Circumscribed Masses on Breast MRI: Can MRI Features Guide Management?

OBJECTIVE: Management of circumscribed breast masses seen on MRI is largely extrapolated from mammography and US data with limited MRI-specific data available. This study aimed to assess clinical and MRI imaging features of malignant circumscribed breast masses. METHODS: In this IRB-approved retrospective study, breast MRIs performed between April 1, 2008, and August 30, 2020, containing circumscribed masses, excluding multiple bilateral circumscribed masses, were reviewed. Clinical and imaging features of all eligible masses were recorded, and associations with malignant outcomes were assessed using Fisher's exact test and Wilcoxon rank sum test, with P < 0.05 considered significant. RESULTS: For the 165 masses that met study criteria in 158 women, the mean age was 48 years (SD 12.0 years). Nine of 165 masses were malignant (5.5%). Round masses were significantly more likely to be malignant (7/37, 18.9%) compared to oval masses (2/128, 1.7%) (P < 0.001). Among masses with available dynamic contrast kinetics data, the malignancy rate was 0/84 (0%) for persistent kinetics, 2/23 (8.7%) for plateau kinetics, and 4/24 (16.7%) for washout kinetics (P = 0.002). The malignancy rate for oval masses without washout kinetics was 0% (0/92). T2 hyperintense masses had a malignancy rate of 7/104 (6.7%), and homogeneously enhancing masses had a malignancy rate of 5/91 (5.5%). CONCLUSION: These data support the use of mass shape and dynamic contrast enhancement kinetics to guide management of circumscribed breast masses seen by MRI, with oval masses without washout kinetics and any circumscribed mass with persistent kinetics showing no malignancies in this study.

High-risk lesions in the breast diagnosed by MRI-guided core biopsy: upgrade rates and features associated with malignancy.

PURPOSE: This study assessed the upgrade rates of high-risk lesions (HRLs) in the breast diagnosed by MRI-guided core biopsy and evaluated imaging and clinical features associated with upgrade to malignancy. METHODS: This IRB-approved, retrospective study included MRI-guided breast biopsy exams yielding HRLs from August 1, 2011, to August 31, 2020. HRLs included atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), radial scar, and papilloma. Only lesions that underwent excision or at least 2 years of MRI imaging follow-up were included. For each HRL, patient history, imaging features, and outcomes were recorded. RESULTS: Seventy-two lesions in 65 patients were included in the study, with 8/72 (11.1%) of the lesions upgraded to malignancy. Upgrade rates were 16.7% (2/12) for ADH, 100% (1/1) for pleomorphic LCIS, 40% (2/5) for other LCIS, 0% (0/19) for ALH, 0% (0/18) for papilloma, and 0% (0/7) for radial scar/complex sclerosing lesion. Additionally, two cases of marked ADH bordering on DCIS and one case of marked ALH bordering on LCIS, were upgraded. Lesions were more likely to be upgraded if they presented as T2 hypointense (versus isotense, OR 6.46, 95% CI 1.27-32.92) or as linear or segmental non-mass enhancement (NME, versus focal or regional, p = 0.008). CONCLUSION: Our data support the recommendation that ADH and LCIS on MRI-guided biopsy warrant surgical excision due to high upgrade rates. HRLs that present as T2 hypointense, or as linear or segmental NME, should be viewed with suspicion as these were associated with higher upgrade rates to malignancy.

Outcomes of Canceled Tomosynthesis-Guided Biopsy of Architectural Distortion Due to Nonvisualization.

Objective: Architectural distortion without a sonographic correlate is an indication for digital breast tomosynthesis-guided vacuum-assisted biopsy (DBT-VAB). However, when the finding is not visualized on the day of biopsy, the procedure is canceled. This study reports the outcomes of canceled DBT-VAB of architectural distortion due to nonvisualization. Methods: In this IRB-approved retrospective study, chart review was performed to identify DBT-VABs of architectural distortion at our institution between June 1, 2017, and November 1, 2020, that were canceled because of nonvisualization at the time of biopsy. Cases without follow-up imaging were excluded. Statistical analysis, including the frequency of cases yielding malignancy by the end of the study period, was performed. Results: In total, 7.2% (39/544) of architectural distortions recommended for biopsy during the study period were canceled because of nonvisualization, 30 of which had follow-up imaging and were included in the study. Mean patient age was 56 years (standard deviation [SD], 9.6 years) and mean follow-up time was 26.7 months (SD, 11.2 months; range, 8.4-50.9 months). During the follow-up period, 16.7% (5/30) underwent repeat biopsy attempt, with one malignant result (1/30, 3.3%; SD, 18%; 95% confidence interval: 0.6%-16.7%). In total, 86.7% (26/30) of cases were declared benign during the follow-up period and 10% (3/30) remained stable with a BI-RADS 3 assessment category. Conclusion: During available follow-up, there was a low likelihood that distortions not visualized at the time of DBT-VAB represented malignancy (3.3%, 1/30). While this low malignancy rate is reassuring, imaging follow-up is warranted.

Breast Arterial Calcium: A Game Changer in Women's Cardiovascular Health?

In 2018, cardiovascular disease (CVD) was the leading cause of death among women, and current CVD prevention paradigms may not be sufficient in this group. In that context, it has recently been proposed that detection of calcification in breast arteries may help improve CVD risk screening and assessment in apparently healthy women. This review provides an overview of breast arterial anatomy; and the epidemiology, pathophysiology, and measurement of breast artery calcium (BAC); and discusses the features of the BAC-CVD link. The potential clinical applications that BAC may offer for CVD prevention in the context of current clinical practice guidelines and recommendations are also discussed. Finally, current gaps in evidence gaps are outlined, and future directions in the field are explored with a focus on the implementation of BAC mammography as a CVD risk-screening tool in routine clinical practice.

Coronary Artery Calcium Score: the "Mammogram" of the Heart?

PURPOSE OF REVIEW: To discuss the classic analogy of "coronary artery calcium (CAC) as a mammogram of the heart", by evaluating the conceptual strengths, weaknesses, opportunities, and threats of a potential cardiovascular disease (CVD) screening strategy using CAC in apparently healthy adults. RECENT FINDINGS: CAC is typically used for further CVD risk assessment. CAC is also currently being used as a screening test in specific subgroups of individuals, particularly in some Asian countries. Although this has yielded valuable insights on the determinants and pathophysiology of CVD, whether this approach results in improved clinical outcomes compared to other assessment and management approaches is currently unclear. Although CAC and mammograms share a number of characteristics, there are also important conceptual differences. The evidence supporting CAC, which is a robust CVD risk assessment tool, for CVD screening purposes is currently very limited, and further research is needed.

Breast Cancer Screening.

Breast cancer screening has become a controversial topic. Understanding the points of contention requires an appreciation of the conceptual framework underpinning cancer screening in general, knowledge of the strengths and limitations of available screening modalities, and familiarity with published clinical trial data. This review is data intense with the intention of presenting enough information to permit the reader to enter into the discussion with an ample knowledge base. The focus throughout is striking a balance between the benefits and harms of breast cancer screening.