Contrast-enhanced ultrasound to predict malignant upgrading of atypical ductal hyperplasia.

BACKGROUND: A malignancy might be found at surgery in cases of atypical ductal hyperplasia (ADH) diagnosed via US-guided core needle biopsy (CNB). The objective of this study was to investigate the diagnostic performance of contrast-enhanced ultrasound (CEUS) in predicting ADH diagnosed by US-guided CNB that was upgraded to malignancy after surgery. METHODS: In this retrospective study, 110 CNB-diagnosed ADH lesions in 109 consecutive women who underwent US, CEUS, and surgery between June 2018 and June 2023 were included. CEUS was incorporated into US BI-RADS and yielded a CEUS-adjusted BI-RADS. The diagnostic performance of US BI-RADS and CEUS-adjusted BI-RADS for ADH were analyzed and compared. RESULTS: The mean age of the 109 women was 49.7 years ± 11.6 (SD). The upgrade rate of ADH at CNB was 48.2% (53 of 110). The sensitivity, specificity, positive predictive value, and negative predictive value of CEUS for identification of malignant upgrading were 96.2%, 66.7%,72.9%, and 95.0%, respectively, based on BI-RADS category 4B threshold. The two false-negative cases were low-grade ductal carcinoma in situ. Compared with the US, CEUS-adjusted BI-RADS had better specificity for lesions smaller than 2 cm (76.7% vs. 96.7%, P = 0.031). After CEUS, 16 (10 malignant and 6 nonmalignant) of the 45 original US BI-RADS category 4A lesions were up-classified to BI-RADS 4B, and 3 (1 malignant and 2 nonmalignant) of the 41 original US BI-RADS category 4B lesions were down-classified to BI-RADS 4A. CONCLUSIONS: CEUS is helpful in predicting malignant upgrading of ADH, especially for lesions smaller than 2 cm and those classified as BI-RADS 4A and 4B on ultrasound.

Combination of Breast Ultrasound With Magnetic Resonance Imaging in the Diagnosis of Non-mass-like Breast Lesions Detected on Ultrasound: A New Integrated Strategy to Improve Diagnostic Performance.

OBJECTIVE: The aim of the work described here was to evaluate the diagnostic performance of a new integrated strategy using breast ultrasound (US) combined with magnetic resonance imaging (MRI) to differentiate benign and malignant breast non-mass-like lesions (NMLs) detected on US. METHODS: From October 2017 to January 2021, 183 NMLs detected on US that had undergone MRI examinations were included in this respective study. Pathological results were used as the reference standard. The integrated diagnostic strategy of breast US combined with MRI based on a combination of MRI Breast Imaging Reporting and Data System (BI-RADS) with discriminant sonographic indicators highly associated with malignancy was established and validated in a cohort of 61 women. The diagnostic performances of US, MRI and the combined method were calculated and compared. RESULTS: In the training set, the area under the receiver operating characteristic curve (AUC), sensitivity and specificity of US, MRI and the integrated diagnostic strategy using US combined with MRI for NMLs were 0.730, 93.7% and 52.3%; 0.849, 94.7% and 75.0%; and 0.901, 92.6% and 87.5%, respectively. Compared with US or MRI alone, the integrated diagnostic strategy significantly increased the AUC (p < 0.001, p = 0.007) and specificity (p < 0.001, p = 0.034) while maintaining high sensitivity (p = 0.774, p = 0.551). In the validation set, the integrated strategy of US combined with MRI (AUC = 0.899) also had good performance compared with US (AUC = 0.728) or MRI (AUC = 0.838). CONCLUSION: The integrated diagnostic strategy of US combined with MRI exhibited good performance for breast NMLs compared with either modality used alone, which can improve the diagnostic specificity while maintaining high sensitivity.

Benign Phyllodes Tumors: Comparison of Prognosis among Three Different Surgical Approaches.

Purpose: To evaluate the prognosis of patients with benign phyllodes tumors (PTs) treated by different surgical methods and to explore the influencing factors of local recurrence. Methods: We retrospectively analyzed 215 benign PTs from 193 patients who underwent surgery at Chinese PLA General Hospital between October 2008 and December 2020. We stratified our analysis according to surgical factors and explored the clinicopathological factors to influence local recurrence. Results: Among 193 patients, a total of 17 (8.8%, 17/193) recurred during follow-up. There were 89 patients in the US-VAE group, of whom 6 (6.7%) recurred; 8 of 57 patients (14%) in the local lumpectomy group recurred, while 3 of 47 patients (6.4%) in the extended lumpectomy group recurred (P=0.252). Multivariate logistic regression analysis showed that tumor diameter, mitosis, and history of breast myoma were independent risk factors for tumor recurrence (P=0.005, P=0.006, and P=0.004, respectively). The intraoperative blood loss, operation time, and scar length of the US-VAE group were shorter than those of the other two groups (P < 0.05). Conclusion: Negative surgical margins of benign PTs can obtain similar prognosis as negative surgical margins >10 mm. Therefore, we recommend that a follow-up observation policy be adopted for patients with unexpected benign PTs, rather than unnecessary open surgical resection. Patients' maximum tumor diameter, mitosis, and fibroadenoma history were independent predictors for recurrence of benign PTs.

Conventional ultrasound combined with contrast-enhanced ultrasound: could it be helpful for the diagnosis of thoracic wall recurrence after mastectomy?

OBJECTIVES: To develop a predictive model using conventional ultrasound combined with CEUS to identify thoracic wall recurrence after mastectomy. METHODS: A total of 162 women with pathologically confirmed thoracic wall lesions (benign 79, malignant 83; median size 1.9 cm, ranging 0.3-8.0 cm) underwent a mastectomy and were checked by both conventional ultrasound and CEUS and were retrospectively included. Logistic regression models of B-mode ultrasound (US) and color Doppler flow imaging (CDFI) with or without CEUS were established to assess the thoracic wall recurrence after mastectomy. The established models were validated by bootstrap resampling. The models were evaluated using calibration curve. The clinical benefit of models were assessed using decision curve analysis. RESULTS: The area under the receiver characteristic was 0.823 (95% CI: 0.76, 0.88) for model using US alone, 0.898 (95% CI: 0.84, 0.94) for model using US combined with CDFI, and 0.959 (95% CI: 0.92, 0.98) for model using US combined with both CDFI and CEUS. The diagnostic performance of the US combined with CDFI was significantly higher than that of the US alone (0.823 vs 0.898, p = 0.002) but significantly lower than that of the US combined with both CDFI and CEUS (0.959 vs 0.898, p < 0.001). Moreover, the unnecessary biopsy rate of the US combined with both CDFI and CEUS was significantly lower than that of the US combined with CDFI (p = 0.037). CONCLUSIONS: Compared to B-mode ultrasound and CDFI, CEUS improves the diagnostic performance to evaluate thoracic wall recurrence after mastectomy. KEY POINTS: • CUES is an effective supplementary method for US in the diagnosis of thoracic wall recurrence after mastectomy. • CEUS combined with both US and CDFI can significantly improve the accuracy of diagnosis of thoracic wall recurrence after mastectomy. • CEUS combined with both US and CDFI can reduce the rate of unnecessary biopsy of thoracic wall lesions after mastectomy.

Determining whether the diagnostic value of B-ultrasound combined with contrast-enhanced ultrasound and shear wave elastography in breast mass-like and non-mass-like lesions differs: a diagnostic test.

Background: Mass-like (ML) and non-mass-like (NML) are two manifestations of breast lesions on ultrasound. Contrast-enhanced ultrasound (CEUS) can make up for the limitation of B-ultrasound (US) in the observation of focal blood flow, and shear wave elastography (SWE) can supplement the hardness information of the lesion. The present study aimed to analyze the characteristic manifestations of US, CEUS, and SWE in NML and ML breast and evaluate whether the diagnostic performance of these three ultrasound techniques differs in terms of differentiating between benign and malignant breast lesions. Methods: From January to August 2021, 382 patients (417 breast lesions) underwent US, CEUS, and SWE examinations. Of these, 204 women (218 breast lesions) were included in our study due to subsequent biopsy or surgery with pathological findings. The patients were divided into ML and NML groups according to the ultrasound characteristics, and the differences in multimodal ultrasound performance between benign and malignant NML and benign and malignant ML breast lesions were compared. The diagnostic performance of US, US + CEUS, US + SWE, US + CEUS + SWE for ML, NML and all breast lesions was evaluated by analyzing sensitivity, specificity and area under receiver operating characteristic (ROC) curve (AUC). Results: Pathologically, the 218 lesions included 96 malignant and 122 benign breast lesions. The sensitivity and specificity of US + CEUS + SWE in all lesion groups, ML group and NML group were 92.7% and 90.2%, 95.9% and 90.3%, 91.3% and 79.3%, respectively. In all breast group, AUCs of US + CEUS, US + SWE, US + CEUS + SWE were statistically different from AUC of US (P=0.0010, 0.0001, 0.0001). In the ML group, the AUC of US + CEUS, US + SWE, US + CEUS + SWE were statistically different from that of US (P=0.0120, 0.0008, 0.0002). In the NML group, there was a statistical difference between US + SWE and US AUC (P=0.0149). Conclusions: US, CEUS, and SWE have an important diagnostic value for benign and malignant ML and NML breast lesions. Multimodal ultrasound combined with US, CEUS, and SWE can improve the diagnostic efficacy in distinguishing between benign and malignant ML and NML lesions.

Collagen fiber features and COL1A1: are they associated with elastic parameters in breast lesions, and can COL1A1 predict axillary lymph node metastasis?

BACKGROUND: This study aimed to explore whether collagen fiber features and collagen type I alpha 1 (COL1A1) are related to the stiffness of breast lesions and whether COL1A1 can predict axillary lymph node metastasis (LNM). METHODS: Ninety-four patients with breast lesions were consecutively enrolled in the study. Amongst the 94 lesions, 30 were benign, and 64 were malignant (25 were accompanied by axillary lymph node metastasis). Ultrasound (US) and shear wave elastography (SWE) were performed for each breast lesion before surgery. Sirius red and immunohistochemical staining were used to examine the shape and arrangement of collagen fibers and COL1A1 expression in the included tissue samples. We analyzed the correlation between the staining results and SWE parameters and investigated the effectiveness of COL1A1 expression levels in predicting axillary LNM. RESULTS: The optimal cut-off values for Emax, Emean, and Eratio for diagnosing the benign and malignant groups, were 58.70 kPa, 52.50 kPa, and 3.05, respectively. The optimal cutoff for predicting axillary LNM were 107.5 kPa, 85.15 kPa, and 3.90, respectively. Herein, the collagen fiber shape and arrangement features in breast lesions were classified into three categories. One-way analysis of variance (ANOVA) showed that Emax, Emean, and Eratio differed between categories 0, 1, and 2 (P < 0.05). Meanwhile, elasticity parameters were positively correlated with collagen categories and COL1A1 expression. The COL1A1 expression level > 0.145 was considered the cut-off value, and its efficacy in benign and malignant breast lesions was 0.808, with a sensitivity of 66% and a specificity of 90%. Furthermore, when the COL1A1 expression level > 0.150 was considered the cut-off, its efficacy in predicting axillary LNM was 0.796, with sensitivity and specificity of 96% and 59%, respectively. CONCLUSIONS: The collagen fiber features and expression levels of COL1A1 positively correlated with the elastic parameters of breast lesions. The expression of COL1A1 may help diagnose benign and malignant breast lesions and predict axillary LNM.

Efficacy and safety of percutaneous ultrasound-guided vacuum-assisted excision for the treatment of clinical benign breast lesions larger than 3 cm: a retrospective cohort study.

Background: Breast ultrasound-guided vacuum-assisted excision (US-VAE) has become a scarless solution for the removal of benign breast lesions. This procedure is now favored by more and more female patients for its satisfactory cosmetic outcome and few postoperative complications. However, controversy have been raised regarding its efficacy and safety in treating larger benign breast lesions. This study aimed to evaluate whether US-VAE is sufficient for the treatment of clinical benign breast lesions larger than 3 cm and to investigate the lesion features that affect the complete excision rate and hematoma occurrence rate. Methods: From January 2018 to July 2021, a total of 1,812 lesions in 1,367 patients underwent US-VAE at the Chinese People's Liberation Army General Hospital. A total of 89 benign breast lesions in 87 patients enrolled in this retrospective cohort study. The baseline clinical characteristics and ultrasonographic features of the lesions were recorded. Patients were followed up by US to record if there are any serious issues and the occurrence of hematoma and the recurrence of the lesions within 3 days and 6-12 months later, then at 1-year intervals. Lesions were classified to analyze the possible factors associated with complete excision rate and hematoma occurrence rate. Results: The mean age was 35.9±9.5 years (range, 18-54 years), and the median maximum size of benign breast lesions was 3.5 cm (range, 3.1-5.0 cm). The complete excision rate was 91.0% (81/89). Histopathology (P=0.002) and vascularity (P=0.032) of lesions showed statistically significant differences in groups with or without recurrent lesions. A total of 17 cases (17/89, 19.1%) presented with hematoma after the procedure. The maximum lesion size in patients with hematoma was significantly larger than that in those without hematoma (P<0.001). Conclusions: US-VAE is an effective and safe alternative method for the treatment of benign breast lesions larger than 3 cm, especially for fibroadenoma, adenosis, hamartoma. For benign phyllodes tumors and intraductal papillomas larger than 3 cm and lesions with hypervascularity, the possibility of recurrence after US-VAE should be noted. The size of lesions needs to be considered when evaluating the occurrence of hematoma after US-VAE.

Breast metastases from primary lung cancer: a retrospective case series on clinical, ultrasonographic, and immunohistochemical features.

BACKGROUND: Lung cancer metastases to the breast are less common and consequently have received much less attention in clinical practice. The purpose of this study was to provide a better understanding of clinical, ultrasonographic, and immunohistochemical features of breast metastases from primary lung cancer. METHODS: This retrospective case series included patients with breast metastases from primary lung cancer between January 2012 and December 2020. Clinical features, ultrasonographic characteristics, and immunohistochemical findings were evaluated in this analysis. RESULTS: In all, 7 cases (mean ± standard deviation age: 57.4±8.3 years; range, 49-70 years) were evaluated. The maximum size of breast lesions in 6 cases ranged from 1.2 to 4.5 cm, while 1 case showed a diffused pattern. Ultrasound features of breast metastases from lung cancer were irregular (5/7, 71.4%), indistinct (6/7, 85.7%), hypoechoic (7/7, 100.0%), and parallel (6/7, 85.7%) masses without calcification. Immunohistochemical staining test was positive for thyroid transcription factor 1 (TTF-1) in all patients (7/7, 100.0%), 3 cases (3/5, 60.0%) were negative for p63, 5 cases (5/5, 100.0%) were positive for cytokeratin 7 (CK7), 4 cases (4/5, 80.0%) were positive for napsin A. CONCLUSIONS: The ultrasonographic features of lung metastases to the breast are clinically important to understand. A known history of the primary lung cancer is of great importance when evaluating patients with a breast nodule. The presence of an ipsilateral lung cancer, breast nodule and axillary lymphadenopathy should be considered with pathological and immunohistochemical data to differentiate breast metastases from a primary breast malignancy in this setting.

Papillary breast lesions detected using conventional ultrasound and contrast-enhanced ultrasound: Imaging characteristics and associations with malignancy.

OBJECTIVE: This study aimed to evaluate the imaging features of papillary breast lesions detected using conventional ultrasonography (US) and contrast-enhanced ultrasound (CEUS) and to correlate the pathological results. Furthermore, the diagnostic efficiencies of these imaging features to predict the malignancy potential of papillary lesions were explored. METHODS: The findings of the conventional US and CEUS of 74 consecutive papillary breast lesions were assessed retrospectively. The obtained data were analyzed using univariate and multivariate logistic regressions to evaluate the ability of each parameter and combined parameters in distinguishing the benign and atypical or malignant papillary lesions. RESULTS: Among the imaging features of breast papillary lesions on conventional US and CEUS, two sonographic features (lesion size ≥1 cm and not circumscribed margin) on conventional US and four enhancement features (irregular enhancement, heterogeneous enhancement, enlargement of scope, and perfusion defect) on CEUS were found to be significantly different between the benign and atypical or malignant papillary lesions (P < 0.05). A multivariate logistic regression analysis further showed that only heterogeneous enhancement and enlarged enhancement scope were associated with malignancy. The sensitivity and specificity of heterogeneous enhancement, enlarged enhancement scope, and combined analysis for predicting atypical and malignant papillary lesions were 78.6 % and 39.1 %, 75 % and 37 %, and 75 % and 82.6 %, respectively. The combination of enhancement homogeneity and enhancement scope improved the diagnostic accuracy (AUC = 0.875). CONCLUSIONS: The results suggested that the imaging features on conventional US and CEUS could help in identifying benign and malignant papillary lesions and predict their malignancy potential.