Impact of pre-operative MRI on surgical management of screening digital breast tomosynthesis-detected invasive lobular carcinoma.

PURPOSE: The purpose of this study is to determine the impact of pre-operative MRI on surgical management of screening digital breast tomosynthesis (DBT)-detected invasive lobular carcinoma (ILC). METHODS: A retrospective medical record analysis was conducted of women with screening DBT-detected ILC and subsequent surgery from 2017-2021. Clinical, imaging, and pathological features were compared between women who did and did not undergo MRI, and between women with and without additional disease detected on MRI, using the Pearson's chi-squared test and Wilcoxon signed-rank test. Concordance between imaging and surgical pathology sizes was also evaluated. RESULTS: Of 125 women (mean age 67 years, range 44-90) with screening-detected ILC, MRI was obtained in 62 women (49.6%) with a mean age of 63 years (range 45-80). Compared to women without MRI, women who had MRI examinations were younger, more likely to have dense breast tissue, and more likely to undergo mastectomy initially rather than lumpectomy (p < 0.001-0.01). Eighteen biopsies were performed based on MRI findings, of which 55.6% (10/18) were malignant. Conventional imaging more frequently underestimated ILC span at the biopsy site than MRI, using a 25% threshold difference (17.5% [7/40] versus 58.5% [24/41], p < 0.001). MRI detected more extensive disease at the biopsy site in six patients (9.7%, 6/62), additional ipsilateral disease in six patients (9.7%, 6/62), and contralateral disease in one patient (1.6%, 1/62). MRI therefore impacted surgical management in 21.0% (13/62) of patients. CONCLUSION: MRI led to the detection of additional disease, thus impacting surgical management, in one-fifth of patients with ILC.

Lobular Neoplasia Diagnosed by MRI-Guided Breast Biopsy: Identifying Upgrade Rate to Malignancy and Outcomes of Clinical and Surgical Management.

OBJECTIVE: The aim of this study was to determine surgical and clinical outcomes of lobular neoplasia (LN) diagnosed by magnetic resonance imaging (MRI) biopsy, including upgrade to malignancy, and to assess for characteristics associated with upgrade. METHOD: A single-institution retrospective study, between 2013 and 2022, of patients with histopathological findings of LN via MRI-guided biopsy was performed using an institutional database and review of the electronic medical records. Decision for excision or surveillance was made by a multidisciplinary team per institutional practice. Patient demographics and imaging characteristics were summarized using descriptive analyses. Upgrade was defined as upgrade to cancer on surgical pathology for patients treated with excision or the development of cancer at the biopsy site during surveillance. The Wilcoxon rank-sum test and Fisher's exact test were used to compare features of the upgraded cohort with the remainder of the group. RESULTS: Ninety-four MRI biopsies diagnosing LN were included. Median age was 57 years (range 37-78 years). Forty-six lesions underwent excision while 48 lesions were surveilled. The upgrade rate was 7.4% (7/94). Upgrades in the excised cohort consisted of pleomorphic lobular carcinoma in situ (LCIS; n = 1), ductal carcinoma in situ (DCIS; n = 3) and invasive lobular carcinoma (ILC; n = 2), while one interval development of DCIS was observed at the site of biopsy in the surveillance cohort. No MRI or patient variables were associated with upgrade. CONCLUSIONS: In this contemporary cohort of MRI-detected LNs, the upgrade rate was low. Omission of surgery for MRI-detected LNs in carefully selected patients may be considered in a shared decision-making capacity between the patient and the treatment team. Larger cohorts are needed to determine factors predictive of upgrade risk.

Surveillance Strategies After Primary Treatment for Patients with Invasive Lobular Carcinoma of the Breast: Method of Local Recurrence Detection After Breast-Conserving Surgery.

BACKGROUND: Invasive lobular carcinoma (ILC) is the second most common subtype of breast cancer. Although mammography is known to have low sensitivity for ILC, there are no data to guide the optimal surveillance after treatment. We explored surveillance strategies after breast-conserving surgery (BCS) for ILC and determined the proportion of imaging-detected recurrences versus interval cancers. METHODS: From an institutional database of 813 women, we retrospectively identified patients who underwent BCS for stage I-III ILC and subsequently had a recurrence. We categorized patients by surveillance strategy and determined the modality of recurrence detection. Interval cancer rates for local recurrences were compared across surveillance strategies using the Chi-square test. We evaluated overall survival with the log-rank test and a Cox proportional hazards model. RESULTS: We included 58 patients with ILC who had a recurrence after BCS. Of these, 22 (37.9%) had local recurrence, 27 (46.6%) had distant recurrence, and 9 (15.5%) had both local and distant recurrence. Most patients underwent routine mammographic surveillance (65.2%), with 19.6% having supplemental breast magnetic resonance imaging (MRI) and 15.2% having no surveillance. The interval cancer rate was significantly higher in the mammographic surveillance group compared with the MRI surveillance group (61.9% vs. 16.7%; p < 0.001). CONCLUSION: In this study of patients with recurrence after BCS for primary treatment of stage I-III ILC, we found that most local recurrences were not detected by surveillance mammography. These data support further investigation of supplemental imaging beyond mammography specifically for patients with ILC who undergo BCS.

The role of contrast-enhanced mammography in the preoperative evaluation of invasive lobular carcinoma of the breast.

AIM: To assess the performance of contrast-enhanced mammography (CEM) in the preoperative staging of invasive lobular carcinoma (ILC) of the breast. MATERIALS AND METHODS: The present study was a multicentre, multivendor, multinational retrospective study of women with a histological diagnosis of ILC who had undergone CEM from December 2013 to December 2021. Index lesion size and multifocality were recorded for two-dimensional (2D) mammography, CEM, and when available magnetic resonance imaging (MRI). Comparison with histological data was undertaken for women treated by primary surgical excision. Pearson correlation coefficients and Bland-Altman's analysis of agreement were used to assess differences with a significance level of 0.05. RESULTS: One hundred and fifteen ILC lesions were included, 46 (40%) presented symptomatically and 69 were screening detected. CEM demonstrated superior sensitivity when compared to standard mammography. The correlation between the histological size measured on the surgical excision specimen size was greater than with standard mammography (r=0.626 and 0.295 respectively, p=0.001), with 19% of lobular carcinomas not visible without a contrast agent. The sensitivity of CEM for multifocal disease was greater than standard mammography (70% and 20% respectively, p<0.0001). CEM overestimated tumour size by an average of 1.5 times, with the size difference increasing for larger tumour. When MRI was performed (n=22), tumour size was also overestimated by an average of 1.3 times. The degree of size overestimation was similar for both techniques, with the tumour size on CEM being on average 0.5 cm larger than MRI. CONCLUSION: CEM is a useful tool for the local staging of lobular carcinomas and could be an alternative to breast MRI.

Prospective Pilot Study of 18F-Fluoroestradiol PET/CT in Patients With Invasive Lobular Carcinomas.

BACKGROUND. PET/CT with 18F-fluoroestradiol (FES) (FDA-approved in 2020) depicts tissues expressing estrogen receptor (ER). Invasive lobular carcinoma (ILC) is commonly ER positive. OBJECTIVE. The primary aim of this study was to assess the frequency with which sites of histologically proven ILC have abnormal uptake on FES PET/CT. METHODS. This prospective single-center pilot study, conducted from December 2020 to August 2021, enrolled patients with histologically confirmed ILC to undergo FES PET/CT; patients optionally underwent FDG PET/CT. Two nuclear radiologists assessed FES PET/CT and FDG PET/CT studies for abnormal uptake corresponding to known ILC sites at enrollment and for additional sites of abnormal uptake, resolving differences by consensus. The primary endpoint was percentage of known ILC sites showing abnormal FES uptake. The alternative to the null hypothesis was that more than 60% of sites would have abnormal FES uptake, exceeding the percentage of ILC with abnormal FDG uptake described in prior literature. A sample size of 24 biopsied lesions was preselected to provide 81% power for the alternative hypothesis (one-sided α = .10). Findings on FES PET/CT and FDG PET/CT were summarized for additional secondary endpoints. RESULTS. The final analysis included 17 patients (mean age, 59.1 ± 13.2 years) with 25 sites of histologically confirmed ILC at enrollment (22 breast lesions, two axillary lymph nodes, one distant metastasis). FES PET/CT showed abnormal uptake in 22 of 25 (88%) lesions, sufficient to reject the null hypothesis (p = .002). Thirteen patients underwent FDG PET/CT. Four of 23 (17%) sites of histologically confirmed ILC, including additional sites detected and confirmed after enrollment, were identified with FES PET/CT only, and 1 of 23 (4%) was identified only with FDG PET/CT (p = .18). FES PET/CT depicted additional lesions not detected with standard-of-care evaluation in 4 of 17 (24%) patients (two contralateral breast cancers and two metastatic axillary lymph nodes, all with subsequent histologic confirmation). Use of FES PET/CT resulted in changes in clinical stage with respect to standard-of-care evaluation in 3 of 17 (18%) patients. CONCLUSION. The primary endpoint of the trial was met. The frequency of abnormal FES uptake among sites of histologically known ILC was found to be to be significantly greater than 60%. CLINICAL IMPACT. This pilot study shows a potential role of FES PET/CT in evaluation of patients with ILC. TRIAL REGISTRATION. ClinicalTrials.gov NCT04252859.

Management of Lobular Neoplasia Diagnosed by Core Biopsy.

Lobular neoplasia (LN) involves proliferative changes within the breast lobules. LN is divided into lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH). LCIS can be further subdivided into three subtypes: classic LCIS, pleomorphic LCIS, and LCIS with necrosis (florid type). Because classic LCIS is now considered as a benign etiology, current guidelines recommend close follow-up with imaging versus surgical excision. The goal of our study was to determine if the diagnosis of classic LN on core needle biopsy (CNB) merits surgical excision. This is a retrospective, observational study conducted at Mount Auburn Hospital, Cambridge, MA, from May 17, 2017, through June 30, 2020. We reviewed the data of breast biopsies conducted at our hospital over this period and included patients who were diagnosed with classic LN (LCIS and/or ALH) and excluded patients having any other atypical lesions on CNB. All known cancer patients were excluded. Of the 2707 CNBs performed during the study period, we identified 68 women who were diagnosed with ALH or LCIS on CNB. CNB was performed for an abnormal mammogram in the majority of patients (60; 88%) while 7(10.3%) had an abnormal breast magnetic resonance imaging study (MRI), and 1 had an abnormal ultrasound (US). A total of 58 patients (85%) underwent excisional biopsy, of which 3 (5.2%) showed malignancy, including 2 cases of DCIS and 1 invasive carcinoma. In addition, there was 1 case (1.7%) with pleomorphic LCIS and 11 cases with ADH (15.5%). The management of LN found on core biopsy is evolving, with some advocating surgical excision and others recommending observation. Our data show a change in diagnosis with excisional biopsy in 13 (22.4%) of patients with 2 cases of DCIS, 1 invasive carcinoma, 1 pleomorphic LCIS, and 9 cases of ADH, diagnosed on excisional biopsy. While ALH and classic LCIS are considered benign, the choice of ongoing surveillance versus excisional biopsy should be made with shared decision making with the patient, with consideration of personal and family history, as well as patient preferences.

[A case of extensive digestive tract metastasis from invasive lobular carcinoma of the breast].

A 59-year-old female patient underwent surgery for invasive lobular carcinoma of the right breast 12 years ago. The final diagnosis was invasive lobular carcinoma (T4N1M0 stage IIIB). She underwent chemotherapy, radiotherapy, and hormonal therapy after surgery. She had abdominal bloating and vomiting 12 years after surgery. Contrast-enhanced computed tomography (CECT) and esophagogastroduodenoscopy showed edematous thickening from the stomach to the duodenum and moderate amounts of ascites. Lymph node metastasis was not observed. Biopsy specimens of the stomach revealed signet ring cell carcinoma. Immunochemical studies (ER, GCDFP-15, MUC1, MUC5AC, and MUC6) confirmed gastroduodenal metastasis of invasive lobular carcinoma. Ascites disappeared after she underwent chemotherapy with paclitaxel and bevacizumab; however, wall thickening had spread from the lower esophagus to the stomach, small intestine, colon, and rectum on the CECT. She died 7 months after the diagnosis of gastroduodenal metastasis. Herein, we report a case of invasive lobular carcinoma of the breast with extensive digestive tract metastasis.

Atypical Lobular Hyperplasia and Classic Lobular Carcinoma In Situ Can Be Safely Managed Without Surgical Excision.

BACKGROUND: Based on modern series demonstrating low upgrade rates for pure lobular neoplasia (LN) diagnosed on core needle biopsy (CNB), our institution no longer recommends routine excision, provided imaging is concordant. This study describes outcomes in patients managed without surgical excision. METHODS: From an institutional database, we identified all patients with a diagnosis of pure atypical lobular hyperplasia and/or classic lobular carcinoma in situ on CNB managed without surgical excision (i.e., conservative management) from 2015 to 2019. The primary outcome of interest was failure of conservative management, defined as development of ipsilateral same-quadrant ductal carcinoma in situ or invasive breast cancer within 2 years of CNB, or need for ipsilateral same-quadrant excisional biopsy. We also evaluated rates of ipsilateral same-quadrant CNB during follow-up. RESULTS: Among 96 pure LN lesions on CNB since 2015, 80 (83%) were managed without surgical excision. Median follow-up was 27 months (IQR: 16-28), with only 2 (2%) patients lost to follow-up. No patients developed an ipsilateral, same-quadrant breast cancer. The 3-year risk of conservative management failure was 6.2% (95% CI 2.3-15.7%). All failures were a result of need for excisional biopsy due to progressive imaging abnormalities at the initial CNB site, with benign final pathology. The 3-year risk of ipsilateral same-quadrant CNB was 9.2% (95% CI 3.8-21.5%). CONCLUSION: Non-surgical management of pure LN is safe, and the likelihood of requiring subsequent surgical excision or repeat CNB during follow-up is low. These data provide reassurance that routine excision of pure LN in the setting of radiologic-pathologic concordance is not required.

A review on the added value of whole-body MRI in metastatic lobular breast cancer.

Invasive lobular breast carcinomas (ILC) account for approximately 15% of breast cancer diagnoses. They can be difficult to diagnose both clinically and radiologically, due to their infiltrative growth pattern. The pattern of metastasis of ILC is unusual, with spread to the serosal surfaces (pleura and peritoneum), retroperitoneum and gastrointestinal (GI)/genitourinary (GU) tracts and a higher rate of leptomeningeal spread than IDC. Routine staging and response assessment with computed tomography (CT) can be undertaken quickly and measurements can be reproduced easily, but this is challenging with metastatic ILC as bone-only/bone-predominant patterns are frequently seen and assessment of the disease status is limited in these scenarios. Functional imaging such as whole-body MRI (WBMRI) allows the assessment of bone and soft tissue disease by providing functional information related to differences in cellular density between malignant and benign tissues. A number of recent studies have shown that WBMRI can detect additional sites of disease in metastatic breast cancer (MBC), resulting in a change in systemic anti-cancer therapy. Although WBMRI and fluorodeoxyglucose-positron-emission tomography-computed tomography (FDG-PET/CT) have a comparable performance in the assessment of MBC, WBMRI can be particularly valuable as a proportion of ILC are non-FDG-avid, resulting in the underestimation of the disease extent. In this review, we explore the added value of WBMRI in the evaluation of metastatic ILC and compare it with other imaging modalities such as CT and FDG-PET/CT. We also discuss the spectrum of WBMRI findings of the different metastatic sites of ILC with CT and FDG-PET/CT correlation. KEY POINTS: • ILC has an unusual pattern of spread compared to IDC, with metastases to the peritoneum, retroperitoneum and GI and GU tracts, but the bones and liver are the commonest sites. • WBMRI allows functional assessment of metastatic disease, particularly in bone-only and bone-predominant metastatic cancers such as ILC where evaluation with CT can be challenging and limited. • WBMRI can detect more sites of disease compared with CT, can reveal disease progression earlier and provides the opportunity to change ineffective systemic treatment sooner.

The Importance of the Pathological Perspective in the Management of the Invasive Lobular Carcinoma.

Background: Invasive lobular carcinomas (ILC) account for 10-15% of all breast cancers and are the second most common histological form of breast cancer. They usually show a discohesive pattern of single cell infiltration, tend to be multifocal, and the tumor may not be accompanied by a stromal reaction. Because of these histological features, which are not common in other breast tumors, radiological detection of the tumor may be difficult, and its pathological evaluation in terms of size and spread is often problematic. The SSO-ASTRO guideline defines the negative surgical margin in breast-conserving surgeries as the absence of tumor detection on the ink. However, surgical margin assessment in invasive lobular carcinomas has not been much discussed from the pathological perspective. Methods: The study included 79 cases diagnosed with invasive lobular carcinoma by a Tru-cut biopsy where operated in our center between 2014 and 2021. Clinicopathological characteristics of the cases, results of an intraoperative frozen evaluation in cases that underwent conservative surgery, the necessity of re-excision and complementary mastectomy, and consistency in radiological and pathological response evaluation in cases receiving neoadjuvant treatment were questioned. Results: The tumor was multifocal in 37 (46.8%) cases and single tumor focus in 42 (53.2%) cases. When the entire patient population was evaluated, regardless of focality, mastectomy was performed in 27 patients (34.2%) and breast-conserving surgery (BCS) was performed in 52 patients (65.8%). Of the 52 patients who underwent BCS, 26 (50%) required an additional surgical procedure (cavity revision or completion mastectomy). There is a statistical relationship between tumor size and additional surgical intervention (p < 0.05). BCS was performed in 7 of 12 patients who were operated on after neoadjuvant treatment, but all of them were reoperated with the same or a second session and turned to mastectomy. Neoadjuvant treatment and the need for reoperation were statistically significant (p < 0.05). Additional surgical procedures were performed in 20 (44.4%) of 45 patients in BCS cases who did not receive neoadjuvant therapy. Conclusions: Diagnostic difficulties in the intraoperative frozen evaluation of invasive lobular carcinoma are due to the different histopathological patterns of the ILC. In our study, it was determined that large tumor size and neoadjuvant therapy increased the need for additional surgical procedures. It is thought that the pathological perspective is the determining factor in order to minimize the negative effects such as unsuccessful cosmesis, an additional surgical burden on the patient, and cost increase that may occur with additional surgical procedures; for this reason, new approaches should be discussed in the treatment planning of invasive lobular carcinoma cases.

Clinical Differences between Invasive Lobular Breast Cancer and Invasive Carcinoma of No Special Type in the German Mammography-Screening-Program.

Invasive lobular carcinoma (ILC) of the breast is known to have typical molecular, clinical, and pathological characteristics that differ from invasive cancer of no special type (NST). In the German mammography screening program (MSP), we evaluated clinical differences between these tumor types at the time of their detection. Clinical features of NSTs (n = 785) and ILCs (n = 141) diagnosed in the MSP between 2009 and 2016 were compared. Compared to NST, ILC was significantly correlated with advanced age (59.1 years versus 60.6 years) and larger tumor size (1.5 cm versus 2.3 cm). ILC was significantly more frequently associated with moderate tumor differentiation (G2), whereas NST was associated with a higher rate of poorly differentiated tumors (p < .001). Furthermore, ILC presented more often as multifocal tumors (36% versus 11%, p < .001), and mastectomies were performed more often in the ILC group (27% versus 12%, p < .001). ILCs and NSTs had different clinical features at the time of detection. The pathological profile of ILC may explain some of these features. Specialists should be aware of the fact that ILC may escape detection by conventional imaging modalities for a long time, and may present later in life as more advanced multifocal disease.

Prediction of axillary nodal burden in patients with invasive lobular carcinoma using MRI.

PURPOSE: To investigate clinical and imaging features associated with a high nodal burden (≥ 3 metastatic lymph nodes [LNs]) and compare diagnostic performance of US and MRI in patients with invasive lobular carcinoma (ILC) and invasive ductal carcinoma (IDC). METHODS: Retrospective search revealed 239 patients with ILC and 999 with IDC who underwent preoperative US and MRI between January 2016 and June 2019. Patients with ILC were propensity-score-matched with patients with IDC. Univariate and multivariate logistic regression analyses were performed to determine factors associated with ≥ 3 metastatic LNs. RESULTS: 412 patients (206 ILC and 206 IDC) were evaluated. Of all patients with ILC, 27.2% (56/206) were node-positive and 7.8% (16/206) showed a high nodal burden. In multivariate analysis, the clinical N stage was the only independent factor associated with a high nodal burden in patients with IDC (odds ratio [OR] 6.24; 95% confidence interval [CI] 1.57-24.73; P = 0.009), but not in patients with ILC. Increased cortical thickness with loss of fatty hilum on US was associated with a high nodal burden in patients with ILC (OR 58.40; 95% CI 5.09-669.71; P = 0.001) and IDC (OR 24.14; 95% CI 3.52-165.37; P = 0.001), while suspicious LN findings at MRI were independently associated with a high nodal burden in ILC only (OR 13.94; 95% CI 2.61-74.39; P = 0.002). CONCLUSION: In patients with ILC, MRI findings of suspicious LNs were helpful to predict a high nodal disease burden.

Is axillary imaging for invasive lobular carcinoma accurate in determining clinical node staging?

PURPOSE: Preoperative evaluation of clinical N-stage (cN) is difficult in breast cancer patients with invasive lobular carcinoma (ILC). Our goal was to assess the predictive value of axillary imaging in ILC by comparing imaging cN and pathologic N-stage (pN). METHODS: A single-institution retrospective review was performed for newly diagnosed stage I-III ILC patients undergoing preoperative breast imaging from 2011 to 2016. Clinicopathologic factors; mammogram, MRI, and ultrasound findings; and surgical pathology data were reviewed. Sub-analysis for pN2-N3 patients was performed to determine imaging sensitivity for patients with a larger nodal disease burden. Statistical analysis included sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each imaging modality. RESULTS: Of the total 349 patients included, 70.5% were cN0, and 62% were pN0 (p = 0.03). For all patients, mammogram sensitivity was 7%, specificity 97%, PPV 50%, NPV 72%; ultrasound sensitivity was 26%, specificity 86%, PPV 52%, NPV 67%; MRI sensitivity was 7%, specificity 98%, PPV 80%, NPV 51%. For pN2/N3 patients, 38% were identified as cN0. Mammogram sensitivity was 10%; ultrasound 42%; MRI 65%. Pathology evaluation of N2/N3 patients indicated LN were replaced with ILC but maintained normal architecture. The average largest pathologic tumor deposit (1.5 ± 0.8 cm) correlated with average largest imaging LN size (1.4 ± 0.6 cm) (p = 0.58). CONCLUSION: A statistically significant difference between clinical and pathologic N-stage exists for ILC patients. MRI was most sensitive for identification of pN2-N3 patients and should be considered part of routine axillary imaging evaluation for ILC patients.

Invasive Lobular Breast Cancer: Data to Support Surgical Decision Making.

BACKGROUND: Invasive lobular carcinoma (ILC) is thought be a unique entity with higher rates of multifocal/multicentric and bilateral disease. This study aimed to evaluate the true extent of the disease, risk of bilaterality, lymph node involvement, and impact of preoperative imaging to help guide surgical decision making. METHODS: A retrospective analysis identified patients treated for ILC between 2004 and 2017. Clinical staging and pathologic results were compared. Follow-up details including local recurrence, contralateral breast cancer (CBC), and survival outcomes were evaluated. RESULTS: The study identified 692 patients with ILC, including 43 patients (6%) with a diagnosis of CBC and 232 patients (33%) with a diagnosis of multifocal/multicentric disease at presentation. Preoperative magnetic resonance imaging (MRI) led to an identification of additional disease in 20% of the patients. Preoperative MRI resulted in a more accurate prediction of tumor size staging but did not improve the discordance between clinical and pathologic nodal staging. Overall, the rate of imaging occult lymph node disease was 24%. At the 6-year follow-up evaluation, a local recurrence had developed in 2.3%, a CBC in 2.3, and a distant metastasis in 9.4% of the patients. The overall survival rate was 96% at 3 years and 91% at 5 years. CONCLUSIONS: Invasive lobular carcinoma is a distinct subset of cancer that poses a diagnostic staging challenge. The results of this study favor MRI for accurate tumor staging and for improving detection of multicentricity and bilaterality. However, clinicians should be aware of the higher likelihood of occult lymph node involvement with ILC and subsequent early metastasis.

Does the Addition of Breast MRI Add Value to the Diagnostic Workup of Invasive Lobular Carcinoma?

BACKGROUND: Invasive lobular carcinoma (ILC) has unique histologic growth pattern. Few studies have focused on the value of breast magnetic resonance imaging (MRI) specifically for ILC. We hypothesized that MRI adds value to the diagnostic workup in ILC by better defining the extent of disease and identifying additional foci of malignancy, which can change the surgical plan. MATERIALS AND METHODS: This was a single-institution retrospective review of women diagnosed with ILC from 1/2012 to 7/2019 who underwent preoperative MRI. Patient, tumor characteristics, and initial surgical plan were reviewed. MRI had added value if ILC size correlated best to final pathologic size or if additional malignancy was identified. MRI was considered harmful if additional biopsies were benign or if the size was overestimated. RESULTS: ILC was identified in 166 breasts in 165 women. Original surgical plan was for lumpectomy in 86 (52%), mastectomy in 49 (30%), and undecided in 31 (18%). MRI changed the plan in 25 (19%) with 24 (96%) changing from lumpectomy to mastectomy. Additional biopsy was performed in 28% after MRI, the majority (n = 41, 72%) were benign or high risk and 16 (28%) identified additional malignancy. MRI was not a better size estimate than mammogram/ultrasound. Re-excision rate after lumpectomy was 6.8% (5/73). MRI added value in 48 (28.9%) and was harmful in 48 (28.9%). CONCLUSIONS: Using breast MRI in the diagnostic workup of ILC has both positive and negative implications on surgical treatment planning. A shared decision-making conversation is warranted before proceeding with MRI to maximize value and minimize harms associated with this diagnostic tool.

Contrast-Enhanced Digital Mammography Screening for Intermediate-Risk Women With a History of Lobular Neoplasia.

OBJECTIVE. The objective of this study was to assess to the role of contrast-enhanced digital mammography (CEDM) as a screening tool in women at intermediate risk for developing breast cancer due to a personal history of lobular neoplasia without additional risk factors. MATERIALS AND METHODS. In this institutional review board-approved, observational, retrospective study, we reviewed our radiology department database to identify patients with a personal history of breast biopsy yielding lobular neoplasia who underwent screening CEDM at our institution between December 2012 and February 2019. A total of 132 women who underwent 306 CEDM examinations were included. All CEDM examinations were interpreted by dedicated breast imaging radiologists in conjunction with a review of the patient's clinical history and available prior breast imaging. In statistical analysis, sensitivity, specificity, NPV, positive likelihood ratio, and accuracy of CEDM in detecting cancer were determined, with pathology or 12-month imaging follow-up serving as the reference standard. RESULTS. CEDM detected cancer in six patients and showed an overall sensitivity of 100%, specificity of 88% (95% CI, 84-92%), NPV of 100%, and accuracy of 88% (95% CI, 84-92%). The positive likelihood ratio of 8.33 suggested that CEDM findings are 8.3 times more likely to be positive in an individual with breast cancer when compared with an individual without the disease. CONCLUSION. CEDM shows promise as a breast cancer screening examination in patients with a personal history of lobular neoplasia. Continued investigation with a larger patient population is needed to determine the true sensitivity and positive predictive value of CEDM for these patients.

Contrast-Enhanced Mammography for Newly Diagnosed Breast Cancer in Women With Breast Augmentation: Preliminary Findings.

In 17 women with newly diagnosed breast cancer who underwent contrast-enhanced mammography (CEM) and MRI, both modalities were found to be concordant for the index cancer. In six of the 17 women, CEM showed an additional lesion that was confirmed by MRI. Of these six additional lesions, three were multifocal, one was multicentric, and two were contralateral; two of the six were malignant. MRI did not identify any additional cancers that were not identified on CEM. CEM may have a role in women with breast augmentation and either a contraindication or limited access to MRI.

Management of Lobular Neoplasia Found on Core Needle Biopsy Performed for Calcifications Using Precise Radiologic-Pathologic Correlation.

OBJECTIVE. The purpose of our study was to evaluate the upgrade rate of calcified lobular neoplasia (LN) versus incidental noncalcified classic LN found on core needle biopsy performed for the evaluation of suspicious calcifications. MATERIALS AND METHODS. This retrospective study included 390 consecutive image-guided breast core needle biopsies with microcalcifications as the target that were performed between December 2009 and July 2017. In 81 of the 390 core biopsies, the highest-risk lesion was LN that then underwent either excision or imaging follow-up. Core biopsy results were compared with excision and imaging follow-up findings. An upgrade of LN was defined as ductal carcinoma in situ or invasive ductal or lobular carcinoma. RESULTS. Of 81 LN diagnosed on core biopsy performed for calcifications, 16 had calcifications within the LN. Fifteen of these 16 cases underwent surgical excision, and three (3/15, 20.0%) were upgraded on excision. Of the 64 core biopsies showing incidental noncalcified LN with benign concordant entities containing calcifications, 42 underwent surgical excision, and one LN (1/42, 2.4%) was upgraded. Twenty-three total lesions (one calcified LN and 22 noncalcified LN) were followed with imaging rather than excision. No cancers were detected among the follow-up group. One case was deemed to have discordant findings on radiologic-pathologic review and was sent for excision, which showed invasive cancer with tubulolobular and lobular features. CONCLUSION. Women undergoing stereotactic core needle biopsy for calcifications revealing noncalcified incidental classic LN and a benign concordant entity that could explain the presence of the target calcifications have a low risk of upgrade and may be followed with imaging. Surgical excision should be offered to women who have LN with calcifications.

Longitudinal study of breast cancer risk markers.

Atypical hyperplasia (AH) and lobular carcinoma in situ (LCIS) are markers for an increased risk of breast cancer, yet outcomes for these diagnoses are not well-documented. In this study, all breast biopsies performed for radiologic abnormalities over a 10-year period were reviewed. Patients with AH or LCIS were followed for an additional 10 years to assess subsequent rates of cancer diagnosis. Long-term follow-up showed that 25 (7.8%) patients with AH and 5 patients with LCIS (5.7%) developed breast cancer over the follow-up period, a lower rate of breast cancer development than predicted by risk models.

The lobular neoplasia enigma: management and prognosis in a long follow-up case series.

BACKGROUND: Many oncologists debate if lobular neoplasia (LN) is a risk factor or an obligatory precursor of more aggressive disease. This study has three aims: (i) describe the different treatment options (surgical resection vs observation), (ii) investigate the upgrade rate in surgically treated patients, and (iii) evaluate the long-term occurrences of aggressive disease in both operated and unoperated patients. METHODS: A series of 122 patients with LN bioptic diagnosis and follow-up information were selected. Clinical, radiological, and pathological data were collected from medical charts. At definitive histology, either invasive or ductal carcinoma in situ was considered upgraded lesions. RESULTS: Atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS), and high-grade LN (HG-LN) were diagnosed in 44, 63, and 15 patients, respectively. The median follow-up was 9.5 years. Ninety-nine patients were surgically treated, while 23 underwent clinical-radiological follow-up. An upgrade was observed in 28/99 (28.3%). Age ≥ 54 years (OR 4.01, CI 1.42-11.29, p = 0.009), Breast Imaging-Reporting and Data System (BI-RADS) categories 4-5 (OR 3.76, CI 1.37-10.1, p = 0.010), and preoperatory HG-LN diagnosis (OR 8.76, 1.82-42.27, p = 0.007) were related to upgraded/aggressive disease. During follow-up, 8 patients developed an ipsilateral malignant lesion, four of whom were not initially operated (4/23, 17%). CONCLUSIONS: BI-RADS categories 4-5, HG-LN diagnosis, and age ≥ 54 years were features associated with an upgrade at definitive surgery. Moreover, 17% of unoperated cases developed an aggressive disease, emphasizing that LN patients need close surveillance due to the long-term risk of breast cancer.