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.

The Value of a Second Opinion for Breast Cancer Patients Referred to a National Cancer Institute (NCI)-Designated Cancer Center with a Multidisciplinary Breast Tumor Board.

BACKGROUND: This study aimed to investigate the changes in diagnosis after a second opinion for breast cancer patients from a multi-disciplinary tumor board (MTB) review at an National Cancer Institute (NCI)-designated cancer center. METHODS: A retrospective study analyzed patients with a breast cancer diagnosed at an outside institution who presented for a second opinion from August 2015 to March 2016 at the Medical University of South Carolina (MUSC). Radiology, pathology, and genetic testing reports from outside institutions were compared with reports generated after an MTB review and subsequent workup at MUSC. The second-opinion cases were categorized based on whether diagnostic variations were present or not. RESULTS: The review included 70 patients seeking second opinions, and 33 (47.1%) of these patients had additional radiologic images. A total of 30 additional biopsies were performed for 25 patients, with new cancers identified in 16 patients. Overall, 16 (22.8%) of the 70 of patients had additional cancers diagnosed. For 14 (20%) of the 70 patients, a second opinion led to a change in pathology interpretation. Genetic testing was performed for 11 patients (15.7%) who met the National Comprehensive Cancer Network (NCCN) guidelines for genetic testing, but none showed a mutation other than a variant of unknown significance. After a complete workup, 30 (42.8%) of the 70 patients had a change in diagnosis as a result of the MTB review. CONCLUSION: A review by an MTB at an NCI-designated cancer center changed the diagnosis for 43% of the patients who presented for a second opinion for breast cancer. The study findings support the conclusion that referral for a second opinion is beneficial and has a diagnostic impact for many patients.

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.

Ovarian cystic lesions: a current approach to diagnosis and management.

The primary imaging modality for evaluation of ovarian cystic lesions is pelvic ultrasonography. Most ovarian cysts are benign and demonstrate typical sonographic features that support benignity. However, some ovarian cystic lesions have indeterminate imaging features, and the approach to management varies. This article discusses how to recognize and diagnose different types of ovarian cystic lesions, including an approach to management. The learning objective is to recognize imaging features of ovarian cystic lesions.

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.