enhancement on breast MRI: interpretation pearls]. / Le rehaussement sans masse en IRM mammaire: comment j'interprète?

The MR Breast Imaging Reporting and Data System (BI-RADS) lexicon of the American College of Radiology (ACR) includes a new lesion category defined as non-masslike enhancement. The purpose of this paper is to review the definition of this new entity, illustrate the main imaging features described in the BI-RADS lexicon and to propose a diagnostic approach based on data from the literature in order to achieve diagnosis and optimal patient management.

[How to measure breast density?]. / Comment mesurer la densité mammaire?

The relation between breast tissue density and cancer risk is well known. Early quantification techniques were based on subjective visual assessment. Quantitative techniques were then developed using planimetric measurements, surface area calculations or volumetric measurements. More recently, digital mammography should allow objective computer-based density measurements using mathematical models.

[Imaging in pelvic inflammatory disease]. / Imagerie de l'infection pelvienne.

This is a review of evolutive aspects in pelvic inflammatory disease (salpingitis, endometritis, pyosalpinx, tubo ovarian abscess) assessed by different imaging modalities (Ultrasound, CT, MRI and hysterosalpingography).

[Breast imaging of mass, architectural distortion and asymmetry: Clinical practice guidelines]. / Imagerie mammaire du syndrome de masse, distorsion architecturale et asymétrie: recommandations pour la pratique clinique.

The development of the mammary imaging (mammography, ultrasound, MRI) enables the discovery of more and more lesions. The BI-RADS lexicon is the reference book for their descriptive analysis. Four elementary images must be individualized: masses and architectural distortion described in 3 imaging techniques, asymmetries and microcalcifications described in mammography. The aim of this work was to review three of these images: mass, architectural distortion and asymmetry, allowing the various actors involved in senology to propose an up-to-date diagnostic and interventional strategy, based on their positive predictive values (PPV) or negative predictive values of cancer and allowing the classification BI-RADS of the lesion. The masses are the most often encountered lesions as well in screening as in diagnosis. Their PPV is superior in diagnosis than in screening and it increases with the age. Their irregular forms, their spiculated outlines and their evolutionary character are the most relevant elements of suspicion. The architectural distortion is the rarest image and always classified suspect BI-RADS 4, except in case of a known scar. The asymmetry is less common; its PPV is low and rises only in case of evolutionary asymmetry.

[Explorations of breast microcalcifications: Guidelines]. / Exploration des microcalcifications mammaires: recommandations.

OBJECTIVES: To assess imaging performances for the detection, characterization and biopsy of breast microcalcifications and make recommendations. MATERIALS AND METHODS: French and English publications were searched using PubMed, Cochrane Library and international learned societies recommendations. RESULTS: Digital mammography (DR [Direct Radiography] and CR [Computed Radiography]) and screen-film mammography demonstrate good performances for the detection and the characterization of breast microcalcifications. Systematic use of the 2013 edition of the BI-RADS lexicon is recommended for description and characterization of microcalcifications. Faced with BI-RADS 4 or 5 microcalcifications, breast ultrasound is recommended but a normal result does not eliminate the diagnosis of cancer and other examination should be performed. Literature review does not allow recommending digital breast tomosynthesis, elastography or MRI to analyze microcalcifications. In case of probably benign microcalcifications (BI-RADS 3), six months, one year and at least two years follow-up are recommended. In case a biopsy is indicated, it is recommended to use a vacuum-assisted macrobiopsy system with 11-gauges needles or bigger. If no calcification is visible on the radiography of the specimen, it is recommended to obtain additional samples.

[Management of breast nipple discharge: Recommendations]. / Exploration d'un écoulement mamelonnaire du sein uni- ou bilatéral: recommandations.

OBJECTIVES: To investigate diagnostic value of imaging procedures and management strategies of the patients with nipple discharge (ND) to establish management recommendations. METHODS: Bibliographical search in French and English languages by consultation of PubMed, Cochrane and Embase databases. RESULTS: Although, all ND require an systematic evaluation guided by clinical data, bloody ND could be a predictor of breast cancer risk among different colors of discharge particularly in patients of more than 50 years (LE2). The mammography and breast ultrasography are the imaging procedures to realize in first intention (grade C) but they turn out useful only when they detect radiological abnormalities (LE4). Galactography has only a localizing value of possible ductal abnormalities (when standard imaging procedures is not contributive) (LE4). Thus, in the diagnostic investigation of a suspicious ND, galactography it is not recommended in standard practice (grade C). The breast Magnetic Resonance Imaging (MRI) is recommended when breast standard imaging procedures are not contributive (grade C). The ND cytology is useful only if it is positive (i.e. reveal cancer cells). There is no proof on the diagnostic performance of the cytological analysis of the ND to allow a recommendation on its realization or not. In front of a suspicious ND, when breast-imaging procedures reveals an associated radiological lesion, an adapted percutaneous biopsy is recommended by percutaneous way (grade C). Vacuum-assisted breast biopsies is a diagnostic tool but can also be therapeutic allowing to avoid surgery in case of benign lesion but current literature data do not allow recommendations on the therapeutic aspect of vacuum-assisted breast biopsy (LE4). In the absence of associated radiological signal, and in case of reproducible bloody persistent ND, a pyramidectomy is recommended (grade C).

[Clinical practice guidelines: Benign breast tumor--Aims, methods and organization]. / Recommandations pour la pratique clinique: tumeurs bénignes du sein--Objectifs, méthodes et organisation.

Conversely to breast cancer, few data and guidelines are available to explore and manage benign breast disorders. Therefore, the Collège national des gynécologues et obstétriciens français (CNGOF - French College of Gynaecologists and Obstetricians) decided to establish clinical practice guidelines for benign breast tumour (BBT). CNGOF appointed a committee with responsibility for selecting experts, compiling questions and summarizing the recommendations. The summary of valid scientific data for each question analyzed by the experts included a level of evidence, based on the quality of the data available and defined accordingly rating scheme developed by the Haute Autorité de santé (French National Authority for Health).

[Benign breast tumors: Recommendations of Collège National des Gynécologues Obstétriciens Français (CNGOF)--Short text]. / Tumeurs bénignes du sein: recommandations pour la pratique clinique du Collège national des gynécologues et obstétriciens français (CNGOF)--Texte court.

Breast sonography is required with mammogram to explore clinical breast mass (grade B), colored unipore breast nipple discharge (grade C), or mastitis (grade C). Bi-RADS system is recommended to describe and classify breast-imaging abnormalities. For breast abscess, a percutaneous biopsy is recommended in case of mass or persistent symptoms (grade C). For mastodynia, when breast imaging is normal, no MRI neither breast biopsy is recommended (grade C). Percutaneous biopsy is recommended for BI-RADS 4-5 mass (grade B). For persistent erythematous breast nipple or atypical eczema lesion, a nipple biopsy is recommended (grade C). For distortion and asymmetry, a vacuum core needle biopsy is recommended because of the risk of underestimation by simple core needle biopsy (grade C). For BI-RADS 4-5 microcalcifications without ultrasound signal, a vacuum core needle biopsy of at least 11 gauges is recommended (grade B); in the absence of microcalcifications on radiograph carrots, additional samples are recommended (grade B). For atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ, flat epithelial with atypia, radial scar, mucocele with atypia, surgical excision is commonly recommended (grade C). Expectant management is feasible after multidisciplinary concertation. For these lesions, when excision is not in sano, no new excision is recommended except for pleomorphic or with necrosis CLIS (grade C). For grade 1 phyllode tumour, in sano surgical resection is recommended; for grade 2 phyllode, 10-mm margins are recommended (grade C). For breast papillary without atypia, complete disappearance of the radiologic signal is recommended (grade C). For breast papillary with atypia, complete surgical excision is recommended (grade C).

[Role of microbiopsies in the therapeutic and diagnostic approach in cases of mammary microcalcification: preliminary results]. / Place des microbiopsies dans la stratégie diagnostique et thérapeutique à l'égard des microcalcifications mammaires: résultats préliminaires.

The increase of mammographies has lead to the discovery of more frequent mammary microcalcifications. Presently, about 30% of breast tumors are discovered from infraclinics lesions. Instead of the different classifications, the microcalcifications are the omnious sign with bad specificity. It is in the aim to improve the diagnostic etiology and the choice of therapy, that the directed microbiopsies on microcalcifications had been realized. After an orthogonal location and under local anesthesia, we performed at least six biopsies with a 2.1 mm (14 gauge) needle. This allowed recovery of malignant lesions during the control of microcalcifications and permitted considerable early operative treatment. In fact, a diagnostic and therapeutic advancement of 12 months as compared to a clinical diagnosis, permitting a 30% reduction of metastasis.

[Use of stereotaxic aspiration macrobiopsies in managing breast microcalcifications: first series of 115 prospective cases]. / Apport des macrobiopsies stéréotaxiques par aspiration dans la stratégie de prise en charge des microcalcifications mammaires: première série prospective de 115 cas.

UNLABELLED: The objective of this prospective study of a 115-case series cases was to delineate the specific usefulness of this technique for the diagnosis and management of patients with microcalcifications. MATERIALS AND METHODS: Patients with probably benign ACRII and III (n = 87) or suspicious ACRIV (n = 14) and high suspicious lesion ACRV (n = 7) lesions. The microcalcification sites were blopsied with a dedicated table and a vacuum assisted aspiration system (Mammotome). The results were correlated either with the results of any surgery or, for the lesions with benign histology findings, with the results of the six-month follow-up mammography. RESULTS: These results concern a series with a follow-up longer than one year. The patients' mean age was 53 years. The procedure was possible in 108 of 115 cases (feasibility). There were two failures. We studied 87 patients with ACRII or III findings; the mean size of the microcalcification cluster was 8.3 +/- 6 mm. For 67, it was less than or equal to 10 mm. The mean size for the 21 patients initially staged as ACRIV or V was 18 +/- 9 mm, and for 15 of them, it was less than or equal to 10 mm. Microcalcifications were found on the radiographs of 96% of the biopsies specimens. Excision was complete in 59 of 73 cases for the clusters less than or equal to 10 mm and in only 12 of 35 cases for the larger clusters. The correlation between the ACR staging and the histology results was excellent. CONCLUSION: Vacuum-aspirated biopsies are indicated especially among patients with an ACRIII finding and a cluster smaller than 10 mm. Surgery was avoided in more than 60% of these cases. When surgery was performed, it most often resulted in the discovery of malignant lesions. This procedure was also useful for the very small ACRIV clusters, which were totally benign and completely excised. Finally it can be useful for obtaining a preoperative diagnosis in the case of extensive ACRIV or ACRV lesions (strategic biopsies).

[Non-palpable breast lesions: radio-pathologic correlations on open excisional biopsies. Significance of the choice of technique for minimal excisional biopsy]. / Lésions infracliniques mammaires: corrélations radiopathologiques sur les pièces d'exérèse chirurgicale. Intérêt pour le choix des techniques d'exérèse a minima.

OBJECTIVE: To decrease the number of open excisional breast biopsies, percutaneous breast biopsies have been developed to perform the histologic diagnosis of non-palpable breast lesions. Some techniques allow a complete removal of small radiologic lesions. To evaluate the accuracy of a pathologic analysis performed only on the radiologic findings, we studied the radiologic and histologic correlation on open excisional biopsy (OEB) specimens. The aim of our study was to determine how many carcinomas were found distant from the radiologic findings. MATERIAL AND METHODS: Non-palpable breast lesions have been excised after preoperative localization. The radiologic findings were classified in microcalcifications, masses, architectural distortion and in sonographic masses. The correlation between the radiologic and pathologic findings was studied and all the lesions incidentally discovered on histology with no correlation with the imaging findings or distant from the radiologic findings were described. One hundred and twenty-nine lesions have been evaluated in 99 patients. Radiologic findings included 79 clusters of microcalcifications, 30 masses, six architectural distortions and 14 sonographic lesions. RESULTS: The histopathological results were benign in 41.9%, malignant in 49.6% and atypical hyperplasia lesions were discovered in 8.5%. All benign lesions were correlated to radiologic findings. No malignant lesion was found at a distance. In three cases atypical hyperplasia lesions were coexistent with the radiologic findings correlated with benign lesions and in three cases they were found at a distance. All but two malignant lesions were correlated with radiologic findings. In two cases a microinvasive carcinoma and foci of labular carcinoma in situ were found coexistent with benign lesions. The subgroup of small lesions lesser than 10 mm included 31 benign lesions. A complete removal of these lesions should be obtained with percutaneous biopsies. CONCLUSION: A pathologic analysis targeted on radiologic findings is accurate. Numerous open excisional biopsies performed for benign pathology should be avoided.

[Staging of cancers of the utero-vagino-vulvar tract]. / Bilan d'extension des cancers de l'axe utéro-vagino-vulvaire.

Cervical and endometrial carcinomas are the most frequent cancers of the female genital tract. Accurate staging of these diseases is crucial in determining the prognosis and the mode of treatment. Clinical evaluation is often inaccurate. Magnetic resonance (MR) using conventional SE sequences (T2 and contrast-enhanced T1 weighted imaging) has become the imaging technique of choice for pretreatment staging of such cancers. Transvaginal and transrectal sonography with Doppler are of limited value. Helicoidal scanner has to be evaluated especially for endometrial carcinomas.

[Myometrium diseases]. / Pathologie myométriale.

Leiomyoma and adenomyosis are the most frequent myometrial disorders, followed by cystic and vascular disorders. After an update on the anatomy, physiology and histology of the myometrium, the authors will describe the normal sonographic and MRI aspects of the uterus. The pathology of leiomyoma will be recalled, and the various forms of myoma encountered during Doppler US, hysterography, hysterosonography, MRI and computed tomography will be described. The therapeutic use of pelvic arteriography with arterial embolization will be discussed. Adenomyosis is the second most frequent essential myometrial disorder, and is often associated with leiomyoma. After giving a histopathologic definition, the authors will examine in some detail the diagnostic value and limitations of transabdominal, pelvic and endovaginal sonography and MRI. Intramyometrial cystic disorders (cystic adenomyosis, myoma with cystic degeneration and vestigial cysts) and vascular disorders (intramyometrial and parametrial vascular malformations) are rare, but a sound knowledge is required to optimize their management, which is based on surgery and interventional vascular techniques.

[Imaging of digestive involvements after irradiation]. / Imagerie des atteintes digestives après irradiation.

The main limiting factor of the abdominal and pelvic radiotherapy is radiation damage of the digestive organs. The intestinal abnormalities resulting from irradiation are due to damaged blood vessels and connective tissue. Radiation changes in the small bowel and the recto-sigmoid are frequent and often symptomatic. Imaging is able to detect the induced radiation damage, even the asymptomatic scars. It is relevant to differentiate them from tumoral recurrence. The lesion location within the irradiated volume is important in the evaluation of post-radiotherapy imaging. Computerized tomography (CT) and magnetic resonance imaging (MRI) detect asymptomatic lesions in the liver, spleen and pancreas. We insist on the CT-imaging of induced radiotherapy changes, which are of major importance during the follow-up of irradiated patients.

[Solid breast nodules: reliability of ultrasonographic and cytological studies]. / Les nodules mammaires solides: fiabilité de l'étude échographique et cytologique.

The authors evaluated the usefulness of US study and US guided fine-needle aspiration cytology (FNAC) in 144 solid breast lesions. US studies was performed with a 10-MHz transducer. Homogenous hypoechogenicity, elongation along the general orientation of the breast tissue plane, regular margins, and intensification of posterior echoes were considered as benign signs. US guided FNAC was performed when lesions were depicted at US. The smears were performed immediately by the cytologist who was present during the procedure. US signs and FNAC diagnoses were compared with surgical/core biopsy diagnoses or negative imaging follow-up. The sensitivity of US was 93%, specificity 75%, accuracy 81%. Among 41 malignant lesions the cytologic findings were malignant (n = 26) or suspicious (n = 7) with 1 false positive and 2 false negative. Inadequate samplings were less frequent last year study (13.5%). The sensitivity of cytologic diagnosis was 94%, specificity 85%, and accuracy 88%. US study and FNAC could be helpful in evaluating solid breast lesions. A better accuracy may be obtained if FNAC is associated with core biopsy.

[Stereotactic core biopsy of breast microcalcifications. Aid to diagnosis?]. / Microbiopsies dirigées des foyers de microcalcifications mammaires. Aide au diagnostic?

We assessed the accuracy with which stereotactic core biopsy of breast microcalcifications helps to justify follow-up or indicate required surgical planning. Eighty-nine patients underwent stereotactic breast biopsy performed with large core needles. Histopathologic findings of microbiopsies were correlated with radiological findings, with follow up and with surgical findings. Agreement between radiological and histopathologic findings on biopsies was obtained in 86% for benign results. Even in the case of benign radiological findings, the histological results of microbiopsies required a surgical biopsy justified in 10% of cases. Radiologically suspicious or malignant microcalcifications were correlated with 35% benign and 65% malignant histologies on biopsies. The positive predictive value, negative predictive value and accuracy were respectively 93%, 86% and 95%. Invasive lesions were found on microbiopsies in 39% of excised malignant lesions. Multifocal lesions were proved on microbiopsies in 50% of all excised carcinomas. Microbiopsies help to disclose malignant lesions undetected on radiological analysis, and may obviate diagnostic surgical biopsy in many cases.

Standardized diagnosis and reporting of breast cancer.

Standardized terminology developed by the American College of Radiography (ACR) through the Breast-Imaging Reporting and Data System (BI-RADS) lexicon is used worldwide to describe the findings of the various breast-imaging techniques (mammography, ultrasound, and magnetic resonance imaging (MRI)). A 7-level positive predictive value (PPV) of malignancy classification system (from BI-RADS category 0 to category 6) has been based on this terminology, giving imaging a central role in the diagnostic strategy. This document presents the standardized, compulsory BI-RADS terminology used in breast-imaging reports in 2013 in view of the new edition that will be published at the end of the year.

Radiopathological correlations: masses, non-masslike enhancements and MRI-guided biopsy.

MRI-guided biopsy is a recent interventional breast technique. Validating the procedure poses a new problem because the signal targeted is created by the injection of a paramagnetic contrast agent and is thus transitory. In the first instance, the procedure is validated by the radiologist, who checks that targeting is accurate and inserts a clip at the end of the procedure, and secondly by analysis of the histopathological results, which should be representative of the lesion. The pathologist needs to know the nature of the image, i.e. whether it is of mass or non-masslike enhancement, and its BI-RADS classification. The objective is that the image and the pathological result should concur. If the result is non-specific and benign, a follow-up MRI is required six months later.

[Delays in treatment of breast cancer: experience of an expert center of the Assistance Publique-Hôpitaux de Paris (AP-HP)]. / Délais au traitement du cancer du sein : expérience d'un centre expert (CEX) de l'Assistance Publique des Hôpitaux de Paris (AP-HP).

OBJECTIVES: The National Institute of the Cancer (INCA) recently published a study over the deadlines of medical care of breast cancers. We compared our delay within the framework of our expert center with their results. PATIENTS AND METHODS: Our work is a retrospective unicentric non-interventional study. We included all the patients taken care for a breast cancer to the hospital Tenon in Paris. The criteria of inclusion were a primitive breast cancer, having accepted a care for a first cancer operated over a period of three months. We recovered 9 key deadlines to study the care of our patients. RESULTS: Sixty-six patients were included. The mean age was of 55.6 years. The deadline of access to the hospital Tenon was 8.7 ± 7.7 days for the meetings of gynecology and 4.3 ± 4 days for those of radiology. The deadline of access to the diagnosis was 31.8 ± 26 days. The deadlines of access to the meeting of multidisciplinary dialogue pre-therapeutic was 13 ± 11 days. The access to the first management time was 18.5 days for the neoadjuvant chemotherapy and 13.5 days for surgery. The deadline of access to the postoperative therapeutic proposal was on average 20 ± 8 days. The deadline of access to the postoperative radiotherapy was of 197 days in case of postoperative chemotherapy vs 47.5 days without chemotherapy. The global deadline mammography-radiotherapy was of 188 days. DISCUSSION AND CONCLUSION: The deadline of access to the diagnosis, to the postoperative therapeutic proposal and the global deadline mammography-radiotherapy with adjuvant chemotherapy or neoadjuvant were longer in our center compared with the results of the INCA. The deadlines of access to the surgery and access to the radiotherapy without postoperative chemotherapy were shorter on the other hand. The contribution of the diagnosis in one day for breast cancer is probably going to allow us to improve the deadlines of care in our structure.