Venous malformation of the pectoral muscle depicted on mammogram.

Venous malformation of the pectoral muscle diagnosed on a mammogram of a 41-year-old patient presenting with clinical suspicion of a gynecomastia.

Comparative Evaluation of Iodine-125 Radioactive Seed Localization and Wire Localization for Resection of Breast Lesions.

PURPOSE: Radioactive seed localization (RSL) uses a titanium seed labeled with iodine-125 energy for surgery of nonpalpable breast lesions. RSL facilitates radiology-surgery scheduling and allows for improved oncoplasty compared with wire localization (WL). The purpose of this work was to compare the 2 techniques. METHODS: We performed a retrospective study of all breast lesions operated with RSL between February 2013 and March 2015 at our university institution, and compared with an equivalent number of surgeries performed with a single WL. Imaging and pathology reports were reviewed for information on guidance mode, accuracy of targeting, nature of excised lesion, size and volume of surgical specimen, status of margins, and reinterventions. RESULTS: A total of 254 lesions (247 women) were excised with RSL and compared with 257 lesions (244 women) whose surgery was guided by WL. Both groups were comparable in lesion pathology, guidance mode for RSL or WL positioning, and accuracy of targeting (98% correct). Mean delay between biopsy and surgery was 84 days for RSL versus 103 after WL (P = .04). No differences were noted after RSL or WL for surgical specimen mean weight, largest diameter, and volume excised. For malignancies, the rate of positive margins was comparable (2.8%-3%), with 5 of 10 women in the RSL group who underwent a second surgery displaying residual malignancy compared with 3 of 9 women in the WL group. CONCLUSIONS: RSL is safe and accurate, and has comparable surgical endpoints to WL. Because RSL offers flexible scheduling and facilitated oncoplasty, RSL may replace WL for resection of nonpalpable single breast lesions.

Lupus mastitis as a first manifestation of systemic disease: About two cases with a review of the literature.

Lupus mastitis is an uncommon manifestation of systemic lupus erythematosus (SLE) that affects the subcutaneous fat in the breast, much like lupus panniculitis, but additionally involves the mammary gland. We report on two women for whom lupus mastitis was the initial manifestation of SLE and provide a literature review of 34 additional cases reported in the Anglo-Saxon and French literature since 1971, making this the largest review to date. Lupus mastitis (LM) can manifest clinically as subcutaneous masses that may be painful, or may present cutaneous involvement such as thickening and discolouration. The radiologic manifestations of LM are broad and include calcifications, masses and asymmetries. Most often, excluding malignancy requires percutaneous biopsy, with histologic findings that are virtually pathognomonic for SLE. Thus, surgery is avoided and medical management can begin, antimalarial drugs and corticosteroids in most cases.

Breast Biopsies Under Magnetic Resonance Imaging Guidance: Challenges of an Essential but Imperfect Technique.

Magnetic resonance imaging (MRI)-guided breast biopsy is an essential tool of a breast imager; yet, a decade after its introduction, this technique remains challenging and imperfect. This article presents the technique of MRI-guided biopsy, with an emphasis on challenges particular to the technique: technical considerations related to adequate lesion sampling and difficulties in confirming radiologic-pathologic correlation for enhancing lesions. Through clinical vignettes, challenges unique to MRI-guided biopsy are discussed and practical tips are offered. Prebiopsy planning including second-look targeted studies, patient preparation, and equipment is covered. Challenging situations pertaining to breast size, lesion location, or type of enhancement are illustrated, as well as the topic of performing multiple MRI-guided breast biopsies in a single session and biopsies of women with implants. Postbiopsy management is discussed. Success of MRI-guided biopsies requires careful prebiopsy planning, as well as appropriate choice of biopsy device, optimized for the specifics of breast shape and lesion size and location. Special features of biopsy systems (smaller apertures and blunt tips) facilitate the sampling of lesions in challenging locations. Vanishing lesions should undergo short-term follow-up, because malignancy cannot be excluded, as should lesions diagnosed as benign after pathologic analysis when the result is felt to be concordant with imaging features. To this end, radiologic-pathologic correlation is essential. Underestimation rates after MRI-guided breast biopsy are superior to those for vacuum-assisted stereotactic biopsy and ultrasound-guided biopsy. Close follow-up and rebiopsy should be considered when there is imaging-discordant histology. For benign and concordant histology, a first follow-up can be offered at 6 months.

Breast imaging reporting and data system (BI-RADS) lexicon for breast MRI: interobserver variability in the description and assignment of BI-RADS category.

PURPOSE: To retrospectively evaluate interobserver variability between breast radiologists when describing abnormal enhancement on breast MR examinations and assigning a BI-RADS category using the Breast Imaging Reporting and Data System (BI-RADS) terminology. MATERIALS AND METHODS: Five breast radiologists blinded to patients' medical history and pathologic results retrospectively and independently reviewed 257 abnormal areas of enhancement on breast MRI performed in 173 women. Each radiologist described the focal enhancement using BI-RADS terminology and assigned a final BI-RADS category. Krippendorff's α coefficient of agreement was used to asses interobserver variability. RESULTS: All radiologists agreed on the morphology of enhancement in 183/257 (71%) lesions, yielding a substantial agreement (Krippendorff's α=0.71). Moderate agreement was obtained for mass descriptors - shape, margins and internal enhancement - (α=0.55, 0.51 and 0.45 respectively) and NME (non-mass enhancement) descriptors - distribution and internal enhancement - (α=0.54 and 0.43). Overall substantial agreement was obtained for BI-RADS category assignment (α=0.71). It was however only moderate (α=0.38) for NME compared to mass (α=0.80). CONCLUSION: Our study shows good agreement in describing mass and NME on a breast MR examination but a better agreement in predicting malignancy for mass than NME.

Molecular classification of infiltrating breast cancer: toward personalized therapy.

Breast cancer is a heterogeneous disease, which comprises several molecular and genetic subtypes, each with characteristic clinicobiologic behavior and imaging patterns. Traditional classification of breast cancer is based on the histopathologic features but offers limited prognostic value. Novel molecular characterization of breast cancer with cellular markers has allowed a new classification that offers prognostic value, with predictive categories of disease aggressiveness. These molecular signatures also open the door to personalized therapeutic options, with new receptor-targeted therapies. For example, invasive cancer subtypes such as the luminal A and B subtypes show better prognosis and response to hormone receptor-targeted therapies compared with the triple-negative subtypes; on the other hand, triple-negative tumors respond better than luminal tumors to chemotherapy. Tumors that display amplification of the oncogene ERBB2 (also known as the HER2/neu oncogene) respond to drugs directed against this oncogene, such as trastuzumab. The imaging aspects of tumors correlate with molecular subgroups, as well as other pathologic features such as nuclear grade. Smooth tumor margins at mammography may be suggestive of a triple-negative breast cancer, and a human epidermal growth factor receptor 2 (HER2)-positive tumor is characteristically a spiculated mass with calcifications. Low-grade ductal carcinoma in situ (DCIS) is better detected with mammography, although magnetic resonance (MR) imaging may allow better characterization of high-grade DCIS. MR imaging diffusion sequences show higher values for the apparent diffusion coefficient for triple-negative and HER2-positive subtypes, compared with luminal A and B tumors. MR imaging is also a useful tool in the prediction of tumor response after chemotherapy, especially for triple-negative and HER2-positive subtypes.

Chronic granulomatous mastitis: Imaging, pathology and management.

PURPOSE: The aim of this study is to describe the clinical and radiological presentation of chronic granulomatous mastitis. MATERIAL AND METHODS: We retrospectively reviewed the clinical and radiological data of 11 women with histologically proven chronic granulomatous mastitis (CGM) diagnosed between March 2008 and September 2011. RESULTS: The diagnosis of CGM is often a challenging one that can mimic infectious and malignant breast conditions. Clinically, CGM most commonly presents as a mass, occasionally with associated erythema. The most frequent mammographic presentation is an asymmetric density, while ultrasound most commonly reveals a hypoechoic mass with tubular extensions and a striated echotexture. On MRI, the most specific finding is peripherally enhancing fluid or solid masses with fistulous tract to the skin, although the latter is not commonly encountered. Diagnosis can be reliably obtained by needle core or vacuum-assisted biopsy, and is established pathologically by the identification of granulomatous inflammation without caseous necrosis. CGM is a diagnosis of exclusion after infectious and foreign body causes are ruled out. Treatment options include oral steroids or surgery; both options are associated with similar recurrence rates. The disease tends to burn itself out and the option of conservative management with observation is a valid one. CONCLUSION: CGM is a rare benign disease with no specific features clinically or at imaging. There are no radiologic findings that are specific of CGM, but in the appropriate clinical setting, the diagnosis can be suggested by the radiologist.

Second-look targeted studies after breast magnetic resonance imaging: practical tips to improve lesion identification.

Second-look studies, so-called because a re-evaluation of the breast is performed after review of magnetic resonance imaging (MRI) findings, offer the possibility of identifying correlates to MRI-detected lesions that were not previously suspected at mammography or ultrasound, thereby permitting immediate biopsy. To maximize the identification of ultrasound and mammographic correlates to MRI-identified lesions, one must carefully review the initial MRI examination as well as be cognizant of breast normal anatomy and variations in breast position across imaging modalities. We review the steps required for planification and realization of a successful second-look evaluation. After a correlate has been found and percutaneous biopsy performed, we recommend obtaining a T1-weighted noncontrast MRI sequence to verify metallic marker placement at the site of biopsy. This step ensures correct correlation between imaging modalities, provides immediate feedback for the radiologist, and, in case of error, allows the patient to be immediately redirected to repeat biopsy, often under MRI guidance. In the case of correct correlation, short-term follow-up is recommended, as for other breast percutaneous interventional procedures. We propose a simple management algorithm following second-look targeted studies.

Evaluation of an audiovisual-FM system: investigating the interaction between illumination level and a talker's skin color on speech-reading performance.

A program designed to evaluate the benefits of an audiovisual-frequency modulated (FM) system led to some questions concerning the effects of illumination level and a talker's skin color on speech-reading performance. To address those issues, the speech of a Caucasian female was videotaped under 2 conditions: a light skin color condition and a dark skin color condition. For the latter condition, makeup was applied to the talker's face. For both skin color conditions, the talker was recorded while speaking sentences under 7 different levels of illumination: 2, 3, 4, 16, 60, 256, and 600 footcandles (fc). Fifteen participants completed the speech perception task in a visual-only modality. The results revealed a significant interaction of illumination level and skin color. For the light skin color condition, speech-reading performance improved systematically as the illumination level increased from 3 to 16 fc. For the dark skin color condition, no differences in speech-reading performance were observed between the 2-fc and the 3-fc conditions. However, a large improvement in speech-reading performance was observed as the illumination level increased from 4 fc to 16 fc. It is speculated that in addition to an overall effect of illumination level, the contrast in luminance at the level of the talker's face has an effect on speech-reading performance.