Faculty Bibliography

OBJECTIVE: The purpose of this study was to evaluate the usefulness of MRI of the breast in cases in which mammographic or sonographic findings are inconclusive. MATERIALS AND METHODS: We retrospectively reviewed images from 115 MRI examinations of the breast performed from 1999 to 2005 for the indication of problem-solving for inconclusive findings on a mammogram. Forty-eight of the 115 women (41.8%) were at high risk. We discerned whether sonography or MRI was used as an adjunctive tool and correlated the findings with those in the pathology database. RESULTS: The equivocal findings most frequently leading to MRI were asymmetry and architectural distortion. No suspicious MRI correlate was found in 100 of 115 cases (87%). These cases were found stable at follow-up mammography or MRI after a mean of 34 months. Fifteen enhancing masses (13%) that corresponded to the mammographic abnormality were seen on MR images. All masses identified at MRI were accurately localized for biopsy, and six malignant lesions were identified. Four of six malignant tumors were seen in one mammographic view only; two were seen on second-look ultrasound images. MRI had a sensitivity of 100% and compared with mammography had significantly higher specificity (91.7% vs 80.7%, p = 0.029), positive predictive value (40% vs 8.7%, p = 0.032), and overall accuracy (92.2% vs 78.3%, p = 0.0052). Eighteen incidental lesions (15.7%) were detected at MRI, and all were subsequently found benign. CONCLUSION: We found breast MRI to be a useful adjunctive tool when findings at conventional imaging were equivocal. Strict patient selection criteria should be used because of the high frequency of incidental lesions seen on MR images

Triple negative breast cancer has recently been recognized as a distinct subtype of breast cancer. While TNBC and basal-type breast cancers are not identical, the terms are often used synonomously. TNBC have a poorer prognosis than other molecular subtypes of breast cancer. There are no known targeted agents, leaving chemotherapy as the primary adjuvant therapy. TNBC are associated with BRCA1 mutations, are more common in African-American women, and have a more aggressive clinical course, with high early rates of metastatic disease and early relapse. Current research is examining epidemiologic features associated with TNBC, and searching for effective targeted therapy

The educational objectives for this self-assessment module on the interpretation and clinical applications of breast MRI are for the participant to exercise, self-assess, and improve his or her understanding of the imaging and clinical features of cancer and other breast masses on MRI

OBJECTIVE: We evaluated the benefit of placing a marker under sonographic guidance at the time of localization to aid in identifying mammographically occult lesions within the specimen at the time of surgical excision and to evaluate margin status. MATERIALS AND METHODS: We reviewed 135 sonographically guided needle localizations performed on mammographically occult lesions. Imaging during the localization procedure, marker placement, and specimen radiographs were reviewed, and the findings were correlated with the histopathologic findings. RESULTS: Of the 135 mammographically occult lesions, 77 were localized without marker placement and 58 with marker placement. The 58 localizations with marker placement were for masses with a mean lesion size of 9 mm. Specimen radiography of these lesions showed a marker within the specimen in 56 cases (97%) and visualization of the lesion in only seven cases (12%). Specimen radiography of localizations without marker placement showed visualization of the lesion in 18 cases (23%). Of the 11 malignant lesions (19%) localized with marker placement, none had a positive inked margin, but five (46%) had close margins necessitating reexcision. Of the 26 malignant lesions (34%) localized without marker placement, two (8%) had a positive inked margin, and eight (31%) had close margins necessitating reexcision. CONCLUSION: At needle localization of breast lesions, marker placement under sonographic guidance is beneficial because it enables immediate confirmation of accurate surgical removal of the localized lesion at surgical excision. Use of marker placement, however, does not reduce the percentage of cases with close margins necessitating reexcision

CONTEXT: Both atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS) have traditionally been considered to be risk factors for the development of invasive carcinoma and are followed by close observation. Recent studies have suggested that these lesions may represent true precursors with progression to invasive carcinoma. Due to the debate over the significance of these lesions and the small number of cases reported in the literature, the treatment for lobular neoplasia diagnosed by percutaneous core biopsy (PCB) remains controversial. OBJECTIVE: To review our experience with pure LCIS or ALH diagnosed by PCB and correlate the radiologic findings and surgical excision diagnoses to develop management guidelines for lobular neoplasia diagnosed by PCB. DESIGN: We searched the pathology database for patients who underwent PCB with a diagnosis of either pure LCIS or ALH and had subsequent surgical excision. We compared the core diagnoses with the surgical excision diagnoses and the radiologic findings. RESULTS: Thirty-eight PCBs with a diagnosis of ALH (18 cases) or LCIS (20 cases) were identified. Carcinoma was present at excision in 1 (6%) of the ALH cases and in 2 (10%) of the LCIS cases. In summary, 8% (3/38) of PCBs diagnosed as lobular neoplasia (ALH or LCIS) were upgraded to carcinoma (invasive carcinoma or ductal carcinoma in situ) at excision. CONCLUSIONS: Surgical excision is indicated for all PCBs diagnosed as ALH or LCIS, as a significant percentage will show carcinoma at excision

Ductal carcinoma in situ with microinvasion (DCISM) is a distinct clinicopathologic entity. Its true metastatic potential has been unclear, due in part to historical differences in the definition of microinvasion. The role of routine axillary staging for DCISM is controversial, given the reportedly low incidence of axillary metastases. We describe our institutional experience with DCISM, and define the role of axillary staging. A retrospective analysis was made of patients with DCISM. Forty-four patients underwent axillary staging (24 axillary lymph node dissection [ALND], 22 sentinel node biopsy [SNB]). Macrometastatic disease was present in three patients (7%), and two patients had isolated tumor cells (itc) in the sentinel node. Patients with axillary metastases tended to be younger. Comedonecrosis, nuclear grade, multifocal microinvasion or presentation as a clinical mass was not associated with a higher rate of axillary metastases. In this series, 7% of patients had macrometastatic disease, and two patients (5%) had itc only. Axillary staging is indicated, and SNB is appropriate for the identification of axillary metastatic disease