Chest CT of Incidental Breast Lesions

Radiology of fibrosis. Part I: Thoracic organs

Sustained injury from factors such as hypoxia, infection, or physical damage may provoke improper tissue repair and the anomalous deposition of connective tissue that causes fibrosis. This phenomenon may take place in any organ, ultimately leading to their dysfunction and eventual failure. Tissue fibrosis has also been found to be central in both the process of carcinogenesis and cancer progression. Thus, its prompt diagnosis and regular monitoring is necessary for implementing effective disease-modifying interventions aiming to reduce mortality and improve overall quality of life. While significant research has been conducted on these subjects, a comprehensive understanding of how their relationship manifests through modern imaging techniques remains to be established. This work intends to provide a comprehensive overview of imaging technologies relevant to the detection of fibrosis affecting thoracic organs as well as to explore potential future advancements in this field.

Mammary nodules as incidental findings on chest computed tomography: a retrospective analysis on their frequency and predictive value

PURPOSE

To evaluate the frequency of mammary nodules as incidental findings on chest CT scans and to determine a correlation between semiological features and mammographic and histopathological outcomes.

METHODS

A total of 42,864 chest CT scans performed on patients with breast-unrelated working diagnoses by the Radiology Department at AOU Maggiore della Carità, between 1st January 2016 and 30th April 2022, were analysed. Sixty-eight patients (3 males and 65 females) with mammary nodule CT detection were selected and subjected to mammography, mammary ultrasound and, eventually, biopsy.

RESULTS

Thirty-five of the 68 patients received a histopathological confirmation of malignancy. According to Pearson's Chi-square test, the CT features most likely associated with BI-RADS 5 following mammography were post-contrast enhancement (p = 0.001), margin irregularity (p = 0.0001), nipple retraction (p = 0.001), skin thickening (p = 0.024), and the presence of structurally atypical lymph nodes suspicious for metastatic involvement (p = 0.0001). The CT features predictive of a biopsy positive for malignancy were post-contrast enhancement (p = 0.0001), margin irregularity (p = 0.0001), and the presence of suspicious lymph nodes (p = 0.011). Finally, 63.4% of patients with a working diagnosis related to cancer were diagnosed with breast cancer.

CONCLUSION

Chest CT incidental findings of mammary nodules had a 0.21% incidence rate. The accurate description of some CT scan features, such as post-contrast enhancement, margin irregularity, nipple retraction, skin thickening and the presence of structurally atypical lymph nodes, may help to establish a radiological suspicion of malignancy, especially if these characteristics are supported by a working diagnosis of cancer.

Endoscope-Assisted Minimally Invasive Surgery for the Treatment of Glandular Gynecomastia

BACKGROUND

Gynecomastia (GYN) is the most common benign disease in males. A vacuum-assisted biopsy is a minimally invasive surgical technique for GYN treatment that achieves satisfactory aesthetic results. However, due to the operation under non-direct vision, it is difficult to localize the bleeding points and assess the residual glandular tissue. Endoscopy was applied to observe the operative field after subcutaneous mastectomy. The present study aimed to recommend our initial experience in glandular GYN with endoscope-assisted minimally invasive subcutaneous mastectomy.

METHODS

A total of 34 patients diagnosed with glandular GYN (50 breasts), treated with endoscope-assisted minimally invasive surgery at The First Affiliated Hospital with Nanjing Medical University between June 2018 and June 2020, were enrolled in this study. According to Simon's classification of the breast, 10 was grade I, 25 was grade IIA, and 15 was grade IIB. The characteristics of patients, operative data, postoperative complications, cosmetic outcome, and patient satisfaction were recorded.

RESULTS

Endoscope-assisted minimally invasive mastectomy was performed successfully in all cases. The operative duration of the operation was 55-120 min/side. The total weight of the resected tissue of the 50 breasts was 55-350 g, and the blood loss was 10-105 mL/breast. Endoscopy detected five breasts with bleeding and three with residual glandular during the operation. Postoperative bleeding occurred in 1 breast, subcutaneous seroma in 3 breasts, dysesthesia of the nipple-areolar complex in 2 breasts, and skin redundancy in a bilateral patient. None of the patients experienced severe pain, infection, nipple necrosis, and nipple retraction, a saucer-like deformity. With a median follow-up of 21 months, all patients were satisfied with their cosmetic outcome (100%), and no recurrence occurred.

CONCLUSION

Endoscope-assisted minimally invasive mastectomy could be used as a feasible technique for the treatment of glandular GYN.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online. Instructions to Authors www.springer.com/00266 .

Suspicious breast lesions incidentally detected on chest computer tomography with histopathological correlation

OBJECTIVE

To evaluate incidental breast lesions on chest computed tomography with histopathological correlation. It is important for general radiologist to characterize a breast lesion as benign, indetermined, or sufficiently suspicious to warrant further work-up.

METHODS

A total of 35.000 chest CT examinations were performed between January 2016 and December 2020. 27 patients (mean age 70 years, age range 48-87 years) with incidental breast lesions were identified in this retrospective study. Two radiologists scored incidental breast lesions independently regarding their morphology, and the results were compared to histopathology which was obtained by an ultrasound-guided core needle biopsy or a surgical excision.

RESULTS

Out of 35.000 chest CT examinations, a total of 31 incidental breast lesions in 27 patients were detected. Among the 31 lesions, 23 were malignant and 8 benign. The malignant lesions included 17 carcinomas and 6 metastases (4 lymphomas and 2 melanomas). The benign lesions contained 2 hematomas, 4 fat necrosis, and 2 fibrosis lumps.

CONCLUSION

Chest computed tomography as a standard imaging technique is helpful for evaluation of suspicious breast lesions. This may ultimately influence patient management and lead to further imaging.

Incidental Breast Findings on Computed Tomography and MR Imaging

Computed tomography (CT) and magnetic resonance (MR) imaging may demonstrate a wide variety of incidental findings in the breast, including primary breast carcinoma, the second most common cancer in women. It important to recognize the spectrum of pathologic conditions in order to properly assess the need for further workup. Some findings may be diagnosed as benign on the basis of CT/ MR imaging and clinical history alone, whereas others will require evaluation with dedicated breast imaging and possibly biopsy. This article serves to guide radiologists' management of the wide spectrum of incidental breast findings encountered on cross-sectional imaging.

A Case of Asymmetric Nipple Enhancement as an Imaging Precursor to Invasive Ductal Carcinoma

On multidetector computed tomography (CT), it is important to scrutinize the imaged portions of the breasts. In recent years, the dramatic rise in CT imaging has led to the increased detection of incidental breast lesions. We describe a case of invasive ductal carcinoma that presented as stage IV cancer, and retrospective review of prior imaging study revealed asymmetric nipple enhancement on a trauma protocol CT chest acquired three years earlier. This report highlights the importance of being attentive to breast abnormalities on CT performed for indications other than breast disease and additionally focuses on the approach to address abnormal enhancement of the nipple areolar complex (NAC).

Breast mass assessment on chest CT: Axial, sagittal, coronal or maximal intensity projection?

OBJECTIVES

The goal of this work is to determine the optimal projection to detect breast masses on Chest CT.

METHODS

Institutional Review Board (HIPPA compliant) approval was obtained with a waiver of consent. 10 image pairs of Chest CT images containing breast masses were selected for review by 10 chest radiologists: the pairs consisted of axial, sagittal, coronal and axial MIP images (MIP images) with each projection compared to a MIP and with one another. For each pair, the image where the mass was most conspicuous was recorded.

RESULTS

MIPs were preferred to any cross sectional projection 82% of the time; sagittal (63%) or coronal (63%) images were preferred to the axial projection. When sagittal and coronal images were compared there was no preference.

CONCLUSIONS

MIP images should be obtained and reviewed for breast pathology; sagittal or coronal projections may provide additional information.

Value of tomography in detecting breast masses and discriminating malign and benign lesions

Objectives

The main purpose of the present study was to determine the effectivity of computerized tomography (CT) in detecting breast masses and discriminating masses as malignant or benign.

Material and Methods

After having received the institutional local ethics committee approval, an experienced radiologist who did not participate in the study created a patient pool by searching our health center's Pathology department database between 2010 and 2018. The group created consisted of dense and non-dense breast types equally and included approximately similar percentages of benign and malignant breast mass sizes. Finally, 70 subjects were included: 30 females with definite malign, 20 with definite benign breast masses, and 20 without any breast pathology based on mammography and ultrasonography results, who were considered as the control group. Three experienced Radiologists (R1, R2, R3) who were not aware of the final diagnosis evaluated all images independently. Radiologist performance was assessed by calculating the area under the receiver operating characteristic curve (AUC) and interobserver reliability values were estimated by intraclass correlation coefficient (ICC) analysis.

Results

The diagnostic accuracy suitability of CT according to BI-RADS scores for R1, R2 and R3 were found as p <0.001, p <0.001 and p <0.001, respectively. There were significant interobserver reliability rates between all investigators (p= 0.0001).

Conclusion

CT may be used as a valuable diagnostic tool in discriminating breast masses with further training in widely varying appearances of normal breast tissues leading to false positive findings.

A practical guide to managing CT findings in the breast

While it is well accepted that CT is not an optimal imaging study to evaluate the breasts, findings on chest CT may be the first indication of an occult malignancy. The nonspecific appearance of breast findings and the lack of consensus guidelines for managing incidental breast findings may dissuade radiologists from thoroughly evaluating the breasts on CT. We review commonly encountered breast findings on CT and present an algorithm for managing incidentally detected breast findings.

Incidentally detected breast lesions on chest CT with US correlation: a pictorial essay

With the increasing use of computed tomography (CT), incidental breast lesions are detected more frequently. When interpreting chest CT findings, it is important for radiologists to carefully review the breast to recognize any abnormal findings that could affect patient management. The purpose of this study is to discuss incidental breast lesions on chest CT with ultrasonography correlation that may be encountered in routine clinical practice.

Differentiation of Malignant and Benign Incidental Breast Lesions Detected by Chest Multidetector-Row Computed Tomography: Added Value of Quantitative Enhancement Analysis

To retrospectively determine the association between breast lesion morphology and malignancy and to determine the optimal value of lesion enhancement (HU, Hounsfield units) to improve the diagnostic accuracy of breast cancer in patients with incidental breast lesions (IBLs). A total of 97 patients with 102 IBLs detected from July 2009 to December 2012 were enrolled in this study. Two radiologists analyzed CT images for the presence of malignancy based on the morphology of the lesions alone and in combination with an enhancement value (HU) analysis. There were 36 malignant and 66 benign IBLs. When the morphology and enhancement values were combined, the sensitivity, specificity, and accuracy were 92%, 97%, and 95%, respectively, for reader 1 and 89%, 94%, and 92%, respectively, for reader 2. The addition of HU values led to correct changes in the diagnosis; specifically, the accuracy of the diagnosis of reader 1 and reader 2 improved by 6.9% and 11.8%, respectively. The addition of the enhancement value (HU) to the CT morphology improved the diagnostic accuracy in the differentiation of malignant from benign IBLs by using the region of interest (ROI) to measure the HU within the most suspicious part of the lesion.

Costs associated with evaluation of incidental breast lesions identified on computed tomography

OBJECTIVE

The purpose of this study was to calculate the costs associated with the evaluation of breast incidentalomas (BI) identified on CT.

METHODS

All CT scans of the thorax performed at the radiological department of the University Hospital of the Martin-Luther-University Halle-Wittenberg between the years 2006 and 2014 were reanalysed retrospectively. 111 patients with BI were identified. The radiological and clinical reports of these cases were examined, and the costs of all further diagnostic procedures performed to clarify the detected BI were calculated.

RESULTS

In 31 (27.9%) of the 111 patients, BI were not further investigated. Of the remaining 80 (72.1%) cases of BI, primary breast carcinoma was diagnosed in 10 (12.5%) cases, breast involvement by lymphoma in 7 (8.8%) cases, intramammary metastases in 19 (23.7%) cases and different benign findings in 44 (55.0%) cases. The total costs associated with clarification of BI in our institution (n = 53) amounted to €14,045.71. The costs per BI were €265.01 and per newly identified breast cancer €1560.63.

CONCLUSION

Breast lesions incidentally detected on CT should be categorized as major incidental findings because of the high frequency of malignancy. The radiologist should carefully evaluate the breast on CT images and all identified BI should be clarified. The clarification of BI is associated with a low economic burden in comparison with screening programmes for primary breast cancer.

ADVANCES IN KNOWLEDGE

The radiologist should carefully evaluate the breast on CT and all identified BI should be clarified. The evaluation of BI is associated with a low economic burden.

Incidental Breast Lesions Detected on Computed Thorax Tomography

OBJECTIVE

Although mammography is the primary imaging method of the breast, incidental benign and malignant breast lesions are increasingly being detected on computed tomographies (CTs) performed to detect different pathologies. Therefore, the detection and accurate identification of these lesions is important. In this study, we aimed to evaluate the frequency, morphological features, and results of incidental breast lesions on CTs performed for the detection of extramammarian pathologies.

MATERIALS AND METHODS

Incidental breast lesions on CTs performed in our department between 2011 and 2013 were evaluated. Patients who had previously diagnosed breast lesions were excluded from the study. The inclusion criteria were histopathologic diagnose and being followed-up for at least 2 years.

RESULTS

The study population consisted of 33 women whose mean age was 55±1.38 (37-78) years. Of the 33 women, 12 (36%) had malignant and 21 (64%) had benign or normal findings. The most common malignant lesion was invasive ductal carcinoma, and the most common benign lesion was fibroadenoma. Ill-defined contour and lymphadenopathy in malignant lesions and well-defined contour in benign lesions were the most important CT findings.

CONCLUSION

Breast must be carefully evaluated if it is included in the scans. An accurate report of breast lesions gives an opportunity for early diagnosis and treatment.

Targeted sonography using an image fusion technique for evaluation of incidentally detected breast lesions on chest CT: a pilot study

BACKGROUND

With increasing use of computed tomography (CT), incidentally detected breast lesions are being encountered more frequently. The aim of our study was to verify the utility of targeted sonography using an image fusion technique, real-time virtual sonography (RVS) that coordinates real-time sonography images with previously obtained CT images using a magnetic position tracking system, for evaluation of incidentally detected breast lesions on chest CT.

METHODS

Eleven lesions in 11 women with no history of breast cancer who were referred to our unit for assessment of breast lesions incidentally detected on CT were enrolled in this study. To assess the efficacy of targeted sonography using RVS, we analyzed the frequency of sonographic detection of incidentally detected breast lesions and the difference between sonography- and CT-determined diameters.

RESULTS

Using RVS guidance, all 11 lesions were sonographically detected. Ten (91 %) of 11 lesions underwent sonography-guided biopsy, yielding a success rate of 90 % (9/10). The remaining sonography-guided biopsy failure lesion required surgical biopsy for definitive diagnosis; this was performed after RVS was used to mark CT imaging information onto the breast surface. Four (36 %) lesions subsequently proved to be malignant. The mean diameters provided by RVS were 14.9 ± 6.7 mm for sonography and 16.8 ± 7.5 mm for CT (p = 0.538).

CONCLUSION

Using RVS, a sonographic probe was precisely guided to the lesions. Our results suggest that targeted sonography using RVS is a useful technique for identifying incidentally detected breast lesions on chest CT.

Incidental detection of clinically unexpected breast lesions by computed tomography

BACKGROUND

Increased use of computed tomography (CT) has resulted in greater detection of incidental breast lesions unrelated to the primary diagnostic inquiry.

PURPOSE

To investigate the morphology and clinical significance of breast abnormalities detected incidentally by conventional CT.

MATERIAL AND METHODS

A total of 2945 female patients underwent CT examinations of the body, including the chest, from May 2006 to April 2010. Two radiologists interpreted these CT scans independently and pointed out a mass or non-mass-like lesion as abnormalities in the breast. Patients who incidentally showed breast lesions on CT scans were identified by a computer-based search of the diagnostic reports and were enrolled in this study. The morphology and enhancement patterns of CT-detected breast lesions were evaluated according to BI-RADS-MRI.

RESULTS

In total, 32 clinically unexpected abnormal breast lesions were found in 31 (1.1%) patients. Twenty-nine of the 32 lesions were detected by contrast-enhanced CT and three by unenhanced CT. Ten breast cancers were found in 10 patients (0.34%), which yielded the prevalence for malignancy of 31% (10/32). Invasive ductal carcinomas accounted for eight lesions, while two were ductal carcinomas in situ (DCIS). Nine lesions were depicted as a mass and one DCIS was a non-mass-like lesion. Good morphological predictors of breast cancers for a mass were an irregular shape, a lobulated shape, and an irregular margin. Benign lesions accounted for 22 lesions from 21 patients (0.71%). Of these, 13 lesions in 13 patients were depicted as a mass and nine lesions in nine patients as a non-mass-like lesion.

CONCLUSION

Unexpected breast lesions can be identified as a mass or non-mass-like lesion on conventional chest CT scans. Among these, breast cancers that are not clinically apparent occur with considerable prevalence. We suggest that careful interpretation of the breast should be a routine part of CT examinations.

Comparison between incidental malignant and benign breast lesions detected by computed tomography: a systematic review

INTRODUCTION

With increasing use of CT for a variety of diagnostic pathways, breast incidentalomas will be identified more frequently. Therefore, it is important for radiologists to know typical CT appearances of malignant and benign breast lesions. The aim of this study was to compare radiological features of benign and malignant incidental breast findings on CT reported in the literature.

METHODS

A search for appropriate studies published between 1988 and 2012 yielded five results with a total of 214 patients/257 lesions. Morphological features of the described breast masses, such as shape, margins, enhancement, axillary lymphadenopathy and calcifications, were analysed.

RESULTS

The prevalence of incidental breast carcinoma varied from 9.2% to 60.9% of the lesions. The frequency of benign lesions was 30.4-71.8%. The remaining incidental findings were intramammary metastases and primary or secondary breast lymphomas. Malignant lesions were larger in size, were round in shape and demonstrated a higher density compared with benign lesions. There was no significant difference in the margin characteristics of the masses between the groups. The morphological features previously postulated as typical for malignancy turned out to be non-specific.

CONCLUSIONS

Benign and malign breast incidentalomas are not safely distinguished from each other on standard chest CT. Therefore, all breast incidentalomas should be evaluated by further radiological/histological investigations.

Technical parameters and interpretive issues in screening computed tomography scans for lung cancer

Lung cancer screening computed tomographies (CTs) differ from traditional chest CT scans in that they are performed at very low radiation doses, which allow the detection of small nodules but which have a much higher noise content than would be acceptable in a diagnostic chest CT. The technical parameters require a great deal of attention on the part of the user, because inappropriate settings could result in either excess radiation dose to the large population of screened individuals or in low-quality images with impaired nodule detectability. Both situations undermine the main goal of the screening program, which is to detect lung nodules using as low a radiation dose as can reasonably be achieved. Once an image has been obtained, there are unique interpretive issues that must be addressed mainly because of the very high noise content of the images and the high prevalence of incidental findings in the chest unrelated to the sought-after pulmonary nodules.

Incidentally detected enhancing breast lesions on chest computed tomography

Objective

To evaluate the nature and imaging appearance of incidental enhancing breast lesions detected on a routine contrast-enhanced chest CT.

Materials and Methods

Twenty-three patients with incidental enhancing breast lesions on contrast-enhanced chest CT were retrospectively reviewed. The breast lesions were reviewed by unenhanced and enhanced CT, and evaluated by observing the shapes, margins, enhancement patterns and backgrounds of breast lesions. A histopathologic diagnosis or long-term follow-up served as reference standard.

Results

Sixteen (70%) patients had malignant breast lesions and seven (30%) had benign lesions. In 10 patients, the breast lesions were exclusively detected on contrast-enhanced CT. Using unenhanced CT, breast lesions with fibroglandular backgrounds were prone to be obscured (p < 0.001). Incidental primary breast cancer showed an non-significant trend of a higher percentage irregular margin (p = 0.056). All of the four incidental breast lesions with non-mass-like enhancement were proven to be malignant.

Conclusion

Routine contrast-enhanced chest CT can reveal sufficient details to allow for the detection of unsuspected breast lesions, in which some cases may be proven as malignant. An irregular margin of incidental enhancing breast lesion can be considered a suggestive sign of malignancy.

Incidental breast lesions detected on CT: what is their significance?

An increasing number of breast lesions are being detected incidentally on CT. The aim of this study was to investigate the rate of referrals to the breast unit for assessment of lesions identified on CT and the resulting yield of previously undiagnosed breast malignancies from this pathway. A retrospective review was undertaken of CT examinations conducted over a period of 14 years. All patients (with no previous history of breast cancer) whose report contained the keyword "breast" and who were referred to a specialist breast unit for assessment were reviewed. CT lesion morphology and enhancement pattern were identified and compared with the final diagnostic outcome. 70 patients were identified by retrospective analysis, yielding 78 incidental breast lesions, of which 22 (28.2%) were malignant (category B5). This gave a positive predictive value (PPV) for malignancy of 28.2%. The best morphological predictor of malignancy was spiculation (PPV, 76%) and irregularity (PPV, 58%), whereas calcification patterns (PPV, 36%) were diagnostically unhelpful. Malignant lesions were likely to be larger (mean, 28.5 mm) than benign lesions (mean, 20.2 mm; p<0.05). In conclusion, 30% of incidental breast lesions in this large series of patients proved to be unsuspected breast cancers, particularly irregular spiculated masses. Referral for formal triple assessment of CT-diagnosed breast lesions is worthwhile, and careful examination of the breast should be a routine part of CT examinations.