Prognostic value of response evaluation based on breast MRI after neoadjuvant treatment: a retrospective cohort study.

OBJECTIVE: To investigate the impact of response evaluation after neoadjuvant chemotherapy (NAC) in breast cancer patients, assessed by both magnetic resonance imaging (MRI) and pathology, on disease-free survival (DFS). METHODS: This single-center, retrospective cohort study included consecutive breast cancer patients who underwent NAC and preoperative breast MRI. Resolution of invasive carcinoma in the breast and axilla was defined as complete pathological response (pCR). Radiological complete response (rCR) was defined as the absence of abnormal enhancement in the tumor site. Kaplan-Meier estimator was used to estimate the disease-free survival on 60 months. Cox regression analysis was used to estimate hazard ratio (HR) values. RESULTS: In total, 317 patients were included with a mean age of 47.3 years and a mean tumor size of 39.8 mm. The most common immunophenotype was luminal (44.9%), followed by triple-negative (26.8%). Overall, 126 patients (39.7%) had an rCR, while 119 (37.5%) had pCR; the radiological and pathological responses agreed in 252 cases (79.5%). During follow-up, patients who had rCR and pCR had a better DFS curve compared to patients with non-rCR and non-pCR, while those who had rCR or pCR presented an intermediate curve (Log-rank p = 0.003). Multivariate analysis showed a higher risk of recurrence in patients with non-rCR and non-pCR (HR: 5,626; p = 0.020) and those who had a complete response on MRI or pathology only (HR: 4,369; p = 0.067), when compared to patients with rCR and pCR. CONCLUSIONS: The association of MRI and pathological responses after NAC might better stratify the risk of recurrence and prognosis in breast cancer patients. KEY POINTS: • Association of response evaluation after neoadjuvant chemotherapy by pathology and MRI allows better stratification of prognosis. • Complete response to neoadjuvant chemotherapy on pathology and MRI was related to better disease-free survival. • Complete response on MRI or pathology only had a greater risk of recurrence.

CT-guided biopsy of breast lesions: When should it be considered?

Mammography, ultrasound, and magnetic resonance imaging (MRI) are the most commonly used modalities for interventional radiology procedures involving the breast. Computed tomography (CT) is rarely used for breast imaging yet it is able to detect breast lesions and can often provide safe and effective access to breast lesions. The aim of this study was to demonstrate situations in which CT should be considered as an alternative guidance method for the biopsy of breast lesions that are not accessible with conventional imaging modalities.

MRI Features of Mucinous Cancer of the Breast: Correlation With Pathologic Findings and Other Imaging Methods.

OBJECTIVE: Mucinous breast carcinoma is an uncommon histologic type of invasive breast carcinoma that can be differentiated in pure and mixed forms, which have different prognosis and treatment. CONCLUSION: MRI features of both types of mucinous breast carcinomas are discussed, illustrated, and compared with pathologic findings and with other imaging methods, including mammography, ultrasound, and PET/CT.

Multidetector Computed Tomography with Dedicated Protocol for Breast Cancer Locoregional Staging: Feasibility Study.

BACKGROUND: The aim of this study was to demonstrate the feasibility of performing multidetector computed tomography (MDCT) with a dedicated protocol for locoregional staging in breast cancer patients. METHODS: This prospective single-center study included newly diagnosed breast cancer patients submitted to contrast-enhanced chest MDCT and breast magnetic resonance imaging (MRI). MDCT was performed in prone position and using subtraction techniques. Fleiss' Kappa coefficient (K) and intraclass correlation coefficient (ICC) were used to assess agreement between MRI, MDCT, and pathology, when available. RESULTS: Thirty-three patients were included (mean age: 47 years). Breast MRI and MDCT showed at least substantial agreement for evaluation of tumor extension (k = 0.674), presence of multifocality (k = 0.669), multicentricity (k = 0.857), nipple invasion (k = 1.000), skin invasion (k = 0.872), and suspicious level I axillary lymph nodes (k = 0.613). MDCT showed higher number of suspicious axillary lymph nodes than MRI, especially on levels II and III. Both methods had similar correlation with tumor size (MRI ICC: 0.807; p = 0.008 vs. MDCT ICC: 0.750; p = 0.020) and T staging (k = 0.699) on pathology. CONCLUSIONS: MDCT with dedicated breast protocol is feasible and showed substantial agreement with MRI features in stage II or III breast cancer patients. This method could potentially allow one-step locoregional and systemic staging, reducing costs and improving logistics for these patients.

Analysis of the indications for and results of breast cancer screening by magnetic resonance imaging at a cancer center in Brazil / Análise das indicações e resultados da ressonância magnética para rastreamento de câncer de mama em um centro oncológico brasileiro

Abstract Objective: To evaluate the indications for and results of magnetic resonance imaging (MRI) examinations for breast cancer screening at a cancer center in Brazil. Materials and Methods: This was a retrospective observational study, based on electronic medical records, of patients undergoing MRI for breast cancer screening at a cancer center in Brazil. Results: We included 597 patients between 19 and 82 years of age. The main indications for MRI screening were a personal history of breast cancer, in 354 patients (59.3%), a family history of breast cancer, in 102 (17.1%), and a confirmed genetic mutation, in 67 (11.2%). The MRI result was classified, in accordance with the categories defined in the Breast Imaging Reporting and Data System, as benign (category 1 or 2), in 425 patients (71.2%), probably benign (category 3), in 143 (24.0%), or suspicious (category 4 or 5), in 29 (4.9%). On MRI, 11 malignant tumors were identified, all of which were invasive carcinomas. Among those 11 carcinomas, six (54.5%) were categorized as minimal cancers (< 1 cm), and the axillary lymph nodes were negative in 10 (90.9%). The cancer detection rate was 18.4/1,000 examinations, and the positive predictive value for suspicious lesions submitted to biopsy was 37.9%. Conclusion: In our sample, the main indication for breast MRI screening was a personal history of breast cancer. The results indicate that MRI is a highly accurate method for the early detection of breast neoplasms in this population.

Resumo Objetivo: Avaliar as indicações e resultados de exames de ressonância magnética (RM) para rastreamento de câncer de mama em um centro oncológico no Brasil. Materiais e Métodos: Estudo observacional, realizado mediante análise retrospectiva de pacientes submetidos a RM das mamas para rastreamento de câncer de mama, por meio de revisão do prontuário eletrônico em um centro oncológico. Resultados: Foram incluídas 597 pacientes com idade variando de 19 a 82 anos. As principais indicações para rastreamento foram história pessoal de câncer de mama em 354 (59,3%) pacientes, história familiar em 102 (17,1%) e mutação genética confirmada em 67 (11,2%). O resultado da RM foi benigno (BI-RADS 1 ou 2) em 425 (71,2%) pacientes, provavelmente benigno (BI-RADS 3) em 143 (24,0%) e suspeito (BI-RADS 4 ou 5) em 29 (4,9%). Foram identificados 11 tumores malignos na RM, todos carcinomas invasivos, porcentagem de cânceres "mínimos" (< 1 cm) de 54,5% e porcentagem de axila negativa de 90,9%. A taxa de detecção de câncer na RM foi 18,4/1000 exames e o valor preditivo positivo para as lesões suspeitas submetidas a biópsia foi 37,9%. Conclusão: A principal indicação para RM de rastreamento na nossa população foi história pessoal de câncer de mama. Os resultados mostraram que a RM constitui um método com alta acurácia para detecção precoce de neoplasias da mama nessa população.

Intramammary lymph nodes: normal and abnormal multimodality imaging features.

Intramammary lymph nodes (IMLN) are one of the most common benign findings at screening mammography. However, abnormal IMLN features, such as diminished or absent hilum, thickened cortex, not circumscribed margins, increased size or interval change, warrants additional follow-up or pathologic analysis to exclude malignancy. Some benign inflammatory conditions may be associated with imaging-detected suspected abnormal IMLN, such as reactive hyperplasia and silicone-induced lymphadenopathy. In patients with known breast cancer, IMLN are a potential site of locoregional spread, which can change the prognosis and management. In some cases, initial breast carcinomas can also mimic IMLN. Breast radiologists must also be aware of the typical and atypical characteristics of IMLN to suggest further investigation when it is necessary.

Ultrasound-guided biopsy of breast calcifications using a new image processing technique: initial experience.

The aim of this paper is to describe the use of a new ultrasound imaging processing technique to guide biopsies of suspicious breast calcifications. We used this technique in 13 patients with suspicious breast calcifications that could not be submitted to stereotactic biopsy. Suspicious calcifications were identified by ultrasound, and the biopsy was successfully performed in all cases. Although mammography continues to be the method of choice for the detection and characterization of microcalcifications, this new technique can be an alternative means of guiding biopsy procedures in selected patients who are not candidates for stereotactic biopsy.

O objetivo deste trabalho é descrever o uso de uma nova técnica de processamento de imagens na ultrassonografia para guiar biópsia de microcalcificações mamárias suspeitas. Utilizamos esta técnica em 13 pacientes que não puderam ser submetidos a biópsia por estereotaxia. As calcificações suspeitas foram identificadas na ultrassonografia e a biópsia foi realizada com sucesso em todos os casos. Apesar de a mamografia ser o método de escolha para detecção e caracterização de microcalcificações, esta técnica pode ser uma alternativa para guiar biópsia em pacientes selecionados em que não foi possível realizar biópsia estereotáxica.

Can diffusion-weighted imaging add information in the evaluation of breast lesions considered suspicious on magnetic resonance imaging?

OBJECTIVE: To assess the role of diffusion-weighted imaging (DWI) in the evaluation of breast lesions classified as suspicious on magnetic resonance imaging (MRI), correlating the findings with the results of the histological analysis. MATERIALS AND METHODS: This was a retrospective, descriptive study based on a review of the medical records of 215 patients who were submitted to MRI with DWI before undergoing biopsy at a cancer center. Apparent diffusion coefficient (ADC) values were calculated for each lesion, and the result of the histological analysis was considered the gold standard. RESULTS: The mean age was 49 years. We identified 252 lesions, 161 (63.9%) of which were found to be malignant in the histological analysis. The mean ADC value was higher for the benign lesions than for the malignant lesions (1.50 × 10-3 mm2/s vs. 0.97 × 10-3 mm2/s), the difference being statistically significant (p < 0.001). The ADC cut-off point with the greatest sensitivity and specificity on the receiver operating characteristic curve was 1.03 × 10-3 mm2/s. When the DWI and conventional MRI findings were combined, the accuracy reached 95.9%, with a sensitivity of 95.7% and a specificity of 96.4%. CONCLUSION: The use of DWI could facilitate the characterization of breast lesions, especially those classified as BI-RADS 4, increasing the specificity and diagnostic accuracy of MRI.

OBJETIVO: Avaliar o papel da sequência em difusão na avaliação de lesões mamárias suspeitas na ressonância magnética (RM), correlacionando seus achados com os resultados histológicos. MATERIAIS E MÉTODOS: Foi realizado estudo retrospectivo, descritivo, baseado na análise de prontuários médicos de 215 pacientes que realizaram RM com sequência em difusão e que foram submetidas a biópsia em um centro de referência oncológico. Foi calculado o valor do coeficiente de difusão aparente (ADC ­ apparent diffusion coefficient) para cada lesão e o resultado histológico foi considerado como padrão ouro. RESULTADOS: A idade média das pacientes foi 49 anos. Foram identificadas 252 lesões, e destas, 161 (63,9%) eram lesões malignas na avaliação histológica. A média obtida do valor do ADC nas lesões benignas (1,50 × 10­3 mm2/s) foi superior à média das lesões malignas (0,97 × 10­3 mm2/s), com significância estatística (p < 0,001). O ponto de corte com maior sensibilidade e especificidade pela curva receiver operating characteristic foi 1,03 × 10­3 mm2/s. Com a combinação da difusão com os achados da RM, a acurácia chegou a 95,9%, com sensibilidade de 95,7% e especificidade de 96,4%. CONCLUSÃO: O uso da sequência em difusão pode auxiliar na caracterização das lesões mamárias, principalmente daquelas classificadas como BI-RADS 4, aumentando a especificidade e a acurácia diagnóstica da RM.

Elastographic Evaluation of Indeterminate Breast Masses on Ultrasound.

Objective To evaluate the diagnostic accuracy of elastography for breast cancer identification in patients with indeterminate lesions on ultrasound. Methods This prospective, descriptive study included patients with indeterminate breast lesions in the ultrasound and with indication for percutaneous or surgical biopsy. The elastography was evaluated by qualitative analysis and by two methods for the semi quantitative analysis. Results We evaluated 125 female patients with 159 lesions, with a mean age of 47 years, and a range of 20-85 years. Ultrasound has shown to be a method with good sensitivity (98.1%), but with a lower specificity (40.6%). On the elastography qualitative analysis, the specificity and accuracy were of 80.2% and 81.8% respectively. The mean size of the lesions showed no difference in classification by elastography. For the semiquantitative elastography, the mean values ​​of the malignant lesions were statistically higher when compared with the subcutaneous tissue or the adjacent fibroglandular tissue. The analysis of the receiver operating characteristic (ROC) curves for these two semiquantitative methods showed that both are considered satisfactory, with an area under the curve above 0.75 and statistical significance (p < 0.0001). The best results were obtained when using the findings of combined conventional ultrasound and qualitative elastography, with 100% sensitivity and 63.2% specificity. Conclusions Elastography can be a useful complementary method, increasing the specificity and diagnostic accuracy of conventional ultrasound for the diagnosis of breast cancer in patients with indeterminate breast lesions.

Role of magnetic resonance imaging in the planning of breast cancer treatment strategies: comparison with conventional imaging techniques.

OBJECTIVE: To assess the role of magnetic resonance imaging (MRI) in the planning of breast cancer treatment strategies. MATERIALS AND METHODS: The study included 160 women diagnosed with breast cancer, who underwent breast MRI for preoperative staging. Using Pearson's correlation coefficient (r), we compared the size of the primary tumor, as determined by MRI, by conventional imaging (mammography and ultrasound), and in the pathological examination (gold standard). The identification of lesions not identified in previous examinations was also evaluated, as was its influence on treatment planning. RESULTS: The mean age of the patients was 52.2 years (range, 30-81 years), and the most common histological type was invasive ductal carcinoma (in 60.6% of the patients). In terms of the tumor size determined, MRI correlated better with the pathological examination than did mammography (r = 0.872 vs. 0.710) or ultrasound (r = 0.836 vs. 0.704). MRI identified additional lesions in 53 patients (33.1%), including malignant lesions in 20 (12.5%), which led to change in the therapeutic planning in 23 patients (14.4%). CONCLUSION: Breast MRI proved to be more accurate than conventional imaging in determining the dimensions of the main tumor and was able to identify lesions not identified by other methods evaluated, which altered the therapeutic planning in a significant proportion of cases.

OBJETIVO: Avaliar o papel da ressonância magnética (RM) no planejamento terapêutico de pacientes com câncer de mama. MATERIAIS E MÉTODOS: Foram avaliadas 160 mulheres com diagnóstico de câncer de mama submetidas a RM para estadiamento préoperatório. O tamanho do tumor principal avaliado pela RM e pelos exames convencionais (mamografia e ultrassonografia) foi comparado com o exame anatomopatológico (padrão ouro), utilizando o coeficiente de correlação de Pearson (r). Foi avaliada, ainda, a presença de lesões adicionais não identificadas nos exames prévios e sua influência no planejamento terapêutico. RESULTADOS: A idade média das pacientes foi 52,2 anos (variação: 30­81 anos) e o tipo histológico mais comum foi o carcinoma ductal invasivo (60,6%). A medida do tumor na RM teve melhor correlação com o tamanho no exame anatomopatológico, quando comparado com a mamografia (r: 0,872 × 0,710) e com a ultrassonografia (r: 0,836 × 0,704). A RM identificou lesões adicionais em 53 pacientes (33,1%), sendo 20 malignas (12,5%), e modificou o planejamento terapêutico em 23 pacientes (14,4%). CONCLUSÃO: A RM das mamas demonstrou ser mais acurada que os exames convencionais na avaliação das dimensões do tumor principal e foi capaz de identificar lesões adicionais não identificadas pelos outros métodos, que alteraram o planejamento terapêutico em um percentual importante dos casos.

Breast metastases from extramammary malignancies: multimodality imaging aspects.

Breast metastases from extramammary cancers are rare and usually related to poor prognosis. The extramammary tumours most frequently exhibiting breast metastases are melanoma, lymphomas, ovarian cancer, lung and neuroendocrine tumours, and sarcomas. Owing to the lack of reliable and specific clinical or radiological signs for the diagnosis of breast metastases, a combination of techniques is needed to differentiate these lesions from primary breast carcinoma or even benign breast lesions. Multiple imaging methods may be used to evaluate these patients, including mammography, ultrasound, MRI, CT and positron emission tomography CT. Clinical and imaging manifestations are varied, depend on the form of dissemination of the disease and may mimic primary benign and malignant breast lesions. Haematologically disseminated metastases often develop as a circumscribed mass, whereas lymphatic dissemination often presents as diffuse breast oedema and skin thickening. Unlike primary carcinomas, breast metastases generally do not have spiculated margins, skin or nipple retraction. Microlobulated or indistinct margins may be present in some cases. Although calcifications are not frequently present in metastatic lesions, they occur more commonly in patients with ovarian cancer. Although rare, secondary malignant neoplasms should be considered in the differential diagnosis of breast lesions, in the appropriate clinical setting. Knowledge of the most common imaging features can help to provide the correct diagnosis and adequate therapeutic planning.

Metaplastic squamous cell carcinoma of the breast: A case report and literature review.

Metaplastic tumors are rare and represent a heterogeneous group of neoplasms showing dominant areas of non-glandular differentiation. Etiology and pathogenesis of this type of lesion in the breast is uncertain. The most common sources of metastatic squamous cell carcinoma of the breast are lung, esophagus, cervix, and urinary bladder. Squamous cell carcinomas may present clinically with inflammation and average size greater than breast adenocarcinoma. As for imaging studies, mammography shows no typical findings and ultrasound can show a complicated cyst or an inflammatory process, among the differential diagnoses. Therefore, knowing this pathological entity, its clinical course and imaging findings is important to safely treat such a rare and aggressive disease. We herein report a case of metaplastic carcinoma, squamous subtype, diagnosed by core needle biopsy.

Imaging features of idiopathic granulomatous mastitis - Case report.

Idiopathic granulomatous mastitis is a rare disorder of unknown etiology. This disease occurs mostly in young women and often after the lactation period. Women usually present with a fixed, painful mass, sparing the retroareolar region, associated with skin thickening and possible ulceration that mimics carcinoma. Nipple discharge can be present and bilateral involvement may occur in up to 25% of cases. In this case report, we present a typical case of histologically confirmed idiopathic granulomatous mastitis, highlighting the imaging findings, including magnetic resonance imaging (MRI), which may favor this diagnosis and enable better clinical management of these patients.

Breast cancer features in women under the age of 40 years.

OBJECTIVE:: To describe the clinical features, imaging findings and pathological aspects of breast cancer diagnosed in women under the age of 40 years. METHOD:: A retrospective, descriptive study was performed through analysis of medical records between November 2008 and August 2012. One hundred and twenty (120) patients were included, of whom 112 underwent mammography, 113 underwent ultrasonography, and 105 underwent magnetic resonance imaging (MRI). The histopathological data was obtained in most cases from post-surgical analysis, which was available for 113 patients. RESULTS:: The mean age at diagnosis of primary breast cancer was 34 years. Only 11 patients (9.0%) had a family history of breast or ovarian cancer in first-degree relative. Ninety-two (92) patients sought medical attention after showing breast symptoms, and the presence of a palpable nodule was the main complaint. One hundred and twenty-two (122) primary tumors were diagnosed, of which 112 were invasive (95%). The most common histological type was invasive ductal carcinoma (73.8%). Luminal B was the predominant molecular subtype (42.6%). Ultrasonography was positive in 94.5% of the cases and the most common finding were nodules (94.8%). At mammography, the malignancy was observed in 92.8% and the presence of suggestive calcifications was the dominant feature. The MRI was positive in 98% of patients, and mass lesions were the most common. CONCLUSION:: Most cases of breast cancer diagnosed in patients under the age of 40 years, in our population, had symptoms at diagnosis and tumor with more aggressive biological behavior. Despite the ultrasound has been the most widely used method, we found improved characterization of breast lesions when also used mammography and MRI.

Hyperechoic breast lesions: anatomopathological correlation and differential sonographic diagnosis.

Hyperechoic lesions are not a frequent finding at breasts ultrasonography, and most of times are associated with benign pathologies that do not require further evaluation. However, some neoplasms such as invasive breast carcinomas and metastases may present with hyperechogenicity. Thus, the knowledge about differential diagnoses and identification of signs of lesion aggressiveness are of great relevance to avoid unnecessary procedures or underdiagnosis, and to support the correct clinical/surgical approach. On the basis of such concepts, the present essay describes and illustrates the main features of hyperechoic lesions at breast ultrasonography in different cases, with anatomopathological correlation.

As lesões hiperecogênicas constituem um achado com baixa prevalência nos exames ultrassonográficos das mamas, em sua maior parte associado a doenças benignas que não necessitam de avaliação adicional. Porém, algumas neoplasias, como o carcinoma invasivo da mama e as metástases, podem apresentar-se desta forma. Assim, o conhecimento dos diagnósticos diferenciais e a identificação dos sinais de agressividade das lesões são de grande relevância, a fim de evitar procedimentos desnecessários ou o subdiagnóstico, e apoiar a conduta clínica/cirúrgica correta. Com base nestes conceitos, este artigo descreve e ilustra os principais aspectos das lesões hiperecogênicas presentes no exame ultrassonográfico das mamas, por meio de diferentes casos, e sua correlação anatomopatológica.

Lobular Carcinoma in Situ with Atypical Mass Presentation: a Case Report.

Lobular carcinoma in situ (LCIS) is associated with an increased risk of breast cancer and accounts for 1 to 2% of all breast cancers. LCIS diagnosis currently remains one of the major identifiable risk factors for subsequent breast cancer development. Imaging methods are becoming increasingly sensitive, and the consequent detection of small lesions and subtle abnormalities increases the chance of detection of in situ and invasive carcinomas, leading to a reduction in mortality. This report describes a case of a palpable complaint with abnormal imaging findings, including a solid LCIS mass.