Breast lumps in pregnant women.

Breast lumps detected during pregnancy are generally benign and reflect fibroadenoma, lactating adenoma, cysts, infarction of the breast or galactocele. Although rare, the possibility of breast cancer must also be considered to avoid any delays in diagnosis. After patient questioning and clinical examination, the first imaging modality to use is ultrasound. No further assessment is called for if lesions are categorized as BI-RADS 2 and no suspicious clinical signs are observed. Depending on the clinical setting, lesions classified BI-RADS 3 require monitoring and mammographic assessment (which can be helpful in diagnosing cancer and incurs no risk to the embryo or fetus). If the clinical signs are unclear and/or the lesion(s) are categorized as ≥ BI-RADS 4a, then mammography and often biopsy should be performed. Strict BI-RADS scoring (American College of Radiology) should be applied, bearing in mind that benign lesions can appear suspicious during pregnancy, and some cancers can exhibit what seem to be reassuring characteristics.

A single-institution study of 117 pregnancy-associated breast cancers (PABC): Presentation, imaging, clinicopathological data and outcome.

BACKGROUND: This retrospective single-institution study was designed to describe the main clinical, radiological and histological features, as well as the outcome of pregnancy-associated breast cancer (PABC), with a special emphasis on imaging and diagnostic difficulties. MATERIAL AND METHODS: We reviewed all breast cancers diagnosed during pregnancy or during the 12 months following delivery at our institution, between 1993 and 2009. Out of a total of 16,555 new cases of breast cancer observed during this period, 117 PABC (0.7%) were diagnosed. RESULTS: Mean age at diagnosis was 33.7 years. Most cancers (81.2%) were diagnosed after delivery. Intermediate or high family risk was frequent (27.5%). The most common mode of presentation was a palpable mass (89.7%). Mean time to diagnosis was 5.8 months. Sensitivity for mammography was 80.9% and for ultrasound 77%. Most prognostic factors were unfavourable: frequent lymph node involvement (51.8%), high-grade tumours, hormone receptor negativity (45.9%) and HER2 positivity (38.7%). Treatments generally included surgery (61.7% mastectomies), radiotherapy (96%) and chemotherapy (79.6%). Overall 5-year survival was 81.8%. CONCLUSION: PABC is an uncommon but aggressive form of breast cancer and must be considered in the presence of any breast abnormality during pregnancy or the months following delivery. Mammography and ultrasound should both be performed at the slightest clinical suspicion. Radiologists must be aware that masses may lack typical malignant ultrasound characteristics. Biopsies should be largely performed.

Masses in mammography: what are the underlying anatomopathological lesions?

The semiological description of masses in mammography is based on the BI-RADS system provided by the American College of Radiology. The contour is the most discriminating morphological criterion between benign and malignant masses. Most circumscribed masses are benign. Nevertheless, due to specific histological characteristics, certain malignant lesions or lesions with a risk of malignancy may appear in the mammography in this falsely reassuring form. An indistinct contour in the mammography is suspicious and requires a tissue sample. The positive predictive value of malignancy varies according to the morphology of the contour. It is lower for microlobulated contours, increases for masked, then indistinct contours and reaches 96% for spiculated contours. However, in rare cases, certain benign lesions may appear in the form of spiculated masses. In these specific cases, a correlation between the histological results with the imaging data is essential in order to avoid failing to recognise an underlying malignant lesion that the biopsy may have underestimated.

[The lesions of flat epithelial atypia diagnosed on breast biopsy]. / Les lésions de métaplasies cylindriques atypiques diagnostiquées sur biopsie mammaire.

Among pre-invasive breast diseases, the lesion of flat epithelial atypia has a level of risk that remains unclear. The clinical significance of these lesions and how to behave during their diagnostic biopsy (monitoring vs. surgery) are still uncertain, because few studies (including monitoring) are available and because of the polymorphic spectrum of lesions and their many denominations across the studies in the literature. This article aims to update our knowledge and provide elements for the management of these lesions diagnosed on breast biopsy.

18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) imaging in the staging and prognosis of inflammatory breast cancer.

BACKGROUND: : To prospectively assess fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) staging and prognosis value in patients with suspected inflammatory breast cancer (IBC). METHODS: : Sixty-two women (mean age 50.7 +/- 11.4 years) presenting with unilateral inflammatory breast tumors (59 invasive carcinomas; 3 mastitis) underwent a PET/CT scan before biopsy. RESULTS: : PET/CT scan was positive for the primary malignant tumor in 100% and false positive in 2 of 3 benign mastitis. In 59 IBC patients, FDG nodal foci were detected in axillary (90%; n = 53) and extra-axillary areas (56%; n = 33) ipsilateral to the cancer. Compared with clinical examination, the axillary lymph node status by PET/CT was upstaged and downstaged in 35 and 5 patients, respectively. In 7 of 9 N0 patients, the axillary lymph node positivity on PET/CT was correct, as revealed by pathological postsurgery assessment (not available in the 2 remaining patients). The nodal foci were compared with preoperative fine needle aspiration and/or pathological postchemotherapy findings available in 44 patients and corresponded to 38 true positive, 4 false-negative, and 2 false-positive cases. In 18 of 59 IBC patients (31%), distant lesions were found. On the basis of a univariate analysis of the first enrolled patients (n = 42), among 28 patients who showed intense tumoral uptake (standard uptake value(max)>5), the 11 patients with distant lesions had a worse prognosis than the 17 patients without distant lesions (P = .04). CONCLUSIONS: : FDG-PET/CT imaging provides additional invaluable information regarding nodal status or distant metastases in IBC patients and should be considered in the initial staging. It seems also that some prognostic information can be derived from FDG uptake characteristics. Cancer 2009. (c) 2009 American Cancer Society.

[Mammographic evaluation of dense breasts: techniques and limits]. / Exploration des seins denses en mammographie: techniques et limites.

Breast density is a radiological concept based on the proportion of radiopaque glandular tissue relative to radiolucent fatty tissue. Mammographic evaluation of dense breasts is more difficult, related to technical difficulties, with decreased rates for detection and characterization of breast lesions, resulting in reduced sensitivity with increased number of interval cancers at routine follow-up when compared to radiolucent breasts. We will review the definition of dense breasts and their frequency, especially their relationship with the age of patients. We will discuss the current technical problems and the impact of breast density on the efficacy of conventional mammography. We will discuss the value of digital mammography, the role of computer assisted diagnosis (CAD) systems and tomosynthesis in the evaluation of dense breasts.

Leiomyosarcoma of the great saphenous vein.

Peripheral vascular leiomyosarcomas are rare. A case of leiomyosarcoma of the great saphenous vein diagnosed pre-surgically by MRI and fine-needle aspiration is presented. Characteristics of the tumour and imaging features are discussed.

Response to neoadjuvant chemotherapy in lobular and ductal breast carcinomas: a retrospective study on 860 patients from one institution.

BACKGROUND: We compared the impact of neoadjuvant chemotherapy on pathologic response and outcome in operable invasive lobular breast carcinoma (ILC) and invasive ductal breast carcinoma (IDC). PATIENTS AND METHODS: We extracted from our database all patients with pure invasive lobular (n=118, 14%) or pure invasive ductal carcinomas (n=742, 86%). Their treatment included neoadjuvant chemotherapy, adapted surgery, radiotherapy and adjuvant hormonal treatment. RESULTS: Compared with IDC, ILC presented with larger tumors (T3: 38.1% versus 21.4%, P=0.0007), more N0 nodes status (55.9% versus 43.3%, P=0.01), less inflammatory tumors (5.9% versus 11.8%, P=0.01), more hormone receptor positivity (65.5% versus 38.8%), lower histological grade (P<0.0001). Final surgery was a mastectomy in 70% of patients with ILC (34% were reoperated after initial partial mastectomy) and in 52% of IDC after 8% of reoperation (P=0.006). A pathological complete response (pCR) was achieved in 1% of ILC and 9% of IDC (P=0.002). The outcome at 60 months was significantly better for ILC, but histologic type was not an independent factor for survival in multivariate analysis. CONCLUSIONS: ILC appeared less responsive to chemotherapy but presented a better outcome than IDC. While new information on biological features of ILC is needed, we consider that neoadjuvant endocrine therapy in hormone receptor-positive ILC may be a more adapted approach than neoadjuvant chemotherapy.

[Local recurrence of ductal carcinoma in situ after conservative breast surgery: mammographic appearance]. / Caractéristiques mammographiques des récidives locales des carcinomes canalaires in-situ après traitement conservateur.

OBJECTIVE: To review the mammographic features of local recurrences of DCIS treated conservatively. MATERIALS AND METHODS: Thirty-five patients treated conservatively for a DCIS have presented subsequently a local recurrence. Three patients had double metachronous and one a bi-focal recurrence. The mammographic appearances of these 39 recurrences were analyzed retrospectively and compared to initial mammograms. RESULTS: Median delay to recurrence was of 47 months (interval 8-240 months). Two-thirds of the recurrent lesions were similar to the initial presentation, of which 90% occurred at the lumpectomy site. In 18/ 35 cases (51%), an intra-ductal component was found at histological diagnosis and among these 11/18 (61%) were strictly intra-ductal. CONCLUSION: Local recurrences of DCIS are proteiform. However, the majority of which, occurring at the lumpectomy site were similar to the primary tumor, raising again the hypothesis of incomplete eradication even when the margins were considered free.

Normal and pathological breast, the histological basis.

Breast tissue is heterogeneous, associating connective and glandular structures, which grow and change cyclically under hormonal regulation. Hormones are also thought to be the main determinant of the major benign and malignant pathologies encountered in the breast. Benign lesions are more frequent and fibrocystic changes are by far the most common among them. They usually associate different entities, (adenosis, fibrosis, cysts and hyperplasia) but vary in intensity and extension. Thus, their clinical and radiographic presentation is extremely different from one patient to another. Adenofibroma is the most frequent tumour. It also undergoes modifications according to hormonal conditions. About 90% of malignant tumours are primary carcinoma. The incidence of intra-ductal carcinoma has risen dramatically since the development of screening because of its ability to induce calcification. Two mechanisms could be involved in the formation of calcification: one active (tumour cell secretion of vesicles), the other passive (necrotic cell fragments are released). Invasive carcinoma comprises numerous histological types. Stromal reactions essentially determines their shape: a fibrous reaction commonly found in ductal carcinoma creates a stellate lesion while other stroma, inflammatory (medullary carcinoma), vascular (papillary carcinoma) or mucinous determine nodular lesions whose borders push the surrounding tissue. The histological features which give rise to the radiographic pattern will be emphasised.

Stellate images: anatomic and radiologic correlations.

The stellate images are the most well-known and most typical finding in the diagnosis of breast cancer. Its positive predictive value is very high. However, in some cases, the stellate images can correspond to benign lesions. Stellate images require high quality mammograms, precise analysis, and as always in senology, confirmation by clinical examination, ultrasound if necessary, and in the case of palpable lesions, cytology. In this work, we will study malignant and benign stellate images mammographic-pathologic correlation as well as the importance of stellate images in the detection of non-palpable lesions. The typical stellate finding is correlated with the phenomena of fibrosis and elastosis and it is impossible to distinguish benign spicules from malignant spicules on mammography. We will present guidelines in the face of stellate image. Stellate images are for the most part suggestive of malignant lesions, and their discovery should lead to suspicion of cancer until the contrary is proven.

[40 years of progress in breast imaging]. / Quarante ans de progrès en imagerie mammaire.

In the sixties, mammary diagnosis is just clinical, then the low contrast mammography, not very efficient, appears in the seventies. During the eighties, the ultrasound is set up while modern mammography with high contrast allows the non palpable breast lesions diagnosis. In the nineties years the mammography come before the clinical examination within the context of the breast cancer screening program. Some histological correlation are more specific about the ductal carcinoma in situ grading with microcalcifications, while new techniques (MRI, CT) are evaluated. At present the stereotactic large core breast biopsies benefit from the digital prone table, allow a histological diagnosis and avoid surgical excision of some indeterminate images. After the pernicious effects of imaging, we assess the progress according to the cancerous disease results. We also consider the problem of over-diagnosis and over-treatment of ductal carcinoma in situ.

[Treatment of breast cancer after 70 years of age. Report of 1143 cases]. / Le traitement du cancer du sein après 70 ans. A propos de 1143 cas.

STUDY AIM: Breast cancer is the most frequent type of cancer in women, increasing in frequency with the elderly. In Europe, a third of new breast cancers occur in women over 70 years of age. The aim of this retrospective study was to analyse the tumoural lesions and therapeutic results in a female population over 70, treated in the same medical centre over a 15-year period. PATIENTS AND METHODS: From 1978 to 1992, 1,143 female patients aged 70 or over were treated for a unilateral breast cancer without metastases and followed-up during a mean 6-year period. The initial treatment was surgical in 1,012 patients: radical mastectomy in 95% of the cases with axillary node dissection in 97.6%. Adjuvant radiotherapy was performed in 289 patients and adjuvant treatment with Tamoxifen in 411 patients. The results were compared with those obtained in 2,947 patients aged 50 to 69, treated during the same period in the same medical centre. RESULTS: The 5-year survival rate in women 70 and over was 80% vs 85.5% in women aged 50 to 69 (P < 0.000001). The same rate of loco-regional recurrences and metastases occurred in both populations. In the patients who initially underwent surgery, after multivariate analysis according to the Cox model, the prognosis factors (similar to those observed in the group of younger women) were: the number of involved nodes (P = 0.000001), the clinical size of the tumour (P = 0.00001), the histological grade (P = 0.01), and the estrogen receptors (P = 0.02). CONCLUSIONS: In this series, the treatment was focused on surgery complemented with adjuvant radiotherapy according to node invasion and adjuvant hormonotherapy according mostly to hormonal receptors. However, the complete treatment could not be applied to all cases: only 50% of patients with node involvement were irradiated. The 5-year survival rate lower than that of younger patients may be attributed to incomplete adjuvant treatment. Specific controlled trials taking into account quality of life had to be undertaken in elderly patients in order to adjust the treatment in relation with the patients' age and physiological condition.

Contrast-enhanced CT: value for diagnosing local breast cancer recurrence after conservative treatment.

PURPOSE: To assess contrast material-enhanced computed tomography (CT) of breast for diagnosing local recurrence after conservative therapy. MATERIALS AND METHODS: In 111 patients, 118 lesions were evaluated with unenhanced and enhanced CT. Criterion for cancer recurrence was detection of a lesion with an enhancement of 45 HU or more. RESULTS: One group comprised 52 lesions with pathologic diagnoses, obtained within 1 month of CT, of malignancy in 43 and benignancy in nine. Scans were positive in 40 of 43 recurrences and negative in six of nine benign lesions. Seventeen recurrent lesions were nonpalpable, and contrast-enhanced CT results were true-positive in 15 of these. A second group comprised 66 lesions with a mean follow-up of the treated breast of 28 months after CT. In 56 lesions, the scans were negative, with no recurrence in 55; local recurrence was proved with a 14-month delayed surgical biopsy in one. In 10 lesions, scans were positive, with a delayed diagnosis of recurrence 5 and 6 months after CT in two and no evidence of recurrence in eight (false-positive results). The sensitivity of breast CT for both groups was 91% (42 of 46 lesions) with a specificity of 85% (61 of 72 lesions). CONCLUSION: Contrast-enhanced CT is sensitive in the diagnosis of local recurrence of breast cancer, even in nonpalpable lesions, and may be a useful tool in patients with equivocal clinical and/or mammographic findings during follow-up after conservative therapy.

Laryngeal schwannomas.

As laryngeal schwannomas are a threat to breathing, they must be removed. CT and MR provide an accurate pre-operative work-up of these lesions. The clear delineation of the tumoral attachment to the larynx proved to be very useful in the difficult management of our second patient. Our two laryngeal schwannomas exhibited a similar appearance which differed from those of the few other laryngeal nerve sheath tumors reported in the literature The low attenuating outer part correlated with Antoni B areas. The denser enhancing inner part correlated with Antoni A areas containing large vessels. This unusual tumoral appearance, which has been observed in some other peripheral schwannomas, must bring this diagnostic possibility to mind. However, this clearly contrasting distribution of the two components of schwannomas is not the most commonly observed in other locations. More reports are needed to establish whether this special appearance is characteristic of laryngeal location.

Thoracic CT-scanning follow-up of residual mediastinal masses after treatment of Hodgkin's disease.

Sequential thoracic CT-scanning was performed for 14 patients presenting with residual mediastinal masses on chest X-ray after treatment of stage I and II Hodgkin's disease (HD). Eleven patients initially presented with bulky mediastinal involvement. No mediastinal biopsy was performed. No local recurrence was detected at a 48 month median follow-up. Early evaluation by CT-scanning showed cystic degeneration in three cases. Sequential CT-scans on longer follow-up demonstrated continuous regression of residual masses in six cases and no or limited volume reduction in six other cases. In two patients, part of the residual mass remained stable and the other part showed reduction in size. In addition, late calcifications developed in four cases. The results of sequential CT-scanning suggest that residual mediastinal masses do not generally represent active disease. Hence additional, potentially toxic, therapy can be avoided.