Literature review on the bilateral occurrence of invasive lobular breast cancer.

Historically, it has been believed that invasive lobular carcinomas (ILC) occur more frequently bilaterally compared to other invasive subtypes, with estimates ranging between 20% and 29%. This study aims to determine if this historical perspective still holds true. A comprehensive literature review was conducted to examine the bilateral occurrence of lobular carcinoma using various imaging methods. Additionally, the role of magnetic resonance imaging (MRI) in detecting contralateral carcinomas was also investigated. A comprehensive search was conducted in the MedLine database on the PubMed platform, resulting in 307 articles published between January 1, 2014, and January 1, 2023. Various selection criteria were applied to identify articles relevant to the research question. After careful assessment, eight articles remained that met the eligibility criteria, all of which provided level-three evidence and were therefore included in the literature review. A total of 599 patients were included in this review, comprising a total of 602 cases of ILC. Six out of the eight articles reviewed provided information on the bilateral occurrence of ILC based on histopathology. A weighted average calculation yielded a bilaterality percentage of 4.95% (24 out of 485 cases). Four articles reported the number of bilateral cases identified through MRI, resulting in a weighted average of 10.2% (26 out of 255 cases). It is worth noting that 20.4% (100 out of 491) of the performed MRIs were found to be either useless or even harmful. Furthermore, MRI led to a change in the treatment plan in 27.7% (136 out of 491) of cases. Overall, it can be concluded that there is limited available data regarding the bilateral occurrence of ILC. The numbers found in the literature are also inconsistent and tend to vary. The literature review revealed a decrease in the percentage of bilaterality compared to historical beliefs. Based on this study, it can be concluded that a high number of MRI scans were found to be either useless or harmful. As a result of this conclusion and a higher sensitivity of other screening modalities, MRI may no longer be indicated as part of the standard workup for ILC. However, further research is necessary to validate these findings.

Retrospective cohort study on the bilateral occurrence of invasive lobular breast cancer.

OBJECTIVE: Invasive lobular carcinoma (ILC) is the second most common histological subtype of invasive breast cancer, following the no special type (NST) invasive carcinoma. It has historically been assumed that ILC occurs bilaterally in 20-29 % of cases, which has influenced the inclusion of MRI in the standard workup of ILC according to European guidelines. However, challenging this long-held belief regarding the bilateral occurrence of ILC opens up the possibility of revising the guidelines and using MRI only for more specific indications. This study aims to evaluate whether the previously reported high percentage of bilaterality still holds true and to question the added value of MRI in the standard workup of ILC. STUDY DESIGN: A retrospective cohort study was conducted following approval from the institutional review board (EC 21/18/249) at Antwerp University Hospital (UZA). The cohort comprised female patients of all ages who had been diagnosed with either ILC or NST invasive carcinoma and had sought consultation at the UZA breast clinic. A comprehensive database was established to collect information on patient characteristics, imaging, and pathology. RESULTS: A total of 271 patients with ILC were included in the study, with incidence dates ranging from 01/01/2007 to 01/01/2023. Among these patients, a synchronous bilateral ILC lesion was observed in 1.85 % (5/271) of cases. This proportion is significantly lower than the reported percentage of patients with a bilateral lesion in the literature population, which stands at 4.95 %. The reference group consisted of 809 patients with NST invasive carcinoma, with incidence dates ranging from 01/01/2017 to 01/01/2023. In the control group, a synchronous bilateral NST lesion was observed in 3.96 % (32/809) of cases. There is no significant difference in the bilaterality rates between the group of ILC patients and the group of NST patients. Furthermore, MRI did not detect any histopathologically confirmed contralateral ILC lesion that had not already been detected by mammography or ultrasound. CONCLUSIONS: The study results indicate a lower occurrence of bilateral ILC than previously assumed. Additionally, the incidence of synchronous bilateral lesions in ILC patients is not higher compared to patients with NST invasive carcinoma. Performing an MRI does not provide additional value in detecting bilateral carcinomas in ILC. Consequently, it is recommended that the current European guidelines be reassessed, and the indications for undergoing an MRI should be adjusted accordingly.

Preoperative breast MRI positively impacts surgical outcomes of needle biopsy-diagnosed pure DCIS: a patient-matched analysis from the MIPA study.

OBJECTIVES: To investigate the influence of preoperative breast MRI on mastectomy and reoperation rates in patients with pure ductal carcinoma in situ (DCIS). METHODS: The MIPA observational study database (7245 patients) was searched for patients aged 18-80 years with pure unilateral DCIS diagnosed at core needle or vacuum-assisted biopsy (CNB/VAB) and planned for primary surgery. Patients who underwent preoperative MRI (MRI group) were matched (1:1) to those who did not receive MRI (noMRI group) according to 8 confounding covariates that drive referral to MRI (age; hormonal status; familial risk; posterior-to-nipple diameter; BI-RADS category; lesion diameter; lesion presentation; surgical planning at conventional imaging). Surgical outcomes were compared between the matched groups with nonparametric statistics after calculating odds ratios (ORs). RESULTS: Of 1005 women with pure unilateral DCIS at CNB/VAB (507 MRI group, 498 noMRI group), 309 remained in each group after matching. First-line mastectomy rate in the MRI group was 20.1% (62/309 patients, OR 2.03) compared to 11.0% in the noMRI group (34/309 patients, p = 0.003). The reoperation rate was 10.0% in the MRI group (31/309, OR for reoperation 0.40) and 22.0% in the noMRI group (68/309, p < 0.001), with a 2.53 OR of avoiding reoperation in the MRI group. The overall mastectomy rate was 23.3% in the MRI group (72/309, OR 1.40) and 17.8% in the noMRI group (55/309, p = 0.111). CONCLUSIONS: Compared to those going directly to surgery, patients with pure DCIS at CNB/VAB who underwent preoperative MRI had a higher OR for first-line mastectomy but a substantially lower OR for reoperation. CLINICAL RELEVANCE STATEMENT: When confounding factors behind MRI referral are accounted for in the comparison of patients with CNB/VAB-diagnosed pure unilateral DCIS, preoperative MRI yields a reduction of reoperations that is more than twice as high as the increase in overall mastectomies. KEY POINTS: • Confounding factors cause imbalance when investigating the influence of preoperative MRI on surgical outcomes of pure DCIS. • When patient matching is applied to women with pure unilateral DCIS, reoperation rates are significantly reduced in women who underwent preoperative MRI. • The reduction of reoperations brought about by preoperative MRI is more than double the increase in overall mastectomies.

Screening and diagnostic breast MRI: how do they impact surgical treatment? Insights from the MIPA study.

OBJECTIVES: To report mastectomy and reoperation rates in women who had breast MRI for screening (S-MRI subgroup) or diagnostic (D-MRI subgroup) purposes, using multivariable analysis for investigating the role of MRI referral/nonreferral and other covariates in driving surgical outcomes. METHODS: The MIPA observational study enrolled women aged 18-80 years with newly diagnosed breast cancer destined to have surgery as the primary treatment, in 27 centres worldwide. Mastectomy and reoperation rates were compared using non-parametric tests and multivariable analysis. RESULTS: A total of 5828 patients entered analysis, 2763 (47.4%) did not undergo MRI (noMRI subgroup) and 3065 underwent MRI (52.6%); of the latter, 2441/3065 (79.7%) underwent MRI with preoperative intent (P-MRI subgroup), 510/3065 (16.6%) D-MRI, and 114/3065 S-MRI (3.7%). The reoperation rate was 10.5% for S-MRI, 8.2% for D-MRI, and 8.5% for P-MRI, while it was 11.7% for noMRI (p ≤ 0.023 for comparisons with D-MRI and P-MRI). The overall mastectomy rate (first-line mastectomy plus conversions from conserving surgery to mastectomy) was 39.5% for S-MRI, 36.2% for P-MRI, 24.1% for D-MRI, and 18.0% for noMRI. At multivariable analysis, using noMRI as reference, the odds ratios for overall mastectomy were 2.4 (p < 0.001) for S-MRI, 1.0 (p = 0.957) for D-MRI, and 1.9 (p < 0.001) for P-MRI. CONCLUSIONS: Patients from the D-MRI subgroup had the lowest overall mastectomy rate (24.1%) among MRI subgroups and the lowest reoperation rate (8.2%) together with P-MRI (8.5%). This analysis offers an insight into how the initial indication for MRI affects the subsequent surgical treatment of breast cancer. KEY POINTS: • Of 3065 breast MRI examinations, 79.7% were performed with preoperative intent (P-MRI), 16.6% were diagnostic (D-MRI), and 3.7% were screening (S-MRI) examinations. • The D-MRI subgroup had the lowest mastectomy rate (24.1%) among MRI subgroups and the lowest reoperation rate (8.2%) together with P-MRI (8.5%). • The S-MRI subgroup had the highest mastectomy rate (39.5%) which aligns with higher-than-average risk in this subgroup, with a reoperation rate (10.5%) not significantly different to that of all other subgroups.

Magnetic resonance imaging before breast cancer surgery: results of an observational multicenter international prospective analysis (MIPA).

OBJECTIVES: Preoperative breast magnetic resonance imaging (MRI) can inform surgical planning but might cause overtreatment by increasing the mastectomy rate. The Multicenter International Prospective Analysis (MIPA) study investigated this controversial issue. METHODS: This observational study enrolled women aged 18-80 years with biopsy-proven breast cancer, who underwent MRI in addition to conventional imaging (mammography and/or breast ultrasonography) or conventional imaging alone before surgery as routine practice at 27 centers. Exclusion criteria included planned neoadjuvant therapy, pregnancy, personal history of any cancer, and distant metastases. RESULTS: Of 5896 analyzed patients, 2763 (46.9%) had conventional imaging only (noMRI group), and 3133 (53.1%) underwent MRI that was performed for diagnosis, screening, or unknown purposes in 692/3133 women (22.1%), with preoperative intent in 2441/3133 women (77.9%, MRI group). Patients in the MRI group were younger, had denser breasts, more cancers ≥ 20 mm, and a higher rate of invasive lobular histology than patients who underwent conventional imaging alone (p < 0.001 for all comparisons). Mastectomy was planned based on conventional imaging in 22.4% (MRI group) versus 14.4% (noMRI group) (p < 0.001). The additional planned mastectomy rate in the MRI group was 11.3%. The overall performed first- plus second-line mastectomy rate was 36.3% (MRI group) versus 18.0% (noMRI group) (p < 0.001). In women receiving conserving surgery, MRI group had a significantly lower reoperation rate (8.5% versus 11.7%, p < 0.001). CONCLUSIONS: Clinicians requested breast MRI for women with a higher a priori probability of receiving mastectomy. MRI was associated with 11.3% more mastectomies, and with 3.2% fewer reoperations in the breast conservation subgroup. KEY POINTS: • In 19% of patients of the MIPA study, breast MRI was performed for screening or diagnostic purposes. • The current patient selection to preoperative breast MRI implies an 11% increase in mastectomies, counterbalanced by a 3% reduction of the reoperation rate. • Data from the MIPA study can support discussion in tumor boards when preoperative MRI is under consideration and should be shared with patients to achieve informed decision-making.

Solving the preoperative breast MRI conundrum: design and protocol of the MIPA study.

Despite its high diagnostic performance, the use of breast MRI in the preoperative setting is controversial. It has the potential for personalized surgical management in breast cancer patients, but two of three randomized controlled trials did not show results in favor of its introduction for assessing the disease extent before surgery. Meta-analyses showed a higher mastectomy rate in women undergoing preoperative MRI compared to those who do not. Nevertheless, preoperative breast MRI is increasingly used and a survey from the American Society of Breast Surgeons showed that 41% of respondents ask for it in daily practice. In this context, a large-scale observational multicenter international prospective analysis (MIPA study) was proposed under the guidance of the European Network for the Assessment of Imaging in Medicine (EuroAIM). The aims were (1) to prospectively and systematically collect data on consecutive women with a newly diagnosed breast cancer, not candidates for neoadjuvant therapy, who are offered or not offered breast MRI before surgery according to local practice; (2) to compare these two groups in terms of surgical and clinical endpoints, adjusting for covariates. The underlying hypotheses are that MRI does not cause additional mastectomies compared to conventional imaging, while reducing the reoperation rate in all or in subgroups of patients. Ninety-six centers applied to a web-based call; 36 were initially selected based on volume and quality standards; 27 were active for enrollment. On November 2018, the target of 7000 enrolled patients was reached. The MIPA study is presently at the analytic phase. Key Points • Breast MRI has a high diagnostic performance but its utility in the preoperative setting is controversial. • A large-scale observational multicenter prospective study was launched to compare women receiving with those not receiving preoperative MRI. • Twenty-seven centers enrolled more than 7000 patients. The study is presently at the analytic phase.

Development and clinimetric properties of the Dutch Breast Edema Questionnaire (BrEQ-Dutch version) to diagnose the presence of breast edema in breast cancer patients.

PURPOSE: To develop a diagnostic tool, the Breast Edema Questionnaire (BrEQ) and to determine its clinimetric properties. METHODS: The BrEQ was developed based on information from literature, experts and breast edema patients. Content validity, construct validity, test-retest reliability, internal consistency and cut-off point were investigated in a group of breast cancer patients. Construct validity made up two parts; convergent and known-groups validity. Convergent validity was tested by correlating the BrEQ with skin thickness measured with ultrasound (US). RESULTS: In part 1 of the BrEQ, symptoms of breast edema were scored from 0 to 10: pain, heaviness, swelling, tensed skin, redness, pitting sign, enlarged skin pores and hardness. Taking into account the International Classification of Functioning, Disability and Health, several activity limitations and participation restrictions were scored from 0 to 10 in part 2. Clinimetric properties of part 1 were examined in 55 patients. US showed that 35 women had breast edema. Content validity was good. Regarding convergent validity, all breast symptoms correlated moderately with skin thickness. The total symptom score had a strong correlation with skin thickness. Concerning known-groups validity, patients with breast edema had a higher total symptom score. Test-retest reliability ranged between moderate and strong. The internal consistency was good for all items and the total symptom score. We identified that a score cut-off point of ≥ 8.5 discriminates between patients with breast edema and those without. CONCLUSION: Part 1 of the BrEQ-Dutch version is a valid and reliable tool for assessing clinical indicators of breast edema.

Guidelines and recommendations for MRI in breast cancer follow-up: A review.

OBJECTIVE: Present article will perform a review regarding the current recommendations of Magnetic resonance imaging (MRI) in routine follow-up after successfully treated breast cancer by surgery, radiation and/or systemic therapy. METHODS: For this review, a literature review search was done with the MeSH-terms: Magnetic Resonance Imaging, breast neoplasm, post-operative period and follow-up, according to PRISMA. The literature published between 2006 and 2016 in MedBase, PubMed and Embase was consulted. RESULTS: The 10 articles and 8 guidelines were analysed for their recommendations regarding MRI use in routine follow-up for breast cancer. One article concluded that MRI could influence further policy, all others did not find superiority of MRI over mammography or were inconclusive. One guideline recommended annual MRI for patients with a positive personal history (PPH) for breast cancer without further risk factors, one guideline offered no MRI to these patients and all other guidelines were inconclusive. CONCLUSION: There is insufficient evidence regarding superiority of MRI versus mammography in routine follow-up for patients with a PPH of breast cancer. MRI does not improve survival in all patients and should therefore not be offered to patients in follow-up without increased risk for recurrences.

Preoperative ultrasound staging of the axilla make's peroperative examination of the sentinel node redundant in breast cancer: saving tissue, time and money.

OBJECTIVE: To evaluate the role of preoperative axillary staging with ultrasound (US) and fine needle aspiration cytology (FNAC). Can we avoid intraoperative sentinel lymph node (SLN) examination, with an acceptable revision rate by preoperative staging? DESIGN: This study is based on the retrospective data of 336 patients that underwent US evaluation of the axilla as part of their staging. A FNAC biopsy was performed when abnormal lymph nodes were visualized. Patients with normal appearing nodes on US or a benign diagnostic biopsy had removal of the SLNs without intraoperative pathological examination. We calculated the sensitivity, specificity and accuracy of US/FNAC in predicting the necessity of an axillary lymphadenectomy. Subsequently we looked at the total cost and the operating time of 3 models. Model A is our study protocol. Model B is a theoretical protocol based on the findings of the Z0011 trial with only clinical preoperative staging and in Model C preoperative staging and intraoperative pathological examination were both theoretically done. sentinel node, staging, ultrasound, preoperative axillary staging, FNAC, axilla RESULTS: The sensitivity, specificity and accuracy are respectively 0.75 (0.66-0.82), 1.00 (0.99-1.00) and 0.92 (0.88-0.94). Only 26 out of 317 (8.2%) patients that successfully underwent staging needed a revision. The total cost of Model A was 1.58% cheaper than Model C and resulted in a decrease in operation time by 9,46%. The benefits compared with Model B were much smaller. CONCLUSION: Preoperative US/FNAC staging of the axillary lymph nodes can avoid intraoperative examination of the sentinel node with an acceptable revision rate. It saves tissue, reduces operating time and decreases healthcare costs in general.

International Day of Radiology: Breast Imaging.

November 8, 2016, is the International Day of Radiology (IDoR), which is dedicated to breast imaging and the essential role that radiology plays in the detection, diagnosis, and management of diseases of the breast (http://www.internationaldayofradiology.com). On the website, you can find the book to honour the International Day of Radiology, Screening & Beyond, which provides an amazing overview of breast imaging, with contributions from many of the world's top breast radiologists.

Role of MRI of the breast in the evaluation of the symptomatic patient.

PURPOSE OF REVIEW: The role of MRI in breast pathology is still controversial. The technique has a high sensitivity for detection of breast carcinoma, but specificity is low. Therefore, it is only useful for right indications. RECENT FINDINGS: Studies are still performed to define the role of MRI. For diagnosis of a breast lesion, image-guided percutaneous core biopsy is the method of choice, and MRI is not indicated. It has a place in the detection of carcinoma in patients with nipple discharge. MRI has a role in the search of an occult primary breast carcinoma in patients with metastasis and primary unknown cancer. MRI is the best technique for locoregional staging of breast carcinoma. Its role in detection of recurrence is controversial, as image-guided biopsy has to be done if a suspicious lesion is seen. In dense breasts or difficult scar formation, MRI is able to detect recurrence. MRI is sensitive in detection of implant rupture in symptomatic augmented patients. SUMMARY: MRI has a role in well defined indications, but its role is still controversial even in some of these indications. MRI is not indicated in diagnosis in which image-guided percutaneous biopsy is the method of choice. Further studies must be performed.

Axillary lymphadenopathy as a first symptom of diabetic mastopathy.

Diabetic mastopathy is an unusual fibroinflammatory breast lesion that characteristically presents in premenopausal women with long-standing type 1 diabetes mellitus.Patients present with clinically suspicious breast masses or axillary lymph nodes with imaging characteristics indistinguishable from malignancy. Fine needle aspiration is often inadequate and a core biopsy should be performed. Excisional biopsy is not necessary, and annual follow-up is recommended. Recognition of diabetic mastopathy should lead to better care of patients with breast nodules or axillary masses who are diabetic, avoiding surgery for this benign condition.

MR mammography of a primary squamous cell carcinoma of the breast: a case report.

A case of a primary squamous cell carcinoma of the breast in a patient with synchronous contralateral invasive ductal adenocarcinoma is reported. To our knowledge, no dynamic MR mammography of this pathology is described in the literature. On MR, it presented as a mainly non-enhancing, partially cystic mass with an enhancing irregular peripheral rim. In the differential diagnosis of a mass with unsharp margins and an irregular border of the cystic or the non-enhancing area on MR mammography, a primary squamous cell carcinoma must be included.