Pushing the envelope in breast conserving surgery - is multiple-wire localization (3 or more wires) associated with increased risk of compromised margins and long-term recurrence?

INTRODUCTION: In the last two decades there has been a paradigm shift with breast conserving surgery (BCS) being applied to larger and more extensive breast malignancies. The aim of this study is to examine the success of BCS being performed in patients with extensive breast malignancies requiring at least 3 wires for localization, and to assess possible risk factors for failure. MATERIALS AND METHODS: We performed a retrospective single center review of 232 patients who underwent BCS between 2010 and 2020 requiring at least 3 wires for localization, thus comprising the multi-wire group (MWG). The cohort included a control group of 232 single-wire BCS patients (SWG) chronologically matched with the MWG. Patients with either invasive malignancy or ductal carcinoma in situ (DCIS) were included in the study. Clinical, radiological, and pathological data was collected. Proportions of positive surgical margins, re-lumpectomies and conversion to mastectomy were calculated. Survival analysis for locoregional and distant recurrence was performed. RESULTS: Women in the MWG were younger (mean age 57 vs. 63.1, P < 0.001), had larger tumor size (mean size 5.1 cm vs. 1.3 cm, p < 0.001), a higher prevalence of calcifications on mammograms (72 % vs. 17 %, P < 0.001), a higher proportion of positive lymph nodes (75 % vs. 45 %, P = 0.019), and an elevated incidence of a ductal carcinoma in situ (DCIS) component (72 % vs. 38 %, P < 0.001). Positive surgical margins were higher in the MWG (13 % vs 7 %, P = 0.03), which lead to higher proportions of re-lumpectomies or conversion to mastectomies (7 % vs 4 %, P = 0.17). On multivariate analysis of the entire cohort, patients with positive margins were more likely to have a DCIS component (77 % vs 53 %, P = 0.001), an infiltrating lobular carcinoma (ILC) component (15 % vs 9 %, P = 0.013), and positive ER hormonal status (94 % vs 85 %, p = 0.05). The number of wires was not an independent predictor of positive margins. On long-term analysis, the locoregional disease-free survival was similar between the SWG and MWG (P = 0.1). However, the MWG showed higher rates of distant metastasis (12 % vs 4 %, P = 0.006). CONCLUSIONS: BCS requiring 3 or more wires is associated with a slightly higher proportion of positive margins. The increased risk of positive margins appears to be related to the type of tumor (DCIS component, ILC component and ER status) rather than to the number of wires. The number of wires does not significantly impact locoregional disease-free survival.

Clinical breast exam contribution to breast cancer diagnosis in BRCA mutation carriers vs. average to intermediate risk women.

PURPOSE: The contribution of clinical breast exam (CBE) to breast cancer diagnosis in average risk women undergoing regular screening mammography is minimal. To evaluate the role of CBE in high-risk women, we compared BC diagnosis by CBE in BRCA mutation carriers undergoing regular BC surveillance to average to intermediate risk women undergoing regular breast cancer screening. METHODS: A retrospective chart review of all consecutive screening visits of BRCA mutation carriers (January 2012-October 2022) and average to intermediate risk women (November 2016-December 2022) was completed. Women with histologically confirmed BC diagnosis were included. Additional CBE yield for BC diagnosis, defined as the percentage of all BC cases detected by CBE alone, was assessed in both groups. RESULTS: Overall, 12,997 CBEs were performed in 1,328 BRCA mutation carriers in whom 134 BCs were diagnosed. In 7,949 average to intermediate risk women who underwent 15,518 CBEs, 87 BCs were diagnosed. CBE contributed to BC diagnosis in 3 (2%) BRCA mutation carriers and 3 (4%) non-carriers. In both groups, over 4,000 CBEs were needed in order to diagnose one cancer. In all 3 BRCA mutation carriers BC was palpated during the surveillance round that did not include MRI. In the average to intermediate risk group, 2 of 3 cancers diagnosed following CBE findings were in a different location from the palpable finding. CONCLUSIONS: The contribution of CBE to BC diagnosis is marginal for all women including BRCA mutation carriers. In BRCA mutation carriers, CBE appears redundant during the MRI surveillance round.

The diagnostic performance of ultrafast MRI to differentiate benign from malignant breast lesions: a systematic review and meta-analysis.

OBJECTIVES: To assess the diagnostic performance of ultrafast magnetic resonance imaging (UF-DCE MRI) in differentiating benign from malignant breast lesions. MATERIALS AND METHODS: A comprehensive search was conducted until September 1, 2023, in Medline, Embase, and Cochrane databases. Clinical studies evaluating the diagnostic performance of UF-DCE MRI in breast lesion stratification were screened and included in the meta-analysis. Pooled summary estimates for sensitivity, specificity, diagnostic odds ratio (DOR), and hierarchic summary operating characteristics (SROC) curves were pooled under the random-effects model. Publication bias and heterogeneity between studies were calculated. RESULTS: A final set of 16 studies analyzing 2090 lesions met the inclusion criteria and were incorporated into the meta-analysis. Using UF-DCE MRI kinetic parameters, the pooled sensitivity, specificity, DOR, and area under the curve (AUC) for differentiating benign from malignant breast lesions were 83% (95% CI 79-88%), 77% (95% CI 72-83%), 18.9 (95% CI 13.7-26.2), and 0.876 (95% CI 0.83-0.887), respectively. We found no significant difference in diagnostic accuracy between the two main UF-DCE MRI kinetic parameters, maximum slope (MS) and time to enhancement (TTE). DOR and SROC exhibited low heterogeneity across the included studies. No evidence of publication bias was identified (p = 0.585). CONCLUSIONS: UF-DCE MRI as a stand-alone technique has high accuracy in discriminating benign from malignant breast lesions. CLINICAL RELEVANCE STATEMENT: UF-DCE MRI has the potential to obtain kinetic information and stratify breast lesions accurately while decreasing scan times, which may offer significant benefit to patients. KEY POINTS: • Ultrafast breast MRI is a novel technique which captures kinetic information with very high temporal resolution. • The kinetic parameters of ultrafast breast MRI demonstrate a high level of accuracy in distinguishing between benign and malignant breast lesions. • There is no significant difference in accuracy between maximum slope and time to enhancement kinetic parameters.

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.

Our Experience in Diagnosing and Treating Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL).

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T-cell lymphoma detected in association with textured implants. It presents as a fluid accumulation around the implant, usually years after the implantation. We present our experience in diagnosing and treating four patients with BIA-ALCL, each widely differing from the other. Data on patients' surgical history, relevant medical information, and findings on pathological slides were retrieved from their medical charts and retrospectively reviewed. Each of the four patients was diagnosed with BIA-ALCL, one after breast augmentation, one after breast reconstruction with an implant, one after breast reconstruction with a latissimus dorsi flap and implant, and the fourth after the removal of breast implants. The cases were presented to a multidisciplinary team and subsequently underwent surgery. All four are currently free of tumors, as established by a negative follow-up via positron emission tomography-computed tomography. Although the incidence of BIA-ALCL is rare, these cases emphasize the need to rule out the diagnosis of BIA-ALCL in patients with textured implants or a history of implanted textured devices who present with symptoms such as late seroma or peri-implant mass. This pathology is typically indolent and slow-growing and heightened awareness for an early diagnosis could lead to quicker intervention and enhanced patient management.

Ultrafast DCE-MRI for discriminating pregnancy-associated breast cancer lesions from lactation related background parenchymal enhancement.

OBJECTIVE: To investigate the utility of ultrafast dynamic-contrast-enhanced (DCE) MRI in visualization and quantitative characterization of pregnancy-associated breast cancer (PABC) and its differentiation from background-parenchymal-enhancement (BPE) among lactating patients. MATERIALS AND METHODS: Twenty-nine lactating participants, including 10 PABC patients and 19 healthy controls, were scanned on 3-T MRI using a conventional DCE protocol interleaved with a golden-angle radial sparse parallel (GRASP) ultrafast sequence for the initial phase. The timing of the visualization of PABC lesions was compared to lactational BPE. Contrast-noise ratio (CNR) was compared between the ultrafast and conventional DCE sequences. The differences in each group's ultrafast-derived kinetic parameters including maximal slope (MS), time to enhancement (TTE), and area under the curve (AUC) were statistically examined using the Mann-Whitney test and receiver operator characteristic (ROC) curve analysis. RESULTS: On ultrafast MRI, breast cancer lesions enhanced earlier than BPE (p < 0.0001), enabling breast cancer visualization freed from lactation BPE. A higher CNR was found for ultrafast acquisitions vs. conventional DCE (p < 0.05). Significant differences in AUC, MS, and TTE values were found between the tumor and BPE (p < 0.05), with ROC-derived AUC of 0.86 ± 0.06, 0.82 ± 0.07, and 0.68 ± 0.08, respectively. The BPE grades of the lactating PABC patients were reduced as compared with the healthy lactating controls (p < 0.005). CONCLUSION: Ultrafast DCE MRI allows BPE-free visualization of lesions, improved tumor conspicuity, and kinetic quantification of breast cancer during lactation. Implementation of this method may assist in the utilization of breast MRI for lactating patients. CLINICAL RELEVANCE: The ultrafast sequence appears to be superior to conventional DCE MRI in the challenging evaluation of the lactating breast. Thus, supporting its possible utilization in the setting of high-risk screening during lactation and the diagnostic workup of PABC. KEY POINTS: • Differences in the enhancement slope of cancer relative to BPE allowed the optimal visualization of PABC lesions on mid-acquisitions of ultrafast DCE, in which the tumor enhanced prior to the background parenchyma. • The conspicuity of PABC lesions on top of the lactation-related BPE was increased using an ultrafast sequence as compared with conventional DCE MRI. • Ultrafast-derived maps provided further characterization and parametric contrast between PABC lesions and lactation-related BPE.

Characterization of patients with a diagnosis of breast cancer and melanoma: genetic susceptibility or increased surveillance?

BACKGROUND: Breast cancer diagnosis had been linked to an increased risk of melanoma in several reports. The aim of the current study was to assess the role of genetics, increased surveillance, and radiation treatment in patients with a dual diagnosis of breast cancer and melanoma (DBM). MATERIALS AND METHODS: All patients treated at Sheba Medical Center between 2007 and 2021 with DBM were included in the cohort. Data on family history, genetic tests, characteristics, and treatment of both cancers were collected. The proportion of patients with a pathogenic variant (PV) in BRCA1 and BRCA2 genes was compared to a control group of patients with breast cancer. The proportion of patients presenting with in-situ disease was compared to the national registry data. RESULTS: The cohort included 222 DBM patients of whom 114 had documentation of genetic testing. Twenty patients tested positive for PVs of which 13 (11%) were in BRCA genes. This was comparable to the proportion in patients with a diagnosis of breast cancer (736; 19%). The proportion of melanoma diagnosed at stage 0 was comparable to the national proportion ( N = 40; 30% vs. 28%, respectively). In comparison to the national registry, a larger proportion of breast cancers were ductal carcinoma in situ or lobular carcinoma in situ [10% in the registry vs. 19% (22) in the cohort; P < 0.003]. CONCLUSIONS: In patients with DBM we did not find an increased proportion of PVs in BRCA genes. Our findings suggest that the increased standardized incidence ratio of the dual diagnosis may be partially explained by increased surveillance and detection of earlier-stage cancers.

Patient Satisfaction and Surgical Outcome After Oncoplastic Reconstruction following Radical Lumpectomy Versus Standard Lumpectomy: A Retrospective Cohort Study.

Objective: Oncoplastic reconstruction (OR) enables widening of the indications for breast conserving therapy (BCT) and is redefining the limits of breast conservation. We examined the outcome and satisfaction of patients undergoing OR after radical lumpectomy (excision of more than 25% of the breast volume) and compared it to the outcome of women undergoing OR after standard lumpectomy. Materials and Methods: A retrospective, cohort study, including all patients undergoing OR after BCT between 2009 and 2018, was conducted. The ratio of volume of excision to breast volume was calculated using imaging studies. The study group included women that had more than 25% of their breast volume removed. The remainder formed the control group. Demographic characteristics, oncological treatment, and operation properties were collected. We compared post-operative complications, margin status and need for further surgery, as well as patient satisfaction, evaluated using the BREAST-Q Questionnaire. Results: One hundred and fifty women were included, of whom 24 (16%) comprised the study group with a mean breast volume reduction of 39%, while the remainder (mean volume reduction 8%) served as controls. Patient, tumor characteristics and treatment were comparable. There was a non-significant higher proportion of women in the radical group that underwent a second operation due to complications or positive margins [4/24 (16.7%) vs. 14/126 (11%), p = 0.4). Physical well-being was similar but satisfaction with breasts and with outcome was slightly lower for the study group. These differences did not reach statistical significance. Conclusion: Surgical outcome and patient satisfaction in women undergoing very extensive breast resections with OR are comparable to standard resections.

Contribution of clinical breast exam to cancer detection in women participating in a modern screening program.

PURPOSE: Despite the controversy surrounding the role of clinical breast exam (CBE) in modern breast cancer screening, it is widely practiced. We examined the contribution of CBE in women undergoing routine screening mammography and in women under the screening age. METHODS: A retrospective cohort study including all women participating in a voluntary health screening program between 2007 and 2016. All participants undergo CBE; Screening mammography is done selectively based on age, breast imaging history and insurance coverage. Data collected included demographics, risk factors, previous imaging, and findings on CBE and mammography. Cancer detection rates within 3 months of the visit were calculated separately for women undergoing routine screening mammography, and women under the screening age. RESULTS: There were 14,857 CBE completed in 8378; women; 7% were abnormal. Within 3 months of the visit, 35 breast cancers (2.4 per 1000 visits) were diagnosed. In women within the screening age who completed a mammogram less than one year prior to the visit (N = 1898), 4 cancers (2.1 cancers per 1000 visits) were diagnosed. Only one was diagnosed in a woman with an abnormal CBE, suggesting that the cancer detection rate of CBE in women undergoing regular screening is very low (0.5 per 1000 visits). In women under the screening age (45), 3 cancers (0.4 per 1000 visits) were diagnosed; all were visualized on mammography, one had an abnormal CBE. CONCLUSIONS: The contribution of CBE to cancer detection in women undergoing routine screening and in women under the screening age is rare.

The characteristics associated with upgrade on surgical pathology of conventional imaging occult DCIS diagnosed by MRI.

PURPOSE: To characterize the clinical, pathological, and imaging features of DCIS occult on conventional imaging diagnosed on MRI-guided biopsy associated with increased risk of invasive disease on surgical excision. MATERIALS AND METHODS: All consecutive patients with MRI-detected DCIS occult on conventional imaging between January 2009 and December 2018 were included. Women were divided into two groups based on final pathology: Pure DCIS or DCIS with invasive component. Clinical, imaging, and pathological risk factors for upgrade to invasion were evaluated. RESULTS: Of 50 patients who met the inclusion criteria, 12 (24%) were upgraded to invasive malignancy in the final pathology. The only parameters that showed statistically significant association with upgrade were related to kinetic characteristics: 53% of patients with the combination of fast early upstroke and either plateau or washout curve were upgraded, compared to 12% of women without this combination (p = 0.006). The sensitivity of combined kinetic features for predicting upgrade was 67% (95% CI 35-90%), specificity was 84% (CI 95% 68-94%), positive predictive value was 57% (CI 95% 37-75%), negative predictive value was 89% (CI 95% 77-95%), and OR was 78% (64-88%). CONCLUSION: Kinetic characteristics show the strongest association with upgrade to invasion in DCIS occult on mammogram and US. Larger studies should be encouraged to consolidate our findings, which may have implication for treatment planning.

The impact of tumor detection method on genomic and clinical risk and chemotherapy recommendation in early hormone receptor positive breast cancer.

BACKGROUND: Symptomatic breast cancers share aggressive clinico-pathological characteristics compared to screen-detected breast cancers. We assessed the association between the method of cancer detection and genomic and clinical risk, and its effect on adjuvant chemotherapy recommendations. PATIENTS AND METHODS: Patients with early hormone receptor positive (HR+) HER2neu-negative (HER2-) breast cancer, and known OncotypeDX Breast Recurrence Score test were included. A natural language processing (NLP) algorithm was used to identify the method of cancer detection. The clinical and genomic risks of symptomatic and screen-detected tumors were compared. RESULTS: The NLP algorithm identified the method of detection of 401 patients, with 216 (54%) diagnosed by routine screening, and the remainder secondary to symptoms. The distribution of OncotypeDX recurrence score (RS) varied between the groups. In the symptomatic group there were lower proportions of low RS (13% vs 23%) and higher proportions of high RS (24% vs. 13%) compared to the screen-detected group. Symptomatic tumors were significantly more likely to have a high clinical risk (59% vs 40%). Based on genomic and clinical risk and current guidelines, we found that women aged 50 and under, with a symptomatic cancer, had an increased probability of receiving adjuvant chemotherapy recommendation compared to women with screen-detected cancers (60% vs. 37%). CONCLUSIONS: We demonstrated an association between the method of cancer detection and both genomic and clinical risk. Symptomatic breast cancer, especially in young women, remains a poor prognostic factor that should be taken into account when evaluating patient prognosis and determining adjuvant treatment plans.

In Search of the Lost Clip: Outcome of Women After Needle-Guided Lumpectomy of a Marking Clip.

BACKGROUND: Needle localization of a marking clip is required to guide accurate removal of many breast lesions. When the clip is not visualized on specimen radiography, concerns regarding the completeness of cancer removal and long-term outcomes arise. Using a large cohort of women undergoing breast conservation, we examined the magnitude of the problem and the outcome of women with a missing clip. METHODS: We conducted a case-control study including all women undergoing mammographic wire-guided localization between 2013 and 2018 with a specimen radiograph showing a missing clip. The control group included women with successful removal of the clip(s). Data included demographics, cancer and treatment characteristics, and outcome. The groups were compared in regard to margin status, repeat surgery, and recurrence rates. RESULTS: The research group included 43 women [5% of the cohort; 95% confidence interval (CI) 3.9-7.2] with a missing clip. Positive margins were comparable (7, 17% of cases; 29, 15% of 196 cases in the control group; p = 0.96). Eleven women (33%) had a residual clip visualized on post-operative mammography; in four cases, a percutaneous biopsy of the clip was successful, all with no residual tumor. There was no significant difference in re-excision rates (14% vs. 8%, p = 0.23) or in local or distant recurrence. CONCLUSIONS: In the majority of women with a missing clip, the clip is not visualized on post-operative mammography. Those with a residual clip can be managed with percutaneous biopsy as long as the lesion was removed with clear margins, with comparable outcomes as women in whom the clip is visualized on specimen radiograph.

Postirradiation Capsular Contracture in Implant-Based Breast Reconstruction: Management and Outcome.

BACKGROUND: Implant-based breast reconstruction is commonly avoided in the setting of radiation therapy, mainly because of risks of capsular contracture. Nevertheless, as breast reconstruction is becoming more available, more patients undergo both implant-based breast reconstruction and radiotherapy. The dilemma is how to manage capsular contracture if it does occur. The goal of this study was to examine the outcome of patients with implant-based breast reconstruction who developed postirradiation capsular contracture and were treated with capsulotomy or capsulectomy, with or without fat grafting. METHODS: The authors reviewed charts of patients who developed capsular contracture following alloplastic breast reconstruction followed by radiation therapy, between 2008 and 2018. The surgical treatment methods for capsular contracture were evaluated along with their outcomes. A follow-up of at least 1 year was required. RESULTS: Forty-eight breasts with postirradiation capsular contracture underwent surgical implant exchange with capsular release, of which 15 had combined fat grafting and 33 did not. Overall, 35 breasts (72.9 percent) showed long-term resolution of capsular contracture; 24 underwent a single procedure and 11 required an additional fat grafting procedure. Some patients [six breasts (12.5 percent)] were offered a consecutive round of fat grafting, and some [seven breasts (14.5 percent)] were offered autologous reconstruction because of lack of improvement. Fat grafting increased the success rate by more than 30 percent when it was initially and consecutively used. CONCLUSIONS: Postirradiation capsular contracture may be treated successfully by secondary procedures, sustaining implant-based breast reconstruction in over 70 percent of breasts. Fat grafting may elevate resolution rates even further, to 86 percent. Larger prospective studies are required to validate these findings. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Lobular neoplasia occult on conventional imaging and diagnosed on MRI-guided biopsy: can we estimate upgrade on surgical pathology?

PURPOSE: The goal of this study is to evaluate the frequency and imaging features of lobular neoplasia (LN) diagnosed on MRI-guided biopsy, determine the upgrade rate to malignancy, and assess for any features that may be associated with an upgrade on surgical excision. MATERIALS AND METHODS: Research ethical board approved the review of consecutive patients with MRI-detected LN between January 2009 and December 2018 with differentiation between pure LN and LN with associated other high-risk lesions. The final outcome was determined by final pathology results from surgical excision or 24 months of follow-up. Appropriate statistical tests were used. RESULTS: Out of 1250 MRI-guided biopsies performed, 76 lesions (6%) fulfilled the inclusion criteria and formed the study cohort. Of the 76 lesions, 54 (71%) were pure LN while the rest had coexistent high-risk lesion. Non-mass enhancement (NME) was the most common lesion type (62, 82%). Fifty-nine lesions (78%) were surgically excised, the other 17 had benign follow-up. Overall, 8 lesions (11%) were upgraded to malignancy on final pathology. Malignant outcome was associated with larger lesion size (5.5 versus 1.9 cm, P < 0.001) and a clumped NME pattern (75% versus 24%, P = 0.006). Lesion size and clumped NME remained significantly associated with upgrade on sub-analysis of the pure LN group. CONCLUSION: Larger lesion size and clumped NME are imaging findings associated with upgrade of LN diagnosed by MRI-guided biopsy. This may influence patient management in this clinical setting. Additional larger studies are needed to consolidate our results and to potentially detect additional factors associated with upgrade.

Comparison of Patient Susceptibility Genes Across Breast Cancer: Implications for Prognosis and Therapeutic Outcomes.

Hereditary breast cancer syndromes affect a small (10-15% of cases) but significant group of patients. BRCA1 and BRCA2 are the most familiar and well-studied genes associated with inherited breast cancer. However, mutations in the high-penetrance genes, TP53, PTEN, CDH1, MSH1, MLH1, MSH6, PMS2, PALB2, and STK11, and in the moderate-penetrance genes, CHEK2, ATM, and BRIP1, also correlate with high lifetime risks of breast cancer and other malignancies as well. Advances in breast cancer genetics have led to an improved perception of diagnosis and screening strategies. The specific considerations and challenges involved in treating this unique population have become a fertile ground for research. Indeed, these genes and downstream molecular pathways have now become potential therapeutic targets in breast cancer patients, including those with BRCA1 or BRCA2 mutations. This review describes the variety of hereditary breast cancer genes, from their molecular origins to the prognosis and multidisciplinary clinical decision-making processes. Key publications and other reported recent clinical trials and guidelines are provided.

Can breast MRI accurately exclude malignancy in mammographic architectural distortion?

OBJECTIVES: To investigate the diagnostic accuracy of problem-solving breast magnetic resonance imaging (MRI) in excluding malignancy in a cohort of patients diagnosed with mammographic architectural distortion (MAD). METHODS: The Institutional Review Board approved the study. Imaging database with 40,245 breast MRIs done between January 2008 and September 2018 was retrospectively reviewed. The study included all exams considered problem-solving MRI for MAD. Two radiologists reviewed the imaging data. Outcome was determined by the pathology results of biopsy/surgical excision or at least 1 year of clinical and radiological follow-up. Predictors for malignancy were examined, and appropriate statistical tests were applied. RESULTS: One hundred seventy-five patients (median age 53 years) fulfilled the inclusion criteria and formed the study cohort. No cancers were diagnosed in 106 patients with a negative MRI. Out of 69 women with positive MRI findings, 48 (70%) had benign outcome defined either by pathology result or by negative follow-up, and 21 (30%) yielded malignancy. Malignancy was significantly associated with positive MRI (p < 0.001) and older age (p = 0.014). Falsely positive MRIs were frequently found in women with radial scars. The sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy of breast MRI were 100% (95% CI 84 to 100%), 68% (CI 61 to 76%), 100% (CI 95 to 100%), 30% (CI 26 to 36%), and 73% (95% CI 66-79), respectively. CONCLUSION: A negative breast MRI in patients with MAD was reliable in excluding malignancy in this cohort and may have a role as a precision medicine tool for avoiding unnecessary interventions. KEY POINTS: • MRI shows a high negative predictive value in MAD cases. • MRI displays low accuracy in differentiating malignancy from RS. • MRI is a reliable non-invasive method to exclude malignancy in women with mammographic architectural distortion, potentially avoiding unnecessary biopsies and surgeries.

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.

Ultrasound guided tattooing of axillary lymph nodes in breast cancer patients prior to neoadjuvant therapy, and identification of tattooed nodes at the time of surgery.

BACKGROUND: Breast cancer patients with lymph node (LN) metastases at diagnosis often undergo neoadjuvant therapy (NAT). Identification of a LN which regressed after NAT remains a challenge. OBJECTIVE: To evaluate marking of involved nodes by tattooing with carbon suspension, and identifying these nodes during surgery. METHODS: A small amount (0.2-0.5 ml) of carbon suspension was injected into one or two axillary LNs under ultrasound guidance at the time of LN biopsy or before or shortly after starting NAT for LN positive breast cancer. During surgery an attempt was made to identify and remove the tattooed LN as a separate specimen. All patients underwent sentinel LN mapping and biopsy and/or axillary LN dissection as mandated by their clinical status. RESULTS: Sixty three patients underwent tattooing of axillary LNs with no complications or adverse events. At surgery a tattooed node was identified in 60 patients (95%; 95% CI 87, 98). Of 56 patients who underwent sentinel mapping with Tc99, in 51 (91%; 95% CI 81, 96) at least one radioactive LN was identified. Of 50 patients in whom both radioactivity and tattoo were identified in axillary LNs, in 40 (80%; 95% CI 67, 89) LNs were radioactive and tattooed, however in 10 patients (20%; 95% CI 11, 33), the tattooed LN was not radioactive. CONCLUSIONS: Tattooing of axillary LNs is safe and easily performed. Tattooing was helpful in identifying the marked LN in the majority of cases. This technique helps to ensure that metastatic LNs are identified and removed at surgery after NAT.

Time to Cancer Diagnosis in Young Women Presenting to Surgeons with Breast-Related Symptoms: A Population-Based Cohort Study.

Background: Delay in diagnosis may be a contributing factor to the observed correlation between young age and advanced disease. We examined time to cancer diagnosis in young women presenting to surgeons with breast-related complaints. Materials and Methods: This population-based cohort study included all women aged 18-44 presenting to a surgeon with breast-related complaints between 2005 and 2015 in a large health care plan (n = 157,264). Data included demographics, diagnosis codes, and workup. Cancer diagnosis was ascertained from the national cancer registry. Time to breast imaging and biopsy was compared between the different age groups. Logistic regression analysis was used to determine the association between age and delay to biopsy while adjusting for possible confounders. Results: During the 1st year after the visit, 45,434 (29%) women had breast imaging; 5,766 (3.7%) women had a breast biopsy; and 676 (0.43%) were diagnosed with breast cancer. Overall, time to first breast imaging and biopsy did not differ significantly between the age groups. But nonspecific visit codes (other than breast mass) were associated with delays to imaging and biopsy. Among, women diagnosed with breast cancer, age under 40 years (odds ratio [OR]: 2.3, 95% confidence interval [CI]: 1.4-3.9), being postpartum (OR: 2.6, 95% CI: 1.1-5.9), and a nonspecific visit code (OR: 8.3, 95% CI: 4.9-14.2) were associated with delay. Conclusions: Symptomatic women with lower a-priori likelihood of malignancy (younger age, postpartum, or nonspecific visit code) are at significantly greater risk of delayed diagnosis of cancer. Physicians should be aware of the diagnostic challenge in young women presenting with nonspecific symptoms.