Prognostic value of response evaluation based on breast MRI after neoadjuvant treatment: a retrospective cohort study.

OBJECTIVE: To investigate the impact of response evaluation after neoadjuvant chemotherapy (NAC) in breast cancer patients, assessed by both magnetic resonance imaging (MRI) and pathology, on disease-free survival (DFS). METHODS: This single-center, retrospective cohort study included consecutive breast cancer patients who underwent NAC and preoperative breast MRI. Resolution of invasive carcinoma in the breast and axilla was defined as complete pathological response (pCR). Radiological complete response (rCR) was defined as the absence of abnormal enhancement in the tumor site. Kaplan-Meier estimator was used to estimate the disease-free survival on 60 months. Cox regression analysis was used to estimate hazard ratio (HR) values. RESULTS: In total, 317 patients were included with a mean age of 47.3 years and a mean tumor size of 39.8 mm. The most common immunophenotype was luminal (44.9%), followed by triple-negative (26.8%). Overall, 126 patients (39.7%) had an rCR, while 119 (37.5%) had pCR; the radiological and pathological responses agreed in 252 cases (79.5%). During follow-up, patients who had rCR and pCR had a better DFS curve compared to patients with non-rCR and non-pCR, while those who had rCR or pCR presented an intermediate curve (Log-rank p = 0.003). Multivariate analysis showed a higher risk of recurrence in patients with non-rCR and non-pCR (HR: 5,626; p = 0.020) and those who had a complete response on MRI or pathology only (HR: 4,369; p = 0.067), when compared to patients with rCR and pCR. CONCLUSIONS: The association of MRI and pathological responses after NAC might better stratify the risk of recurrence and prognosis in breast cancer patients. KEY POINTS: • Association of response evaluation after neoadjuvant chemotherapy by pathology and MRI allows better stratification of prognosis. • Complete response to neoadjuvant chemotherapy on pathology and MRI was related to better disease-free survival. • Complete response on MRI or pathology only had a greater risk of recurrence.

Diffusion-Weighted Magnetic Resonance Imaging of Patients with Breast Cancer Following Neoadjuvant Chemotherapy Provides Early Prediction of Pathological Response - A Prospective Study.

The purpose of this study was to evaluate the capacity of diffusion-weighted magnetic resonance imaging (DW-MRI) for early prediction of pathological response in breast cancer patients undergoing neoadjuvant chemotherapy (NCT). This prospective unicentric study evaluated 62 patients who underwent NCT. MRI was performed prior to the start of treatment (MR1), after the first NCT cycle (MR2), and upon completion of NCT (MR3). Pathological response was used as the gold-standard. Patients' median age was 45.5 years and the median tumor size was 40 mm. Twenty-four (38.7%) tumors presented complete pathological response (pCR). The percent increase in apparent diffusion coefficient (ADC) value between MR1 and MR2 was higher in the pCR group (p < 0.001). When the minimum increase in ADC between MR1 and MR2 was set at 25%, sensitivity was 83%, specificity was 84%, positive predictive value was 77%, negative predictive value was 89%, and accuracy was 84% for an early prediction of pCR to NCT. Meanwhile, there were no significant changes in major tumor dimensions between MR1 and MR2. In conclusion, an increase in ADC after the first cycle of NCT correlates well with pCR after the chemotherapy in our cohort, precedes reduction in tumor size on conventional MRI, and may therefore be used as an early predictor of treatment response.

Breast cancer phenotype influences MRI response evaluation after neoadjuvant chemotherapy.

PURPOSE: To evaluate which factors may influence magnetic resonance imaging (MRI) performance in the detection of pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC). METHOD: This retrospective study included 219 patients diagnosed with invasive breast carcinoma who underwent breast MRI before and after NAC. The MRI findings were compared to gold standard pathological examinations. Resolution of invasive breast disease was defined as pCR. RESULTS: The mean age of our cohort was 48 years (range: 20-85). The molecular subtypes included: Luminal B/Her-2 negative (n = 89; 40%), triple-negative (n = 69; 32%), Luminal B/Her-2 positive (n = 43; 20%), and Her-2 overexpression (n = 18; 8%). MRI analysis after NAC showed complete response in 76 cases (35%), while pathological analysis of surgical specimens after NAC detected pCR in 85 cases (39%). The accuracy of MRI in diagnosing pCR was 80%, with 69% sensitivity, 87% specificity, and positive and negative predictive values of 78% and 82%, respectively. The only factor statistically associated with a higher discordance rate between MRI and pathologic response was the presence of non-mass enhancement at pre-treatment MRI (p = 0.003). CONCLUSIONS: MRI demonstrated good accuracy in predicting pCR after NAC among the breast cancer patients examined. However, non-mass enhancement at pre-treatment MRI negatively affected the diagnostic performance of MRI in assessing treatment response after NAC.

Intramammary lymph nodes: normal and abnormal multimodality imaging features.

Intramammary lymph nodes (IMLN) are one of the most common benign findings at screening mammography. However, abnormal IMLN features, such as diminished or absent hilum, thickened cortex, not circumscribed margins, increased size or interval change, warrants additional follow-up or pathologic analysis to exclude malignancy. Some benign inflammatory conditions may be associated with imaging-detected suspected abnormal IMLN, such as reactive hyperplasia and silicone-induced lymphadenopathy. In patients with known breast cancer, IMLN are a potential site of locoregional spread, which can change the prognosis and management. In some cases, initial breast carcinomas can also mimic IMLN. Breast radiologists must also be aware of the typical and atypical characteristics of IMLN to suggest further investigation when it is necessary.

Prognostic significance of preoperative MRI findings in young patients with breast cancer.

The objective is to evaluate the prognostic value of preoperative magnetic resonance imaging (MRI) findings in breast cancer patients aged less than 40 years. This retrospective, single-center study evaluated 92 women aged <40 years who received a diagnosis of invasive breast carcinoma between 2008 and 2012. These patients underwent a breast MRI before treatment and follow-up at the same institution. Kaplan-Meier survival curves were used to analyze overall survival, with the log-rank test used to compare different groups. Cox regression analysis was used to estimate hazard ratios (HRs) with 95% confidence interval (95% CI) values. The mean age of the patients was 34 years (range: 25-39 years) and the mean tumor size was 3.9 cm in maximal dimension (range: 0.7-10.5 cm). Recurrence was observed in 21 (22.8%) patients and 15 (16.3%) patients did not survive during a mean follow-up period of 5.4 ± 1.9 years. MRI findings associated with worse overall survival included tumor size >5 cm (HR:5.404; 95% CI:1.922-15.198; p = 0.017), presence of non-mass enhancement (HR:3.730; 95% CI:1.274-10.922; p = 0.016) and multifocal tumor (HR:3.618; 95% CI:1.151-11.369; p = 0.028). Inconclusion, MRI findings that are suggestive of more extensive disease were associated with worse overall survival in young breast cancer patients.

Breast metastases from extramammary malignancies: multimodality imaging aspects.

Breast metastases from extramammary cancers are rare and usually related to poor prognosis. The extramammary tumours most frequently exhibiting breast metastases are melanoma, lymphomas, ovarian cancer, lung and neuroendocrine tumours, and sarcomas. Owing to the lack of reliable and specific clinical or radiological signs for the diagnosis of breast metastases, a combination of techniques is needed to differentiate these lesions from primary breast carcinoma or even benign breast lesions. Multiple imaging methods may be used to evaluate these patients, including mammography, ultrasound, MRI, CT and positron emission tomography CT. Clinical and imaging manifestations are varied, depend on the form of dissemination of the disease and may mimic primary benign and malignant breast lesions. Haematologically disseminated metastases often develop as a circumscribed mass, whereas lymphatic dissemination often presents as diffuse breast oedema and skin thickening. Unlike primary carcinomas, breast metastases generally do not have spiculated margins, skin or nipple retraction. Microlobulated or indistinct margins may be present in some cases. Although calcifications are not frequently present in metastatic lesions, they occur more commonly in patients with ovarian cancer. Although rare, secondary malignant neoplasms should be considered in the differential diagnosis of breast lesions, in the appropriate clinical setting. Knowledge of the most common imaging features can help to provide the correct diagnosis and adequate therapeutic planning.

Can positron emission mammography help to identify clinically significant breast cancer in women with suspicious calcifications on mammography?

OBJECTIVE: To evaluate the diagnostic accuracy of positron emission mammography (PEM) for identifying malignant lesions in patients with suspicious microcalcifications detected on mammography. METHODS: A prospective, single-centre study that evaluated 40 patients with suspicious calcifications at mammography and indication for percutaneous or surgical biopsy, with mean age of 56.4 years (range: 28-81 years). Patients who agreed to participate in the study underwent PEM with 18F-fluorodeoxyglucose before the final histological evaluation. PEM findings were compared with mammography and histological findings. RESULTS: Most calcifications (n = 34; 85.0 %) were classified as BIRADS 4. On histology, there were 25 (62.5 %) benign and 15 (37.5 %) malignant lesions, including 11 (27.5 %) ductal carcinoma in situ (DCIS) and 4 (10 %) invasive carcinomas. On subjective analysis, PEM was positive in 15 cases (37.5 %) and most of these cases (n = 14; 93.3 %) were confirmed as malignant on histology. There was one false-positive result, which corresponded to a fibroadenoma, and one false negative, which corresponded to an intermediate-grade DCIS. PEM had a sensitivity of 93.3 %, specificity of 96.0 % and accuracy of 95 %. CONCLUSION: PEM was able to identify all invasive carcinomas and high-grade DCIS (nuclear grade 3) in the presented sample, suggesting that this method may be useful for further evaluation of patients with suspected microcalcifications. KEY POINTS: • Many patients with suspicious microcalcifications at mammography have benign results at biopsy. • PEM may help to identify invasive carcinomas and high-grade DCIS. • Management of patients with suspicious calcifications can be improved.

MRI Features of Mucinous Cancer of the Breast: Correlation With Pathologic Findings and Other Imaging Methods.

OBJECTIVE: Mucinous breast carcinoma is an uncommon histologic type of invasive breast carcinoma that can be differentiated in pure and mixed forms, which have different prognosis and treatment. CONCLUSION: MRI features of both types of mucinous breast carcinomas are discussed, illustrated, and compared with pathologic findings and with other imaging methods, including mammography, ultrasound, and PET/CT.

Role of MRI in the staging of breast cancer patients: does histological type and molecular subtype matter?

OBJECTIVE: To assess the role of MRI in the pre-operative staging of patients with different histological types and molecular subtypes of breast cancer, by the assessment of the dimensions of the main tumour and identification of multifocal and/or multicentric disease. METHODS: The study included 160 females diagnosed with breast cancer who underwent breast MRI for pre-operative staging. The size of the primary tumour evaluated by MRI was compared with the pathology (gold standard) using the Pearson's correlation coefficient (r). The presence of multifocal and/or multicentric disease was also evaluated. RESULTS: The mean age of patients was 52.6 years (range 30-81 years). Correlation between the largest dimension of the main tumour measured by MRI and pathology was worse for non-special type/invasive ductal carcinoma than for other histological types and was better for luminal A and triple-negative than for luminal B and Her-2 molecular subtypes. Multifocal and/or multicentric disease was present in 48 patients (30.0%), and it was more common in breast carcinomas classified as Her-2 molecular subtype. There was no statistically significant difference in the frequency of multifocal and/or multicentric tumours identified only by MRI in relation to histological type or molecular subtype. CONCLUSION: The results of this retrospective study demonstrated that histological types and molecular subtypes might influence the MRI assessment of breast cancers, especially in the evaluation of tumour size. ADVANCES IN KNOWLEDGE: The real benefit of MRI for treatment planning in patients with breast cancer may be different according to the histological type and molecular subtype.

Multiparametric evaluation of breast lesions using PET-MRI: initial results and future perspectives.

The purpose of this study was to evaluate the diagnostic accuracy of multiparametric evaluation of breast lesions combining information of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), diffusion-weighted imaging (DWI), and F-fluoro-deoxi-glucose (F-FDG) positron emission tomography/computed tomography (PET-CT). After approval of the institutional research ethics committee, 31 patients with suspicious breast lesions on MRI performed F-FDG PET-CT with a specific protocol for breast evaluation. Patients' mean age was 47.8 years (range, 29-77 years). Positron emission tomography and magnetic resonance imaging (PET-MRI) images were fused. A lesion was considered positive on multiparametric evaluation if at least 1 of the following was present: washout/type 3 kinetic curve on DCE-MRI, restricted diffusion on DWI with minimum apparent diffusion coefficient value <1.00 × 10 mm/s, and abnormal metabolism on F-FDG PET-CT (higher than the physiologic uptake of the normal breast parenchyma). Thirty-eight lesions with histologic correlation were evaluated on the 31 included patients, being 32 mass lesions (84.2%), and 6 nonmass lesions (15.8%). Lesions' mean diameter was 31.1 mm (range, 8-94 mm). Multiparametric evaluation provided 100% sensitivity, 55.5% specificity, 87.9% positive predictive value, 100% negative predictive value, and 89.5% accuracy, with 29 true-positives results, 5 true-negatives, 4 false-positives, and no false-negative results. Multiparametric evaluation with PET-MRI functional data showed good diagnostic accuracy to differentiate benign from malignant breast lesions, reducing the number of unnecessary biopsies, without missing any diagnosis of cancer in our case series.

Can 18F-FDG PET improve the evaluation of suspicious breast lesions on MRI?

OBJECTIVE: To evaluate the impact of adding 18F-fluorine-2-deoxy-d-glucose (FDG) positron emission tomography (PET) in the evaluation of suspicious breast lesions on magnetic resonance imaging (MRI). METHODS: Sixty patients with suspicious breast lesions on MRI were selected to perform a PET-CT in prone position, dedicated to the evaluation of the breasts. The areas with increased 18F-FDG concentration relative to normal parenchyma were considered positive on PET-CT. Fusion of PET and MRI images (PET-MRI) was performed on a dedicated workstation to better locate corresponding lesions, and its findings were compared with histological results. RESULTS: 76 lesions were evaluated, including 64 mass lesions (84.2%) and 12 non-mass lesions (15.8%). Lesions' mean diameter on MRI was 29.6 ± 19.2 mm (range 6-94 mm). PET-CT showed increased metabolically activity on 57 lesions (75.0%), with mean maximum SUV of 5.7 ± 5.0 (range 0.8-23.1). On histopathology, there were 17 (22.4%) benign and 59 (79.7%) malignant lesions. Considering all lesions, PET-MRI fusion provided 89.8% sensitivity, 76.5% specificity and 86.8% accuracy. Considering only mass lesions higher than 10mm, PET-MRI fusion provided 95.8% sensitivity, 83.3% specificity and 93.3% accuracy. CONCLUSION: The inclusion of 18F-FDG PET on the evaluation of suspicious breast lesions on MRI helped to differentiate benign from malignant breast lesions, especially for mass lesions with a diameter higher than 10 mm.

Identification of occult breast lesions detected by magnetic resonance imaging with targeted ultrasound: a prospective study.

OBJECTIVE: To verify the capacity of targeted ultrasound (US) to identify additional lesions detected on breast magnetic resonance imaging (MRI), but occult to initial mammography, US and clinical examinations. METHODS: This prospective study included 68 additional relevant breast lesions identified on MRI of 49 patients. As an inclusion criterion, breast US and mammography were required and performed up to six months before MRI. These lesions were then subjected to targeted "second-look" US up to 2 weeks after MRI, performed by one or two radiologists with expertise on breast imaging. Lesions were evaluated according to the established Breast Imaging Report and Data System (BI-RADS) lexicon. RESULTS: Targeted US identified 46/68 (67.6%) lesions revealed by MRI. No significant associations were observed between US identification and the type of lesion, dimensions, morphological characteristics and enhancement pattern according to MRI findings. Targeted US identified 100% of BI-RADS category 5 lesions, 90% of category 4 lesions, and just over 50% of category 3 lesions (p<0.05). There was significant agreement (p<0.001) between MRI and US BI-RADS classification for all three categories. CONCLUSION: Targeted US can identify a large proportion of the lesions detected by breast MRI, especially those at high risk of malignancy, when performed by a professional with experience in both breast US and MRI.

Melanoma intra-ocular metastático: comprometimento incomum mamário: relato de um caso / Metastatic ocular melanoma to the breast: a rare presentation of tumor dissemination

Os autores relatam um caso de melanoma intra-ocular metastático para múltiplos para múltiplos órgäos, com comprometimento incomum em paciente do sexo feminino. É feita breve revisäo da literatura, discutida a patologia e relacionado o papel dos vários métodos de diagnóstico por imagem

Quimioterapia intra-arterial, radioterapia e cirurgia, na preservaçäo do membro inferior, em sarcomas de partes moles de alto grau / Lower limb-sparing with intra-arterial chemotherapy, radiotherapy and surgery in high grade soft tissue sarcoma

Os autores apresentam cinco casos de pacientes portadores de sarcomas de partes moles, de alto grau de malignidade histologica, de membros inferiores, tratados com o objetivo de preservacao do membro, usando quimioterapia intra-arterial(QTIA), radioterapia(RXT) e cirurgia. Os pacientes eram adultos, com idade variando entre 22 e 54 anos e candidatos a amputacoes, caso fossem tratados inicialmente pela cirurgia. A droga foi a Adriamicina, 20 mg/m2/dia,em infusao continua, durante tres dias; o plano de irradiacao foi de 3.000 cGy, em doze sessoes de 250 cGy; em um caso, a dose de irradiacao chegou a 4.500 cGy. A cirurgia foi feita entre a terceira e quarta semana apos o termino da irradiacao. O membro foi preservado em quatro paciente; o unico amputado, ja apresentava um extenso comprometimento osseo antes do tratamento pre-operatorio. o exame anatomo-patologico revelou que a necrose da peca operatoria foi completa em tres casos e parcial em dois. Em um periodo de acompanhamento, que variou de 01 a 48 meses, com media de 12.6, nao houve nenhuma recidiva local. Dois pacientes faleceram por metastases e tres estao vivos e assintomaticos. Nao houve nenhuma complicacao que pudesse ser atribuida exclusivamente ao tratamento pre-operatorio