Shear-wave elastography improves the specificity of breast US: the BE1 multinational study of 939 masses.

PURPOSE: To determine whether adding shear-wave (SW) elastographic features could improve accuracy of ultrasonographic (US) assessment of breast masses. MATERIALS AND METHODS: From September 2008 to September 2010, 958 women consented to repeat standard breast US supplemented by quantitative SW elastographic examination in this prospective multicenter institutional review board-approved, HIPAA-compliant protocol. B-mode Breast Imaging Reporting and Data System (BI-RADS) features and assessments were recorded. SW elastographic evaluation (mean, maximum, and minimum elasticity of stiffest portion of mass and surrounding tissue; lesion-to-fat elasticity ratio; ratio of SW elastographic-to-B-mode lesion diameter or area; SW elastographic lesion shape and homogeneity) was performed. Qualitative color SW elastographic stiffness was assessed independently. Nine hundred thirty-nine masses were analyzable; 102 BI-RADS category 2 masses were assumed to be benign; reference standard was available for 837 category 3 or higher lesions. Considering BI-RADS category 4a or higher as test positive for malignancy, effect of SW elastographic features on area under the receiver operating characteristic curve (AUC), sensitivity, and specificity after reclassifying category 3 and 4a masses was determined. RESULTS: Median participant age was 50 years; 289 of 939 (30.8%) masses were malignant (median mass size, 12 mm). B-mode BI-RADS AUC was 0.950; eight of 303 (2.6%) BI-RADS category 3 masses, 18 of 193 (9.3%) category 4a lesions, 41 of 97 (42%) category 4b lesions, 42 of 57 (74%) category 4c lesions, and 180 of 187 (96.3%) category 5 lesions were malignant. By using visual color stiffness to selectively upgrade category 3 and lack of stiffness to downgrade category 4a masses, specificity improved from 61.1% (397 of 650) to 78.5% (510 of 650) (P<.001); AUC increased to 0.962 (P=.005). Oval shape on SW elastographic images and quantitative maximum elasticity of 80 kPa (5.2 m/sec) or less improved specificity (69.4% [451 of 650] and 77.4% [503 of 650], P<.001 for both), without significant improvement in sensitivity or AUC. CONCLUSION: Adding SW elastographic features to BI-RADS feature analysis improved specificity of breast US mass assessment without loss of sensitivity.

Value of MRI in the surgical planning of invasive lobular breast carcinoma: a prospective and a retrospective study of 57 cases: comparison with physical examination, conventional imaging, and histology.

PURPOSE: The objective of this study was to determine the value of magnetic resonance imaging (MRI) for the surgical planning of invasive lobular carcinoma (ILC)-a diagnostic challenge for radiologists. MATERIALS AND METHODS: Fifty-seven patients with histologically proven ILC were studied between 1998 and 2006. All patients underwent physical examination, mammography, ultrasound, and MRI. All anomalies detected were graded using the Breast Imaging Reporting and Data System (BI-RADS) classification, and careful research was made for the presence of multifocal/multicentric disease. RESULTS: On MRI, 72% of images were visualized as masses and 18% corresponded to non-mass-like enhancements. The size correlations, compared with histological findings, were .88 (MRI; P<.001), .57 (ultrasound), .53 (physical examination), and .40 (mammography). The kappa correlations for multifocality were .87 (MRI), .22 (ultrasound), and .22 (mammography). MRI had a sensitivity of 100% and a specificity of 87%. Forty-nine percent of therapeutic strategy cases were modified. CONCLUSION: MRI is unquestionably valuable for the management of ILC. It provides the most accurate estimate of tumor size and is highly sensitive for multifocal disease. Its main drawback is its lack of specificity, which requires preoperative histological verification. MRI often justifies the modification of the initial therapeutic strategy, generally ruling out conservative procedures.

Long-term results of hypofractionated radiotherapy and hormonal therapy without surgery for breast cancer in elderly patients.

BACKGROUND AND PURPOSE: To evaluate early and late reactions, local control, disease-free survival, cause-specific survival, and overall survival of elderly breast cancer patients treated with definitive once-a-week hypofractionated radiotherapy together with hormonal therapy. PATIENTS AND METHODS: Between 1987 and 1999, 115 patients with a median age of 83 presenting with 124 non-metastatic breast carcinoma were treated with definitive once weekly hypofractionated radiotherapy associated with hormonal therapy. The main reasons for adopting this schedule were patient refusal of surgery, very old age, locally advanced case, and/or comorbid disease. Radiation was delivered as once-a-week, 6.5 Gy for a total breast dose of 32.5 Gy in five fractions, followed with 1-3 fractions of 6.5 Gy to the tumour site. The median follow-up was 41 months. RESULTS: Neoadjuvant hormonal therapy led to 56% reduction of the tumour volume. Late reactions occurred in 46 patients; they were mild to moderate in 87% of these patients. The Kaplan-Meier rate was 52% of patients, with 6% experiencing grade 3 reactions. The 5-year local progression-free rate was 78%. The corresponding cause-specific survival was 71%, and was influenced by T classification, nodal status, oestrogen receptors and the total dose. The first three factors retained an independent prognostic impact on multivariate analysis. The 5-year overall survival was 38%. It was affected by the T classification, lymph node involvement and the performance status (PS). Using a multivariate analysis, only T classification and PS were identified as independent factors regarding overall survival. CONCLUSIONS: Definitive hypofractionated radiotherapy allows a good local control, with acceptable toxicity. This schedule associated with hormonal therapy is a good alternative to surgery in non-operable old patients and in case of patient refusal to surgery and to standard fractionation.

Vacuum-assisted breast biopsies. Experience at the Antoine Lacassagne Cancer Center (Nice, France).

This article presents the results of the first 318 aspiration-guided breast macrobiopsies performed using a dedicated table at the Antoine Lacassagne Cancer Center (Nice, France) between January 2001 and November 2002. A total of 288 procedures (90%) was performed for microcalcifications whereas that of 30 (10%) was performed for isolated opacities. There were 170 American College of Radiology (ACR) Category 4 (53.45%), 35 ACR 5 (11%), 111 ACR 3 (34.9%), and 2 ACR 2 lesions. There were 233 benign lesions that included 19 cases of atypical epithelial hyperplasia. Of the 85 malignant lesions, 33 had an invasive component. Seven of the atypical epithelial hyperplasia cases and all of the malignant lesions were managed surgically. Atypical epithelial hyperplasia was underestimated in 28.57% of the cases; ductal carcinomas in situ, in 21.15%. The positive predictive value of ACR 4 for the diagnosis of malignancy was 24.7% (42/128 cases), versus that of 12.6% for ACR 3 (14/97 cases). Among the 233 benign lesions, 128 were classified as ACR 4 and 6 as ACR 5 (all of these procedures obviated surgery). The advantages, drawbacks, and limitations of the technique are analyzed and indications are discussed, particularly for ACR 3 lesions.

Rhabdomyosarcoma of the breast.

AIM: The aim of this study was to describe the first imaging studies of a primary embryonal rhabdomyosarcoma of the breast in an adult woman. PATIENT: This 45-year-old woman was seen for investigation of a palpable mass in the left breast. Examinations included mammography, Doppler ultrasound, and MRI. The diagnosis was made after surgical biopsy. Treatment consisted in neoadjuvant chemotherapy, followed by quadrantectomy and interstitial curietherapy. Imaging studies were performed both prior to and during therapy (i.e., after three then after six courses of chemotherapy). Imaging findings were correlated with histopathological findings. RESULTS: Mammography was not very contributive as the breasts were dense, particularly in the external left quadrants. On ultrasound, the mass had a tissue density and sharp contours; the mass was not highly vascularized on Doppler. MRI revealed a mass that enhanced markedly on both early and late contrast-enhanced T1-weighted sequences and was hyperintense on T2-weighted sequences. MRI appeared to be the best technique for the evaluation of the residual tissue. CONCLUSION: Rhabdomyosarcoma is a rare tumor in adults; to our knowledge, this is the first report describing the imaging features and value of MRI for the work-up and follow-up of mammary rhabdomyosarcoma.