Mouse-INtraDuctal (MIND): an in vivo model for studying the underlying mechanisms of DCIS malignancy.

Due to widespread adoption of screening mammography, there has been a significant increase in new diagnoses of ductal carcinoma in situ (DCIS). However, DCIS prognosis remains unclear. To address this gap, we developed an in vivo model, Mouse-INtraDuctal (MIND), in which patient-derived DCIS epithelial cells are injected intraductally and allowed to progress naturally in mice. Similar to human DCIS, the cancer cells formed in situ lesions inside the mouse mammary ducts and mimicked all histologic subtypes including micropapillary, papillary, cribriform, solid, and comedo. Among 37 patient samples injected into 202 xenografts, at median duration of 9 months, 20 samples (54%) injected into 95 xenografts showed in vivo invasive progression, while 17 (46%) samples injected into 107 xenografts remained non-invasive. Among the 20 samples that showed invasive progression, nine samples injected into 54 xenografts exhibited a mixed pattern in which some xenografts showed invasive progression while others remained non-invasive. Among the clinically relevant biomarkers, only elevated progesterone receptor expression in patient DCIS and the extent of in vivo growth in xenografts predicted an invasive outcome. The Tempus XT assay was used on 16 patient DCIS formalin-fixed, paraffin-embedded sections including eight DCISs that showed invasive progression, five DCISs that remained non-invasive, and three DCISs that showed a mixed pattern in the xenografts. Analysis of the frequency of cancer-related pathogenic mutations among the groups showed no significant differences (KW: p > 0.05). There were also no differences in the frequency of high, moderate, or low severity mutations (KW; p > 0.05). These results suggest that genetic changes in the DCIS are not the primary driver for the development of invasive disease. © 2021 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Supplemental Screening With Automated Breast Ultrasound in Women With Dense Breasts: Comparing Notification Methods and Screening Behaviors.

OBJECTIVE: Supplemental screening with ultrasound has been shown to detect additional breast malignancies in women with dense breast tissue and normal mammogram findings. The frequency of supplemental screening with automated breast ultrasound and the effect and type of breast tissue density notification on automated screening breast ultrasound utilization rates are unknown. MATERIALS AND METHODS: We examined normal mammogram results letters for patients with heterogeneously or extremely dense breast tissue between July 1, 2013, and June 30, 2014, by type of results letter, notification method, and sociodemographic characteristics. Logistic regression was used to examine the association between type of results letter and subsequent automated screening breast ultrasound. RESULTS: Among 3012 women with dense breast tissue and normal mammogram findings, 15% returned for supplemental automated screening breast ultrasound within 18 months of results letter notification. Compared with a similarly sized control group of women who did not undergo automated ultrasound, a significantly greater proportion of patients (86.9%) returned for breast ultrasound if they received a results letter indicating breast density in combination with a courtesy phone call (p < 0.001). Patients who received results letters with breast density notification including a statement that they may benefit from additional screening with automated breast ultrasound examination were 9.91 times (95% CI, 6.08-16.16) more likely to return for the examination than patients who did not receive breast density notification or mention of supplemental screening. CONCLUSION: Patient breast density notification and radiologists' recommendations for supplemental screening with breast ultrasound increase patient utilization of automated screening breast ultrasound examinations.

Mammography Positioning Standards in the Digital Era: Is the Status Quo Acceptable?

OBJECTIVE: The objective of our study was to evaluate positioning of full-field digital mammography (FFDM) and digital breast tomosynthesis (DBT) compared with film-screen (FS) mammography positioning standards. MATERIALS AND METHODS: A retrospective study was conducted of consecutive patients who underwent screening FFDM in 2010-2012 and DBT in 2012-2013 at an academic institution. Examinations were performed by five experienced technologists who underwent updated standardized positioning training. Positioning criteria were assessed by consensus reads among three breast radiologists and compared with FS mammography data from a 1993 study by Bassett and colleagues. RESULTS: One hundred seventy patients (n = 340 examinations) were analyzed, showing significant differences between FFDM and DBT examinations (p < 0.05) for medial or inferior skin folds (FFDM vs DBT: craniocaudal [CC] view, 16% [n = 56] vs 23% [n = 77]; mediolateral oblique [MLO] view, 35% [n = 118] vs 45% [n = 154]), inclusion of lateral glandular tissue on CC view (FFDM vs DBT, 73% [n = 247] vs 81% [n = 274]), and concave pectoralis muscle shape (FFDM vs DBT, 36% [n = 121] vs 28% [n = 95]). In comparison with Bassett et al. data, all positioning criteria for both FFDM and DBT examinations were significantly different (p < 0.05). The largest differences were found in visualization of the pectoralis muscle on CC views and the inframammary fold on MLO views, inclusion of posterior or lateral glandular tissue, and inclusion of skin folds, with DBT and FFDM more frequently exhibiting all criteria than originally reported Bassett et al. CONCLUSION: DBT and FFDM mammograms more frequently include posterior or lateral tissue, the inframammary fold on MLO views, the pectoralis muscle on CC views, and skin folds than FS mammograms. Inclusion of more breast tissue with newer technologies suggests traditional positioning standards, in conjunction with updated standardized positioning training, are still applicable at the expense of including more skin folds.

Expression profiling of in vivo ductal carcinoma in situ progression models identified B cell lymphoma-9 as a molecular driver of breast cancer invasion.

INTRODUCTION: There are an estimated 60,000 new cases of ductal carcinoma in situ (DCIS) each year. A lack of understanding in DCIS pathobiology has led to overtreatment of more than half of patients. We profiled the temporal molecular changes during DCIS transition to invasive ductal carcinoma (IDC) using in vivo DCIS progression models. These studies identified B cell lymphoma-9 (BCL9) as a potential molecular driver of early invasion. BCL9 is a newly found co-activator of Wnt-stimulated ß-catenin-mediated transcription. BCL9 has been shown to promote progression of multiple myeloma and colon carcinoma. However BCL9 role in breast cancer had not been previously recognized. METHODS: Microarray and RNA sequencing were utilized to characterize the sequential changes in mRNA expression during DCIS invasive transition. BCL9-shRNA knockdown was performed to assess the role of BCL9 in in vivo invasion, epithelial-mesenchymal transition (EMT) and canonical Wnt-signaling. Immunofluorescence of 28 patient samples was used to assess a correlation between the expression of BCL9 and biomarkers of high risk DCIS. The cancer genome atlas data were analyzed to assess the status of BCL9 gene alterations in breast cancers. RESULTS: Analysis of BCL9, by RNA and protein showed BCL9 up-regulation to be associated with DCIS transition to IDC. Analysis of patient DCIS revealed a significant correlation between high nuclear BCL9 and pathologic characteristics associated with DCIS recurrence: Estrogen receptor (ER) and progesterone receptor (PR) negative, high nuclear grade, and high human epidermal growth factor receptor2 (HER2). In vivo silencing of BCL9 resulted in the inhibition of DCIS invasion and reversal of EMT. Analysis of the TCGA data showed BCL9 to be altered in 26 % of breast cancers. This is a significant alteration when compared to HER2 (ERBB2) gene (19 %) and estrogen receptor (ESR1) gene (8 %). A significantly higher proportion of basal like invasive breast cancers compared to luminal breast cancers showed BCL9 amplification. CONCLUSION: BCL9 is a molecular driver of DCIS invasive progression and may predispose to the development of basal like invasive breast cancers. As such, BCL9 has the potential to serve as a biomarker of high risk DCIS and as a therapeutic target for prevention of IDC.

Incidental Breast Cancer on Chest CT: Is the Radiology Report Enough?

OBJECTIVE: To determine the frequency of incidental breast findings reported on chest CT for which breast imaging follow-up is recommended, the follow-up adherence rate, and the breast malignancy rate. The relationship between strength of recommendation verbiage and follow-up was also explored. METHODS: A retrospective review was conducted of chest CT reports from July 1, 2018, to June 30, 2019, to identify those with recommendation for breast imaging follow-up. Patients with recently diagnosed or prior history of breast malignancy were excluded. Medical records were reviewed to evaluate patient adherence to follow-up, subsequent BI-RADS assessment, and diagnosis (if tissue sampling performed). Adherence was defined as diagnostic breast imaging performed within 6 months of CT recommendation. Chi-square and Mann-Whitney U tests were used to determine statistical significance of categorical and continuous variables, respectively. RESULTS: A follow-up recommendation for breast imaging was included in chest CT reports of 210 patients; 23% (48/210) returned for follow-up breast imaging. All patients assessed as BI-RADS 4 or 5 underwent image-guided biopsy. Incidental breast cancer was diagnosed in 15% (7/48) of patients who underwent follow-up breast imaging as a result of a CT report recommendation and 78% (7/9) of patients undergoing biopsy. There was no significant difference in follow-up adherence when comparing report verbiage strength. CONCLUSION: It is imperative that incidental breast findings detected on chest CT undergo follow-up breast imaging to establish accurate and timely diagnosis of breast malignancy. Outreach to referring providers and patients may have greater impact on the diagnosis of previously unsuspected breast cancer.

Radiologic and Pathologic Features Associated With Upgrade of Atypical Ductal Hyperplasia at Surgical Excision.

RATIONALE AND OBJECTIVES: To evaluate radiologic and pathologic features associated with upgrade of atypical ductal hyperplasia (ADH) to ductal carcinoma in situ or invasive breast cancer at surgical excision, in order to identify patients who may consider alternatives to excision. MATERIALS AND METHODS: This retrospective analysis examined patients who underwent surgical excision of biopsy-proven ADH at our institution. Imaging and pathology from biopsy were reviewed to determine radiologic (lesion size, radiologic abnormality, biopsy type, needle gauge, number of cores, percent of lesion removed) and pathologic features (histologic calcifications, presence of necrosis, micropapillary features, extent of ADH) associated with ADH upgrade. RESULTS: One hundred twenty four cases of percutaneous biopsy-proven ADH with subsequent excision were included. The overall upgrade rate was 17.7% (n = 22), with 17 cases to ductal carcinoma in situ and five to invasive cancer. Radiologic features associated with a lower upgrade rate were smaller lesion size (p = 0.032) and larger percent of lesion removed at biopsy (p = 0.047). Larger needle gauge at biopsy (p = 0.070), absence of necrosis (p = 0.051) and focal ADH (<3 foci, p = 0.12) were nearly associated with a lower rate of upgrade and were included for the purpose of multi parameter analyses. CONCLUSION: For women with ADH identified on percutaneous biopsy, the risk of upgrade may in part be determined by lesion size, percent of lesion removed at biopsy, presence of necrosis, and extent of ADH. Using a combination of these radiographic and pathologic features to stratify patients with biopsy-proven ADH may help identify women who could be considered for alternative treatment options.

Automated Breast Ultrasound Interpretation Times: A Reader Performance Study.

RATIONALE AND OBJECTIVES: This study aimed to determine the average time for breast radiologists of varied experience to interpret automated breast ultrasound (ABUS) examinations. MATERIALS AND METHODS: A reader performance study was conducted on female patients, with ACR BI-RADS 4 breast density classifications of C or D, who received both an ABUS screening examination and a digital mammogram from 2013 to 2014 at an academic institution. Three faculty breast radiologists with varied levels of ABUS experience (advanced, intermediate, novice) read all ABUS examinations, with interpretation times and final impressions (categorized as "normal" or "abnormal") recorded for each examination. RESULTS: Ninety-nine patients were included, with all readers demonstrating an average ABUS interpretation time of less than 3 minutes. Compared to the other two readers, the intermediate reader had a significantly longer mean interpretation time at 2.6 minutes (95% confidence interval 2.4-2.8; P < .001). In addition to having the shortest mean interpretation time, the novice reader also demonstrated reduced times in subsequent interpretations, with a significant decrease in interpretation times of 3.1 seconds (95% confidence interval 0.4-5.8) for every 10 ABUS examinations interpreted (P < .05). CONCLUSIONS: Overall, mean ABUS interpretation time by radiologists of all experience levels was short, at less than 3 minutes per examination, which should not deter radiologists from incorporating ABUS examinations into a busy clinical environment.

Longitudinal epiphyseal bracket.

A longitudinal epiphyseal bracket (LEB) is a defect of the tubular bones and has been primarily described in the hands and feet, especially the proximal phalanges, metacarpals, and metatarsals. The LEB results from a defective C-shaped secondary ossification center that brackets the diaphysis and metaphysis, causing restricted longitudinal growth in these bones with resultant shortening and angular deformities. Deformities associated with metatarsal epiphyseal bracket include a short, broad metatarsal and medial deviation of the metatarsophalangeal joint (hallux varus deformity). Excision of the cartilaginous LEB has been proposed to prevent future soft tissue contractures and osseous deformities. The LEB has been associated with numerous syndromes including Rubinstein-Taybi syndrome, Cenani-Lenz syndactyly, isolated oligosyndactyly, and Nievergelt syndrome. We describe a two-month-old patient in whom plain film and MR imaging demonstrated bilateral bracketed first metatarsals with associated hallux varus deformities. Bilateral bracket excision was performed with excellent clinical results.

NEMO, a Transcriptional Target of Estrogen and Progesterone, Is Linked to Tumor Suppressor PML in Breast Cancer.

The beneficial versus detrimental roles of estrogen plus progesterone (E+P) in breast cancer remains controversial. Here we report a beneficial mechanism of E+P treatment in breast cancer cells driven by transcriptional upregulation of the NFκB modulator NEMO, which in turn promotes expression of the tumor suppressor protein promyelocytic leukemia (PML). E+P treatment of patient-derived epithelial cells derived from ductal carcinoma in situ (DCIS) increased secretion of the proinflammatory cytokine IL6. Mechanistic investigations indicated that IL6 upregulation occurred as a result of transcriptional upregulation of NEMO, the gene that harbored estrogen receptor (ER) binding sites within its promoter. Accordingly, E+P treatment of breast cancer cells increased ER binding to the NEMO promoter, thereby increasing NEMO expression, NFκB activation, and IL6 secretion. In two mouse xenograft models of DCIS, we found that RNAi-mediated silencing of NEMO increased tumor invasion and progression. This seemingly paradoxical result was linked to NEMO-mediated regulation of NFκB and IL6 secretion, increased phosphorylation of STAT3 on Ser727, and increased expression of PML, a STAT3 transcriptional target. In identifying NEMO as a pivotal transcriptional target of E+P signaling in breast cancer cells, our work offers a mechanistic explanation for the paradoxical antitumorigenic roles of E+P in breast cancer by showing how it upregulates the tumor suppressor protein PML. Cancer Res; 77(14); 3802-13. ©2017 AACR.

Bilateral diffuse tumorous pseudoangiomatous stromal hyperplasia: a case of bilateral mastectomy in a 29-year-old woman.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign breast lesion commonly encountered as an incidental microscopic finding. However, it can also manifest as a mass-forming lesion (tumorous PASH) capable of recurrence after surgical excision. Most of the previously reported cases of tumorous PASH present as a single dominant mass. Here we reported a rare case of diffuse tumorous PASH involving bilateral breasts clinically mimicking malignancy. A 29-year-old African-American female presented with a one-year history of bilateral breast enlargement and asymmetry. Physical examination revealed multiple palpable nodules in bilateral breasts. Imaging studies demonstrated innumerable homogeneously enhancing masses throughout both breasts, greater on the left, with multiple cysts and edema. Biopsy of the breast nodules demonstrated histopathological changes consistent with PASH. Due to the extent of the lesions and progressive clinical symptoms, decision was made to perform bilateral mastectomy. Macroscopic examination of the bilateral mastectomy specimens revealed markedly enlarged breasts with marked edema and numerous well-defined firm nodules. Microscopic evaluation of the nodules confirmed the diagnosis of PASH. No evidence of malignancy was identified. Recognition of this rare form of PASH is essential for the proper clinical management.