Improving resource utilization: Axillary lymph node core biopsy triaging for lymphoma.

OBJECTIVES: To evaluate the utilization of hematopathology resources within our enterprise on axillary lymph node core biopsy (AxLNCB) specimens, particularly those obtained in the context of breast cancer screening. METHODS: The utilization of hematopathology resources was determined for all AxLNCB specimens over a 30-month period from across our enterprise, and chart review was performed for select patient demographics and radiographic features. The AxLNCB cases with benign histology were reviewed for subtyping of histologic patterns. RESULTS: Of the total 594 AxLNCB specimens, 61.6% were benign and 38.6% malignant. Of malignant cases, only 9.3% contained any hematologic malignancy, yet 94% of all cases received tissue triage for lymphoma, and 81% were reviewed at least in part by a hematopathologist. Six clinical parameters were found to independently predict risk of hematologic malignancy: male sex (P = .041), bilateral lymphadenopathy (P = .004), diffuse cortical thickening (P = .005), lack of breast cancer (P = .001), older age (P < .001), and history of hematologic malignancy (P < .001). CONCLUSIONS: Our enterprise overused hematopathology resources in the evaluation of AxLNCB performed in the study period. Our process could improve from the application of a simple tool generated from this cohort to predict percent risk of the specimen containing hematologic malignancy using patient characteristics easily found via routine chart review.

Enhancing foci on breast MRI: Identifying criteria that increase levels of suspicion.

OBJECTIVE: Prior studies evaluating features of foci associated with malignancy have not been conclusive. This study evaluates foci that were deemed suspicious and assesses multiple imaging and clinical findings with the goal of identifying criteria that can increase diagnostic confidence when evaluating foci on breast MRI. METHODS: After Institutional Review Board approval, a retrospective chart review was performed to identify patients who underwent an image-guided biopsy of an enhancing focus. To be included in the study, a breast MRI performed between 2012 and 2019 must have been classified as suspicious for an enhancing focus or foci, and a biopsy using imaging guidance must have been subsequently performed. Patient and imaging characteristics as well as the corresponding biopsy results were recorded and statistically analyzed. RESULTS: There were 74 patients with 85 foci of enhancement who underwent biopsy within the study period. Thirteen of the 85 foci yielded malignant results for an overall positive predictive value of 15.3% (95% confidence interval: 7.7-22.9%). Additionally, twenty-six of the 85 cases (30.6%) yielded high risk lesions. There was a statistically significant negative correlation between screening breast MRIs and biopsies that yielded cancer or atypia (p = 0.04). There was also a significant association between foci and malignant results if the focus was in the same quadrant of a known malignancy (p = 0.001). CONCLUSION: Clinical information, such as the indication for a breast MRI or the location of a focus relative to a known cancer, can play an important role in evaluating foci of enhancement. Diagnostic confidence in identifying suspicious foci can be aided by incorporating clinical context with imaging findings deemed suspicious by prior research studies.

Architectural Distortion on Screening Digital Breast Tomosynthesis: Pathologic Outcomes and Indicators of Malignancy.

OBJECTIVE: Digital breast tomosynthesis (DBT) has significantly improved cancer detection capabilities through its identification of subtle findings often imperceptible on 2D digital mammography, particularly architectural distortion (AD). The purpose of this study was to analyze of suspicious AD detected on screening DBT to evaluate the incidence of malignancy and to determine other patient or imaging characteristics in these cases as possible predictors of malignancy. METHODS: This was an IRB approved retrospective analysis of subjects with AD detected on DBT screening mammography who were given a biopsy recommendation between January 1, 2016, and June 30, 2018. Univariate analysis of various imaging characteristics and patient high-risk factors was performed for statistical correlation with diagnosis of malignancy. RESULTS: In the 218 DBT-detected AD findings with a final BI-RADS assessment of 4 or 5 on diagnostic workup, 94 (43.1%) yielded malignancy, 57 (26.2%) were classified as high-risk, and 67 (30.7%) were benign. There was a strong statistically significant association with malignancy in the cases with an US correlate (P < 0.0001). There was a statistically significant inverse correlation between malignancy and one-view findings (P = 0.0002). The presence of AD on 2D (P = 0.005) or synthetic 2D views (P = 0.002) showed statistically significant correlations with malignancy, whereas breast density or high-risk factors (P = 0.316) did not. CONCLUSION: AD detected on DBT that persists on further workup and has no explainable cause should be considered suspicious for malignancy. Identification of the AD on both standard mammographic views and the presence of an US correlate significantly increase the probability of malignancy.

A high mitotic score in breast cancer after neoadjuvant chemotherapy is predictive of outcome and associated with a distinct morphology.

AIMS: Neoadjuvant chemotherapy (NAC) is frequently used for the treatment of breast cancer. We sought to analyse the clinical, morphological and immunohistochemical features of tumours from patients who did not achieve pathological complete response following NAC. METHODS AND RESULTS: We identified stage I-III post-NAC breast cancers from surgical resections (2000-2016) with evaluable residual invasive carcinoma [ypT1a(m) or greater and ≥15% tumour cellularity]. One hundred and forty-three tumours from 142 patients were included. On univariable analysis, a high (score 3) post-NAC mitotic score (as compared with 1 or 2) was significantly associated with invasive ductal carcinoma (IDC) subtype (P = 0.023), high grade, pushing borders with zones of necrosis, hormone receptor and triple-negative status, lack of hormonal therapy, higher cellularity (P < 0.001), and a higher percentage of tumour-infiltrating lymphocytes (P = 0.016). Multivariable analysis showed a high post-NAC mitotic score to be significantly associated with recurrence, distant metastasis, and shortened survival (hazard ratios of 5.73, 4.49, and 3.68, respectively). High post-NAC mitotic score tumours (n = 32) were IDC and had a high Ki67 proliferation index (median, 55%). Of these, 24 (75%) had pushing borders with zones of necrosis; 19 (79.2%) of these had necrosis on preoperative imaging, and 24 (75%), 15 (46.9%) and four (12.5%) lacked androgen receptor, GATA-3 and cytokeratin 18 expression, respectively. CONCLUSIONS: High post-NAC mitotic score breast cancers cause high morbidity and mortality, frequently have pushing borders and zones of necrosis, and may show loss of common 'breast cancer markers'. Our findings support that necrosis in pretreatment studies and post-NAC mitotic score should be routinely reported, as they offer significant additional prognostic information to guide management.

Comparison of the artifacts caused by metallic implants in breast MRI using dual-echo dixon versus conventional fat-suppression techniques.

OBJECTIVE: The purpose of this article is to evaluate and compare the artifacts caused by metal implants in breast MR images acquired with dual-echo Dixon and two conventional fat-suppression techniques. SUBJECTS AND METHODS: Two types of biopsy markers were embedded into a uniform fat-water emulsion. T1-weighted gradient-echo images were acquired on a clinical 3-T MRI scanner with three different fat-suppression techniques-conventional or quick fat saturation, spectrally selective adiabatic inversion recovery (SPAIR), and dual-echo Dixon-and the 3D volumes of artifacts were measured. Among the subjects of a clinical breast MRI study using the same scanner, five patients were found to have one or more metal implants. The artifacts in Dixon and SPAIR fat-suppressed images were evaluated by three radiologists, and the results were compared with those of the phantom study. RESULTS: In the phantom study, the artifacts appeared as interleaved bright and dark rings on SPAIR and quick-fat-saturation images, whereas they appeared as dark regions with a thin bright rim on Dixon images. The artifacts imaged with the Dixon technique had the smallest total volume. However, the reviewers found larger artifact diameters on patient images using the Dixon sequence because only the central region was recognized as an artifact on the SPAIR images. CONCLUSION: Metal implants introduce artifacts of different types and sizes, according to the different fat-suppression techniques used. The dual-echo Dixon technique produces a larger central void, allowing the implant to be easily identified, but presents a smaller overall artifact volume by obscuring less area in the image, according to a quantitative phantom study.