Breast cancer screening in BRCA1/2 pathogenic sequence variant carriers during pregnancy and lactation.

OBJECTIVES: Women harboring germline BRCA1/BRCA2 pathogenic sequence variants (PSVs) are at an increased risk for breast cancer. There are no established guidelines for screening during pregnancy and lactation in BRCA carriers. The aim of this study was to evaluate the utility of whole-breast ultrasound (US) screening in pregnant and lactating BRCA PSV carriers. METHODS: Data were retrospectively collected from medical records of BRCA PSV carriers between 2014 and 2020, with follow-up until 2021. Associations between imaging intervals, number of examinations performed and pregnancy-associated breast cancers (PABCs) were examined. PABCs and cancers diagnosed at follow-up were evaluated and characteristics were compared between the two groups. RESULTS: Overall 212 BRCA PSV carriers were included. Mean age was 33.6 years (SD 3.93, range 25-43 years). During 274 screening periods at pregnancy and lactation, eight (2.9 %) PABCs were diagnosed. An additional eight cancers were diagnosed at follow-up. Three out of eight (37.5 %) PABCs were diagnosed by US, whereas clinical breast examination (n = 3), mammography (n = 1) and MRI (n = 1) accounted for the other PACB diagnoses. One PABC was missed by US. The interval from negative imaging to cancer diagnosis was significantly shorter for PABCs compared with cancers diagnosed at follow-up (3.96 ± 2.14 vs. 11.2 ± 4.46 months, P = 0.002). CONCLUSION: In conclusion, pregnant BRCA PSV carriers should not delay screening despite challenges like altered breast tissue and hesitancy towards mammography. If no alternatives exist, whole-breast ultrasound can be used. For lactating and postpartum women, a regular screening routine alternating between mammography and MRI is recommended.

Incidental Axillary Lymphadenopathy Found on Radiation Planning Computed Tomography.

PURPOSE: The aim of this study was to evaluate the rate of axillary node-positive disease in patients with early breast cancer who had a suspicious axillary lymph node on radiation planning computed tomography (CT). METHODS AND MATERIALS: A retrospective review was conducted of the medical records of all patients with breast cancer who were referred for axillary ultrasound from the radiation unit to the breast imaging unit at the Meirav Breast Center, Sheba Medical Center, from 2012 to 2022. Ethics approval was obtained. Only the records of patients who were referred due to an abnormal axillary lymph node seen on radiation planning CT were further evaluated. RESULTS: During the study period, a total of 21 patients were referred to the breast imaging unit for evaluation of suspicious nodes seen on radiation planning CT. Of these, 3 cases were excluded. A total of 15 out of the 18 (83%) patients included had an abnormal lymph node in the ultrasound, and an ultrasound-guided biopsy was recommended (BI-RADS 4). Of these, 3 (out of 15, 20%) had a positive biopsy for tumor cells from the axillary lymph node. Two were cases after primary systemic therapy without complete pathologic response. Thickening of the lymph node cortex and complete loss of the central fatty hilum were associated with pathologic lymph node. CONCLUSION: Sonar had limited ability to differentiate reactive nodes from involved nodes. The presence of lymph nodes with loss of cortical-hilum differentiation on ultrasound together with clinical features are parameters that can help guide the need of further biopsy. Histopathology evaluation is important to make the diagnosis of residual axillary disease. Future studies and guidelines are needed to improve the diagnostic abilities and reduce the number of patients who are undergoing biopsy for noninvolved nodes.

Breast cancer diagnosed after age 70 years in Israeli BRCA1/BRCA2 pathogenic sequence variant carriers: a single institution experience.

PURPOSE: A semi-annual surveillance scheme from age 25 to 30 years is offered to BRCA1/BRCA2 pathogenic sequence variants (PSVs) carriers for early detection of breast cancer (BC). There is a paucity of data on the yield of adhering to this scheme beyond 70 years of age. METHODS: Female BRCA1/BRCA2 PSV carriers followed at the Meirav high-risk clinic, Sheba Medical center, Israel were eligible. Type and frequencies if use of Imaging modalities, breast biopsies and histological outcomes for participants after age 70 years were retrieved and analyzed. RESULTS: Overall, the study encompassed 88 consenting participants (46 BRCA1 carriers) mean age ± SD 73.7 ± 3.3 years (range 70-90 years), followed for an average of 3.8 years (range 1-11 years). Ten carriers (11.3%) were diagnosed with BC after age 70 years (mean age at diagnosis 72 ± 2 years) and an additional case was diagnosed with breast lymphoma. The imaging modality that has led to most diagnoses was MRI (8/11 cases). Eight of these ten cases were previously diagnosed with BC prior to age 70 and in six, BC past 70 years was in the contralateral breast. The lesions size averaged 1.29 ± 0.75 cm, with IDC and DCIS diagnosed in five cases each, and none had lymph node involvement. CONCLUSION: In ~10% of BRCA1/BRCA2 PSV carriers BC is diagnosed by breast imaging after age 70 years. If these results are validated in a larger study, the guidelines for the maximum age for BC surveillance in high risk women should be revisited and set at 75 years.

Treatment-Induced Bone Marrow Enhancement at MRI in Breast Cancer Patients Receiving Granulocyte-Colony Stimulating Factor Adjunct to Chemotherapy.

RATIONALE AND OBJECTIVES: Granulocyte-colony stimulating factor (G-CSF) induces the reconversion of fatty bone marrow to hematopoietic bone marrow. The bone marrow changes are detectable as signal intensity changes at MRI. The aim of this study was to evaluate sternal bone marrow enhancement following G-CSF and chemotherapy treatment in women with breast cancer. MATERIALS AND METHODS: This retrospective study included breast cancer patients who received neoadjuvant chemotherapy with adjunct G-CSF. The signal intensity of sternal bone marrow at MRI on T1-weighted contrast-enhanced subtracted images was measured before treatment, at the end of treatment, and at 1-year follow-up. The bone marrow signal intensity (BM SI) index was calculated by dividing the signal intensity of sternal marrow by the signal intensity of the chest wall muscle. Data were collected between 2012 and 2017, with follow-up until August 2022. Mean BM SI indices were compared before and after treatment, and at 1-year follow-up. Differences in bone marrow enhancement between time points were analyzed using a one-way repeated measures ANOVA. RESULTS: A total of 109 breast cancer patients (mean age 46.1 ± 10.4 years) were included in our study. None of the women had distal metastases at presentation. A repeated-measures ANOVA determined that mean BM SI index scores differed significantly across the three time points (F[1.62, 100.67] = 44.57, p < .001). At post hoc pairwise comparison using the Bonferroni correction BM SI index significantly increased between initial assessment and following treatment (2.15 vs 3.33, p < .001), and significantly decreased at 1-year follow-up (3.33 vs 1.45, p < .001). In a subgroup analysis, while women younger than 50 years had a significant increase in marrow enhancement after G-CSF treatment, in women aged 50 years and older, the difference was not statistically significant. CONCLUSION: Treatment with G-CSF as an adjunct to chemotherapy can result in increased sternal bone marrow enhancement due to marrow reconversion. Radiologists should be aware of this effect in order to avoid misinterpretation as false marrow metastases.

Pacemaker in patients undergoing mammography: A limitation for breast cancer diagnosis?

INTRODUCTION: A pacemaker may affect the utility of a mammogram in several ways. The aim of this study is to summarize our institution's experience with mammograms among patients with a cardiac pacemaker, focusing on the diagnostic workup among patients with a newly diagnosed ipsilateral breast cancer. METHODS: A retrospective search of all mammography reports between January 2011 and April 2021 was conducted for identifying cases of patients with a pacemaker. Demographic and clinical characteristics as well as mammography-derived quality parameters and findings were categorized and statistically compared. RESULTS: The incidence of pacemaker concurrence in mammographic examination, although apparently slightly under-documented, accounted for 0.33% of cases. Population mean age was 71.7 years, and most patients (79%) had a left-sided pacemaker. The pacemaker was much more likely to be projected on the medio-lateral-oblique (96%) than on the cranio-caudal view (10%), on the axilla rather than the breast, and on the retro-pectoral rather than the pre-pectoral region (P < 0.001 for all). Compression force decreased by up to 23.0% (P < 0.001) and breast thickness increased by up to 9.5% (P < 0.001) for the ipsilateral vs. the contralateral side. Among 11 patients with newly diagnosed ipsilateral breast cancer, the pacemaker partially projected on the tumour region in two cases, and significantly obscured the tumour in another two. CONCLUSION: Although rare, the coexistence of a pacemaker in patients undergoing mammography is associated with reduced image quality due to suboptimal breast visualization and reduced compression, and as a result, this may eventually lead to decreased diagnostic efficacy.

MRI can accurately diagnose breast cancer during lactation.

OBJECTIVE: To test the diagnostic performance of breast dynamic contrast-enhanced (DCE) MRI during lactation. MATERIALS AND METHODS: Datasets of 198 lactating patients, including 66 pregnancy-associated breast cancer (PABC) patients and 132 controls, who were scanned by DCE on 1.5-T MRI, were retrospectively evaluated. Six blinded, expert radiologists independently read a single DCE maximal intensity projection (MIP) image for each case and were asked to determine whether malignancy was suspected and the background-parenchymal-enhancement (BPE) grade. Likewise, computer-aided diagnosis CAD MIP images were independently read by the readers. Contrast-to-noise ratio (CNR) analysis was measured and compared among four consecutive acquisitions of DCE subtraction images. RESULTS: For MIP-DCE images, the readers achieved the following means: sensitivity 93.3%, specificity 80.3%, positive-predictive-value 70.4, negative-predictive-value 96.2, and diagnostic accuracy of 84.6%, with a substantial inter-rater agreement (Kappa = 0.673, p value < 0.001). Most false-positive interpretations were attributed to either the MIP presentation, an underlying benign lesion, or an asymmetric appearance due to prior treatments. CAD's derived diagnostic accuracy was similar (p = 0.41). BPE grades were significantly increased in the healthy controls compared to the PABC cohort (p < 0.001). CNR significantly decreased by 11-13% in each of the four post-contrast images (p < 0.001). CONCLUSION: Breast DCE MRI maintains its high efficiency among the lactating population, probably due to a vascular-steal phenomenon, which causes a significant reduction of BPE in cancer cases. Upon validation by prospective, multicenter trials, this study could open up the opportunity for breast MRI to be indicated in the screening and diagnosis of lactating patients, with the aim of facilitating an earlier diagnosis of PABC. KEY POINTS: • A single DCE MIP image was sufficient to reach a mean sensitivity of 93.3% and NPV of 96.2%, to stress the high efficiency of breast MRI during lactation. • Reduction in BPE among PABC patients compared to the lactating controls suggests that several factors, including a possible vascular steal phenomenon, may affect cancer patients. • Reduction in CNR along four consecutive post-contrast acquisitions highlights the differences in breast carcinoma and BPE kinetics and explains the sufficient conspicuity on the first subtracted image.

Pregnancy Associated Breast Cancer Among Israeli BRCA1/BRCA2 Carriers in a High-Risk Clinic.

RATIONALE AND OBJECTIVES: Female carriers of pathogenic sequence variants (PSVs) in the BRCA1 /BRCA2 (Breast Cancer gene - BRCA) genes are at a substantially high-risk for developing breast cancer (BC), hence are offered active surveillance scheme based on semiannual breast exam and imaging from age 25 years to facilitate BC early detection (mammography/breast ultrasound depending on the age, and MRI). However, there are not specific guidelines for screening in case of pregnancy or lactation. In the current study, we summarize the experience at the largest high-risk clinic in Israel. MATERIALS AND METHODS: Data of consecutive BRCA-PSV carriers undergoing surveillance as well as diagnostic ultrasound at the Meirav high-risk clinic from January 2014 to 2021 who were pregnant and/or breastfeeding at time of follow-up were identified. Relevant clinical data including results of breast exam, breast ultrasonography, biopsies and histological results were retrieved. Percentage of biopsies with malignancy, cancer detection rate and positive predictive values were calculated. Data is presented in descriptive statistics. RESULTS: A total of 263 BRCA-carriers were included. Of these, 593 breast-ultrasonograms were performed in 263 BRCA-carriers for 292 pregnancies and 409 breast-ultrasonograms for 175 breastfeeding carriers. Of 36 breast biopsies in 292 pregnancies, 4 (PPV = 11%) had BC diagnosed (high grade invasive). Of 175 breastfeeding women, 25 biopsies were performed and 2 (PPV = 8%) were high grade invasive BC. Five of 6 BC were diagnosed in BRCA1 carriers, and 4/6 were screen detected. The rate of pregnancy-associated breast cancer was 6/292 (2.05%). CONCLUSION: The overall detection rate of pregnancy-associated BC in BRCA-carriers is relatively low (2.05%), but still much higher than that in the general population. Two thirds of the BC were detected by screening. Therefore, despite the changes of the glandular breast tissue at time of pregnancy and breastfeeding, screening plays an important role in early detection. Ultrasound should be considered as a screening tool during this period of life of high-risk patients.

Ductal Carcinoma In Situ (DCIS) Diagnosed by MRI-Guided Biopsy among BRCA1/BRCA2 Mutation Carriers.

Background: While BRCA1/BRCA2 pathogenic sequence variants (PSVs) clearly confer an increased risk for invasive breast cancer, the extent to which these mutant alleles increase DCIS risk is less clear. Objective: To assess the rate of detection over a 5-year period, and MRI imaging features of pure noncalcified DCIS in a cohort of Israeli BRCA1/BRCA2 PSV carriers attending a high-risk clinic from 2015 to 2020. Materials and Methods: All female BRCA1/BRCA2 PSV-carriers followed at the Meirav High-risk clinic from 2015 to 2020 were eligible if they underwent semiannual breast imaging (MRI/mammography) and MRI-guided biopsy-proven pure DCIS. Clinical data, pathology information, and imaging characteristics were retrieved from the computerized archiving system. Results: 18/121 (15.2%) participating BRCA1 PSV carriers and 8/81 (10.1%) BRCA2 PSV-carriers who underwent MRI-guided biopsy were diagnosed with DCIS. The median age of BRCA1 carriers and BRCA2 carriers was 49.8 years and 60.6 years, respectively (p = 0.55). Negative estrogen-receptor tumors were diagnosed in 13/18 (72%) BRCA1 and 2/8 (25%) BRCA2 PSV carriers (p < 0.05). Thirteen (13/18-72%) BRCA1 carriers had intermediate to high-grade or high-grade DCIS compared with 4/8 (50%) of BRCA2 carriers (p = 0.03). Over the 5-year study period, 29/1100 (2.6%) BRCA1/BRCA2 PSV carriers were diagnosed with DCIS seen on MRI only. Conclusion: MRI-detected noncalcified DCIS is more frequent in BRCA1 PSV carriers compared with BRCA2 carriers, unlike the BRCA2 predominance in mammography-detected calcified DCIS. BRCA1-related DCIS is diagnosed earlier, more likely to be estrogen receptor-negative and of higher grade compared with BRCA2-related DCIS. Future prospective studies should validate these results and assess the actual impact they might have on clinical management of BRCA PSV carriers.

MRI of the Lactating Breast: Computer-Aided Diagnosis False Positive Rates and Background Parenchymal Enhancement Kinetic Features.

RATIONALE AND OBJECTIVES: To investigate the application of computer-added diagnosis (CAD) in dynamic contrast-enhanced (DCE) MRI of the healthy lactating breast, focusing on false-positive rates and background parenchymal enhancement (BPE) coloring patterns in comparison with breast cancer features in non-lactating patients. MATERIALS AND METHODS: The study population was composed of 58 healthy lactating patients and control groups of 113 healthy premenopausal non-lactating patients and 55 premenopausal non-lactating patients with newly-diagnosed breast cancer. Patients were scanned on 1.5-T MRI using conventional DCE protocol. A retrospective analysis of DCE-derived CAD properties was conducted using a commercial software that is regularly utilized in our routine radiological work-up. Qualitative morphological characterization and automatically-obtained quantitative parametric measurements of the BPE-induced CAD coloring were categorized and subgroups' trends and differences between the lactating and cancer cohorts were statistically assessed. RESULTS: CAD false-positive coloring was found in the majority of lactating cases (87%). Lactation BPE coloring was characteristically non-mass enhancement (NME)-like shaped (87%), bilateral (79%) and symmetric (64%), whereas, unilateral coloring was associated with prior irradiation (p <0.0001). Inter-individual variability in CAD appearance of both scoring-grade and kinetic-curve dominance was found among the lactating cohort. When compared with healthy non-lactating controls, CAD false positive probability was significantly increased [Odds ratio 40.2, p <0001], while in comparison with the breast cancer cohort, CAD features were mostly inconclusive, even though increased size parameters were significantly associated with lactation-BPE (p <0.00001). CONCLUSION: BPE was identified as a common source for false-positive CAD coloring on breast DCE-MRI among lactating population. Despite several typical characteristics, overlapping features with breast malignancy warrant a careful evaluation and clinical correlation in all cases with suspected lactation induced CAD coloring.

COVID-19 Vaccination Induced Lymphadenopathy in a Specialized Breast Imaging Clinic in Israel: Analysis of 163 cases.

INTRODUCTION: Following vaccination of Israeli population with Pfizer-BioNTech COVID-19 Vaccine, an unusual increase in axillary-lymphadenopathy was noted. This study assesses the rate and magnitude of this trend from breast-imaging standpoint. MATERIALS AND METHODS: Participants undergoing breast-imaging, in whom isolated axillary-lymphadenopathy was detected were questioned regarding SARS-CoV-2 vaccine to the ipsilateral arm. Patients' and imaging characteristics were statistically compared. In order to perform a very short-term follow-up, twelve healthy vaccinated medical staff-members, underwent axillary-ultrasound shortly after the second dose, and follow-up. RESULTS: Axillary-lymphadenopathy attributed to vaccination was found in 163 women undergoing breast-imaging, including BRCA-carriers. During the study, number of detected lymphadenopathies increased by 394% (p = 0.00001) in comparison with previous 2 consecutive years. Mean cortical-thickness of abnormal lymph-nodes after second dose vaccination was 5 ± 2 mm. Longer lymph-node diameter after second vaccination was noted (from 15 ± 5 mm, to 18 ± 6 mm, p = 0.005). In the subgroup of medical staff members, following trends were observed: in patients with positive antibodies, lymph-node cortical-thickness was larger than patients with negative serology (p = 0.03); lymph-node cortical-thickness decreased in 4-5 weeks follow-up (p = 0.007). Lymphadenopathy was evident on mammography in only 49% of cases. DISCUSSION: Vaccine-associated lymphadenopathy is an important phenomenon with great impact on breast-imaging clinic workload. Results suggest the appearance of cortical thickening shortly after both doses. Positive serology is associated with increased lymph-node cortical-thickness. In asymptomatic vaccinated women with ipsilateral axillary-lymphadenopathy as the only abnormal finding, radiological follow-up is probably not indicated. BRCA-carriers, although at higher risk for breast-cancer, should probably receive the same management as average-risk patients.

Post-mastectomy surveillance of BRCA1/BRCA2 mutation carriers: Outcomes from a specialized clinic for high-risk breast cancer patients.

Female BRCA1/BRCA2 mutation carriers may elect bilateral risk-reducing mastectomy. There is a paucity of data on yield of imaging surveillance after risk-reducing mastectomy. This retrospective study focused on female BRCA1/BRCA2 mutation carriers who underwent bilateral mastectomy either as primary preventative, or as secondary preventative, after breast cancer diagnosis. All participants underwent breast imaging at 6- to 12-month intervals after mastectomy. Data on subsequent breast cancer diagnosis and timing were collected and compared between the groups. Overall, 184 female mutation carriers (134 BRCA1, 45 BRCA2, 5 both BRCA genes) underwent bilateral mastectomy after initial breast cancer diagnosis, between April 1, 2009 and August 31, 2018. During a mean follow-up of 6.2 ± 4.2 years, 13 (7.06%) were diagnosed with breast cancer; 12 ipsilateral (range: 0.4-28.8 years) and 1 contralateral breast cancer, 15.9 years after surgery. On the contrary, among asymptomatic BRCA1 (n = 40) and BRCA2 (n = 13) mutation carriers who underwent primary risk-reducing mastectomy (mean age at surgery 39.5 ± 8.4 years); none has developed breast cancer after a mean follow-up of 5.4 ± 3.4 years. BRCA1/BRCA2 mutation carriers with prior disease who underwent risk-reducing mastectomy after breast cancer diagnosis are still prone for developing ipsi or contralateral breast cancer, and therefore may benefit from continues clinical and imaging surveillance, unlike BRCA1/BRCA2 mutation carriers who undergo primary preventative bilateral mastectomy.

Contrast-enhanced spectral mammography (CESM) in women presenting with palpable breast findings.

OBJECTIVE: Palpable breast abnormalities in women warrant diagnostic evaluation. Contrast-enhanced spectral mammography (CESM) is a novel technique which has demonstrated early promising results in the diagnostic imaging setting. The purpose of this study was to evaluate the role of CESM for imaging of palpable breast abnormalities and compare it to the current routine imaging work-up. MATERIALS AND METHODS: This retrospective study included women with palpable breast masses who underwent diagnostic CESM and ultrasound between 2012 and 2019. Diagnostic parameters for low-energy images, CESM and targeted ultrasound were calculated and compared. Analysis was performed at the lesion level. Additional incidental findings were reported separately. RESULTS: Included in this study were 138 women with 147 palpable breast abnormalities, of which 38 were cancers. Standard 2D mammography revealed 36/38 cancers (sensitivity 94.7%). All 38 cancers (100%) were detected at CESM and at targeted ultrasound. Negative predictive value for 2D mammography was 97.8% (91/93), and 100% for both ultrasound (74/74) and for CESM (80/80). None of the palpable masses that were negative at CESM but positive at ultrasound (n = 13) were malignant. Two additional incidental cancers were detected with CESM at the contralateral breast to the palpable lump. CONCLUSION: CESM could be useful for assessment of palpable breast abnormalities, potentially decreasing the number of unnecessary benign biopsies performed.

Breast MRI during lactation: effects on tumor conspicuity using dynamic contrast-enhanced (DCE) in comparison with diffusion tensor imaging (DTI) parametric maps.

PURPOSE: To investigate the effect of lactation on breast cancer conspicuity on dynamic contrast-enhanced (DCE) MRI in comparison with diffusion tensor imaging (DTI) parametric maps. MATERIALS AND METHODS: Eleven lactating patients with 16 biopsy-confirmed pregnancy-associated breast cancer (PABC) lesions were prospectively evaluated by DCE and DTI on a 1.5-T MRI for pre-treatment evaluation. Additionally, DCE datasets of 16 non-lactating age-matched breast cancer patients were retrospectively reviewed, as control. Contrast-to-noise ratio (CNR) comprising two regions of interests of the normal parenchyma was used to assess the differences in the tumor conspicuity on DCE subtraction images between lactating and non-lactating patients, as well as in comparison against DTI parametric maps of λ1, λ2, λ3, mean diffusivity (MD), fractional anisotropy (FA), and maximal anisotropy index, λ1-λ3. RESULTS: CNR values of breast cancer on DCE MRI among lactating patients were reduced by 62% and 58% (p < 0.001) in comparison with those in non-lactating patients, when taking into account the normal contralateral parenchyma and an area of marked background parenchymal enhancement (BPE), respectively. Among the lactating patients, DTI parameters of λ1, λ2, λ3, MD, and λ1-λ3 were significantly decreased, and FA was significantly increased in PABC, relative to the normal lactating parenchyma ROIs. When compared against DCE in the lactating cohort, the CNR on λ1, λ2, λ3, and MD was significantly superior, providing up to 138% more tumor conspicuity, on average. CONCLUSION: Breast cancer conspicuity on DCE MRI is markedly reduced during lactation owing to the marked BPE. However, the additional application of DTI can improve the visualization and quantitative characterization of PABC, therefore possibly suggesting an additive value in the diagnostic workup of PABC. KEY POINTS: • Breast cancer conspicuity on DCE MRI has decreased by approximately 60% among lactating patients compared with non-lactating controls. • DTI-derived diffusion coefficients and the anisotropy indices of PABC lesions were significantly different than those of the normal lactating fibroglandular tissue. • Among lactating patients, breast cancer conspicuity on DTI-derived parametric maps provided up to 138% increase in contrast-to-noise ratio compared with DCE imaging.

Background Parenchymal Enhancement at Contrast-Enhanced Spectral Mammography (CESM) as a Breast Cancer Risk Factor.

RATIONALE AND OBJECTIVES: To assess the extent of background parenchymal enhancement (BPE) at contrast-enhanced spectral mammography (CESM), association between clinical factors and BPE, and between BPE extent and breast cancer. MATERIALS AND METHODS: This study included 516 women who underwent CESM imaging for screening and diagnostic purposes between 2012 and 2015 in a single center. BPE at CESM images was retrospectively, independently and blindly graded by six experienced radiologists using the following scale: minimal, mild, moderate, or marked. Agreement between readers was estimated using Kendall's W coefficient of concordance. Associations between clinical factors and BPE, and between BPE and breast cancer were examined using generalized estimating equations. Association between BPE and breast cancer was assessed for the whole study group, and for the screening population separately. RESULTS: Most women underwent CESM for breast cancer screening (424/516, 82.2%). Mean age was 53 years, the majority had dense breasts (50.4-94%, depending on the reviewer), and minimal to mild BPE (75.8-89.9%). A total of 53/516 women had breast cancer. Overall concordance (W) values between the readers were 0.611 for breast density and 0.789 on BPE. Increased breast density and younger age were positive predictors for increased BPE (odds ratio [OR] 4.07, 95% confidence interval [CI] 2.32-7.14, p < 0.001; OR 2.88, 95% CI 1.87-4.42, p < 0.001, respectively). Breast radiation therapy was a negative predictor for BPE (OR 0.13, 95% CI 0.06-0.31, p < 0.001). Women with increased BPE had increased odds for breast cancer (OR 2.24, 95% CI 1.23-4.09, p = 0.008). This result was consistent when screening cases were analyzed separately (OR 6.27, 95% CI 2.38-16.53, p < 0.001). CONCLUSION: BPE at CESM was associated with breast density. Women with increased BPE had increased odds for breast cancer, independently of other potential risk factors.

Trends in Imaging Workup of the Male Breast: Experience from a Single Center.

BACKGROUND: Male breast cancer (MBC) is a rare disease representing less than 1% of breast cancers. In the absence of a screening program, such as for females, the diagnostic workup is critical for early detection of MBC. OBJECTIVES: To summarize our institutional experience in the workup of male patients referred for breast imaging, emphasizing the clinical, imaging, and histopathological characteristics of the MBC cohort. METHODS: All male patients who underwent breast imaging between 2011 and 2016 in our institution were retrospectively reviewed. Clinical, radiological, and histopathological data were collected and statistically evaluated. All images were reviewed using the American College of Radiology Breast Imaging Reporting and Data System. RESULTS: 178 male patients (average age 61 years, median age 64), underwent breast imaging in our institution. The most common indication for referral was palpable mass (49%) followed by gynecomastia (16%). Imaging included mostly mammography or ultrasound. Biopsies were performed on 56 patients, 38 (68%) were benign and 18 (32%) were malignant. In all, 13 patients had primary breast cancer and 5 had metastatic disease to the breast. Palpable mass at presentation was strongly associated with malignancy (P = 0.007). CONCLUSIONS: Mammography and ultrasound remain the leading modalities in breast imaging among males for diagnostic workup of palpable mass, with gynecomastia being the predominant diagnosis. However, presentation with palpable mass was also associated with malignancy. Despite a notable MBC rate in our cohort, the likelihood of cancer is low in young patients and in cases of gynecomastia.

Noncontrast Breast MRI During Pregnancy Using Diffusion Tensor Imaging: A Feasibility Study.

BACKGROUND: Pregnancy-associated breast cancer (PABC) is often a delayed diagnosis and contrast-enhanced MRI is contraindicated because gadolinium agents are known to cross the placenta. PURPOSE: To investigate the feasibility and clinical utility of noncontrast breast MRI using diffusion tensor imaging (DTI) in the diagnostic workup of PABC. STUDY TYPE: Prospective. POPULATION: Between November 2016 and January 2018, 25 pregnant participants (median gestational age: 17 weeks) were recruited from eight referral breast-care centers nationwide. Imaging indications included: newly-diagnosed PABC (n = 10, with 11 lesions), palpable mass/mastitis (n = 4), high-risk screening (n = 10), and monitoring neoadjuvant-chemotherapy response (n = 1). FIELD STRENGTH/SEQUENCE: 1.5T, T2 -weighted, and DTI sequences, prone position, with a scan duration of ∼12 minutes. ASSESSMENT: DTI parametric maps were generated and analyzed at pixel resolution, with reference to ultrasound (US) and pathology. STATISTICAL TESTS: Two-tailed Student's t-test was applied for evaluating differences between DTI parameters of PABC vs. healthy fibroglandular tissue. Pearson's correlation test was applied to measure the agreements between λ1-based longest tumor diameter, US, and pathology. RESULTS: All scans were technically completed and reached diagnostic quality, except one with notable motion artifacts due to positional discomfort, which was excluded. Nine out of 11 known PABC lesions and one newly-diagnosed lesion were visible on λ1, λ2, λ3, mean diffusivity (MD), and λ1-λ3 maps, with substantial parametric contrast compared with the apparently normal contralateral fibroglandular tissue (P < 0.001 for all). Two lesions of 0.7 cm were not depicted by the diffusivity maps. Tumor diameter measured on a thresholded λ1 map correlated well with US (r = 0.97) and pathology (r = 0.95). Malignancy was excluded by DTI parametric maps in scans of symptomatic and high-risk patients, in agreement with US follow-up, except for one false-positive case. DATA CONCLUSION: Noncontrast breast MRI is feasible and well-tolerated during pregnancy. Further studies with a larger and homogeneous cohort are required to validate DTI's additive diagnostic value, albeit this study suggests a potential adjunct role for this noninvasive approach in breast evaluation during pregnancy. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2019;49:508-517.

Outcomes after Surgery for Early Stage Breast Cancer in Women Staged With Preoperative Breast Magnetic Resonance Imaging According to Breast Tissue Density.

PURPOSE: To determine surgical outcomes and breast cancer disease-free survival outcomes of women with early stage breast cancer with and without use of preoperative breast MRI according to breast tissue density. METHODS: Women with early stage breast cancer diagnosed from 2004 to 2009 were classified into 2 groups: 1) those with dense and heterogeneously dense breasts (DB); 2) those with nondense breasts (NDB) (scattered fibroglandular and fatty replaced tissue). The 2 groups were reviewed to determine who underwent preoperative MRI. Breast tissue density was determined with mammography according to ACR BI-RADS. Patients were compared according to tumor size, grade, stage, and treatment. Survival analysis was performed using Kaplan-Meier estimates. RESULTS: In total, 261 patients with mean follow-up of 85 months (25-133) were included: 156 DB and 105 NDB. Disease-free survival outcomes were better in the DB group in patients with MRI than in those without MRI: patients with MRI had significantly fewer local recurrences (P < 0.016) and metachronous contralateral breast cancers (P < 0.001), but this was not the case in the NDB group. Mastectomies were higher in the DB group with preoperative MRI than in those without MRI (P < 0.01), as it was in the NDB group (P > 0.05). CONCLUSIONS: Preoperative breast MRI was associated with reduced local recurrence and metachronous contralateral cancers in the DB group, but not in the NDB group; however, the DB patients with MRI had higher mastectomy rates.

Tumor-to-breast volume ratio as measured on MRI: a possible predictor of breast-conserving surgery versus mastectomy.

BACKGROUND: The surgical approach to breast cancer changed dramatically in the past 20 years. The surgical objective today is to remove the tumor, ensuring negative margins and good cosmetic results, and preserving the breast when possible. Magnetic resonance imaging of the breast has become an essential imaging tool prior to surgery, diagnosing additional tumors and assessing tumor extent. Tumor-to-breast volume ratio, an important predictor of breast conservation, can be measured with MRI and may change the surgical decision. OBJECTIVES: To measure the tumor-to-breast volume ratio using MRI in order to assess whether there is a correlation between this ratio and the type of surgery selected (breast-conserving or mastectomy). METHODS: The volumes of the tumor and the breast and the tumor-to-breast volume ratio were retrospectively calculated using preoperative breast MRI in 76 patients who underwent breast-conserving surgery or mastectomy. RESULTS: Breast-conserving surgery (lumpectomy) was performed in 64 patients and mastectomy in 12. The average tumor-to-breast volume ratio was 0.06 (6%) in the lumpectomy group and 0.30 (30%) in the mastectomy group (P < 0.0001). CONCLUSION: The tumor-to-breast volume ratio correlated with the type of surgery. As measured on MRI, this ratio is an accurate means of determining the type of surgery best suited for a given patient. It is recommended that MRI-determined tumor-to-breast volume ratio become part of the surgical planning protocol for patients diagnosed with breast cancer.

Focal dermal hypoplasia associated with split sternum--Goltz syndrome.

Focal dermal hypoplasia (Goltz syndrome) is an unusual congenital mesoectodermal syndrome. We report on a baby girl with multiple malformations, including focal dermal hypoplasia, characteristic facial features, skeletal anomalies and split sternum.