Suspicious Imaging Findings Research Articles

Pseudoangiomatous stromal hyperplasia: overview and clinical management

: Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal lesion of the breast characterized by dense collagenous stroma forming “pseudoangiomatous” capillary-like spaces lined by slender spindle cells. A rare condition overall, PASH is most common in premenopausal women, though cases have been described at ages ranging from 14 to 86, and in men, usually associated with gynecomastia. While the exact etiology is unknown, PASH is considered hormonally responsive, with myofibroblastic proliferation leading to stromal hyperplasia. It may present as a palpable mass or an incidental imaging finding. The usual appearance on mammography and ultrasound is that of a well-circumscribed mass which must be differentiated from other benign and malignant lesions such as fibroadenoma, phyllodes tumor, and myofibroblastoma; histologically it must be distinguished from angiosarcoma. Core needle biopsy is indicated for diagnosis and must be concordant with imaging and clinical findings. PASH lesions should be surgically excised if enlarging, associated with symptoms, suspicious imaging findings are present, or other lesions are synchronously diagnosed that warrant removal; otherwise, observation with clinical and imaging follow-up can be considered. Progression and recurrence, each reported at rates of approximately 15–20%, indicate change in management and/or additional surgical intervention. PASH is not associated with an increased risk of breast cancer and prognosis is generally favorable.

Incidentally discovered COVID-19 in low-suspicion patients-a threat to front line health care workers.

PurposeThe COVID-19 pandemic has been responsible for thousands of deaths worldwide. Testing remains at a premium, and criteria for testing remains reserved for those with lower respiratory infection symptoms and/or a known high-risk exposure. The role of imaging in COVID-19 is rapidly evolving; however, few algorithms include imaging criteria, and it is unclear what should be done in low-suspicion patients with positive imaging findings.MethodsFrom 03/01/2020–03/20/2020, a retrospective review of all patients with suspected COVID-19 on imaging was performed. Imaging was interpreted by a board-certified, fellowship-trained radiologist. Patients were excluded if COVID-19 infection was suspected at the time of presentation, was the reason for imaging, or if any lower respiratory symptoms were present.ResultsEight patients with suspected COVID-19 infection on imaging were encountered. Seven patients received testing due to suspicious imaging findings with subsequent lab-confirmed COVID-19. No patients endorsed prior exposure to COVID-19 or recent international travel. COVID-19 was suggested in six patients incidentally on abdominal CT and two on chest radiography. At the time of presentation, no patients were febrile, and seven endorsed gastrointestinal symptoms. Five COVID-19 patients eventually developed respiratory symptoms and required intubation. Two patients expired during the admission.ConclusionsPatients with imaging findings suspicious for COVID-19 warrant prompt reverse transcription polymerase chain reaction (RT-PCR) testing even in low clinical suspicion cases. The prevalence of disease in the population may be underestimated by the current paradigm of RT-PCR testing with the current clinical criteria of lower respiratory symptoms and exposure risk.

Abstract P5-16-04: Evaluation of autologous fat grafting local morbidity (fat necrosis and biopsy rates) in breast reconstruction after breast cancer: A retrospective study on 257 patients in Oscar Lambret Center

Abstract Background.Autologous fat grafting (AFG) is a widely used procedure in breast reconstruction after breast cancer. Indications are in constant increase but there is a lack of dataabout global morbidity, especially fat necrosis and management of local complications. The purpose of this study was to evaluate the complications rate in term of abnormal clinical examination or imaging and the proportion of additional explorations. Methods. We retrospectively reviewed the computerized files of consecutive patients who underwent AFG for breast reconstruction after breast cancer or for preventive surgery and aesthetic sequelae after lumpectomy in the Oscar Lambret center between January 2013 and December 2016. Fat grafts were harvested with a fat trap then processed and injected according the Coleman technique. We collected demographics, operative details, local complications, incidence of palpable masses and/or suspicious breast imaging findings leading to additional explorations (breast imaging or biopsy), and locoregional cancer recurrence. Descriptive statistics were generated. Results. Over a 4-year period, 257 women underwent autologous fat grafting for breast reconstruction and aesthetic sequelae after lumpectomy. Their mean age was 50 years [range 28-75], the mean BMI was 25 [range 18-44], 26% (n=66) were smoking and 74% (n=190) underwent radiotherapy. A total of 303 breasts were operated by 270 mastectomies (89%) or33 lumpectomies (11%). The reconstruction was delayed in 63% (n=171) and the main techniques used were breast implant (44%, n=119) and autologous latissimus dorsi (31%, n=84). The mean number of fat grafting procedures was 1,9 per patient [range 1-7] with a mean volume of 181 mL [range 30-535]. The mean time interval between cancer diagnosis and first fat graft session was 56 months [range 3-285], and the follow-up ranged from 0 to 51 months (mean=16). The prevalence of donor site complications was 6% (n=16) and infections was 2% (n=5). Sixty six (25,6%) patients had a clinically palpable lesion and 54 (21%) underwent additional imagings, mostly by ultrasounds (53 patients, 98%) except the usual follow-up. Twenty one biopsies (8%) were performed and showed 16 benign results (76,2%) and 5 malignant results (23,8%) leading to 6,2% of fat necrosis and 1,9% of locoregional recurrence after AFG in our study.Tobacco (p=0.45), BMI (p=0.95), radiotherapy (p=0.56) and amount of fat grafted ( p=0.09) didn't appear to be risk factors for fat necrosis. Conclusions. A good knowledge of local complications by surgeons and radiologists enables to avoid systematic and repeated further imaging explorations. Multicentric, prospective studies with long term follow up and evaluation of patients reported outcomes are needed to evaluate anxiety generated by biopsies and costs generated by repeated imagings. Key words: autologous fat grafting, breast cancer, local morbidity, fat necrosis. Citation Format: Hannebicque K, Renaudeau C, Giard S, Regis C, Boulanger L, Bogart E, Le Deley M-C, Ceugnart L, Chauvet M-P. Evaluation of autologous fat grafting local morbidity (fat necrosis and biopsy rates) in breast reconstruction after breast cancer: A retrospective study on 257 patients in Oscar Lambret Center [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-04.

Charcoal granuloma mimicking breast cancer: an emerging diagnosis.

BackgroundImage-guided charcoal injection in suspicious breast lesions for preoperative localization is a procedure that has been increasing over the years because it is safer, faster, and more affordable when compared to needle-wire preoperative localization. To date, no complications have been associated with the method. However, in recent years there have been some reports about charcoal granulomas mimicking malignant lesions in some postoperative patients or in a conservative follow-up.PurposeTo report a series of 11 cases which had suspicious imaging findings for malignancy and resulted in charcoal granulomas on histopathological analysis.Material and MethodsA database of 1650 patients that attended our center from January 2007 to June 2018 was reviewed and detected 495 patients who had been previously submitted to ultrasound-guided charcoal marking in a breast lesion. Then, patients whose imaging studies were compatible with new suspicious lesions on mammography, breast ultrasound, and/or magnetic resonance imaging and biopsy of this new lesion indicating charcoal granuloma were selected.ResultsFrom 495 patients who had undergone charcoal localization injections in previous biopsies, we selected 11 who had new lesions with malignant characteristics on imaging studies but histopathological analysis resulted in charcoal granuloma.ConclusionCharcoal granuloma should be considered in patients with previous preoperative injection localization, since the residual charcoal in the breast tissue may form granulomas and mimic malignant lesions on follow-up imaging studies.

Autologous fat grafting to lumpectomy defects: complications, imaging, and biopsy rates

BackgroundAutologous fat grafting is emerging as a promising reconstructive technique after breast conservation therapy (BCT). Recent evidence suggests that autologous fat grafting does not increase the risk of cancer recurrence; however, women may still be subject to unnecessary biopsies secondary to suspicious radiologic findings. The purpose of this study was to assess surgical complications and biopsy rates in these patients. MethodsWe retrospectively reviewed the records of women who underwent autologous fat grafting after BCT at a single institution over a 6-y period. Independent variables included demographic and operative details. Outcome variables included complications, and incidence of palpable masses and/or suspicious breast imaging findings requiring biopsy. Descriptive statistics were generated. ResultsBetween June 2008 and February 2015, 37 women aged 41 to 74 y (mean 54.4 y) underwent a total of 56 fat grafting sessions for correction of contour deformities after BCT. The mean number of fat grafting procedures was 1.5 (range 1-4) per breast. Follow-up ranged from 1 to 99 mo (mean 29.5 mo). Imaging data were available for 31 (83.7%) breasts after autologous fat grafting. Biopsy was recommended in four cases after suspicious imaging findings or palpable masses (10.8%), with benign pathology in all cases. There was one incidence of a local wound infection. No other local or systemic complications were noted. ConclusionsOur study demonstrated a risk of unnecessary biopsies after autologous fat grafting. Complication rates were low, and it appears to be a safe reconstructive option for the correction of contour deformities after BCT.

Breast density does not impact the ability of Videssa® Breast to detect breast cancer in women under age 50.

Breast density is associated with reduced imaging resolution in the detection of breast cancer. A biochemical approach that is not affected by density would provide an important tool to healthcare professionals who are managing women with dense breasts and suspicious imaging findings. Videssa® Breast is a combinatorial proteomic biomarker assay (CPBA), comprised of Serum Protein Biomarkers (SPB) and Tumor Associated Autoantibodies (TAAb) integrated with patient-specific clinical data to produce a diagnostic score that reliably detects breast cancer (BC) as an adjunctive tool to imaging. The performance of Videssa® Breast was evaluated in the dense (a and b) and non-dense (c and d) groups in a population of n = 545 women under age 50. The sensitivity and specificity in the dense breast group were calculated to be 88.9% and 81.2%, respectively, and 92.3% and 86.6%, respectively, for the non-dense group. No significant differences were observed in the sensitivity (p = 1.0) or specificity (p = 0.18) between these groups. The NPV was 99.3% and 99.1% in non-dense and dense groups, respectively. Unlike imaging, Videssa® Breast does not appear to be impacted by breast density; it can effectively detect breast cancer in women with dense and non-dense breasts alike. Thus, Videssa® Breast provides a powerful tool for healthcare providers when women with dense breasts present with challenging imaging findings. In addition, Videssa® Breast provides assurance to women with dense breasts that they do not have breast cancer, reducing further anxiety in this higher risk patient population.

Intralesional Injection of Collagenase Clostridium histolyticum May Increase the Risk of Late-Onset Penile Fracture.

The use of intralesional injection of collagenase Clostridium histolyticum (CCH) has become a valid treatment option in the management of Peyronie's disease (PD). Multiple studies have shown the drug's safety and efficacy. However, sparse literature exists on the utility of the injection protocol's 14-day "observation period," in which patients are instructed to abstain from all sexual activity. To summarize the contemporary literature and report on our series of patients treated with CCH in an effort to explore the effectiveness of the postinjection observation period. We retrospectively reviewed the clinical course of men treated with at least one CCH injection at our institution from April 2014 through February2017. The main outcome measure for our cohort was complication rate (hematoma, fracture). Secondary outcomes included progression to corrective surgery. Of the 102 patients treated, 5 (4.9%) developed a corporal fracture. Four of these occurred outside the 14-day observation period. One fracture was managed conservatively and the rest underwent surgical exploration and repair. Twelve penile hematomas were reported; one of these patients was surgically explored because of suspicious magnetic resonance imaging findings. Seven patients (6.9%) progressed to corrective surgery. Penile hematoma and corporal fracture are serious complications that must be discussed with patients before initiation of intralesional CCH treatment. Little evidence exists to direct physicians on the proper management of post-CCH penile fractures; many caregivers and patients elect to treat these injuries conservatively and avoid surgical exploration. Further studies are warranted to generate discussion and reassessment regarding the safety and effectiveness of this 14-day observation period. Beilan JA, Wallen JJ, Baumgarten AS, Morgan KN, Parker JL, Carrion RE. Intralesional Injection of Collagenase Clostridium histolyticum May Increase the Risk of Late-Onset Penile Fracture. Sex Med Rev 2018;6:272-278.

A Noninvasive Blood-based Combinatorial Proteomic Biomarker Assay to Detect Breast Cancer in Women Under the Age of 50 Years

BackgroundDespite significant advances in breast imaging, the ability to detect breast cancer (BC) remains a challenge. To address the unmet needs of the current BC detection paradigm, 2 prospective clinical trials were conducted to develop a blood-based combinatorial proteomic biomarker assay (Videssa Breast) to accurately detect BC and reduce false positives (FPs) from suspicious imaging findings. Patients and MethodsProvista-001 and Provista-002 (cohort one) enrolled Breast Imaging Reporting and Data System 3 or 4 women aged under 50 years. Serum was evaluated for 11 serum protein biomarkers and 33 tumor-associated autoantibodies. Individual biomarker expression, demographics, and clinical characteristics data from Provista-001 were combined to develop a logistic regression model to detect BC. The performance was tested using Provista-002 cohort one (validation set). ResultsThe training model had a sensitivity and specificity of 92.3% and 85.3% (BC prevalence, 7.7%), respectively. In the validation set (BC prevalence, 2.9%), the sensitivity and specificity were 66.7% and 81.5%, respectively. The negative predictive value was high in both sets (99.3% and 98.8%, respectively). Videssa Breast performance in the combined training and validation set was 99.1% negative predictive value, 87.5% sensitivity, 83.8% specificity, and 25.2% positive predictive value (BC prevalence, 5.87%). Overall, imaging resulted in 341 participants receiving follow-up procedures to detect 30 cancers (90.6% FP rate). Videssa Breast would have recommended 111 participants for follow-up, a 67% reduction in FPs (P < .00001). ConclusionsVidessa Breast can effectively detect BC when used in conjunction with imaging and can substantially reduce unnecessary medical procedures, as well as provide assurance to women that they likely do not have BC.

Abstract P5-03-03: A blood-based proteomic Videssa® breast assay performs comparably in women with dense and non-dense breasts

Abstract Breast density is associated with reduced imaging sensitivity and specificity for breast cancer (BC). Women with dense breasts are at a four- to six-fold increased risk of developing BC. A biochemical approach that is not affected by density would provide an additional tool to health-care professionals who are managing women with dense breasts and suspicious imaging findings. Videssa® Breast, a combinatorial proteomic biomarker assay, comprised of Serum Protein Biomarkers (SPBs) and Tumor –Associated Autoantibodies (TAAbs) integrated with clinical characteristic data to produce one diagnostic score that reliably detects BC was recently developed as an adjunctive tool to imaging. The goal of this study was to determine whether the diagnostic performance of Videssa® Breast was impacted by breast density. Provista-001 enrolled 351 participants under the age of 50 years with no prior history of breast biopsy, and Provista-002 cohort one enrolled 210 participants under the age of 50 years with no history of breast biopsy within six months; all participants were assessed as BI-RADS 3 or 4. Breast density status was retrospectively obtained for participants; the four American College of Radiology breast density categories (a, b, c, and d) used for clinical reporting were applied. Serum was collected and tested with Videssa® Breast. Women were categorized into Dense, which included categories c and d, and Non-dense, which included categories a and b, groups. To understand the performance of Videssa® Breast in women with dense breasts, the clinical sensitivity, specificity, NPV and PPV were evaluated in the dense and non-dense groups from the comprehensive Provista-001 and Provista-002 set (n=545). Of these 545, breast density information was available for 454; 62.6% (n=284) were categorized as having dense breasts and 37.4% (n=170) were categorized as having non-dense breasts. The sensitivity of Videssa® Breast in the non-dense and dense groups was 92.3% and 88.9%, respectively, and the specificity in the non-dense and dense groups was 86.6% and 81.2%, respectively. No significant differences were observed in the sensitivity (p=1.0) or specificity (p=0.1783) of Videssa® Breast in detecting BC in participants with non-dense breasts compared to those with dense breasts. The NPV in both groups exceeded 99%; the PPV was similar across groups. In summary, this study demonstrates that Videssa® Breast has comparable performance in women with dense and non-dense breasts. Videssa® Breast demonstrates high sensitivity and specificity for detecting BC (Grades I through III), irrespective of density status. Videssa® breast provides an additional tool for health-care providers when women with dense breasts present with challenging imaging findings. In addition, Videssa® breast provides assurance to a woman with dense breasts that she does not have BC, potentially reducing further anxiety in this higher risk patient population. Citation Format: Silver M, Tran Q, Gordon K, Benson KL, Henderson MC, Letsios E, Mulpuri R, Reese DE. A blood-based proteomic Videssa® breast assay performs comparably in women with dense and non-dense breasts [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-03-03.

Sonographic Appearance is Useful in Predicting the Extent of Initial Operative Therapy for Thyroid Nodules Classified as “Suspicious for Malignancy”

The "suspicious for malignancy" (SFM) category of the Bethesda system for reporting thyroid cytopathology predicts an incidence of malignancy from 60 to 75 per cent. Recommended treatment is via either lobectomy or total/near total thyroidectomy. Identification of predictors of malignancy in this category would be useful in selecting the extent of operative therapy in these patients. Published literature has suggested that suspicious ultrasound (US) findings are useful in predicting malignancy in both the "benign," "atypia of uncertain significance/follicular lesion of uncertain significance," and "suspicious for follicular neoplasm" categories. We hypothesized that US would be similarly useful in patients with nodules classified as SFM. We performed a retrospective analysis of patients with fine needle aspiration biopsy (FNAB) classified as SFM who underwent thyroidectomy from October 2007 to October 2012. Data collected included symptoms, suspicious imaging findings, FNAB results, and histopathology results-all obtained via chart review. Findings were compared between patients with/without a diagnosis of thyroid malignancy. Significance was set at P < 0.05. Of 3839 FNAB, 53 were classified as SFM. Of these, 36 were available for review. Twenty-four (66.7%) carcinomas were identified-19 papillary, 3 follicular variant of papillary, 1 follicular, and 1 medullary. No symptoms/signs reached significance as a predictor of malignancy. A suspicious US appearance, however, was significantly associated with an underlying carcinoma (P = 0.002). Patients with a Bethesda system for reporting thyroid cytopathology report of SFM and suspicious US findings are statistically more likely to harbor an underlying malignancy. This information is useful in selecting which patients are most likely to benefit from total/near total thyroidectomy as opposed to lobectomy as the initial operative strategy.

Autologous Fat Grafting After Breast Reconstruction in Postmastectomy Patients: Complications, Biopsy Rates, and Locoregional Cancer Recurrence Rates.

Autologous fat grafting is widely used for refinements in postmastectomy breast reconstruction. However, there are few studies evaluating outcomes in this patient population. The purpose of this study was to assess outcomes of autologous fat grafting after breast reconstruction in postmastectomy patients. We retrospectively reviewed the records of consecutive postmastectomy patients who underwent autologous fat grafting after breast reconstruction at a university center over a 5-year period. Patients with at least 6 months of follow-up were included. Medical records were reviewed for demographics, operative details, complications, incidence of palpable masses, and/or suspicious breast imaging findings requiring biopsy, and locoregional cancer recurrence. Descriptive statistics were generated. Between January 2008 and July 2013, 108 women and a total of 167 breast reconstructions underwent autologous fat grafting for revision of postmastectomy breast reconstruction. Their ages ranged from 22 to 71 years (mean, 48 years). Fat grafts were harvested, processed, and injected using the Coleman technique. The mean number of fat grafting procedures was 1.3 (range, 1-4) per breast. Follow-up ranged from 6 to 57 months (mean, 20.2 months). Fifty-three (31.7%) breasts underwent imaging after autologous fat grafting. Suspicious imaging findings requiring biopsy were discovered in 4 (2.4%) breasts, and clinically palpable lesions combined with suspicious imaging findings requiring biopsy were present in another 4 (2.4%) breasts. All 8 biopsies showed fat necrosis, scar, or oil cysts without evidence of malignancy. One (0.6%) local complication (a wound infection at the recipient site requiring oral antibiotics) after autologous fat grafting was reported. During the limited follow-up period, there were no locoregional cancer recurrences. Autologous fat grafting in conjunction with breast reconstruction resulted in a biopsy rate of 4.8%, and no cases of locoregional cancer recurrence were observed. Based on these preliminary findings, autologous fat grafting appears to be a relatively safe procedure for refinement of the reconstructed breast in postmastectomy patients.

Lateral Lymph Node Metastasis Prediction in Papillary Thyroid Cancer Patients with Suspicious Preoperative Imaging Findings

Lateral Lymph Node Metastasis Prediction in Papillary Thyroid Cancer Patients with Suspicious Preoperative Imaging Findings

Lateral Lymph Node Metastasis Prediction in Papillary Thyroid Cancer Patients with Suspicious Preoperative Imaging Findings

Lateral Lymph Node Metastasis Prediction in Papillary Thyroid Cancer Patients with Suspicious Preoperative Imaging Findings

Randomized controlled clinical trial comparing radioguided occult lesion localization with wire-guided lesion localization to evaluate their efficacy and accuracy in the localization of nonpalpable breast lesions

The aim of this study was to compare the radioguided occult lesion localization (ROLL) technique with the wire-guided lesion localization (WGLL) technique to assess their efficacy and accuracy in the localization of nonpalpable breast lesions in patients at a unique reference medical center. These patients' reports were negative for malignancy but included highly suspicious imaging findings. A controlled clinical trial was designed to compare the WGLL and ROLL techniques in women presenting with breast lesions diagnosed by mammography or ultrasonography at the Instituto Nacional de Cancerología in Bogotá, Colombia, from March 2006 to June 2011. This study examined 129 patients; 64 (49.6%) patients were treated with ROLL, and 65 (51.4%) were treated with WGLL. The ROLL technique achieved better median lesion centricity (ROLL = 11.7 and WGLL = 15.4; P = .038). No significant differences were found regarding demographic variables, operative specimen characteristics, the need to extend margins, operative complications, the degree of difficulty, or patient or surgeon satisfaction. The ROLL technique is as effective as WGLL for the localization of nonpalpable breast lesions. In our study, ROLL achieved better lesion centricity. Therefore, we propose that this technique could be used as a standard procedure in the detection of nonpalpable breast lesions at experienced centers.

Accuracy and Adequacy of Computed Tomography–Guided Lung Biopsies: Experience From a Community Hospital

Small tissue biopsies obtained through minimally invasive methods have become the primary diagnostic tools for the pathologic characterization and testing of lung masses. In view of recent advances in targeted therapy for non-small cell lung carcinoma, and lung adenocarcinoma in particular, pathologists are now expected to thoroughly characterize lung lesions microscopically while making certain that enough tissue remains for potential molecular analysis if indicated. To report our experience with computed tomography (CT)-guided lung needle biopsies with particular concentration on diagnostic yield, diagnostic accuracy, and adequacy of tissue for molecular testing if indicated. A retrospective observational study analyzed 224 biopsies in 222 patients undergoing CT-guided lung needle biopsies. Accuracy of diagnosis and adequacy of tissue for molecular testing, if applicable, was evaluated. A standardized protocol for specimen evaluation, triage, and processing was used. This protocol included intraprocedural real-time microscopic specimen evaluation and triage by a pathologist and use of a histologic protocol specifically designed to conserve tissue for ancillary testing. The initial biopsy was considered successful if the specimen was malignant, had specific benign features, or had nonspecific benign features with follow-up supporting benign lesion. Initial biopsy failure cases were those with inadequate tissue or a nonspecific result with highly suspicious imaging or clinical findings. Of the 224 biopsies, 8 cases with benign but nonspecific findings lacked follow-up and were excluded from the study. The biopsy was diagnostically successful in 189 of 216 (88%) cases. Of these 189 cases, 154 (81%) were malignant, and 35 (19%) were benign. There were 28 diagnostic failures. Subsequent tissue sampling of 13 of 28 diagnostic failures found 9 (69%) to be malignant. Molecular studies were requested on 25 cases: 24 had sufficient material for some of the requested tests, and 20 had enough tissue for all requested testing. A standardized protocol and team approach for CT-guided lung needle biopsy optimizes the ability to achieve a high accurate diagnostic yield with adequate tissue for molecular testing.

Development and Validation of Electronic Health Record-based Triggers to Detect Delays in Follow-up of Abnormal Lung Imaging Findings.

Purpose To develop an electronic health record (EHR)-based trigger algorithm to identify delays in follow-up of patients with imaging results that are suggestive of lung cancer and to validate this trigger on retrospective data. Materials and Methods The local institutional review board approved the study. A "trigger" algorithm was developed to automate the detection of delays in diagnostic evaluation of chest computed tomographic (CT) images and conventional radiographs that were electronically flagged by reviewing radiologists as being "suspicious for malignancy." The trigger algorithm was developed through literature review and expert input. It included patients who were alive and 40-70 years old, and it excluded instances in which appropriate timely follow-up (defined as occurring within 30 days) was detected (eg, pulmonary visit) or when follow-up was unnecessary (eg, in patients with a terminal illness). The algorithm was iteratively applied to a retrospective test cohort in an EHR data warehouse at a large Veterans Affairs facility, and manual record reviews were used to validate each individual criterion. The final algorithm aimed at detecting an absence of timely follow-up was retrospectively applied to an independent validation cohort to determine the positive predictive value (PPV). Trigger performance, time to follow-up, reasons for lack of follow-up, and cancer outcomes were analyzed and reported by using descriptive statistics. Results The trigger algorithm was retrospectively applied to the records of 89 168 patients seen between January 1, 2009, and December 31, 2009. Of 538 records with an imaging report that was flagged as suspicious for malignancy, 131 were identified by the trigger as being high risk for delayed diagnostic evaluation. Manual chart reviews confirmed a true absence of follow-up in 75 cases (trigger PPV of 57.3% for detecting evaluation delays), of which four received a diagnosis of primary lung cancer within the subsequent 2 years. Conclusion EHR-based triggers can be used to identify patients with suspicious imaging findings in whom follow-up diagnostic evaluation was delayed. (©) RSNA, 2015.

Mammographic and Sonographic Features of Triple-Negative Invasive Carcinoma of No Special Type

The aim of this study was to compare the mammography, ultrasound (US) and histologic features of triple-negative (TN) invasive carcinoma of no special type (NST) to non-TN invasive carcinoma of NST. The second aim was to assess whether the distinct imaging characteristics of TN breast cancer would persist after controlling for the histologic features. A total of 344 invasive carcinomas of NST in 337 patients from January 2007 to February 2008 were included in this study. Two radiologists retrospectively reviewed the mammography and US findings using the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) lexicon and our institution's criteria. On mammography, TN invasive carcinoma of NST most commonly presented as a mass with round shape and non-spiculated margin. On US, it was more likely to have internal hypoechogenicity, an abrupt boundary and posterior acoustic enhancement. TNBC lacked major suspicious imaging findings such as an irregular shape, spiculated margin and calcification.

Detection of Significant Prostate Cancer with Magnetic Resonance Targeted Biopsies—Should Transrectal Ultrasound-Magnetic Resonance Imaging Fusion Guided Biopsies Alone be a Standard of Care?

Magnetic resonance imaging-transrectal ultrasound fusion targeted prostate biopsies were suggested to detect significant cancer with more accuracy than systematic biopsies. In this study we evaluate the pathological characteristics of multiparametric magnetic resonance imaging detected and undetected tumor foci on radical prostatectomy specimens. We selected 125 consecutive patients treated with radical prostatectomy for clinically localized prostate cancer diagnosed on magnetic resonance imaging-transrectal ultrasound targeted biopsy and/or systematic biopsy. On multiparametric magnetic resonance imaging each suspicious area was graded according to the PI-RADS score. On radical prostatectomy specimen, tumor foci with a Gleason score greater than 3+3 and/or tumor volume greater than 0.5 ml were considered significant. A correlation analysis between multiparametric magnetic resonance imaging and pathological findings was performed. Pathological analysis of radical prostatectomy specimens detected 230 tumor foci. Of these, 137 were considered significant (Gleason score greater than 3+3 in 112) and were observed in 111 (89%) glands. A total of 95 individual tumor foci, including 14 significant foci, were missed with multiparametric magnetic resonance imaging. All of them were located in glands where another focus was detected with multiparametric magnetic resonance imaging. An additional 9 individual tumor foci, including 7 significant, were detected on multiparametric magnetic resonance imaging but missed with targeted biopsy, resulting in 5 (4%) significant cancers undetected with magnetic resonance imaging-transrectal ultrasound fusion targeted biopsy. The magnetic resonance imaging target largest diameter was associated with high volume (greater than 0.5 cc) foci detection, while PI-RADS score and cancer involvement on targeted biopsy were associated with significant foci detection. In these series of men with suspicious prostate multiparametric magnetic resonance imaging findings, magnetic resonance imaging-transrectal ultrasound fusion guided targeted biopsy alone strategy would have resulted in the under detection of only 4% significant cancers.

Breast imaging findings in haematological malignancies.

ObjectivesThe objectives of this article are to review and illustrate the imaging appearances of haematological malignancies in the breast.MethodsWith Institutional Review Board approval, a search of the surgical pathology records from 1st January 2000 to 1st July 2012 was performed for haematological malignancies.ResultsForty-eight cases of haematological malignancies (42 women and 6 men) were identified with imaging available for review: 39 cases of breast lymphoma, 6 cases of chronic lymphocytic leukaemia, 2 cases of acute leukaemia and 1 case of known multiple myeloma.ConclusionsBreast manifestations of haematological malignancies are rare. They can have a variable appearance at imaging and can mimic primary breast carcinoma. In the setting of suspicious breast imaging findings, pathological diagnosis of haematological malignancy is concordant. Correlation with a clinical history of prior haematological malignancy can be helpful in suggesting the diagnosis and help prevent unnecessary surgical treatment.Teaching Points• Breast haematological malignancies are rare but the imaging appearances can mimic breast carcinoma.• Breast lymphoma, most often B-cell non-Hodgkin lymphoma, may be primary or due to secondary disease.• At ultrasound, haematological malignancies may present as a heterogeneous or predominantly echogenic mass.• Haematological malignancies show intense activity on PET/CT except myeloma which has low FDG uptake.

Columnar Cell Lesions Without Atypia Initially Diagnosed on Breast Needle Biopsies: Is Imaging Follow-Up Enough?

The purpose of this study was to evaluate the underestimation rate and predictive factor of underestimation of columnar cell lesions (CCLs) without atypia diagnosed through breast core needle biopsies (CNBs). From January 2007 through December 2011, 141 CCLs without atypia, including columnar cell change and columnar cell hyperplasia, were diagnosed in 138 women by CNB. Excisional (n = 16) or imaging follow-up (n = 125) findings were available in all cases. On a per-lesion basis, the underestimation rate and predictive factor of underestimation were evaluated. Among the 16 surgically excised lesions, there were two malignancies (one ductal carcinoma in situ and one invasive ductal carcinoma) and one lobular carcinoma in situ. Overall, the pooled underestimation rate of malignancy was 1.4% (2/141). With regard to lesion variables, the mean lesion size was significantly larger in the underestimation group of CCLs (p = 0.007). Fine pleomorphic morphology of microcalcifications (p < 0.001), the distribution of the microcalcifications (p = 0.007), BI-RADS final assessment (p = 0.001), and imaging-pathologic correlation (p < 0.001) were significantly associated with underestimation. Multivariate analysis showed that fine pleomorphic morphology of microcalcifications (p < 0.0001) was an independent predictor of underestimation in 58 lesions with microcalcifications on mammography. The overall underestimation rate of malignancy was 1.4%. Imaging follow-up is reasonable for CCLs without atypia at CNB, especially in small lesions with less suspicious imaging findings. Fine pleomorphic microcalcifications and higher BI-RADS category might be helpful in the prediction of underestimation of a high-risk lesion or malignancy.