Radiologic-pathologic Discordance Research Articles

Factors associated with radiologic-pathologic discordance in magnetic resonance imaging after neoadjuvant chemotherapy for breast cancer

BackgroundAlthough breast MRI is known to be the best imaging modality for assessing the response after neoadjuvant chemotherapy (NAC), discordance still remains between MRI findings and final pathology findings. PurposeTo evaluate imaging and clinicopathologic factors associated with radiologic-pathologic discordance in breast cancer patients after NAC. Material and methodsThis retrospective study included 104 breast cancer patients (mean age: 50.2 years) who underwent breast MRI examinations before and after NAC between June 2015 and December 2019. Radiologic complete response (rCR) was defined as equal or lesser enhancement compared with breast tissue in post-NAC MRI. Pathologic CR (pCR) was defined as absence of invasive cancer in final pathology. Imaging and clinicopathologic factors associated with radiologic-pathologic discordance were analyzed with logistic regression analysis. ResultsOverall rCR and pCR rates were 37.5% (39/107) and 40.2% (43/107), respectively. Multivariate analysis revealed that the presence of non-mass enhancement (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.1–11.2; P = 0.03) and multicentric lesions on pre-NAC MRI (OR, 4.2; 95% CI, 1.2–14.9; P = 0.03) were independently associated with radiologic-pathologic discordance. False-positive rate for predicting residual tumor was the most prevalent in HER2-positive cancers (86.7%). ConclusionWhen determining rCR, the presence of non-mass enhancement and multicentric lesions on pre-NAC MRI, and HER2-positive cancers should be interpreted with caution.

Impact of multidisciplinary radiologic-pathologic correlation conference for benign image-guided breast biopsies on discordance rates and patient outcomes in a community teaching hospital

As the assessment for radiologic-pathologic concordance, particularly for benign image-guided breast biopsies, is crucial in the management of patients with imaging abnormalities, many health institutions now conduct multidisciplinary conferences to assess the imaging and pathology findings in patients who had image-guided needle biopsy. We aimed to identify the radiologic-pathologic discordance rates and changes in patient outcomes resulting from the implementation of radiologic-pathologic correlation conferences in a community teaching hospital. Twenty-two (5.6%) out of 393 cases presented were deemed discordant given that the imaging characteristics of the lesions were far too suspicious radiologically to correlate with the benign pathology. Six cases were recommended for further imaging (four had stable lesion on follow- up, one was lost to follow-up and one case eventually had surgical excision which showed atypia); 14 cases for repeat core needle/excisional biopsy (seven had surgical excision with benign histology, five did not have surgery but showed stable lesion on imaging, two were lost to follow-up); one case for close imaging follow-up (lesion ultimately disappeared); the remaining case for second opinion (no follow-up data). The rad-path correlation conference led to a higher level of patient care with significant change in practice across our hospital network.

Hepatocellular Carcinoma Staging: Differences Between Radiologic and Pathologic Systems and Relevance to Patient Selection and Outcomes in Liver Transplantation.

Liver transplant is indicated with curative intent for patients with early-stage hepatocellular carcinoma (HCC). The radiologic T category is used to determine candidacy and priority of patients on the waiting list. After transplant, the explant liver pathologic TNM stage is used as a predictor of postoperative outcomes and overall prognosis. Although the comparison of radiologic and pathologic T categories for concordance is often considered to be straightforward, the staging conventions significantly differ. Not accounting for these differences is in part the reason for the high rates of radiologic-pathologic discordance reported in the literature, with inconsistent terminology being an additional source of confusion when evaluating concordance. These factors may affect the understanding of important radiopathologic phenotypes of disease and the adequate investigation of their prognostic capabilities. The aims of this article are to provide an overview of the pathologic and radiologic TNM staging systems for HCC while describing staging procedures, emphasize the differences between these staging systems to highlight the limitations of radiologic-pathologic stage correlation, present a review of the literature on the prognostic value of individual features used for HCC staging; and signal significant aspects of preoperative risk stratification that could be improved to positively impact posttransplant outcomes.

High-Risk Lesions Detected by MRI-Guided Core Biopsy: Upgrade Rates at Surgical Excision and Implications for Management.

OBJECTIVE. The purpose of our study was to evaluate the upgrade rates of high-risk lesions (HRLs) diagnosed by MRI-guided core biopsy and to assess which clinical and imaging characteristics are predictive of upgrade to malignancy. MATERIALS AND METHODS. A retrospective review was performed of all women who presented to an academic breast radiology center for MRI-guided biopsy between January 1, 2015, and November 30, 2018. Histopathologic results from each biopsy were extracted. HRLs-that is, atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), radial scar, papilloma, flat epithelial atypia (FEA), benign vascular lesion (BVL), and mucocelelike lesion-were included for analysis. Clinical history, imaging characteristics, surgical outcome, and follow-up data were recorded. Radiologic-pathologic correlation was performed. RESULTS. Of 810 MRI-guided biopsies, 189 cases (23.3%) met the inclusion criteria for HRLs. Of the 189 HRLs, 30 cases were excluded for the following reasons: 15 cases were lost to follow-up, six cases were in patients who received neoadjuvant chemotherapy after biopsy, two lesions that were not excised had less than 2 years of imaging follow-up, and seven lesions had radiologic-pathologic discordance at retrospective review. Of the 159 HRLs in our study cohort, 13 (8.2%) were upgraded to carcinoma. Surgical upgrade rates were high for ADH (22.5%, 9/40) and FEA (33.3%, 1/3); moderate for LCIS (6.3%, 3/48); and low for ALH (0.0%, 0/11), radial scar (0.0%, 0/28), papilloma (0.0%, 0/26), and BVL (0.0%, 0/3). Of the upgraded lesions, 69.2% (9/13) were upgraded to ductal carcinoma in situ (DCIS) or well-differentiated carcinoma. ADH lesions were significantly more likely to be upgraded than non-ADH lesions (p = .005). CONCLUSION. ADH diagnosed by MRI-guided core biopsy warrants surgical excision. The other HRLs, however, may be candidates for imaging follow-up rather than excision, especially after meticulous radiologic-pathologic correlation.

Upgrade rate of intraductal papilloma without atypia on breast core needle biopsy: A clinical, radiological and pathological correlation study

BackgroundThe aim of the study was to determine the upgrade rate on excision of intraductal papilloma (IDP) without atypia diagnosed on breast core needle biopsy (CNB). MethodsWe searched our pathology department database for breast CNB with a diagnosis of IDP from 2013 to 2018. The exclusion criteria included radiologic-pathologic discordance, atypia on the same CNB, absence of histologic slides to review or absence of excision information. Upgrade was defined as ductal carcinoma in situ (DCIS) or invasive cancer identified on excision. Results126 IDP without atypia cases from 94 patients were identified. The upgrade rate was 1.58% (2/126). Both upgrade cases showed DCIS with low and intermediate nuclear grade. Histologic size of IDP ≥1 cm was the only statistically significant predictor factor for an upgrade on excision. ConclusionThe results suggest that non-surgical management of patients with radiologic-pathologic concordant IDP without atypia diagnosed on CNB may be appropriate in routine practice.

Complete response on MR imaging after neoadjuvant chemotherapy in breast cancer patients: Factors of radiologic-pathologic discordance

PurposeTo evaluate the radiologic and clinicopathologic factors in radiologic-pathologic discordance (false-negative results) in breast cancer patients who demonstrate radiologic complete response (rCR) in MR imaging after neoadjuvant chemotherapy (NAC). MethodOur institutional review board approved this retrospective study. We included 209 consecutive patients who showed rCR in MR imaging after NAC. rCR was diagnosed when the original lesion site showed no enhancement. Pathologic CR (pCR) was defined as the complete absence of both invasive cancer and ductal carcinoma in situ in the breast upon pathology. Clinicopathologic and radiologic factors affecting the radiologic-pathologic correlation were analyzed. ResultspCR was noted in 108 patients (51.7%); the remaining 101 (48.3%) had residual lesion on pathology. False negative rCR findings were significantly more frequent in cases of 1 or 2 histologic grade (p = 0.001), low tumor-infiltrating lymphocytes (p = 0.004), and luminal A or B subtype (p < 0.001). Multivariate analysis of radiologic findings to identify predictors of false negative findings found calcifications in mammography (p = 0.037), multifocal multicentric lesions (p = 0.004), and non-mass enhancement in pretreatment MR imaging (p = 0.023) to be significantly associated with false-negative findings. ConclusionsPatients with calcification in mammography, multifocal multicentric lesions, and non-mass enhancement in pretreatment MR imaging are significantly associated with false-negative results who showed rCR on MR imaging after NAC. These patient populations should be interpreted with caution.

Measuring Tumor Extent Based on Subtypes Using Magnetic Resonance Imaging: Radiologic-Pathologic Discordance and High Positive Margin Rates in Breast Cancer.

PurposeWe evaluated the clinical value of breast magnetic resonance imaging (MRI) in patients who underwent breast-conserving surgery (BCS). The degree of correlation between pathology size and MRI or ultrasonography (US) size was compared based on breast cancer subtypes. In addition, we investigated the positive margin rates.MethodsPatients with invasive breast cancer who underwent preoperative breast MRI and US between 2011 and 2016 were included in the study. Lin's concordance correlation coefficient was used to measure the correlation between MRI or US andpathologic tumor extent. Tumor extent was defined as pathologic tumor size, including in situ carcinoma. Margin positivity was assessed based on frozen-section examination.ResultsA total of 516 patients with a single tumor who underwent BCS were included in the study. The correlation between pathologic size and MRI was significantly higher than that of US (r = 0.6975 vs. 0.6211, p = 0.001). The superiority of MRI over US in measuring the pathologic extent was only observed in triple-negative breast cancer (TNBC; r = 0.8089 vs. 0.6014, p < 0.001). The agreement between MRI or US and tumor extent was low for the human epidermal growth factor receptor 2 (HER2)-positive subtype (MRI: 0.5243, US: 0.4898). Moreover, the positive margin rate was higher in the HER2-positive subtype than in the others (luminal/HER2-negative: 11.6%, HER2-positive: 23.2%, TNBC: 17.8%, p = 0.019). The post hoc analysis showed that the HER2-positive subtype was more likely to show positive margins than the luminal/HER2-negative subtype (p = 0.007).ConclusionBreast MRI was superior to US in the preoperative assessment of the pathologic extent of tumor size; this was most evident in TNBC. For HER2-positive tumors, imaging-pathologic discordance resulted in higher positive margin rates than that with other subtypes.

Core Breast Biopsies Showing Lobular Carcinoma In Situ Should Be Excised and Surveillance Is Reasonable for Atypical Lobular Hyperplasia.

The purpose of this article is to determine the upgrade rate to ductal carcinoma in situ (DCIS) or invasive carcinoma at excision at the same site after percutaneous breast biopsy findings of atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) using current imaging and strict pathologic criteria. From January 2006 through September 2013, 32,960 breast core biopsies were performed; 1084 (3.3%) core biopsies found ALH or classic LCIS. For 447 lesions in 433 women, this was the only high-risk lesion at that site, with no ipsilateral malignancy, and results of excision were available. Among the 447 lesions, 22 (4.9%) were malignant at excision, including 10 invasive carcinomas (two grade 2 and eight grade 1; all node negative) and 12 DCIS. The upgrade rate of LCIS was 9.3% (10/108; 95% CI, 5.1-16.2%) and that of ALH was 3.5% (12/339; 95% CI, 2.0-6.1%; p = 0.02). After excluding five cases with radiologic-pathologic discordance and reclassifying one core from ALH to LCIS at review, the upgrade rate for LCIS remained higher (8.4%; 9/107; 95% CI, 4.5-15.2%) than that for ALH (2.4%; 8/335; 95% CI, 1.2-4.6%; p = 0.01). Excision is recommended for LCIS on core biopsy because of its 8.4-9.3% upgrade rate. Excluding discordant cases, patients with other high-risk lesions or concurrent malignancy, the risk of upgrade of ALH was 2.4%. Surveillance at 6, 12, and 24 months can be performed in lieu of excision because a short delay in diagnosis of the few malignancies is not expected to cause harm.

Pathologic Upgrade Rates on Subsequent Excision When Lobular Carcinoma In Situ Is the Primary Diagnosis in the Needle Core Biopsy With Special Attention to the Radiographic Target

Lobular carcinoma in situ (LCIS) as the primary pathologic diagnosis in a needle core biopsy is an infrequent finding, and the management of patients in this setting is controversial. To determine the rate of pathologic upgrade (defined as the presence of a clinically more-significant lesion in the subsequent excision) in patients with a primary pathologic diagnosis of LCIS in the needle core biopsy. Patients with a primary diagnosis of LCIS in a needle core biopsy who underwent subsequent excision were identified. Core biopsies containing a concurrent high-risk lesion and cases with radiologic-pathologic discordance were excluded. The presence of selected microscopic features in the needle core biopsy was correlated with pathologic upgrade. Microscopic findings were correlated with the radiographic target in the needle core biopsy. Sixty-one women with primary LCIS in their needle core biopsy showed a 10% pathologic upgrade rate. The percentage of cores involved by LCIS was significantly associated with pathologic upgrade (P= .04), whereas the remaining measured parameters were not. When LCIS represented the radiographic target, the pathologic upgrade rate was 18%, whereas when it was an incidental finding, the pathologic upgrade rate was 4%. It may be reasonable for patients with primary, yet incidental, LCIS on needle core biopsy to be managed in a nonsurgical fashion. Larger studies are needed to confirm our findings.

Atypical lobular hyperplasia and classic lobular carcinoma in situ in core biopsy specimens: routine excision is not necessary

Standardized recommendations for the management of lobular neoplasia in core biopsy specimens are not established. The aim of our study was to define morphologic features of lobular neoplasia in core biopsies that predict the finding of ductal carcinoma in situ or invasive carcinoma in the subsequent excisional specimen. We reviewed 333 cases of atypical lobular hyperplasia or lobular carcinoma in situ without ductal carcinoma in situ or invasive carcinoma diagnosed in core biopsies from 1996 to 2006. Subsequent excision was performed in 41% (136/333) of cases, including atypical lobular hyperplasia (n=48), lobular carcinoma in situ (n=39), and lobular neoplasia associated with atypical ductal hyperplasia (n=49). Upgrades were identified in 2% (1/48) of atypical lobular hyperplasia, 23% (9/39) of lobular carcinoma in situ, and 27% (13/49) of lobular neoplasia associated with atypical ductal hyperplasia cases. When further analyzed, the upgraded cases of lobular carcinoma in situ were associated with radiologic–pathologic discordance in 6/9 cases and with nonclassic pathology (two lobular carcinoma in situ with necrosis and one pleomorphic lobular carcinoma in situ) in the remaining three cases. The frequency of upgrade was 11% (3/26) in classic lobular carcinoma in situ, and 46% (6/13) in nonclassic types (pleomorphic or with necrosis). After excluding cases with discordant imaging/pathology, there was a 5% upgrade in our excisional specimens. After excluding cases where the upgrade was associated with nonclassic morphology, the upgrade in our study was 1%. Our results suggest that atypical lobular hyperplasia and classic lobular carcinoma in situ with concordant radiology and pathology can be appropriately managed with clinical follow-up without surgery.

Percutaneous Biopsy of Papillary Lesions of the Breast: Accuracy of Pathologic Diagnosis

Objective: The purpose of this study was to determine the accuracy of the pathologic diagnosis of papillary breast lesions when evaluated by percutaneous biopsy. Materials and Methods: A total of 2307 consecutive breast lesions, diagnosed by percutaneous biopsy, were retrospectively reviewed. Of these, 45 lesions were papillary lesions; 15 of the 45 cases were lost to follow-up or had not had imaging follow-up and were excluded. The remaining 30 papillary lesions constituted the study population. Subsequent surgical excision or imaging follow-up (a minimum of 6 months) was performed and correlated with the initial diagnoses. Results: Of the 30 lesions, 11 intraductal papillomas were diagnosed with stereotactic vacuum assisted biopsy (SVAB). Surgical excision was performed on four lesions (36.4%). Pathologic findings in all four lesions (100%) were benign. Of the 13 papillary lesions diagnosed with ultrasound-guided core needle biopsy, three (23.1%) demonstrated papillomatosis. Subsequent surgical excision was performed on 11 (84.6%) of the 13 papillary lesions, including two of the three papillomatosis. Pathology was benign in all. The two (18.2%) other lesions, initially diagnosed as papillomatosis and benign papilloma, were a fibroadenoma and organizing papillomatosis, respectively, at surgery. The six lesions that were sampled with fine needle aspiration (FNA) demonstrated intraductal papillary lesions, two (33.3%) of which had cytologic atypia. Surgical excision was performed on all six (100%) with benign breast tissue in four (66.7%) including one of the lesions demonstrating atypia. The two (33.3%) other lesions demonstrated high-grade invasive papillary carcinoma with in-situ components. Conclusion: Surgical excision is warranted when a percutaneous breast biopsy demonstrates a papillary lesion with atypia or when there is radiologic-pathologic discordance. Otherwise, these lesions can be followed conservatively. Furthermore, for improved diagnostic accuracy, indeterminate intraductal lesions should undergo biopsy with CNB or stereotactic vacuum assisted biopsy and not fine needle aspiration. The cytologic diagnosis of papillary lesions is considered only preliminary by fine needle aspiration, and should await surgical resection and histologic examination to further classify these lesions.