Paget's disease of the nipple with underlying occult invasive carcinoma detected by magnetic resonance imaging and second-look ultrasound: Case report.

INTRODUCTION: Paget's disease of the nipple (PDN) is a rare and often misdiagnosed condition characterized by the infiltration of adenocarcinoma cells into the nipple epidermis. It poses substantial diagnostic and therapeutic challenges due to its similarity to benign dermatological conditions and its association with in situ or invasive carcinoma. CASE PRESENTATION: This report details the case of a 47-year-old woman with persistent nipple itching, rash, and occasional bloody discharge. No abnormalities were seen on the mammogram and ultrasound scans; punch biopsy was performed to confirm PDN. A small lesion missed by other imaging methods was detected via breast magnetic resonance imaging (MRI). A second-look ultrasound with needle localization enabled precise surgery. The pathology report after breast-conserving surgery (BCS) revealed invasive ductal carcinoma with no metastasis in the sentinel lymph node biopsy. DISCUSSION: PDN often mimics benign skin conditions, leading to delayed diagnosis. Furthermore, timely identification is crucial as PDN is frequently associated with underlying breast malignancies. Additional imaging, such as breast MRI, is essential for comprehensive evaluation, as it can reveal hidden lesions previously undetected by conventional mammography and ultrasound. A second-look ultrasound guided needle placement for tumor localization, enhancing surgical precision, aesthetics, and reducing patient harm. Surgical management, including mastectomy, BCS with radiotherapy, and oncoplastic surgery, offers suitable options without affecting recurrence or survival in selected patients. CONCLUSION: This case emphasizes the importance of employing additional imaging tools, such as breast MRI and second-look ultrasound for the early detection and surgical management of PDN.

T1-Weighted Dynamic Contrast-Enhanced Magnetic Resonance Imaging (DCE-MRI) to Distinguish Between Concurrent Cholesterol Granuloma and Invasive Ductal Carcinoma of the Breast: A Case Report.

BACKGROUND Cholesterol granuloma is a benign condition that can be misdiagnosed as breast cancer on mammographic and ultrasound imaging. A case of concomitant cholesterol granuloma with invasive ductal carcinoma of the left breast was imaged with ultrasound elastography and magnetic resonance imaging (MRI) methods, including T1-weighted dynamic contrast-enhanced MRI (DCE-MRI), before biopsy and histopathology. CASE REPORT A 52-year-old woman, with a previous history of intraduct papillomas in both breasts, underwent six-monthly follow-up breast imaging. The most recent breast mammogram showed a progressively enlarging oval mass in the upper inner quadrant (UIQ) of the left breast, and an adjacent irregular mass with microcalcifications. Virtual Touch IQ (VTIQ) shear wave elastography was used with ultrasound of the breast lesions. T1-weighted fat saturation (T1WFS) MRI, T2-weighted short-tau inversion recovery (STIR) MRI, and T1-weighted DCE-MRI were used to image the left breast. T1-weighted DCE-MRI showed that the oval lesion had a high T1-weighted signal and mild progressive enhancement, with a Type I (benign) time-signal intensity curve; the second, irregular, mass showed rapid, intense enhancement with a washout pattern or Type III (malignant) time-signal intensity curve. Histopathology confirmed that the oval mass was a cholesterol granuloma, and the irregular mass was an invasive ductal carcinoma. CONCLUSIONS A case of concomitant cholesterol granuloma with invasive ductal carcinoma of the left breast, showed that ultrasound with shear wave elastography and T1-weighted DCE-MRI could distinguish between cholesterol granuloma and invasive ductal carcinoma.

Differentiation of Malignant and Benign Incidental Breast Lesions Detected by Chest Multidetector-Row Computed Tomography: Added Value of Quantitative Enhancement Analysis.

To retrospectively determine the association between breast lesion morphology and malignancy and to determine the optimal value of lesion enhancement (HU, Hounsfield units) to improve the diagnostic accuracy of breast cancer in patients with incidental breast lesions (IBLs). A total of 97 patients with 102 IBLs detected from July 2009 to December 2012 were enrolled in this study. Two radiologists analyzed CT images for the presence of malignancy based on the morphology of the lesions alone and in combination with an enhancement value (HU) analysis. There were 36 malignant and 66 benign IBLs. When the morphology and enhancement values were combined, the sensitivity, specificity, and accuracy were 92%, 97%, and 95%, respectively, for reader 1 and 89%, 94%, and 92%, respectively, for reader 2. The addition of HU values led to correct changes in the diagnosis; specifically, the accuracy of the diagnosis of reader 1 and reader 2 improved by 6.9% and 11.8%, respectively. The addition of the enhancement value (HU) to the CT morphology improved the diagnostic accuracy in the differentiation of malignant from benign IBLs by using the region of interest (ROI) to measure the HU within the most suspicious part of the lesion.

The Values of Combined and Sub-Stratified Imaging Scores with Ultrasonography and Mammography in Breast Cancer Subtypes.

BACKGROUND AND OBJECTIVES: The Breast Imaging Reporting and Data System (BI-RADS) of Mammography (MG) and Ultrasonography (US) were equivalent to the "5-point score" and applied for combined and sub-stratified imaging assessments. This study evaluated the value of combined and sub-stratified imaging assessments with MG and US over breast cancer subtypes (BCS). MATERIALS AND METHODS: Medical records of 5,037 cases having imaging-guided core biopsy, performed from 2009 to 2012, were retrospectively reviewed. This study selected 1,995 cases (1,457 benign and 538 invasive cancer) having both MG and US before biopsy. These cases were categorized with the "5-point score" for their MG and US, and applied for combined and sub-stratified imaging assessments. Invasive cancers were classified on the basis of BCS, and correlated with combined and sub-stratified imaging assessments. RESULTS: These selected cases were evaluated by the "5-point score." MG, US, and combined and sub-stratified imaging assessments all revealed statistically significant (P < 0.001) incidence of malignancy. The sensitivity was increased in the combined imaging score (99.8%), and the specificity was increased in the sub-stratified combined score (75.4%). In the sub-stratified combined imaging assessment, all BCS can be classified with higher scores (abnormality hierarchy), and luminal B subtype showed the most salient result (hierarchy: higher, 95%; lower, 5%). CONCLUSIONS: Combined and sub-stratified imaging assessments can increase sensitivity and specificity of breast cancer diagnosis, respectively, and Luminal B subtype shows the best identification by sub-stratified combined imaging scoring.

Breast Nonmass Enhancement Detected with MRI: Uility and Lesion Characterization with Second-Look Ultrasonography.

The purpose of this study was to verify the utility of second-look ultrasonography (US) in evaluating nonmass enhancement (NME) lesions detected on breast magnetic resonance imaging (MRI) by analysing its correlation and imaging features. From July 2008 to June 2012, 102 consecutive MRI-detected NME lesions were subsequently evaluated with US. Lesions were evaluated according to the established Breast Imaging Reporting and Data System (BI-RADS) lexicon. The correlation between MRI-detected NME lesion characteristics, lesion size, histopathological findings and features at second-look US were analysed. Second-look US identified 44/102 (43%) of the NME lesions revealed by MRI. A US correlate was seen in 34/45 (76%) malignant lesions compared with 10/57 (18%) benign lesions (p < 0.0001). The likelihood of malignancy was significantly higher for NME lesions with a US correlate than lesions without: 34/44 (77%) versus 11/58 (19%) (p < 0.0001). The malignancy of the 44 (43%) MRI-detected NME lesions with a US correlate was significantly associated with US lesion margins and BI-RADS categories (p = 0.001 and 0.002 respectively). Second-look US of MRI-detected NME lesions is useful for decision-making as part of the diagnostic workup. Familiarity with the US features associated with malignancy improves the utility of US in the workup of these NME abnormalities.

Non-mass-like breast lesions at ultrasonography: feature analysis and BI-RADS assessment.

OBJECTIVE: To analyze the features of non-mass-like (NML) breast lesions on ultrasound (US) and determine their corresponding malignancy rate and to stratify these lesion patterns according to US BI-RADS categories. MATERIALS AND METHODS: One hundred sixty-four consecutive lesions were retrospectively classified into four types according to the US features, the corresponding positive predictive values (PPVs) were obtained. Clinical, imaging, and histopathological findings were reviewed. RESULTS: Among the 164 lesions, 39 (24%) were classified as type Ia, 14 (8%) as type Ib, 39 (24%) as type IIa, 19 (12%) as type IIb, 19 (12%) as type III, and 34 (21%) as type IV. The PPVs for malignancy were 21% for type Ia, 79% for type Ib, 10% for type IIa, 58% for type IIb, 16% for type III, and 21% for type IV. All NML lesions were classified as BI-RADS category 4a (type IIa), 4b (type Ia, III and IV) and 4c (type Ib and IIb) according to their PPVs. There was a significantly higher frequency of malignancy among lesions of type Ib and type IIb compared with the other types (P<0.01 for each). Lesions with associated calcifications, presence of abnormal axillary nodes, or a mammographic finding of suspected malignancy had a higher probability of malignancy (P<0.05 for each). CONCLUSION: US is useful in clarifying the indication for biopsy of NML lesions. The types of US classifications used in our study establish reliable references for the NML patterns when stratified according to the BI-RADS categories.

Value of ¹8F-FDG uptake on PET/CT and CEA level to predict epidermal growth factor receptor mutations in pulmonary adenocarcinoma.

PURPOSE: The identification of the mutation status of the epidermal growth factor receptor (EGFR) is important for the optimization of treatment in patients with pulmonary adenocarcinoma. The acquisition of adequate tissues for EGFR mutational analysis is sometimes not feasible, especially in advanced-stage patients. The aim of this study was to predict EGFR mutation status in patients with pulmonary adenocarcinoma based on (18)F-fluorodeoxyglucose (FDG) uptake and imaging features in positron emission tomography/computed tomography (PET/CT), as well as on the serum carcinoembryonic antigen (CEA) level. METHODS: We retrospectively reviewed 132 pulmonary adenocarcinoma patients who underwent EGFR mutation testing, pretreatment FDG PET/CT and serum CEA analysis. The associations between EGFR mutations and patient characteristics, maximal standard uptake value (SUVmax) of primary tumors, serum CEA level and CT imaging features were analyzed. Receiver-operating characteristic (ROC) curve analysis was performed to quantify the predictive value of these factors. RESULTS: EGFR mutations were identified in 69 patients (52.2 %). Patients with SUVmax ≥6 (p = 0.002) and CEA level ≥5 (p = 0.013) were more likely to have EGFR mutations. The CT characteristics of larger tumors (≥3 cm) (p = 0.023) and tumors with a nonspiculated margin (p = 0.026) were also associated with EGFR mutations. Multivariate analysis showed that higher SUVmax and CEA level, never smoking and a nonspiculated tumor margin were the most significant predictors of EGFR mutation. The combined use of these four criteria yielded a higher area under the ROC curve (0.82), suggesting a good discrimination. CONCLUSION: The combined evaluation of FDG uptake, CEA level, smoking status and tumor margins may be helpful in predicting EGFR mutation status in patients with pulmonary adenocarcinoma, especially when the tumor sample is inadequate for genetic analysis or genetic testing is not available. Further large-scale prospective studies are needed to validate these results.

Underestimation of invasive lesions in patients with ductal carcinoma in situ of the breast diagnosed by ultrasound-guided biopsy: a comparison between patients with and without HER2/neu overexpression.

PURPOSE: To determine the rate of underestimation of ductal carcinoma in situ (DCIS) diagnosed at imaging-guided biopsy and to analyze its association with HER2/neu oncogene, an important biomarker in assessing the tumour aggressiveness and guiding hormone therapy for breast cancer. METHODS: We retrospectively reviewed 162 patients with DCIS diagnosed by imaging-guided core needle biopsy between January 2008 and March 2013. All of these patients received surgical excision, and in 25, the diagnosis was upgraded to invasive breast cancer. In this study, we examined the ultrasound, mammographic features and histopathological results for each patient, and compared these parameters between those with and without HER2/neu overexpression. RESULTS: Of the 162 DCIS lesions, 110 (67.9%) overexpressed HER2/neu. Nineteen patients with HER2/neu overexpressing DCIS (n=19/110, 17.3%) were upgraded after surgery to a diagnosis of invasive breast cancer. In this group, the upgrade rate was highest in patients with a dilated mammary duct pattern (42.1%, n=8/19, p=0.02) and the presence of abnormal axillary nodes (40.0%, n=12/30, p<0.01) at ultrasound and was significantly associated with comedo tumour type on pathology. CONCLUSIONS: Biopsy may underestimate the invasive component in DCIS patients. Sonographic findings of dilated mammary ducts and presence of abnormal axillary lymph nodes may help predicting the invasive components and possibly driving more targeted biopsy procedures.

Impact of interstitial pneumonia on the survival and risk factors analysis of patients with hematological malignancy.

BACKGROUND: The emergence of interstitial pneumonia (IP) in patients with hematological malignancy (HM) is becoming a challenging scenario in current practice. However, detailed characterization and investigation of outcomes and risk factors on survival have not been addressed. METHODS: We conducted a retrospective study of 42,584 cancer patients covering the period between 1996 and 2008 using the institutional cancer registry system. Among 816 HM patients, 61 patients with IP were recognized. The clinical features, laboratory results, and histological types were studied to determine the impact of IP on survival and identify the profile of prognostic factors. RESULTS: HM patients with IP showed a significant worse survival than those without IP in the 5-year overall survival (P = 0.027). The overall survival showed no significant difference between infectious pneumonia and noninfectious interstitial pneumonia (IIP versus nIIP) (P = 0.323). In a multivariate Cox regression model, leukocyte and platelet count were associated with increased risk of death. CONCLUSIONS: The occurrence of IP in HM patients is associated with increased mortality. Of interest, nIIP is a prognostic indicator in patients with lymphoma but not in patients with leukemia. However, aggressive management of IP in patients with HM is strongly advised, and further prospective survey is warranted.

Case of pulmonary cryptococcosis mimicking hematogeneous metastases in an immunocompetent patient: value of absent 18F-fluorodeoxyglucose uptake on positron emission tomography/CT scan.

The radiologic appearance of multiple discrete pulmonary nodules in immunocompetent patients, with cryptococcal infection, has been rarely described. We describe a case of pulmonary cryptococcosis, presenting with bilaterally and randomly distributed nodules on a computed tomography, mimicking hematogeneous metastases. Positron emission tomography does not demonstrate 18F-fluorodeoxyglucose (FDG) uptake, suggesting a low probability for malignancy, which is a crucial piece of information for clinicians when making a management decision. We find the absence of FDG uptake correlates with the pathologic finding of an infectious nodule, composed of fibrosis and necrosis.

The fifth chamber of the heart: huge left atrial aneurysm.

Cardiomegaly is a common but nonspecific finding in the emergency department. The etiology may be explained by left ventricular dilation, biventricular dilation, right ventricular dilation, or pericardial abnormalities, or it may be found to be spurious on the echocardiogram. Rarely, isolated abnormalities of the atrium, particularly the left atrium, may cause abnormalities on the chest radiograph but will not cause true cardiomegaly. We reported a 37-year-old woman who presented with persistent palpitation of a 6-hour duration. An electrocardiogram revealed atrial fibrillation with rapid ventricular response. A chest radiograph showed cardiomegaly with unusual prominence of the left heart border. A subsequent transthoracic echocardiography demonstrated an echo-free chamber adjacent to the left lateral wall of the left ventricle. The diagnosis of a rare huge left atrial aneurysm was finally established by multidetector-row computed tomography, which had been seldom used as a diagnostic tool in the past. Patients with this cardiac anomaly usually are asymptomatic until the second or third decade of life, when the aneurysms can reach remarkable sizes and are often complicated with atrial tachyarrhythmia or thromboembolic events. Early surgical intervention is advised even in asymptomatic patients to prevent the occurrence of myocardial dysfunction, atrial fibrillation, and systemic embolism.

Incidentally detected enhancing breast lesions on chest computed tomography.

OBJECTIVE: To evaluate the nature and imaging appearance of incidental enhancing breast lesions detected on a routine contrast-enhanced chest CT. MATERIALS AND METHODS: Twenty-three patients with incidental enhancing breast lesions on contrast-enhanced chest CT were retrospectively reviewed. The breast lesions were reviewed by unenhanced and enhanced CT, and evaluated by observing the shapes, margins, enhancement patterns and backgrounds of breast lesions. A histopathologic diagnosis or long-term follow-up served as reference standard. RESULTS: Sixteen (70%) patients had malignant breast lesions and seven (30%) had benign lesions. In 10 patients, the breast lesions were exclusively detected on contrast-enhanced CT. Using unenhanced CT, breast lesions with fibroglandular backgrounds were prone to be obscured (p < 0.001). Incidental primary breast cancer showed an non-significant trend of a higher percentage irregular margin (p = 0.056). All of the four incidental breast lesions with non-mass-like enhancement were proven to be malignant. CONCLUSION: Routine contrast-enhanced chest CT can reveal sufficient details to allow for the detection of unsuspected breast lesions, in which some cases may be proven as malignant. An irregular margin of incidental enhancing breast lesion can be considered a suggestive sign of malignancy.

Value of sonographically guided needle sampling of cystic versus solid components in the diagnosis of complex cystic breast masses.

BACKGROUND: The common practice for diagnosis of complex cystic breast masses (CCBM) may be imaging-guided aspiration or biopsy of cystic or solid components. PURPOSE: To assess the diagnostic value of sonographically guided needle sampling of cystic and solid components for CCBM. MATERIAL AND METHODS: Twenty patients with 20 CCBM underwent sonographically guided fine-needle aspiration biopsy (FNAB) for cystic components, followed by core needle biopsy (CNB) for residual solid components. The diagnostic results of each were evaluated. Excisional biopsy or mastectomy served as a reference standard. RESULTS: Fourteen (70%) masses were malignant. Needle sampling for cystic components of the 14 malignant tumors showed malignancy in one (7%), atypia in four (29%), benign findings in four (29%), and insufficient samples in five (36%). Needle sampling for residual solid components showed malignancy in 11 (79%), atypia in two (14%), and insufficient sample in one (7%). The diagnostic yield of needle sampling of solid components was significantly higher than that of cystic components for malignant CCBM (P<0.05). Sixteen (80%) of 20 CCBMs showed bloody fine-needle aspirates. There was no significant difference between the rates of bloody aspirates of malignant and benign CCBM (86% vs. 67%, P=0.55). CONCLUSION: Sonographically guided needle sampling of solid components may help to identify most malignant CCBMs, and the aspirated fluid may be discarded due to low diagnostic value.

Atypical pulmonary metastases from a true malignant mixed tumor of the parotid gland.

A 58-year-old male patient presented with a recurrent true malignant mixed tumor of the parotid gland. Patchy pulmonary opacities were identified with a chest radiograph. Subsequently, a CT scan of the chest showed pulmonary parenchymal consolidation with amorphous calcifications. This abnormality was confirmed to be the result of a metastatic true malignant mixed tumor by using CT-guided biopsy. The current case demonstrated an extremely rare example of atypical pulmonary metastases from a true malignant mixed tumor of the parotid gland showing an air-space pattern and calcification.

Midgut volvulus in an adult with congenital malrotation.

Congenital midgut malrotation, a rare anatomic anomaly that can lead to duodenal or small-bowel obstruction, rarely is observed beyond the first year of life. Symptomatic patients present with either acute bowel obstruction and intestinal ischemia with a midgut or cecal volvulus or with chronic vague abdominal pain. Chronic symptoms often can make the diagnosis difficult. By using several modalities such as barium studies, computerized tomography, angiography, and emergency laparotomy, we diagnosed midgut volvulus and partial intestinal obstruction, which occur rarely in an adult with congenital midgut malrotation.