Heterogeneous Internal Enhancement Research Articles

Fibrosarcomatous Transformation in Dermatofibrosarcoma Protuberans of the Male Breast and its Association with Magnetic Resonance Imaging and Immunohistopathologic Features.

Dermatofibrosarcoma Protuberans (DFSP) is a rare soft tissue sarcoma, accounting for approximately 1% of all tumors; however, DFSP of the breast is extremely rare. Moreover, DFSP generally has a low malignant potential and is characterized by a high rate of local recurrence along with a small but definite risk of metastasis. The risk of metastasis is higher in fibrosarcomatous transformation in DFSP than in ordinary DFSP. We have, herein, reported a case of a 61-year-old male patient with fibrosarcomatous transformation in DFSP. Preoperative Dynamic Contrastenhanced Magnetic Resonance Imaging (DCE-MRI) of the breast revealed an oval-shaped mass with heterogeneous internal enhancement, a large vessel embedded within, and a washout curve pattern on kinetic curve analysis. The mass exhibited a hyperintense signal on Diffusion-weighted Imaging (DWI), with a low apparent diffusion coefficient value. Histologically, the bland spindle tumor cells were arranged in a storiform pattern. Areas with the highest histological grade demonstrated increased cellularity, cytological atypia, and mitotic activity. Immunohistochemically, Ki-67 and p53 were highly expressed. Recognizing the risk and accurately diagnosing fibrosarcomatous transformation in male breast DFSP are critical for improving prognosis and establishing appropriate treatment and follow-up plans. This emphasizes the significance of combining immunohistopathological features with DCE-MRI and DWI to assist clinicians in the early and accurate diagnosis of sarcomas arising from male breast DFSP.

Characteristics of Suspicious Breast Lesions Visible Only on MR Imaging: Is It Possible to Classify into Immediate Biopsy and Careful Observation Groups?

To investigate the characteristics of suspicious MRI-only visible lesions and to explore the validity of subcategorizing these lesions into the following two groups: lesions that would require immediate biopsy (4Bi) and lesions for which careful clinical follow-up could be recommended (4Fo). A retrospective review of 108 MRI-only visible lesions in 106 patients who were diagnosed as Breast Imaging Reporting and Data System (BI-RADS) category 4 between June 2018 and June 2022 at our institution was performed by two radiologists. The breast MR images were evaluated according to BI-RADS and additional MRI descriptors (linear ductal, branching, and apparent diffusion coefficient values). The lesions were categorized by previously reported classification systems, and the positive predictive values (PPVs) for the different categories were determined and compared. Subsequently, a new classification system was developed in this study. The total malignancy rate was 31% (34/108). No significant differences between benign and malignant lesions were identified for focus and mass lesions. For non-mass lesions, linear ductal and heterogeneous internal enhancement suggested a benign lesion (P = 0.0013 and P = 0.023, respectively), and branching internal enhancement suggested malignancy (P = 0.0066). Segmental distribution suggested malignancy (P = 0.0097). However, the PPV of segmental distribution with heterogeneous enhancement was significantly lower than that of category 4 segmental lesions with other enhancement patterns (11% vs. 59%; P = 0.0198).As a new classification, the distribution of focal, linear, and segmental was given a score of 0, 1, or 2, and the internal enhancement of heterogeneous, linear-ductal, clumped, branching, and clustered-ring enhancement was given a score of 0, 1, 2, 3, and 4, respectively. When categorized using a scoring system, a statistically significant difference in PPV was observed between 4Fo (n = 27) and 4Bi (n = 33) (7% vs. 61%, P = 0.000029). The new classification system was found to be highly capable of subcategorizing BI-RADS category 4 MRI-only visible non-mass lesions into 4Fo and 4Bi.

Invasive micropapillary breast carcinoma: A retrospective study on the clinical imaging features and pathologic findings.

PurposeTo describe the clinical imaging and pathological features of invasive micropapillary breast carcinoma (IMPC), including breast mammography, sonography, magnetic resonance imaging (MRI), and molecular imaging findings.Patients and methodsWe retrospectively reviewed our institution's surgical pathology database and identified 65 patients with pathologically proven IMBC; 63/65 patients had available imaging results. Two radiologists retrospectively reviewed all imaging evaluations according to the Breast Imaging Reporting / Data System (BI-RADS) Lexicon. Clinical and histopathologic features, receptor statuses, and clinical follow-up data were recorded.ResultsSixty-three patients were admitted with palpable abnormalities; one patient's mammogram revealed no abnormality (3.3%, 1/32), whereas 31 had abnormal mammograms (31/32, 96.8%) demonstrating 37 lesions. Twenty-four had irregular, spiculated masses, 12 had microcalcifications, and 19 had architectural distortion. Sonography detected 69 masses (54 patients), characterized by irregular shapes (61/69, 88.4%), hypoechoic structures (50/69, 72.4%), angular or spiculated margins (38/69, 55.1%; 30/69, 43.4%), echogenic halo (8/69, 11.5%), and abnormal vascularity (52/69, 75.3%). MRI detected 68 lesions (52 patients); 59/68 (86.8%) appeared as masses with angular or spiculated margins (32/68, 47.1%; 35/68, 51.4%), 58 exhibited irregular or lobulated shapes (58/68, 89.7%), 29 displayed heterogeneous internal enhancement (29/68, 42.5%), and 64 demonstrated type II or III washout kinetic curves (37/68, 55%; 27/68, 40%). Breast molecular imaging showed mild-to-moderate radiotracer uptake in 15 focal areas among 13 patients. Thirty-two, 38, and 43 patients had abnormal lymph nodes identified mammographically, by breast sonography, and by MRI, respectively. Immunohistochemistry revealed high estrogen receptor (90.5%), high progesterone receptor (71.6%), and low HER-2 (26.4%) positivity.ConclusionIMPC mammography, sonography, and MRI clinical imaging features highly suggest malignancy. Breast molecular imaging also contributed to the diagnosis. IMPC's invasiveness correlated well with regional lymph node metastasis. Radiologists and surgeons should be more attentive to these imaging findings and additional clinical and pathological IMPC features.

Imaging Features Derived From Dynamic Contrast-Enhanced Magnetic Resonance Imaging to Differentiate Malignant From Benign Breast Lesions: A Systematic Review and Meta-Analysis.

The PubMed, Web of Science, Embase, and the Cochrane Library databases were searched up to January 2021 to identify original studies that investigated the accuracy of individual DCE-MRI features in differentiating malignant from benign breast lesions. Pooled sensitivity, specificity, and area under the curve were calculated by STATA software based on the data extracted from included studies. Moreover, quality assessment, subgroup analysis, and publication bias evaluation were performed. Twenty-nine studies comprising 2976 patients and 3365 suspicious breast lesions were included. Malignant breast lesions tended to present irregular shapes (83.59%), noncircumscribed margins (85.50%), mass enhancement (52.31%), heterogeneous internal enhancement (71.72%), and type II or III time intensity curve (TIC) patterns (91.17%), showing significant differences compared with benign breast lesions (P < 0.05). For differentiating malignant from benign breast lesions, the area under the curve values of irregular shape, noncircumscribed margin, mass enhancement, heterogeneous internal enhancement, and type II or III TIC patterns were 0.79 (0.76-0.83), 0.87 (0.84-0.90), 0.63 (0.58-0.67), 0.82 (0.78-0.85), and 0.89 (0.86-0.92), respectively. Imaging features derived from DCE-MRI, especially TIC patterns, are important for diagnosing and differentiating malignant from benign breast lesions.

Magnetic Resonance Imaging Assessment of Radial Scars/complex Sclerosing Lesions of the Breast.

To describe the magnetic resonance characteristics of radial scars/complex sclerosing lesions (RS/CSL) of the breast using the current BI-RADS lexicon. To investigate the value of diffusion weighted imaging to predict malignancy. From 2010 to 2017, we have found 25 women with architectural distortion at mammography who underwent surgical resection with a final hystopathologic report of RS/CSL. For the description of MRI findings, we adhered to BI-RADS classification (5th edition). The final pathological diagnosis was: "pure" RS/CSL in 7 cases (28%), RS/CSL with associated high risk lesions in 12 (48%) and 6 cases (24%) were associated with malignancy. Magnetic resonance findings: four of 25 negative or focus. Five of 25 mass enhancement: irregular, non circumscribed spiculated mass with heterogeneous or rim enhancement and most with type II curves. Sixteen of 25 non mass enhancement: focal or linear distribution and heterogeneous internal enhancement most with type I curves. Six of 25 had cancer associated with the complex sclerosing lesion. All six showed non-mass enhancement. Two cases with invasive breast carcinoma had ADC values under 1.15 x10-3 mm/s while most of the rest had the values above. Most RS/CSL showed enhancement at MR. The predominant pattern was a non-mass, focal, heterogeneous internal enhancement with type 1 curves. All cases with associated cancer showed non mass enhancement. Invasive breast cancers had ADC values < 1.15 10-3 s/mm2.

Multiparameter MRI Model With DCE-MRI, DWI, and Synthetic MRI Improves the Diagnostic Performance of BI-RADS 4 Lesions.

ObjectivesTo evaluate the value of synthetic magnetic resonance imaging (syMRI), diffusion-weighted imaging (DWI), DCE-MRI, and clinical features in breast imaging–reporting and data system (BI-RADS) 4 lesions, and develop an efficient method to help patients avoid unnecessary biopsy.MethodsA total of 75 patients with breast diseases classified as BI-RADS 4 (45 with malignant lesions and 30 with benign lesions) were prospectively enrolled in this study. T1-weighted imaging (T1WI), T2WI, DWI, and syMRI were performed at 3.0 T. Relaxation time (T1 and T2), apparent diffusion coefficient (ADC), conventional MRI features, and clinical features were assessed. “T” represents the relaxation time value of the region of interest pre-contrast scanning, and “T+” represents the value post-contrast scanning. The rate of change in the T value between pre- and post-contrast scanning was represented by ΔT%.ResultsΔT1%, T2, ADC, age, body mass index (BMI), menopause, irregular margins, and heterogeneous internal enhancement pattern were significantly associated with a breast cancer diagnosis in the multivariable logistic regression analysis. Based on the above parameters, four models were established: model 1 (BI-RADS model, including all conventional MRI features recommended by BI-RADS lexicon), model 2 (relaxation time model, including ΔT1% and T2), model 3 [multi-parameter (mp)MRI model, including ΔT1%, T2, ADC, margin, and internal enhancement pattern], and model 4 (combined image and clinical model, including ΔT1%, T2, ADC, margin, internal enhancement pattern, age, BMI, and menopausal state). Among these, model 4 has the best diagnostic performance, followed by models 3, 2, and 1.ConclusionsThe mpMRI model with DCE-MRI, DWI, and syMRI is a robust tool for evaluating the malignancies in BI-RADS 4 lesions. The clinical features could further improve the diagnostic performance of the model.

Metastatic breast tumors from extramammary malignancies: a case series

BackgroundMetastatic breast tumors from extramammary malignancies are quite rare. Characteristics of such tumors are unclear due to small number of reported cases. During 2012–2019, approximately 3,500 malignant breast tumors were diagnosed with needle biopsy at our hospital and we experienced three cases (0.09%) of metastatic extramammary malignancies. We herein report these cases focused on imaging and pathological findings.Case presentationThe first case was a 59-year-old woman who underwent curative surgery for thyroid cancer. After developing lung and ovarian metastases, she visited our department with a mass in her right breast. Ultrasound revealed a 7 mm-sized oval mass. With high depth–width ratio and abundant blood flow, primary breast cancer was suspected. Core needle biopsy revealed atypical cells with nuclear grooves proliferating in papillary formation. With immunohistochemical examination, her final diagnosis was metastatic thyroid cancer. The second case was a 74-year-old woman with metastatic spinal tumors and referred to our department for searching primary tumor. She was diagnosed with gastric cancer at the age of 41. Ultrasound revealed a hypoechoic area including cysts and the internal echo level was uneven. Contrast-enhanced magnetic resonance imaging showed a non-mass lesion with heterogeneous internal enhancement pattern, suggesting ductal carcinoma in situ. Core needle biopsy showed alveolar lesion with predominant signet cell-like morphology. We histologically diagnosed her disease as metastatic gastric cancer. The last case was 33-year woman with Stage IV clear cell sarcoma of the left foot. She came to our department after she felt a lump on her right breast. Ultrasound revealed a 45 mm-sized mass. Her disease was confirmed as metastatic clear cell sarcoma by needle biopsy.ConclusionsImaging suggested malignancies, but it was difficult to distinguish them from primary breast cancer. Our cases indicate that metastatic tumors to the breast might have imaging patterns specific to primary organs, although more cases should be accumulated to establish such patterns on imaging. The first two cases shared some similar pathological findings with breast cancer, but also had some histological characteristics of the primary tumors. Hence, it was possible to diagnose these cases as metastatic tumors with careful observation.

Non-mass Enhancement in Breast MRI: Characterization with BI-RADS Descriptors and ADC Values

Objectives: The purpose of this study was to assess the accuracy of contrast-enhanced magnetic resonance imaging and diffusion-weighted imaging in distinguishing benign from malignant non-mass-like breast lesions. Methods: 103 lesions showing non-mass-like enhancement in 100 consecutive patients were analyzed. Distribution, internal enhancement patterns, and contrast kinetic curve patterns were classified according to the BI-RADS lexicon. Apparent diffusion coefficient (ADC) values were obtained from manually placed regions of interest (ROIs) on diffusion-weighted images. The optimal ADC value threshold for the distinction between benign and malignant lesions was determined by ROC analysis. Univariate and multivariate analyses were performed to identify independent predictors of malignancy, and the probability of malignancy was calculated for various combinations of findings. Histological diagnosis obtained by means of core needle biopsy was used as gold standard. Results: According to the univariate and multivariate analysis, odds ratios for malignancy were significantly elevated for clumped or clustered ring internal enhancement and low ADC values (p &lt; 0.001), whereas distribution patterns and contrast kinetic patterns were not significantly correlated with benignity or malignancy. In non-mass lesions with homogeneous or heterogeneous internal enhancement and ADC values greater than 1.26×10-3mm2/s, no malignancy was detected, while all other combinations of findings had a probability of malignancy ranging from 22.2 to 76.6%. Conclusions: A combination of BI-RADS descriptors of internal enhancement and ADC values is useful for the differential diagnosis of lesions showing non-mass enhancement. Lesions with homogeneous or heterogeneous enhancement and high ADC can be followed up, while all other lesions should be biopsied. Doi: 10.28991/SciMedJ-2021-0302-1 Full Text: PDF

SUN-LB067 Uncontrolled Diabetes with Severe Ketoacidosis: Blame It on the Pheochromocytoma!

Background: Pheochromocytomas are rare catecholamine secreting tumors that arise from chromaffin cells of the adrenal medulla and sympathetic ganglia. Typical symptoms include paroxysmal hypertension, headache, and palpitations. Hyperglycemia is seen in 35-50% of these patients. There are a few case reports depicting the rare presentation of diabetic ketoacidosis (DKA) precipitated by a catecholamine-secreting tumor. We present a patient with recurrent DKA in the setting of a pheochromocytoma. Clinical Case: A 57-year-old woman with a history of breast cancer, hypertension, adrenal mass, and uncontrolled diabetes mellitus presented with severe DKA after taking oral steroids. Her review of systems noted intermittent pounding headaches, blurred vision, dizziness, unintentional weight loss, palpitations, and fluctuating blood pressure (BP). She had an episode of DKA 6 months prior. She was treated in the ICU with intravenous fluid and insulin with resolution of DKA. Subsequently, she acutely became severely hypertensive. BP was uncontrolled despite aggressive intravenous anti-hypertensive medication. Pertinent labs included hemoglobin A1c (HbA1c) 9.1%, GAD-65 Ab <5 IU/mL, fasting C-peptide 0.81 ng/mL, plasma free total metanephrines 29073 pg/mL(<205) and 24 hour urine total metanephrines 34633 mcg (149-603). A CT scan of the abdomen showed a 7.8 cm right adrenal mass with heterogeneous internal enhancement. Her BP was stabilized with clonidine and doxazosin and she was discharged on these medications and insulin. After appropriate alpha and beta blockade, she underwent right adrenalectomy at another hospital. Postoperatively her BP has been controlled off alpha-blockade and her diabetes has been controlled on metformin alone. Conclusion: This case illustrates the causative role of a pheochromocytoma in a patient with hyperglycemia and severe ketoacidosis. Epinephrine secreted by a pheochromocytoma inhibits insulin secretion by stimulation of alpha-adrenergic receptors and induces glucagon secretion by stimulation of beta and alpha-adrenergic receptors in the pancreas. In addition, stimulation of these receptors promotes glycogenolysis and gluconeogenesis in the liver and activates lipolysis contributing to insulin resistance. In a predisposed patient, these factors may lead to DKA. In a patient who presents with DKA and paroxysmal or uncontrolled hypertension, the diagnosis of pheochromocytoma should be considered. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Relationships Between Human-Extracted MRI Tumor Phenotypes of Breast Cancer and Clinical Prognostic Indicators Including Receptor Status and Molecular Subtype

The purpose of this study was to investigate if human-extracted MRI tumor phenotypes of breast cancer could predict receptor status and tumor molecular subtype using MRIs from The Cancer Genome Atlas project. Our retrospective interpretation study utilized the analysis of HIPAA-compliant breast MRI data from The Cancer Imaging Archive. One hundred and seven preoperative breast MRIs of biopsy proven invasive breast cancers were analyzed by 3 fellowship-trained breast-imaging radiologists. Each study was scored according to the Breast Imaging Reporting and Data System lexicon for mass and nonmass features. The Spearman rank correlation was used for association analysis of continuous variables; the Kruskal-Wallis test was used for associating continuous outcomes with categorical variables. The Fisher-exact test was used to assess correlations between categorical image-derived features and receptor status. Prediction of estrogen receptor (ER), progesterone receptor, human epidermal growth factor receptor, and molecular subtype were performed using random forest classifiers. ER+ tumors were associated with the absence of rim enhancement (P = 0.019, odds ratio [OR] 5.5), heterogeneous internal enhancement (P = 0.02, OR 6.5), peritumoral edema (P = 0.0001, OR 10.0), and axillary adenopathy (P = 0.04, OR 4.4). ER+ tumors were smaller than ER- tumors (23.7 mm vs 29.2 mm, P = 0.02, OR 8.2). All of these variables except the lack of axillary adenopathy were also associated with progesterone receptor+ status. Luminal A tumors (n = 57) were smaller compared to nonLuminal A (21.8 mm vs 27.5 mm, P = 0.035, OR 7.3) and lacked peritumoral edema (P = 0.001, OR 6.8). Basal like tumors were associated with heterogeneous internal enhancement (P = 0.05, OR 10.1), rim enhancement (P = 0.05, OR6.9), and perituomral edema (P = 0.0001, OR 13.8). Human extracted MRI tumor phenotypes may be able to differentiate those tumors with a more favorable clinical prognosis from their more aggressive counterparts.

Interpretation of patterns of enhancement on contrast-enhanced spectral mammography: An approach to a standardized scheme

ObjectiveApplying the morphological descriptors described in the MRI breast imaging and reporting data system (BIRADS) in characterizing enhancing breast lesions seen on CESM. Methods178 breast lesions in patients with mean age 46 years in a prospective study were included. Morphological categorization of the included lesions was presented into focus, mass and non-mass forms. Furthermore classifications included (1) the margin, enhancement intensity for “focus” (2), the shape, margin and internal enhancement for “mass” and (3) the distribution and internal enhancement for “non-mass”. Each morphology descriptor was evaluated separately (irrespective of the other descriptors) by calculating its sensitivity, specificity, (PPV) and (NPV). ResultsThis study included 104 malignant lesions versus 74 benign. Diagnostic accuracy parameters for CESM were sensitivity 98% (102/104) and specificity 76% (56/74). Irregular margin intense enhancement focus (1/8) was diagnosed malignant, (7/8) while regular margin faint enhancing foci were benign.Irregular shape, spiculated margin and heterogeneous internal enhancement descriptors of mass lesion descriptors conformed to malignancy (PPV 92.5% of the former and 88.7% of the latter, p value ≤ 0.001).Asymmetry with segmental distribution, (17/27) (70.8%) heterogeneous and clumped internal enhancement patterns were indicative for malignancy in non mass enhancement (PPV < 0.001). ConclusionMRI lexicon morphology descriptors can be applied (yet with few exceptions) in the characterization of enhancing breast lesions on CESM.The most sensitive descriptors for malignant lesions regarding masses are irregular, margins yet for NME the focal, ductal and segmental distribution with heterogeneous or clumped enhancing patterns. Still foci are controversial.

White matter tract recovery following medial temporal lobectomy and selective amygdalohippocampectomy for tumor resection via a ROVOT-m port-guided technique: A case report and review of literature

Abstract Background Surgical approaches to the temporal region for resection of tumors is challenging due to the anatomic complexity and, in particular, understanding of the critical subcortical white matter. Knowledge of the location of white matter fiber tracts and delicate vessels is essential in preventing complications. As a result, accurate navigation, planning and trajectory are necessary in designing a safe corridor for resection. Case description We describe here a 49-year-old male with a history of right mesial temporal lobe mass since 2012, with concomitant intractable seizures. MRI showed heterogeneous internal enhancement and multiple internal calcifications, resulting in local mass effect with uncal herniation. DTI showed lateral deviation of the Inferior Longitudinal Fasciculus (ILF) and focally diminished anisotropy of the uncinate. The findings were consistent with a WHO grade I pilocytic astrocytoma. BrightMatter Plan software (Synaptive Medical, Toronto, Canada) was then used to plan a trajectory for insertion of a port system (NICO BrainPath, Indianapolis, IN). Complete resection of the tumor, along with partial temporal lobectomy and amygdalohippocampectomy was performed to treat the seizure focus. Conclusions To our knowledge, this is the first reported case of a temporal lobectomy and amygdalohippocampectomy using a port technique, in particular, one that demonstrates recovery of the critical (ILF and uncinate fasciculus) subcortical white matter tracts. The combination of real-time, rapid, geometrically accurate 3D-planning of white matter tracts is imperative, especially in conjunction with minimally invasive approaches, thereby offering a new, safer perspective into the approach of temporal lobe lesions.

Can we apply the MRI BI-RADS lexicon morphology descriptors on contrast-enhanced spectral mammography?

To assess the feasibility of using the MRI breast imaging reporting and data system (BI-RADS) lexicon morphology descriptors to characterize enhancing breast lesions identified on contrast-enhanced spectral mammography (CESM). The study is a retrospective analysis of the morphology descriptors of 261 enhancing breast lesions identified on CESM in 239 patients. We presented the morphological categorization of the included lesions into focus, mass and non-mass. Further classifications included (1) the multiplicity for "focus" category, (2) the shape, margin and internal enhancement for "mass" category and (3) the distribution and internal enhancement for "non-mass" category. Each morphology descriptor was evaluated individually (irrespective of all other descriptors) by calculating its sensitivity, specificity, positive-predictive value (PPV) and negative-predictive value (NPV) and likelihood ratios (LRs). The study included 68/261 (26.1%) benign lesions and 193/261 (73.9%) malignant lesions. Intensely enhancing foci, whether single (7/12, 58.3%) or multiple (2/12, 16.7%), were malignant. Descriptors of "irregular"-shape (PPV: 92.4%) and "non-circumscribed" margin (odds ratio: 55.2, LR positive: 4.77; p-value: <0.001) were more compatible with malignancy. Internal mass enhancement patterns showed a very low specificity (58.0%) and NPV (40.0%). Non-mass enhancement (NME) was detected in 81/261 lesions. Asymmetrical NME in 81% (n = 52/81) lesions was malignant lesions and internal enhancement patterns indicative of malignancy were the heterogeneous and clumped ones. We can apply the MRI morphology descriptors to characterize lesions on CESM, but with few expectations. In many situations, irregular-shaped, non-circumscribed masses and NME with focal, ductal or segmental distribution and heterogeneous or clumped enhancement are the most suggestive descriptors of malignant pathologies. (1) The MRI BI-RADS lexicon morphology descriptors can be applied in the characterization of enhancing lesions on CESM with a few exceptions. (2) Multiple bilateral intensely enhancing foci should not be included under the normal background parenchymal enhancement unless they are proved to be benign by biopsy. (3) Mass lesion features that indicated malignancy were irregular-shaped, spiculated and irregular margins and heterogeneous internal enhancement patterns. The rim enhancement pattern should not be considered as a descriptor of malignant lesions unless CESM is coupled with an ultrasound examination.

Morphology evaluation of nonmass enhancement on breast MRI: Effect of a three-step interpretation model for readers’ performances and biopsy recommendations

ObjectiveTo evaluate and compare the use of a newly introduced interpretation model for breast nonmass enhancement (NME, defined as an area of enhancement without a three-dimensional, space-occupying lesion) with the use of the standard interpretation method based on BI-RADS. Materials and methodsTwo expert and two less-experienced breast imaging radiologists performed reading sessions of 86 malignant and 64 benign NME lesions twice. First, radiologists characterized NME using BI-RADS descriptors and assessed the likelihood of malignancy and need for a biopsy. Second, the likelihood of malignancy and need for a biopsy were assessed with the use of the model, in which three-step characterization of morphological features were performed: (1) selection of distribution modifiers, (2) homogeneous vs. heterogeneous internal enhancement (IE) pattern, and (3) evaluation of presence of “clumped”, “clustered ring enhancement (CRE)”, and “branching” IE signs.Multireader-multicase receiver operating characteristic analysis was used to evaluate observers’ performances. Univariate and multivariate logistic regression analyses were performed for morphology descriptors. ResultsWith use of the model, average Az of less-experienced radiologists (0.77–0.83; p=0.013) and average sensitivity of all radiologists (96.2–98.2%; p=0.007) improved significantly. NPV also improved but nonsignificantly (81.1–91.9%; p=0.055).Multivariate analyses of the second reading showed branching, clumped, and CRE signs to be significant predictors of malignancy in the results of 3, 2, and 2 readers, respectively. ConclusionThe three-step interpretation model for NME has the potential to improve less-experienced radiologists’ performances, making them comparable to expert breast imagers.

TU‐CD‐BRB‐07: Identification of Associations Between Radiologist‐Annotated Imaging Features and Genomic Alterations in Breast Invasive Carcinoma, a TCGA Phenotype Research Group Study

Purpose:To determine associations between radiologist‐annotated MRI features and genomic measurements in breast invasive carcinoma (BRCA) from the Cancer Genome Atlas (TCGA).Methods:98 TCGA patients with BRCA were assessed by a panel of radiologists (TCGA Breast Phenotype Research Group) based on a variety of mass and non‐mass features according to the Breast Imaging Reporting and Data System (BI‐RADS). Batch corrected gene expression data was obtained from the TCGA Data Portal. The Kruskal‐Wallis test was used to assess correlations between categorical image features and tumor‐derived genomic features (such as gene pathway activity, copy number and mutation characteristics). Image‐derived features were also correlated with estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2/neu) status. Multiple hypothesis correction was done using Benjamini‐Hochberg FDR. Associations at an FDR of 0.1 were selected for interpretation.Results:ER status was associated with rim enhancement and peritumoral edema. PR status was associated with internal enhancement. Several components of the PI3K/Akt pathway were associated with rim enhancement as well as heterogeneity. In addition, several components of cell cycle regulation and cell division were associated with imaging characteristics.TP53 and GATA3 mutations were associated with lesion size. MRI features associated with TP53 mutation status were rim enhancement and peritumoral edema. Rim enhancement was associated with activity of RB1, PIK3R1, MAP3K1, AKT1,PI3K, and PIK3CA. Margin status was associated with HIF1A/ARNT, Ras/ GTP/PI3K, KRAS, and GADD45A. Axillary lymphadenopathy was associated with RB1 and BCL2L1. Peritumoral edema was associated with Aurora A/GADD45A, BCL2L1, CCNE1, and FOXA1. Heterogeneous internal nonmass enhancement was associated with EGFR, PI3K, AKT1, HF/MET, and EGFR/Erbb4/neuregulin 1. Diffuse nonmass enhancement was associated with HGF/MET/MUC20/SHIP, and HGF/MET/RANBP9. Linear nonmass enhancement was associated with PIK3R1 and AKT activity.Conclusion:MRI‐genomic association analysis revealed that several BRCA‐associated gene features were associated with radiologist‐annotated image features.

The features of breast lymphoma on MRI

To investigate the morphological features of breast lymphoma (BL) on MRI. MRI features of 20 patients with BL (12 primary and 8 secondary) were reviewed according to Breast Imaging-Reporting and Data System categories. 19 cases were unilateral and 1 was bilateral. According to the enhanced images, of the 20 cases, BL presented as a mass in 11 (55%), as an enhancement with no mass effect in 7 (35%) and as a mass and mixed enhancement with no mass effect in 2 (10%). There were 38 masses and 44 lesions with no mass effect in our study. All lesions showed mild heterogeneous internal enhancement. For lesions with mass effect, the margins were smooth in 32% (12/38) and irregular in 68% (26/38); and the shape was oval in 87% (32/38). Kinetic curve assessment (13 cases, 38 lesions) revealed that the average initial rise rate was 104%. The type II enhancement curve appeared in 55% (21/38) of lesions. No significant differences between the primary and secondary BL were observed for any of the MRI features. BL mostly appeared oval with irregular margins showing mild heterogeneous internal enhancement and/or as enhanced lesions with no mass effect with mild heterogeneous internal enhancement. Some special features on MRI are useful for the diagnosis of BL.

Inflammatory breast cancer: defining breast magnetic resonance imaging features.

Abstract Abstract #4008 PURPOSE: &amp;#x2028; Inflammatory breast carcinoma (IBC) is an aggressive cancer with radiological and clinical features of a heterogeneous disease. The clinical presentation of IBC is characterized by the sudden onset of breast erythema and edema, often without an associated palpable breast mass. Mammography is associated with variable, not descriptive findings and it is often not diagnostic. We planned to address the role of Magnetic Resonance Imaging (MRI) of the breast in women with newly diagnosed IBC.&amp;#x2028; MATERIALS AND METHODS:&amp;#x2028; We performed a retrospective analysis of newly diagnosed IBC cases evaluated at the University of Texas. M D Anderson Cancer Center between December 2003 and February 2008. Baseline breast MRI exams were performed on 1.5-Tesla (T) or 3.0-T GE scanners and included dynamic three-dimensional T1-weighted fast spoiled gradient echo sequences with parallel imaging after a bolus injection of gadolinium based IV contrast. Exams were reviewed in batches and the findings rated in accordance with the ACR BI-RADS MRI Lexicon. The following parameters were evaluated; presence and characteristics of breast masses and skin description. All patients had concomitant mammograms and ultrasound exams.&amp;#x2028; RESULTS: &amp;#x2028; Eighty women with a clinical diagnosis of IBC were included in the study with a median age of 52 years, (range, 25 to 78). MRI detected a primary breast lesion in 80 of 82 symptomatic breasts (98%), compared to only 53 of 78 (68%) with mammogram (p &amp;lt; 0.0001). The most common MRI morphologic characteristic of the lesions was irregular margins (72%) with heterogeneous internal enhancement (82%). Qualitative evaluation of the enhancement pattern demonstrated wash-out in 85% of the cases.&amp;#x2028; MRI detected skin thickening in 90% of the patients (average skin thickness of 8 mm [range, 4-17 mm]), compared to 69% with mammogram. Heterogeneous skin enhancement (82%) and nodular or irregular skin lesions (43%) were identified only with MRI. These skin lesions demonstrated a progressive enhancing pattern, in contrast to the rapid wash-out pattern expected for malignant breast lesion.&amp;#x2028; CONCLUSIONS: &amp;#x2028; This study establishes breast MRI as the most sensitive and accurate imaging modality in assessing the breast of IBC patients. The most common radiological features are represented by the presence of a primary breast lesion and global skin thickening with heterogeneous skin enhancement. The combination of morphology and enhancing pattern may provide information to understand the biology of this disease and accurately monitor residual disease during neoadjuvant therapies. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4008.

Enhanced mass on contrast‐enhanced breast MR imaging: Lesion characterization using combination of dynamic contrast‐enhanced and diffusion‐weighted MR images

To evaluate the diagnostic accuracy of a combination of dynamic contrast-enhanced MR imaging (DCE-MRI) and diffusion-weighted MR imaging (DWI) in characterization of enhanced mass on breast MR imaging and to find the strongest discriminators between carcinoma and benignancy. We analyzed consecutive breast MR images in 270 patients; however, 13 lesions in 93 patients were excluded based on our criteria. We analyzed tumor size, shape, margin, internal mass enhancement, kinetic curve pattern, and apparent diffusion coefficient (ADC) values. We applied univariate and multivariate analyses to find the strongest indicators of malignancy and calculate a predictive probability for malignancy. We added the corresponding categories to these prediction probabilities for malignancy and calculated diagnostic accuracy when we consider category 4b, 4c, and 5 lesions as malignant and category 4a, 3, and 2 lesions as benign. In a validation study, 75 enhancing lesions in 71 patients were examined consecutively. Irregular margin, heterogeneous internal enhancement, rim enhancement, plateau time-intensity curve (TIC) pattern, and washout TIC pattern were the strongest indicators of malignancy as well as past studies, and ADC values less than 1.1x10(-3) mm2/s were also the strongest indicators of malignancy. In a validation study, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 92% (56/61), 86% (12/14), 97% (56/58), 71% (12/17), and 91% (68/75), respectively. The combination of DWI and DCE-MRI could produce high diagnostic accuracy in the characterization of enhanced mass on breast MR imaging.

High-Spatial-Resolution MRI of Non-Masslike Breast Lesions: Interpretation Model Based on BI-RADS MRI Descriptors

The purpose of this study was to assess an interpretation model based on BI-RADS MRI descriptors and high-spatial-resolution MR images in lesions showing non-masslike enhancement. Retrospective review was performed of 30 consecutive lesions showing non-masslike enhancement. MRI was performed on a 1.5-T scanner using the volumetric interpolated breath-hold examination sequence. The distribution patterns were classified into three categories: single quadrant/solitary lesion (linear), single quadrant/grouped lesion (focal, regional, segmental), and multiquadrant lesion (multiple regions, diffuse). The presence of a ductal pattern was assessed in the enhancing lesions after the tumor distribution had been decided. In addition to the BI-RADS MRI descriptors, the presence of clustered ring enhancement was also assessed in heterogeneous enhancing lesions. The most frequent morphologic finding among the benign lesions was a linear pattern (50%) followed by homogeneous internal enhancement (42%), whereas a segmental pattern (56%) (p = 0.003), heterogeneous internal enhancement (44%), and clustered ring enhancement (44%) (p = 0.01) were the most frequent findings in malignant lesions. The features with the highest positive predictive value for carcinoma were a segmental distribution (100%), a clustered ring enhancement (100%), and a clumped internal architecture (88%). Using this interpretation model, the positive predictive value for carcinoma was 94%. A combination of BI-RADS MRI descriptors and clustered ring enhancement criteria is useful for the differential diagnosis of lesions showing non-masslike enhancement.

Breast MRI Using the VIBE Sequence: Clustered Ring Enhancement in the Differential Diagnosis of Lesions Showing Non-Masslike Enhancement

The purpose of this study was to assess the frequency of a finding in which minute ring enhancements are clustered (defined as clustered ring enhancement) in lesions showing non-masslike enhancement and to evaluate the clinical usefulness of this sign, in addition to that of the BI-RADS MRI descriptors, in the differentiation between benign and malignant lesions. Retrospective review was performed of 61 consecutive lesions showing non-masslike enhancement. MRI was performed on a 1.5-T system using the volumetric interpolated breath-hold examination (VIBE) sequence. The kinetic parameter was visually assessed as follows: washout, plateau, and persistent. The most frequent morphologic finding among the malignant lesions was heterogeneous internal enhancement (69%) (p = 0.003), followed in frequency by segmental distribution (54%) (p < 0.001); whereas, stippled internal enhancement was the most frequent finding in benign lesions (50%) (p < 0.001). The presence of clustered ring enhancement was found in 63% of the malignant lesions and only 4% of the benign lesions (p < 0.001). The features with the highest positive predictive value for malignancy were a segmental distribution (100%), clustered ring enhancement (96%), and a washout pattern (94%). The specificity of clustered ring enhancement was 96% (25/26). In cases showing focal and regional enhancement, the combination of clumped internal architecture and clustered ring enhancement showed a statistically significant association with malignant lesions (p < 0.001). Clustered ring enhancement is thought to be a useful sign to differentiate between benign and malignant lesions, in addition to the BI-RADS MRI descriptors.