The imaging appearances of non-calcified ductal carcinoma in situ: A pictorial essay.

Non-calcified ductal carcinoma in situ (NCDCIS) presents as a heterogeneous entity on various imaging modalities, most frequently presenting symptomatically as a palpable lump. The combination of multiple modalities and knowledge of its potential radiological appearances are important in minimising misdiagnosis. Compared to conventional 2D mammography, both sonography and digital breast tomosynthesis show higher diagnostic accuracy in the detection of NCDCIS. Newer modalities of contrast-enhanced digital mammography and MRI have limited data at present, but early results indicate greater sensitivity for the detection of lesions that may be occult on ultrasound or mammography. Here, we present an illustrative study highlighting the varied appearances of NCDCIS on several imaging modalities including a brief review of the literature.

Is staging breast magnetic resonance imaging prompted upgrade to mastectomy appropriate?

BACKGROUND: Breast magnetic resonance imaging (MRI) use for surgical staging is increasing, though remains controversial. We aimed to evaluate the accuracy of MRI in surgical decision-making to determine if mastectomy prompted by MRI was appropriate. METHODS: A single-centre observational study in Perth, Western Australia, with the inclusion of all preoperative and postoperative studies (e.g. involved margins after breast-conserving surgery) undergoing staging breast MRI from 1 January 2015 to 26 August 2019. A standard protocol using gadolinium contrast was used. The reference standard was postoperative histopathology or, for studies without additional surgery after MRI following breast-conserving surgery, the next and subsequent annual screening episodes. By reviewing the final histopathology, the medical case notes and multidisciplinary team decision process, we evaluated whether the reported MRI disease extent was accurate in prompting an appropriate upgrade to mastectomy. Outcomes are reported with descriptive statistics. RESULTS: Of 130 cancers staged with MRI; seven were excluded as information was incomplete, 104 were performed preoperatively and 19 postoperatively. The majority (60%) staged lobular carcinoma (invasive 59%, in situ 1%) compared to ductal carcinoma (invasive 31%, in situ 8%). For preoperative MRI, half (54% - 56/104) underwent subsequent mastectomy. Of these, MRI prompted mastectomy in 45% (25/56), all appropriate for disease extent. In the postoperative staging group, two mastectomies were performed, one planned before imaging, the other prompted when MRI diagnosed residual disease and confirmed on histopathology. No false-negative staging MRI was identified. CONCLUSIONS: In our cohort, MRI prompted an upgrade to mastectomy in 21% (26/123), appropriate for cancer extent.

Does Medicare-eligible high-risk breast cancer screening MRI target the right women?

INTRODUCTION: MRI is the most sensitive modality to screen for breast cancer, but it is expensive with somewhat limited access. Audit of screening performance should reflect appropriate population targeting. METHODS: An observational study on consecutively screened high-risk women, assessment of the contralateral breast staging a new cancer, or surveillance in women with prior breast cancer or high-risk lesion in Perth, Western Australia. All breast MRI studies from 1 January 2015 to 7 September 2018 were included. Studies were 3T comprising T2, DWI, ADC and T1-weighted +/- fat saturation +/- IV gadolinium, +/- subtraction. DCE was read on the dynamics or DynaCAD (Invivo, Gainesville, FL, USA). Fellowship-trained breast radiologists blindly double-read by consensus; additional reader/s arbitrated. The reference standard was the histopathology result or cancer registry notification for cancer diagnoses and benign biopsies, benign follow-up imaging or subsequent screening MRI. RESULTS: Of 993 MRI studies in 554 women, 870 eligible MRI were performed in 471 women, and 706 had a reference standard. Median age was 44 years (range 18-80). The majority of studies (65% 457/706) were screening Medicare rebate-eligible high familial risk; 26% for surveillance after a breast cancer or contralateral staging; 6% screened BRCA carriers. Eleven cancers were diagnosed, eight were MRI-detected. Only two of these were at high-risk screening MRI. Five were detected at staging contralateral ILC, after negative 2D mammography and ultrasound. Cancer prevalence was highest for staging contralateral ILC, at 600/10,000 MRI, for high-risk screening 77/10,000 MRI and surveillance 116/10,000 MRI. CONCLUSIONS: Cancers were predominantly detected in women undergoing preoperative staging of new invasive lobular carcinoma in the contralateral breast, rather than the Medicare rebate-eligible high-risk screening group.

Added value of second biopsy target in screen-detected widespread suspicious breast calcifications.

INTRODUCTION: There is controversy on the optimal work-up of screen-detected widespread breast calcifications: whether to biopsy a single target or multiple targets. This study evaluates agreement between multiple biopsy targets within the same screen-detected widespread (≥25 mm) breast calcification to determine if the second biopsy adds value. METHODS: Retrospective observational study of women screened in a statewide general population risk breast cancer mammographic screening program from 2009 to 2016. Screening episodes recalled for widespread calcifications where further views indicated biopsy, and two or more separate target areas were sampled within the same lesion were included. Percentage agreement and Cohen's Kappa were calculated. RESULTS: A total of 293317 women were screened during 761124 separate episodes with recalls for widespread calcifications in 2355 episodes. In 171 women, a second target was biopsied within the same lesion. In 149 (86%) cases, the second target biopsy result agreed with the first biopsy (κ = 0.6768). Agreement increased with increasing mammography score (85%, 86% and 92% for score 3, 4 and 5 lesions). Same day multiple biopsied lesions were three times more likely to yield concordant results compared to post-hoc second target biopsy cases. CONCLUSION: While a single target biopsy is sufficient to discriminate a benign vs. malignant diagnosis in most cases, in 14% there is added value in performing a second target biopsy. Biopsies performed prospectively are more likely to yield concordant results compared to post-hoc second target biopsy cases, suggesting a single prospective biopsy may be sufficient when results are radiological-pathological concordant; discordance still requires repeat sampling.

Is axillary sonographic staging less accurate in invasive lobular breast cancer than in ductal breast cancer?

OBJECTIVES: The purpose of this study was to determine whether axillary sonography is less accurate in invasive lobular breast cancer than in ductal breast cancer. METHODS: Patients with invasive breast cancer were retrospectively identified from histologic records from 2010 to 2012. Staging axillary sonograms from 96 patients with primary breast cancer in each of 2 subgroups, invasive lobular carcinoma (ILC) and invasive ductal carcinoma (IDC), were reviewed. Preoperative sonographically guided 14-gauge core biopsy was performed on morphologically abnormal lymph nodes. RESULTS: Thirty-one of 96 patients (32%) in each subgroup were node positive on final postoperative histopathologic analysis. Axillary staging sensitivity was 17 of 31 patients (54%) in the IDC subgroup and 15 of 31(48%) in the ILC subgroup. Further analysis of the data showed no statistically significant differences between these subgroups. CONCLUSIONS: We found that there was no statistically significant difference in the accuracy of axillary sonographic staging between ILC and IDC.

Influence of mammographic parenchymal pattern in screening-detected and interval invasive breast cancers on pathologic features, mammographic features, and patient survival.

OBJECTIVE: The aim of our study was to assess the effect of mammographic parenchymal pattern on patient survival, mammographic features, and pathologic features of breast cancer in a screened population. MATERIALS AND METHODS: We classified the parenchymal pattern (according to BI-RADS) of 759 screened women who presented with a screening-detected (n = 455) or interval (n = 304) invasive breast cancer. Pathologic details (tumor size, histologic grade, lymph node stage, vascular invasion, and histologic type) and mammographic appearances were recorded. Breast cancer-specific survival was ascertained, with a median follow-up of 9.0 years. RESULTS: An excess of interval cancers was seen in women with dense breasts (p < 0.0001). Screening-detected (but not interval) tumors were significantly smaller in fatty breasts (p = 0.014). Tumor grade, lymph node stage, vascular invasion, and histologic type did not vary significantly with mammographic parenchymal pattern in screening-detected or interval cancers. Screening-detected cancers in fatty breasts were more likely to appear as indistinct (p = 0.003) or spiculated (p = 0.002) masses in contrast to cancers in dense breasts, which more commonly appeared as architectural distortions (p < 0.0001). No significant breast cancer-specific survival difference was seen by mammographic parenchymal pattern for screening-detected cancers (p = 0.75), interval cancers (p = 0.82), or both groups combined (p = 0.12). CONCLUSION: The prognosis of screened women presenting with breast cancer is unrelated to dense mammographic parenchymal pattern despite an excess of interval cancers and larger screening-detected tumors in this group. These data support the mammographic screening of women with dense parenchymal patterns.

Interval breast cancers: prognostic features and survival by subtype and time since screening.

OBJECTIVES: To investigate the hypothesis that interval cancers arising soon after the previous screen and true interval cancers are biologically aggressive and have a relatively poor prognosis compared with other interval cancers, and to assess which prognostic features are relevant to interval cancers. METHODS: Analysis of prognostic pathological features (grade, lymph node stage, size, vascular invasion, oestrogen receptor [ER] status and histological type), radiological features (comedo/non-comedo calcification and spiculation) and survival for 538 invasive interval breast cancer cases by type and time since previous screen. RESULTS: Late interval cancers were less likely to be lymph node positive (13 versus 43%, P = 0.003). Type 1 interval cancers were more likely to be histological grade 3 than type 2 (minimal signs) and type 3 (false-negative) intervals (52 versus 35%, P = 0.05). Type 3 interval cancers were more likely to have lobular features than other intervals (47 versus 20%, P < 0.0001). There was no significant survival difference by interval cancer type (P = 0.64) or interval year (P = 0.83). At univariate analysis of all interval cancers, tumour size, grade, nodal stage, ER status, vascular invasion and comedo calcification were associated with survival. On multivariate analysis of prognostic features significant at univariate analysis, nodal stage (P value = 0.009), tumour size (P = 0.001), ER status (P < 0.0001) and vascular invasion (P < 0.0001) maintained independent significance. CONCLUSIONS: Our study shows that true intervals and interval cancers arising quickly after screening do not have a worse prognosis than other interval cancers, and that interval cancers have a unique set of prognostic features.