Sonographic and pathologic image analysis of pure mucinous carcinoma of the breast

Deep Learning for Distinguishing Mucinous Breast Carcinoma From Fibroadenoma on Ultrasound

PURPOSE

Mucinous breast carcinoma (MBC) tends to be misdiagnosed as fibroadenomas (FA) due to its benign imaging characteristics. We aimed to develop a deep learning (DL) model to differentiate MBC and FA based on ultrasound (US) images. The model could contribute to the diagnosis of MBC for radiologists.

METHODS

In this retrospective study, 884 eligible patients (700 FA patients and 184 MBC patients) with 2257 US images were enrolled. The images were randomly divided into a training set (n = 1805 images) and a test set (n = 452 images) in a ratio of 8:2. First, we used the training set to establish DL model, DL+ age-cutoff model and DL+ age-tree model. Then, we compared the diagnostic performance of three models to get the optimal model. Finally, we evaluated the diagnostic performance of radiologists (4 junior and 4 senior radiologists) with and without the assistance of the optimal model in the test set.

RESULTS

The DL+ age-tree model yielded higher areas under the receiver operating characteristic curve (AUC) than DL model and DL+ age-cutoff model (0.945 vs. 0.835, P < .001; 0.945 vs. 0.931, P < .001, respectively). With the assistance of DL+ age-tree model, both junior and senior radiologists' AUC had significant improvement (0.746-0.818, P = .010, 0.827-0.860, P = .005, respectively).

CONCLUSIONS

The DL+ age-tree model based on US images and age showed excellent performance in the differentiation of MBC and FA. Moreover, it can effectively improve the performance of radiologists with different degrees of experience that may contribute to reducing the misdiagnosis of MBC.

Differential diagnosis of breast mucinous carcinoma with an oval shape from fibroadenoma based on ultrasonographic features

BACKGROUND

Approximately 50% of breast mucinous carcinomas (MCs) are oval and have the possibility of being misdiagnosed as fibroadenomas (FAs). We aimed to identify the key features that can help differentiate breast MC with an oval shape from FA on ultrasonography (US).

METHODS

Seventy-six MCs from 71 consecutive patients and 50 FAs with an oval shape from 50 consecutive patients were included in our study. All lesions pathologically diagnosed. According to the Breast Imaging Reporting and Data System (BI-RADS), first, the ultrasonographic features of the MCs and FAs were recorded and a final category was assessed. Then, the differences in ultrasonographic characteristics between category 4 A (low-risk group) and category 4B-5 (medium-high- risk group) MCs were identified. Finally, other ultrasonographic features of MC and FA both with an oval shape were compared to determine the key factors for differential diagnosis. The Mann-Whitney test, χ2 test or Fisher's exact test was used to compare data between groups.

RESULTS

MCs with an oval shape (81.2%) and a circumscribed margin (25%) on US were more commonly assessed in the low-risk group (BI-RADS 4 A) than in the medium-high-risk group (BI-RADS 4B-5) (20%, p < 0.001 and 0%, p = 0.001, respectively). Compared with those with FA, patients with MC were older, and tended to have masses with non-hypoechoic patterns, not circumscribed margins, and a posterior echo enhancement on US (p < 0.001, p < 0.001, and p = 0.003, respectively).

CONCLUSION

The oval shape was the main reason for the underestimation of MCs. On US, an oval mass found in the breast of women of older age with non-hypoechoic patterns, not circumscribed margins, and a posterior echo enhancement was associated with an increased risk of being an MC, and should be subjected to active biopsy.

Necrotising cellulitis of the breast associated with a fungating mucinous adenocarcinoma

Breast necrotising soft tissue infections (NSTIs) are rare surgical emergencies with limited cases described in the literature. Here, we discuss a unique case of a woman in her 70s who presented with newly diagnosed diabetes and a neglected right breast cancer associated with breast erythema, skin necrosis, crepitus on examination and breast soft tissue gas seen on CT requiring emergent total mastectomy with partial pectoralis muscle excision. Pathology revealed a 15 cm invasive mucinous adenocarcinoma and necrotising polymicrobial cellulitis with a large abscess cavity. She recovered from her surgery with strict glycaemic control and a 10-day course of antibiotics. Multidisciplinary tumour board recommended adjuvant anastrozole, abemaciclib and postmastectomy radiation to complete her oncological treatment. Although exceedingly rare, it is important that clinicians be aware of, promptly recognise and properly treat NSTIs of the breast, as correct care can be life-saving from both infection and malignancy.

On Ultrasonographic Features of Mucinous Carcinoma with Micropapillary Pattern

Objective

To describe the sonographic features of pure mucinous carcinoma with micropapillary pattern (MUMPC) and compare with different pathological type of mucinous breast carcinoma.

Methods

Subjects were retrospectively reviewed at Suzhou Municipal Hospital from January 2015 to June 2019. Sonographic features of 49 cases (9 MUMPC, 19cPMBC, and 21 MMBC) pathologically confirmed MBC were recorded according to the Breast Imaging Reporting and Data System (BI-RADS) lexicon. The differences in sonographic features among different type of mucinous breast carcinoma were discussed, including clinical features and sonographic features, shape, lesion boundary, peripheral hyperechoic ring, echo pattern, posterior acoustic feature, thickness peripheral hyperechoic area, and blood flow.

Results

All MUMPC had no lymph node metastasis (88.9%, 8/9), and most of the MUMPC showed no thickness peripheral hyperechoic area (88.9%, 8/9) and blood flow (55.6%, 5/9) within the tumor. Furthermore, MUMPC had mixed cystic and solid components (33.3%, 3/9) and solid echoic (66.7%, 6/9) structures, with regular shape (66.7%, 6/9) and peripheral hyperechoic ring (66.7%, 6/9). Seven cases of the MUMPC showed circumscribed margin (77.8%, 7/9), and there was significant difference among the three groups (p < 0.05). In addition, there were 7 cases (77.8%, 7/9) of MUMPC tumor ≤2cm, which was significantly different from cPMBC (26.3%, 5/19) and MMBC (28.6%, 6/21) (p < 0.05). There was no significant difference in ultrasonographic features of MBC with different sizes when stratified by tumor size (p > 0.05).

Conclusion

Most of the MUMPC showed a circumscribed margin, peripheral hyperechoic ring, and without lymph node metastasis and thickness peripheral hyperechoic area. However, it is challenging to distinguish MUMPC from PMBC and MMBC on ultrasound. Future research should focus on developing novel analysis methods for ultrasound imaging, conducting studies with larger sample sizes and diverse population groups.

Advanced magnetic resonance imaging of mixed mucinous breast cancer: A case report

Well-differentiated adenocarcinoma, a rare subtype of infiltrating ductal carcinoma, is a kind of mucinous cancer of the breast. It accounts for around 2% of all invasive breast cancers. The average age of presentation is 65-70 years, whereas women under the age of 35 account for 1% of cases. They are classified as pure or mixed carcinomas depending on the amount of mucin they include; knowing the difference is crucial for prognosis and therapy. Despite the lack of sufficient proof, the primary therapy for breast cancer is still surgery. Special forms of breast cancer are still being treated, although this is still a contentious topic. In this article, we intended to present a case of a mixed mucinous carcinoma in a 52-year-old female who was assessed by advanced magnetic resonance imaging.

Association Between Contrast-Enhanced Ultrasound Characteristics and Molecular Subtypes of Breast Cancer

OBJECTIVE

This study aimed to investigate the correlation between contrast-enhanced ultrasound (CEUS) features and molecular subtypes of breast cancer (BC).

METHODS

A total of 116 patients (116 lesions) with pathologically diagnosed BC who received conventional ultrasound and CEUS before surgery were enrolled in this study. BC molecular subtypes were identified by postoperative pathological and immunohistochemical analysis as Luminal A (LA), Luminal B (LB), HER2 (H2) over-expression, and triple-negative (TN). Qualitative and quantitative CEUS characteristics were analyzed by one-way analysis of variance (continuous variables) or Pearson's χ² test or Fisher's exact probability method (categorical variables).

RESULTS

There were significant differences in enhancement speed and enhancement degree among the four subtypes (P < .05). The area under the curve (AUC), time to peak (TTP), and peak intensity (PI) differed among the four subtypes (P < .05). The AUC of the LA subtype (305.1 ± 188.4) was significantly smaller compared with the H2 (535.7 ± 222.0, P = .007) and TN subtypes (496.6 ± 254.7, P = .019). In addition, TTP was shorter in the H2 subtype (19.8 ± 4.9) compared with the other subtypes, and was significantly shorter than in the LA subtype (26.3 ± 7.2, P = .008) and LB subtype (23.1 ± 6.7, P = .036). The PI of the LA subtype (4.7 ± 2.3) was significantly lower than that of the LB (6.6 ± 2.3, P = .027), H2 (7.4 ± 2.2, P = .005), and TN subtypes (6.9 ± 2.6, P = .014).

CONCLUSIONS

CEUS features differed significantly among different molecular subtypes of BC. The enhancement patterns and parameters may be important predictive features of different subtypes of BC.

Sonographic Features of Pure Mucinous Brelast Carcinoma With Micropapillary Pattern

Objective

Previous studies have mostly discussed the clinical manifestations and prognosis of mucinous breast carcinoma with a micropapillary pattern. The purposes of this study were to investigate the sonographic features of pure mucinous breast carcinoma with micropapillary pattern (MUMPC) and to identify the role of ultrasound in the differential diagnosis between MUMPC and conventional pure mucinous breast carcinoma (cPMBC).

Materials and Methods

We obtained written informed consent from all patients, and the Ethics Committee of West China Hospital approved this retrospective study. The study was conducted between May and August 2020. We enrolled 133 patients with 133 breast lesions confirmed as mucinous breast carcinoma (MBC) histopathologically between January 2014 and January 2020.We retrospectively assessed sonographic features (margin, shape, internal echogenicity, calcification, posterior acoustic feature, invasive growth, blood flow grade, and rate of missed diagnosis) and clinical characteristics (age, tumor size, tumor texture, initial symptom, and lymph node metastasis). Bivariable analyses were performed using SPSS version 19.0.

Results

The 133 lesions included 11 MUMPCs, 65 cPMBCs, and 57 mixed MBCs (MMBCs). There were significant differences in margin, shape, calcification, posterior acoustic feature, invasive growth, rate of missed diagnosis, average tumor size, and lymph node metastasis among the three groups (p < 0.05). The subsequent pairwise comparisons showed that there were significant differences in lymph node metastasis, margin, and invasive growth between MUMPC and cPMBC (p < 0.05). In patients aged >45 years, there was a significant difference in tumor size among the three groups (p = 0.045), and paired comparison showed that the average tumor size in the cPMBC group was larger than that in the MMBC group (p = 0.014).

Conclusion

MUMPC showed a non-circumscribed margin and invasive growth more frequently than cPMBC did. Lymphatic metastasis was more likely to occur in MUMPC than cPMBC. Ultrasound is helpful to distinguish MUMPC from cPMBC.

Imaging features of pure mucinous breast carcinoma: correlation with extracellular mucus content

AIM

To analyse the correlation between imaging features using multiple techniques and extracellular mucus content in pure mucinous breast carcinoma (PMBC).

MATERIALS AND METHODS

A retrospective review of available images from 25 patients with 25 PMBC tumours was conducted, with ultrasonography (US), ultrasonic elastography (USE), mammography, and breast-specific gamma imaging (BSGI) available for 25, 15, 11, and eight patients, respectively. Microscopic slides from each tumour were evaluated for extracellular mucus content. The correlation between imaging features and mucus content was analysed using linear-by-linear association chi-square tests or Spearman's rank correlation analyses.

RESULTS

On US images, a significant correlation was found between mucus content and echo pattern (p=0.042) and colour Doppler blood flow (p=0.032), with a trend that the lower mucus content present in tumours, the more likely they were detected with isoechoic echo and high blood flow. On USE images, a moderate negative correlation (r=-0.60, p=0.029) was observed between mucus content and tumour stiffness. On BSGI images, a strong negative correlation (r=-0.92, p=0.001) was shown between mucus content and lesion to non-lesion ratio (L/N) values of radioactivity counts. No significant correlation was found between mucus content and mammography imaging features (all p>0.05).

CONCLUSION

Imaging features at US, USE, and BSGI correlated with extracellular mucus content in PMBC tumours, among which the L/N value using BSGI imaging is the most relevant feature.

The sonographic findings of micropapillary pattern in pure mucinous carcinoma of the breast

BACKGROUND

The aim of this study was to describe the sonographic features of pure mucinous carcinoma with micropapillary pattern (MUMPC) and compare them with conventional pure mucinous breast carcinoma without micropapillary architecture (cPMBC) and mixed mucinous breast carcinoma (MMBC).

METHODS

Eighty-eight patients (17 MUMPCs, 43 cPMBCs, and 28 MMBCs) were included in the study. Sonographic features according to the Breast Imaging Reporting and Data System (BI-RADS) lexicon for ultrasound (US) were recorded and analyzed for each patient. The age, sonographic lesion size, menstrual status, mass location, palpation, tenderness, and axillary lymph node metastasis (LNM) were also analyzed.

RESULTS

Most of the MUMPCs showed an irregular shape (82.4%, 14/17), a parallel orientation (94.1%, 16/17), a non-circumscribed margin (88.2%, 15/17), and distal acoustic enhancement (88.2%, 15/17). Furthermore, MUMPC had mixed cystic and solid components (35.3%, 6/17) and hypoechoic (29.4%, 5/17) and isoechoic (35.3%, 6/17) structures, with calcification (29.4%, 5/17) and blood flow (41.2%, 7/17) within the tumor. The differences in sonographic features were not found between the MUMPC and cPMBC and between the MUMPC and MMBC. Moreover, there was no significant difference between the three groups based on age, menstrual status, mass location, palpation, and tenderness (p > 0.05). Similar axillary LNMs were observed between MUMPC and cPMBC (p > 0.05), but both MUMPC and cPMBC were statistically different from MMBC (p < 0.05), so as the lesion size.

CONCLUSIONS

At this particular stage, it is challenging to distinguish MUMPC from cPMBC and MMBC on ultrasound according to the BI-RADS-US lexicon.

Differentiation between Pure Mucinous Breast Carcinomas and Fibroadenomas with Strong High-Signal Intensity on T2-Weighted Images from Dynamic Contrast-Enhanced Magnetic Resonance Imaging

Objective

This study aimed to identify characteristics that can differentiate between pure mucinous breast carcinomas (PMBCs) and fibroadenomas (FAs) with strong high-signal intensity on T2-weighted images (T2-SHi) from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).

Methods

The DCE-MRI tumor characteristics were compared and analyzed between 35 PMBCs and 70 FAs with T2-SHi.

Results

Multivariate analysis revealed that delayed enhancement pattern was the only significant independent predictor (p = 0.007).

Conclusion

A delayed enhancement pattern is the most reliable characteristic for differentiating PMBCs from FAs with T2-SHi from DCE-MRI.

Imaging features of automated breast volume scanner: Correlation with molecular subtypes of breast cancer

OBJECTIVES

To investigate the correlation between the imaging features obtained by an automated breast volume scanner (ABVS) and molecular subtypes of breast cancer.

METHODS

We examined 303 malignant breast tumours by ABVS for specific imaging features and by immunohistochemical analysis to determine the molecular subtype. ABVS imaging features, including retraction phenomenon, shape, margins, echogenicity, post-acoustic features, echogenic halo, and calcifications were analysed by univariate and multivariate logistic regression analyses to determine the significant predictive factors of the molecular subtypes.

RESULTS

By univariate logistic regression analysis, the predictive factors of the Luminal-A subtype (n=128) were retraction phenomenon (odds ratio [OR]=10.188), post-acoustic shadowing (OR=5.112), and echogenic halo (OR=3.263, P<0.001). The predictive factors of the Human-epidermal-growth-factor-receptor-2-amplified subtype (n=39) were calcifications (OR=6.210), absence of retraction phenomenon (OR=4.375), non-mass lesions (OR=4.286, P<0.001), absence of echogenic halo (OR=3.851, P=0.035), and post-acoustic enhancement (OR=3.641, P=0.008). The predictors for the Triple-Negative subtype (n=47) were absence of retraction phenomenon (OR=5.884), post-acoustic enhancement (OR=5.255, P<0.001), absence of echogenic halo (OR=4.138, P=0.002), and absence of calcifications (OR=3.363, P=0.001). Predictors for the Luminal-B subtype (n=89) had a relatively lower association (OR≤2.328). By multivariate logistic regression analysis, retraction phenomenon was the strongest independent predictor for the Luminal-A subtype (OR=9.063, P<0.001) when present and for the Triple-Negative subtype (OR=4.875, P<0.001) when absent.

CONCLUSIONS

ABVS imaging features, especially retraction phenomenon, have a strong correlation with the molecular subtypes, expanding the scope of ultrasound in identifying breast cancer subtypes with confidence.

Magnetic resonance imaging and pathological characteristics of pure mucinous carcinoma in the breast according to echogenicity on ultrasonography

Purpose

The aim of this study was to explore the clinical and pathological characteristics of pure mucinous breast carcinoma (PMBC) according to internal echogenicity on ultrasonography (US).

Methods

Thirty-three patients with PMBC diagnosed at surgery were included in this study. Cases of PMBC were classified according to internal echogenicity on US. The imaging features on magnetic resonance (MR) imaging and clinicohistopathological characteristics were compared between the hypoechogenic and the isoechogenic to hyperechogenic groups.

Results

Eleven cases of PMBC (33.3%) exhibited hypoechogenicity on US, while 22 cases (66.7%) exhibited isoechogenicity or hyperechogenicity. Of the isoechogenic to hyperechogenic PMBCs, 95.5% showed a high signal on T2-weighted images, which was a significantly greater percentage than was observed for the hypoechogenic group (54.5%) (P=0.010). Of the hypoechogenic PMBCs, 63.6% showed a washout pattern in the delayed phase, which was substantially more than the result of 23.8% observed for the isoechogenic to hyperechogenic PMBCs (P=0.053).

Conclusion

PMBCs with isoechogenicity or hyperechogenicity were more likely to show a high signal intensity on T2-weighted images than hypoechogenic PMBCs. However, other MR imaging and clinicohistopathological characteristics were not significantly different between the two groups.

A pure mucocele-like lesion of the breast diagnosed on ultrasonography-guided core-needle biopsy: is imaging follow-up sufficient?

Purpose:

To evaluate the upgrade rate of ultrasonography (US)-guided core-needle biopsy (CNB) of the breast for a pure mucocele-like lesion (MLL), to evaluate the clinical and radiologic features, and to correlate the image-pathologic features further on to guide the management of MLL.

Methods:

Between January 2003 and February 2013, 14-gauge US-guided CNB was performed in 18,111 cases. Thirty-two cases associated with MLL were identified, and five cases of MLLs associated with breast carcinoma or with other high-risk breast lesions (i.e., atypical ductal hyperplasia [ADH], papillary lesions, lobular carcinoma in situ, and radial scar complex) were excluded. Among these 27 pure MLLs, 21 cases with surgical or vacuum-assisted excision (VAE) pathology were included in our study. Medical records, mammograms, and ultrasonograms were reviewed for the clinical and radiologic features of the cases.

Results:

Among the 21 cases with pure MLLs at CNB, the final pathology showed a 0% proportion of cases upgraded to malignancy. All the 21 cases with either surgical or VAE pathology were benign MLLs including three cases of focal involvement of ADH (14.3%). The common features were mammographic features of microcalcifications that were round in shape and had a grouped distribution. The US features included oval shape, circumscribed margin, parallel orientation, complex solid and cystic echo pattern, no posterior feature, and complex solid and cystic echoic masses. The predominant Breast Imaging Reporting and Data System (BIRADS) category was 4A. All the lesions showed image-pathologic concordance.

Conclusion:

For pure MLL on US-guided CNB with image-pathologic concordance, close imaging follow-up might be considered instead of surgical excision.