Faculty Bibliography

OBJECTIVE. The purposes of this study were to determine the frequency of underestimation of high-risk lesions at MRI-guided 9-gauge vacuum-assisted breast biopsy and to determine the imaging and demographic characteristics predictive of lesion upgrade after surgery. MATERIALS AND METHODS. We retrospectively reviewed consecutively detected lesions that were found only at MRI and biopsied under MRI guidance from May 2007 to April 2012. Imaging indications, imaging features, and histologic findings were reviewed. The Fisher exact test was used to assess the association between characteristics and lesion upgrade. Patients lost to follow-up or who underwent mastectomy were excluded, making the final study cohort 140 women with 151 high-risk lesions, 147 of which were excised. RESULTS. A database search yielded the records of 1145 lesions in 1003 women. Biopsy yielded 252 (22.0%) malignant tumors, 184 (16.1%) high-risk lesions, and 709 (61.9%) benign lesions. Thirty of the 147 (20.4%) excised high-risk lesions were upgraded to malignancy. The upgrade rate was highest for atypical ductal hyperplasia, lobular carcinoma in situ, and radial scar. No imaging features were predictive of upgrade. However, there was a significantly higher risk that a high-risk lesion would be upgraded to malignancy if the current MRI-detected high-risk lesion was in the same breast as a malignant tumor previously identified in the remote history, a recently diagnosed malignant tumor, or a high-risk lesion previously identified in the remote history (p = 0.0001). The upgrade rate was significantly higher for women with a personal cancer history than for other indications combined (p = 0.0114). CONCLUSION. The rate of underestimation of malignancy in our series was 20%. No specific imaging features were seen in upgraded cases. Surgical excision is recommended for high-risk lesions found at MRI biopsy and may be particularly warranted for women with a personal history of breast cancer.

Objective: To investigate the frequency, imaging features, and surgical outcome of papillary lesions identified at 3-T MRI. Materials and Methods: This HIPAA-compliant institutional review board-approved retrospective study evaluated papillary lesions detected on MRI and sampled with either MR-guided 9-gauge vacuum assisted biopsy (VAB) or ultrasound-guided biopsy from 2008 to 2010. Lesion description, size, BI-RADS category, percutaneous biopsy results (MR-guided, ultrasound-guided, or stereotactic) and any upgrade at final excision were recorded for each lesion. Results: In total, 23 cases of pathology proven MRI-detected papillary lesions were identified in 22 patients. The indication for the initial MR study was a personal history of breast cancer in 13 (59%), a history of high-risk lesions in 2 patients (9%), a history of family history of breast cancer in 1 patient (5%), and other indications in 6 patients (27%). Nine papillary lesions presented as nonmasslike enhancement (NMLE), 13 presented as masses, and one presented as a focus on MR. Eight lesions had a sonographic correlate and were biopsied under ultrasound guidance; of this group, 6 cases were masses and 2 were NMLE. Those lesions with a correlate had a mean size of 1.7 cm, larger than those lesions without a correlate (mean of 1.3 cm), but the difference in means was not statistically significant. Nine of 23 cases (39%) of papillary lesions were in a retroareolar location. Of the 13 masses, 8 cases had irregular margins (62%). No kinetic features were identified more frequently in papillary lesions. In 7 cases (30%), the initial biopsy found additional high risk lesion(s) in association with the papillary finding. Two (8.7%) papillary lesions with associated high-risk lesions were upgraded to DCIS at surgical excision. One of these was found on ultrasound and the other on MR-guided biopsy. There were no cases of an isolated papillary lesion being upgraded to DCIS or invasive carcinoma. Conclusion: Review of the MR findings demons!

OBJECTIVE: Imaging of the male breast is most often performed for the evaluation of a clinical abnormality such as breast enlargement or tenderness, a palpable mass, nipple skin changes, or nipple discharge. Most breast lesions encountered in men are benign. Malignant breast lesions are less frequent; breast cancer accounts for less than 1% of all male cancers in the United States. The initial imaging evaluation of a finding in the male breast is performed with mammography. Sonography is frequently used as an adjunct to mammography but is less often used as the primary imaging modality. The objective of this article is to provide readers with a thorough review of the sonographic appearances of benign and malignant male breast disease. METHODS: We reviewed our institution's case database to identify male patients who underwent mammography, sonography, and subsequent biopsy of a breast lesion. These cases were collected and reviewed to select the best imaging examples. RESULTS: A spectrum of benign and malignant male breast disease is presented with corresponding sonographic, mammographic, and pathologic imaging. For each entity, the salient imaging findings and typical clinical presentation are discussed. CONCLUSIONS: Most studies in the literature have reported on the mammographic and sonographic imaging features of primary breast carcinoma in men. However, very little has been reported on the sonographic appearance of benign and malignant male breast conditions. Recognition and correct identification of pathologic male breast entities on sonography is essential to determine appropriate management recommendations and avoid unnecessary biopsies

The technical requirements for magnetic resonance imaging (MRI) of the breasts are challenging because high temporal and high spatial resolution are necessary. This article describes the necessary equipment and pulse sequences for performing a high-quality study. Although imaging at 3-Tesla (T) has a higher signal-to-noise ratio, the protocol needs to be modified from the 1.5-T system to provide optimal imaging. The article presents the requirements for performing breast MRI and discusses techniques to ensure high-quality examinations on 1.5-T and 3-T systems

OBJECTIVE: The purpose of our study was to describe the clinical features, imaging characteristics, pathologic findings and outcome of microinvasive ductal carcinoma in situ (DCISM). MATERIALS AND METHODS: The records of 21 women diagnosed with microinvasive ductal carcinoma in situ (DCISM) from November 1993 to September 2006 were retrospectively reviewed. The clinical presentation, imaging and histopathologic features, and clinical follow-up were reviewed. RESULTS: The 21 lesions all occurred in women with a mean age of 56 years (range, 27-79 years). Clinical findings were present in ten (48%): 10 with palpable masses, four with associated nipple discharge. Mean lesion size was 21mm (range, 9-65mm). The lesion size in 62% was 15mm or smaller. Mammographic findings were calcifications only in nine (43%) and an associated or other finding in nine (43%) [mass (n=7), asymmetry (n=1), architectural distortion (n=1)]. Three lesions were mammographically occult. Sonographic findings available in 11 lesions showed a solid hypoechoic mass in 10 cases (eight irregular in shape, one round, one oval). One lesion was not seen on sonography. On histopathologic examination, all lesions were diagnosed as DCISM, with a focus of invasive carcinoma less than or equal to 1mm in diameter within an area of DCIS. Sixteen (76%) lesions were high nuclear grade, four (19%) were intermediate and one was low grade (5%). Sixteen (76%) had the presence of necrosis. Positivity for ER and PR was noted in 75% and 38%. Nodal metastasis was present in one case with axillary lymph node dissection. Mean follow-up time for 16 women was 36 months without evidence of local or systemic recurrence. One patient developed a second primary in the contralateral breast 3 years later. CONCLUSION: The clinical presentation and radiologic appearance of a mass are commonly encountered in DCISM lesions (48% and 57%, respectively), irrespective of lesion size, mimicking findings seen in invasive carcinoma. Despite its potential for nodal metastasis (5% in our series), mean follow-up at 36 months was good with no evidence of local or systemic recurrence at follow-up. Knowledge of these clinical and imaging findings in DCISM lesions may alert the clinician to the possibility of microinvasion and guide appropriate management