Pushing the envelope in breast conserving surgery - is multiple-wire localization (3 or more wires) associated with increased risk of compromised margins and long-term recurrence?

INTRODUCTION: In the last two decades there has been a paradigm shift with breast conserving surgery (BCS) being applied to larger and more extensive breast malignancies. The aim of this study is to examine the success of BCS being performed in patients with extensive breast malignancies requiring at least 3 wires for localization, and to assess possible risk factors for failure. MATERIALS AND METHODS: We performed a retrospective single center review of 232 patients who underwent BCS between 2010 and 2020 requiring at least 3 wires for localization, thus comprising the multi-wire group (MWG). The cohort included a control group of 232 single-wire BCS patients (SWG) chronologically matched with the MWG. Patients with either invasive malignancy or ductal carcinoma in situ (DCIS) were included in the study. Clinical, radiological, and pathological data was collected. Proportions of positive surgical margins, re-lumpectomies and conversion to mastectomy were calculated. Survival analysis for locoregional and distant recurrence was performed. RESULTS: Women in the MWG were younger (mean age 57 vs. 63.1, P < 0.001), had larger tumor size (mean size 5.1 cm vs. 1.3 cm, p < 0.001), a higher prevalence of calcifications on mammograms (72 % vs. 17 %, P < 0.001), a higher proportion of positive lymph nodes (75 % vs. 45 %, P = 0.019), and an elevated incidence of a ductal carcinoma in situ (DCIS) component (72 % vs. 38 %, P < 0.001). Positive surgical margins were higher in the MWG (13 % vs 7 %, P = 0.03), which lead to higher proportions of re-lumpectomies or conversion to mastectomies (7 % vs 4 %, P = 0.17). On multivariate analysis of the entire cohort, patients with positive margins were more likely to have a DCIS component (77 % vs 53 %, P = 0.001), an infiltrating lobular carcinoma (ILC) component (15 % vs 9 %, P = 0.013), and positive ER hormonal status (94 % vs 85 %, p = 0.05). The number of wires was not an independent predictor of positive margins. On long-term analysis, the locoregional disease-free survival was similar between the SWG and MWG (P = 0.1). However, the MWG showed higher rates of distant metastasis (12 % vs 4 %, P = 0.006). CONCLUSIONS: BCS requiring 3 or more wires is associated with a slightly higher proportion of positive margins. The increased risk of positive margins appears to be related to the type of tumor (DCIS component, ILC component and ER status) rather than to the number of wires. The number of wires does not significantly impact locoregional disease-free survival.

Evaluating persistent T1-weighted lesions without concurrent abnormal enhancement on breast MRI in neoadjuvant chemotherapy patients: implications for complete pathological response.

OBJECTIVE: This study aims to determine whether persistent T1-weighted lesions signify a complete pathological response (pCR) in breast cancer patients treated with neoadjuvant chemotherapy and surgery, and to evaluate their correlation with imaging responses on MRI. MATERIALS AND METHODS: A retrospective review was conducted on data from breast cancer patients treated between January 2011 and December 2018. Patients who underwent breast MRI and pre- and post-neoadjuvant chemotherapy followed by surgery were included. Those with distant metastasis, no planned surgery, pre-surgery radiation, ineligibility for neoadjuvant chemotherapy, or unavailable surgical pathology were excluded. Groups with and without persistent T1-weighted lesions were compared using the chi-square test for categorical variables and the Student t test or Wilcox rank sum test for continuous variables. Univariate logistic regression was used to evaluate the association of the final pathological response with the presence of T1-persistent lesion and other characteristics. RESULTS: Out of 319 patients, 294 met the inclusion criteria (breast cancer patients treated with neoadjuvant chemotherapy and subsequent surgery); 157 had persistent T1 lesions on post-chemotherapy MRI and 137 did not. A persistent T1 lesion indicated reduced likelihood of complete pathological response (14% vs. 39%, p < 0.001) and imaging response (69% vs. 93%, p < 0.001). Multivariable analysis confirmed these findings: OR 0.37 (95% CI 0.18-0.76), p = 0.007. No other characteristics correlated with T1 residual lesions. CONCLUSION: Persistent T1-weighted lesions without associated abnormal enhancement on post-treatment breast MRI correlate with lower complete pathological and imaging response rates. CLINICAL RELEVANCE STATEMENT: The study underscores the importance of persistent T1-weighted lesions on breast MRI as vital clinical markers, being inversely related to a complete pathological response following neoadjuvant chemotherapy; they should be a key factor in guiding post-neoadjuvant chemotherapy treatment decisions. KEY POINTS: • Persistent T1 lesions on post-chemotherapy breast MRI indicate a reduced likelihood of achieving a complete pathological response (14% vs. 39%, p < 0.001) and imaging response (69% vs. 93%, p < 0.001). • Through multivariable analysis, it was confirmed that the presence of a persistent T1 lesion on breast MRI post-chemotherapy is linked to a decreased likelihood of complete pathological response, with an odds ratio (OR) of 0.37 (95% CI 0.18-0.76; p = 0.007). • In addition to the convention of equating the absence of residual enhancement to complete imaging response, our results suggest that the presence or absence of residual T1 lesions should also be considered.

The diagnostic performance of ultrafast MRI to differentiate benign from malignant breast lesions: a systematic review and meta-analysis.

OBJECTIVES: To assess the diagnostic performance of ultrafast magnetic resonance imaging (UF-DCE MRI) in differentiating benign from malignant breast lesions. MATERIALS AND METHODS: A comprehensive search was conducted until September 1, 2023, in Medline, Embase, and Cochrane databases. Clinical studies evaluating the diagnostic performance of UF-DCE MRI in breast lesion stratification were screened and included in the meta-analysis. Pooled summary estimates for sensitivity, specificity, diagnostic odds ratio (DOR), and hierarchic summary operating characteristics (SROC) curves were pooled under the random-effects model. Publication bias and heterogeneity between studies were calculated. RESULTS: A final set of 16 studies analyzing 2090 lesions met the inclusion criteria and were incorporated into the meta-analysis. Using UF-DCE MRI kinetic parameters, the pooled sensitivity, specificity, DOR, and area under the curve (AUC) for differentiating benign from malignant breast lesions were 83% (95% CI 79-88%), 77% (95% CI 72-83%), 18.9 (95% CI 13.7-26.2), and 0.876 (95% CI 0.83-0.887), respectively. We found no significant difference in diagnostic accuracy between the two main UF-DCE MRI kinetic parameters, maximum slope (MS) and time to enhancement (TTE). DOR and SROC exhibited low heterogeneity across the included studies. No evidence of publication bias was identified (p = 0.585). CONCLUSIONS: UF-DCE MRI as a stand-alone technique has high accuracy in discriminating benign from malignant breast lesions. CLINICAL RELEVANCE STATEMENT: UF-DCE MRI has the potential to obtain kinetic information and stratify breast lesions accurately while decreasing scan times, which may offer significant benefit to patients. KEY POINTS: • Ultrafast breast MRI is a novel technique which captures kinetic information with very high temporal resolution. • The kinetic parameters of ultrafast breast MRI demonstrate a high level of accuracy in distinguishing between benign and malignant breast lesions. • There is no significant difference in accuracy between maximum slope and time to enhancement kinetic parameters.

Contralateral Breast Screening with Preoperative MRI: Long-Term Outcomes for Newly Diagnosed Breast Cancer.

Background The diagnostic value of screening the contralateral breast with MRI in patients with newly diagnosed breast cancer is poorly understood. Purpose To assess the impact of MRI for screening the contralateral breast on long-term outcomes in patients with newly diagnosed breast cancer and to determine whether subgroups with unfavorable prognoses would benefit from MRI in terms of survival. Materials and Methods Data on consecutive patients with newly diagnosed breast cancer seen from January 2008 to December 2010 were reviewed retrospectively. Patients with neoadjuvant chemotherapy, previous breast cancer, distant metastasis, absence of contralateral mammography at diagnosis, and no planned surgical treatment were excluded. Groups that did and did not undergo preoperative MRI were compared. Survival analysis was performed using the Kaplan-Meier method for propensity score-matched groups to estimate cause-specific survival (CSS) and overall survival (OS). A marginal Cox proportional hazards model was used to evaluate association of MRI and clinicopathologic variables with OS. Results Of 1846 patients, 1199 fulfilled the inclusion criteria. Median follow-up time was 10 years (range, 0-14 years). The 2:1 matched sample comprised 705 patients (470 in the MRI group and 235 in the no-MRI group); median ages at surgery were 59 years (range, 31-87 years) and 64 years (range, 37-92 years), respectively. MRI depicted contralateral synchronous disease more frequently (27 of 470 patients [5.7%] vs five of 235 patients [2.1%]; P = .047) and was associated with a higher OS (hazard ratio [HR], 2.51; 95% CI: 1.25, 5.06; P = .01). No differences were observed between groups in metachronous disease rate (MRI group: 21 of 470 patients [4.5%]; no-MRI group: 10 of 235 patients [4.3%]; P > .99) or CSS (HR, 1.34; 95% CI: 0.56, 3.21; P = .51). MRI benefit was greater in patients with larger tumor sizes (>2 cm) (HR, 2.58; 95% CI: 1.11, 5.99; P = .03) and histologic grade III tumors (HR, 2.94; 95% CI: 1.18, 7.32; P = .02). Conclusion Routine MRI screening of the contralateral breast after first diagnosis of breast cancer improved overall survival; the most pronounced benefit was found in patients with larger primary tumor size and primary tumors of histologic grade III. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Taourel in this issue.

The characteristics associated with upgrade on surgical pathology of conventional imaging occult DCIS diagnosed by MRI.

PURPOSE: To characterize the clinical, pathological, and imaging features of DCIS occult on conventional imaging diagnosed on MRI-guided biopsy associated with increased risk of invasive disease on surgical excision. MATERIALS AND METHODS: All consecutive patients with MRI-detected DCIS occult on conventional imaging between January 2009 and December 2018 were included. Women were divided into two groups based on final pathology: Pure DCIS or DCIS with invasive component. Clinical, imaging, and pathological risk factors for upgrade to invasion were evaluated. RESULTS: Of 50 patients who met the inclusion criteria, 12 (24%) were upgraded to invasive malignancy in the final pathology. The only parameters that showed statistically significant association with upgrade were related to kinetic characteristics: 53% of patients with the combination of fast early upstroke and either plateau or washout curve were upgraded, compared to 12% of women without this combination (p = 0.006). The sensitivity of combined kinetic features for predicting upgrade was 67% (95% CI 35-90%), specificity was 84% (CI 95% 68-94%), positive predictive value was 57% (CI 95% 37-75%), negative predictive value was 89% (CI 95% 77-95%), and OR was 78% (64-88%). CONCLUSION: Kinetic characteristics show the strongest association with upgrade to invasion in DCIS occult on mammogram and US. Larger studies should be encouraged to consolidate our findings, which may have implication for treatment planning.

Lobular neoplasia occult on conventional imaging and diagnosed on MRI-guided biopsy: can we estimate upgrade on surgical pathology?

PURPOSE: The goal of this study is to evaluate the frequency and imaging features of lobular neoplasia (LN) diagnosed on MRI-guided biopsy, determine the upgrade rate to malignancy, and assess for any features that may be associated with an upgrade on surgical excision. MATERIALS AND METHODS: Research ethical board approved the review of consecutive patients with MRI-detected LN between January 2009 and December 2018 with differentiation between pure LN and LN with associated other high-risk lesions. The final outcome was determined by final pathology results from surgical excision or 24 months of follow-up. Appropriate statistical tests were used. RESULTS: Out of 1250 MRI-guided biopsies performed, 76 lesions (6%) fulfilled the inclusion criteria and formed the study cohort. Of the 76 lesions, 54 (71%) were pure LN while the rest had coexistent high-risk lesion. Non-mass enhancement (NME) was the most common lesion type (62, 82%). Fifty-nine lesions (78%) were surgically excised, the other 17 had benign follow-up. Overall, 8 lesions (11%) were upgraded to malignancy on final pathology. Malignant outcome was associated with larger lesion size (5.5 versus 1.9 cm, P < 0.001) and a clumped NME pattern (75% versus 24%, P = 0.006). Lesion size and clumped NME remained significantly associated with upgrade on sub-analysis of the pure LN group. CONCLUSION: Larger lesion size and clumped NME are imaging findings associated with upgrade of LN diagnosed by MRI-guided biopsy. This may influence patient management in this clinical setting. Additional larger studies are needed to consolidate our results and to potentially detect additional factors associated with upgrade.

Can breast MRI accurately exclude malignancy in mammographic architectural distortion?

OBJECTIVES: To investigate the diagnostic accuracy of problem-solving breast magnetic resonance imaging (MRI) in excluding malignancy in a cohort of patients diagnosed with mammographic architectural distortion (MAD). METHODS: The Institutional Review Board approved the study. Imaging database with 40,245 breast MRIs done between January 2008 and September 2018 was retrospectively reviewed. The study included all exams considered problem-solving MRI for MAD. Two radiologists reviewed the imaging data. Outcome was determined by the pathology results of biopsy/surgical excision or at least 1 year of clinical and radiological follow-up. Predictors for malignancy were examined, and appropriate statistical tests were applied. RESULTS: One hundred seventy-five patients (median age 53 years) fulfilled the inclusion criteria and formed the study cohort. No cancers were diagnosed in 106 patients with a negative MRI. Out of 69 women with positive MRI findings, 48 (70%) had benign outcome defined either by pathology result or by negative follow-up, and 21 (30%) yielded malignancy. Malignancy was significantly associated with positive MRI (p < 0.001) and older age (p = 0.014). Falsely positive MRIs were frequently found in women with radial scars. The sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy of breast MRI were 100% (95% CI 84 to 100%), 68% (CI 61 to 76%), 100% (CI 95 to 100%), 30% (CI 26 to 36%), and 73% (95% CI 66-79), respectively. CONCLUSION: A negative breast MRI in patients with MAD was reliable in excluding malignancy in this cohort and may have a role as a precision medicine tool for avoiding unnecessary interventions. KEY POINTS: • MRI shows a high negative predictive value in MAD cases. • MRI displays low accuracy in differentiating malignancy from RS. • MRI is a reliable non-invasive method to exclude malignancy in women with mammographic architectural distortion, potentially avoiding unnecessary biopsies and surgeries.

Yield of surveillance magnetic resonance imaging after bilateral mastectomy and reconstruction: a retrospective cohort study.

PURPOSE: There are no evidence-based guidelines for surveillance of women after bilateral mastectomy and reconstruction. Several societies recommend against routine breast imaging in this setting. Despite these recommendations, magnetic resonance imaging (MRI) is frequently used to follow these women. We sought to examine the findings on MRI studies done in this setting. METHODS: This is a retrospective cohort study including all consecutive MRI exams done after bilateral mastectomy and reconstruction between January 2010 and April 2018. Data collected included demographic information, family history, BRCA status, indication for bilateral mastectomy, type of reconstruction, findings on MRI, and work-up of MRI findings. Cancer detection rate and interval cancer rates were calculated. RESULTS: One hundred fifty-nine women had 415 surveillance MRI exams. Most (372, 90%) studies were done in women with implant-based reconstruction. Four hundred and five (98%; 95% confidence interval (CI) 96-99%) of the studies were negative. One breast recurrence was found on MRI (cancer detection rate 2.4 per 1000 MRI exams, 95% CI 0.4-13); however, this woman was simultaneously diagnosed with metastatic disease. The false-positive rate was 90% (95% CI 54-99%). During follow-up three women were diagnosed with local recurrence (interval cancer rate 5 per 1000, 95% CI 1.3-17) and 4 women were diagnosed with metastatic disease. CONCLUSION: The yield of surveillance MRI in women with bilateral mastectomy and reconstruction is very low. As most of the cohort had retro-pectoral implant-based reconstruction, it appears safe to recommend against surveillance MRI in this setting regardless of the indication for mastectomy.

Use of Breast Magnetic Resonance Imaging in Women Diagnosed With Atypical Ductal Hyperplasia at Core Needle Biopsy Helps Select Women for Surgical Excision.

PURPOSE: The study sought to investigate the role of breast magnetic resonance imaging (MRI) in patients diagnosed with atypical ductal hyperplasia (ADH) at core needle biopsy (CNB). METHODS: The breast MRI database at our centre was queried for studies performed between January 2010 and December 2016 for the clinical indication of ADH diagnosed at CNB. Medical files were reviewed for demographic data, clinical information, and radiology and pathology reports. Pathological results of the surgical specimens were considered the gold standard for comparison with breast MRI findings. In women not undergoing excision, at least 2 years of follow-up was used to ascertain the benign nature of the finding. RESULTS: Fifty patients were included in the study. Thirty-one (62%) patients had surgical excision of the ADH lesion, and 7 (23%) were upgraded to malignancy. Breast MRI accurately identified 6 of the 7 cases. Six of the 12 women (50%) with positive MRI findings at the biopsy site were upgraded to malignancy on surgical pathology, compared with only 1 of 19 (5%) with negative MRI findings. Forty-nine percent of the women with a negative MRI did not undergo surgical excision of the ADH lesion, compared with 8% of the women with a positive MRI (P = .009), with no cancer diagnosed during follow-up. The sensitivity, specificity, negative predictive value, and positive predictive value of breast MRI for predicting upgrade to malignancy were 86%, 83%, 97%, and 46%, respectively. CONCLUSIONS: MRI may have a role in the management of women diagnosed with ADH on CNB, to minimize diagnostic excisional biopsies.

Follow-up of patients undergoing oncoplastic surgery - more palpable masses and benign biopsies.

BACKGROUND: Oncoplastic reconstruction is increasingly used in the management of women undergoing breast conserving surgery. We examined the findings on breast exam and imaging of patients who underwent breast conservation with or without oncoplastic reconstruction. OBJECTIVE: We hypothesized that patients undergoing immediate breast reconstruction would present with more palpable and imaging abnormalities compared to lumpectomy alone and undergo therefore more biopsies. METHODS: All patients undergoing breast conservation with oncoplastic reconstruction for breast cancer between 2009 and 2014 were included in the study group. The control group was created by matching 4 women that underwent lumpectomy alone during the same week to each patient in the study group. The two groups were compared regarding demographics, tumor characteristics, post-operative complaints, breast exam, imaging and biopsies done during follow-up. RESULTS: The study group included 67 women who had lumpectomy and immediate oncoplastic reconstruction and 268 women that underwent lumpectomy alone.Patients undergoing immediate oncoplastic reconstruction had more advanced disease; larger mean tumor size (3.1 cm versus 1.9 cm, P < 0.001), higher rate of involved lymph nodes (48% versus 26%; P < 0.001) and use of neoadjuvant treatment (39% versus 15%; P < 0.001).After oncoplastic reconstruction, new lumps (18% versus 5%; P = 0.004) were found more frequently, and there was a higher rate of women undergoing biopsies (31% versus 11%; P < 0.001). This finding remained significant after controlling for age, type of tumor, use of neoadjuvant treatment and volume of tissue removed. Over ninety percent of biopsies in the oncoplastic group were benign, most commonly-fat necrosis (N = 15, 60% of the biopsies). CONCLUSIONS: Immediate oncoplastic reconstruction is associated with increased palpable masses and imaging abnormalities, requiring biopsies. Patients and clinicians should be aware of the benign nature of most of these findings.

Do All Women With Abnormal Sonographic Axillary Lymph Nodes Need a Biopsy?

PURPOSE: With the increased use of breast ultrasound for different indications, sonographically abnormal axillary lymph nodes are not a rare finding. We examined clinical and imaging characteristics in correlation with pathological reports of the sonographic guided biopsies to assess the yield of needle biopsy of these nodes. METHODS: Clinical, imaging and pathology data were collected for 171 consecutive patients who underwent sonographic guided needle biopsy of an abnormal lymph node between 2008 and 2013. Malignancy rates were examined for different clinical settings: palpable axillary mass, previous history of breast cancer, findings suggestive of a systemic disease, and those with a breast finding of low suspicion or an incidental abnormal axillary lymph node. Patients with newly diagnosed breast cancer were excluded. RESULTS: Twelve patients (7%) were found to have a malignancy on their axillary lymph node biopsy. Malignancy rates increased with age, and varied with clinical presentation: Axillary mass (8, 26%); history of breast cancer (2, 11%); systemic disease (0%) and breast finding of low suspicion or incidental abnormal lymph node on screening (1, 1%). Low rates of malignancy were found when the cortex was <6 mm (1, 0.8%). The most important imaging finding associated with malignancy was lack of a preserved hilum, in which case almost a third (10, 29%) of the biopsies were malignant. Only 1 of 89 women with a breast finding of low suspicion or an incidental abnormal axillary lymph node was found to have malignancy. In this case the lymph node had no hilum. CONCLUSIONS: In women without breast cancer, a highly suspicious breast mass or an axillary mass, more stringent criteria should be used when evaluating an abnormal axillary lymph node on sonography, as the malignancy rates are very low (1%).

Prediction of Mortality in Pulmonary Embolism Based on Left Atrial Volume Measured on CT Pulmonary Angiography.

BACKGROUND: Preliminary reports suggest that a small left atrium (LA) is associated with severe acute pulmonary embolism (PE). This study used data derived from volumetric analyses of computed tomographic pulmonary angiography (CTPA) to investigate whether a reduced LA volume can predict adverse outcome in a large series of patients with acute PE. METHODS: We retrospectively analyzed 756 consecutive patients who received a diagnosis of acute PE by nongated CTPA between January 2007 and December 2010. Each CTPA was investigated with volumetric analysis software that automatically provides the volumes of the LA, right atrium, right ventricle, and left ventricle. A classification tree divided the cardiac chamber volumes and ratios into categories according to mortality. Cox regression assessed the association between these categories and 30-day mortality after adjustment for age, sex, and clinical background. RESULTS: The final study group consisted of 636 patients who had successful volumetric segmentation and complete outcome data. Eighty-four patients (13.2%) died within 30 days of PE diagnosis. There was a higher mortality rate among patients with an LA volume ≤62 mL compared with those with an LA volume >62 mL (19.6% vs 8.9%, respectively; HR, 2.44; P < .001), a left ventricle volume ≤67 mL (16.4% vs 8.3%; HR, 1.8; P = .024) and a right atrium/LA volume ratio >1.2 (17% vs 9.4%; HR, 2.1; P = .002). A reduced LA volume was the best predictor of adverse outcome. CONCLUSIONS: Decreased LA volume is associated with higher mortality and is the first among the various cardiac compartments to predict mortality in patients with acute PE.