Imaging and Histopathologic Features of BI‐RADS 3 Lesions Upgraded during Imaging Surveillance

To evaluate imaging and histopathologic differences between screen‐detected benign and malignant upgraded lesions initially assessed as BI‐RADS 3 at diagnostic evaluation. An IRB approved retrospective review of the mammography data base from January 1, 2004 to December 31, 2008 identified 1,188 (1.07%) of 110,776 screening examinations assessed as BI‐RADS 3 following diagnostic evaluation at our academic center (staffed by breast specialists) or our outpatient center (staffed by general radiologists), 1,017 with at least 24 months follow‐up or biopsy. Sixty (5.9%) BI‐RADS 3 lesions were upgraded to BI‐RADS 4 or 5 during imaging surveillance (study population). Prospective reports, patient demographics, and clinical outcomes were abstracted from the longitudinal medical record. Mean patient age was 54.1 years (range 35–85). Lesions consisted of 7 masses, 12 focal asymmetries and 41 calcifications. Fifteen (25%) of 60 lesions upgraded from initial BI‐RADS 3 assessment were malignant (1.47% of total; 15/1,017 BI‐RADS 3 studies). Malignancy rates by upgraded lesion type showed no significant difference: Thirty‐three (73.3%) of 45 benign upgraded lesions were calcifications compared to 8 (53.3%) of 15 malignant upgraded lesions (p = 0.202). Twelve (26.7%) of 45 benign upgraded lesions were masses or focal asymmetries, compared to 7 (46.7%) of 15 upgraded malignant lesions (p = 0.202). Six (85.7%) of 7 malignant upgraded masses/focal asymmetries had no US correlate at initial BI‐RADS 3 assessment compared to 7 (58.3%) of 12 benign upgraded masses/focal asymmetries (p = 0.33). Breast‐imaging specialists interpreted 21 studies, 3 (14.3%) malignant; general radiologists interpreted 39 studies, 12 (30.8%) malignant (p = 0.218). There was no significant difference in malignancy rate among different types of upgraded mammographic lesions, nor depending on subspecialty interpretation versus nonsubspecialist interpretation. Although calcifications made up a majority of upgraded lesions, most were benign, suggesting that decreased surveillance of calcifications may be appropriate.     

BI‐RADS 3 (short‐interval follow‐up) assessment rate at diagnostic mammography: Correlation with recall rates and utilization as a performance benchmark

The purpose of this study was to identify a correlation between the screening BI‐RADS 0 (recall) rates and diagnostic BI‐RADS 3 (short‐interval follow‐up) rates of individual interpreting radiologists, with the goal of utilizing the BI‐RADS 3 rate as an acceptable performance metric in the diagnostic population. A multicenter retrospective analysis of medical audit statistics was conducted on annual radiologist performance data collected over a 14‐year period in a community hospital‐based practice. Mixed regression models were used to estimate the association between screening BI‐RADS 0 and diagnostic BI‐RADS 3 examinations while adjusting for calendar year, annual radiologist screening volume, annual radiologist diagnostic volume, and diagnostic examination indication. A moderate statistically significant positive correlation was established between the screening BI‐RADS 0 rates and Diagnostic BI‐RADS 3 rates (Pearson correlation coefficient + 0.349, P ≤ .001). Furthermore, when utilizing a national benchmark range of 8%‐12% as an acceptable BI‐RADS 0 rate within a screening population, the correlative BI‐RADS 3 assessment rate was demonstrated to be approximately 16%. We propose that this BI‐RADS category 3 rate may represent an additional acceptable performance metric in the diagnostic population. Routine inclusion of an interpreting mammographer's diagnostic BI‐RADS 3 rate in the annual medical audit may help reduce inappropriate and/or excess use of the BI‐RADS 3 category, which may lead to significant potential reductions in follow‐up examinations with their associated healthcare‐related costs, resource expenditure, and induced patient anxiety.     

Misclassification of Breast Imaging Reporting and Data System (BI‐RADS) Mammographic Density and Implications for Breast Density Reporting Legislation

USA states have begun legislating mammographic breast density reporting to women, requiring that women undergoing screening mammography who have dense breast tissue (Breast Imaging Reporting and Data System [BI‐RADS] density c or d) receive written notification of their breast density; however, the impact that misclassification of breast density will have on this reporting remains unclear. The aim of this study was to assess reproducibility of the four‐category BI‐RADS density measure and examine its relationship with a continuous measure of percent density. We enrolled 19 radiologists, experienced in breast imaging, from a single integrated health care system. Radiologists interpreted 341 screening mammograms at two points in time 6 months apart. We assessed intra‐ and interobserver agreement in radiologists'; interpretations of BI‐RADS density and explored whether agreement depended upon radiologist characteristics. We examined the relationship between BI‐RADS density and percent density in a subset of 282 examinations. Intraradiologist agreement was moderate to substantial, with kappa varying across radiologists from 0.50 to 0.81 (mean = 0.69, 95% CI [0.63, 0.73]). Intraradiologist agreement was higher for radiologists with ≥10 years experience interpreting mammograms (difference in mean kappa = 0.10, 95% CI [0.01, 0.24]). Interradiologist agreement varied widely across radiologist pairs from slight to substantial, with kappa ranging from 0.02 to 0.72 (mean = 0.46, 95% CI [0.36, 0.55]). Of 145 examinations interpreted as “nondense” (BI‐RADS density a or b) by the majority of radiologists, 82.8% were interpreted as “dense” (BI‐RADS density c or d) by at least one radiologist. Of 187 examinations interpreted as “dense” by the majority of radiologists, 47.1% were interpreted as “nondense” by at least one radiologist. While the examinations of almost half of the women in our study were interpreted clinically as having BI‐RADS density c or d, only about 10% of examinations had percent density >50%. Our results suggest that breast density reporting based on a single BI‐RADS density interpretation may be misleading due to high interradiologist variability and a lack of correspondence between BI‐RADS density and percent density.     

Low Compliance in a Health‐Conscience Spending Era Likely Helps Obviates the Need for 6 month BI‐RADS 3 Breast MRI Follow‐up After 1 year

The goal of our IRB‐approved study was to assess if a follow‐up MRI every 6 months for 2 years is the most appropriate short‐interval follow‐up schedule. 203 breast MRI exams were performed from October 2009 to January 2014 as part of a BI‐RADS 3 follow‐up representing 2.6% of all breast MRIs (7,822) performed. We performed a retrospective longitudinal medical records review of compliance; malignancy rate of BI‐RADS 3 exams; and average time and number of breast MRIs necessary prior to definitive disposition. While 77.8% eventually returned, only 45.5% of patients were compliant with follow‐up at or near 6 months (4.5–7.5 months). Of those who eventually returned, it took an average of 1.31 follow‐up MRIs (95% CI: 1.20–1.43 exams) and 10.3 months (95% CI: 9.0–11.7 months) before definitive disposition. 93.5% of initial findings were dispositioned as benign after two follow‐up MRI exams (malignancy rate: 0.98%). Our results lend support to the possibility that the follow‐up interval for BI‐RADS 3 breast MRIs could be lengthened to 12 months if additional follow‐up MRIs are necessary after the first year of 6‐month follow‐up breast MRIs. Foremost, this appears to be a safe follow‐up alternative since benign definitive disposition can usually be made in less than 1 year. Supplemental reasons include persistent low‐patient compliance (as redemonstrated in our study) and the higher cost of breast MRI compared to mammogram/ultrasound follow‐up. Finally, this paper's findings further support the suggested MRI follow‐up interval in the newest BI‐RADS atlas.     

Flat Epithelial Atypia on Breast Needle Core Biopsy: A Retrospective Study with Clinical–Pathological Correlation

Abstract: There are limited data to guide clinical management when flat epithelial atypia (FEA) is identified in breast needle core biopsies (NCBs). Our objectives were to determine the frequency of malignancy in subsequent breast excisions following NCB diagnosis of FEA, and to characterize the pathological and clinical features of associated tumors. Two hundred and fifty‐six breast NCBs from a retrospective search (January 1999–July 2007) were blindly reviewed for FEA/other columnar cell lesions (CCLs). NCBs with co‐existing carcinoma were excluded. The study included 211 NCBs: 116 (55%) with CCLs without atypia; 40 (19%) with CCLs with atypical ductal hyperplasia (ADH), 15 (7%) with FEA and 40 (19%) with FEA and ADH; 94 cases had follow‐up excisions. Ductal carcinoma in situ and/or invasive carcinoma were present in: 4/26 (15%) excisions with CCLs on NCB, 11/30 (37%) with CCLs + ADH, 1/7 (14%) with FEA alone, and 9/31 (29%) with FEA + ADH. (a) FEA was more frequently seen with ADH, than without ADH in NCBs, (b) FEA and CCLs were more frequently associated with malignancy when with ADH, and (c) tumors excised following NCB diagnosis of FEA+/?ADH had favorable prognostic factors. A conservative excision is warranted following a NCB diagnosis of FEA and ADH, and may be warranted for FEA alone.     

Papillary Lesions of the Breast: Outcomes of 156 Patients Managed without Excisional Biopsy

Papillomas of the breast are benign epithelial neoplasms. Because of the low, but continued potential for malignancy, the treatment options after initial diagnosis remain controversial. The aim of this study was to analyze the clinical course of patients with papilloma who were managed by active surveillance following initial diagnosis by core needle biopsy or vacuum‐assisted biopsy. This retrospective study analyzed 174 patients with 180 papillomas that were diagnosed by core needle biopsy (113 cases) or vacuum‐assisted biopsy (67 cases) at the Breast Center Seefeld Zurich between February 2002 and May 2011. We excluded 24 cases that underwent excisional biopsy for removal of the lesion. Over a mean follow‐up of 3.5 years, 13 further events occurred in 156 cases (8%). These events included two cases of ductal carcinoma in situ (one after 4 and one after 6 years), one case of atypical ductal hyperplasia, one radial scar, eight cases of papilloma, and one case of flat epithelial atypia. No invasive carcinomas occurred during the follow‐up period. Conservative management of 156 papillary lesions with removal by vacuum‐assisted biopsy and surveillance was not associated with invasive cancer over a median follow‐up of 3.5 years. Therefore, this approach seems to be a safe option for the clinical management of papillary lesions.     

Follow‐up of Probably Benign Lesions (BI‐RADS 3 category) in Breast MR Imaging

Abstract: The purpose of our study was to determine the frequency of BI‐RADS 3 lesions in breast MR imaging in a clinical patient population and their frequency of malignancy in follow‐up breast MR imaging. In 44/698 (6.3%) patients with breast MR imaging, 56 lesions were categorized to BI‐RADS 3. These lesions were all not palpable and not detectable at conventional mammography or ultrasound. In follow‐up, lesions were score in complete resolved (CRL), partial resolved (PRL), stable lesions (SL), and progressive lesions (PL). Initial signal enhancement of lesions was coded by color intensity (bright for high, medium for medium, dark for low), the postinitial signal enhancement by color hue (blue for increase, green for plateau, red for wash‐out). In first follow‐up breast MR imaging 23/56 (41%) lesions were PRL, 14/56 (25%) lesions were CRL, 14/56 (25%) lesions remained SL. In one of five PL lesions, histopathology revealed a malignant tumor. In initial breast MR imaging, CRL showed significant fewer high pixels (p = 0.002), medium pixels (p = 0.006) significant more low pixels (p = 0.005) and significant more increase pixels (p = 0.037) than PRL. In a clinical patient population the frequency of malignancy of BI‐RADS 3 lesions in breast MR imaging and their frequency of malignancy are similar to that in conventional mammography. In initial breast MR imaging, complete resolved lesions showed less suspicious contrast kinetics than other lesions. In follow‐up, the increase of lesion size should warrant histopathological diagnosis.     

Breast Nonmass Enhancement Detected with MRI: Uility and Lesion Characterization with Second‐Look Ultrasonography

The purpose of this study was to verify the utility of second‐look ultrasonography (US) in evaluating nonmass enhancement (NME) lesions detected on breast magnetic resonance imaging (MRI) by analysing its correlation and imaging features. From July 2008 to June 2012, 102 consecutive MRI‐detected NME lesions were subsequently evaluated with US. Lesions were evaluated according to the established Breast Imaging Reporting and Data System (BI‐RADS) lexicon. The correlation between MRI‐detected NME lesion characteristics, lesion size, histopathological findings and features at second‐look US were analysed. Second‐look US identified 44/102 (43%) of the NME lesions revealed by MRI. A US correlate was seen in 34/45 (76%) malignant lesions compared with 10/57 (18%) benign lesions (p < 0.0001). The likelihood of malignancy was significantly higher for NME lesions with a US correlate than lesions without: 34/44 (77%) versus 11/58 (19%) (p < 0.0001). The malignancy of the 44 (43%) MRI‐detected NME lesions with a US correlate was significantly associated with US lesion margins and BI‐RADS categories (p = 0.001 and 0.002 respectively). Second‐look US of MRI‐detected NME lesions is useful for decision‐making as part of the diagnostic workup. Familiarity with the US features associated with malignancy improves the utility of US in the workup of these NME abnormalities.     

Digital Breast Tomosynthesis: A New Diagnostic Method for Mass‐Like Lesions in Dense Breasts

To compare the rates and accuracy of digital breast tomosynthesis (DBT) and 2D digital mammography (DM) for detecting and diagnosing mass‐like lesions in dense breasts. Mediolateral and craniocaudal images taken with DBT (affected breast) and DM (both breasts) of the dense breasts of 631 women were assessed independently using Breast Imaging Reporting and Data System (BI‐RADS) scores. Images were compared for detection and diagnostic accuracy for masses; sensitivity and specificity of diagnosis; false‐negative and recall rates; and clarity of display, particularly of margins and spicules. Histopathology was conducted via surgical biopsies of all patients. The detection and diagnostic accuracy rates of DBT images (84.3% and 82.3%, respectively) were significantly higher than that of DM (77.3% and 73.4%; p < 0.01, both). The sensitivity and specificity of DBT (68.1% and 95.2%) were higher than that of DM (58.8% and 86.7%), whereas the recall rate of DBT was lower (3.6% cf. 9.8%). The number of cases of benign circumscribed masses and malignant spiculated masses detected by DBT (172 and 182) was significantly higher than the number detected through DM (75 and 115; p < 0.01, both). Radiologists assigned higher BI‐RADS scores for probability of malignancy to DBT images than DM, to lesions proved malignant (p = 0.025); for benign cases, the methods were comparable (p = 0.065). Compared with DM, DBT yielded significantly higher rates of detection and diagnostic accuracy for benign and malignant masses, with greater sensitivity and specificity and lower recall rates. In addition, DBT images facilitated analysis of margins, and the rate of accuracy for judgments of malignancy probability was higher, as proved on biopsy.     

Inter‐Institutional Pathology Consultation: The Importance of Breast Pathology Subspecialization in a Setting of Tertiary Cancer Center

Inter‐institutional pathology consultation (IPC) has shown to be significant in patient care. The purpose of the study was to evaluate the impact of IPC for breast biopsies in our institution. A total of 502 consecutive consult cases of breast core needle biopsies were reviewed. The original pathology reports from the referring institutions and our reports were compared for all cases. All cases were reviewed by specialized breast pathologists. Discordance was divided into minor and major based on the impact on patient care. We reviewed the subsequent excisional biopsy for all discordant cases. Discordance was seen in 104 (20.7%) cases; 40 (8%) had a major discordance and 64 (13%) had a minor discordance. Subsequent surgical excision was available for 25 (62.5%) cases with major discordance and for 13 (20.3%) with minor discordance. Our interpretation changed management in 15 (3%) patients, while 25 (5%) had a potential of management change. The cases with major discordance could be subcategorized into five groups, malignant 5 (12.5%), premalignant 16 (40%), biomarkers 10 (25%), fibroepithelial lesions 6 (15%), and others 3 (7.5%). Our findings support the value of IPC review in decreasing the likelihood of diagnostic errors that may lead to significant impact on patient care. It is necessary that outside pathology material in the referral settings been reviewed by a specialized breast pathologist.     

Breast implant‐associated anaplastic large cell lymphoma: A rare case report of lymphoma in the form of a pericapsular solid formation

Breast cancer is the most frequently diagnosed cancer in women in the western world and a major cause of premature death. Consequently, breast implants are widely used for breast reconstruction. Despite this, the prevalence of implant complications is low. Given widespread use of breast implants, there is an increased awareness of the risk for developing a breast implant associated‐ anaplastic large cell Lymphoma (BI‐ALCL) although rare. Clinical presentation is variable and may include a palpable mass in the breast or axilla, generalized breast pain, or breast firmness. The estimated incidence of BI‐ALCL is <3 per 1 million person years, approximately 0.1‐0.3 per 100 000 women with prostheses per year. Since the publication by Keech and Creech in 1997, which reported the first case of BI‐ALCL, an increasing number of BI‐ALCL have appeared, in patients with both aesthetic and reconstructive indications. In this paper, we describe a patient who was diagnosed with invasive BIA‐ALCL seventeen years after placement of silicone breast implants and was treated with only surgery.     

Extraprostatic extension of prostatic adenocarcinoma on needle core biopsy: report of 72 cases with clinical follow‐up

Study Type – Prognosis (case series)
Level of Evidence 4

OBJECTIVE

To describe the histological findings and prognosis that are associated with extraprostatic extension (EPE) on needle core biopsy of prostatic adenocarcinoma.

PATIENTS AND METHODS

We retrieved 99 cases of prostatic adenocarcinoma with EPE at initial diagnosis on biopsy from the consultation files of one of the authors between 1997 and 2009. The 72 cases that had available clinical follow‐up data formed the basis of this study.

RESULTS

The mean (range) age of the patients was 64 (48–87) years, the median (mean, range) serum prostatic specific antigen level was 7.8 (64.8, 0.3–1505) ng/mL, and 60 of the patients (83%) had abnormalities on a digital rectal examination. The mean (range) number of malignant cores was 7.7 (1–23); the mean percentage of carcinoma in each core was 69.6%, and that in the core(s) with EPE was 76.8%. The mean Gleason score in the core(s) with EPE was 8, with a mean highest Gleason score per case of 8.4. Perineural invasion was detected in 54 cases (75%). Ten of 11 patients treated surgically had EPE on the radical prostatectomy (RP) specimen; also six had positive resection margins, five showed invasion into the seminal vesicles and one had lymph node metastasis. The Gleason scores in nine of the RP specimens did not differ from the highest grade found in the associated biopsies (score 9 in three, 8 in two, 7 in four); in one case it increased (from score 6 to 8) and in one it decreased (from score 9 to 8). Patients were followed for a mean (median, range) of 2.9 (2, 0.1–9) years, with metastases identified in 29 (40%); 10 (14%) died from the disease.

CONCLUSION

EPE on needle core biopsy of the prostate is strongly associated with extensive, high‐grade prostatic adenocarcinoma, such that its usefulness as an isolated prognostic factor is relatively limited.