ACR Appropriateness Criteria Palpable Breast Masses

Positive association between progestins and the evolution of multiple fibroadenomas in 72 women

OBJECTIVE

Multiple fibroadenomas (MFA) of the breast is a rare benign disease, thus its natural history is poorly understood. The aim of our study was to describe the radiological evolution of MFA and to evaluate the influence of different factors on this evolution.

METHODS

This was a longitudinal cohort study. All patients included had two clinical and radiological assessments (breast ultrasound (US) and/or MRI) at least 5 years apart.

RESULTS

Seventy-two women were followed for 7.6 ± 2.1 years. The radiological evolution showed a decrease or stability in the number of fibroadenomas (FA) in 26/44 cases on the MRI and in 38/64 cases on the US. There was a decrease of size in 35/44 cases on the MRI and in 53/64 cases on the US. An increase in the number of FAs was found in 18/44 cases in the MRI and 26/64 cases in the US with, for the majority, a decrease of size (19/26 by MRI and 16/18 by MRI). Older age at the first FA (P < 0.0001) and at the diagnosis of MFA (P < 0.0001), pregnancy (P = 0.003) and progestin use (P < 0.001), particularly lynestrenol (P < 0.0001), had a beneficial effect on the evolution of MFA.

CONCLUSION

This is the first longitudinal study describing women with MFA. The radiological evolution of MFA seamed favorable and similar to that expected for a single FA. We identified factors influencing the evolution of the disease, including progestin treatments such as lynestrenol, which could have a beneficial effect. Our cohort should be followed further in order to expand our knowledge of MFA, especially concerning the risk of breast cancer.

Primary and Secondary Breast Lymphoma: Focus on Epidemiology and Imaging Features

Aim of this study was to select all the cases of Primary (PBL) and Secondary (SBL) Breast Lymphoma from our breast unit since 01/01/2000, to obtain up-to-date data on the prevalence of this rare pathology and to analyze imaging features, with a special focus on CT. All pathological reports of breast biopsies performed from 01/01/2000 to 01/01/2019 were at first screened. Among them, we performed two different researches, looking for key words suggesting either a diagnosis of lymphoma or any other malignant disease. Using the Wiseman criteria, we identify PBL and SBL. All imaging features of PBL and SBL were analyzed. Prevalence of lymphoma amongst suspicious breast masses and amongst all breast malignancies were calculated. Out of 42,505 histopathology reports from mammary nodule biopsies, we found 19,354 malignancies. We were able to identify 11 patients affected by PBL (0,03% of suspicious breast lesions, 0.06% of breast malignancies), and 23 cases of SBL (0,05% of suspicious breast lesions, 0,12% of breast malignancies). Most common isotype in PBL was DLBC lymphoma, whereas in SBL that resulted Follicular lymphoma. In PBL group, we were able to retrieve images 7 CT or CT-PET study performed at diagnosis 7 US, 1 mammography and and 1 MR. In SBL group, we analyzed 14 CT/CT-PET examinations, 11 US studies and 3 mammography. PBL and SBL are rarer than considered until now. There is no definite imaging characteristic able to distinguish between these two pathologies and among them and breast cancer.

Clinical Hypnosis and Music In Breast Biopsy:A Randomized Clinical Trial

A randomized clinical study was conducted to evaluate the effects on anxiety, depression, stress and optimism levels of an audio-recorded clinical hypnosis intervention and a music session and compare them with a control group in women scheduled for breast biopsy. We analyzed the data of 170 patients with an average age of 47 years, who were randomly assigned to each of the groups. The psychosocial variables were measured in three moments: baseline, which corresponds to the period before the intervention with hypnosis, music or waiting in the room before biopsy; a second measurement after the interventions and a third measurement after the breast biopsy procedure was finished. The results showed a statistically significant reduction in the stress (p < .001, η²p = .06); pain, (p < .01, η²p = .04); anxiety, (p < .001, ƞ²p = .07) and depression, (p < .001, ƞ²p = .05) in hypnosis and music groups compared with the control group. Before biopsy, hypnosis decrease significantly pain and depression levels compared with music, but after biopsy there were no differences between both groups. It is recommended to use audio-recorded hypnosis and music interventions to reduce physical and emotional discomfort during the biopsy procedure and to improve the quality of life of patients with suspected breast cancer.

What is the yield of breast MRI in the assessment of palpable breast findings?

AIM

To examine the contribution of magnetic resonance imaging (MRI) to characterise palpable breast masses after conventional imaging was found to be non-contributory.

MATERIALS AND METHODS

The breast MRI database was reviewed for studies performed between January 2010 and December 2015 for the clinical indication of palpable breast finding with negative standard imaging. Medical files were reviewed for demographic data, clinical information, radiology, and pathology reports. Benign versus malignant outcomes were determined at histopathology or a minimum of 12 month follow-up.

RESULTS

Investigation of palpable breast finding was the clinical indication for 167 of 7,782 (2%) examinations. Thirty-two (19%) women in the study had positive MRI findings. Most (20, 63%) findings corresponded to the palpable area, resulting in three carcinomas being diagnosed. Only one carcinoma required MRI-guided biopsy for diagnosis. Eighteen women with negative MRI underwent ultrasound-guided biopsy from the palpable area, which resulted in a diagnosis of one carcinoma. One carcinoma was incidentally detected in another location. Within the present population, the sensitivity for detecting malignancy was 80%, specificity 78%, negative predictive value 99%, and positive predictive value 13%.

CONCLUSIONS

Although cancer was found in four cases in the palpable area, the biopsy was directed using MRI in only one case. A new palpable finding with non-contributory standard imaging should prompt a needle-guided biopsy and not further evaluation using MRI.

First ultrasound diagnosis of BI-RADS 3 lesions in young patients: Can 6-months follow-up be sufficient to assess stability?

OBJECTIVES

To evaluate the outcome of repeated short-term follow-up with ultrasound in no high-risk young patients with a BI-RADS3 lesion at first examination.

METHODS

In this IRB-approved study 492 women, aged 18-34 years (mean±standard deviation, 28±4.5years) with first breast ultrasound examination in 2012-2014 were retrospectively evaluated. Inclusion criteria were: at least one BI-RADS3 lesion and (a) biopsy/surgical excision or (b) follow-up of at least 18 months (including a 6-month follow-up). BI-RADS category assigned during follow-up and pathologic findings in cases undergoing biopsy/surgical excision were collected. At the 6- and 18-month follow-up the recommended biopsy rates (RBR) and the corresponding positive predictive value (PPV) were calculated.

RESULTS

In 97 patients, 151 BI-RADS3 lesions were identified. Biopsy/surgical excision was initially performed in 25/151 (16.5%) lesions. After 6-month, category was downgraded to BI-RADS1/2 in 23/126 (15.3%) and upgraded to BI-RADS4 in 9/126 lesions (7.1%). Pathological diagnosis of these lesions was fibroadenoma in 5 and benign phyllodes tumor in 4 cases (RBR 7%, PPV_bio 44.4%). After 18-month one lesion was classified BI-RADS4 and pathological diagnosis was fibroadenoma (RBR 1.1%, PPV_bio 0%).

CONCLUSIONS

Our preliminary data show that follow-up imaging performed after 18 months from a first BI-RADS3 diagnosis does not affect clinical treatment and 6-month follow-up may be sufficient to assess the stability of probably benign lesions.

Advancements in Imaging Technology for Detection and Diagnosis of Palpable Breast Masses

Breast cancer is the most commonly diagnosed cancer among women worldwide and the most common cause of cancer death in women. The most common presentation of breast cancer is the presence of a palpable mass, whether noted by the patient during breast self-examination or noted during clinical breast examination. There are a variety of imaging modalities now available for the evaluation of a palpable abnormality. A thorough understanding of the indications, risks, and benefits can help the clinician guide the patient through an appropriate, comprehensive imaging work up.

PET/MR in Breast Cancer

Breast cancer is an international public health concern in which an optimal treatment plan requires a precise staging. Both MRI and PET imaging techniques have made significant progress in the last decades with constant improvements that made both modalities clinically relevant in several stages of breast cancer management and follow-up. On one hand, specific breast MRI permits high diagnostic accuracy for local tumor staging, and whole-body MRI can also be of great use in distant staging, eventually accompanied by organ-specific MRI sequences. Moreover, many different MRI sequences can be performed, including functional MRI, letting us foresee important improvements in breast cancer characterization in the future. On the contrary, (18)F-FDG-PET has a high diagnostic performance for the detection of distant metastases, and several other tracers currently under development may profoundly affect breast cancer management in the future with better determination of different types of breast cancers allowing personalized treatments. As a consequence PET/MR is a promising emerging technology, and it is foreseeable that in cases where both PET and MRI data are needed, a hybrid acquisition is justified when available. However, at this stage of deployment of such hybrid scanners in a clinical setting, more data are needed to demonstrate their added value beyond just patient comfort of having to undergo a single examination instead of two, and the higher confidence of diagnostic interpretation of these co-registered images. Optimized imaging protocols are still being developed and are prone to provide more efficient hybrid protocols with a potential improvement in diagnostic accuracy. More convincing studies with larger number of patients as well as cost-effectiveness studies are needed. This article provides insights into the current state-of-the-art of PET/MR in patients with breast cancer and gives an outlook on future developments of both imaging techniques and potential applications in the future.

Do Primary Care Physician Perform Clinical Breast Exams Prior to Ordering a Mammogram?

Both the American Cancer Society and National Comprehensive Cancer Network recommend annual clinical breast examination (CBE) along with screening mammogram (SM) for patients starting at 40 years of age. However, patients with a palpable breast mass should have a diagnostic mammogram (DM) during workup. Review at our institution demonstrated that 11% of patients with newly diagnosed breast cancer and self-identified breast mass had SM instead of DM. This led us to question whether primary care physicians (PCP) perform CBE prior to ordering mammography. As part of the routine preimaging screening, patients were asked if they had undergone breast examination by a medical provider prior to mammogram order. Data on mammogram type, ordering physician specialty, and presence of symptoms on day of mammogram were recorded. Of 6,109 mammograms, 4,823 were ordered by PCPs. CBE was performed prior to 67.2% SM and 64.8% DM (p = 0.12). OB/GYN performed statistically significantly higher CBE (81.6%) compared to internal (45.4%) and family (50.5%) medicine physicians (p < 0.001). Of patients with self-reported breast symptoms, 8.7% had SM ordered rather than DM. Despite recommendations, approximately 1/3 of women report not having CBE prior to mammogram. The chances of having a CBE varied significantly by PCP specialty. Lack of CBE can lead to incorrect type of mammogram, with possibly increased cost and delay in diagnosis. Further evaluation is needed to understand why CBE was not performed in some patients.

Ultrasonographic features and clinical implications of benign palpable breast lesions in young women

PURPOSE

The purpose of this study was to describe the breast ultrasonography (US) features and to investigate whether performing a core biopsy is warranted in young women having palpable solid breast masses.

METHODS

A total of 76 solid palpable masses in 68 consecutive women (≤25 years old) underwent tissue diagnosis by percutaneous core biopsy. Two radiologists, who were blinded to the clinical history and histopathology, independently evaluated the US features according to Breast Imaging-Reporting and Data System (BI-RADS) lexicon. The frequency of benign and malignant descriptor terms that were used to characterize the lesions were compared to the final pathology.

RESULTS

All 76 palpable solid masses yielded benign pathology. On the US, the shape of the mass was described by radiologists 1 and 2 as oval or round (63.2% and 71.1%), margin as circumscribed (68.4% and 77.6%) and orientation as parallel (85.5% and 90.8%); the frequency of using all three benign descriptors was 61.8% and 68.5%, respectively. Suspicious descriptors were used less frequently by radiologists 1 and 2 including irregular shape (9.2% and 13.1%), non-circumscribed margin (31.6% and 22.4%) and non-parallel orientation (14.5% and 9.2%); the frequency of using all three suspicious descriptors was 9.2% and 11.8%, respectively.

CONCLUSION

Despite the variable US features, breast malignancy seems extremely low in 25 years or younger women for palpable breast lesions. Using the BI-RADS lexicon, US accurately predicted benignity in about two thirds of our patients, supporting US surveillance as a safe alternative to invasive tissue sampling in this setting.