Discriminative Factors of Malignancy of Ipsilateral Nonmass Enhancement in Women With Newly Diagnosed Breast Cancer on Initial Staging Breast MRI.

BACKGROUND: Nonmass enhancement (NME) on breast MRI impacts surgical planning. PURPOSE: To evaluate positive predictive values (PPVs) and identify malignancy discriminators of NME ipsilateral to breast cancer on initial staging MRI. STUDY TYPE: Retrospective. SUBJECTS: Eighty-six women (median age, 48 years; range, 26-75 years) with 101 NME lesions (BI-RADS 4 and 5) ipsilateral to known cancers and confirmed histopathology. FIELD STRENGTH/SEQUENCE: 1.5 T and 3.0 T dynamic contrast-enhanced fat-suppressed T1-weighted fast spoiled gradient-echo. ASSESSMENT: Three radiologists blinded to pathology independently reviewed MRI features (distribution, internal enhancement pattern, and enhancement kinetics) of NME, locations relative to index cancers (contiguous, non-contiguous, and different quadrants), associated mammographic calcifications, lymphovascular invasion (LVI), axillary node metastasis, and radiology-pathology correlations. Clinical factors, NME features, and cancer characteristics were analyzed for associations with NME malignancy. STATISTICAL TESTS: Fisher's exact, Chi-square, Wilcoxon rank sum tests, and mixed-effect multivariable logistic regression were used. Significance threshold was set at P < 0.05. RESULTS: Overall NME malignancy rate was 48.5% (49/101). Contiguous NME had a significantly higher malignancy rate (86.7%) than non-contiguous NME (25.0%) and NME in different quadrants (10.7%), but no significant difference was observed by distance from cancer for non-contiguous NME, P = 0.68. All calcified NME lesions contiguous to the calcified index cancer were malignant. NME was significantly more likely malignant when index cancers were masses compared to NME (52.9% vs. 21.4%), had mammographic calcifications (63.2% vs. 39.7%), LVI (81.8% vs. 44.4%), and axillary node metastasis (70.8% vs. 41.6%). NME features with highest PPVs were segmental distribution (85.7%), clumped enhancement (66.7%), and nonpersistent kinetics (77.1%). On multivariable analysis, contiguous NME, segmental distribution, and nonpersistent kinetics were associated with malignancy. DATA CONCLUSION: Malignancy discriminators of ipsilateral NME on staging MRI included contiguous location to index cancers, segmental distribution, and nonpersistent kinetics. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY: Stage 2.

High Peritumoral and Intratumoral T2 Signal Intensity in HER2-Positive Breast Cancers on Preneoadjuvant Breast MRI: Assessment of Associations With Histopathologic Characteristics.

BACKGROUND. Intratumoral necrosis and peritumoral edema are features of aggressive breast cancer that may present as high T2 signal intensity (T2 SI). Implications of high T2 SI in HER2-positive cancers are unclear. OBJECTIVE. The purpose of this study was to assess associations with histopathologic characteristics of high peritumoral T2 SI and intratumoral T2 SI of HER2-positive breast cancer on MRI performed before initiation of neoadjuvant therapy. METHODS. This retrospective study included 210 patients (age, 24-82 years) with 211 HER2 breast cancers who, from January 1, 2015, to July 30, 2022, underwent breast MRI before receiving neoadjuvant therapy. Two radiologists independently assessed cancers for high peritumoral T2 SI and high intratumoral T2 SI on fat-suppressed T2-weighted imaging and classified patterns of high peritumoral T2 SI (adjacent to tumor vs prepectoral extension). A third radiologist resolved discrepancies. Multivariable logistic regression analyses were performed to identify associations of high peritumoral and intratumoral T2 SI with histopathologic characteristics (associated ductal carcinoma in situ, hormone receptor status, histologic grade, lymphovascular invasion, and axillary lymph node metastasis). RESULTS. Of 211 HER2-positive cancers, 81 (38.4%) had high peritumoral T2 SI, and 95 (45.0%) had high intratumoral T2 SI. A histologic grade of 3 was independently associated with high peritumoral T2 SI (OR = 1.90; p = .04). Otherwise, none of the five assessed histopathologic characteristics were independently associated with high intratumoral T2 SI or high peritumoral T2 SI (p > .05). Cancers with high T2 SI adjacent to the tumor (n = 29) and cancers with high T2 SI with prepectoral extension (n = 52) showed no significant difference in frequency for any of the histopathologic characteristics (p > .05). Sensitivities and specificities for predicting the histopathologic characteristics ranged from 35.6% to 43.7% and from 59.7% to 70.7%, respectively, for high peritumoral T2 SI, and from 37.3% to 49.6% and from 49.3% to 62.7%, respectively, for high intratumoral T2 SI. Interreader agreement was almost perfect for high peritumoral T2 SI (Gwet agreement coefficient [AC] = 0.93), high intratumoral T2 SI (Gwet AC = 0.89), and a pattern of high peritumoral T2 SI (Gwet AC = 0.95). CONCLUSION. The only independent association between histopathologic characteristics and high T2 SI of HER2-positive breast cancer was observed between a histologic grade of 3 and high peritumoral T2 SI. CLINICAL IMPACT. In contrast with previously reported findings in broader breast cancer subtypes, peritumoral and intratumoral T2 SI had overall limited utility as prognostic markers of HER2-positive breast cancer.

Comprehensive genetic testing in children with a clinical diagnosis of ARPKD identifies phenocopies.

BACKGROUND: Autosomal recessive polycystic kidney disease (ARPKD) is genetically one of the least heterogeneous ciliopathies, resulting primarily from mutations of PKHD1. Nevertheless, 13-20% of patients diagnosed with ARPKD are found not to carry PKHD1 mutations by sequencing. Here, we assess whether PKHD1 copy number variations or second locus mutations explain these cases. METHODS: Thirty-six unrelated patients with the clinical diagnosis of ARPKD were screened for PKHD1 point mutations and copy number variations. Patients without biallelic mutations were re-evaluated and screened for second locus mutations targeted by the phenotype, followed, if negative, by clinical exome sequencing. RESULTS: Twenty-eight patients (78%) carried PKHD1 point mutations, three of whom on only one allele. Two of the three patients harbored in trans either a duplication of exons 33-35 or a large deletion involving exons 1-55. All eight patients without PKHD1 mutations (22%) harbored mutations in other genes (PKD1 (n = 2), HNF1B (n = 3), NPHP1, TMEM67, PKD1/TSC2). Perinatal respiratory failure, a kidney length > +4SD and early-onset hypertension increase the likelihood of PKHD1-associated ARPKD. A patient compound heterozygous for a second and a last exon truncating PKHD1 mutation (p.Gly4013Alafs*25) presented with a moderate phenotype, indicating that fibrocystin is partially functional in the absence of its C-terminal 62 amino acids. CONCLUSIONS: We found all ARPKD cases without PKHD1 point mutations to be phenocopies, and none to be explained by biallelic PKHD1 copy number variations. Screening for copy number variations is recommended in patients with a heterozygous point mutation.

Interfering effect of maternal cell contamination on invasive prenatal molecular genetic testing.

OBJECTIVE: Fetal samples obtained by invasive techniques are prone to maternal cell contamination (MCC), which may lead to false genotyping results. Our aim was to determine 3 molecular genetic tests' sensitivity to MCC. METHOD: By mixing experiments, 1%, 5%, 10%, 20%, 30%, and 40% MCC was simulated, and significant MCC levels were determined for Sanger DNA sequencing, multiplex ligation-dependent probe amplification (MLPA), and pyrosequencing, a next-generation sequencing method. RESULTS: For Sanger sequencing, the limit of sensitivity to MCC was 5% to 30%. For MLPA, a higher proportion of MCC (≥40%) was shown to lead to diagnostic uncertainty. In contrast, pyrosequencing proved to be very sensitive to MCC, detecting a proportion as low as 1%. CONCLUSION: In the case of Sanger sequencing, sensitivity to MCC was variable, while for MLPA, only high levels of MCC proved to be significant. Although the next-generation sequencing method was sensitive to low-level MCC, if MCC level is determined in parallel, accurate quantification of allelic ratios can help to interpret the diagnostic results. Knowledge of significant MCC levels allows correct prenatal diagnosis even if samples are not purely of fetal origin and repeated sampling can be avoided in many of the cases.

Computer-aided heterogeneity analysis in breast MR imaging assessment of ductal carcinoma in situ: Correlating histologic grade and receptor status.

PURPOSE: To identify breast MR imaging biomarkers to predict histologic grade and receptor status of ductal carcinoma in situ (DCIS). MATERIALS AND METHODS: Informed consent was waived in this Health Insurance Portability and Accountability Act-compliant Institutional Review Board-approved study. Case inclusion was conducted from 7332 consecutive breast MR studies from January 1, 2009, to December 31, 2012. Excluding studies with benign diagnoses, studies without visible abnormal enhancement, and pathology containing invasive disease yielded 55 MR-imaged pathology-proven DCIS seen on 54 studies. Twenty-eight studies (52%) were performed at 1.5 Tesla (T); 26 (48%) at 3T. Regions-of-interest representing DCIS were segmented for precontrast, first and fourth postcontrast, and subtracted first and fourth postcontrast images on the open-source three-dimensional (3D) Slicer software. Fifty-seven metrics of each DCIS were obtained, including distribution statistics, shape, morphology, Renyi dimensions, geometrical measure, and texture, using the 3D Slicer HeterogeneityCAD module. Statistical correlation of heterogeneity metrics with DCIS grade and receptor status was performed using univariate Mann-Whitney test. RESULTS: Twenty-four of the 55 DCIS (44%) were high nuclear grade (HNG); 44 (80%) were estrogen receptor (ER) positive. Human epidermal growth factor receptor-2 (HER2) was amplified in 10/55 (18%), nonamplified in 34/55 (62%), unknown/equivocal in 8/55 (15%). Surface area-to-volume ratio showed significant difference (P < 0.05) between HNG and non-HNG DCIS. No metric differentiated ER status (0.113 < p ≤ 1.000). Seventeen metrics showed significant differences between HER2-positive and HER2-negative DCIS (0.016 < P < 0.050). CONCLUSION: Quantitative heterogeneity analysis of DCIS suggests the presence of MR imaging biomarkers in classifying DCIS grade and HER2 status. Validation with larger samples and prospective studies is needed to translate these results into clinical applications. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2017;46:1748-1759.

Feasibility of Intraoperative Breast MRI and the Role of Prone Versus Supine Positioning in Surgical Planning for Breast-Conserving Surgery.

We assessed the feasibility of supine intraoperative MRI (iMRI) during breast-conserving surgery (BCS), enrolling 15 patients in our phase I trial between 2012 and 2014. Patients received diagnostic prone MRI, BCS, pre-excisional supine iMRI, and postexcisional supine iMRI. Feasibility was assessed based on safety, sterility, duration, and image-quality. Twelve patients completed the study; mean duration = 114 minutes; all images were adequate; no complications, safety, or sterility issues were encountered. Substantial tumor-associated changes occurred (mean displacement = 67.7 mm, prone-supine metric, n = 7). We have demonstrated iMRI feasibility for BCS and have identified potential limitations of prone breast MRI that may impact surgical planning.

Intraoperative Supine Breast MR Imaging to Quantify Tumor Deformation and Detection of Residual Breast Cancer: Preliminary Results.

Purpose To use intraoperative supine magnetic resonance (MR) imaging to quantify breast tumor deformation and displacement secondary to the change in patient positioning from imaging (prone) to surgery (supine) and to evaluate residual tumor immediately after breast-conserving surgery (BCS). Materials and Methods Fifteen women gave informed written consent to participate in this prospective HIPAA-compliant, institutional review board-approved study between April 2012 and November 2014. Twelve patients underwent lumpectomy and postsurgical intraoperative supine MR imaging. Six of 12 patients underwent both pre- and postsurgical supine MR imaging. Geometric, structural, and heterogeneity metrics of the cancer and distances of the tumor from the nipple, chest wall, and skin were computed. Mean and standard deviations of the changes in volume, surface area, compactness, spherical disproportion, sphericity, and distances from key landmarks were computed from tumor models. Imaging duration was recorded. Results The mean differences in tumor deformation metrics between prone and supine imaging were as follows: volume, 23.8% (range, -30% to 103.95%); surface area, 6.5% (range, -13.24% to 63%); compactness, 16.2% (range, -23% to 47.3%); sphericity, 6.8% (range, -9.10% to 20.78%); and decrease in spherical disproportion, -11.3% (range, -60.81% to 76.95%). All tumors were closer to the chest wall on supine images than on prone images. No evidence of residual tumor was seen on MR images obtained after the procedures. Mean duration of pre- and postoperative supine MR imaging was 25 minutes (range, 18.4-31.6 minutes) and 19 minutes (range, 15.1-22.9 minutes), respectively. Conclusion Intraoperative supine breast MR imaging, when performed in conjunction with standard prone breast MR imaging, enables quantification of breast tumor deformation and displacement secondary to changes in patient positioning from standard imaging (prone) to surgery (supine) and may help clinicians evaluate for residual tumor immediately after BCS. © RSNA, 2016 Online supplemental material is available for this article.

Radiation-Associated Angiosarcoma of the Breast: What the Radiologist Needs to Know.

OBJECTIVE: The purpose of this article is to describe the diagnosis, treatment, and follow-up of radiation-associated angiosarcoma (RAS) of the breast. CONCLUSION: Radiologists play an important role in the diagnosis of RAS, which may initially present clinically as erythema, ecchymosis, or skin thickening. Conventional imaging with mammography and ultrasound is less sensitive than MRI for the diagnosis of RAS. Follow-up CT is important to monitor treatment response.

MRI findings of radiation-associated angiosarcoma of the breast (RAS).

PURPOSE: To describe the magnetic resonance imaging (MRI) characteristics of radiation-associated breast angiosarcomas (RAS). MATERIALS AND METHODS: In this Institutional Review board (IRB)-approved retrospective study, 57 women were diagnosed with pathologically confirmed RAS during the study period (January 1999 to May 2013). Seventeen women underwent pretreatment breast MRI (prior to surgical resection or chemotherapy), of which 16 studies were available for review. Imaging features, including all available mammograms, ultrasounds, and breast MRIs, of these patients were evaluated by two radiologists independently and correlated with clinical management and outcomes. RESULTS: The median age of patients at original breast cancer diagnosis was 69.3 years (range 42-84 years), with average time from initial radiation therapy to diagnosis of RAS of 7.3 years (range 5.1-9.5 years). Nine women had mammograms (9/16, 56%) and six had breast ultrasound (US) (6/16, 38%) prior to MRI, which demonstrated nonsuspicious findings in 5/9 mammograms and 3/6 ultrasounds. Four patients had distinct intraparenchymal masses on mammogram and MRI. MRI findings included diffuse T2 high signal skin thickening (16/16, 100%). Nearly half (7/16, 44%) of patients had T2 low signal intensity lesions; all lesions rapidly enhanced on postcontrast T1 -weighted imaging. All women underwent surgical resection, with 8/16 (50%) receiving neoadjuvant chemotherapy. Four women died during the study period. CONCLUSION: Clinical, mammographic, and sonographic findings of RAS are nonspecific and may be occult on conventional breast imaging; MRI findings of RAS include rapidly enhancing dermal and intraparenchymal lesions, some of which are low signal on T2 weighted imaging.

MRI kinetics with volumetric analysis in correlation with hormonal receptor subtypes and histologic grade of invasive breast cancers.

OBJECTIVE. The aim of this study was to assess whether computer-assisted detection-processed MRI kinetics data can provide further information on the biologic aggressiveness of breast tumors. MATERIALS AND METHODS. We identified 194 newly diagnosed invasive breast cancers presenting as masses on contrast-enhanced MRI by a HIPAA-compliant pathology database search. Computer-assisted detection-derived data for the mean and median peak signal intensity percentage increase, most suspicious kinetic curve patterns, and volumetric analysis of the different kinetic patterns by mean percentage tumor volume were compared against the different hormonal receptor (estrogen-receptor [ER], progesterone-receptor [PR], ERRB2 (HER2/neu), and triple-receptor expressivity) and histologic grade subgroups, which were used as indicators of tumor aggressiveness. RESULTS. The means and medians of the peak signal intensity percentage increase were higher in ER-negative, PR-negative, and triple-negative (all p ≤ 0.001), and grade 3 tumors (p = 0.011). Volumetric analysis showed higher mean percentage volume of rapid initial enhancement in biologically more aggressive ER-negative, PR-negative, and triple-negative tumors compared with ER-positive (64% vs 53.6%, p = 0.013), PR-positive (65.4% vs 52.5%, p = 0.001), and nontriple-negative tumors (65.3% vs 54.6%, p = 0.028), respectively. A higher mean percentage volume of rapid washout component was seen in ERRB2-positive tumors compared with ERRB2-negative tumors (27.5% vs 17.9%, p = 0.020). CONCLUSION. Peak signal intensity percentage increase and volume analysis of the different kinetic patterns of breast tumors showed correlation with hormonal receptor and histologic grade indicators of cancer aggressiveness. Computer-assisted detection-derived MRI kinetics data have the potential to further characterize the aggressiveness of an invasive cancer.

Pilot study to evaluate feasibility of image-guided breast-conserving therapy in the advanced multimodal image-guided operating (AMIGO) suite.

BACKGROUND: The rate of reexcision in breast-conserving surgery remains high, leading to delay in initiation of adjuvant therapy, increased cost, increased complications, and negative psychological impact to the patient.1 (-) 3 We initiated a phase 1 clinical trial to determine the feasibility of the use of intraoperative magnetic resonance imaging (MRI) to assess margins in the advanced multimodal image-guided operating (AMIGO) suite. METHODS: All patients received contrast-enhanced three-dimensional MRI while under general anesthesia in the supine position, followed by standard BCT with or without wire guidance and sentinel node biopsy. Additional margin reexcision was performed of suspicious margins and correlated to final pathology (Fig. 1). Feasibility was assessed via two components: demonstration of safety and sterility and acceptable duration of the operation and imaging; and adequacy of intraoperative MRI imaging for interpretation and its comparison to final pathology. Fig. 1 Schema of AMIGO trial RESULTS: Eight patients (mean age 48.5 years), 4 with stage I breast cancer and 4 with stage II breast cancer, were recruited. All patients underwent successful BCT in the AMIGO suite with no AMIGO-specific complications or break in sterility during surgery. The mean operative time was 113 min (range 93-146 min). CONCLUSIONS: Our experience with AMIGO suggests that it is feasible to use intraoperative MRI imaging to evaluate margin assessment in real time. Further research is required to identify modalities that will lead to a reduction in reexcision in breast cancer therapy.

Automatic segmentation of invasive breast carcinomas from dynamic contrast-enhanced MRI using time series analysis.

PURPOSE: To accurately segment invasive ductal carcinomas (IDCs) from dynamic contrast-enhanced MRI (DCE-MRI) using time series analysis based on linear dynamic system (LDS) modeling. MATERIALS AND METHODS: Quantitative segmentation methods based on black-box modeling and pharmacokinetic modeling are highly dependent on imaging pulse sequence, timing of bolus injection, arterial input function, imaging noise, and fitting algorithms. We modeled the underlying dynamics of the tumor by an LDS and used the system parameters to segment the carcinoma on the DCE-MRI. Twenty-four patients with biopsy-proven IDCs were analyzed. The lesions segmented by the algorithm were compared with an expert radiologist's segmentation and the output of a commercial software, CADstream. The results are quantified in terms of the accuracy and sensitivity of detecting the lesion and the amount of overlap, measured in terms of the Dice similarity coefficient (DSC). RESULTS: The segmentation algorithm detected the tumor with 90% accuracy and 100% sensitivity when compared with the radiologist's segmentation and 82.1% accuracy and 100% sensitivity when compared with the CADstream output. The overlap of the algorithm output with the radiologist's segmentation and CADstream output, computed in terms of the DSC was 0.77 and 0.72, respectively. The algorithm also shows robust stability to imaging noise. Simulated imaging noise with zero mean and standard deviation equal to 25% of the base signal intensity was added to the DCE-MRI series. The amount of overlap between the tumor maps generated by the LDS-based algorithm from the noisy and original DCE-MRI was DSC = 0.95. CONCLUSION: The time-series analysis based segmentation algorithm provides high accuracy and sensitivity in delineating the regions of enhanced perfusion corresponding to tumor from DCE-MRI.

Patient compliance and diagnostic yield of 18-month unilateral follow-up in surveillance of probably benign mammographic lesions.

OBJECTIVE: The purpose of this study is to determine the patient compliance with and diagnostic yield of 18-month unilateral mammography in surveillance of probably benign (BI-RADS category 3) lesions. MATERIALS AND METHODS: This retrospective study identified lesions prospectively classified BI-RADS 3 in asymptomatic women from January 1, 2004, to December 31, 2008. Surveillance protocol for BI-RADS 3 lesions included 6-month (unilateral), 12-month (bilateral), 18-month (unilateral), and 24-month (bilateral) imaging, with subsequent annual screening. Demographics, surveillance data, BI-RADS upgrades and downgrades, and biopsy results were abstracted from the longitudinal medical record. RESULTS: One thousand one hundred eighty-eight lesions in 1077 patients (mean age, 51.5 years; age range, 26-89 years) had BI-RADS 3 assessment, representing 1.07% of all screening examinations. The compliance rates for follow-up at 6, 12, 18, and 24 months were 83.3%, 75.9%, 54.8%, and 53.9%, respectively. Sixty lesions were upgraded to BI-RADS 4 or 5 during surveillance. Biopsy revealed 15 cancers (cancer yield of 1.47%) from 1017 lesions with either 24-month imaging stability or tissue diagnosis available. Five, six, one, and three cancers were detected at 6, 12, 18, and 24 months, respectively. Cancers were all stage 0 or 1 except for one stage 2A cancer. Seven hundred forty-four of 1188 (62.6%) BI-RADS 3 lesions were downgraded before completing 2-year surveillance. CONCLUSION: Most (11/15 [73%]) breast cancers initially assessed as BI-RADS 3 are diagnosed at up to 12 months' surveillance. Eighteen-month unilateral mammography performed as BI-RADS 3 surveillance contributes minimally to cancer detection and has poor patient compliance.

Breast Cancer Screening in High-risk Women During Pregnancy and Lactation.

Women who are at high risk of developing breast cancer warrant screening that is often initiated at younger ages than in average-risk women; this is usually with a combination of annual mammography and breast MRI. Compared to average-risk women, those at high risk are more frequently recommended to undergo screening during childbearing age and thus potentially during pregnancy and lactation. Understanding the appropriate use of screening breast imaging during pregnancy and lactation can be challenging due to limited data defining the evidence-based roles of the different imaging modalities, including mammography, US, and MRI. There have also been assumptions about the diagnostic accuracy of these modalities secondary to physiological changes. This scientific review discusses the current state of evidence- and expert-based guidelines and data for breast imaging screening of high-risk pregnant and/or lactating women, and the clinical and imaging presentations of breast cancer for these women.

MR imaging assessment of the breast after breast conservation therapy: distinguishing benign from malignant lesions.

Dynamic contrast material-enhanced magnetic resonance (MR) imaging has emerged as a valuable tool in evaluation of women who have undergone lumpectomy and whole-breast radiation therapy for breast cancer. Early diagnosis of local recurrence by means of close clinical and imaging follow-up is an important component of a breast-conserving strategy, as it may improve survival. In the post-breast conservation therapy (BCT) breast, resolving edema, fat necrosis, a small focal area of non-masslike enhancement (NMLE), and thin linear NMLE at the lumpectomy site can all be expected findings. In contrast, masslike enhancement or NMLE of ductal or segmental distribution can indicate recurrence. Therefore, at MR imaging of the post-BCT breast, it is important to identify lesions that are benign or appropriate for short-interval imaging surveillance to minimize unnecessary intervention, as well as to discern suspicious lesions and optimize the diagnosis of recurrence.

Mammographic positioning in women with pectus excavatum: An anatomic challenge.

PURPOSE: To assess mammographic image quality in women with pectus excavatum (PEx) compared to women without PEx. MATERIALS & METHODS: Fifty-six women with PEx between the ages 36-80 (median, 57 years) with screening mammograms from 2006 to 2020 were identified in an IRB-approved HIPAA-compliant retrospective review. Two fellowship-trained breast radiologists independently evaluated mammographic quality of 109 individual breasts in the 56 women using Enhancing Quality Using the Inspection Program (EQUIP) positioning criteria and visual breast density assessments. The number of images per breast was documented. Comparison was made to 2:1 age-matched controls whose screening mammograms were performed in the same year. A power analysis for the difference in the number of images per breast between study groups was performed before data collection. RESULTS: Statistically significant differences with worse performance in women with PEx included: the pectoralis muscle extending to the posterior nipple line (p < 0.0001); adequacy of tissue visualized (p < 0.0001); inframammary fold included (p < 0.0001); breast free of skin folds (p = 0.003); presence of fibroglandular tissue at the CC view posterior edge (p < 0.0001); and CC and MLO within 1 cm of each other (p < 0.001). The average number of images per breast in the PEx group was greater than the control group (2.94 vs. 2.24, p < 0.0001). CONCLUSION: PEx women more often fail to meet mammographic positioning quality standards and more often require additional views for screening.

Breast Malignancies After Mastectomy With Autologous or Implant Reconstruction.

There are multiple indications for mastectomy for breast cancer, including extent of tumor, inability to achieve negative margins after re-excision, patient preference, or prevention in women with a high lifetime risk of breast cancer. Multiple types of autologous or implant reconstruction options are available for cosmesis. Although rare, breast cancers after mastectomy can occur, and it is important for both surgeons and radiologists to be aware of the associated risk factors, common locations, and classic imaging features of these malignancies. This article reviews the types of mastectomies, reconstruction options, and information about the location, presentation, and prognosis of cancers in the reconstructed breast.

Lobular neoplasia detected at MRI-guided biopsy: imaging findings and outcomes.

OBJECTIVE: To review MRI findings of pure lobular neoplasia (LN) on MRI guided biopsy, evaluate surgical and clinical outcomes, and assess imaging findings predictive of upgrade to malignancy. METHODS: HIPAA compliant, IRB-approved retrospective review of our MRI-guided breast biopsy database from October 2008-January 2015. Biopsies yielding atypical lobular hyperplasia or lobular carcinoma in situ were included in the analysis; all biopsy slides were reviewed by a dedicated breast pathologist. Imaging indications, MRI findings, and histopathology were reviewed. Statistical analysis was performed using the two-tailed Fisher exact-test and the t-test, and 95% CIs were determined. A p < 0.05 was considered statistically significant. RESULTS: Database search yielded 943 biopsies in 785 patients of which 65/943 (6.9%) reported LN as the highest risk pathologic lesion. Of 65 cases, 32 were found to have LN as the dominant finding on pathology and constituted the study population. All 32 findings were mammographically and sonographically occult. Three of 32 (9.3%) cases of lobular neoplasia were upgraded to malignancy, all LCIS (one pleomorphic and two classical). The most common MRI finding was focal, heterogenous non-mass enhancement with low T2 signal. No clinical features or imaging findings were predictive of upgrade to malignancy. CONCLUSION: Incidence of pure lobular neoplasia on MRI guided biopsy is low, with comparatively low incidence of upgrade to malignancy. No imaging or clinical features are predictive of upgrade on surgical excision, therefore, prudent radiologic-pathologic correlation is necessary.

Lesion conspicuity on synthetic screening mammography compared to full field digital screening mammography.

OBJECTIVE: To compare lesion conspicuity on synthetic screening mammography (SM) plus digital breast tomosynthesis (DBT) versus full field digital mammography (FFDM) plus DBT. MATERIALS AND METHODS: Seven breast imagers each prospectively evaluated 107-228 screening mammograms (FFDM, DBT, and SM; total 1206 examinations) over 12 weeks in sets of 10-50 consecutive examinations. Interpretation sessions alternated as follows: SM + DBT, then FFDM, or FFDM + DBT, then SM. Lesion conspicuity on SM versus FFDM (equal/better versus less) was assessed using proportions with 95% confidence intervals. DBT-only findings were excluded. RESULTS: Overall 1082 of 1206 (89.7%) examinations were assessed BI-RADS 1/2, and 124 of 1206 (10.3%) assessed BI-RADS 0. There were 409 evaluated findings, including 134 masses, 119 calcifications, 72 asymmetries, 49 architectural distortion, and 35 focal asymmetries. SM conspicuity compared to FFDM conspicuity for lesions was rated 1) masses: 77 (57%) equal or more conspicuous, 57 (43%) less conspicuous; 2) asymmetries/focal asymmetries: 61 (57%) equal or more conspicuous, and 46 (43%) less conspicuous; 3) architectural distortion: 46 (94%) equal or more conspicuous, 3 (6%) less conspicuous; 4) calcifications: 115 (97%) equal or more conspicuous, 4 (3%) less conspicuous. SM had better conspicuity than FFDM for calcifications and architectural distortion and similar conspicuity for most masses and asymmetries. CONCLUSION: Compared to FFDM, SM has better conspicuity for calcifications and architectural distortion and similar conspicuity for most masses and asymmetries.

Factors that impact the duration of MRI-guided core needle biopsy.

OBJECTIVE: The purpose of our study was to determine which patient-related, target lesion-related, or procedure-related variables impact the duration of MRI-guided core needle breast biopsy. MATERIALS AND METHODS: Between July 11, 2006, and September 26, 2007, data were collected for 75 single-target MRI-guided 9-gauge vacuum-assisted core needle biopsy procedures using a grid-guidance technique and performed at a single institution. The following variables were studied: MRI suite occupation time, number of operators, patient age and breast size, target morphology and location, approach to target, equipment used, number of image acquisitions and times the patient was moved in and out of the closed magnet, and occurrence of complications. Statistical analysis was performed using the Student's t test, analysis of variance, and Pearson's correlation, with p values < 0.05 considered significant. RESULTS: The mean duration was 57.9 minutes (SD, 17.2 minutes; range, 30-109 minutes). None of the patient- or target-related variables significantly impacted the duration, although lesions located in the anterior third of the breast showed a trend to prolong the procedure (p = 0.059). The time to complete a procedure was reduced when the operating radiologist was assisted by a breast imaging fellow-in-training (p = 0.01). Increasing numbers of image acquisitions and times the patient was moved in and out of the magnet significantly lengthened the procedure duration (p = 0.0001 for both). No major complications occurred. Biopsies yielded 16% (12/75) malignant and 84% (63/75) benign diagnoses. CONCLUSION: Variables that minimized procedure duration were number of image acquisitions, number of patient insertions or removals from the magnet, and assistance of a breast imaging fellow-in-training. No patient-related or target-related variables impacted procedure time.