Idiopathic Granulomatous Mastitis - a new approach in diagnostics and treatment.

Idiopathic granulomatous mastitis (IGM) is a rare inflammatory breast disease mimicking carcinoma and puerperal or non-puerperal mastitis. The primary purpose of this prospectively performed case control study was to compare clinical and imaging signs of IGM with the reference group of nonspecific, non- puerperal mastitis (NM) to identify the most typical clinical and imaging signs essential for a correct differential diagnosis. The secondary purpose was to present a new approach to non-invasive treatment. Thirty-nine women with histologically proven IGM and twenty-six patients with nonspecific mastitis underwent clinical examination, breast ultrasound (US), mammography (MG) and MRI examination. The most typical signs were selected for each group, and method and were statistically evaluated. The effectivity of colchicine, vitamin E and ribwort plantain tincture in treatment was assessed by clinical examination and imaging. Typical clinical signs of IGM included unilateral acute onset of breast edema, redness, palpable masses, missing fever, lymphadenopathy, no response to antibiotics or surgical interventions. Ultrasound revealed: "finger-like" structures (100%), ductectasias (76.9%), abscesses (76.9%), and lymphadenopathy (15.4%), while in MRI skin and tissue edema (100%), multicentric lesions (100%), abscesses (76.9%), ring enhancement (84.6%), lymphadenopathy (15.4%) and small enhancing lymph nodes (38.5%) were observed. Among the clinical signs, fistulas, hypoechoic mass, ductectasias and diffusion weighted images (DWI) restriction were significantly more frequent in patients with IGM than in those with NM. Treatment effectivity yielded 100% with a complete response between 6-19 months, depending on the disease extent. Targeted questions together with imaging can speed up selection for proper treatment with colchicine, vitamin E and local treatment. Long lasting use of antibiotics and repeated surgical interventions should be avoided.

Multiparametric MRI analysis of morphologico-functional features of DCIS - correlation with grade of nuclear atypia.

The aim was to analyze morphologico-functional characteristics of ductal carcinoma in situ (DCIS) in breast MRI to assess signs correlating with the degree of nuclear atypia. From 636 malignant lesions, 114 were DCIS (17.92%): 44 cases of high-grade (38.60%), 37 intermediate (32.45%), 33 low-grade (28.95%). MRI characteristics - T2 signal intensity (SI), shape, margins, contrast enhancement, peripheral/ductal enhancement, kinetic curve, presence of restriction of diffusion were correlated with the nuclear grade of DCIS. Statistical analysis was performed, statistical significance and Odds ratio (OR) were calculated. Signs of high-grade lesions were low SI in T2w (p=0.042), nonhomogeneous contrast enhancement (p=0.012), wash-out phenomenon (p=0.04), high SI in diffusion weighted imaging (DWI) (p<0.0001), restriction of diffusion in apparent diffusion coefficient map (p<0.0001). DWI and wash-out phenomenon reached the highest OR (56.00, 9.76). Breast MRI using DWI and multiparametric analysis provides important information about the degree of nuclear atypia.

Pitfalls of Contrast Enhanced Ultrasound (CEUS) in determination of breast tumor biological dignity.

The aim of this prospective study was to identify characteristics of breast lesions on contrast enhanced ultrasound (CEUS) that can be a source of diagnostic ambiguity and cause under- or overestimation of examined breast lesions. 215 women (range 23-76 y., mean age 53.16 y) with 215 breast lesions were examined by B-mode ultrasound, followed by CEUS and core biopsy. CEUS parameters: degree of opacification, character of washout and preliminary CEUS result (suspicious, non-suspicious, uncertain) were subsequently correlated with histopathological outcomes. Observed qualitative variables, CEUS results and their analysis with respect to histological type were evaluated using Pearson χ2 square test, p<0.05 was statistically significant. Differences in mean lesion size, mean age of patients, mean size between groups (malignant/benign) with respect to CEUS result were evaluated by t-test. 215 tumors, 116 (53.93%) benign and 99 (46.05%) malignant lesions. 17 (14.66%) benign and 15 (15.15%) malignant lesions expressed atypical washout, 5 (4.31%) benign lesions had early washout and 38 (38.38%) had continuous washout (p<0.0001). 56 (48.28%) benign and 55 (55.56%) malignant lesions had middle degree of opacification, 19 (16.38%) benign had high and 5 (5.05%) malignant lesions low degree of opacification (p<0.0001). Finally, 38 (32.72%) benign and 20 (20.20%) malignant were marked CEUS uncertain. As risk lesions are considered fibroadenomas, fibrocystic lesions, papillomas and low grade DCIS or invasive breast tumors, especially lesions smaller than 10 mm.Identification of CEUS pitfalls with respect to problematic histopathologic entities can reduce the risk of misdiagnosis and improve further management of breast lesions.

MR-mammography - impact on disease extent determination and surgical treatment of invasive ductal and lobular breast cancers.

UNLABELLED: The aim of this study is to assess the impact of multiparametric MR imaging to an exact determination of the extent of invasive ductal and lobular breast cancers in routine clinical practice.180 women aged 27-74 years (median 52.4 years) with newly diagnosed invasive ductal and lobular breast cancers confirmed by core-cut or vacuum-assisted biopsy were examined by all three imaging modalities, i.e. digital X-ray mammography, ultrasonography and 3T MR-mammography. In case of MR-mammography an extended protocol, i.e. combination of morphological breast MRI + DCE + DWI was used. For overall detection and determination of the extent of invasive breast cancers (IDC + ILC) MRmammography alone reached the diagnostic accuracy of 72.48%, while X-ray mammography 69.12% and ultrasonography 59.87%. In cases of ILC combination of X-ray mammography and MR- mammography with sensitivity of 96.15% was the most effective. In comparison with X-ray mammography and ultrasonography MR-mammography had higher sensitivity (96.15%, versus 90.28%) in the diagnosis of multifocal/ multicentric invasive lobular carcinoma and invasive ductal carcinoma with extensive intraductal component, as well. 3T MR-mammography is an effective complementary consulting modality to digital X-ray mammography and ultrasonography, and it is particularly beneficial in the detection of additional mammographically and ultrasonografically occult breast lesions, as well as in the determination of the real extent of pathological changes in the ipsilateral and contralateral breast. KEYWORDS: MR-mammography, occult breast cancer, invasive ductal cancer, invasive lobular cancer, multifocality, multicentricity.

Analysis of radiation-induced angiosarcoma of the breast.

Breast angiosarcoma may occur de novo, or as a complication of radiation therapy, or chronic lymphedema secondary to axillary lymph node dissection for mammary carcinoma. Both primary and secondary angiosarcomas may present with bruise like skin discoloration, which may delay the diagnosis. Imaging findings are nonspecific. In case of high-grade tumours, MRI may be used effectively to determine lesion extent by showing rapid enhancement, nevertheless earliest possible diagnostics is crucial therefore any symptoms of angiosarcoma have to be carefully analysed. The case analysed here reports on results of 44-year old premenopausal woman who was treated for a T1N1M0 invasive ductal carcinoma. After a biopsy diagnosis of carcinoma, the patient underwent quadrantectomy with axillary lymph node dissection. She received partial 4 cycles of chemotherapy with adriamycin and cyclophosphamide, followed by radiation treatment. Thereafter, a standard postoperative radiotherapy was applied at our institution four months after chemotherapy (TD 46 Gy in 23 fractions followed by a 10 Gy electron boost to the tumour bed). Adjuvant chemotherapy was finished six months after operation, followed by tamoxifen. Follow up: no further complications were detected during regular check-ups. However, 12-years later, patient reported significant changes at breast region which was exposed to radiation during treatment of original tumour. In this article, we describe the clinical presentation, imaging and pathological findings of secondary angiosarcoma of the breast after radiotherapy (Fig. 2, Ref. 26).

Stereotactic vacuum-assisted breast biopsy: our experience and comparison with stereotactic automated needle biopsy.

OBJECTIVES: To evaluate and compare the outcome of stereotactically guided percutaneous, directional, vacuum-assisted breast biopsy (VAB) with the outcome of those performed with 14-gauge automated gun. METHODS: Between January 2008 and January 2011, altogether 257 stereotactic biopsies were performed in our institute; 193 with the 14-gauge automated needle and 64 with a directional, vacuum-assisted instrument. Patients with malignant or high risk lesions were encouraged to undergo an excisional biopsy. We evaluated and compared concordance between the biopsy results and subsequent examinations (surgical excision or follow up) for both methods. RESULTS: VAB demonstrated 57 (89 %) benign lesions, 2 (3 %) high risk and 5 (8 %) malignant lesions. We obtained post-bioptic mammographic or histological evaluation for altogether 51 lesions, with one (12.5 %) false negative case, one case of underestimation of borderline lesion, and no false positive cases. Clusters of microcalcifiation were completely removed in 18 lesions (28 %). CONCLUSION: Vacuum-assisted biopsy outperformed the 14-gauge automated needle biopsy with a lower disease underestimation, sensitivity and false-negative rates; however these differences were not statistically significant due to small data files and relatively small number of identified malignant lesions in the vacuum-assisted biopsy group.VAB completely removed significantly more clusters of microcalcifications in comparison to the automated needle biopsy, which significantly reduced the need for surgery in benign lesions (Tab. 7, Fig. 3, Ref. 32).

[Ductal carcinoma in situ (DCIS) and biopsy of the sentinel lymph node]. / DCIS a biopsia sentinelovej uzliny.

INTRODUCTION: Ductal carcinoma in situ (DCIS) is the disease with increasing incidence. Nowadays, approximately 80% DCIS are diagnosed via mammography and represent more than 20% of all types of breast cancer. The acceptance of surgical procedures with this type of breast carcinoma is controversial as primary diagnosis of non-invasive carcinoma is often underestimated and in the end, histopathological examination reveals invasive carcinoma with biological potential to metastasize. In cases of "risk" patient groups with DCIS, several studies report lymph node metastases. The aim of the study has been to assess the incidence of sentinel lymph node metastatic involvement in high-risk patient group with DCIS and in ductal carcinoma in situ with microinvasion (DCISMI), to note the incidence of invasive carcinoma in definitive histopathology in patients with pre-operative diagnosis of DCIS and to analyze some predictors of invasivity. STUDY TYPE AND PATIENT GROUP: In retrospective analysis, we evaluated the setting of 119 patients who have been operated on at our Clinic from January, 1st 2008 until December, 31th 2010 for the diagnosis of DCIS. Prospectively, we have created the setting of 44 patients with high-risk DCIS with sentinel lymph node biopsy (SLNB) performed. METHODS AND RESULTS. Metastatic involvement of sentinel lymph node in high-risk DCIS has been found in 4 cases (9.0%)--in 1 patient (2.2%) with correct diagnosis of DCIS and in 3 patients (6.8%) with invasive carcinoma according to final histopathology. In the patient with DCIS, a micrometastasis of 0.4 mm was found in one sentinel lymph node. After complete axillary dissection, non-sentinel axillary lymph nodes metastatic involvement was not demonstrated (14/0). In 6 cases (5.0%), we identified DCISMI and did not find metastasis in sentinel lymph node. In the high-risk DCIS group, in 4 patients (9.0%) DCISMI and in 12 patients (27.2%) invasive carcinoma was found after definitive histopathologic examination. In this group, the overall ratio of invasive lesions was 36.2%. As for predictors of invasivity, high-grade carcinoma (OR 4.2; 95% CI 1,40-12,58) has more than 4-fold higher influence and lesion size

Digital mammography--a new trend in breast carcinoma diagnostics.

OBJECTIVES: To determine the advantages of digital mammography in early detection of breast carcinoma. BACKGROUND: A new full field digital mammograph was installed at St. Elisabeth Oncology Institute in Bratislava 13 months ago. During this period we gained experience using this equipment and compared it to the foreign countries. METHOD: Comparison of digital and conventional mammography. RESULTS: During the period of 13 months 11 799 patients were examined, 5664 with conventional and 6135 with digital mammograph. We diagnosed 98 cases of breast carcinoma (1.6%, p = 0.67) with digital mammography, out of which 17 (17.3%, p = 0.47) were in stage of carcinoma in situ. Using a conventional mammography 68 cases (1.2%) of breast carcinoma were diagnosed, 9 cases (13.2%) as carcinoma in situ. Recall rate differed significantly--for digital mammography it reached 6.9% in comparison to conventional mammography where the recall rate was 9.5%, p < 0.05. Digital mammography seems to be more sensitive in the detection of early stages of breast carcinoma as well as it is selectively advantageous in women with dense breast, perimenopausal women, patients with hormonal replacement therapy. CONCLUSION: Digital mammography is the state-of-the-art method of the early stages breast carcinoma detection especially when enhanced with a CAD system. A considerable contribution of digital mammography will find its use in interventional mammodiagnostic methods (Tab. 1, Fig.5, Ref. 7).

[Significance of the sentinel lymph node biopsy in early breast carcinomas]. / Význam biopsie sentinelovej uzliny pri vcasnom karcinóme prsníka.

We present our experience regarding sentinel lymph node biopsy (SLNB) at St. Elizabeth Institute of Oncology during 48 months. From January 1st, 2006 until December 31st, 2009, we had performed SLNB in 269 patients. Primary tumour size was 0.3-3.5cm including non-invasive breast carcinoma (i.e. TIS, T1 and T2 of TNM classification). Invasive carcinoma accounted for 255 (94.8%) cases, while non-invasive carcinoma for 14 (5.2%) cases. From total of 269 patients with invasive carcinoma, we used validation method in 157 (72.7%). In 255 patients with invasive carcinoma, sentinel node was not identified in 4 (1.6%) cases--in 1 patient with T1 invasive carcinoma and in 3 patients with T2 tumours. False negativity of sentinel node in T1 tumours was 4.3%. The incidence of macrometastases in sentinel nodes was confirmed using standard histopathologic examination with hematoxylin-eosin stain. In negative instances, the examination was then completed with serial sections and immunohistochemistry using cytoskeletal antibodies for confirmation of presence of micrometastases. In 6 (2.4%) cases, we found micrometastase in originally negative sentinel lymph node. Subsequent axillary dissection has not confirmed non-sentinel nodes involvement.