Radiation therapy after sentinel lymph node biopsy for early stage breast cancer using a magnetic tracer: Results of a single institutional prospective study of tolerance.

PURPOSE: . The aim of the study was, through a single institutional analysis of a large population of breast cancer patients, to assess the feasibility of and the tolerance to radiotherapy after the use of magnetic detection method for sentinel lymph node biopsy. MATERIAL AND METHODS: The super paramagnetic iron oxide particles database was collected prospectively and identified 520 cases from October 2013 to December 2016 at our institution. All of them received super paramagnetic iron oxide particles injection 20minutes before the surgical procedure and some of them received also isotope technique. Injection site for super paramagnetic iron oxide particles and isotope was periareolar. Among them, 288 patients received adjuvant radiotherapy. In our study, we evaluated the tolerance of postoperative radiotherapy. RESULTS: The median age of the patients was 64 years. The median follow-up period was 16 months (range: 1-42 months). Double detection of sentinel lymph node was done in the first 30 patients (10.4%). The sentinel lymph node identification rate was 99.7% (287 out of 288). There were 34 axillary lymph node dissections, of which 58.8% were realized straightaway. The total radiation dose was 50Gy EQD2 (range: 28.5-66Gy). Regarding the occurrence of radiodermatitis, 95.8% of patients had grade 0-2 radiodermatitis and 1% had grade 3. During follow-up, 19.4% of patients developed grade 1-2 post-therapeutic fibrosis (of which 92.9% grade 1). CONCLUSION: The results of this large-scale study show that the radiotherapy after sentinel lymph node biopsy using super paramagnetic iron oxide particles is feasible, and that no increase of the toxicity was observed.

Standardized diagnosis and reporting of breast cancer.

Standardized terminology developed by the American College of Radiography (ACR) through the Breast-Imaging Reporting and Data System (BI-RADS) lexicon is used worldwide to describe the findings of the various breast-imaging techniques (mammography, ultrasound, and magnetic resonance imaging (MRI)). A 7-level positive predictive value (PPV) of malignancy classification system (from BI-RADS category 0 to category 6) has been based on this terminology, giving imaging a central role in the diagnostic strategy. This document presents the standardized, compulsory BI-RADS terminology used in breast-imaging reports in 2013 in view of the new edition that will be published at the end of the year.

Histological grade concordance between diagnostic core biopsy and corresponding surgical specimen in HR-positive/HER2-negative breast carcinoma.

BACKGROUND: The identification and validation of suitable predictive and prognostic factors are a challenge to improve the treatment scheme selection. Discordances in histological grade can be established between core biopsy and surgical specimens. This is important in HR-positive/HER2-negative subgroup where histological grade identifies patients at high risk and is a strong determinant for treatment scheme. METHODS: A total of 350 consecutive invasive breast carcinoma biopsies were assessed and compared with surgical specimens in Institut Curie, Paris, France. Clinical, radiological and pathological data were recorded. RESULTS: Histological grade concordance rate in the HR+/HER2- group was 75%. A grade underestimation was mainly due to mitotic index misgrading (23%). Large tumours (P<0.05), premenopausal patients (P=0.005) and non-ultrasound-guided biopsies (P=0.04) were risk factors for misgrading. The highest discordance was found in tumours that required chemotherapy (39%, P<0.05), and it was related to an underestimation of histological grade on core biopsies (94%). CONCLUSIONS: Histological grade in HR+/HER2- group is important to identify patients with poor prognosis and start a systemic therapy. Histological grade discordance was correlated with an underestimation of mitotic index and factors probably associated with intratumor heterogeneity (premenopausal status, tumour size and the type of core biopsy performed). But such discordance did not appear to modify the therapeutic decision, because systemic treatment decision-making also integrates other variables. Determining histological grade in core biopsy can be especially important in HR-positive/HER2-negative subgroup where it identifies patients at high risk and is a strong determinant of the treatment scheme.

Complex cystic breast masses in ultrasound examination.

Complex cystic masses are defined as lesions composed of anechoic (cystic) and echogenic (solid) components, unlike complicated cysts, the echogenic fluid content of which imitates a solid lesion. Complex masses are classified as ACR4 and require histological verification by percutaneous biopsy and/or surgical ablation. The etiology is diverse, and can be benign or high risk (an abscess, hematoma, fat necrosis, fibrocystic mastopathy, a phyllodes tumor, papilloma) as much as malignant (papillary cancer, necrotic cancer, a ductal carcinoma in situ, metastases). The biopsy technique must be adapted to each case and it is often necessary to insert a coil during the procedure. Histopathological correlation is essential to ensure that the samples are representative and concur with the ultrasound appearance, so as not to fail to recognize high risk or malignant lesions requiring appropriate management.

Current opinion on clip placement after breast biopsy: a survey of practising radiologists in France and Quebec.

AIM: To investigate current practice regarding clip placement after breast biopsy. MATERIALS AND METHODS: In June 2011, an online survey instrument was designed using an Internet-based survey site (www.surveymonkey.com) to assess practices and opinions of breast radiologists regarding clip placement after breast biopsy. Radiologists were asked to give personal practice data, describe their current practice regarding clip deployment under stereotactic, ultrasonographic, and magnetic resonance imaging (MRI) guidance, and describe what steps are taken to ensure quality control with regards to clip deployment. RESULTS: The response rate was 29.9% in France (131 respondents) and 46.7% in Quebec (50 respondents). The great majority of respondents used breast markers in their practice (92.1% in France and 96% in Quebec). In both countries, most reported deploying a clip after percutaneous biopsy under stereotactic or MRI guidance. Regarding clip deployment under ultrasonography, 38% of Quebec radiologists systematically placed a marker after each biopsy, whereas 30% of French radiologists never placed a marker in this situation, mainly due to its cost. Finally, 56.4% of radiologists in France and 54% in Quebec considered that their practice regarding clip deployment after breast percutaneous biopsy had changed in the last 5 years. CONCLUSION: There continues to be variations in the use of biopsy clips after imaging-guided biopsies, particularly with regards to sonographic techniques. These variations are likely to decrease over time, with the standardization of relatively new investigation protocols.

Vacuum-assisted biopsies under MR guidance: results of 72 procedures.

OBJECTIVE: To investigate the clinical accuracy of magnetic resonance imaging-guided breast vacuum-assisted biopsy (MR-VAB). METHODS: Of 97 scheduled MR-VAB for single MRI lesions (negative second-look sonography) categorised as BI-RADS 4 or 5, 4 were cancelled (undetected lesion = 2, technical problems = 2). Twenty-one patients lost to follow-up were excluded. RESULTS: Twenty-three patients (median age 51 years) were at high risk (BRCA1 = 11, BRCA2 = 7, familial risk = 5), 23 had a suspected local recurrence of breast cancer. Seventy-two imaged lesions (focus = 1, mass enhancement = 32, non-mass-like enhancement = 39) were targeted with a 10-gauge VAB probe using MRI guidance, with a median of 18 specimens per lesion (median procedural time 72 min, range 50-131 min) followed by clip placement. In the case of benignity, MRI follow-up was performed (19 patients, median 389 days, range 33-1,592) or mammography (3 patients, median 420 days, range 372-1,354). According to histopathology results, 29 lesions were benign, 10 were high-risk (papillary = 2, radial scar = 1, atypical epithelial hyperplasia = 7) and 33 malignant (ductal carcinoma in situ = 8, invasive cancers = 25). Three false negative results and 3 complications occurred (1 malaise, 1 skin defect, 1 infection). CONCLUSION: MRI-guided VAB represents an accurate tool for the histological diagnosis of lesions visible only at MRI.

[How to follow-up women with dense breasts by imaging?]. / Comment surveiller des seins denses en pratique?

Digital mammography has to be proposed in women less than 50 years; after 50 years, no significant difference was reported between digital versus film mammography. The follow-up every 2 years is still valid after 50 years in women without other risk factors for breast cancer. Screening with ultrasound seems to have a low impact in the general population, prevalent detection rates of 0.4% were mainly described in series including young women or with multiple risk factors. Annual screening is recommended in women with dense breasts associated with other significant risk factors; MRI use should be decided on a case-by-case basis.

[MR breast screening in patients with genetic mutation]. / Dépistage du cancer du sein par IRM chez les femmes porteuses d'une mutation génétique.

PURPOSE: To compare screening breast MRI with conventional screening techniques in high-risk patients with genetic mutation. MATERIALS AND METHODS: Prospective study of 85 patients (mean age of 43 years) with genetic mutation and screening > or = 2 years (mean of 2.7 years, 231 screening examinations). BI-RADS lesions 3-5 were biopsied; isolated BI-RADS 3 lesions on MRI were followed. Results from both techniques were compared. The number of short interval follow-up examinations and biopsy results were reviewed. RESULTS: Eight cancers were diagnosed (3 in situ, 5 invasive carcinomas including an interval cancer, mean size of 14 mm). The sensitivity values for mammography, US and MRI were 12.5%, 50% and 95%, and specificity values were 98.7%, 97.3% and 94.8% respectively. Nineteen short interval follow-up MRI examinations were performed (19%): 14% of patients at initial screening and 5% and 6% at the the second and third screenings. Thirty-two biopsies were performed in 17 patients, including 18 after MRI (PPV of cytology: 30%, and biopsy: 58%). CONCLUSION: Our results confirm the value of MRI for screening of high-risk patients with genetic mutation.

[Elastography of the breast: a prospective study of 122 lesions]. / Elastosonographie du sein: étude prospective de 122 lésions.

OBJECTIVE: To evaluate elastography in the characterization of breast nodules. MATERIAL AND METHODS: Elastography (Hitachi, 7.5- to 13-MHz probe; Ueno classification, scores 1-3=benign, 4-5=malignant) was evaluated in 125 subclinical lesions in 114 patients. The results were compared to those of the ACR's BI-RADS sonography categories (benign=2 and 3, malignant=4 and 5) and to the results of the percutaneous samples taken and/or surgery (122 lesions evaluated, 59%<10 mm, 61 cancers, 61 benign lesions). RESULTS: There were three technical failures (2.4%). The elastography was in agreement with histology for 101 lesions, with 13 false-negative results and eight false-positive results (sensitivity, 78.7%; specificity, 86.9%; PPV, 85.7%; NPV, 80.3%); versus agreement with the BI-RADS classification for 98 lesions with one false-negative result and 23 false-positive results (sensitivity, 98.4%; specificity, 47.5%; PPV, 65.2%; NPV, 96.7%). CONCLUSION: Elastography is a simple and rapid complementary method that can improve the specificity and the PPV of morphological imaging studies of breast nodules with a low level of suspicion (BI-RADS categories 3 and 4a), which should decrease the rate of unnecessary benign biopsies.

[Indications of MRI in the initial local staging of early-stage breast cancer]. / Mise au point sur la place de l'IRM dans le bilan initial du cancer du sein localisé

MR Imaging is the most sensitive technique for detecting breast cancer. In patients with breast cancer, the additional value of MRI is validated in patients candidates for a breast-conserving surgery and when: cancer is occult, size evaluation is difficult at standard imaging, parietal involvement is suspected, and before neoadjuvant chemotherapy. In fatty breasts, MRI is not routinely recommended, because of same performances as in standard imaging. In dense breasts, MRI becomes significantly more sensitive than mammography for detecting multifocality and multicentricity with a positive predictive value of 60% for detected additional foci. Thus, a decision of mastectomy should not be made solely on the basis of MRI and may require additional tissue sampling of areas of concern identified by breast MRI. The additional value of breast MRI is particularly useful in patients with dense breasts and high risk factors for local recurrence: young age (< 40 years), familial high risk, or because of a high-grade invasive cancer greater than 2 cm in size. Performing breast MRI in such patients underlies requirements: an expert breast imaging team, optimal MRI protocols, and radiologists working in concert with the multidisciplinary treatment team.

[Usefulness of magnetic resonance imaging in Paget disease of the breast]. / Apport de l'IRM dans la maladie de Paget du sein.

OBJECTIVE: Evaluate the usefulness of MRI in local staging of Paget disease of the breast. MATERIALS AND METHODS: Clinical, radiological (mammographies, MRI), and histological data were analyzed in six female patients presenting Paget disease of the breast. The criteria for analysis in MRI were the following: morphology of the aureola-nipple plaque (thickening, regularity of the contour) and the type of enhancement after injection of contrast medium (signal intensity/time curve), detection of abnormal enhancing in the mammary gland, and ganglion areas. RESULTS: None of the patients presented a palpable mass or a suspicious anomaly on mammography. On MRI, the aureola-nipple plaque was morphologically abnormal in four cases, with suspicious enhancement in two cases (two cases of ductal carcinoma in situ) and normal enhancement in two cases (one case of ductal carcinoma in situ). In the two other cases, the aureola-nipple plaque was normal (one case of ductal carcinoma in situ). Distant abnormal enhancement of the aureola-nipple plaque was noted in two cases (one case of ductal carcinoma in situ and one benign lesion). CONCLUSION: The MRI aspect of the aureola-nipple plaque in Paget disease shows little concordance with the histological results. MRI can be useful in detecting distant lesions when there is no clinical sign nor a suspicious mammography.

[Identification and management of hereditary breast-ovarian cancers (2004 update)]. / Identification et prise en charge des prédispositions héréditaires aux cancers du sein et de l'ovaire (mise à jour 2004).

BACKGROUND: Since the last recommendations, up to 2500 new references had been published on that topic. METHODOLOGY: On the behalf of the health Minister, the Ad Hoc Committee consisted of 13 experts carried out a first version revisited by five additional experts who critically analyzed the first version of the report. MAIN UPDATING: Breast and ovarian cancer seem to be associated with fewer deleterious mutations of BRCA1 and BRCA2 than previously thought. The screening of ovarian cancer is still not an attractive option while in contrast MRI may be soon for these young women with dense breast, the recommended option for breast cancer screening. The effectiveness of prophylactic surgeries is now well established. French position is to favor such surgeries with regard to a quality of life in line with the expected benefit, and providing precise and standardized process described in the recommendation. CONCLUSIONS: Due to methodological flaws, the low power and a short follow-up of the surveys, this statement cannot however aspire to a high stability.

Normal and pathological breast, the histological basis.

Breast tissue is heterogeneous, associating connective and glandular structures, which grow and change cyclically under hormonal regulation. Hormones are also thought to be the main determinant of the major benign and malignant pathologies encountered in the breast. Benign lesions are more frequent and fibrocystic changes are by far the most common among them. They usually associate different entities, (adenosis, fibrosis, cysts and hyperplasia) but vary in intensity and extension. Thus, their clinical and radiographic presentation is extremely different from one patient to another. Adenofibroma is the most frequent tumour. It also undergoes modifications according to hormonal conditions. About 90% of malignant tumours are primary carcinoma. The incidence of intra-ductal carcinoma has risen dramatically since the development of screening because of its ability to induce calcification. Two mechanisms could be involved in the formation of calcification: one active (tumour cell secretion of vesicles), the other passive (necrotic cell fragments are released). Invasive carcinoma comprises numerous histological types. Stromal reactions essentially determines their shape: a fibrous reaction commonly found in ductal carcinoma creates a stellate lesion while other stroma, inflammatory (medullary carcinoma), vascular (papillary carcinoma) or mucinous determine nodular lesions whose borders push the surrounding tissue. The histological features which give rise to the radiographic pattern will be emphasised.

Use of radiology for the pathologist in the management of breast lesions.

Today radiology is an essential step in the pathological analysis of breast biopsies. It is determinant at each stage of the management of non palpable lesions, clusters of microcalcifications and opacities, whether this concerns the needle biopsy or the surgical excision. Firstly, an X-ray is necessary to ensure that the core needle biopsy specimen has been adequately sampled and when samples with microcalcifications are selected by the radiologist, management can be more specific and accurate. In the case of surgical specimens, the X-ray confirms the presence of the radiographic abnormality or the clip indicating the site of the surgical excision which guides sampling. Some radiographic features also provide information on underlying pathologies allowing management to be adapted accordingly. Radiographs are also important to ensure that microscopically detected microcalcifications or lesions exactly correspond to the radiographic abnormality in size and location. The paraffin block can also be X-rayed to select those containing microcalcifications for additional slicing. It is also important to identify the presence of modifications caused by the core needle biopsy (fibrosis, haemorrhage and inflammation) and to carefully recognize displacement of epithelial cells and pseudo-emboli resulting from the needle procedure. Such correlation between radiology and pathology is essential so that appropriate management of the specimen can be adapted and to avoid pitfalls arising from pre-operative procedures.

[New developments in breast imaging]. / Quoi de neuf en imagerie du sein?

In 2004, breast cancer screening will be effective in France. This evolution has a strong impact on our mammographic practice that becomes a real mission of public health. Digital mammography, compared to screen-film mammography, provides the same results for the detection of breast cancer, computer-aided detection systems represent the most relevant application of this technology at this time. The setting up of a quality control will allow the introduction of this technology in screening during 2004. Percutaneous imaging-guided procedures are now currently used for the diagnosis of nonpalpable breast lesions and allow the selection of patients for surgery. These procedures have emphasized the need for a multidisciplinary approach of the patients. Indications of MRI have not changed because of its moderated specificity and no relevant development of interventional-guided procedures. Work on standardization of radiological reports and assessment categories goes on. This classification is already applied for mammography, and new classifications for lesions detected by ultrasound or MRI will be published by the American College of Radiology (Breast Imaging Reporting and Data System, 4th edition, available in 2003).