An Outbreak of Burkholderia cepacia Complex Infections Associated with Contaminated Liquid Docusate.

OBJECTIVE To investigate an outbreak of Burkholderia cepacia complex and describe the measures that revealed the source. SETTING A 629-bed, tertiary-care, pediatric hospital in Houston, Texas. PATIENTS Pediatric patients without cystic fibrosis (CF) hospitalized in the pediatric and cardiovascular intensive care units. METHODS We investigated an outbreak of B. cepacia complex from February through July 2016. Isolates were evaluated for molecular relatedness with repetitive extragenic palindromic polymerase chain reaction (rep-PCR); specific species identification and genotyping were performed at an independent laboratory. The investigation included a detailed review of all cases, direct observation of clinical practices, and respiratory surveillance cultures. Environmental and product cultures were performed at an accredited reference environmental microbiology laboratory. RESULTS Overall, 18 respiratory tract cultures, 5 blood cultures, 4 urine cultures, and 3 stool cultures were positive in 24 patients. Among the 24 patients, 17 had symptomatic infections and 7 were colonized. The median age of the patients was 22.5 months (range, 2-148 months). Rep-PCR typing showed that 21 of 24 cases represented the same strain, which was identified as a novel species within the B. cepacia complex. Product cultures of liquid docusate were positive with an identical strain of B. cepacia complex. Local and state health departments, as well as the CDC and FDA, were notified, prompting a multistate investigation. CONCLUSIONS Our investigation revealed an outbreak of a unique strain of B. cepacia complex isolated in clinical specimens from non-CF pediatric patients and from liquid docusate. This resulted in a national alert and voluntary recall by the manufacturer. Infect Control Hosp Epidemiol 2017;38:567-573.

Direct-Conversion Molecular Breast Imaging of Invasive Breast Cancer: Imaging Features, Extent of Invasive Disease, and Comparison Between Invasive Ductal and Lobular Histology.

OBJECTIVE: The purposes of this study were to compare the tumor appearance of invasive breast cancer on direct-conversion molecular breast imaging using a standardized lexicon and to determine how often direct-conversion molecular breast imaging identifies all known invasive tumor foci in the breast, and whether this differs for invasive ductal versus lobular histologic profiles. MATERIALS AND METHODS: Patients with prior invasive breast cancer and concurrent direct-conversion molecular breast imaging examinations were retrospectively reviewed. Blinded review of direct-conversion molecular breast imaging examinations was performed by one of two radiologists, according to a validated lexicon. Direct-conversion molecular breast imaging findings were matched with lesions described on the pathology report to exclude benign reasons for direct-conversion molecular breast imaging findings and to document direct-conversion molecular breast imaging-occult tumor foci. Associations between direct-conversion molecular breast imaging findings and tumor histologic profiles were examined using chi-square tests. RESULTS: In 286 patients, 390 invasive tumor foci were present in 294 breasts. A corresponding direct-conversion molecular breast imaging finding was present for 341 of 390 (87%) tumor foci described on the pathology report. Invasive ductal carcinoma (IDC) tumor foci were more likely to be a mass (40% IDC vs 15% invasive lobular carcinoma [ILC]; p < 0.001) and to have marked intensity than were ILC foci (63% IDC vs 32% ILC; p < 0.001). Direct-conversion molecular breast imaging correctly revealed all pathology-proven foci of invasive disease in 79.8% of cases and was more likely to do so for IDC than for ILC (86.1% vs 56.7%; p < 0.0001). Overall, direct-conversion molecular breast imaging showed all known invasive foci in 249 of 286 (87%) patients. CONCLUSION: Direct-conversion molecular breast imaging features of invasive cancer, including lesion type and intensity, differ by histologic subtype. Direct-conversion molecular breast imaging is less likely to show all foci of ILC compared with IDC.

Diagnostic workup and costs of a single supplemental molecular breast imaging screen of mammographically dense breasts.

OBJECTIVE: The purpose of this study was to examine additional diagnostic workup and costs generated by addition of a single molecular breast imaging (MBI) examination to screening mammography for women with dense breasts. SUBJECTS AND METHODS: Women with mammographically dense breasts presenting for screening mammography underwent adjunct MBI performed with 300 MBq (99m)Tc-sestamibi and a direct-conversion cadmium-zinc-telluride dual-head gamma camera. All subsequent imaging tests and biopsies were tracked for a minimum of 1 year. The positive predictive value of biopsies performed (PPV3), benign biopsy rate, cost per patient screened, and cost per cancer detected were determined. RESULTS: A total of 1651 women enrolled in the study. Among the 1585 participants with complete reference standard, screening mammography alone prompted diagnostic workup of 175 (11.0%) patients and biopsy of 20 (1.3%) and yielded five malignancies (PPV3, 25%). Results of combined screening mammography plus MBI prompted diagnostic workup of 279 patients (17.6%) and biopsy of 67 (4.2%) and yielded 19 malignancies (PPV3, 28.4%). The benign biopsy rates were 0.9% (15 of 1585) for screening mammography alone and 3.0% (48 of 1585) for the combination (p < 0.001). The addition of MBI increased the cost per patient screened from $176 for mammography alone to $571 for the combination. However, cost per cancer detected was lower for the combination ($47,597) than for mammography alone ($55,851). CONCLUSION: The addition of MBI to screening mammography of women with dense breasts increased the overall costs and benign biopsy rate but also increased the cancer detection rate, which resulted in a lower cost per cancer detected than with screening mammography alone.

Background parenchymal uptake during molecular breast imaging and associated clinical factors.

OBJECTIVE. The purposes of this study were to describe the prevalence of background parenchymal uptake categories observed at screening molecular breast imaging (MBI) and to examine the association of background parenchymal uptake with mammographic density and other clinical factors. MATERIALS AND METHODS. Adjunct MBI screening was performed for women with dense breasts on previous mammograms. Two radiologists reviewed images from the MBI examinations and subjectively categorized background parenchymal uptake into four groups: photopenic, minimal-mild, moderate, or marked. Women with breast implants or a personal history of breast cancer were excluded. The association between background parenchymal uptake categories and patient characteristics was examined with Kruskal-Wallis and chi-square tests as appropriate. RESULTS. In 1149 eligible participants, background parenchymal uptake was photopenic in 252 (22%), minimal-mild in 728 (63%), and moderate or marked in 169 (15%). The distribution of categories differed across BI-RADS density categories (p < 0.0001). In 164 participants with extremely dense breasts, background parenchymal uptake was photopenic in 72 (44%), minimal-mild in 55 (34%), and moderate or marked in 37 (22%). The moderate-marked group was younger on average, more likely to be premenopausal or perimenopausal, and more likely to be using postmenopausal hormone therapy than the photopenic or minimal-mild groups (p < 0.0001). CONCLUSION. Among women with similar-appearing mammographic density, background parenchymal uptake ranged from photopenic to marked. Background parenchymal uptake was associated with menopausal status and postmenopausal hormone therapy but not with premenopausal hormonal contraceptives, phase of menstrual cycle, or Gail model 5-year risk of breast cancer. Additional work is necessary to fully characterize the underlying cause of background parenchymal uptake and determine its utility in predicting subsequent risk of breast cancer.

Journal club: molecular breast imaging at reduced radiation dose for supplemental screening in mammographically dense breasts.

OBJECTIVE. The purpose of this study was to assess the diagnostic performance of supplemental screening molecular breast imaging (MBI) in women with mammographically dense breasts after system modifications to permit radiation dose reduction. SUBJECTS AND METHODS. A total of 1651 asymptomatic women with mammographically dense breasts on prior mammography underwent screening mammography and adjunct MBI performed with 300-MBq (99m)Tc-sestamibi and a direct-conversion (cadmium zinc telluride) gamma camera, both interpreted independently. The cancer detection rate, sensitivity, specificity, and positive predictive value of biopsies performed (PPV3) were determined. RESULTS. In 1585 participants with a complete reference standard, 21 were diagnosed with cancer: two detected by mammography only, 14 by MBI only, three by both modalities, and two by neither. Of 14 participants with cancers detected only by MBI, 11 had invasive disease (median size, 0.9 cm; range, 0.5-4.1 cm). Nine of 11 (82%) were node negative, and two had bilateral cancers. With the addition of MBI to mammography, the overall cancer detection rate (per 1000 screened) increased from 3.2 to 12.0 (p < 0.001) (supplemental yield 8.8). The invasive cancer detection rate increased from 1.9 to 8.8 (p < 0.001) (supplemental yield 6.9), a relative increase of 363%, while the change in DCIS detection was not statistically significant (from 1.3 to 3.2, p =0.250). For mammography alone, sensitivity was 24%; specificity, 89%; and PPV3, 25%. For the combination, sensitivity was 91% (p < 0.001); specificity, 83% (p < 0.001); and PPV3, 28% (p = 0.70). The recall rate increased from 11.0% with mammography alone to 17.6% (p < 0.001) for the combination; the biopsy rate increased from 1.3% for mammography alone to 4.2% (p < 0.001). CONCLUSION. When added to screening mammography, MBI performed using a radiopharmaceutical activity acceptable for screening (effective dose 2.4 mSv) yielded a supplemental cancer detection rate of 8.8 per 1000 women with mammographically dense breasts.

Half-time Tc-99m sestamibi imaging with a direct conversion molecular breast imaging system.

BACKGROUND: In an effort to reduce necessary acquisition time to perform molecular breast imaging (MBI), we compared diagnostic performance of MBI performed with standard 10-min-per-view acquisitions and half-time 5-min-per-view acquisitions, with and without wide beam reconstruction (WBR) processing. METHODS: Eighty-two bilateral, two-view MBI studies were reviewed. Studies were performed with 300 MBq Tc-99 m sestamibi and a direct conversion molecular breast imaging (DC-MBI) system. Acquisitions were 10 min-per-view; the first half of each was extracted to create 5-min-per-view datasets, and WBR processing was applied.The 10-min-, 5-min-, and 5-min-per-view WBR studies were independently interpreted in a randomized, blinded fashion by two radiologists. Assessments of 1 to 5 were assigned; 4 and 5 were considered test positive. Background parenchymal uptake, lesion type, distribution of non-mass lesions, lesion intensity, and image quality were described. RESULTS: Considering detection of all malignant and benign lesions, 5 min-per-view MBI had lower sensitivity (mean of 70% vs. 85% (p ≤ 0.04) for two readers) and lower area under curve (AUC) (mean of 92.7 vs. 99.6, p ≤ 0.01) but had similar specificity (p = 1.0). WBR processing did not alter sensitivity, specificity, or AUC obtained at 5 min-per-view.Overall agreement in final assessment between 5-min-per-view and 10-min-per-view acquisition types was near perfect (κ = 0.82 to 0.89); however, fair to moderate agreement was observed for assessment category 3 (probably benign) (κ = 0.24 to 0.48). Of 33 malignant lesions, 6 (18%) were changed from assessment of 4 or 5 with 10-min-per-view MBI to assessment of 3 with 5-min-per-view MBI. Image quality of 5-min-per-view studies was reduced compared to 10-min-per-view studies for both readers (3.24 vs. 3.98, p < 0.0001 and 3.60 vs. 3.91, p < 0.0001). WBR processing improved image quality for one reader (3.85 vs. 3.24, p < 0.0001). CONCLUSIONS: Although similar radiologic interpretations were obtained with 10-min- and 5-min-per-view DC-MBI, resulting in substantial agreement in final assessment, notable exceptions were found: (1) perceived image quality at 5 min-per-view was lower than that for 10-min-per-view studies and (2) in a number of cases, assessment was downgraded from a recommendation of biopsy to that of short interval follow-up.

Pure lobular carcinoma of the breast presenting as a hyperechoic mass: incidence and imaging characteristics.

OBJECTIVE: The purpose of this study was to determine the proportion of invasive lobular carcinomas with increased sonographic echogenicity. MATERIALS AND METHODS: A retrospective review of mammographic and sonographic findings included cases of pure invasive lobular carcinoma with available images from January 1998 to June 2010. We assessed ultrasound images for the presence of a mass, internal echogenicity, margin characteristics, and attenuation effects. In hyperechoic tumors, more than 90% of the mass had increased echogenicity compared with surrounding fat. In heterogeneously echogenic tumors, the echogenic component constituted 20-90% of the tumor. Findings at mammography, MRI, and surgery were correlated with sonographic findings. A breast pathologist reviewed histologic findings and confirmed the diagnosis of pure invasive lobular carcinoma. RESULTS: Of 509 invasive lobular carcinomas, 27 (5%) were hyperechoic, of which 13 (48%) were associated with posterior acoustic shadowing. Heterogeneously echogenic cancer was seen in 57 (11%) cases. The most common sonographic finding was a hypoechoic, irregular mass with or without posterior shadowing (n = 323; 63%). In 66 (13%) lesions, focal shadowing was seen without a discrete mass. Fourteen (3%) lesions were isoechoic with respect to surrounding normal adipose tissue without acoustic shadowing. Twenty-two (4%) of the malignant tumors were not identified sonographically. Of these, 15 (68%) had mammographic abnormalities, one (5%) was seen at MRI, and six (27%) presented as palpable masses that were surgically excised. CONCLUSION: Pure invasive lobular carcinomas can present as a hyperechoic mass or with substantial hyperechoic component. All sonographic lesion characteristics should be evaluated and biopsy recommended when there are suspicious features, even in a lesion that is predominantly hyperechoic.

99mTc-sestamibi using a direct conversion molecular breast imaging system to assess tumor response to neoadjuvant chemotherapy in women with locally advanced breast cancer.

PURPOSE: The objective of this study was to determine the ability of breast imaging with 99mTc-sestamibi and a direct conversion-molecular breast imaging (MBI) system to predict early response to neoadjuvant chemotherapy (NAC). METHODS: Patients undergoing NAC for breast cancer were imaged with a direct conversion-MBI system before (baseline), at 3 to 5 weeks after onset, and after completion of NAC. Tumor size and tumor-to-background (T/B) uptake ratio measured from MBI images were compared with extent of residual disease at surgery using the residual cancer burden. RESULTS: Nineteen patients completed imaging and proceeded to surgical resection after NAC. Mean reduction in T/B ratio from baseline to 3 to 5 weeks for patients classified as RCB-0 (no residual disease), RCB-1 and RCB-2 combined, and RCB-3 (extensive residual disease) was 56% (SD, 0.20), 28% (SD, 0.20), and 4% (SD, 0.15), respectively. The reduction in the RCB-0 group was significantly greater than in RCB-1/2 (P = 0.036) and RCB-3 (P = 0.001) groups. The area under the receiver operator characteristic curve for determining the presence or absence of residual disease was 0.88. Using a threshold of 50% reduction in T/B ratio at 3 to 5 weeks, MBI predicted presence of residual disease at surgery with a diagnostic accuracy of 89.5% (95% confidence interval [CI], 0.64%-0.99%), sensitivity of 92.3% (95% CI, 0.74%-0.99%), and specificity of 83.3% (95% CI, 0.44%-0.99%). The reduction in tumor size at 3 to 5 weeks was not statistically different between RCB groups. CONCLUSIONS: Changes in T/B ratio on MBI images performed at 3 to 5 weeks following initiation of NAC were accurate at predicting the presence or absence of residual disease at NAC completion.

Preoperative axillary imaging with percutaneous lymph node biopsy is valuable in the contemporary management of patients with breast cancer.

BACKGROUND: ACOSOG Z11 and other studies showing little benefit to axillary dissection (ALND) for early-stage breast cancers with limited nodal disease have led to questioning the value of preoperative axillary imaging ± ultrasound-guided needle biopsy (USNB). Data are lacking on the value of this approach in identifying cases that fall outside Z11 guidelines. METHODS: We studied 988 consecutive patients with invasive breast cancers who underwent operation including axillary surgery in 2010-2011. RESULTS: Preoperative axillary ultrasonography (AUS) was performed in 92% and breast/axillary magnetic resonance imaging (MRI) in 51%; 82 (33.5%) of 245 patients with suspicious lymph nodes (LN) were USNB-positive. Regarding nodal status, AUS, MRI, and USNB had negative and positive predictive values of 78%, 76%, 70% and 54%, 58%, 100%, respectively. AUS/MRI visualization of one versus multiple abnormal LNs visualized predicted >2LN+ on final pathology (13.5%/15.1% % vs 30.8%/32.6%, P < .009). Among USNB-LN+ T1/T2 patients, 51.6% had 1-2 LN+ while 60% with multiple and 31% with one AUS-abnormal LN(s) had > 2LN+, P = .001. CONCLUSION: In our contemporary series, preoperative AUS±USNB streamlined surgical care for 29% of node-positive patients. Two-thirds of T1/T2 USNB-LN+ patients with multiple AUS-suspicious LNs had >2LN+, suggesting they should undergo ALND without SLNB. AUS±USNB helps identify node-positive breast cancer patients who fall outside Z11 guidelines.

Novel factors to improve prediction of nodal positivity in patients with clinical T1/T2 breast cancers.

BACKGROUND: Memorial Sloan Kettering Cancer Center (MSKCC) and MD Anderson Cancer Center (MDACC) have established nomograms to predict sentinel node positivity. We propose the addition of two novel variables-distance of tumor from the nipple and from the skin-can improve their performance. METHODS: Ultrasounds of clinical T1/T2 tumors were reviewed. Distances of the tumor from the skin and from the nipple were measured. MSKCC and MDACC nomogram predictions and the AUC-ROC for each model were calculated. The added utility of the two variables was then examined using multiple logistic regression. RESULTS: Of 401 cancers studied, 79 (19.7 %) were node positive. The mean distance of tumors from the nipple in node-positive patients was 4.9 cm compared with 6.0 cm in node-negative patients (p = 0.0007). The mean distance of tumors from the skin was closer in node-positive cases (0.8 cm) versus node-negative cases (1.0 cm, p = 0.0007). The MSKCC and MDACC nomograms AUC-ROC values were 0.71 (95 % CI 0.64-0.77) and 0.74 (95 % CI 0.68-0.81). When adjusted for the MSKCC predicted probability, addition of both distance from nipple (p = 0.008) and distance from skin (p = 0.02) contributed significantly to prediction of nodal positivity and improved the AUC-ROC to 0.75 (95 % CI 0.70-0.81). Similarly, distance from nipple (p = 0.002), but not distance from skin (p = 0.09), added modestly to the MDACC nomogram performance (AUC 0.77; 95 % CI 0.71-0.83). CONCLUSIONS: Distance of tumor from the nipple and from the skin are important variables associated with nodal positivity. Adding these to established nomograms improves prediction of nodal positivity.

Imaging response and residual metastatic axillary lymph node disease after neoadjuvant chemotherapy for primary breast cancer.

BACKGROUND: Although surgical management of the breast after neoadjuvant chemotherapy (NAC) may be governed by treatment response, axillary management continues to be determined by stage at presentation. Axillary ultrasound (AUS) with fine-needle aspiration (FNA) is used to detect lymph node (LN) metastases for pre-NAC staging, but imaging assessment of treatment response in the axilla remains undefined. We evaluated post-NAC axillary imaging and surgical pathology to understand how imaging might direct axillary surgery. METHODS: We evaluated pre- and post-NAC axillary imaging and clinicopathologic data in 272 patients who received NAC for primary breast cancer and underwent operation at our institution from 2010 to 2012. Treatment response on imaging was categorized as complete (CR), partial (PR), and none/progression (NR). RESULTS: Pre-NAC axillary staging classified patients as AUS negative/no FNA (n = 61), FNA/LN negative (n = 42), and FNA/LN positive (n = 169). Post-NAC axillary imaging included AUS (n = 146), MRI (n = 139), and PET-CT (n = 38). At operation, 128 of 272 patients (47 %) were LN positive: 23.3 % (24 of 103) of cN0 and 61.5 % (104 of 169) of cN1-AUS/FNA-positive patients at presentation. Of the 65 cN1-ypN0 patients, 58.1 % (25 of 43) had an imaging CR by US, 58.6 % (17 of 29) by MRI, and 84.6 % (11 of 13) by PET-CT. The sensitivity of post-NAC axillary imaging in detecting persistent LN metastases for cN1-AUS/FNA-positive patients was 69.8 % for US, 61.0 % for MRI, and 63.2 % for PET-CT. CONCLUSIONS: Performance characteristics of AUS, MRI, and PET-CT, while informative, were inadequate to preclude surgical axillary staging of in breast cancer patients after NAC. Whether this information might be used to tailor surgical and postsurgical treatment requires further investigation.

Invasive micropapillary carcinoma of the breast: imaging features with clinical and pathologic correlation.

OBJECTIVE: The purpose of this article is to present imaging findings of invasive ductal carcinoma with micropapillary features with clinical and pathologic correlation. MATERIALS AND METHODS: We retrospectively searched our institution's surgical pathology database for patients with pathologically proven invasive ductal carcinoma with micropapillary features. Forty-one patients with images available for review were included in the study. Mammographic, sonographic, and MRI findings were assessed using the American College of Radiology's BI-RADS lexicon. Molecular breast imaging findings were reviewed using a molecular breast imaging lexicon. Imaging findings were correlated with clinical presentation and pathologic findings. RESULTS: Mammographically, the most common finding was an irregular spiculated mass. Sonographically, the most common finding was an irregular hypoechoic mass with spiculated margins and posterior acoustic shadowing. With MRI, the most common finding was an irregular mass with washout kinetics, but we also observed diffuse heterogeneous nonmasslike enhancement throughout the breast. Molecular breast imaging was available for one patient and showed multicentric radiotracer uptake. Analysis of 39 pathologic specimens showed 27 (69%) with angiolymphatic invasion. Axillary nodal metastases were present in 23 patients (59%), nine (23%) with extranodal extension. CONCLUSION: The imaging features of invasive ductal carcinoma of the breast with micropapillary features typically were highly suggestive of malignancy. The malignancies were strongly associated with lymphovascular invasion and lymph node metastases. Radiologists should be aware of the imaging features of this unusual variant and should consider axillary sonography if this entity is found in a core needle biopsy specimen.

Management of benign intraductal solitary papilloma diagnosed on core needle biopsy.

BACKGROUND: The purpose of this study was to determine whether surgical excision of benign solitary intraductal papillomas (BSIP) diagnosed by core needle biopsy (CNBx) without an associated high-risk lesion and concordant with imaging is justified. METHODS: A review of all papillary lesions diagnosed by CNBx from January 2003 to June 2010 was performed. Available histologic and radiologic materials were evaluated in a blinded fashion by three pathologists and three dedicated breast radiologists, respectively, to assess for concordance. The papillary lesions were designated as benign, atypical, or malignant. There were 16 BSIPs excluded because of an adjacent high-risk lesion or same-quadrant ipsilateral cancer. All immediate and delayed excisional specimens were reviewed. Clinical and radiologic data were recorded. RESULTS: A total of 299 papillary lesions diagnosed on CNBx and concordant with imaging were identified. Of these, 240 (80 %) were classified as benign, 49 (16 %) atypical, and 10 (3 %) malignant. After exclusions, 77 of 224 women in our study cohort (34 %) underwent surgical excision with no atypical or malignant upgrades. Of the remaining 147 women diagnosed with a BSIP on CNBx, 47 (32 %) were lost to follow-up and 100 (68 %) were observed. All 100 observed patients had stable imaging findings at follow-up (4.8-93.8 months, mean 36.0 months). CONCLUSIONS: The likelihood of diagnosing atypia or malignancy after surgical excision of a BSIP diagnosed on CNBx without associated high-risk lesion or ipsilateral quadrant malignancy is extremely low. For this distinct subset of patients with a BSIP, these data justify close imaging follow-up, rather than surgical excision.

Imaging of the adolescent breast.

The mainstay of breast imaging in the adolescent is ultrasonography. There is occasionally a need for additional imaging, particularly with magnetic resonance imaging (MRI). Imaging of the adolescent breast differs substantially from the adult in both the imaging modalities utilized and the relative likelihood of pathologies encountered. The majority of lesions in the adolescent are benign, but the presence of a breast lesion may cause anxiety to patients and their families due to the wide awareness of breast malignancy in the adult population. It is important to be aware of the imaging modalities available to image the adolescent breast to prevent unnecessary radiation exposure while answering the clinical question. The current recommendations for adolescent diagnostic and screening breast imaging will be reviewed. Benign breast lesions such as fibroadenomas, fibrocystic change, pseudoangiomatous stromal hyperplasia, gynecomastia, and posttraumatic or infectious lesions with their associated imaging findings and management will be outlined. Additionally, review of breast malignancies that can affect adolescents will provide the reader with features to distinguish benign from malignant processes in the adolescent based on imaging findings and clinical presentation.

Nonsurgical management of fibroadenoma and virginal breast hypertrophy.

The management and treatment of an adolescent presenting with a fibroadenoma or virginal breast hypertrophy can be challenging as there is a paucity of original research on these conditions. Although surgical therapies are often discussed as first-line therapy in adolescents presenting with a breast mass, it is prudent that nonsurgical interventions and medical therapies be considered as initial therapy with the goal of maintaining an acceptable cosmetic outcome.

Distance of breast cancer from the skin and nipple impacts axillary nodal metastases.

BACKGROUND: Lymphatic drainage of the breast is via subareolar and dermal lymphatics. The aim of this study was to determine whether distance of breast cancers from the skin and/or distance from the nipple impacts the likelihood of axillary nodal metastases. METHODS: A retrospective review was performed of sonographically visible T1 and T2 breast cancers with breast and axillary surgery performed at Mayo Clinic, Rochester, MN. Distance of tumor from the nipple was reviewed. Ultrasounds were reviewed to measure the distance of tumor from the skin. RESULTS: Data were collected on 233 eligible T1 or T2 breast cancers, of which 177 (76%) were node negative and 56 (24%) were node positive. On multivariable analysis, tumor stage and lymphovascular invasion, as well as decreasing distance of the tumor from the nipple and decreasing distance of the tumor from the skin, were significantly associated with axillary lymph node positivity. Each 1-cm decrease in the distance of the tumor from the nipple was associated with a 23% increased likelihood of positive lymph nodes (odds ratio 1.23; P = .003). Each 1-mm decrease in the distance of the tumor from the skin was associated with a 15% increased likelihood of positive lymph nodes (odds ratio 1.15; P = .003). CONCLUSION: T1 and T2 breast cancers located closer to the skin and those located closer to the nipple have a higher incidence of metastases to axillary lymph nodes. Distance from the skin and distance from the nipple should be considered when estimating a patient's likelihood of axillary nodal positivity.

Imaging features of carcinoid tumors metastatic to the breast.

The objective of this study was to describe the imaging findings of carcinoid tumors metastatic to the breast, with pathologic and clinical correlations. We searched our surgical database for cases of pathologically proven carcinoid tumors metastatic to the breast from October 1, 2000, to May 31, 2010. Of the approximate 10,000 breast biopsies identified, 7000 had malignant findings. Ten cases of metastatic carcinoid (0.1% of all malignancies), all with imaging studies available for review, were included in the study. All patients were women and had their primary carcinoid in the gastrointestinal tract (n=9) or lung (n = 1). One patient presented with a palpable breast mass and no history of carcinoid tumor; an ileal carcinoid was discovered after the pathologic diagnosis of metastatic carcinoid was established. In the breast, tumors presented as solitary lesions in half the cases. Metastases to the breast typically presented as circumscribed masses mammographically and as hypoechoic circumscribed masses ultrasonographically; some showed increased through-transmission and increased vascularity with color Doppler evaluation. Five patients had octreotide scans; of these, 4 had increased focal activity in the region of metastasis within the breast. Six patients underwent computed tomography. Without contrast, nodular masses were observed; with contrast, the masses showed rapid enhancement during arterial phase imaging. Magnetic resonance imaging (n = 4) also showed rapid enhancement and washout kinetics after contrast administration. Recognition of carcinoid metastases to the breast in patients with known or occult primary carcinoid tumors is important to avoid unnecessary treatment for primary breast cancer.

Pseudoangiomatous stromal hyperplasia: imaging findings with pathologic and clinical correlation.

OBJECTIVE: The purpose of this article is to describe the imaging characteristics of pseudoangiomatous stromal hyperplasia, where the primary histologic component was pseudoangiomatous stromal hyperplasia. CONCLUSION: The tumoral form of pseudoangiomatous stromal hyperplasia is rare. The most common mammographic and sonographic finding is a circumscribed mass. Its appearance on MRI is nonspecific, but it may present as clumped nonmasslike persistent enhancement on contrast-enhanced imaging. Biopsy guided by MRI may be necessary to confirm the diagnosis.