Added Value of MRI for Invasive Breast Cancer including the Entire Axilla for Evaluation of High-Level or Advanced Axillary Lymph Node Metastasis in the Post-ACOSOG Z0011 Trial Era.

Background In the post-American College of Surgeons Oncology Group Z0011 trial era, radiologists have increasingly focused on excluding high-level or advanced axillary lymph node metastasis (ALNM) by using an additional MRI scan positioned higher than lower axillae; however, the value of these additional scans remains undetermined. Purpose To evaluate whether a standard MRI protocol is sufficient to exclude high-level or advanced ALNM in breast cancer or additional MRI of entire axilla is needed. Materials and Methods This retrospective study evaluated women with invasive breast cancer who underwent breast MRI from April 2015 to December 2016. Some underwent neoadjuvant chemotherapy (NAC) and others underwent upfront surgery. Standard (routine axial scans including the lower axillae) and combined (routine axial scans plus additional scans including the entire axilla) MRI protocols were compared for high-level or advanced ALNM detection. Clinical-pathologic characteristics were analyzed. Uni- and multivariable logistic regression was performed to identify predictors of high-level or advanced ALNM. Results A total of 435 women (mean age ± standard deviation, 52 years ± 11) were evaluated (65 in the NAC group, 370 in the non-NAC group). With the standard MRI protocol, predictors of high-level ALNM were peritumoral edema (odds ratio [OR], 12.3; 95% CI: 3.9, 39.4; P < .001) and positive axilla (OR, 5.9; 95% CI: 2.0, 15.2; P < .001). Only three of 289 women with negative axillae without peritumoral edema had high-level ALNM. Predictors of advanced ALNM were positive axillae (OR, 8.9; 95% CI: 3.7, 21.5; P < .001) and peritumoral edema (OR, 2.8; 95% CI: 1.1, 6.9; P = .03). Only six of 310 women who had negative axillae without peritumoral edema had advanced ALNM. Conclusion The performance of standard MRI was satisfactory in excluding high-level and advanced axillary lymph node metastasis in most patients with breast cancer. However, the presence of peritumoral edema or positive axillae in the MRI findings emphasizes the benefits of a combined MRI protocol. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Abe in this issue.

Localized primary breast amyloidosis and 1-year changes in imaging: A case report.

Localized primary breast amyloidosis is a very rare benign disease characterized by abnormal protein deposition in the mammary glands. Amyloidosis may mimic the appearance of a number of pathologies, both benign and malignant. Clinically, the patient may present with a breast mass or simply with increased breast density and skin thickening. Herein, we report the case of a 45-year-old woman who presented with a breast mass and was ultimately diagnosed with primary breast amyloidosis, and the mass diagnosed with amyloidosis increased in size and there were a greater number of amorphous and irregular microcalcifications on mammography and ultrasound at the 1-year follow-up. To conclude, we presented changes in a case of localized primary breast amyloidosis on mammography and ultrasound images over a period of 1 year. The current standard of care of primary breast amyloidosis is surgical resection; however, the patient should be followed after surgery to monitor the possibility of recurrence of malignancy.

Axillary sparganosis, changes in ultrasound images over six months: A case report.

Sparganosis is an infestation caused by a tapeworm belonging to the genus Spirometra. The typical radiologic findings of sparganosis describe elongated, folded, band or tubular, hypoechoic structures with surrounding increased echogenicity in ultrasonography. These imaging features have been highly consistent with pathology results. Here, we report an interesting case of axillary sparganosis that manifested changes on ultrasound images over a period of 6 months.

Thyroid cyst mirror artifact mimicking a tracheal cyst on ultrasound in a patient with excessive trachea collapsibility.

Mirror image artifact in ultrasound is not an unusual phenomenon. However, it is rarely seen in thyroid ultrasound because of the natural convexity of the tracheal surface. We report a mirror artifact during thyroid ultrasound in a patient with an excessively collapsible trachea. Minor pressure with the transducer made the trachea surface flat or concave, and then a cyst in the thyroid was mirrored across the trachea, which mimicked an intratracheal cyst. This case illustrates how an unusual collapsible trachea can generate an image that simulates an intratracheal lesion during thyroid ultrasound.

Can Biannual Ultrasound Surveillance Detect Smaller Second Cancers or Detect Cancers Earlier in Patients with Breast Cancer History?

The aim of the work described here was to evaluate whether surveillance with biannual ultrasound (US) plus annual mammography (biannual group) for women with a history of breast cancer surgery results in earlier detection or in the detection of smaller second cancers than annual US plus mammography (annual group). Additionally, we compared the prevalence of distant metastases or palpable second cancers between the biannual and annual groups. The institutional review board of our institution approved this retrospective study, and patient consent was waived. Between January 2011 and December 2012, we retrospectively reviewed the clinical and imaging follow-up of 3023 patients with mammographic and US surveillance after breast cancer surgery to assess second cancers detected by local surveillance (locoregional recurrence, contralateral breast cancer or distant metastasis). The biannual and annual groups were divided with respect to the mean surveillance interval and compared with respect to clinicopathologic findings. Multivariable logistic regression with propensity score methods was used to examine the effect of the type of surveillance on outcomes. As for the size of the second cancer, no difference was seen between the biannual and annual groups (12.8 ± 6.6 mm vs. 14.1 ± 7.1 mm, p = 0.461); neither was there a significant difference between the groups in the presence of symptoms at the time of diagnosis of the second cancer (17.0% [8/47] vs. 10% [2/20], p = 0.711). Regardless of detection by local surveillance, the prevalence of distant metastases did not differ between the two groups (1.1% [27/2370] vs. 1.0% [7/653], p = 0.88) on univariate or multivariate analysis. The results of our retrospective study indicate that second cancers detected by biannual US surveillance in patients with a history of breast cancer surgery are not smaller and do not occur earlier than those detected by annual US surveillance. However, a randomized controlled study is required to verify these results before they can be generalized to clinical practice.

Correlation between electrical conductivity and apparent diffusion coefficient in breast cancer: effect of necrosis on magnetic resonance imaging.

OBJECTIVES: To investigate the correlation between conductivity and ADC in invasive ductal carcinoma according to the presence of necrosis on MRI. METHODS: Eighty-one women with invasive ductal carcinoma ≥1 cm on T2-weighted fast spin echo sequence of preoperative MRI were included. Phase-based MR electric properties tomography was used to reconstruct conductivity. Mean ADC was measured. Necrosis was defined as an area with very high T2 signal intensity. The relationship between conductivity and ADC was examined using Spearman's correlation coefficient (r). Multiple linear regression analysis was performed to identify factors associated with conductivity or ADC. RESULTS: In the total group, conductivity showed negative correlation with ADC (r = -0.357, p = 0.001). This correlation was maintained in the subgroup without necrosis (n = 53, r = -0.455, p = 0.001), but not in the subgroup with necrosis (n = 28, r = -0.080, p = 0.687). The correlation between the two parameters was different according to necrosis (r = -0.455 vs -0.080, p = 0.047). HER2 enriched subtype was independently associated with conductivity (p = 0.029). Necrosis on MRI was independently associated with ADC (p = 0.027). CONCLUSIONS: Conductivity shows negative correlation with ADC that is abolished by the presence of necrosis on MRI. KEY POINTS: • Electric conductivity showed negative correlation with ADC • However, the correlation was abolished by the presence of necrosis on MRI • HER2-enriched subtype was independently associated with conductivity • Necrosis on MRI was independently associated with ADC.

Necessity of Axillary Scanning After Negative Finding on Both Mammography and Subsequent Breast Ultrasound.

The purpose of our study was to assess the cancer detection rate and positive predictive value (PPV) for incidentally detected abnormal axillary lymph nodes with negative mammography and subsequent breast ultrasound (US). We included 7039 screened patients (mean age, 52 y) from January 2012 to March 2015 with negative mammography and subsequent breast US results. In two patients with positive lymph nodes, neither were from breast malignancy. The calculated cancer detection rate, PPV for biopsy and axillary biopsy rate was 0.3 per 1000 axillary US, 14.3% and 0.2%. Cancer rates for patients with a family or personal operation history, with cancer history and with no family/operation/cancer history were 0%, 0.1% and 0.2%, respectively. Our results indicate that the cancer detection rate and PPV for US were too low to recommend routine axillary scanning including screening breast US in patients with negative mammography and subsequent breast US, especially with no history of any cancers.

Clinical application of the BI-RADS final assessment to breast sonography in conjunction with mammography.

OBJECTIVE: The objective of our study was to report the results of classification of sonographic findings according to BI-RADS and to calculate the positive predictive value (PPV) for each BI-RADS assessment category. SUBJECTS AND METHODS: We prospectively classified 4,668 breast sonograms according to BI-RADS final assessment category. Suspicious sonographic findings were divided into major and minor suspicious findings. Category 1 was normal and category 2 was a benign finding such as cyst or nodule with uniform and intense hyperechogenicity. A nodule neither category 2 nor category 4 or 5 was defined as category 3. A nodule with one or more suspicious findings, not category 5, was defined as category 4. A nodule with two or more major suspicious findings was defined as category 5. RESULTS: Of the 4,668 cases, 321 cases failed to undergo follow-up of at least 1 year. The PPV was 0.1% in category 1 (3/2,191), 0% in category 2 (0/773), 0.8% in category 3 (6/737), 31.1% in category 4 (161/519), and 96.9% in category 5 (123/127). In palpable lesions (n = 751), the PPV was 2.2% in category 1 (2/93), 0.9% in category 3 (2/217), 54% in category 4 (107/198), and 98% in category 5 (98/100). In nonpalpable lesions (n = 3,596), the PPV was 0.05% in category 1 (1/2,098), 0.8% in category 3 (4/520), 16.8% in category 4 (54/321), and 92.6% in category 5 (25/27). CONCLUSION: As with mammography, placing sonographic lesions into BI-RADS categories is useful for predicting the presence of malignancy.

Focal fibrosis of the breast diagnosed by a sonographically guided core biopsy of nonpalpable lesions: imaging findings and clinical relevance.

OBJECTIVE: The purpose of this study was to evaluate the frequency of focal fibrosis of the breast diagnosed by a sonographically guided core biopsy of nonpalpable lesions, to characterize imaging features, and to evaluate their clinical relevance. METHODS: In a retrospective review of 724 lesions that underwent sonographically guided core biopsy of nonpalpable breast lesions, 62 cases had a diagnosis of focal fibrosis. Two radiologists analyzed the sonographic and mammographic findings according to the Breast Imaging Reporting and Data System. The results were compared with histologic findings at surgery or imaging findings during surveillance. RESULTS: The incidence of focal fibrosis was 8.6% (62/724). Sonographic films were available in 56 cases, so 56 cases were reviewed for their sonographic findings. Among the mammograms reviewed, 64.7% (33/51) had negative findings. Among the sonograms reviewed, the most common features were oval shape (32/56, 57.1%), parallel orientation (36/56, 64.3%), microlobulated margin (24/56, 42.9%), abrupt interface (50/56, 89.3%), isoechoic pattern (42/56, 75.0%), and a lack of posterior acoustic features (45/56, 80.4%). The Breast Imaging Reporting and Data System final assessment was category 3 in 27 (48.2%) and category 4 in 29 (51.8%). Most of the category 4 lesions were category 4A (26/29, 89.7%). Surgical excision (n = 7) and follow-up for at least 1 year (n = 49) showed no malignancy. CONCLUSIONS: Focal fibrosis was found in 8.6% by a sonographically guided core biopsy of nonpalpable breast lesions. Most of the lesions were categorized as probably benign (category 3) or having a low suggestion of malignancy (category 4A). Focal fibrosis diagnosed at core biopsy can be managed with a 6-month follow-up protocol.

Unilateral breast edema: spectrum of etiologies and imaging appearances.

Breast edema is defined as a mammographic pattern of skin thickening, increased parenchymal density, and interstitial marking. It can be caused by benign or malignant diseases, as a result of a tumor in the dermal lymphatics of the breast, lymphatic congestion caused by breast, lymphatic drainage obstruction, or by congestive heart failure. Here we describe several conditions, that cause unilateral breast edema with the aim of familiarizing radiologists with these disease entities.

Variable breast conditions: comparison of conventional and real-time compound ultrasonography.

OBJECTIVES: To illustrate and compare the appearances of variable breast conditions by conventional and real-time spatial compound images. METHODS: Cases illustrative of a broad range of breast conditions were collected. Each image pair consisted of conventional and real-time compound images with a stationary probe to maintain an identical projection. RESULTS: The various breast conditions, including normal anatomic structures and abnormal lesions, were evaluated and compared by conventional and real-time compound images. The real-time compound images revealed more realistic and clear images with reduced artifacts. CONCLUSIONS: Real-time compound images are superior to conventional images of normal and abnormal breast conditions. Real-time compound imaging is a good technique for evaluating the breast state.

Metastasis of primitive neuroectodermal tumor to the breast.

We performed mammography and sonography on a 49-year-old woman who had a mass in her left axilla that had been present for 1 month and who had undergone excision of a primitive neuroectodermal tumor (PNET) on her back 1 year before. Mammography revealed 2 adjacent, dense nodules in the left breast and enlarged lymph nodes, without a fatty hilum or internal microcalcifications, in the left axilla. Sonography showed 2 round to oval, markedly hypoechoic nodules in the left breast and enlarged, markedly hypoechoic lymph nodes, without microcalcifications, in the left axilla. We then performed sonographically guided core biopsy. Histopathologic analysis of the specimens confirmed the presence of PNET in the left breast and axillary lymph nodes. The patient was then treated with chemotherapy. To our knowledge, this report is the first to describe radiologic findings of metastasis of PNET to the breast.

A case of breast sparganosis.

A 29-year-old Korean woman visited the Department of Surgery in MizMedi Hospital with a palpable itching mass on the right breast that had existed for the past 7 months. She had no history to eat either frogs or snakes, but had the history of drinking impure water. Sonography revealed a serpiginous hypoechoic tubular structure associated with partial fat necrosis in breast parenchymal layer and subcutaneous fat layer. It also revealed oval cystic lesions. At operation, an ivory white opaque ribbon-like worm that measured 16.5 cm in length and 0.5 cm in width was extracted. Anti-sparganum specific serum IgG level in the patient's serum (absorbance = 0.71), measured by ELISA, was found to be significantly higher than those of normal controls (cut off point = 0.21). Sonography and ELISA appear to be helpful to diagnose sparganosis. Breast sparganosis is rarely found throughout the world.