Second-look Ultrasound Research Articles

The Value of Second-look Ultrasound and Mammography for Assessment and Biopsy of MRI-detected Breast Lesions

Rationale and ObjectivesSuspicious lesions detected in multiparametric breast MRI can be further analyzed with second-look ultrasound (SLUS) and/or mammography. This study aims to assess the value of second-look imaging in selecting the appropriate biopsy method for different lesion characteristics. Materials and MethodsBetween January 2021 and December 2023, 212 women underwent contrast-enhanced multiparametric breast MRI at 3.0 Tesla. A total of 241 suspicious lesions (108 malignancies, 44.8%) were further assessed with SLUS and second-look mammography. Subsequent image-guided biopsy of each lesion was performed using the most suitable modality. Size-dependent lesion detection rates in SLUS and mammography were compared by means of the McNemar test. ResultsLesions referred to MRI-guided biopsy were predominantly ≤ 10 mm in size (52.8%). SLUS displayed higher detection rates than mammography for mass lesions (55.6% [95% confidence interval 46.4–64.4%] versus 16.7% [10.6–24.3%]; p<0.001) with a particularly high sensitivity for malignant mass lesions > 10 mm (88.5 % [69.9–97.6%]). In contrast, the detection rate for malignant non-mass lesions was lower in SLUS than in second-look mammography (22.0% [11.5–36.0%] versus 38.0% [24.7–52.8%]; p<0.001). The malignancy rates in ultrasound-, mammography-, and MRI-guided biopsies were 53.7%, 55.2%, and 35.0%, respectively. ConclusionSLUS is an excellent tool for further assessment and biopsy of suspicious mass lesions > 10 mm without associated calcifications. In contrast, supplemental ultrasound is of limited value in the evaluation and biopsy guidance of suspicious non-mass lesions compared to second-look mammography.

MRI-only breast cancers are less aggressive than cancers identifiable on conventional imaging

BackgroundMagnetic resonance imaging (MRI) has a superior sensitivity for the diagnosis of breast cancer, leading to lesions primarily detected by MRI. Some of these lesions cannot be identified by targeted second-look ultrasound (SLUS) examinations and are thus referred to as MRI-only lesions. We hypothesize that biologically more aggressive cancers lead to more distinct tissue damage improving visibility on SLUS. ObjectiveTo investigate whether there are differences in cancer subtypes between MRI-only and SLUS-detected malignant lesions. MethodsThis retrospective single-center observational study evaluated 435 patients who received breast MRI examinations between January 2017 and December 2022, with at least one lesion primarily detected on MRI and histologically confirmed as malignant. Demographic characteristics, lesion type (mass or non-mass), MRI-assessed lesion size (mm), histological diagnosis, stage, immunohistochemical analysis (ER, PR, HER-2, Ki-67), and lymph node status were assessed and compared between MRI-only and SLUS-detected. ResultsAmong 435 patients (mean age of 57.4 ± 13.3), 34.02 % (n = 148) were in the MRI-only group, while the remaining 65.98 % (n = 287) were identified by SLUS. MRI-only cases were significantly smaller in size (10 mm vs 20 mm), mostly staged as T1 (66.9 %) and showed features associated with less biological aggressiveness (higher pure ductal carcinoma in situ rates: 30.4 % vs 5.2 %; lower Ki-67, median values: 10 vs 20) compared to SLUS-detected cases (P < 0.001). SLUS-detected cancers had higher ratios of microscopic (4.9 % vs 3.4 %) and macroscopic axillary metastasis (26.8 % vs 7.4 %) compared to MRI-only lesions (P < 0.001). ConclusionMRI-only lesions presented histologically and immunohistochemically with less aggressive patterns compared to those detected via SLUS.Clinic Impact: Our data provide evidence that MRI-only lesions are biologically less aggressive and of lower stage, offering the potential of earlier treatment chance since they are visible on MRI before becoming more aggressive and destructive.

Evaluation of the intramammary distribution of breast lesions detected by MRI but not conventional second-look B-mode ultrasound using an MRI/ultrasound fusion technique

The objective of this study was to evaluate the intramammary distribution of MRI-detected mass and focus lesions that were difficult to identify with conventional B-mode ultrasound (US) alone. Consecutive patients with lesions detected with MRI but not second-look conventional B-mode US were enrolled between May 2015 and June 2023. Following an additional supine MRI examination, we performed third-look US using real-time virtual sonography (RVS), an MRI/US image fusion technique. We divided the distribution of MRI-detected mammary gland lesions as follows: center of the mammary gland versus other (superficial fascia, deep fascia, and atrophic mammary gland). We were able to detect 27 (84%) of 32 MRI-detected lesions using third-look US with RVS. Of these 27 lesions, 5 (19%) were in the center of the mammary gland and 22 (81%) were located in other areas. We were able to biopsy all 27 lesions; 8 (30%) were malignant and 19 (70%) were benign. Histopathologically, three malignant lesions were invasive ductal carcinoma (IDC; luminal A), one was IDC (luminal B), and four were ductal carcinoma in situ (low-grade). Malignant lesions were found in all areas. During this study period, 132 MRI-detected lesions were identified and 43 (33%) were located in the center of the mammary gland and 87 (64%) were in other areas. Also, we were able to detect 105 of 137 MRI-detected lesions by second-look conventional-B mode US and 38 (36%) were located in the center of the mammary gland and 67 (64%) were in other areas. In this study, 81% of the lesions identified using third-look US with RVS and 64% lesions detected by second-look conventional-B mode US were located outside the center of the mammary gland. We consider that adequate attention should be paid to the whole mammary gland when we perform third-look US using MRI/US fusion technique.

Utility of Second-look Ultrasonography in Distinguishing BI-RADS 4 Calcifications Detected on Mammography: An observational study.

This study aimed to assess the utility of second-look ultrasonography (US) in differentiating breast imaging reporting and data system (BI-RADS) 4 calcifications initially detected on mammography (MG). BI-RADS 4 calcifications have a wide range of positive predictive values. We hypothesized that second-look US would help distinguish BI-RADS 4 calcifications without clinical manifestations and other abnormalities on MG. This study included 1622 pure BI-RADS 4 calcifications in 1510 women (112 patients with bilateral calcifications). The cases were randomly divided into training (85%) and testing (15%) datasets. Two nomograms were developed to differentiate BI-RADS 4 calcifications in the training dataset: the MG-US nomogram, based on multifactorial logistic regression and incorporated clinical information, MG, and second-look US characteristics, and the MG nomogram, based on clinical information and mammographic characteristics. Calibration of the MG-US nomogram was performed using calibration curves. The discriminative ability and clinical utility of both nomograms were compared using the area under the receiver operating characteristic curve (AUC) and the decision analysis curve (DCA) in the test dataset. The clinical information and imaging characteristics were comparable between the training and test datasets. The bias-corrected calibration curves of the MG-US nomogram closely approximate the ideal line for both datasets. In the test dataset, the MG-US nomogram exhibited a higher AUC than the MG nomogram (0.899 vs 0.852, P = .01). DCA demonstrated the superiority of the MG-US nomogram over the MG nomogram. Second-look US features, including ultrasonic calcifications, lesions, and moderate or marked color flow, were valuable for distinguishing BI-RADS 4 calcifications without clinical manifestations and other abnormalities on MG.

Abstract PO2-07-08: The efficacy of an MRI/US fusion technique for MRI-detected lesions previously undetected by conventional B-mode second-look US

Abstract Introduction Breast magnetic resonance imaging (MRI) is performed for preoperative screening of breast cancer and surveillance of BRCA gene carriers, and some lesions, called MRI-detected lesions, can only be detected by MRI. When MRI-detected lesions are found, second-look ultrasound (US) is recommended as the first choice for confirmation. However, the detection of MRI-detected lesions by conventional B-mode (cB-mode) second-look US varies from institution to institution, and it is often difficult to ensure objectivity and reproducibility. We use an MRI/US fusion technique called real-time virtual sonography (RVS) for the detection of MRI-detected lesions. RVS uses a magnetic position tracking system to display real-time US images on the same monitor as MRI images. Few reports on second-look US using RVS have examined its detection rate of MRI-detected lesions and the histopathological results of these lesions. In this study, we retrospectively reviewed MRI-detected lesions identified by second-look US using RVS but not by cB-mode second-look US from January 2018 to December 2022, with the goal of evaluating these lesions’ pathological characteristics. Materials and methods Consecutive patients who had one or more MRI-detected lesions not detected by cB-mode second-look US were enrolled in this study between January 2018 and December 2021. Second-look US using RVS was conducted after an additional supine MRI with a body surface coil was performed. Results A total of 36 patients with 38 lesions were included in this study. The mean age was 54 years old (range: 31–76). We were able to detect 31 (82%) of the 39 MRI-detected lesions by second-look US using RVS. These lesions were characterized as follows: mass, 14; non-mass-enhancement (NME), 13; and focal, 4. US-guided biopsy or excisional biopsy was performed on all lesions, and 11 (35%) of 31 lesions were malignant. We were able to detect 14 (74%) of the 19 mass lesions, and 3 were malignant (invasive ductal carcinoma (IDC) [luminal A type] in all 3 cases). We detected 13 (93%) of the 14 NME lesions, and 7 were malignant: 6 were ductal carcinoma in situ (DCIS) (high grade, 3; intermediate grade, 2; and low grade, 1), and 1 was IDC (luminal A type). Finally, we were able to detect 4 (80%) of the 5 focal lesions, 1 of which was malignant (DCIS [low grade]). Of 22 patients aged 55 years or younger, 3 had malignant lesions (IDC [luminal A type] in 2, DCIS [high grade] in 1). Of 15 patients aged 56 years or older, 8 had malignant lesions (DCIS in 7 [high grade, 2; intermediate grade, 2; low grade, 1] and IDC [luminal A type] in 1). Conclusions In this study, second-look US using RVS identified 82% of MRI-detected lesions that were not identified with cB-mode second-look US. Of these MRI-detected lesions, 35% were malignant. These results suggest that second-look US using RVS is useful for identifying MRI-detected lesions that are not detected by cB-mode second-look US. Citation Format: Masayuki Saito, Hirona Banno, Yukie Ito, Mirai Ido, Manami Goto, Takahito Ando, Yukako Mouri, Junko Kousaka, Kmihito Fujii, Tsuneo Imai, Shogo Nakano. The efficacy of an MRI/US fusion technique for MRI-detected lesions previously undetected by conventional B-mode second-look US [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-07-08.

Locoregional staging of breast cancer: contrast-enhanced mammography versus breast magnetic resonance imaging

PurposeBreast cancer diagnosis often involves assessing the locoregional spread of the disease through MRI, as multicentricity, multifocality and/or bilaterality are increasingly common. Contrast-enhanced mammography (CEM) is emerging as a potential alternative method. This study compares the performance of CEM and MRI in preoperative staging of women with confirmed breast carcinoma. Patients were also asked to fill in a satisfaction questionnaire to rate their comfort level with each investigation.MethodsFrom May 1st, 2021 to May 1st, 2022, we enrolled 70 women with confirmed breast carcinoma who were candidates for surgery. For pre-operative locoregional staging, all patients underwent CEM and MRI examination, which two radiologists evaluated blindly. We further investigated all suspicious locations for disease spread, identified by both CEM and MRI, with a second-look ultrasound (US) and eventual histological examination.ResultsIn our study cohort, MRI and CEM identified 114 and 102 areas of focal contrast enhancement, respectively. A true discrepancy between MRI and CEM occurred in 9 out of 70 patients examined. MRI reported 8 additional lesions that proved to be false positives on second-look US in 6 patients, while it identified 4 lesions that were not detected by CEM and were pathological (true positives) in 3 patients.ConclusionsCEM showed results comparable to MRI in the staging of breast cancer in our study population, with a high rate of patient acceptability.

Pathology of MRI and second-look ultrasound detected multifocal breast cancer

Introduction Targeted second-look ultrasound (US) is often performed following MRI of the breast to determine if an MRI-detected lesion is visible on US and thus amenable to US-guided biopsy. This study aimed to assess the pathology of lesions detected and biopsied on the second-look US. In particular, for multifocal cancers, whether the pathology of additional lesions detected by second-look US is different to the index lesion. Methods Multicentre single-institution retrospective study of 300 consecutive cases of second-look US biopsies from August 2017 to April 2022 was performed, with their histopathology and imaging characteristics recorded. For multifocal cancers, Wilcoxon Signed Ranks Tests were used to compare differences between the index and additional lesions in the histopathology category (i.e., high-risk benign, precursor or malignant) and BRE grade. Results 69 multifocal cancers were detected. For the purposes of this study, additional lesions were considered more invasive if they were of a higher histopathological category or BRE grade, or demonstrated lymphovascular invasion when the primary lesion did not. 15/69 additional lesions were not seen on the initial mammogram/tomography or ultrasound, seen on subsequent MRI and second look US, and were less invasive than the index lesion. 3/69 additional lesions were more invasive than their index lesions. Wilcoxon Signed Ranks test showed additional lesions were of either similar or lesser invasiveness compared to index lesions (z= −3.207, p = 0.001) in the histopathological category, and the same or lower BRE grade (z= –2.972, p = 0.003). Conclusion In multifocal breast cancers, additional lesions detected on MRI and second-look US have the same or less invasive histopathology compared to the index lesion.

Invasive lobular carcinoma of the breast detected with real-time virtual sonography: a case report

BackgroundInvasive lobular carcinoma (ILC) sometimes presents with unique clinical, pathologic, and radiographic features. In this case report, we describe a patient with ILC, whose initial presentation consisted with symptoms secondary to bone-marrow dissemination. In addition, the breast primary was revealed only by magnetic resonance imaging (MRI) followed by real-time virtual sonography (RVS).Case presentationA 51-year-old woman presented to our outpatient clinic with dyspnea on exertion. She had severe anemia (hemoglobin, 5.3 g/dL) and thrombocytopenia (platelet count, 31 × 103/mL). Bone-marrow biopsy was performed to evaluate hematopoietic function. The pathologic diagnosis was bone-marrow carcinomatosis due to metastatic breast cancer. Initial mammography followed by ultrasonography (US) failed to detect the primary tumor. On MRI, a non-mass-enhancement lesion was observed. While second-look US also did not detect the lesion, it was clearly visualized with RVS. We were finally able to biopsy the breast lesion. The pathologic diagnosis was ILC positive for both estrogen receptor and progesterone receptor, with 1 + immunohistochemical staining for human epidermal growth factor receptor 2. This case of ILC was characterized by bone-marrow metastasis. Due to decreased cell adhesion, the risk of bone-marrow metastasis is higher in ILC than in invasive ductal carcinoma, the most prevalent type of breast cancer. Biopsy of the primary lesion, which was initially only detected with MRI, was successfully performed with clear visualization during RVS, which is based on the fusion of MRI and US images.ConclusionIn this case report and literature review, we describe the unique clinical characteristics of ILC and a strategy for identifying primary lesions that are initially only visualized with MRI.

Misinterpretation of a giant idiopathic concealed right iliac artery aneurysm as infantile pelvic tumor imaged by non-angiographic computed tomography: a case report

BackgroundIdiopathic pediatric artery aneurysm is extremely rare and sometimes behaves like a pelvic neoplasm. As it is associated with a high mortality while ruptured, the accurate diagnosis is indispensable to avoid life-threatening complications. Angiographic imaging is the gold standard for diagnosis and treatment planning of the aneurysm. Due to the considerably higher radiation sensitivity of children, single portal venous-phase scanning of the abdominopelvic computed tomography (CT) is, however, reasonably utilized for the evaluation of a clinically palpable mass; the erroneous diagnosis of such aneurysm can be feasible.Case presentationA giant idiopathic concealed right iliac artery aneurysm in a 47-day-old girl presented with a palpable pelvic mass regardless of unidentifiable predisposing factors. Non-angiographic abdominopelvic CT was reappraised by the radiology consultant according to discordance between the mass characteristics on initial CT report and those on second-look sonography, revealing the concealed aneurysm instead of solid neoplasm as it originated from right internal iliac artery. The patient underwent an emergency laparotomy with successful proximal ligation of right internal iliac artery despite intraoperative aneurysmal rupture.ConclusionsTypical CT features for the infantile iliac artery aneurysms may be overlooked, especially if the angiographic phase is omitted; thus, the imaging characteristics of the aneurysms are more difficult to appreciate and can mimic a pelvic neoplasm. Therefore, the identification of the origin of the mass should be more practical to achieve the precise diagnosis.

Recent Advances in Ultrasound Breast Imaging: From Industry to Clinical Practice

Breast ultrasound (US) has undergone dramatic technological improvement through recent decades, moving from a low spatial resolution, grayscale-limited technique to a highly performing, multiparametric modality. In this review, we first focus on the spectrum of technical tools that have become commercially available, including new microvasculature imaging modalities, high-frequency transducers, extended field-of-view scanning, elastography, contrast-enhanced US, MicroPure, 3D US, automated US, S-Detect, nomograms, images fusion, and virtual navigation. In the subsequent section, we discuss the broadened current application of US in breast clinical scenarios, distinguishing among primary US, complementary US, and second-look US. Finally, we mention the still ongoing limitations and the challenging aspects of breast US.

Prospective Evaluation of Ultrasound in a Novel Position with MRI Virtual Navigation for MRI-Detected Only Breast Lesions: A Pilot Study of a More Efficient and Economical Method

The aim of this study was to evaluate the clinical utility of ultrasound (US) with magnetic resonance imaging (MRI) virtual navigation in a novel prone position for MRI-detected incidental breast lesions. Between June 2016 and June 2020, 30 consecutive patients with 33 additional Breast Imaging Reporting and Data System (BI-RADS) category 4 or 5 lesions that were detected on MRI but occult on second-look US were enrolled in the study. All suspicious lesions were located in real-time US using MRI virtual navigation in the prone position and then followed by US-guided biopsy or surgical excision. Pathological results were taken as the standard of reference. The detection rate of US with MRI virtual navigation was calculated. The MRI features and pathological types of these lesions were analyzed. A total of 31 lesions were successfully located with real-time US with MRI virtual navigation and then US-guided biopsy or localization, and the detection rate was 93.9% (31/33). Twenty-seven (87.1%, 27/31) proved to be benign lesions and four (12.9%, 4/31) were malignant lesions at pathology. Of the 33 MRI-detected lesions, 31 (93.9%, 31/33) were non-mass enhancements and two (6.1%, 2/33) were masses. This study showed that real-time US with prone MRI virtual navigation is a novel efficient and economical method to improve the detection and US-guided biopsy rate of breast lesions that are detected solely on MRI.

The Added Value of Second-Look Ultrasound in Patients With Primary Hyperparathyroidism With Discordant or Negative Previous Imaging Findings

ObjectiveThe preoperative localization for patients with primary hyperparathyroidism with negative or discordant previous imaging results has always been a difficult problem to be solved in clinical practice. Second-look ultrasound (US) is a viable but underestimated method. This study aimed to assess the added value of second-look US and explore the attributing factors. MethodsAmong 711 surgically confirmed patients with primary hyperparathyroidism, 63 patients with negative or discordant first-time US and 99mTc-MIBI imaging results were retrospectively studied. All 63 patients underwent second-look US, and the results were compared with intraoperative findings and histopathologic diagnosis. The diagnostic value of second-look US was calculated, and the reasons for changed second-look US results were analyzed. ResultsSixty-three parathyroid lesions were found in 63 patients. The sensitivity, positive predictive value, and accuracy of second-look US were 92.1%, 95.1%, and 88.1%, respectively. Comparing the results of first-time and second-look US, we found that 54.0% of the patients got benefits from second-look US because 34 patients with negative results in the first-time US revealed localization with second-look US. Second-look US was more likely to produce changes in results for lesions with a lower location (OR, 3.23; 95% CI, 1.11-9.43, P < .05) and larger length-to-thickness ratio (3.0 vs 2.4, P < .05). ConclusionSecond-look US is a promising method to determine preoperative localization in patients with negative or discordant results of previous imaging findings. Lesions with elongated shape and lower location are more expected to be detected in second-look US when missed at the first time.

Value of shear wave elastography during second-look breast ultrasonography for suspicious lesions on magnetic resonance imaging.

This study aimed to determine whether the addition of shear wave elastography (SWE) helps to improve diagnostic performance of second-look ultrasonography (SLUS) for suspicious lesions on magnetic resonance imaging (MRI). We retrospectively reviewed 76 breast lesions in 62 patients who underwent SLUS and SWE for suspicious lesions on MRI from August 2017 to November 2019. The six-point color scale (Ecol) and four-type color pattern (Epattern) were used for qualitative evaluation, and the mean (Emean) and maximum elasticity (Emax) and standard deviation of elasticity (ESD) were recorded as quantitative parameters. Clinical and imaging findings between benign and malignant lesions were compared, and the diagnostic performance was assessed using receiver-operating characteristic (ROC) analysis. The biopsies revealed 52 benign and 24 malignant lesions. Of all SWE parameters, only ESD was significantly higher in malignant lesions than in benign lesions (p = 0.012). The sensitivity of B-mode US was 100%, but the specificity was low (19.2%). Using SWE parameters to classify lesions improved specificity at the expense of sensitivity. When lesions assigned to Breast Imaging Reporting and Data System (BI-RADS) category 3 or 4a were reclassified considering each SWE parameter, the area under the ROC curve (AUC) and sensitivity increased. The AUC of the US BI-RADS category adjusted by ESD was higher than that of B-mode US BI-RADS (0.770 vs. 0.746). SWE parameters, and especially ESD, may play a complimentary role in improving the specificity of SLUS. However, the decision to omit biopsies for suspicious lesions with soft features should be made with caution.

Can Pre-biopsy Second-Look Breast Ultrasound Affect Clinical Management? Experience From a Single Tertiary Hospital.

ObjectivesInterpretation discrepancy is a major disadvantage of breast imaging. This study aimed to determine the clinical benefit of the pre-biopsy second-look breast ultrasound (US).MethodsPatients with suspicious breast masses referred to our tertiary hospital for US-guided breast biopsy were retrospectively reviewed between August 2017 and November 2019. Here, second-look assessments were performed by experienced specialized breast radiologists via performing a bilateral breast US scan plus reviewing former imaging studies, and results were compared with the initial assessment. Interpretation changes in terms of biopsy recommendation and surgical management (i.e., lumpectomy to mastectomy) were analyzed.ResultsA total of 537 patients were enrolled in this study. Interpretation discrepancies occurred in 109 patients (20%; 95% CI, 17%–24%). Among them, there were 84 patients (16%; 95% CI, 13%–19%) whose masses were re-classified as BI-RADS 3 by the second-look US and underwent 2-year follow-up, showing 82 benign, 1 malignant, and 1 high-risk lesions. On the other hand, 16 patients (3%; 95% CI, 2%–5%) undertook biopsy at an additional site, identifying 10 new malignant lesions, 3 high-risk lesions, and 3 benign lesions, resulting in surgical management changes in 12 patients. In addition, nine (2%; 95% CI, 1%–3%) patients received discrepant disease ranges, which also altered surgical management. Overall, 21 patients (4%; 95% CI, 3%–6%) got their surgical management altered by the second-look US.ConclusionPre-biopsy second-look assessment of breast US can reduce unnecessary biopsies in 16% of patients and alter surgical management in 4% of patients, suggesting it is a practical and valuable method for patient care improvement.

Tips for finding magnetic resonance imaging-detected suspicious breast lesions using second-look ultrasonography: a pictorial essay.

Second-look ultrasonography (US) is a targeted breast US examination that evaluates suspicious lesions detected on magnetic resonance imaging (MRI). It is a useful tool for determining the probability of malignancy and facilitating US-guided biopsy. Lesions detected on MRI and US should be correlated accurately, which is challenging in some cases. This article documents second-look US and MRI findings that are correlated with the pathology, and suggests helpful approaches for correlating between the two modalities.

The Value of Adding Ductography to Ultrasonography for the Evaluation of Pathologic Nipple Discharge in Women with Negative Mammography.

ObjectiveThe optimal imaging approach for evaluating pathological nipple discharge remains unclear. We investigated the value of adding ductography to ultrasound (US) for evaluating pathologic nipple discharge in patients with negative mammography findings.Materials and MethodsFrom July 2003 to December 2018, 101 women (mean age, 46.3 ± 12.2 years; range, 23–75 years) with pathologic nipple discharge were evaluated using pre-ductography (initial) US, ductography, and post-ductography US. The imaging findings were reviewed retrospectively. The standard reference was surgery (70 patients) or > 2 years of follow-up with US (31 patients). The diagnostic performances of initial US, ductography, and post-ductography US for detecting malignancy were compared using the McNemar’s test or a generalized estimating equation.ResultsIn total, 47 papillomas, 30 other benign lesions, seven high-risk lesions, and 17 malignant lesions were identified as underlying causes of pathologic nipple discharge. Only eight of the 17 malignancies were detected on the initial US, while the remaining nine malignancies were detected by ductography. Among the nine malignancies detected by ductography, eight were detected on post-ductography US and could be localized for US-guided intervention. The sensitivities of ductography (94.1% [16/17]) and post-ductography US (94.1% [16/17]) were significantly higher than those of initial US (47.1% [8/17]; p = 0.027 and 0.013, respectively). The negative predictive value of post-ductography US (96.9% [31/32]) was significantly higher than that of the initial US (83.3% [45/54]; p = 0.006). Specificity was significantly higher for initial US than for ductography and post-ductography US (p = 0.001 for all).ConclusionThe combined use of ductography and US has a high sensitivity for detecting malignancy in patients with pathologic nipple discharge and negative mammography. Ductography findings enable lesion localization on second-look post-ductography US, thus facilitating the selection of optimal treatment plans.

Synchronous BI-RADS category 3 lesions detected by preoperative breast MRI in patients with breast cancer: may follow-up be adequate?

The purpose of this study was to analyze the rate of malignancy of synchronous Breast Imaging Reporting and Data System (BI-RADS) category 3 lesions identified by preoperative magnetic resonance imaging (MRI) in patients with breast cancer that were followed up rather than biopsied. From electronic medical records, we identified 99 patients treated in our institution for whom preoperative breast MRI identified synchronous BI-RADS 3 lesions. Lesion characteristics, rate of second-look ultrasonography (US), rate of collegial decision-making, and rate of biopsies performed during the period of monitoring were analyzed. Second-look US was performed in 96 of 99 patients and did not reveal any lesion. Collegial decision-making for follow-up validation was asked in 32%. The median time to last MRI was 24.4 months (interquartile range [IQR] [19.3; 36.3]). The median follow-up was 39 months (IQR [28; 52]). Two cancers were diagnosed, one at 5 months and one at 26 months of follow-up. The incidence of malignancy of followed up synchronous BI-RADS category 3 lesions was 1.0% (95% CI [0.1%; 7.1%]) at 6 months and 2.2% (95% CI [0.6%; 8.6%]) at 30 months. Monitoring could be proposed for synchronous BI-RADS category 3 lesions detected in preoperative breast cancer patients. A continued follow-up beyond 2 years could be of benefit. • Follow-up can be proposed for MRI BI-RADS category 3 lesions not detected at second-look ultrasound, possibly after a collegial decision. • Follow-up should be continued annually since cancer may occur beyond 2 years.

Assessment of MRI-Detected Breast Lesions: A Benign Correlate on Second-Look Ultrasound Can Safely Exclude Malignancy

Introduction: Due to the increasing use of dynamic breast MRI and the limited availability of MR-guided interventions, MRI-detected lesions usually undergo a second-look ultrasound (SLUS). We investigated the safety of a negative SLUS and a benign SLUS correlate in excluding malignant and high-risk lesions (B3) and evaluated criteria for the rate of detection on SLUS. Methods: In the retrospective analysis, all breast MRIs performed between 2011 and 2013 were screened for newly detected lesions. We analyzed the SLUS detection rate dependent on breast density, mass character, lesion size, and histology. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a negative and benign SLUS for malignant lesions (B5) and lesions requiring surgical excision (including high-risk and B5 lesions). Results: We successfully correlated 110 of 397 lesions. The detection rate was significantly higher for mass than for non-mass lesions and correlated with lesion size for mass lesions only. Lesions without/with a benign SLUS correlate were more frequently benign (including B3) or required no further procedure (B2). The sensitivity of SLUS in the detection of B3 and B5 lesions was 58%, and 73% in the detection of B5 lesions. The NPV of a negative or benign SLUS for B3 and B5 lesions was 89%, and 96% for B5 lesions. Discussion: SLUS is a safe diagnostic tool for the management of MRI-detected lesions and can spare patients from undergoing invasive procedures.

Second Look Ultrasonography-Guided Breast Biopsy with Magnetic Resonance Imaging Confirmation by Intralesional Contrast Injection.

This study aimed to introduce an alternative pre-biopsy confirmation technique that combines sonography-guided intra-lesional contrast injections and single non-enhanced magnetic resonance imaging (MRI) pulse sequence in order to identify sonographic correlates of incidentally detected breast MRI lesions which were occult on primary ultrasonography (USG) and mammography examination. From May 2014 through May 2015, a total of 37 incidental breast lesions of 37 patients, which were detected by breast MRI, were evaluated with targeted second look ultrasound (SLUS). The suspected lesion on USG was marked with a gadolinium-based contrast agent under USG guidance. After a single non-enhanced T1 weighted control MR sequence, positively correlated lesions with initial MRI were sampled by USG guided core biopsy. Of the 37 lesions evaluated, 32 (86%) lesions showed a correlation between MRI and SLUS findings. On SLUS core biopsy, there were eight (25%) malignant and 11 (34.4%) high-risk lesions among these 32 cases with correlated MRI findings; while the remaining 13 (40.6%) cases had benign histopathology. Eleven (34.4%) of the SLUS-discovered lesions were focus, 11 (34.4%) were non-mass enhancements, and the remaining 10 (31.2%) were mass lesions. Of the five lesions (13.5%) that showed no correlations on MRI and SLUS examinations, four were non-mass enhancements and one was focus. SLUS represents a method for identifying MRI-detected lesions and provides a bridge to ultrasound-guided biopsy for histopathological diagnosis. There is a need for confirmation of biopsies to avoid false negative results. We describe a cheap, safe, and easy-to-apply USG-guided pre-biopsy lesions marking method in order to ensure definite correlation.

Can second-look ultrasound downgrade MRI-detected lesions? A retrospective study

PurposeTo determine whether MRI-detected suspicious (BIRADS 4 & 5) breast lesions can be downgraded using second-look ultrasound (SLU) and thus reduce unnecessarily performed breast biopsies. Materials methodsA retrospective single-center review of consecutive patients, who underwent breast MRI studies during a 12-month time period was performed. 94 patients with 103 lesions undergoing SLU of incidentally detected MRI BI-RADS 4&5 lesions which were not identified on previous ultrasound were included in the study. The SLU detection rate and SLU features of the lesions were assessed. Histology (91/103) or two year follow up (n = 12) were defined as the reference standard for lesion diagnosis. Results57 (55.3 %) of the 103 lesions were identified on SLU. 17 of the identified lesions were malignant (29.8 %). Lesions detected on ultrasound presented on MRI as masses in 66.7 % (38/57) and non-mass in 33.3 % (19/57). Our findings showed that it is possible to distinguish between malignant and benign lesions with SLU. The results were significant (p < 0.05) for the following morphological features: shape, orientation, margins, architectural distortion, hyperechoic rim/ edema. All lesions classified as SLU BI-RADS 2 in our study were benign and thus, 30 % of all unnecessary biopsies could potentially have been avoided. Including SLU BI-RADS 3 lesions, this rate increased to 60 %, while yielding one (of 17, 5.8 %) false negative result. All three BI-RADS 5 lesions detected by SLU presented as malignant on ultrasound. ConclusionSLU can potentially downgrade incidental MRI BIRADS 4 lesions. This may reduce the number of unnecessarily performed biopsies by 30–60 %, thus simplifying patient management.