Factors associated with MRI detection of occult lesions in newly diagnosed breast cancers.

BACKGROUND: The use of preoperative magnetic resonance imaging (MRI) for newly diagnosed breast cancer remains controversial. We examined factors associated with detection of occult multicentric, multifocal, and contralateral malignant lesions only seen by MRI. METHODS: We performed a retrospective analysis of consecutive patients undergoing preoperative MRI for breast cancer. Clinicopathologic data were assessed regarding the findings of multifocality, multicentricity, and the presence of contralateral lesions. We analyzed the association of factors with these findings on MRI. RESULTS: Of 857 patients undergoing MRI, 770 patients met inclusion criteria. Mean age was 54.7 years. Biopsy-proven detection rates by MRI for multifocal, multicentric, and contralateral cancers were 6.2% (48 of 770), 1.9% (15 of 770) and 3.1% (24 of 770), respectively. African American race and heterogeneously or extremely dense mammographic density were associated with multifocal cancers on MRI. Larger lesion size and mammographic density were associated with multicentric cancers. Invasive lobular carcinoma (ILC) and progesterone receptor (PR)-positivity were associated with contralateral cancers. CONCLUSIONS: African American race, heterogeneously or extremely dense mammographic density, ILC, and PR-positivity were associated with additional biopsy-proven cancers based on MRI. These factors should be considered when assessing the clinical utility of preoperative breast MRI.

Are we overtreating intraductal papillomas?

BACKGROUND: The management of intraductal papillomas (IDPs) diagnosed on core needle biopsy (CNB) remains controversial regarding whether excision is required. We evaluated whether excision of IDPs might be overtreatment based on a consecutive patient population where all IDPs were routinely excised. MATERIALS AND METHODS: We retrospectively reviewed the records of consecutive patients treated with excision of IDPs at our institution from 2009 to 2016. We evaluated the rate of upgrade of IDPs on CNB and factors predicting for malignant upgrade. RESULTS: Of 153 CNB specimens, 136 (88.9%) were IDPs without atypia and 14 (9.2%) showed atypia. The overall upgrade rate on final pathology was 7.3% with 1.3% for invasive cancer, 2.7% for ductal carcinoma in situ, and 3.3% for atypical ductal hyperplasia. Of the 14 patients with atypia on CNB, two of these patients (14.2%) were found to have ductal carcinoma in situ. In the absence of atypia on CNB, upgrade rates were 1.5% for invasive and 1.5% for in situ carcinoma. Personal history of breast cancer and magnetic resonance imaging-guided biopsy predicted for malignant upgrade. CONCLUSIONS: IDPs on CNB have a low chance of harboring an occult malignancy. Given the low probability of upgrade to invasive breast cancer, it is reasonable to consider watchful surveillance in the absence of a prior personal history of breast cancer or atypia on CNB.

Modified Bi-Rads Scoring of Breast Imaging Findings Improves Clinical Judgment.

In contrast with the reporting requirements currently mandated under the Federal Mammography Quality Standards Act (MQSA), we propose a modification of the Breast Imaging Reporting and Data System (Bi-Rads) in which a concluding assessment category is assigned, not to the examination as a whole, but to every potentially malignant abnormality observed. This modification improves communication between the radiologist and the attending clinician, thereby facilitating clinical judgment leading to appropriate management. In patients with breast cancer eligible for breast conserving therapy, application of this modification brings to attention the necessity for such patients to undergo pretreatment biopsies of all secondary, synchronous ipsilateral lesions scored Bi-Rads 3-5. All contralateral secondary lesions scored Bi-Rads 3-5 also require pretreatment biopsies. The application of this modification of the MSQA demonstrates the necessity to alter current recommendations ("short-interval follow-up") for secondary, synchronous Bi-Rads 3 ("probably benign") image-detected abnormalities prior to treatment of the index malignancy.