Imaging benign inflammatory syndromes

Unilateral primary breast edema: Can T2-weighted images meet the diagnostic challenge?

Background

Unilateral primary breast edema may pose a diagnostic challenge. Excluding malignant etiologies is of utmost importance and may require the use of dynamic MRI examination as a problem solver. Yet, the enhancement pattern of benign and malignant disorders associated with edematous breasts may overlap, and this may add to the dilemma. So, our aim in the current study was to assess the role of T2-weighted MR imaging as a problem-solving sequence in differentiating benign from malignant causes of the edematous breast.

Results

In the current prospective study, 65/96 cases were benign and 31/96 cases were malignant. By the individual analysis of the signal intensity in T2-weighted imaging of MRI examination, there was a significant correlation between low T2 signal intensity lesion and malignant etiology of breast edema with a resultant higher sensitivity of 83.87% and a higher specificity of 98.46% as compared to the contrast-enhanced series, which achieved a sensitivity of 80.65% and a specificity of 20.00%. The combined assessment of T2 WI and the contrast-enhanced series yielded a higher sensitivity of 100% and a specificity of 98.46%.

Conclusions

T2WI is a problem-solving sequence in the evaluation of the primary edematous breast, yielding a significant added value in the diagnostic approach and improving the overall diagnostic performance of dynamic contrast-enhanced MRI.

Quantitative perfusion parameters of benign inflammatory breast pathologies: A descriptive study

PURPOSE

With this study, we evaluated the perfusion magnetic resonance imaging (MRI) features of benign inflammatory breast lesions for the first time and compared their K_trans, K_ep, V_e values and contrast kinetic curves to benign masses and invasive ductal carcinoma (IDC).

MATERIALS AND METHODS

Perfusion MRIs of the benign masses (n = 42), inflammatory lesions (n = 25), and IDCs (n = 16) were evaluated retrospectively in terms of K_trans, K_ep, V_e values and contrast kinetic curves and compared by the Kruskal-Wallis, Mann-Whitney U, chi-square tests statistically. Cronbach α test was used to measure intraobserver and interobserver reliability.

RESULTS

Mean K_trans values were 0.052 for benign masses, 0.086 for inflammatory lesions and 0.101 for IDC (p < 0.001). Mean K_ep values were 0.241 for benign masses, 0.435 for inflammatory lesions and 0.530 for IDC (p < 0.001). Mean V_e values were 0.476 for benign masses, 0.318 for inflammatory lesions and 0.310 for IDC (p = 0.067). For inflammatory and IDC lesions, K_trans and K_ep values were found to be higher and V_e values were lower than benign masses (p = 0.001 for K_trans, p = 0.001 for K_ep, p = 0.045 for V_e). There were excellent or good intra-interobserver reliabilities. For the kinetic curve pattern, most of the benign lesions showed progressive (81%), inflammatory lesions progressive (64%) and IDC lesions plateau (75%) patterns (p < 0.001).

CONCLUSIONS

On T1 perfusion MRI, similar to IDC lesions, inflammatory lesions demonstrate higher K_trans and K_ep and lower V_e values than benign masses. Quantitative perfusion parameters are not helpful in differentiating them from IDC lesions.

Incidence of inflammatory breast cancer in patients with clinical inflammatory breast symptoms

BACKGROUND

To describe a large cohort of women with non-puerperal inflammatory breast and to identify characteristics of inflammatory breast cancer.

METHODS

All patients consulting for inflammatory breast syndrome in the breast unit of our tertiary University hospital between September 2013 and December 2015 were prospectively included. We excluded women who were pregnant or in the postpartum period. Patients underwent systematic clinical examination and imaging (breast ultrasonography and mammography). A biopsy was performed if the clinician suspected a malignant lesion of the breast. Clinicopathologic and radiologic data were registered. Statistics were performed using R (3.0.2 version) software.

RESULTS

Among the 76 patients screened and included, 38 (50%) had a malignant lesion at final diagnosis, 21 (27.6%) were diagnosed with infectious disease and 17 (22.4%) with inflammatory disease of the breast. When compared to patients with benign disease, patients with a malignant lesion were significantly older (p = 0.022, CI95% 1.78-14.7), had a significantly bigger palpable mass (p<0.001, CI 95% 22.8-58.9), were more likely to have skin thickening (p = 0.05) and had more suspicious lymph nodes at clinical examination (p<0.001, CI 95% 2.72-65.3). Precise limits on ultrasonography were significantly associated with benign lesions. The presence of a mass (p = 0.04), micro calcifications (p = 0.04) or of focal asymmetry (p<0.001, CI95% 1.3-618) on mammography was significantly associated with malignant disease.

CONCLUSION

Inflammatory breast cancer was common in our cohort of women consulting for inflammatory breast syndrome. Identifying these patients with high-risk malignancy is crucial in the management of an inflammatory breast.

[Diagnosis and treatment of inflammatory diseases of the mammary ducts]

AIM

The analysis and popularization of the own experience of ultrasonic diagnostics and minimal invasive interventions for inflammatory diseases of the mammary ducts.

PATIENTS AND METHODS

249 women were observed: 182 (73.1%) cases of periductal mastitis and 67 (26.9%) cases of purulent galactophoritis. Patients with purulent galactophoritis were divided into 2 groups (main and control). The main group consisted of 50 patients after minimal invasive interventions, control - 17 women after traditional surgery.

RESULTS

The main US signs of periductal mastitis and purulent galactophoritis were detected. Purulent galactophoritis is associated with the diameter of mammary duct less than 4 mm, ductal content flotation and stream-effect (coloring of dilated duct in Doppler mode). It was proposed the method of US-assisted mini-invasive retrograde drainage of mammary ducts with aspiration of purulent content through the natural orifice in the nipple. This method doesn't demand hospital stay, reduces duration of treatment by 14 days and doesn't cause the cosmetic defects in comparison with traditional surgical approach.

CONCLUSION

Inflammatory diseases of the mammary ducts are represented by the different nosological forms - periductal mastitis (73.1%) and purulent galactophoritis (26.9%). In view of typical ultrasonic picture in patients with purulent galactophoritis US-assisted mini-invasive retrograde drainage of mammary ducts with aspiration of purulent content through the natural orifice in the nipple is advisable. This method has significant advantages in comparison with traditional surgery and may be recommended for widespread clinical use.

[Exploration of breast inflammation excluding pregnancy and breastfeeding: Guidelines]

Breast inflammation, excluding breast-feeding and pregnancy, is a rare breast pathology. We conducted a PubMed database search of all studies focusing on mastitis or breast inflammation exploration. While the most frequent aetiologies are infectious and inflammatory, inflammatory breast cancer can be diagnosed (LE2). Aetiologic diagnostic is difficult due to the absence of any clinical and imaging specific signs (LE3). The presence of mass, suspect lymph nodes or skin thickening in a woman older than 40 years old should orient toward inflammatory breast cancer (LE3). A suspect lesion must lead to perform a biopsy under sonography (grade A). In the absence of evidence for a malignant pathology after initial evaluation, we recommend starting an antibiotic treatment (grade C) with a clinical follow-up at the end of the treatment (grade B). If the symptoms persist, we recommend a new imaging (± MRI) (grade C) and a biopsy (grade C). Benign inflammatory pathologies may require a biopsy to exclude an inflammatory breast cancer and precise the diagnosis. Their specific management and treatment are presented in detail in the following chapters and may involve steroids.

A rim-enhanced mass with central cystic changes on MR imaging: how to distinguish breast cancer from inflammatory breast diseases?

Objective

To evaluate the capacity of magnetic resonance imaging (MRI) to distinguish breast cancer from inflammatory breast diseases manifesting as a rim-enhanced mass with central cystic changes.

Materials and Methods

Forty cases of breast cancer and 52 of inflammatory breast diseases showing a rim-enhanced mass with central cystic changes were retrospectively reviewed. All cases underwent dynamic contrast-enhanced MRI and 31 of them underwent diffusion-weighted imaging (DWI). Morphological features, dynamic parameters and apparent diffusion coefficient (ADC) values were comparatively analyzed using univariate analysis and binary logistic regression analysis.

Results

Breast cancer had a significantly thicker wall than the inflammatory breast diseases (P<0.001) while internal enhancing septa were more common in inflammatory breast diseases (P = 0.003). On DWI, 86.7% of breast cancers demonstrate a peripheral hyperintensity whereas 93.8% of inflammatory breast diseases had a central hyperintensity (P<0.001). Compared to the inflammatory breast diseases, breast cancers had a lower ADC value for the wall (1.09×10⁻³ mm²/s vs 1.42×10⁻³ mm²/s, P<0.001) and a higher ADC value for the central part (1.94×10⁻³ mm²/s vs 1.05×10⁻³ mm²/s, P<0.001).

Conclusions

Both breast cancer and inflammatory breast diseases could present as a rim-enhanced mass with central cystic changes on MRI. Integrated analysis of the MR findings can allow for an accurate differential diagnosis.