Atypia Involving Fibroadenomas: Outcomes and Upgrade Rates.

OBJECTIVE: Fibroadenomas (FAs) involved by atypia are rare. Consensus guidelines for management of FAs involved by atypia when diagnosed on image-guided biopsy do not exist because of limited data reporting surgical upgrade rates to ductal carcinoma in situ (DCIS) or invasive malignancy. Therefore, these lesions commonly undergo surgical excision. METHODS: This single-institution retrospective study identified cases of FAs involved by atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and/or lobular carcinoma in situ (LCIS) diagnosed on image-guided biopsy between January 2014 and April 2023 to determine upgrade rates. Cases with incidental atypia adjacent to but not involving FAs were excluded. RESULTS: Among 1736 FAs diagnosed on image-guided biopsy, 32 cases (1.8%) were FAs involved by atypia including 43.8% (14/32) ALH, 28.1% (9/32) ADH, 18.8% (6/32) LCIS, 6.3% (2/32) LCIS + ALH, and 3.1% (1/32) unspecified atypia. The most common imaging finding was a mass. Most cases, 81.3% (26/32), underwent subsequent surgical excisional biopsy. A single case of ADH involving and adjacent to an FA was upgraded to FA involved by low-grade DCIS on excision for an overall surgical upgrade rate of 3.8%. There were no cases upgraded to invasive malignancy. For those omitting surgical excision, there was no subsequent malignancy diagnosis at the FA biopsy site over a mean follow-up of 73 months. CONCLUSION: Cases of radiologic-pathologic concordant FAs involved by atypia have a low upgrade rate of 3.8% and should undergo multidisciplinary review. Larger multi-institutional analysis is needed to determine whether guidelines for excision of atypia should apply to atypia involving FAs.

The Impact of Closed-Loop Imaging on Actionable CT-Detected Breast Findings.

PURPOSE: Closed-loop imaging programs (CLIPs) are designed to ensure that patients receive appropriate follow-up, but a review of incidental CT-detected breast findings in the setting of CLIPs has not been performed. METHODS: A retrospective review was conducted of CT reports at a single academic institution from July 1, 2020, to January 31, 2022, to identify reports with recommendations for breast imaging follow-up. Medical records were reviewed to evaluate patient adherence to follow-up, CLIP intervention, subsequent BI-RADS assessment, and diagnosis. Adherence was defined as diagnostic breast imaging performed within 6 months of the CT recommendation. RESULTS: Follow-up recommendations for breast imaging were included in CT report impressions for 311 patients. Almost half of patients (47.3% [147 of 311]) underwent follow-up breast imaging within 6 months, yielding breast cancer diagnoses in 12.9% (19 of 147) and a biopsy-proven positive predictive value of 65.5% (19 of 29). Most patients who returned for follow-up within 6 months did so without CLIP intervention. The majority of CT report impressions in the follow-up group (85.0% [125 of 147]) contained specific recommendations for "diagnostic breast imaging." For patients who did not receive follow-up, the CLIP team tracked all cases and intervened in 19.1% (28 of 147). The most common intervention was a phone call and/or fax to the primary care provider. Outpatient CT examination setting and specific recommendation for diagnostic breast imaging were significantly associated with higher follow-up adherence (P < .0001). CONCLUSIONS: Actionable CT-detected breast findings require follow-up diagnostic breast imaging because of a relevant cancer detection rate of 12.9%. Although many patients return for breast imaging without intervention, almost half of patients did not receive follow-up and may account for a significant number of missed cancer diagnoses. Specific CT recommendation verbiage is associated with higher follow-up adherence, which can be addressed across settings even without CLIPs.

Pearls and Pitfalls of Interpretation of Automated Breast US.

Dense breast tissue is an independent risk factor for breast cancer and reduces the sensitivity of mammography. Patients with dense breast tissue are more likely to present with interval cancers and higher-stage disease. Successful breast cancer screening outcomes rely on detection of early-stage breast cancers; therefore, several supplemental screening modalities have been developed to improve cancer detection in dense breast tissue. US is the most widely used supplemental screening modality worldwide and has been proven to demonstrate additional mammographically occult cancers that are predominantly invasive and node negative. According to the American College of Radiology, intermediate-risk women with dense breast tissue may benefit from adjunctive screening US due to the limitations of mammography. Several studies have demonstrated handheld US (HHUS) and automated breast US (AUS) to be comparable in the screening setting. The advantages of AUS over HHUS include lack of operator dependence and a formal training requirement, image reproducibility, and ability for temporal comparison. However, AUS exhibits unique features that can result in high false-positive rates and long interpretation times for new users. Familiarity with the common appearance of benign mammographic findings and artifacts, technical challenges, and unique AUS features is essential for fast, efficient, and accurate interpretation. The goals of this article are to (a) examine the role of AUS as a supplemental screening modality and (b) review the pearls and pitfalls of AUS interpretation. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Ethanol Sclerotherapy for Postoperative Seroma of the Breast and Axilla.

OBJECTIVE: Evaluate the effectiveness of alcohol sclerotherapy in postoperative breast and axillary seromas. METHODS: This was an IRB-approved retrospective review of consecutive patients from 2017 to 2021. The procedure involves aspiration of seroma fluid, injection of ethanol for 15 to 30 minutes, and then aspiration of the injected ethanol. Following review of the medical record, patient and procedure data were recorded. Success was defined as no recurrence of seroma. Statistical analysis was performed using a chi-square or t-test, as appropriate. RESULTS: Twenty seromas were treated in 19 patients (mean age, 63 years; range, 49-79) following mastectomy (9/20, 45%), lumpectomy (25%, 5/20), axillary nodal dissection (5/20, 25%), or chest wall surgery (1/20, 5%). The mean seroma volume was 146 ±â€…165 mL. There was a mean of 1.4 prior aspiration attempts (range, 0-3). Mean injected ethanol volume was 39 mL (range, 8-60 mL) for a mean of 26 ±â€…5 minutes. Seromas recurred in 85% (17/20) of cases, and repeat aspiration was performed in 35% (6/17). The mean recurrence time was 34 ±â€…29 days. The recurrent seromas were 31% smaller (mean, 80 ±â€…48 mL). Only a smaller pre-ablation seroma was associated with successful ablation (P < 0.01), as the mean pre-ablation volume was 36 ± 24 mL for successful ablations and 119 ±â€…56 mL for unsuccessful ablations. There were no post-procedural complications. CONCLUSION: Single-treatment ethanol sclerotherapy is typically unsuccessful in ablating breast and axillary seromas. Only a smaller pre-ablation seroma size was associated with successful ablation.