Borderline breast lesions diagnosed at core needle biopsy: Can magnetic resonance mammography rule out associated malignancy? Preliminary results based on 79 surgically excised lesions

Contrast-enhanced mammography in the management of breast architectural distortions and avoidance of unnecessary biopsies

BACKGROUND

To assess contrast-enhanced mammography (CEM) in the management of BI-RADS3 breast architectural distortions (AD) in digital breast tomosynthesis (DBT).

METHODS

We retrospectively reviewed 328 women with 332 ADs detected on DBT between 2017 and 2021 and selected those classified as BI-RADS3 receiving CEM as problem-solving. In CEM recombined images, we evaluated AD's contrast enhancement (CE) according to its presence/absence, type, and size. AD with enhancement underwent imaging-guided biopsy while AD without enhancement follow-up or biopsy if detected in high/intermediate-risk women.

RESULTS

AD with enhancement were 174 (52.4%): 72 (41.4%) were malignant lesions, 102 (59.6%) false positive results: 28 (16%) B3 lesions, and 74 (42.5%) benign lesions. AD without enhancement were 158 (47.6%): 26 (16.5%) were subjected to biopsy (1 malignant and 25 benign) while the other 132 cases were sent to imaging follow-up, still negative after two years. CEM's sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and accuracy were 98.63%, 60.62%, 41.38%, 99.37%, and 68.98%. The AUC determined by ROC was 0.796 (95% CI, 0.749-0.844).

CONCLUSION

CEM has high sensitivity and NPV in evaluating BI-RADS3 AD and can be a complementary tool in assessing AD, avoiding unnecessary biopsies without compromising cancer detection.

Meta-analysis: Architectural distortion and breast MRI

BACKGROUND

The implementation of digital breast tomosynthesis has increased the detection of architectural distortion (AD). Managing this finding may be experienced as a clinical dilemma in daily practice. Breast Contrast-Enhanced MRI (CE-BMR) is a known modality in case of problem-solving tool for mammographic abnormalities. However, the data about AR and CE-BMR are scant.

OBJECTIVE

The purpose was to estimate the benefit of CE-BMR in the setting of architectural distortion detected mammographically through a systematic review and meta-analysis of the literature.

METHODS

A search of MEDLINE and EMBASE databases were conducted in 2020. Based on the PRISMA guidelines, an analysis was performed using the chi-square test of independence to determine if there was a significant association between the result of the test (positive or negative) and the participant condition (malignant or non-malignant).

RESULTS

Four studies were available. The negative predictive value (NPV) was 98.3% to 100%. The result of the chi-square indicated that there was significant association between the participant test result and the participant condition for the included publications (X(1,175)2= 84.051, p = 0.0001).

CONCLUSIONS

The high NPV could allow for deferral of a biopsy in favor of a short-interval imaging follow-up in the setting of a negative CE-BMR.

Diagnostic value of radiomics and machine learning with dynamic contrast-enhanced magnetic resonance imaging for patients with atypical ductal hyperplasia in predicting malignant upgrade

Purpose

To investigate whether radiomics features extracted from magnetic resonance imaging (MRI) of patients with biopsy-proven atypical ductal hyperplasia (ADH) coupled with machine learning can differentiate high-risk lesions that will upgrade to malignancy at surgery from those that will not, and to determine if qualitatively and semi-quantitatively assessed imaging features, clinical factors, and image-guided biopsy technical factors are associated with upgrade rate.

Methods

This retrospective study included 127 patients with 139 breast lesions yielding ADH at biopsy who were assessed with multiparametric MRI prior to biopsy. Two radiologists assessed all lesions independently and with a third reader in consensus according to the BI-RADS lexicon. Univariate analysis and multivariate modeling were performed to identify significant radiomic features to be included in a machine learning model to discriminate between lesions that upgraded to malignancy on surgery from those that did not.

Results

Of 139 lesions, 28 were upgraded to malignancy at surgery, while 111 were not upgraded. Diagnostic accuracy was 53.6%, specificity 79.2%, and sensitivity 15.3% for the model developed from pre-contrast features, and 60.7%, 86%, and 22.8% for the model developed from delta radiomics datasets. No significant associations were found between any radiologist-assessed lesion parameters and upgrade status. There was a significant correlation between the number of specimens sampled during biopsy and upgrade status (p = 0.003).

Conclusion

Radiomics analysis coupled with machine learning did not predict upgrade status of ADH. The only significant result from this analysis is between the number of specimens sampled during biopsy procedure and upgrade status at surgery.

Positive predictive value for malignancy of uncertain malignant potential (B3) breast lesions diagnosed on vacuum-assisted biopsy (VAB): is surgical excision still recommended?

PURPOSE

Breast lesions classified as of "uncertain malignant potential" represent a heterogeneous group of abnormalities with an increased risk of associated malignancy. Clinical management of B3 lesions diagnosed on vacuum-assisted breast biopsy (VABB) is still challenging: surgical excision is no longer the only available treatment and VABB may be sufficient for therapeutic excision. The aim of the present study is to evaluate the positive predictive value (PPV) for malignancy in B3 lesions that underwent surgical excision, identifying possible upgrading predictive factors and characterizing the malignant lesions eventually diagnosed. These results are compared with a subset of patients with B3 lesions who underwent follow-up.

METHODS

A total of 1250 VABBs were performed between January 2006 and December 2017 at our center. In total, 150 B3 cases were diagnosed and 68 of them underwent surgical excision. VABB findings were correlated with excision histology. A PPV for malignancy for each B3 subtype was derived.

RESULTS

The overall PPV rate was 28%, with the highest upgrade rate for atypical ductal hyperplasia (41%), followed by classical lobular neoplasia (29%) and flat epithelial atypia (11%). Only two cases of carcinoma were detected in the follow-up cohort, both associated with atypical ductal hyperplasia at VABB.

CONCLUSION

Open surgery is recommended in case of atypical ductal hyperplasia while, for other B3 lesions, excision with VABB only may be an acceptable alternative if radio-pathological correlation is assessed, if all microcalcifications have been removed by VABB, and if the lesion lacks high-risk cytological features.

KEY POINTS

• Surgical treatment is strongly recommended in case of ADH, while the upgrade rate in case of pure FEA, especially following complete microcalcification removal by VABB, may be sufficiently low to advice surveillance as a management strategy. • The use of 11-G- or 8-G-needle VABB, resulting in possible complete diagnostic excision of the lesion, can be an acceptable alternative in case of RS, considering open surgery only for selected high-risk patients. • LN management is more controversial: surgical excision may be recommended following classical LN diagnosis on breast biopsy if an additional B3 lesion is concurrently detected while in the presence of isolated LN with adequate radiological-pathological correlation follow-up alone could be an acceptable option.

Atypical ductal hyperplasia: breast DCE-MRI can be used to reduce unnecessary open surgical excision

PURPOSE

To evaluate the diagnostic performance of dynamic contrast-enhanced (DCE)-MRI in predicting malignancy after percutaneous biopsy diagnosis of atypical ductal hyperplasia (ADH).

METHODS AND MATERIALS

In this retrospective study, 68 lesions (66 women) with percutaneous biopsy diagnosis of ADH and pre-operative breast DCE-MRI performed between January 2016 and December 2017 were included. Two radiologists reviewed in consensus mammography, ultrasound, and MR images. The final diagnosis after surgical excision was used as standard of reference. Clinical and imaging features were compared in patients with and without upgrade to malignancy after surgery. The diagnostic performance of DCE-MRI in predicting malignant upgrade was evaluated.

RESULTS

A 9-gauge vacuum-assisted biopsy was performed in 40 (58.8%) cases and a 14-gauge core needle biopsy in 28 (41.2%) cases. Upgrade to malignancy was observed in 17/68 (25%) lesions, including 4/17 (23.5%) cases of invasive cancer and 13/17 (76.5%) cases of ductal carcinoma in situ (DCIS). In 16/17 (94.1%) malignant and 20/51 (39.2%) benign lesions, a suspicious enhancement could be recognized in DCE-MRI. The malignant lesion without suspicious enhancement was a low-grade DCIS (4 mm size). Sensitivity, specificity, positive predictive value, and negative predictive value of DCE-MRI on predicting malignancy were respectively 94.1%, 60.7%, 44.4%, and 96.8%. No other clinical or imaging features were significantly different in patients with and without upgrade to malignancy.

CONCLUSION

After a percutaneous biopsy diagnosis of ADH, malignancy can be ruled out in most of the cases, if no suspicious enhancement is present in the biopsy area at DCE-MRI. Breast DCE-MRI may be used to avoid surgery in more than half of the patients with final benign diagnosis.

KEY POINTS

• Breast DCE-MRI can safely rule out malignancy if no suspicious enhancement is present in the biopsy area after a percutaneous biopsy diagnosis of ADH. • All cases of upgrade to high-grade DCIS and invasive cancers can be identified at breast DCE-MRI after a percutaneous biopsy diagnosis of ADH. • Breast DCE-MRI may be used to avoid surgery in more than half of the patients with final benign diagnosis.

Can breast MRI accurately exclude malignancy in mammographic architectural distortion?

OBJECTIVES

To investigate the diagnostic accuracy of problem-solving breast magnetic resonance imaging (MRI) in excluding malignancy in a cohort of patients diagnosed with mammographic architectural distortion (MAD).

METHODS

The Institutional Review Board approved the study. Imaging database with 40,245 breast MRIs done between January 2008 and September 2018 was retrospectively reviewed. The study included all exams considered problem-solving MRI for MAD. Two radiologists reviewed the imaging data. Outcome was determined by the pathology results of biopsy/surgical excision or at least 1 year of clinical and radiological follow-up. Predictors for malignancy were examined, and appropriate statistical tests were applied.

RESULTS

One hundred seventy-five patients (median age 53 years) fulfilled the inclusion criteria and formed the study cohort. No cancers were diagnosed in 106 patients with a negative MRI. Out of 69 women with positive MRI findings, 48 (70%) had benign outcome defined either by pathology result or by negative follow-up, and 21 (30%) yielded malignancy. Malignancy was significantly associated with positive MRI (p < 0.001) and older age (p = 0.014). Falsely positive MRIs were frequently found in women with radial scars. The sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy of breast MRI were 100% (95% CI 84 to 100%), 68% (CI 61 to 76%), 100% (CI 95 to 100%), 30% (CI 26 to 36%), and 73% (95% CI 66-79), respectively.

CONCLUSION

A negative breast MRI in patients with MAD was reliable in excluding malignancy in this cohort and may have a role as a precision medicine tool for avoiding unnecessary interventions.

KEY POINTS

• MRI shows a high negative predictive value in MAD cases. • MRI displays low accuracy in differentiating malignancy from RS. • MRI is a reliable non-invasive method to exclude malignancy in women with mammographic architectural distortion, potentially avoiding unnecessary biopsies and surgeries.

Relative apparent diffusion coefficient (rADC) in breast lesions of uncertain malignant potential (B3 lesions) and pathologically proven breast carcinoma (B5 lesions) following breast biopsy

PURPOSE

To assess relative apparent diffusion coefficient (rADC) and ADC in B3 and B5 lesions in premenopausal female patients, added to standard morpho-dynamic breast contrast-enhanced MRI.

METHODS

104 patients with histologically confirmed B3 (N1 = 52) and matched B5 lesions (N2 = 52), were examined on MRI (1.5 T, full diagnostic protocol, diffusion weighted imaging - b50, b850) in a retrospective analysis following the IRB approval: Atypical ductal hyperplasia (ADH, n1 = 20), Flat epithelial atypia (FEA, n2 = 11), Classic lobular neoplasia (CLN, n3 = 8), Papillary lesion (PL, n4 = 6) and Phyllodes tumor (PT, n5 = 7). rADC and ADC were computed for each lesion. The two-tailed Mann-Whitney U test was used for comparison with B5 lesions.

RESULTS

Mean rADC value for B3 lesions, (N1 = 52): 0.81+/-0.08 mm2/s x 10-3 and B5 lesions, (N2 = 52): 0.58+/-0.07 mm2/s x 10-3 is statistically different (p < 0.00001). Mean rADC values [mm2/s x 10-3], per entity in B3 are: ADH, 0.82+/-0.06; FEA, 0.75+/-0.03; CLN, 0.73+/-0.03; PL, 0.94+/-0.02; PT 0.86+/-0.05.

CONCLUSIONS

Although morpho-dynamic features of borderline and malignant lesions may overlap, the initial results in this research, suggest the highly significant difference in both ADC and rADC between B3 and B5 lesions. Larger trials are needed to confirm the initial data.

Apparent diffusion coefficient value in breast papillary lesions without atypia at core needle biopsy

PURPOSE

The main aim of the study was to assess if the mean apparent diffusion coefficient (ADC) value was significantly different between papillary lesions (PL) without atypia and PLs with atypical or malignant foci. A secondary objective was to evaluate if patients mean age, MRI BI-RADS® descriptors and assessment category were significantly different between these two PL groups.

METHODS

In this eight year retrospective study were included 122 patients (mean age, 51 years; range, 24-78) with 122 PLs without atypia at micro-histological examination after core needle biopsy (CNB) performed under sonographic guidance. All patients underwent surgical excision biopsy within 3 months after CNB. All patients underwent MRI examination before surgical excision, including STIR, DWI and Dynamic Contrast-Enhanced sequences.

RESULTS

Mean ADC value difference between PLs without and with atypia or malignant foci was statistically significant (p < 0.0001). Mean ADC value optimal threshold in order to distinguish the two groups was 1.418 × 10^-3 mm²/s. A mean ADC value ≤ 1.418 × 10^-3 mm²/s could predict atypical or malignant foci within a PL with 83.9% sensitivity and 75.8% specificity. No statistically significant difference was found with regard to patients mean age, MRI BI-RADS® descriptors and assessment category between these two PL groups.

CONCLUSIONS

Mean ADC value of PLs without atypia at CNB is an efficient tool in order to help distinguish between PLs without and with atypical or malignant foci at final pathology on surgical excision, and it could be used to help decide how to manage these lesions.

Atypical Ductal Hyperplasia and Lobular Neoplasia: Update and Easing of Guidelines

OBJECTIVE. Atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and lobular carcinoma in situ (LCIS) are among high-risk lesions that have been previously recommended for surgical excision when diagnosed on core needle biopsy. Recent studies have examined whether imaging surveillance is a reasonable alternative to surgical management for these lesions. This article synthesizes the evidence regarding management of atypical hyperplasia and LCIS diagnosed on core needle biopsy and clinical implications of these diagnoses on future breast cancer risk as well as highlights areas of further research needed to improve practice guidelines for these high-risk lesions. CONCLUSION. Although surgical excision is still recommended after diagnosis of ADH on core needle biopsy, in specific circumstances ALH and LCIS can safely be managed by imaging surveillance.

Our Radiological Experience on B3 Lesions: Correlation Between Mammographic and MRI Findings With Histologic Definitive Result

INTRODUCTION

The purpose of this study was to evaluate mammographic and magnetic resonance imaging (MRI) features in B3 lesions.

PATIENTS AND METHODS

From 2011 to 2018, 139 patients with histologically proven B3 lesions who underwent mammography or/and MRI, were retrospectively reviewed. B3 lesions were classified in: atypical ductal hyperplasia (ADH), lobular neoplasia (LN), papillary lesion (PL), radial scar (RS), flat epithelial atypia (FEA), phyllodes tumor (PT), or mesenchymal lesion. Imaging features evaluated were: the presence of microcalcifications, mass and architectural distortions on mammograms and type of margins (circumscribed, irregular, spiculate), enhancement (mass-like, non-mass-like), size (≤ 15 mm, > 15 mm), and kinetics curves (I, II, III) on MRI. The definitive histologic results confirmed benign lesion or were upgraded to malignancy, and the positive predictive value was calculated.

RESULTS

Histologic classification of B3 lesions counted 45 (32.37%) ADH, 12 (8.63%) LN, 25 (17.99%) PL, 5 (3.61%) RS, 31 (22.31%) FEA, 20 (14.39%) PT, and 1 (0.70%) mesenchymal lesion. One hundred seven patients had mammography, and 38 had MRI. In 90 (65%) cases, the histologic diagnosis confirmed B3, in 15 (11%) cases, benign lesion, and in 34 (24%) cases, malignancies were found, with best positive predictive value for mesenchymal tumor (1), ADH (0.36), and FEA (0.4). Significant correlations comparing core needle biopsy groups and microcalcifications (P = .016) and presence of mass (P = .002) and comparing definitive histology with the presence of mass (P = .023), were found. Regarding MRI, the morphology correlated with core needle biopsy groups (P = .038); morphology (P = .024), dimension (P = .040), and kinetic curve (P = .005) correlated with malignancy.

CONCLUSIONS

The B3 category includes different entities, with various risk of malignancy; their heterogeneity is associated with specific mammographic and MRI features, although further confirmations are needed.

Role of contrast-enhanced spectral mammography in the post biopsy management of B3 lesions: Preliminary results

PURPOSE

To evaluate the role of contrast-enhanced spectral mammography (CESM) in the post biopsy management of breast lesions classified as lesions of uncertain malignant potential (B3) by core needle biopsy and vacuum-assisted biopsy (VAB).

METHODS

The local ethics committee approved this retrospective study and for this type of study formal consent is not required. A total of 42 B3 lesions in 40 women aged 41-77 years were included in our study. All patients underwent CESM 2-3 weeks after the biopsy procedure and surgical excision was subsequently performed within 60 days of the CESM procedure. Three radiologists reviewed the images independently. The results were then compared with histologic findings.

RESULTS

The sensitivity, specificity, and positive and negative predictive values for confirmed demonstration of malignancy at CESM were 33.3%, 87.2%, 16.7%, and 94.4% for reader 1; 66.7%, 76.9%, 18.2%, and 96.7% for reader 2; 66.7%, 74.4%, 16.7%, and 96.7% for reader 3. Overall agreement on detection of malignant lesions using CESM among readers ranged from moderate to substantial (κ = .451-.696), for categorization of BPE from moderate to substantial (κ = .562-.711), and for evaluation of lesion intensity enhancement from fair to moderate (κ = .346-.459).

CONCLUSION

In cases of Breast Imaging Reporting and Data System (BI-RADS) 1, BI-RADS 2, or BI-RADS 3 results at CESM, follow-up or VAB rather than surgical biopsy might be performed.

Do clinical and radiologic features help predict malignancy of B3 breast lesions without epithelial atypia (B3a)?

OBJECTIVES

To evaluate excision histology outcome of B3a lesions diagnosed at imaging-guided core biopsy and assess whether clinical and radiologic features may predict upgrade to malignancy.

METHODS

A total of 153 B3a lesions (74 papillomas, 51 radial scars and 28 fibro-epithelial lesions) that underwent surgical excision were assessed. PPV for malignancy in all B3a lesions and specific for each sub-category was evaluated. Multivariate analysis was conducted to identify association between clinical (age, family or personal history of breast cancer, symptoms), diagnostic findings (imaging modality, lesion size, final BI-RADS category) and final excision outcome.

RESULTS

Eleven (7%) of 153 B3a lesions were upgraded to malignancy. All carcinomas diagnosed on excision were non-high grade DCIS. Following features were significantly associated with malignancy: lesions identified only on mammography (3/21; 14%), both mammography and ultrasound (7/44; 16%), lesion size > 10 mm (10/74; 13.5%) and BI-RADS category 4-5 (8/29; 27.6%). The absence of residual microcalcification after biopsy was associated with decreased risk for malignancy (15/16[93.7%]; p = 0.0297). Lesion size > 10 mm (OR = 9.3832; 95%; p = 0.0398) and BI-RADS category 4-5 (OR = 12.6004; 95%; p = 0.0006) were found to be independent predictors of upgrade to malignancy.

CONCLUSIONS

B3a lesions are associated with low risk of malignancy at excision. Lesion size > 10 mm and BI-RADS 4-5 category may represent useful predictors of upgrade to malignancy.

Use of Breast Magnetic Resonance Imaging in Women Diagnosed With Atypical Ductal Hyperplasia at Core Needle Biopsy Helps Select Women for Surgical Excision

PURPOSE

The study sought to investigate the role of breast magnetic resonance imaging (MRI) in patients diagnosed with atypical ductal hyperplasia (ADH) at core needle biopsy (CNB).

METHODS

The breast MRI database at our centre was queried for studies performed between January 2010 and December 2016 for the clinical indication of ADH diagnosed at CNB. Medical files were reviewed for demographic data, clinical information, and radiology and pathology reports. Pathological results of the surgical specimens were considered the gold standard for comparison with breast MRI findings. In women not undergoing excision, at least 2 years of follow-up was used to ascertain the benign nature of the finding.

RESULTS

Fifty patients were included in the study. Thirty-one (62%) patients had surgical excision of the ADH lesion, and 7 (23%) were upgraded to malignancy. Breast MRI accurately identified 6 of the 7 cases. Six of the 12 women (50%) with positive MRI findings at the biopsy site were upgraded to malignancy on surgical pathology, compared with only 1 of 19 (5%) with negative MRI findings. Forty-nine percent of the women with a negative MRI did not undergo surgical excision of the ADH lesion, compared with 8% of the women with a positive MRI (P = .009), with no cancer diagnosed during follow-up. The sensitivity, specificity, negative predictive value, and positive predictive value of breast MRI for predicting upgrade to malignancy were 86%, 83%, 97%, and 46%, respectively.

CONCLUSIONS

MRI may have a role in the management of women diagnosed with ADH on CNB, to minimize diagnostic excisional biopsies.

Neoplasm of uncertain behaviour of the breast-a retrospective study in a breast unit

Introduction

Breast lesions include a heterogeneous group of entities with variable clinical behaviour and morphological presentation, mostly classified as benign or malignant, with predictable behaviour. However, there are lesions with clinical, breast imaging and/or biopsy characteristics that do not clarify their nature. These lesions have an uncertain behaviour regarding their malignant potential at diagnosis.We intend to relate the preoperative diagnosis of neoplasm of uncertain behaviour of the breast (NUnBB) regarding the core needle biopsy and the histological result after excisional biopsy.

Methods

This is a retrospective study of patients submitted to local excision of breast lesions with a perioperative diagnosis of NUnBB, classified as 2383 at 'International Statistical Classification of Diseases and Related Health Problems' (ICD 9), between January 2007 and October 2016 in a breast unit.

Results

Ninety-two cases with the diagnosis of NUnBB were analysed: 91 females with a mean age of 59 ± 14 years. All were submitted to local excision of breast lesion as ambulatory surgery with the following histology: 64% benign, 3% malignant potential and 33% malignant. Of those who presented malignant results, 69% underwent a surgical re-intervention for local control of the disease.

Discussion

Regarding the considerable number of malignant lesions at final histology and the high percentage of which are re-operated, NUnBB should be treated with the same priority as a confirmed malignant neoplasm and whenever possible, using the most appropriate surgical technique.

Atypical ductal hyperplasia: Our experience in the management and long term clinical follow-up in 71 patients

INTRODUCTION

Atypical ductal hyperplasia (ADH) is a high-risk benign lesion found in approximately 1-10% of breast biopsies and associated with a variable incidence of carcinoma after surgical excision. The main goal of our study is to present our experience in the management and long-term follow-up of 71 patients with ADH diagnosed on breast biopsy.

MATERIALS AND METHODS

Results of 3808 breast biopsy specimens from 1 January 2000 to 31 December 2005 were analyzed to identify all biopsies which resulted in a diagnosis of ADH. The histopathological results of the 45 patients who underwent surgery were analyzed. Long-term follow-up for the remaining patients was carried out.

RESULTS

45 of 71 (63.4%) patients with histological diagnosis of ADH on breast biopsy underwent surgery. Definitive histological results revealed invasive carcinoma in 7 cases (15.6%), high grade Ductal Carcinoma in situ (DCIS) in 10 (22.2%) patients, Lobular Carcinoma in situ (LCIS) in 4 cases (8.9%) and benign findings in 24 cases (53.3%). 12 of 71 (16.9%) patients underwent only long term follow-up; one (8,3%) of these developed invasive breast carcinoma after 6 years.

CONCLUSION

Atypical ductal hyperplasia diagnosed on breast biopsy is associated with a relatively high incidence of invasive carcinoma and high grade ductal carcinoma in situ at the time of surgical excision. Certain radiological and cytological criteria can be used to help determine which patients should forgo surgery and be followed up with good results. Long term follow-up is always crucial for patients who have not undergone surgery.

Value of breast MRI for patients with a biopsy showing atypical ductal hyperplasia (ADH)

PURPOSE

To evaluate the diagnostic value of dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) for patients with atypical ductal hyperplasia (ADH) in predicting malignant upgrade.

MATERIALS AND METHODS

3T DCE-MRI was performed for 17 patients with ADH (median age 52, range 42-76) proven by stereotactic biopsy (n = 15), and ultrasound-guided biopsy (n = 2) from January 2011 to April 2015. All patients underwent surgical excision after the MRI. Two radiologists prospectively reviewed the MRI to determine the presence or absence of suspicious findings at the site of biopsy, and evaluated the MR features of any lesion present according to the Breast Imaging Reporting and Data System (BI-RADS) lexicon. MRI findings and clinical information were correlated with the final surgical pathology by multivariate analysis.

RESULTS

Nine of 17 lesions were upgraded to malignancy. MRI demonstrated suspicious nonmass enhancement (NME) at the site of biopsy in all upgraded patients. The median size was 19.5 mm (range, 9-44 mm). In the eight patients without upgrade, no enhancement (n = 2), linear enhancement along the biopsy track (n = 4), thin rim enhancement around hematoma (n = 1), and a focal NME (n = 1) were seen. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MRI findings were 100, 87.5, 90, and 100%, respectively. Multivariate analysis revealed that the presence of suspicious enhancement on MRI was the most significant predictor of upgrade to malignancy (P = 0.0006) CONCLUSION: Our study revealed a high NPV of DCE-MRI for patients with ADH in terms of malignant upgrade at subsequent surgery. This suggests that patients with ADH without suspicious enhancement on DCE-MRI might be followed with DCE-MRI rather than undergoing surgical excision.

LEVEL OF EVIDENCE

1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;46:1738-1747.

Management of atypical lobular hyperplasia, atypical ductal hyperplasia, and lobular carcinoma in situ

Atypical hyperplasia and lobular carcinoma in situ are rare proliferative breast lesions, growing inside ducts and terminal ducto-lobular units. They represent a marker of increased risk for breast cancer and a non-obligate precursor of malignancy. Evidence available on diagnosis and management is scarce. They are frequently found incidentally associated with other lesions, but can be visible through mammography, ultrasound or magnetic resonance. Due to the risk of underestimation, surgical excision is often performed. The analysis of imaging and histopathological characteristics could help identifying low-risk cases, for which surgery is not necessary. Chemopreventive agents can be used for risk reduction. Careful imaging follow up is mandatory; the role of breast MRI as screening modality is under discussion.

Role of Breast Imaging in Predicting Outcome of Lesions of Uncertain Malignant Potential (B3) Diagnosed at Core Needle Biopsy

Aims

To elucidate whether breast imaging can predict final histologic diagnosis of lesions of uncertain malignant potential diagnosed at ultrasound core needle biopsy (CNB).

Methods

The imaging characteristics (mammography, ultrasound, and magnetic resonance imaging [MRI]) of lesions of uncertain malignant potential in the breast that were obtained by ultrasound CNB were retrospectively analyzed in 87 women. Radiologic characteristics of lesions were compared to definitive histopathologic findings.

Results

Out of 87 breast lesions of uncertain malignant potential, 27 (31%) were diagnosed as papillary lesions, 24 (28%) atypical ductal hyperplasia, 19 (22%) lobular intraepithelial neoplasia, 9 (10%) phyllodes tumors, 3 (3%) radial sclerosing lesions, and 5 (6%) unspecified lesions of uncertain malignant potential. The underestimation rate of malignancy at CNB based on the total number of lesions on final follow-up was 22%. Using multivariate logistic regression, Breast Imaging-Reporting and Data System (BI-RADS) score (odds ratio [OR] = 12.29, p = 0.027) and Göttingen MRI scoring system (OR = 8.1, p = 0.008) were found to be independent predictors of malignancy. Receiver operating characteristic analysis showed that Göttingen MRI score >3 provides a plausibly good cutoff value with sensitivity of 100 (95% confidence interval [CI] 74%-100%) and specificity of 76% (95% CI 61%-88%).

Conclusions

Lesions of uncertain malignant potential classified as BI-RADS 5 and Göttingen score 4 or higher are at significantly higher risk of harboring malignancy and therefore should be recommended for surgical excision.

MRI vacuum-assisted breast biopsies

The indications, technique, results and limitations of MRI vacuum-assisted breast biopsies are discussed from a review of the literature. This was initially a home-grown technique and its development was slowed down by several factors. As a result of major technical advances, it has become a reliable and very consistent procedure with a low rate of underestimation. It is now an undisputed technique when suspicious MRI enhancement is seen with no corresponding mammography or ultrasound features.

High-risk breast lesions at imaging-guided needle biopsy: usefulness of MRI for treatment decision

OBJECTIVE

The purpose of this study is to evaluate the role of MRI for characterization of high-risk breast lesions diagnosed at imaging-guided needle biopsy.

MATERIALS AND METHODS

In this retrospective analysis of 220 patients, 227 high-risk lesions (94 papillomas, 64 radial sclerosing lesions, 46 lobular neoplasias, and 23 atypical ductal hyperplasias) found at 11-gauge vacuum-assisted or 14-gauge needle biopsy were studied with dynamic MRI (time resolution, 84 or 88 seconds; gadopentetate dimeglumine or gadobenate dimeglumine, 0.1 mmol/kg). When lesions showed contrast enhancement on subtracted images, they were considered suspicious for malignancy. The reference standard was histopathologic examination after surgical excision in 190 of 227 (84%) lesions and negative follow-up (≥ 24 months) in 37 of 227 (16%) lesions. Predictive values and likelihood ratios were calculated.

RESULTS

Of 227 lesions, 155 (68%) were contrast enhancing and 72 (32%) were not. Of 155 contrast-enhancing lesions, 28 (18%) were upgraded to malignancy after surgical excision (nine papillomas, one radial sclerosing lesion, 11 lobular neoplasias, and seven atypical ductal hyperplasias); there were 11 invasive carcinomas and 17 ductal carcinomas in situ, four of the latter being G3. Of 72 non-contrast-enhancing lesions, two (3%) were upgraded to malignancy after surgical excision (one radial sclerosing lesion and one lobular neoplasia), both of which were G1 ductal carcinoma in situ. Cancer probability was significantly higher for contrast-enhancing (18%) than for non-contrast-enhancing (3%) lesions (p = 0.001) and for nonmasslike (43%) than for masslike (14%) lesions (p = 0.005). The positive predictive value was 18% (28/155; 95% CI, 13-24%), the negative predictive value was 97% (70/72; 95% CI, 94-99%), the positive likelihood ratio was 1.448 (95% CI, 1.172-1.788), and the negative likelihood ratio was 0.188 (95% CI, 0.152-0.232).

CONCLUSION

The absence of enhancement at dynamic MRI allowed reliable exclusion of invasive cancers among high-risk lesions diagnosed at needle biopsy.

Low frequency of cancer occurrence in same breast quadrant diagnosed with lobular neoplasia at percutaneous needle biopsy

PURPOSE

To determine the type of mammographic abnormality leading to needle biopsy of lobular neoplasia (LN) and define the clinical evolution of low-risk LN lesions diagnosed at needle biopsy but not surgically removed.

MATERIALS AND METHODS

This study was approved by the institutional review board, and the requirement to obtain informed consent was waived. Among 16 945 needle biopsies performed between April 1998 and August 2008, LN was determined to be the most suspicious lesion in 352 samples (2.1%) (pleomorphic and necrotic forms were excluded). Among 299 pure LN lesions that were not surgically removed, follow-up was available for 276 lesions in 275 women.

RESULTS

Needle biopsy was performed because of mammographic calcifications in 215 of the 276 lesions (77.9%) and because of mammographic masses in 35 (12.7%). The mean follow-up was 5.0 years ± 2.4 (range, 0.6-12.2 years). All 275 women underwent one mammographic follow-up, 205 (74.5%) underwent a second mammographic follow-up, and 147 (53.5%) underwent a third mammographic follow-up. Cancer was diagnosed in 27 of the 275 cases (9.8%) after a mean of 3.9 years ± 2.6 (range, 1.2-10.8 years). Only three cancers (1.1%) occurred in the same breast quadrant as the one originally diagnosed with LN at needle biopsy.

CONCLUSION

Lumpectomy of pure LN lesions may not prevent malignancy in most cases. Consequently, women with pure LN of a low-risk type diagnosed at needle biopsy are strongly encouraged to undergo a yearly breast clinical examination and yearly mammographic follow-up to detect an eventual cancer in its early stages.

Borderline breast lesions: comparison of malignancy underestimation rates with 14-gauge core needle biopsy versus 11-gauge vacuum-assisted device

OBJECTIVE

To compare malignancy underestimation rates in the case of percutaneous diagnosis of borderline breast lesions(B3) at 14-g core-needle-biopsy (CNB) and at 11-g vacuum-assisted-biopsy (VAB).

METHODS

The histological results of 4764 image-guided breast biopsies were retrospectively reviewed. 300 B3, 151 benign papillomas, 88 radial sclerosing lesions, 46 lobular neoplasia, 15 atypical ductal hyperplasia diagnosed at ultrasound-guided 14-g CNB (76%) or stereotactically-guided 11-g VAB (24%) were identified. On average, 5 cores were obtained with CNB and 12 with VAB. Biopsy variables were reviewed and correlated with surgical excision or follow-up (>24 months). Lesion- and device-specific underestimation rates of malignancy were calculated.

RESULTS

Surgical excision was performed on 237 lesions: 178 were benign, 21 atypical, 38 cancers. The remaining 63 lesions were unchanged at follow-up. Overall malignancy underestimation rate was 12.7% at 14-g CNB and 12.5% at 11-g VAB. Based on excision histology or follow-up, lesion-specific underestimation rates were: benign papillomas: 14-g CNB 11%, 11-g VAB 0%; RSL: 14-g CNB 6%, 11-g VAB 4%; LN: 14-g CNB 40%, 11-g VAB 23%; ADH: 14-g CNB 33%; 11-g VAB 22%.

CONCLUSION

In the case of percutaneous diagnosis of B3 lesions, underestimation of malignancy occurs regardless of the biopsy method.

Accuracy of magnetic resonance in suspicious breast lesions: a systematic quantitative review and meta-analysis

Dynamic contrast-enhanced breast magnetic resonance (MR) is a promising emerging technique for evaluating breast lesions. A quantitative systematic review was performed to estimate the accuracy of breast MR in the diagnosis of high-risk breast lesions and breast cancer. A comprehensive search of the Cochrane Library, MEDLINE, CANCERLIT, LILACS, and EMBASE databases was performed from January 1985 to August 2010. The medical subjects heading (MeSH) and text words for the terms "breast neoplasm", "breast lesions", "breast cancer" and "magnetic resonance" were combined with the MeSH term diagnosis ("sensitivity and specificity"). Studies that compared breast MR with paraffin-embedded sections parameters for the diagnosis of breast lesions (benign, high-risk borderline, and breast cancer) were included. Sixty-nine studies were analyzed, which included 9,298 women with 9,884 breast lesions. Interrater overall agreement between breast MR and paraffin section diagnosis was 79% (κ = 0.55), indicating moderate agreement. Pooled sensitivity and specificity were 90% [95% CI 88-92%] and 75% [95% CI 70-79%], respectively. The pooled likelihood positive ratio was 3.64 (95% CI 3.0-4.2) and the negative ratio was 0.12 (95% CI 0.09-0.15). For breast cancer or high-risk lesions versus benign lesions, the AUC was 0.91 for breast MR and the point Q* was 0.84. In summary, breast MR is a useful pre-operative test for predicting the diagnosis of breast lesions.

B3 Lesions: Radiological Assessment and Multi-Disciplinary Aspects

B3 lesions comprise different histopathological entities that are considered benign but 'of unknown biological potential'. These entities may act as risk indicators (for both breasts) or as non-obligatory precursors of malignancy. Being diagnosed at percutaneous breast biopsy, an additional risk of underestimate exists. Imaging appearances, histopathological appearance and risk of associated malignancy are presented. B3 lesions of high risk, which thus should usually be excised, include atypical ductal hyperplasia (ADH), pleomorphic or necrotic type of lobular neoplasia (LIN 3), and papillary lesions with atypias. Intermediate risk may be associated with classic lobular carcinoma in situ (LIN 2) or flat epithelial atypia (FEA), and low risk with radial sclerosing lesions (RSLs) and papillary lesions without atypias. LIN 1 is mostly an incidental finding acting as risk indicator. Follow-up is adequate if the initial diagnostic problem is solved. According to international guidelines, risk and subsequent recommendations should be discussed for each individual patient, taking into account biological risk, representative sampling, lesion size, lesion extent, percentage of lesion removal, other individual risks, and the possibility of surveillance. With vacuum-assisted breast biopsy (VABB), surgery may be avoided for more of the small lesions at low risk. Further data collection and diligent evaluation may help to better assess the individual risk, to better adapt treatment recommendations and avoid overtreatment.

Columnar cell lesions of the breast: an update and significance on core biopsy

Columnar cell lesions of the breast refer to the morphological spectrum of alterations of the epithelial lining of variably dilated acini of the terminal duct lobular unit (TDLU), often related to secretions and calcifications. After decades of varied terminologies, the term of 'flat epithelial atypia' by the World Health Organization (WHO) consensus group encompasses the part of the spectrum where columnar cell change or columnar cell hyperplasia acquires low grade cytological atypia, merging with atypical ductal hyperplasia and low grade ductal carcinoma in situ. Its association with low grade invasive carcinoma and lobular neoplasia, whether by proximity to these lesions, or by similar molecular expressions, has prompted greater scrutiny into its clinical significance. Although recent literature attempts to refine the term 'flat epithelial atypia', the applicability of its morphological criteria in routine diagnostic practice remains to be seen, and interobserver variability is highly possible. This poses even greater challenges especially in limited samples of breast tissue, such as in core biopsies, for pre-operative decision-making. The purpose of this review is to elucidate evolving clinical and diagnostically relevant principles that surround and influence the significance of this still controversial entity, especially when discovered on core biopsy in the initial phase of breast diagnosis and management.