Extramedullary relapse of acute myeloid leukemia in the breast: A radiological case report.

This report presents a unique case of a 42-year-old female with a history of acute myeloid leukemia (AML) who exhibited an extramedullary relapse in the breast. Given the rarity of such presentations, this case underscores the importance of considering AML in the differential diagnosis of breast lesions, especially in patients with a pertinent medical history. Additionally, this case highlights the radiological and pathological challenges in distinguishing AML from other breast malignancies. The importance of timely diagnosis and the clinical implications of such a presentation are also discussed.

Pediatric breast lymphatic malformation with recurrent presentation in an adolescent female.

This case report summarizes a rare case of left chest wall/breast lymphatic malformation or cystic lymphangioma in a female child of 18 months with multiple late recurrences in adolescence. By maternal history, the mass was excised initially, but the patient presented at age 15 and 17 years for recurrences and associated symptoms. Comments focus on a complex clinical history and treatment management of patient symptoms and concerns. Breast sparing treatments were employed with sclerotherapy and the T lymphocyte inhibitor, Sirolimus (Rapamune).

Disappearing grouped breast calcifications: An ominous sign.

Spontaneous disappearing breast calcifications is a rarely-reported phenomenon and the relatively small number of studies that have been done mostly associated the resolution of benign-appearing breast calcifications with benign processes. We present a case of a postmenopausal woman who had spontaneously resolving grouped, coarse heterogenous calcifications in the setting a new soft tissue mass which was pathologically proven to be invasive ductal carcinoma. A handful of studies have shown the resolution of indeterminant calcifications to be associated with malignancy, and interestingly, all of these cases also demonstrated a new parenchymal abnormality which is akin to the present case. Overall, the majority of benign-appearing spontaneous resolving microcalcifications likely are related to benign processes; however, radiologists should be aware of the association of disappearing grouped, indeterminant calcifications with the resulting development of malignancy, especially in the presence of a nearby, newly-forming soft tissue mass.

Pilomatrixoma, a Rare Mimicker of Male Breast Cancer.

Pilomatrixoma or calcifying epithelioma of Malherbe is a benign skin tumor arising from the hair follicle; breast occurrence is considered a rarity. Clinically presenting as a palpable abnormality and with both benign and malignant mammographic and sonographic features, it can be easily misdiagnosed as a breast neoplasm. We report a very rare case of pilomatrixoma of the male breast in a 36-year-old male presenting with a firm, superficial nodule in the upper outer quadrant. Though the sonographic trifecta of imaging features (shape- margins-orientation/oval, circumscribed mass, parallel to the skin) is consistent with a benign lesion, a histologic diagnosis was warranted based on its most suspicious feature of internal pleomorphic calcifications. Pathologic diagnosis revealed the uncommon benign entity of pilomatrixoma in the male breast. Our patient was recommended for surgical excision based on current literature recommendations for management in most reports of pilomatrixoma. One alternative recommendation presented in a single report of pilomatrixoma in the breast supported follow-up imaging based on benign imaging characteristics.

Effectiveness of a Mobile Mammography Program.

OBJECTIVE: Mobile mammography units have increasingly been used to address patient health care disparities; however, there are limited data comparing mobile units to stationary sites. This study aims to evaluate the characteristics of women who underwent mammography screening in a mobile unit versus those who underwent mammography screening at a cancer center. MATERIALS AND METHODS: In this retrospective study, we analyzed all screening mammography examinations performed in a mobile unit in 2014 (n = 1433 examinations). For comparison, we randomized and reviewed an equivalent number of screening mammography examinations performed at our cancer center in 2014 (n = 1434 examinations). BI-RADS assessment, adherence to follow-up, biopsies performed, cancer detection rate, and sociodemographic variables were recorded. An independent-samples t test was conducted to identify potential differences in age between cancer center patients and mobile unit patients. Chi-square analyses were used to test for associations between location and factors such as health insurance, race, marital status, geographic area, adherence to screening guidelines, recall rate, adherence to follow-up, and cancer detection rates. RESULTS: Patients visiting our cancer center (mean = 57.74 years; SD = 10.55) were significantly older than those visiting the mobile unit (mean = 52.58 years; SD = 8.19; p < 0.001). There was a significant association between location and health insurance status (χ2 = 610.92; p < 0.001) with more uninsured patients undergoing screening in the mobile van (cancer center = 3.70%, mobile unit = 38.73%). There was a significant association between screening location and patient race (χ2 = 118.75, p < 0.001), with more white patients being screened at the cancer center (cancer center = 47.28%, mobile unit = 33.30%), more black patients being screened in the mobile van (cancer center = 49.30%, mobile unit = 54.15%), and more Hispanic patients being screened in the mobile van (cancer center = 1.05%, mobile unit = 6.77%). There was a significant association between location and patient marital status (χ2 = 135.61, p < 0.001), with more married patients screened at the cancer center (cancer center = 49.16%, mobile unit = 38.31%), more single patients screened in the mobile van (cancer center = 25.17%, mobile unit = 34.47%), and more widowed patients being screened at the cancer center (cancer center = 8.09%, mobile unit = 4.47%). There was a significant association between location and geographic area (χ2 = 33.33, p < 0.001), with both locations reaching more urban than rural patients (cancer center = 79.99%, mobile unit = 70.62%). There was a significant association between location and adherence to screening guidelines (χ2 = 179.60, p < 0.001), with patients screened at the cancer center being more compliant (cancer center = 56.90%, mobile unit = 34.47%). Finally, there was a significant association between location and recall rate (χ2 = 4.06, p < 0.001). The cancer center had a lower recall rate (13.32%) than the mobile van (15.98%). Of those patients with BI-RADS 0, there was a significant association between location and adherence to follow-up (χ2 = 22.75, p < 0.001) with patients using the mobile unit less likely to return for additional imaging (cancer center = 2.65%, mobile unit = 17.03%). CONCLUSION: Significant differences were found among patients visiting the cancer center versus the mobile mammography van. The cancer center's population is older and more adherent to guidelines, whereas the mobile mammography population exhibited greater racial and marital diversity, higher recall rate, and lack of adherence to follow-up recommendations. By identifying these characteristics, we can develop programs and materials that meet these populations' needs and behaviors, ultimately increasing mammography screening and follow-up rates among underserved populations.

Changes in Breast Density Reporting Patterns of Radiologists After Publication of the 5th Edition BI-RADS Guidelines: A Single Institution Experience.

OBJECTIVE: The objective of our study was to determine the impact of 5th edition BI-RADS breast density assessment guidelines on density reporting patterns in our clinical practice. MATERIALS AND METHODS: PenRad reporting system was used to collect mammographic breast density data reported by five radiologists: 16,907 density assignments using 5th edition BI-RADS guidelines were compared with 19,066 density assessments using 4th edition guidelines. Changes in the density assessment pattern were noted between the 4th and 5th edition guidelines, and agreement in density distribution was compared using the intraclass correlation coefficient. A chi-square analysis was conducted for each reader to examine the change in the proportion of dense versus nondense assignments and on each category type to examine specific changes in proportion of density assignments from the 4th to the 5th edition. All reported p values are two-sided, and statistical significance was considered at the p < 0.001 threshold. RESULTS: Using the 5th edition, there was an overall 5.0% decrease in fatty assessments (p < 0.001), 2.8% increase in scattered densities (p < 0.001), 2.6% increase in heterogeneously dense (p < 0.001), and 0.4% decrease in extremely dense assessments (p = 0.15). Comparing the dense with nondense categories, there was a 2.3% overall increase in the dense assessments (p < 0.001) using 5th edition guidelines, mainly in the heterogeneously dense category. Two radiologists showed increased dense assessments (p < 0.001) using the 5th edition, and three radiologists showed no change (p = 0.39, 0.67, and 0.76). CONCLUSION: There was an overall increase in the dense assessments using the 5th edition, but individual radiologists in our clinical practice showed a variable adaptation to new guidelines.

Effects of Neoadjuvant Chemotherapy on Benign Breast Lesions Compared to Cancers: Should an Additional Lesion on Magnetic Resonance Imaging Responding Similar to Cancer after Neoadjuvant Chemotherapy be Viewed with Suspicion?

PURPOSE: Determining the effects of neoadjuvant chemotherapy (NAC) on benign breast lesions and to evaluate their response in comparison to breast cancers. METHODS: A retrospective analysis performed on breast cancer patients between 2008 and 2014 to identify patients who had a pre- and post-NAC magnetic resonance imaging (MRI) and biopsy-proven benign lesions. Pre- and post-NAC size and intensity of enhancement of benign lesions and cancers were measured. Breast glandularity and background enhancement were graded. A 2 × 2 repeated measures ANOVAs and Sidak post hoc tests were conducted for multiple comparisons. Paired t-tests were conducted to examine changes over time, and two-tailed P values were reported. RESULTS: The effects of NAC in 38 cancers were compared to the effects of NAC in 47 benign lesions in these patients. From pre- to post-NAC, the mean size (cm) of malignant lesions on MRI decreased from 4.09 (±standard deviation [SD] 2.51) to 1.54 (±SD 2.32), (P < 0.001); the mean size (cm) of benign lesions decreased from 0.83 (±SD 0.54 cm) to 0.28 (±SD 0.51), (P < 0.001). Both benign and malignant lesions decreased in size after NAC, the size reduction in malignant lesions was significantly greater than benign lesions. From pre- to post-NAC, the mean lesion enhancement of the malignant lesions (scale 1-4) decreased from 3.43 (±SD 0.80) to 1.02 (±SD 1.34); the mean lesion enhancement of benign lesions decreased from 2.96 (±SD 1.04) to 0.98 (±SD 1.51). For both benign and malignant lesions, there was a significant overall reduction in enhancement after NAC from moderate at pre-NAC to minimal at post-NAC, P < 0.001. There was no overall difference in the enhancement of cancers (mean = 2.22, SD = 0.79) versus benign lesions (mean = 1.97, SD = 1.08), (P = 0.23). There was no significant change in glandularity from pretherapy (mean = 3.11, SD = 0.84) to posttherapy (mean = 3.13, SD = 0.82), P < 0.001. CONCLUSION: Similar to cancers, benign breast lesions also show a significant decrease in size and enhancement after NAC; however, the decrease in size is less compared to cancers.

Effects of Changes in BI-RADS Density Assessment Guidelines (Fourth Versus Fifth Edition) on Breast Density Assessment: Intra- and Interreader Agreements and Density Distribution.

OBJECTIVE: The objective of our study was to determine intra- and interreader agreements for density assessment using the fifth edition of the BI-RADS guidelines and to compare with those for density assessment using the fourth edition of the BI-RADS guidelines. MATERIALS AND METHODS: Five radiologists assessed breast density four times in 104 mammographic examinations: twice using the fourth edition of the BI-RADS guidelines and twice using the fifth edition. The intra- and interreader agreements for density assessment based on each guideline were determined and compared. The density distribution pattern under each of the four BI-RADS density categories using each guideline was also noted and compared. RESULTS: The intrareader agreement for density assessment using the fifth-edition criteria was lower than that using the fourth-edition criteria (p = 0.0179). The overall intrareader agreement (weighted kappa) using the old criteria was 0.84 (95% CI, 0.80-0.87), and the individual intrareader agreement values in five readers ranged from 0.78 (95% CI, 0.69-0.88) to 0.92 (95% CI, 0.87-0.97). The overall intrareader agreement using the new BI-RADS criteria was 0.77 (95% CI, 0.73-0.81), and the individual intrareader agreement values in five readers ranged from 0.74 (95% CI, 0.64-0.84) to 0.99 (95% CI, 0.98-1.00). The interreader agreement values obtained using the fifth-edition criteria were also lower than those obtained using the fourth-edition criteria (p = 0.006). The overall interreader agreement using the old BI-RADS criteria was 0.65 (95% CI, 0.61-0.69), whereas the overall interreader agreement using the new BI-RADS criteria was 0.57 (95% CI, 0.53-0.61). Overall a higher number of dense assessments were given when the fifth-edition guidelines were used (p < 0.0001). CONCLUSION: Compared with the intra- and interreader agreements obtained using the fourth edition of the BI-RADS guidelines, the intra- and interreader agreements were lower using the fifth-edition guidelines. An increased number of dense assessments were given when the fifth-edition guidelines were used.

Assessing the Relationship of Mammographic Breast Density and Proliferative Breast Disease.

Increased breast density and a history of benign breast biopsy are both considered risk factors for developing breast cancer. Understanding the specifics of these risk factors and their relationship to each other can lead to a better understanding of a patient's propensity for breast cancer development and improved surveillance strategies. We included 245 women who underwent a benign breast biopsy without atypia between October 2011 and June 2013. Biopsies were performed for suspicious calcifications as well as masses and architectural distortion. Lesions biopsied were divided into two groups: calcified and noncalcified lesions. The patient's breast density was assessed on most recent mammogram and was classified using the American College of Radiology BI-RADS density categories. Based on histologic diagnosis, each case was classified as proliferative or nonproliferative breast disease. The median age of the cohort (n = 245) was 55 years (range, 40-84 years). There were 162 (66%) postmenopausal women in the study. A core biopsy was performed for calcifications in 33.5% cases and for noncalcified lesions in 58% cases. In patients with dense breast tissue, an underlying proliferative histology was found significantly more frequently with calcifications (66.7%) as opposed to noncalcified lesions (35.9%) (RR = 2.3 (1.3-4.0); χ(2) = 8.7; p = 0.003). In nondense breast patients, there was no significant difference (RR = 1.1 (0.7-1.8); χ(2) = 0.1; p = 0.738). In the postmenopausal group, women with dense breasts had proliferative histology significantly more frequently than women with nondense breasts (55.3% versus 38.3%; p < 0.05), regardless of the underlying lesion type. Postmenopausal women with dense breasts who underwent a breast biopsy with benign histology had a significantly higher likelihood of having proliferative breast disease, regardless of underlying lesion type. Women with dense breasts also showed proliferative histology significantly more often for calcifications as opposed to noncalcified lesions.

Comparative accuracy of preoperative tumor size assessment on mammography, sonography, and MRI: Is the accuracy affected by breast density or cancer subtype?

PURPOSE: To compare the accuracy of preoperative breast tumor size measurements obtained on three imaging modalities (mammography [MM], sonography [US], and MRI) with those obtained on final pathologic examination for different breast densities and various tumor types. METHODS: Records from patients who underwent breast cancer lumpectomy between 2008 and 2012 and in whom tumor was seen on all three imaging modalities were retrospectively reviewed for maximum tumor size measurements. Patients with positive tumor margins and those who had undergone neoadjuvant chemotherapy were excluded. Tumor size measurements obtained on the three imaging modalities were compared for accuracy with those obtained during the final pathologic examination. Differences were analyzed for the whole group and for subgroups according to breast density and tumor type. RESULTS: In total, 57 patients were included, in whom wire-localization lumpectomy was performed without neoadjuvant chemotherapy; negative surgical margins for tumor were obtained, and tumor was preoperatively visualized on all three imaging modalities. The mean (± SEM) tumor size measured on MRI was significantly greater than that measured on pathology (p < 0.001), whereas the sizes measured on US and MM were not statistically significantly different from that measured on pathology (p = 0.62 and p = 0.57). Tumor size measured on MRI was greater than that measured on both US and MM (p = 0.003 and p < 0.001). Compared with the measurements obtained on pathology, that obtained on US showed moderate agreement (Lin concordance correlation coefficient [CCC], 0.71; 95% confidence interval [CI], 0.56-0.82); poorer agreement was found for the sizes obtained on MM (CCC, 0.58; 95% CI, 0.38-0.72) and MRI (CCC, 0.50; 95% CI, 0.31-0.65). No difference in comparative accuracy of size measurement was noted between dense and nondense breast tissue. MRI overestimated tumor size in ductal cancers (p < 0.001) and slightly underestimated it in lobular cancers. CONCLUSIONS: Preoperative MRI significantly overestimated tumor size. Measurements obtained on US and MM were more accurate irrespective of breast density, with US measurements being slightly more accurate than MM measurements.

Mammographic detection of breast arterial calcification as an independent predictor of coronary atherosclerotic disease in a single ethnic cohort of African American women.

OBJECTIVE: Accumulating data on predominantly Caucasian women suggests an association between breast arterial calcification (BAC) and coronary artery disease (CAD). We sought to comprehensively examine the correlation between mammographic BAC and CAD endpoints detected by cardiac computed tomography (CCT) in African American (AA) women. METHODS: Consecutive AA women who underwent digital screening mammography and CCT were identified. In blinded fashion, mammographic and CCT studies were reviewed. Patient-related pertinent covariates were assessed. RESULTS: Two-hundred-four AA women (median age, 52.5 years) were included. BAC was present in 42 women (20.6%). BAC was significantly associated with coronary artery calcium score >100 (odds ratio [OR], 7.66; 95% confidence interval [CI], 2.75-21.29; P < 0.001), atherosclerotic luminal narrowing (OR, 9.99; CI, 3.65-27.32; P < 0.001), and stenosis ≥50% (OR, 5.48; CI, 1.97-15.23; P = 0.001) by CCT. CONCLUSION: In AA women, BAC is associated with increased probability of coronary calcification, atherosclerosis, and CAD on CCT.

Acquired arteriovenous fistula of the breast following ultrasound guided biopsy of invasive ductal carcinoma.

Image guided large-core breast biopsies are commonly performed procedures with relatively rare complications. The majority of these complications are minor, though at times more significant vascular injuries can occur with these biopsies as demonstrated by this case. Patient developed a pulsatile vascular breast mass after an ultrasound guided breast biopsy of invasive ductal carcinoma. Sonographic evaluation of this new breast mass demonstrated this mass to represent an arteriovenous fistula (AVF). Though multiple therapies are available for an iatrogenic fistula within the breast, the AVF was surgically excised in this case as it was immediately adjacent to a known cancer.

Role of breast ultrasound and mammography in evaluating patients presenting with focal breast pain in the absence of a palpable lump.

To determine if ultrasound and/or mammography is helpful in detecting breast cancers in patients presenting with focal breast pain. Patients who presented between February 2008 and April 2011 with focal breast pain without a lump were included in the study. The mammographic and US findings were retrospectively reviewed. BIRADS 0, 4, and 5 were considered positive on mammogram while BIRADS 4 and 5 were considered positive on US. The efficacy of mammogram-alone, ultrasound-alone, and in combination to detect breast cancer was evaluated. The performance of mammography for detecting any mass lesions that were present on subsequent US was also evaluated. A total of 257 patients were evaluated with US and 206 (80.1%) of these also had mammograms prior to the US. Cancer incidence was 1.2% (n = 3). The sensitivity, specificity, PPV, and NPV of mammogram-alone and US-alone for detection of breast cancer in these patients were 100%, 87.6%, 10.7%, 100% and 100%, 92.5%, 13.6%, and 100%, respectively, while for combined mammogram and US was 100%, 83.7%, 8.3%, and 100%. The sensitivity, specificity, PPV, and NPV of mammogram for identifying an underlying suspicious mass lesion that was subsequently detected by US was 58%, 91%, 39%, and 95%. The NPV of a BIRADS 1 mammogram for any underlying mass lesion was 75%. Addition of an ultrasound to a mammogram did not detect additional cancers; likely due to low cancer incidence in these patients. However, US detected underlying mass lesions in 25% cases with a BIRADS 1 mammogram result.

Assessing the role of ultrasound in predicting the biological behavior of breast cancer.

OBJECTIVE: The purpose of this article is to correlate various ultrasound features of breast cancer with tumor grade, and with estrogen, progesterone, and ERRB2 (formerly HER2) receptor status as well as to assess the predictive value of these features. MATERIALS AND METHODS: The features of breast cancers found by using ultrasound between January 2010 and June 2011 were reviewed for tumor size, margins, and posterior acoustic features. The tumor margins were classified into spiculated, angular, indistinct, lobulated or microlobulated, and circumscribed. The posterior acoustic features were classified into shadowing, enhancement, mixed pattern, and no change. The individual features were correlated with the estrogen receptor (ER)-progesterone receptor (PR) and ERRB2 receptor status and tumor grade. RESULTS: Among 160 patients with breast cancer, 102 (63.8%) were ER-positive/PR-positive, 32 (20.0%) were ER-positive/PR-negative, and 26 (16.3%) were ER-negative/PR-negative (22 were triple-negative). Tumors with posterior shadowing have greater than nine times the odds of having ER-positive findings (95% CI, 2.09-40.81; p = 0.011) and greater than 13 times the odds of having a lower-grade tumor (I or II vs III; 95% CI, 4.90-36.54; p < 0.001) than those without posterior shadowing. Tumors with posterior enhancement have greater than eight times the odds of having at least one negative receptor (95% CI, 3.97-18.11; p < 0.001) and 24 times the odds of having a high-grade tumor (95% CI, 9.91-58.14; p < 0.001) than those without posterior enhancement. CONCLUSION: The presence of posterior shadowing is strongly associated with an ER-positive and low-grade tumor, whereas the presence of posterior enhancement is strongly associated with a high-grade tumor and with moderate risk of being receptor negative.

Correlation of sonographic features of invasive ductal mammary carcinoma with age, tumor grade, and hormone-receptor status.

PURPOSE: To determine whether presenting sonographic features of invasive ductal carcinomas (IDC) are associated with patient age, tumor histologic grade, and hormonal receptor status. METHODS: Sonographic features of 101 consecutive cases of IDC seen at ultrasound were retrospectively assessed based on the BI-RADS criteria of posterior acoustic appearance, tumor margins, and echogenicity. Associations between sonographic features and tumor characteristics were statistically evaluated with attention to patient age. RESULTS: IDC with shadowing compared with unchanged posterior acoustic appearance were significantly more likely to be of low histologic grade (Odds Ratio [OR] = 5.00; p < 0.05) and estrogen receptor (ER) -positive (OR = 10.00; p < 0.05). Conversely, posterior enhancement was associated with ER-negative status (OR = 4.45; p < 0.01), particularly among patients younger than 60 years of age (OR = 5.36, p < 0.05). Circumscribed tumors were more often high grade, particularly among older women (p < 0.01), and hormone receptor--negative regardless of age group. Among older women, tumors with mixed echogenicity tended to be high grade and progesterone receptor--negative (p values < 0.05). Noncircumscribed borders were observed for all tumors with posterior shadowing, and 97% of such tumors were also ER positive. CONCLUSIONS: Sonographic features were significantly associated with tumor grade and hormone receptor status, with some differences based on patient age. Specifically, the presence of posterior shadowing was associated with lower histologic grade and ER-positive status, especially in older patients. In contrast, we found that posterior acoustic enhancement was more commonly associated with ER-negative status, especially in younger patients.

Primary sarcoid of the breast with incidental malignancy.

Breast sarcoidosis is rare and usually presents in patients with known sarcoid involving other organ systems. In the breast, sarcoidosis may mimic malignancy which must be excluded by core biopsy. We report a very unusual case of primary breast sarcoidosis with incidentally discovered breast carcinoma. The roles of mammography, ultrasound, and MRI in the diagnosis as well as other potential differential diagnosis are discussed.

Review of metaplastic carcinoma of the breast: imaging findings and pathologic features.

Metaplastic carcinoma (MPC), an uncommon but often aggressive breast cancer, can be challenging to differentiate from other types of breast cancer and even benign lesions based on the imaging appearance. It has a variable pathology classification system. These types of tumors are generally rapidly growing palpable masses. MPCs on imaging can present with imaging features similar to invasive ductal carcinoma and probably even benign lesions. The purpose of this article is to review MPC of the breast including the pathology subtypes, imaging features, and imaging pathology correlations. By understanding the clinical picture, pathology, and overlap in imaging characteristics of MPC with invasive ductal carcinoma and probably benign lesions can assist in diagnosing these difficult malignancies.

Asymptomatic Incidental Ductal Carcinoma in situ in a Male Breast Presenting with Contralateral Gynecomastia.

Ductal carcinoma in situ (DCIS) in males is rare and usually presents with symptoms on the affected side, such as, palpable mass or bloody nipple discharge. Even as DCIS has been reported in conjunction with gynecomastia in the same breast, we report an unusual case of a 62-year-old Caucasian male, with no family history of breast cancer, who presented with symptomatic side gynecomastia, and was incidentally found to have DCIS in a completely asymptomatic left breast. To the best of our knowledge, this case is the first report in literature of asymptomatic, incidentally discovered DCIS in a male patient.