Breast hematoma with active bleeding due to seat belt injury.

Breast emergencies are not frequent but play an important part in routine breast imaging applications. Diagnosis and identification of seat belt injury in emergency department are essential for patient management and early treatment of advanced cases. Herein we reported imaging findings of a patient who had prominent swollen at her left breast accompanying tissue edema and painful palpable mass formed by active bleeding hematoma as a result of seat belt injury due to a car accident. Radiologic examinations revealed hematoma in the breast accompanying active bleeding.

Use of shear-wave elastography to distinguish complex and complicated fibroadenomas from simple fibroadenomas.

PURPOSE: Simple fibroadenomas (SFAs), complex fibroadenomas (CFAs), and cellular fibroadenomas (CeFAs) are variants of fibroadenomas. Additionally, some degenerative, hyperplastic, and metaplastic changes may occur in fibroadenomas, forming complicated fibroadenomas. Distinctive ultrasonography (US) features in variants of fibroadenomas and complicated fibroadenomas have not been reported. Shear-wave elastography (SWE) can be applied to effectively discriminate between these variants and complicated fibroadenomas. In this study, we aimed to evaluate SWE findings to discriminate between SFAs and other variants. METHODS: In total, 48 patients (26 with SFAs, 16 with CFAs, 3 with CeFAs, and 3 with complicated fibroadenomas) participated in this study. The lesions were classified into two groups according to histopathologic diagnoses. The SWE evaluation and lesion elasticity scores (Emax, Emean, and Emin) were both assessed in m/s and k/Pa, respectively. Two observers measured Emax, Emean, and Emin. Brightness (B)-mode US findings based on the Breast Imaging Reporting and Data System categorization and elasticity scores were recorded. In the statistical analyses, the chi-square test and non-parametric tests were performed. Fisher's exact test was used to compare independent groups, and Spearman's correlation coefficients were used to correlate the SWE data between the two observers. Additionally, receiver operating characteristic curves were analyzed to evaluate the diagnostic performance of the elasticity values. RESULTS: The B-mode US features in both groups showed no statistical significance. The set of SWE values of both observers demonstrated strong statistical significance in discriminating between group 1 (SFAs) and Group 2 (CFAs, CeFAs, and complicated fibroadenomas). CONCLUSION: As the fibroadenoma variants and complicated fibroadenomas have similar US findings, SWE in addition to a conventional B-mode examination can increase the diagnostic performance to discriminate SFAs from other complex and complicated forms of fibroadenomas.

Outcomes of high-risk breast lesions diagnosed using image-guided core needle biopsy: results from a multicenter retrospective study.

PURPOSE: The clinical management of high-risk lesions using image-guided biopsy is challenging. This study aimed to evaluate the rates at which such lesions were upgraded to malignancy and identify possible predictive factors for upgrading high-risk lesions. METHODS: This retrospective multicenter analysis included 1.343 patients diagnosed with high-risk lesions using an image-guided core needle or vacuum-assisted biopsy (VAB). Only patients managed using an excisional biopsy or with at least one year of documented radiological follow-up were included. For each, the Breast Imaging Reporting and Data System (BI-RADS) category, number of samples, needle thickness, and lesion size were correlated with malignancy upgrade rates in different histologic subtypes. Pearson's chi-squared test, the Fisher-Freeman-Halton test, and Fisher's exact test were used for the statistical analyses. RESULTS: The overall upgrade rate was 20.6%, with the highest rates in the subtypes of intraductal papilloma (IP) with atypia (44.7%; 55/123), followed by atypical ductal hyperplasia (ADH) (38.4%; 144/375), lobular neoplasia (LN) (12.7%; 7/55), papilloma without atypia (9.4%; 58/611), flat epithelial atypia (FEA) (8.7%; 10/114), and radial scars (RSs) (4.6%; 3/65). There was a significant relationship between the upgrade rate and BI-RADS category, number of samples, and lesion size Lesion size was the most predictive factor for an upgrade in all subtypes. CONCLUSION: ADH and atypical IP showed considerable upgrade rates to malignancy, requiring surgical excision. The LN, IP without atypia, pure FEA, and RS subtypes showed lower malignancy rates when the BI-RADS category was lower and in smaller lesions that had been adequately sampled using VAB. After being discussed in a multidisciplinary meeting, these cases could be managed with follow-up instead of excision.

Multimodality imaging and histopathology of metaplastic breast cancer

Metaplastic breast cancer (MBC) is a rare subtype of invasive breast cancer characterized by mixed epithelial and mesenchymal differentiation. Commonly seen subtypes include squamous cell carcinoma, spindle cell carcinoma, and metaplastic carcinoma with heterologous mesenchymal differentiation. MBC tends to have a more aggressive clinical presentation, higher metastatic potential, higher rates of local recurrence, and a worse prognosis compared with invasive breast carcinoma of no special type. Most MBCs are triple-negative breast cancers, which explains their resistance to most systemic therapies. Therefore, accurately diagnosing MBC early is crucial for deciding the treatment strategy and predicting the prognosis. In this pictorial essay, the imaging findings of MBC in different modalities and the histopathologic features of its subtypes are reviewed.

Adenoid Cystic Carcinoma of the Breast: Multimodality Imaging Findings and Review of the Literature.

RATIONALE AND OBJECTIVES: Adenoid cystic carcinoma (ACC) of the breast is a rare type of breast cancer with favorable prognosis. There is limited data on the radiological findings of this rare tumor in literature. The aim of this study is to determine the most common imaging features and review the literature. MATERIALS AND METHODS: Pathological databases of seven institutions from 2009 to 2021 were retrospectively reviewed, and patients with a diagnosis of ACC of the breast were determined. Thirteen patients whose imaging studies could be recalled from the picture archiving systems (PACS) were included in the study. Clinical and pathological findings as well as follow-up data were recorded. Radiological findings were analyzed and categorized based on BI-RADS 5th edition. RESULTS: There were 16 mass lesions in 13 patients (two multifocal cases, one case with recurrence). Mammography demonstrated 14 masses, while ultrasound (US) demonstrated all. MRI was available in only seven cases, with eight masses. The most common findings were round or oval shape on all modalities (78.57%-93.75%). Other frequent findings were parallel orientation (81.25%), isoechoic or hyperechoic echogenicity (62.5%), high T2 signal (87.5%), restricted diffusion (71.43%), and homogeneous enhancement (62.5%). Mammography, US and MRI showed circumscribed margins resembling a benign lesion in 35.71%, 37.5% and 50% of the lesions respectively. Three patients had a cyst-like echogenicty on US. Half of the lesions were avascular on Doppler US (6/12) and half were soft (2/4) on strain elastography. Although there were benign features on all imaging modalities seperately, all lesions could be categorized as BI-RADS 4 or 5 when the findings were combined. However 9/16 masses were BI-RADS 4A, emphasizing the subtlety of the malignant features. CONCLUSION: ACC of the breast can present with findings resembling a benign lesion on different imaging modalities. Although combination of all imaging findings correctly indicated the suspicious nature of the lesions in all cases, final classification was BI-RADS 4A in most of them. Radiologists should be aware of the more frequent findings of ACC of the breast for early diagnosis. US findings of isoechoic or hyperechoic appearance, and cyst-like echogenicity have not been reported previously in literature.

Machine Learning-Based Ultrasound Texture Analysis in Differentiation of Benign Phyllodes Tumors from Borderline-Malignant Phyllodes Tumors.

PURPOSE: Phyllodes tumors (PTs) are uncommon fibroepithelial breast lesions that are classified as three different forms as benign phyllodes tumor (BPT), borderline phyllodes tumor (BoPT), and malignant phyllodes tumor (MPT). Conventional radiologic methods make only a limited contribution to exact diagnosis, and texture analysis data increase the diagnostic performance. In this study, we aimed to evaluate the contribution of texture analysis of US images (TAUI) of PTs in order to discriminate between BPTs and BoPTs-MPTs. METHODS: The number of patients was 63 (41 BPTs, 12 BoPTs, and 10 MPTs). Patients were divided into two groups (Group 1-BPT, Group 2-BoPT/MPT). TAUI with LIFEx software was performed retrospectively. An independent machine learning approach, MATLAB R2020a (Math- Works, Natick, Massachusetts) was used with the dataset with p < 0.004. Two machine learning approaches were used to build prediction models for differentiating between Group 1 and Group 2. Receiver operating characteristics (ROC) curve analyses were performed to evaluate the diagnostic performance of statistically significant texture data between phyllodes subgroups. RESULTS: In TAUI, 10 statistically significant second order texture values were identified as significant factors capable of differentiating among the two groups (p < 0.05). Both of the models of our dataset make a diagnostic contribution to the discrimination between BopTs-MPTs and BPTs. CONCLUSION: In PTs, US is the main diagnostic method. Adding machine learning-based TAUI to conventional US findings can provide optimal diagnosis, thereby helping to choose the correct surgical method. Consequently, decreased local recurrence rates can be achieved.

Sonoelastography findings of myofibroblastoma.

Myofibrolastoma of the breast (MFB) is a rare and benign stromal tumor. Although MFB is a benign entity, in radiologic evaluation, there is no specific diagnostic feature. Conventional breast imaging findings have been published before. Sonoelastography has been used as an imaging method that allows us to evaluate tissue stiffness in vivo and increases the specificity of B-mode ultrasonography in the discrimination of benign-malignant lesions. In this case report, it was shown that MFB is of high stiffness in shear wave elastography (SWE) evaluation. SWE findings of MFB, which is a benign lesion, have been described for the first time in the literature.

Tuberculous mastitis: A masquerading face of granulomatous mastitis.

Introduction: Tuberculosis (TB) mastitis is a rare form of granulomatous mastitis. We aimed to evaluate the clinical characteristics and prognosis of patients diagnosed with TB mastitis. Materials and Methods: A descriptive study was carried out on patients who were reported to national tuberculosis control authorities as having TB mastitis between 2003 and 2021. Demographic, histopathological, and radiological data including mammography, ultrasonography (US), and magnetic resonance imaging (MRI) were reviewed. All were followed up to 24 months and prognosis was also evaluated. Result: This study identified 29 TB mastitis patients who had been diagnosed using excisional biopsies. The mean age was 33.5 ± 10.1, all were premenopausal women. The most common symptom was breast mass (n= 24, %82.8), nearly half of the patients also had ipsilateral axillary lymphadenopathy (n= 14, 48.3). One-fourth of the patients had bilateral involvement (n= 7, 24.1%), and half of the patients (n= 16, 55.2%) presented with multiple masses. One patient had co-existing pulmonary TB. Predisposing factors for TB were not identified in any of the patients. Nearly half of the patients received prior mastitis treatment. The most common radiological finding was mass in both mammography and US. All patients received anti-tuberculosis treatment of a standard regimen for six to 21 months, three patients had a relapse but were finally cured. Conclusions: TB mastitis should be suspected in young and premenopausal women presenting with a breast mass and axillary lymphadenopathy in an endemic region. Radiological findings could not identify the diagnosis. A multidisciplinary approach including bacteriology and histopathology should be performed. Anti-tuberculosis treatment can be implemented successfully.

Effect of Local Tranexamic Acid on the Quality of Bone Healing in a Rat Spinal Fusion Model.

Introduction: The use of the antifibrinolytic agent tranexamic acid has positive effects on bleeding control, but our knowledge is still limited regarding how fibrinolysis suppression changes the process of bone formation and the quality of bone. Because of the several side effects of systemic tranexamic acid, topical usage has been established in several procedures. This study aimed to investigate the effect of local tranexamic acid on vertebral fusion by using macroscopic, radiologic, and microscopic techniques. We also attempted to determine the safe dose range in case some doses had negative effects on fusion. Methods: Twenty-eight Wistar albino rats underwent intertransverse fusion. All rats were randomized into four groups: groups treated with local tranexamic acid doses of 1 mg/kg (D1), 10 mg/kg (D10), and 100 mg/kg (D100) and the control group with no drug (D0). At the end of the eighth week, all rats were sacrificed for evaluation in terms of palpation, mammography, and histopathologic analysis. Results: The manual palpation results presented with lower fusion rates in D10 and D100 groups than in the control group. Radiological examination results were significantly higher in the control group. The histopathologic examination revealed no significant differences between groups in the percent of new bone formation. Conclusions: Our results showed that local administration of tranexamic acid reduced the quality and stability of fusion without a delay in bone formation. However, doses of 1 mg/kg did not reduce the stability in the palpation test. Our findings suggest that 1 mg/kg dose is a critical threshold above which tranexamic acid reduced the bone healing process of fusion and that surgeons should consider the doses of local tranexamic acid during surgery.

Evaluation of hereditary/familial breast cancer patients with multigene targeted next generation sequencing panel and MLPA analysis in Turkey.

Breast cancer, a worldwide leading cause of cancer in women, may occur in familial cases. Germline mutations in BRCA1/2 genes are responsible for 15% of the familial cases. With the power of next generation sequencing (NGS) analysis, it is possible to analyze genes related to hereditary susceptibility to breast cancer and investigate the genetic etiology more thoroughly. In this study, we investigated 30 genes identified frequent pathogenic alleles in Turkish population. The study includes 495 unrelated individuals diagnosed with breast cancer who are selected for genetic testing according to NCCN criteria for hereditary breast cancer. All patients were analyzed by NGS for BRCA1/2 genes. Deletion/duplication investigation by Multiplex ligation-dependent probe amplification (MLPA) and massive sequencing of 30 breast cancer-related genes (Oncorisk Gene Panel) were performed in a stepwise manner. BRCA1/2 variants are the most frequent pathogenic variants which are found in 45 of 495 (9.1%) patients. Four previously unreported, novel, pathogenic variants of BRCA2 gene are identified. In four cases, exonic deletions of BRCA1/2 genes are determined and there is no duplication of these genes. NGS panel investigation involving other moderate-high risk genes contributed genetic diagnosis in an extra 39 out of 419 (9.3%) cases. Our study presents the cost effectiveness of the gene panel approach. We suggest that gene panels should be the first-tier genetic testing for hereditary breast cancer and MLPA analysis of BRCA1/2 genes should be investigated as a complementary method of NGS analysis.

Three cases of immunoglobulin G4-related respiratory disease with uncommon imaging findings.

BACKGROUND: Immunoglobulin G4-related disease (IgG4-RD) is a rare multisystemic idiopathic fibroinflammatory disorder. The rare form of IgG4-RD with isolated thorax involvement is called immunoglobulin G4-related respiratory disease (IgG4-RRD). IgG4-RRD, which is reported in a limited number of cases in the literature, can be categorized into four types on the prevalent chest computed tomography (CCT) findings: solid nodular, round-shaped ground-glass opacity, alveolar interstitial, and bronchovascular. Solid nodular form of IgG4-RRD with mass-like lesions is sporadic and described in the literature with a small number of case reports. OBJECTIVES/METHODS: We aim to present the radiologic, pathologic, and clinical findings of three cases of IgG4-RRD mimicking lung cancer. RESULTS: In all three patients, IgG4-RRD occurred with mass-like lesions in the thorax. In case-1 and 2, CCT showed multiple, nodular lesions and multiple mediastinal lymph nodes. On positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro- D-glucose integrated with computed tomography (18F-FDG PET/CT), the masses showed increased 18F-FDG uptake in case-2 and 3. The gold standard histopathological verification for IgG4-RRD was provided for all cases. CONCLUSIONS: IgG4-RD is an immune-mediated condition comprised of a collection of disorders that share particular pathologic, radiologic, serologic, and clinical features. Isolated IgG4-RRD is rarely seen and is available in the literature as case reports. IgG4-RRD, which can make lung involvement in different patterns, rarely appears with mass-like lesions. Still, IgG4-RRD must be considered in the differential diagnosis of mass lesions detected in CCT. Laboratory, radiological, and histopathological findings of the disease should be evaluated together for an accurate diagnosis.

Shear-Wave Elastography-Guided Core Needle Biopsy for the Determination of Breast Cancer Molecular Subtype.

OBJECTIVE: To investigate whether shear-wave elastography (SWE) guidance during core-needle biopsy can improve diagnostic accuracy and accurate determination of the molecular subtypes of breast cancer. METHODS: This controlled, randomized prospective cohort study included 58 patients (mean age: 56.9 ± 16.2) who were referred for image-guided core-needle biopsy between May 2018 and April 2019 for lesions larger than 1 cm. In Group 1, 30 lesions were biopsied without SWE guidance and recorded as Biopsy A. In Group 2, 30 lesions were examined with SWE before biopsy, and then two different parts of the lesions were biopsied; biopsies from the relatively rigid areas of the lesions were recorded as Biopsy B, and biopsies from the less rigid areas of the lesions were recorded as Biopsy C. The histopathological and immunohistochemical results of biopsies were compared with the surgical results. RESULTS: The sensitivity of Biopsy A, B and C were 96.7%, 100% and 100%, respectively. The benign-malignant concordance rates were 94.7%, 100%, and 90% and the diagnostic concordance rates were 89.5%, 100%, and 90% in Biopsies A, B, and C, respectively. When the 10% differences in the estrogen receptor (ER), progesterone receptor (PR), and Ki67 rates were considered significant, the concordance rate of ER was highest in Biopsy B (77.8%; p = 0.040). The concordance rate of immunohistochemical subtyping was 100% in Biopsy B and 71.4% in Biopsies A and C (p = 0.086). CONCLUSION: SWE-guided core-needle biopsy of breast lesions increased the sensitivity, diagnostic accuracy, and accuracy of immunohistochemical subtyping to 100%.

Fibroadenomas: a multidisciplinary review of the variants.

Fibroadenomas are the most common benign breast lesions in women. Hormonal activities, particularly an increase in oestrogenic activity, have an important role in the aetiology of fibroadenomas. They are commonly detected incidentally. Most fibroadenomas have similar imaging findings and these lesions can be defined as simple fibroadenomas (SFAs). However, due to different histopathologic characteristics and components, variants of fibroadenomas have been described. These variants include; juvenile, giant, complex, myxoid, cellular, and hyalinised fibroadenomas. The diagnoses of these variants are important. They have different clinical behaviours, potential for malignant transformation, and treatment strategies. We present imaging findings of SFAs and other variants of fibroadenomas. To our knowledge, there is no review in which imaging findings of all fibroadenoma variants are presented together.

Evaluation of Elastographic Features in Complex Fibroadenomas With Radiologic-Pathologic Correlation.

Fibroadenoma is the most common benign tumor of the breast, and complex fibroadenoma (CFA) is one of its variants. Of the fibroadenomas, 22% are CFAs, and in women with CFAs, the malignancy development is found to be higher than in women with noncomplex fibroadenomas. Although there is an increased risk of malignancy with CFAs, the imaging findings of CFAs are fundamentally similar to those of other variants of fibroadenomas. In the literature, B-mode ultrasound features of CFAs were reported in detail. To our knowledge, there is no study that has specifically described the elastographic findings of CFAs. This article aims to illustrate the elastographic features of CFAs and to correlate radiologic and histopathologic findings of different cases.

Management of the axilla with sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer: A single-center study.

The neoadjuvant chemotherapy (NAC) is the gold standard initial treatment of the locally advanced breast cancer (LABC). However, the reliability of methods that used to assess response the NAC is still controversial. In this study, patients with LABC who underwent NAC were evaluated retrospectively. The assessment of response to NAC and the effect of axillary approach were investigated on LABC course.The study comprised 94 patients who received NAC with an LABC diagnosis between 2008 and 2020. In our center, magnetic resonance imaging, ultrasonography, and F-flouro deoxyglucose positron emission tomography/computed tomography, and, for some patients, fine-needle aspiration biopsy of suspicious axillary lymph nodes have been performed to assess the effects of NAC. Patients with positive hormone receptor status received adjuvant hormonotherapy, and those with human epidermal growth factor receptor 2 gene expression were treated with trastuzumab. Adjuvant radiotherapy was applied to all patients undergoing breast conserving surgery. Radiotherapy was applied to the peripheral lymphatic areas in the clinical N1 to N3 cases regardless of the response to NAC.The clinical response to the NAC was found that partial in 59% and complete in 19% of the patients. However, 21.2% of the patients were unresponsive. The mean of lymph nodes that excised with the procedure of sentinel lymph node biopsy (SLNB) was 2.4 (range 1-7). In 22 of the 56 patients who underwent SLNB, axillary dissection (AD) was added to the procedure upon detection of metastasis in frozen section examinations. There was no difference between the SLNB and AD groups regarding overall survival (OS; P = .472) or disease-free survival (DFS) rates (P = .439). However, there were differences in the OS (P < .05) and DFS (P = .05) rates on the basis of the LABC histopathological subtypes.The study found that a relationship between molecular subtypes and LABC survival. However, the post-NAC axillary approach had no effect on OS or DFS. Therefore, multiple imaging and interventional methods are needed for the evaluation of NAC response. In addition, morbidity can be avoided after AD by the use of SLNB in cN0 patients.

Conventional Imaging and Sonoelastography Findings of Oncocytic Breast Carcinoma in a Man.

Oncocytic breast carcinoma (OBC) is one of the rare types of invasive breast carcinoma in according to the classification of The World Health Organization. Herein we represent imaging findings of a case of 69-year-old male patient with OBC.

Texture Analysis of Ultrasound Images to Differentiate Simple Fibroadenomas From Complex Fibroadenomas and Benign Phyllodes Tumors.

OBJECTIVES: American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) category 4A lesions can be distinguished from BI-RADS 3 lesions with main ultrasound (US) findings such as a well-defined contour, round/oval shape, and parallel orientation with a homogeneous echo pattern. Breast Imaging Reporting and Data System 4A solid masses might be diagnosed as simple fibroadenomas (SFAs), complex fibroadenomas (CFAs), or benign phyllodes tumors (BPTs). Complex fibroadenomas have an increased risk of invasive cancer development than SFAs, and BPTs have a risk of borderline-malignant phyllodes tumor transformation; both of them are surgically treated, whereas follow-up procedures are applied in SFAs. It is essential to differentiate SFAs from CFAs and BPTs. Grayscale features of these lesions include a prominent overlap. Texture analyses in breast lesions have contributions in benign-malignant lesion differentiation. In this study, we aimed to use texture analysis of US images to differentiate these benign lesions. METHODS: Grayscale US features of lesions (32 SFAs, 31 CFAs, and 32 BPTs) were classified according to the BI-RADS. Texture analysis of US images with LIFEx software (http://www.lifexsoft.org) was performed retrospectively. First- and second-order histogram parameters were evaluated. RESULTS: In grayscale US, the shape, orientation, and posterior acoustic characteristics had statistical significance (P < .05). In the statistical analysis, skewness, kurtosis, excess kurtosis, gray-level co-occurrence matrix (GLCM)-energy, GLCM-entropy log 2, and GLCM-entropy log 10 revealed significant differences among all 3 groups (P < .05). CONCLUSIONS: As grayscale US features show prominent intersections, and treatment options differ, correct diagnosis is essential in SFAs, CFAs, and BPTs. In this study, we concluded that texture analysis of US images can discriminate SFAs from CFAs and BPTs. Texture analyses of US images is a potential candidate diagnostic tool for these lesions, and accurate diagnoses will preclude patients from undergoing unnecessary biopsies.

Elastography findings of encapsulated solid papillary carcinoma of breast in a man.

Encapsulated solid papillary carcinoma (ESPC) is one of the malignant papillary lesions and classified it as ductal carcinoma in situ. Radiologic features of ESPC have been reported in the literature many times. However, to our best knowledge US elastography findings of ESPC have not been reported in the published literature yet. In this case report, we present US elastography findings of ESPC.