1.5T乳腺专用磁共振诊断乳腺导管内乳头状瘤的应用价值

目的:探讨乳腺专用磁共振诊断导管内乳头状瘤的应用价值。方法:收集我院经手术病理证实的31例乳腺导管内孤立/多发乳头状瘤病例进行回顾性分析。所有病人术前均行乳腺X线、超声检查及AURORA乳腺专用磁共振平扫及动态增强扫描。参照乳腺影像报告和数据系统(BI-RADS),评价其病灶的形态学(包括病灶大小、形状、部位、边缘、多形性及与导管的关系)、动态增强扫描的强化模式及其他相关的特征,并与X线、超声检查相对照。结果:31例病人孤立导管内乳头状瘤23例,多发导管乳头状瘤8例。MRI共检出30个病灶,其中2例导管内乳头状瘤MRI为阴性,1例双侧多发导管乳头状瘤MRI检出双侧病灶。其MRI形态学表现最多见是沿导管分布多发小结节样或环形强化(38.7%),其次为乳晕后区孤立或多发结节样强化(22.6%)及乳晕后方导管样、线状、分支样强化(12.9%),伴或不伴导管扩张,MRI增强信号-时间曲线以平台型和流出型为主,具有一定的特征性。部分(4例)表现为类似恶性肿瘤的MRI征象(12.9%),难以与恶性肿瘤区分。结论:乳腺专用MRI检查对检出导管内乳头状瘤(病)具有较大的优势,能为临床手术治疗提供准确定位,具有较好的应用价值。     

乳腺浸润性导管癌的MRI诊断价值

目的探讨磁共振成像(MRI)对乳腺浸润性导管癌的临床应用价值。方法回顾性分析了2012年1月至2012年6月期间在四川大学华西医院放射科行MRI检查,且术后经病理学检查证实为乳腺浸润性导管癌的75例患者的术前MRI检查资料。结果形态学分型:团块型54例,结节型21例,囊实混合型0例。肿块形状:圆形3例,卵圆形9例,不规则形63例。边缘:不规则66例,规则9例;呈微小分叶状56例。肿块内有钙化者1例。有淋巴结转移者18例。MRI的T1WI呈低信号(65例)或等信号(10例),T2WI呈低信号(3例)或以稍高信号为主的混杂信号(72例),增强后大部分呈均匀强化(64例),部分呈不均匀强化(11例)。结论通过分析乳腺浸润性导管癌的MRI成像特征,可为临床诊断乳腺浸润性导管癌提供有力的影像学证据。     

Breast MRI in the Evaluation of Patients with Occult Primary Breast Carcinoma

▪ Abstract: Occult primary breast carcinoma presenting as isolated ipsilateral axillary lymph node metastases in patients with normal mammograms and normal physical exams accounts for less than 1% of all breast carcinomas. Contrast-enhanced magnetic resonance imaging (MRI) may identify the site of primary breast carcinoma and effect management of these patients. We report on eight consecutive women evaluated in our multidisciplinary clinic who had biopsy-proven metastatic adenocarcinomas to axillary lymph nodes and occult primary carcinomas. Each patient underwent MRI at 1.5 T with a volumetric fast-spoiled gradient-echo (3D FSPGR) pulse sequence before and after injection of gadopentetate dimeglumine. Wire localization of suspicious areas of enhancement was performed under MRI or mammography guidance followed by surgical excision. Seven (88%) of the eight normal mammograms showed dense (>50%) breast parenchyma. In two (25%) of the eight patients, suspicious focal or regional enhancement was seen on MRI. Following wire localization and excision, pathologic exam showed an invasive ductal carcinoma and ductal carcinoma in situ with invasion corresponding to the MRI enhancement in the two cases. Breast MRI can identify the primary tumor site and influence management of patients presenting with clinically and mammographically occult primary breast carcinomas. ▪     

Factors Associated with Preoperative Magnetic Resonance Imaging Use among Medicare Beneficiaries with Nonmetastatic Breast Cancer

Preoperative breast magnetic resonance imaging (MRI) use among Medicare beneficiaries with breast cancer has substantially increased from 2005 to 2009. We sought to identify factors associated with preoperative breast MRI use among women diagnosed with ductal carcinoma in situ (DCIS) or stage I–III invasive breast cancer (IBC). Using Surveillance, Epidemiology, and End Results and Medicare data from 2005 to 2009 we identified women ages 66 and older with DCIS or stage I–III IBC who underwent breast‐conserving surgery or mastectomy. We compared preoperative breast MRI use by patient, tumor and hospital characteristics stratified by DCIS and IBC using multivariable logistic regression. From 2005 to 2009, preoperative breast MRI use increased from 5.9% to 22.4% of women diagnosed with DCIS and 7.0% to 24.3% of women diagnosed with IBC. Preoperative breast MRI use was more common among women who were younger, married, lived in higher median income zip codes and had no comorbidities. Among women with IBC, those with lobular disease, smaller tumors (<1 cm) and those with estrogen receptor negative tumors were more likely to receive preoperative breast MRI. Women with DCIS were more likely to receive preoperative MRI if tumors were larger (>2 cm). The likelihood of receiving preoperative breast MRI is similar for women diagnosed with DCIS and IBC. Use of MRI is more common in women with IBC for tumors that are lobular and smaller while for DCIS MRI is used for evaluation of larger lesions.     

Invasive micropapillary carcinoma of breast: an under-recognized entity. a series of eight cases

Invasive micropapillary carcinoma (IMPC) of breast is a morphologically distinct and relatively uncommon variant of invasive ductal carcinoma. It is characterized by small clusters of tumor cells with surrounding clear stromal spaces; a tendency for vascular permeation and therefore, an aggressive clinical course. This morphologic pattern can be easily missed especially in a small biopsy specimen because pathologists may disregard the clear spaces as artifactual. With a tendency of presenting at a higher stage, this morphological pattern needs to be mentioned in the histopathology report whenever it is encountered, either in its pure form or admixed with conventional ductal carcinoma. We describe eight cases of IMPC of breast along with their variable clinical presentations.     

Biologic significance of false-positive magnetic resonance imaging enhancement in the setting of ductal carcinoma in situ

BACKGROUND: Imaging patterns of benign proliferative processes often complicate the assessment of ductal carcinoma in situ (DCIS) by magnetic resonance imaging (MRI). We investigated the pathologic and biologic characteristics of false positive enhancement by breast MRI. METHODS: DCIS (n = 45), benign (n = 5), and false-positive (MRI enhancement and nonmalignant pathology) (n = 10) cases were characterized by immunohistochemistry and MRI features. RESULTS: For DCIS cases, images that overestimated pathologic size had heterogeneous enhancement on MR, were estrogen receptor positive, and were low grade by pathology. False-positives had higher rates of proliferation, angiogenesis, and inflammation compared with benign tissue but lower values than DCIS. Benign proliferative processes accounted for all false-positive and size overestimated cases. CONCLUSIONS: Lesions that enhance on MRI have higher proliferation, angiogenesis, and inflammation compared with nonproliferative breast tissue. Benign proliferative processes often enhance on MRI and are difficult to differentiate from low-grade, ER+ DCIS lesions. False-positive MRI enhancement may reflect a spectrum of change within high-risk tissue.     

Features of Occult Invasion in Biopsy‐Proven DCIS at Breast MRI

The purpose of this study is to determine if MRI BI‐RADS criteria or radiologist perception correlate with presence of invasive cancer after initial core biopsy of ductal carcinoma in situ (DCIS). Retrospective search spanning 2000–2007 identified all core‐biopsy diagnoses of pure DCIS that coincided with preoperative MRI. Two radiologists fellowship‐trained in breast imaging categorized lesions according to ACR MRI BI‐RADS lexicon and estimated likelihood of occult invasion. Semiquantitative signal enhancement ratio (SER) kinetic analysis was also performed. Results were compared with histopathology. 51 consecutive patients with primary core biopsy‐proven DCIS and concurrent MRI were identified. Of these, 13 patients (25%) had invasion at excision. Invasion correlated significantly with presence of a mass for both readers (p = 0.012 and 0.001), rapid initial enhancement for Reader 1 (p = 0.001), and washout kinetics for Reader 2 (p = 0.012). Significant correlation between washout and invasion was confirmed by SER (p = 0.006) when threshold percent enhancement was sufficiently high (130%), corresponding to rapidly enhancing portions of the lesion. Radiologist perception of occult invasion was strongly correlated with true presence of invasion. These results provide evidence that certain BI‐RADS MRI criteria, as well as radiologist perception, correlate with occult invasion after an initial core biopsy of DCIS.     

BI-RADS MRI enhancement characteristics of ductal carcinoma in situ

To identify the Breast Imaging Reporting and Data System magnetic resonance imaging (MRI) enhancement characteristics of ductal carcinoma in situ (DCIS). A retrospective review of consecutive patients who underwent breast MRI for newly diagnosed breast carcinoma prior to surgery was conducted. This yielded 381 lesions in 361 patients with pathologic confirmation of either DCIS alone, invasive carcinoma alone, or mixed invasive and in-situ disease. Presence or absence of a MRI lesion at the site of the documented carcinoma was recorded, and for all identified MRI lesions the Breast Imaging Reporting and Data System morphology patterns were recorded. MRI features of the different malignancy types were compared utilizing Fisher's exact tests; 64/381 (16.8%) lesions had DCIS, 101/381 (26.5%) had invasive carcinoma, and 216/381 (56.7%) had mixed invasive/in situ carcinoma. A MRI lesion corresponding to the known cancer was identified in 55/64 (85.9%) cases of DCIS, 98/101 (97.0%) cases of invasive carcinoma, and 212/216 (98.1%) cases of mixed invasive and in-situ carcinoma. For pure DCIS lesions, 38/64 (59.4%) exhibited nonmass-like enhancement (NMLE), 9/64 (14.1%) were masses, and 8/64 (12.5%) were a focus. For pure invasive carcinomas 79/101(78.2%) were masses, 16/101 (15.8%) were NMLE, and 3/101 (3.0%) were a focus. For mixed lesions 163/216 (75.5%) were masses, 44/216 (20.4%) demonstrated NMLE, and 5/216 (2.3%) were a focus. The most common NMLE patterns of pure DCIS were segmental distribution and clumped internal enhancement. Although there is overlap in the MRI morphology and enhancement pattern of in situ and invasive breast carcinoma, DCIS more frequently manifests as NMLE than does invasive carcinoma.     

Magnetic resonance imaging of benign phyllodes tumors of the breast

Magnetic resonance imaging (MRI) has the potential to become a useful adjunct in breast imaging. Contrast-enhanced breast MRI has demonstrated a high sensitivity in the detection of benign and malignant breast disease. Our study aimed to correlate the dynamic contrast-enhanced MRI appearance of benign phyllodes tumor of the breast with histopathologic findings. We retrospectively reviewed the MRI findings in eight patients with benign phyllodes tumor of the breast to describe the image characteristics of this disease. The architectural features and enhancement patterns of this tumor were assessed and compared with other breast diseases. MRIs demonstrated some characteristics for large benign phyllodes tumors (more than 3 cm in size). On T(2)-weighted images, they were imaged as spotted tumors in high to iso signal intensity with cystic components or septations inside. In the time-signal intensity curve for the eight patients in our study who underwent dynamic MRI, we demonstrated two patterns of their curve: rapidly and gradually enhanced. In conclusion, MRI findings in benign phyllodes tumor include dynamic curves of gradually and rapidly enhancing types, and a low and inhomogeneous signal intensity on T(2)-weighted images compared with fibroadenoma. These findings appear to be useful for diagnosis.     

乳腺肿块型浸润性导管癌MRI动态增强扫描征象与WHO病理分级的关系

目的探讨乳腺肿块型浸润性导管癌的MRI动态增强扫描（DcEMRI）征象与其WHO病理分级的关系。方法回顾性分析四川大学华西医院2012年6月至2013年12月期间92例经手术或活检病理证实为肿块型浸润性导管癌的DCEMRI征象,并分析其与WHO病理分级的关系。结果92例乳腺肿块型浸润性导管癌患者中肿瘤长径≤2cm者29例（31．52％）,2～5cm者53例（57．61％）,≥5cm者10例（10．87％）;病灶形态为圆形者3例（3．26％）,卵圆形者7例（7．61％）,分叶形者33例（35．87％）,不规则形者49例（53．26％）。病灶边缘光整者11例（11．96％）,不规则者47例（51．09％）,毛刺状者34例（36．96％）。病灶早期均匀强化者15例（16．30％）,不均匀强化者40例（43．48％）,环形强化者37例（40．22％）。WHO病理分级：1级者5例（5．43％）,2级者30例（32．61％）,3级者57例（61．96％）。经统计分析,肿瘤大小、病灶形态及病灶早期强化特点与WHO病理分级有关（P=0．012,P=0．004,P=0．000）,即病灶长径越大,WHO病理分级越高;圆形和卵圆形肿块的WHO病理分级相对较低,分叶状和不规则形肿块的WHO病理分级高;不均匀强化及环状强化的WHO病理分级高,均匀强化的WHO病理分级较低。病灶边缘形态与WHO病理分级无关（P〉0．05）。结论乳腺肿块型浸润性导管癌DCEMRI特征与WHO分级有一定关系,可根据MRI征象对病灶的生物学行为和预后进行评估。     

Invasive lobular carcinoma: spectrum of enhancement and morphology on magnetic resonance imaging

Invasive lobular carcinoma (ILC) may be a difficult tumor to detect early by physical examination, mammography, or ultrasound. We undertook this study to describe the spectrum of gadolinium enhancement and morphologic features of ILC on magnetic resonance imaging (MRI). Nineteen patients with ILC who presented with a palpable mass, a mammographically visible abnormality, or an unknown primary underwent preoperative MRI of both breasts using a T1-weighted high-resolution gradient echo sequence (pre- and postcontrast), and an echoplanar sequence during the administration of gadolinium. Using a quantitative measure of gadolinium uptake over time, called the extraction flow (EF) product, and a normal tissue threshold EF level of 25 or less, enhancement for 15 of the 19 cancers was characterized. By consensus, three radiologists categorized the morphologic features of the lesions. For the 15 cases of ILC that had echoplanar data, analysis showed peak EFs ranging between 25 and 120, and the majority showed EFs in the 30s. A substantial portion of two tumors enhanced in a similar fashion to normal breast tissue, with EFs in the low 20s. Morphologically MRI showed a focal mass in eight cases, regional enhancement in five, segmental enhancement in one, segmental enhancement with multiple small nodules in one, a mixture of a focal mass and regional enhancement in one, diffuse enhancement in one, multiple small nodules in one, and bilateral disease in one. Of the focal masses, seven were irregular in shape and one was round; six had ill-defined margins and two had spiculated margins. All eight enhanced heterogeneously. Four cases had multifocal disease and one case had unsuspected contralateral disease discovered only on MRI. MRI using a combination of morphology and a quantitative measure of gadolinium uptake was able to detect the majority of cases of ILC. However, there was a variable morphologic appearance and contrast enhancement pattern on MRI. A few lesions were difficult to distinguish from normal tissue. This suggests that some cases of ILC may be difficult to detect on MRI.     

Bilateral extensive ductitis obliterans manifested by bloody nipple discharge in a patient with long-term diabetes mellitus

Abstract:  Ductitis obliterans or mastitis obliterans is a rare late manifestation of mammary ductal ectasia. We describe a long-term diabetic patient who presented with bilateral bloody nipple discharge and poorly defined nodularities around the nipple of both breasts. The ductography showed multiple segments of irregular ductal narrowing and intraluminal filling defects in both breasts. The bilateral resection of the sub-areolar portion of the breast showed exuberant fibrous obliteration of the large- and medium-sized ducts by granulation tissue associated with few histiocytes. Ductal dilatation and intraductal accumulation of histiocytes was also present. This represents a late and florid form of mammary ductal ectasia. Differential diagnostic considerations including fibrocystic changes, diabetic sclerosing lymphocytic lobulitis, idiopathic granulomatous lobular mastitis, and periductal mastitis (Zuska disease) are discussed. Accurate diagnosis can help avoid or limit radical surgeries in this group of patients.     

Hormonal control of alveolar development and its implications for breast carcinogenesis

During puberty and pregnancy, the breast undergoes major restructuring in order to produce a structure that can secrete and eject copious amounts of milk. By analogy to other branched organs such as the lung or the salivary gland, a large increase in surface area of the specialized epithelium is achieved through repeated ramifications of a system of ducts and alveoli arising from the nipple. In the breast, this process culminates in the appearance of thousands of alveoli or acini, saccular outpouchings from the ductal system. This paper focuses on this final stage of proliferation, the formation of alveolar structures and its control by systemic hormones.     

Synchronous presentation of breast carcinoma with plasmacytoid cytomorphology and multiple myeloma

Plasmacytoid morphology is often encountered in both lobular and ductal carcinomas of the breast. The presentation of breast carcinoma in patients with a known history of lymphoma or multiple myeloma has been described in the literature. However, to the best of our knowledge, the synchronous presentation of breast carcinoma and multiple myeloma has not been reported. Here we report the first case of the simultaneous occurrence of breast carcinoma with plasmacytoid morphology and multiple myeloma in a 74-year-old patient, which presented challenges in making the diagnosis on fine-needle aspiration biopsy (FNAB) of the breast.     

MRI features of pseudoangiomatous stromal hyperplasia with histopathological correlation

Pseudoangiomatous stromal hyperplasia (PASH), a rare, noncancerous lesion, is often an incidental finding on magnetic resonance imaging (MRI)-guided biopsy analysis of other breast lesions. We sought to describe the characteristics of PASH on MRI and identify the extent to which these characteristics are correlated with the amount of PASH in the pathology specimens. We identified 69 patients who underwent MRI-guided biopsies yielding a final pathological diagnosis of PASH between 2008 and 2015. We analyzed pre-biopsy MRI scans to document the appearance of the lesions of interest. All biopsy samples were classified as having ≤50% PASH or ≥51% PASH present on the pathological specimen. On MRI, 9 lesions (13%) appeared as foci, 19 (28%) appeared as masses with either washout or persistent kinetics, and 41 (59%) appeared as regions of nonmass enhancement. Of this latter group, 33 lesions (80%) showed persistent kinetic features. Masses, foci, and regions of nonmass enhancement did not significantly correlate with the percentage of PASH present in the biopsy specimens (P ≥ .05). Our findings suggest that PASH has a wide-ranging appearance on MRI but most commonly appears as a region of nonmass enhancement with persistent kinetic features. Our finding that most specimens had ≤50% PASH supports the notion that PASH is usually an incidental finding. We did not identify a definitive imaging characteristic that reliably identifies PASH.     

MR-guided intervention in women at high hereditary risk of breast cancer due to both family and personal history of breast cancer

The purpose of this study was to assess the value of magnetic resonance imaging (MRI)-guided intervention in women with a significant hereditary susceptibility to breast cancer due to both family and personal history of breast cancer (heterozygote risk >20%). Thirty women were referred for MR-guided intervention. MR examinations (1.0 T, T1-weighted 3D FLASH, 0.15 mmol Gd-DTPA/kg body weight, prone position) were performed using a system which allows vacuum-assisted breast biopsy or wire localization. Histologic findings in 41 procedures revealed six invasive carcinomas, eight ductal carcinomas in situ and two atypical ductal hyperplasias. Twenty-three benign histologic results were verified by an MR-guided intervention, retrospective correlation of imaging and histology and by subsequent follow-up. In two lesions the indication dropped as the enhancing lesion was no longer visible on the date of planned intervention. Absent enhancement was confirmed by short-term re-imaging of the non-compressed breast and by follow-up.     

Male ductal carcinoma in situ presenting as bloody nipple discharge: a case report and literature review

Male breast carcinoma accounts for 1% of all diagnosed breast carcinoma. Pure ductal carcinoma in situ in men is extremely rare. Unfortunately, male breast cancer is often diagnosed at a late stage because of the minimal awareness of presenting symptoms by the patient and sometimes by the health care provider. Because of this late presentation, the overall prognosis is less favorable. This case is presented to emphasize the importance of recognizing bloody nipple discharge as a clinical sign of male ductal carcinoma in situ and an opportunity for early diagnosis.     

An Exception to Tumour Neoangiogenesis in a Malignant Breast‐Lesion

Abstract: Magnetic resonance‐mammography is regarded as the most sensitive diagnostic modality in the detection of breast cancer. It uses the tumour neoangiogenesis to depict lesions after intravenous contrast agent injection. It is said, that for tumours exceeding a diameter of three millimetres contrast agent enhancement is mandatory. In our case report we describe a rare tumour growth condition. We observed a large invasive carcinoma (18 millimetres diameter) without contrast enhancement in breast MRI due to an almost missing tumour neoangiogenesis. The cancer had a low cellularity and a strong desmoplastic reaction.     

MRI联合钼靶X线在乳腺导管原位癌的诊断价值

目的探讨MRI联合乳腺钼靶X线诊断乳腺导管原位癌的应用价值。 方法选择2018年2月至2019年2月收治的90例乳腺导管原位癌患者,对所有患者给予乳腺钼靶X线及MRI检查,比较联合检查与单一检查的诊断价值。采用SPSS22.0进行统计分析,年龄和病灶直径计量资料采用( ±s)表示,t检验;将病理诊断作为金标准,分析MRI及联合诊断的敏感度及特异度。计数资料采用n(%)表示,χ²检验,P<0.05为差异有统计学意义。 结果90例乳腺导管原位癌患者均为单发病灶,恶性病灶48例,良性病灶42例。恶性病灶患者的年龄与良性病灶差异无统计学意义(P>0.05),良性病灶肿瘤直径低于恶性病灶(P<0.05)。将病理诊断结果作为金标准,MRI联合乳腺钼靶X线诊断的灵敏度和特异度分别为91.67%和90.48%,均高于单纯MRI的75.00%和71.43%及单纯乳腺钼靶的66.67%和64.29%%,差异有统计学意义(P<0.05)。 结论MRI联合乳腺钼靶X线在诊断乳腺导管原位癌时具有较高灵敏度和特异度,可为临床诊断及判断提供科学依据。     

MR imaging appearance of noncalcified and calcified DCIS

To evaluate the MR appearance of noncalcified ductal carcinoma in situ (DCIS), with comparison to calcified DCIS. A retrospective, IRB‐approved review of all DCIS diagnosed via MR biopsy between 2007 and 2011 was performed. DCIS was categorized as noncalcified based on the absence of calcifications on mammography and specimen radiography. MR morphology (focus, mass, nonmass enhancement [NME]) and enhancement kinetics (initial and delayed) for noncalcified DCIS were recorded and compared based on nuclear grade (1‐3), size (<1.5 cm, 1.5‐5 cm, >5 cm), and presence of necrosis. Imaging features of noncalcified and calcified DCIS were also compared. 115 cases of MR biopsy‐proven DCIS were identified: 65 (56%) noncalcified and 50 (44%) calcified. For noncalcified DCIS, NME morphology was more common than mass or focus (60% vs 30.8% and 9.2%). There was a significant association between morphology and enhancement kinetics, with NME more likely demonstrating medium and persistent kinetics, and foci or masses demonstrating rapid and plateau or washout kinetics (P < .05). There was also a significant association between morphology and nuclear grade, with NME more likely seen with grade 3 DCIS (P = .024), and between size and initial enhancement, with lesions <1.5 cm more likely to have rapid initial enhancement (P = .0036). No significant difference was identified between calcified and noncalcified DCIS in terms of morphology, enhancement characteristics, nuclear grade, or presence of necrosis. The MR appearance of noncalcified DCIS closely mirrors that of calcified DCIS. Recognizing these imaging features may allow for improved identification of this MRI‐detected abnormality, even in the absence of calcifications.