Role of breast MRI in predicting histologic upgrade risks in high-risk breast lesions: A review

Distance of Biopsy-Confirmed High-Risk Breast Lesion from Concurrently Identified Breast Malignancy Associated with Risk of Carcinoma at the High-Risk Lesion Site

High-risk breast lesions including incidental intraductal papilloma without atypia (IPA), lobular hyperplasia (LCIS or ALH), flat epithelial atypia (FEA) and complex sclerosing lesion (CSL) are not routinely excised due to low upgrade rates to carcinoma. We aim to identify features of these lesions predictive of upgrade when identified concurrently with invasive disease. Methods: A single-center retrospective cohort study was performed for patients who underwent multi-site lumpectomies with invasive disease at one site and a high-risk lesion at another site between 2006 and 2021. A multinomial logistic regression was performed. Results: Sixty-five patients met the inclusion criteria. Four patients (6.2%) had an upgrade to in situ disease (DCIS) and one (1.5%) to invasive carcinoma. Three upgraded high-risk lesions were ipsilateral to the concurrent carcinoma and two were contralateral. In the multivariate model, a high-risk lesion within 5 cm of an ipsilateral malignancy was associated with increased risk of upgrade. The 3.8% upgrade rate for high-risk lesions located greater than 5 cm from ipsilateral malignancy or in the contralateral breast suggests that omission of excisional biopsy may be considered. Excisional biopsy of lesions within 5 cm of ipsilateral malignancy is recommended given the 25% upgrade risk in our series.

Imaging Characteristics of and Multidisciplinary Management Considerations for Atypical Ductal Hyperplasia and Flat Epithelial Atypia: Review of Current Literature

High-risk lesions of the breast are frequently encountered in percutaneous biopsy specimens. While benign, these lesions have historically undergone surgical excision due to their potential to be upgraded to malignancy. However, there is emerging evidence that a tailored management approach should be considered to reduce overtreatment of these lesions. Flat epithelial atypia (FEA) and atypical ductal hyperplasia (ADH) are two of the most commonly encountered high-risk lesions. FEA has been shown to have a relatively low rate of progression to malignancy, and some guidelines are now recommending observation over routine excision in select cases. Selective observation may be reasonable in cases where the target lesion is small and completely removed at biopsy and when there are no underlying risk factors, such as a history of breast cancer or genetic mutation or concurrent ADH. ADH has the highest potential upgrade rate to malignancy of all the high-risk lesions. Most society guidelines continue to recommend surgical excision of this lesion. More recently, some literature suggests that ADH lesions that appear completely removed at biopsy, involve limited foci (less than two or three) with no necrosis or significant atypia, manifest as a small group of mammographic calcifications, or demonstrate no enhancement at MRI may be reasonable for observation. Ultimately, management of all high-risk lesions must be based on a multidisciplinary approach that considers all patient, radiologic, clinical, and histopathologic factors. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

High-risk breast lesions: role of multi-parametric DCE-MRI in detection and histopathological upgrade prediction

Background

High-risk breast lesions represent 3–21% of all breast lesions and are non-obligate precursors of malignancy. Various studies have evaluated the value of DCE-MRI including DWI and ADC mapping in the detection of high-risk breast lesions, differentiating them from malignant lesions and predicting upgrade risk after surgical excision reducing misdiagnosis and overtreatment. This study is a retrospective review of all image-guided breast biopsy procedures performed in 2021 at our institution, identified 68 patients with histopathologically proven high-risk breast and available MRI examinations with no concurrent ipsilateral malignancy. Image analysis of MRI examinations included morphological criteria, enhancement pattern, dynamic curves, DWI and ADC mapping assessment. Since our knowledge of high-risk breast lesions is still growing, this study is important to evaluate the merits of DCE-MRI in the assessment of high-risk breast lesions, to allow optimization of treatment, better limit it to those women at risk, and avoid overtreatment in women at low risk.

Results

The mean ADC value of high-risk breast lesions was not significantly different from that of malignant breast lesions (p value = 0.015). Non-mass enhancement and type III enhancing curve proved to be significant indicators of high-risk breast lesions upgrade in surgical pathology. Cut-off average ADC value for differentiating upgraded high-risk lesions from non-upgraded high-risk lesions proved 1.24 mm2/sec with sensitivity and specificity of 94 & 100%, respectively.

Discussion

Management of high-risk breast lesions is important in the screening setting, as they are non-obligate precursors of malignancy, and also function as risk indicators. Frequency and upgrade rates of high-risk lesions detected by MRI provide a reference for clinical management. DCE-MRI has a high negative predictive value in predicting the upgrade risk of high-risk lesions. In this study, non-mass enhancement and type III curve were proven to be indicators of high-risk lesion upgrade. Limitations of the study included small number of patients and limited follow-up period.

Conclusions

The use of multi-parametric DCE-MRI including DWI and ADC mapping provides complementary information to detect high-risk breast lesions and predict their upgrade rate.

The Role of Superb Microvascular Imaging and Shearwave Elastography in the Evaluation of Intraductal Papilloma-Like Lesions

OBJECTIVES

The aim of this study was to investigate the role of quantitative values obtained by superb microvascular imaging (SMI) and shearwave elastography (SWE) in the prediction of malignancy in intraductal papilloma-like lesions (IDPL).

METHODS

In the study, 61 patients between the ages of 14 to 73 years (mean age 44) diagnosed with IDPL on ultrasound (US) examination between the years 2020 and 2021 were included. The B-Mode US findings (shape, margins, size, echo pattern, and accompanying ductal dilatation), SMI vascular index (SMIvi), E-mean, and SWE-ratio values were recorded.

RESULTS

There was a statistically significant difference between malignant (n = 14) and benign (n = 47) groups in terms of symptoms (P = .005), size (P = .042), shape (P = .002), margins (P =  .001), echogenicity (P = .023), microcalcifications (P = .009), SMIvi (P = .031), E-mean (P < .005), and SWE-ratio (P = .007). According to receiver operating characteristic (ROC) curve analysis, sensitivity, specificity, accuracy, area under the curve (AUC), positive predictive values (PPV), and negative predictive values (NPV) were 57.1%, 87.2%, 80%, 0.722, 57.1%, 87.2% for US; 71.4%, 49%, 55.7%, 0.692, 30.3%, 85.7% for SMIvi; 85.7%, 71%, 74%, 0.864, 46%, 94.3% for E-mean, and 50%, 75.4%, 83%, 0.707, 91.5%, and 50% for SWE-ratio, respectively. Best results were obtained when SMI and SWE values were used together, achieving a sensitivity, specificity, accuracy, AUC, PPD, NPD of 78.6%, 93.6%, 93.4%, 0.872, 91.7%, and 93.9%, respectively.

CONCLUSIONS

The SMI and SWE examinations are successful in the differentiation of benign and malignant intraductal lesions. They complement each other and contribute to B-mode US in managing IDPLs especially when used together. Our study is the first to compare the quantitative data of SWE and SMI in the differentiation of IDPLs.