Performance of MRI for standardized lymph nodes assessment in breast cancer: are we ready for Node-RADS?

OBJECTIVES: The Node-RADS score was recently introduced to offer a standardized assessment of lymph node invasion (LNI). We tested its diagnostic performance in accurately predicting LNI in breast cancer (BC) patients with magnetic resonance imaging. The study also explores the consistency of the score across three readers. MATERIALS AND METHODS: A retrospective study was conducted on BC patients who underwent preoperative breast contrast-enhanced magnetic resonance imaging and lymph node dissection between January 2020 and January 2023. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value were calculated for different Node-RADS cut-off values. Pathologic results were considered the gold standard. The overall diagnostic performance was evaluated using receiver operating characteristic curves and the area under the curve (AUC). A logistic regression analysis was performed. Cohen's Kappa analysis was used for inter-reader agreement. RESULTS: The final population includes 192 patients and a total of 1134 lymph nodes analyzed (372 metastatic and 762 benign). Increasing the Node-RADS cut-off values, specificity and PPV rose from 71.4% to 100% and 76.7% to 100%, respectively, for Reader 1, 69.4% to 100% and 74.6% to 100% for Reader 2, and from 64.3% to 100% and 72% to 100% for Reader 3. Node-RADS > 2 could be considered the best cut-off value due to its balanced performance. Node-RADS exhibited a similar AUC for the three readers (0.97, 0.93, and 0.93). An excellent inter-reader agreement was found (Kappa values between 0.71 and 0.83). CONCLUSIONS: The Node-RADS score demonstrated moderate-to-high overall accuracy in identifying LNI in patients with BC, suggesting that the scoring system can aid in the identification of suspicious lymph nodes and facilitate appropriate treatment decisions. CLINICAL RELEVANCE STATEMENT: Node-RADS > 2 can be considered the best cut-off for discriminating malignant nodes, suggesting that the scoring system can effectively help identify suspicious lymph nodes by staging the disease and providing a global standardized language for clear communication. KEY POINTS: Axillary lymphadenopathies in breast cancer are crucial for determining the disease stage. Node-RADS was introduced to provide a standardized evaluation of breast cancer lymph nodes. RADS > 2 can be considered the best cut-off for discriminating malignant nodes.

Could breast multiparametric MRI discriminate between pure ductal carcinoma in situ and microinvasive carcinoma?

BACKGROUND: Ductal carcinoma in situ (DCIS) is often reclassified as invasive cancer in the final pathology report of the surgical specimen. It is of significant clinical relevance to acknowledge the possibility of underestimating invasive disease when utilizing preoperative biopsies for a DCIS diagnosis. In cases where such histologic upgrades occur, it is imperative to consider them in the preoperative planning process, including the potential inclusion of sentinel lymph node biopsy due to the risk of axillary lymph node metastasis. PURPOSE: To assess the capability of breast multiparametric magnetic resonance imaging (MP-MRI) in differentiating between pure DCIS and microinvasive carcinoma (MIC). MATERIAL AND METHODS: Between January 2018 and November 2022, this retrospective study enrolled patients with biopsy-proven DCIS who had undergone preoperative breast MP-MRI. We assessed various MP-MRI features, including size, morphology, margins, internal enhancement pattern, extent of disease, presence of peritumoral edema, time-intensity curve value, diffusion restriction, and ADC value. Subsequently, a logistic regression analysis was conducted to explore the association of these features with the pathological outcome. RESULTS: Of 129 patients with biopsy-proven DCIS, 36 had foci of micro-infiltration on surgical specimens and eight were diagnosed with invasive ductal carcinoma (IDC). The presence of micro-infiltration foci was significantly associated with several MP-MRI features, including tumor size (P <0.001), clustered ring enhancement (P <0.001), segmental distribution (P <0.001), diffusion restriction (P = 0.005), and ADC values <1.3 × 10-3 mm2/s (P = 0.004). CONCLUSION: Breast MP-MRI has the potential to predict the presence of micro-infiltration foci in biopsy-proven DCIS and may serve as a valuable tool for guiding therapeutic planning.

Cryoablation for the treatment of breast cancer: immunological implications and future perspectives. Utopia or reality?

Cryoablation is a minimally invasive technique currently employed in breast cancer care, that uses freeze and thaw cycles to treat benign breast lesions, small breast cancers or focal sites of metastatic disease in patients not eligible for surgery. The final goal of this procedure is to destroy breast cancer cells using extreme cold. In addition, several studies have shown that this technique seems to have an enhancing effect on the immune response, especially by increasing the expression of tumor neoantigens specific to tumor cells, which are then attacked and destroyed. Exploiting this effect, cryoablation in combination with immunotherapy could be the key to treating early-stage breast cancers or patients who are unsuitable for surgery. According to some recent studies, there are other potential tools that could be used to enhance the therapeutic effect of cryoablation, such as FE3O4 nanoparticles or the manipulation of aquaporin expression. The aim of this narrative review is to summarize the current evidence regarding the use, indications, advantages and disadvantages of cryoablation in the treatment of breast cancer.

Diagnostic Performance of Contrast-Enhanced Digital Mammography versus Conventional Imaging in Women with Dense Breasts.

The aim of this prospective study was to compare the diagnostic performance of contrast-enhanced mammography (CEM) versus digital mammography (DM) combined with breast ultrasound (BUS) in women with dense breasts. Between March 2021 and February 2022, patients eligible for CEM with the breast composition category ACR BI-RADS c-d at DM and an abnormal finding (BI-RADS 3-4-5) at DM and/or BUS were considered. During CEM, a nonionic iodinated contrast agent (Iohexol 350 mg I/mL, 1.5 mL/kg) was power-injected intravenously. Images were evaluated independently by two breast radiologists. Findings classified as BI-RADS 1-3 were considered benign, while BI-RADS 4-5 were considered malignant. In case of discrepancies, the higher category was considered for DM+BUS. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated, using histology/≥12-month follow-up as gold standards. In total, 51 patients with 65 breast lesions were included. 59 (90.7%) abnormal findings were detected at DM+BUS, and 65 (100%) at CEM. The inter-reader agreement was excellent (Cohen's k = 0.87 for DM+BUS and 0.97 for CEM). CEM showed a 93.5% sensitivity (vs. 90.3% for DM+BUS), a 79.4-82.4% specificity (vs. 32.4-35.5% for DM+BUS) (McNemar p = 0.006), a 80.6-82.9% PPV (vs. 54.9-56.0% for DM+BUS), a 93.1-93.3% NPV (vs. 78.6-80.0% for DM+BUS), and a 86.1-87.7% accuracy (vs. 60.0-61.5% for DM+BUS). The AUC was higher for CEM than for DM+BUS (0.865 vs. 0.613 for Reader 1, and 0.880 vs. 0.628, for Reader 2) (p < 0.001). In conclusion, CEM had a better diagnostic performance than DM and BUS alone and combined together in patients with dense breasts.

Pregnancy-Associated Breast Cancer: A Diagnostic and Therapeutic Challenge.

Pregnancy-associated breast cancer (PABC) is commonly defined as a breast cancer occurring during pregnancy, throughout 1 year postpartum, or during lactation. Despite being a rare circumstance, PABC is one of the most common types of malignancies occurring during pregnancy and lactation, with growing incidence in developed countries, due both to decreasing age at onset of breast cancer and to increasing maternal age. Diagnosis and management of malignancy in the prenatal and postnatal settings are challenging for practitioners, as the structural and functional changes that the breast undergoes may be misleading for both the radiologist and the clinician. Furthermore, safety concerns for the mother and child, as well as psychological aspects in this unique and delicate condition, need to be constantly considered. In this comprehensive review, clinical, diagnostic, and therapeutic aspects of PABC (including surgery, chemotherapy and other systemic treatments, and radiotherapy) are presented and fully discussed, based on medical literature, current international clinical guidelines, and systematic practice.