Dynamic Contrast‐Enhanced MRI Reveals the Extent and the Microvascular Pattern of Breast Ductal Carcinoma In Situ

To report the role of magnetic resonance imaging (MRI) in assessing the extent of breast ductal carcinoma in situ (DCIS). To assess whether the microvascularity pattern in DCIS correlates with magnetic resonance enhancement. Eighty‐five histologically proven DCIS (77 pure DCIS, eight microinvasive DCIS) were prospectively studied with MRI. The morphology of magnetic resonance enhancement and the kinetic curve was recorded. Histopathologically, intraductal lesions were classified according to Van Nuys score. Tumor microvascularity was immunohistochemically assessed in a subset of 24 DCIS evaluating the number of microvessels, microvascularity area, and microvascularity pattern (diffuse or periductal). On the mammogram, 74% of DCIS appeared as microcalcifications. On MRI, 70% of DCIS showed enhancement. Non‐mass‐like uptake was observed in 78% of cases. The mean size of nonenhancing carcinomas was significantly lower than that of enhancing carcinomas (p = 0.033). The diffuse pattern was more frequent than the periductal pattern. A significant relationship between the morphology of MR enhancement and the microvascularity pattern was observed (p = 0.036); thus, 90% of DCIS showing segmental enhancement on MRI displayed a diffuse pattern while all DCIS with ductal enhancement showed a periductal pattern. There was a significant relationship between the maximum area of microvascularity and the vascular pattern (p = 0.015); periductal patterns showed larger areas than diffuse patterns. The lesion size was significantly larger as the Van Nuys score increased (p < 0.001) and was also related to the number of microvessels (p = 0.012). The mean area of microvascularity of DCIS was significantly larger as the Van Nuys score increased (p = 0.02). Breast MRI helps depict the extent of DCIS and reveals its microvascular pattern.     

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.     

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.     

Breast Lesion Excision Sample (BLES Biopsy) Combining Stereotactic Biopsy and Radiofrequency: Is it a Safe and Accurate Procedure in Case of BIRADS 4 and 5 Breast Lesions?

The aim of this study was to evaluate the accuracy and safety of breast lesion excision system (BLES) procedure with an Intact system device, under stereotactic and ultrasound guidance. Retrospective data review of 32 breast lesions BI‐RADS 4 or 5 underwent Intact procedures, from March 2010 to January 2012. Underestimation rates of atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) were evaluated; percentage of complete radiologic and histologic removal of the breast lesion were analyzed, as were the complications due to procedure. Complete radiologic excision of the target lesion was achieved in all masses and 58.6% of calcifications. Lesion size was less than 11 mm (mean size 5.6 mm). Underestimation of ADH and DCIS was 0% and 10%, respectively. Low complication rate was noted: only one hematoma. BLES appears an accurate and safe biopsy system for sampling nonpalpable breast lesions, especially in case of microcalcifications clusters categorized as BI‐RADS 4 and 5.     

Role of Preoperative Breast MRI in Ductal Carcinoma In Situ for Prediction of the Presence and Assessment of the Extent of Occult Invasive Component

Ductal carcinoma in situ (DCIS) is a common neoplasm that may be associated with focal invasive breast cancer lesions. The aim of our study was to evaluate the role of preoperative magnetic resonance imaging (MRI) in determining occult invasive presence and disease extent in patients with preoperative diagnosis of pure DCIS. We analyzed 125 patients with postoperative pure DCIS (n = 91) and DCIS plus invasive component (n = 34). Diagnostic mammography (MRX) showed a size underestimation rate of 30.4% while MRI showed an overestimation rate of 28.6%. Comparing the mean absolute error between preoperative MRI and MRX evaluations and final disease extent, MRI showed an improved accuracy of 51.2%. In our analysis preoperative breast MRI showed a better accuracy in predicting postoperative pathologic extent of disease, adding strength to the growing evidences that preoperative MRI can lead to a more appropriate management of DCIS patients.     

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.     

Sentinel lymph node positivity in patients undergoing mastectomies for ductal carcinoma in situ (DCIS)

Current guidelines recommend sentinel lymph node biopsy (SLNB) for patients undergoing mastectomy for a preoperative diagnosis of ductal carcinoma in situ (DCIS). We examined the factors associated with sentinel lymph node positivity for patients undergoing mastectomy for a diagnosis of DCIS on preoperative core biopsy (PCB). The Institutional Breast Cancer Database was queried for patients with PCB demonstrating pure DCIS followed by mastectomy and SLNB from 2010 to 2018. Patients were divided according to final pathology (DCIS or invasive cancer). Clinico‐pathologic variables were analyzed using Pearson's chi‐squared, Wilcoxon Rank‐Sum and logistic regression. Of 3145 patients, 168(5%) had pure DCIS on PCB and underwent mastectomy with SLNB. On final mastectomy pathology, 120(71%) patients had DCIS with 0 positive sentinel lymph nodes (PSLNs) and 48(29%) patients had invasive carcinoma with 5(10%) cases of ≥1 PSLNs. Factors positively associated with upstaging to invasive cancer in univariate analysis included age (P = .0289), palpability (P < .0001), extent of disease on imaging (P = .0121), mass on preoperative imaging (P = .0003), multifocality (P = .0231) and multicentricity (P = .0395). In multivariate analysis, palpability (P = .0080), extent of disease on imaging (P = .0074) and mass on preoperative imaging (P = .0245) remained significant (Table 2). In a subset of patients undergoing mastectomy for DCIS with limited disease on preoperative evaluation, SLNB may be omitted as the risk of upstaging is low. However, patients who present with clinical findings of palpability, large extent of disease on imaging and mass on preoperative imaging have a meaningful risk of upstaging to invasive cancer, and SLNB remains important for management.     

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.     

Magnetic Resonance Imaging of the Breast as a Problem‐solving Method: To Be or Not to Be?

The use of dynamic magnetic resonance imaging (MRI) of the breast as a complementary problem‐solving tool was explored in a heterogeneous population sample. A total of 3,076 patients that underwent breast MRI examination between January 2008 and June 2012 in our center were screened retrospectively. Of these, 868 met the following inclusion criteria and were considered eligible for the study: available data on clinical signs, symptoms and on the results of mammography and ultrasound examinations in medical records; at least 1 year of follow‐up; and documented pathology findings. Lesions with a stable course over a follow‐up period of at least 12 months were considered benign. MRI was suggestive of a suspicious abnormality (BI‐RADS 4) or highly suggestive of malignancy (BI‐RADS 5) in 129 (15%) of 868 patients, leading to a biopsy examination in these cases. On the other hand, MRI findings were considered normal in 739 (85%) subjects based on normal (BI‐RADS 1), benign (BI‐RADS 2) or probably benign (BI‐RADS 3) findings. Of the 129 patients undergoing a histopathologic examination based on MRI findings, 63 were diagnosed with cancer, and in 66, the biopsy proved to be benign. Forty of the 63 patients (40/63) with a diagnosis of malignancy and 34 of the 66 patients (34/66) with a benign diagnosis had been categorized as BI‐RADS 4 with conventional methods. A total of 23 patients with BI‐RADS category of 0 to 3 according to conventional methods were diagnosed as having cancer with MRI. In six of these, the family history was positive. The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of MRI for the detection of cancer were 100%, 92%, 52%, and 100%, respectively. In cases with inconclusive findings on conventional imaging studies or in patients with clinical/radiological suspicion of malignancy, MRI should be more effectively used as a problem‐solving approach owing to its high sensitivity and NPV in this condition. Use of MRI as a problem‐solving method in such cases may decrease rather than increase unnecessary biopsy procedures and patient anxiety.     

Clinical Implications of Subcategorizing BI‐RADS 4 Breast Lesions associated with Microcalcification: A Radiology–Pathology Correlation Study

Abstract: Currently radiologists have the option of subcategorizing BI‐RADS 4 breast lesions into 4A (low suspicion for malignancy), 4B (intermediate suspicion of malignancy), and 4C (moderate concern, but not classic for malignancy). To determine the clinical significance of BI‐RADS 4 subcategories and the common pathologic changes associated with these mammographic lesions, a retrospective review of 239 consecutive stereotactic‐needle core biopsies (SNCB) for microcalcifications was performed. All 239 SNCBs were BI‐RADS 4 lesions, and of these, 191 were subcategorized to 4A, 4B or 4C. Ninety‐four of 191 (49%) were 4A, 73 (38%) were 4B, and 24 (13%) were 4C. Fibrocystic change was the most common finding (66/239; 28%) followed by ductal carcinoma in situ (DCIS) accounting for 23% of cases. This was followed by columnar cell alteration with or without atypia (47/239; 19%), and fibroadenoma (45/239; 19%). While 70% (17/24) of BI‐RADS 4C category lesions were DCIS, only 21% (15/73) of BI‐RADS 4B and 10% (10/94) of BI‐RADS 4A were DCIS. Without sub‐categorization, carcinoma was diagnosed in 23% (55/239) of all cases with BI‐RADS 4. Therefore, subcategorizing BI‐RADS 4 lesions is important since it not only benefits the patient and clinician in understanding the level of concern for carcinoma, but will also alert the pathologist.     

Surveillance of Probably Benign (BI‐RADS 3) Lesions in Mammography: What Is The Right Follow‐Up Protocol?

BI‐RADS‐3 is a category in mammography for probably benign lesions and for which periodic follow‐up with repeat imaging is recommended. At our institution repeated mammograms are performed at 6, 12, 18, and 24 months. The purpose of this study was to assess the significance of 18‐month mammogram for evaluation of BI‐RADS‐3 lesions. Following IRB approval, electronic medical records and picture archiving and communications system were used to review 121,862 consecutive mammograms between February, 2002–May, 2009. A total of 8,400 patients with BI‐RADS‐3 mammograms were identified. Of these, 7,632 patients were followed until completion of 24 month mammogram or biopsy following an upgrade in their BI‐RADS status. Over the follow‐up, 197 patients received an upgrade in their BI‐RADS status of which 179 were biopsied. Histopathologic results were reviewed. The majority of the BI‐RADS‐3 lesions were upgraded at 6‐month mammogram (n = 150, 76.1%) followed by 32 (16.2%), 11 (5.6%), and 4 (2.0%) at 12, 18, and 24 month mammograms respectively. Thirty‐four of 179 upgraded and biopsied lesions were found to be malignant. From these 27 (79.4%), 3 (8.8%), 3 (8.8%), and 1 (2.9%) lesions were identified at 6, 12, 18, and 24 month mammograms respectively. At the 18‐month mammogram 3/7,632 lesions (0.04%) were found to be malignant. The vast majority of malignant lesions (88.2%) were detected within the first 12‐months of follow‐up. Only three of 179 biopsies (1.7%) were malignant at 18‐month follow‐up. Based on those results a 6‐, 12‐, and 24‐month follow‐up protocol for BI‐RADS‐3 lesions is sufficient.     

Invasive Micropapillary Carcinoma of the Breast: A Clinicopathologic Study of 103 Cases of an Unusual and Highly Aggressive Variant of Breast Carcinoma

Invasive micropapillary carcinoma (IMPC) of the breast is an uncommon, highly aggressive breast cancer that may occur in pure and mixed forms. Our aim in this study is to investigate the relationship between clinical, histopathologic, and immunohistochemical features of pure and mixed IMPC cases diagnosed and treated at our institution. One hundred and three IMPC cases diagnosed at our institution over a period of 19 years have been selected. Clinical, histopathologic features, as well as hormone status and c‐erb‐B2 overexpression of tumors were re‐evaluated. Mann–Whitney U, chi‐squared, Kaplan–Meier, and Fisher's exact tests were used for statistical analyses. Results were considered to be significant at p < 0.05. Twenty cases (19.4%) were pure, and 83 cases (80.6%) were mixed IMPC. The most common nonmicropapillary invasive carcinoma component in mixed cases was invasive ductal carcinoma (IDC; 78.3%). Progesterone receptor was significantly less positive in pure IMPC cases (p = 0.031). There was no statistically significant difference between the two groups, in terms of mean age of the patients (53.0 versus 52.8), mean tumor size (26.6 mm versus 27.7 mm), presence of high‐grade tumor (p = 0.631), presence of sentinel lymph node (SN) metastasis (p = 1.000), axillary lymph node metastasis (p = 1.000), lymphatic invasion (p = 1.000) and blood vessel invasion (p = 0.475), c‐erbB‐2 overexpression of tumor cells (p = 0.616), distant metastasis (p = 0.549), or overall survival (p = 0.759). The local recurrence rate of the two groups was not statistically significant either (16.7% versus 4.3%). However, local recurrence was detected 12% more commonly (p = 0.100), and ~8 months earlier (p = 0.967) in pure IMPC cases, compared to mixed cases. In addition, presence of local recurrence was found to be statistically significantly associated with estrogen receptor (ER) status (p = 0.004), progesterone receptor (PR) status (p = 0.001), and c‐erb‐B2 overexpression (p = 0.016) in all patients. Overall survival rate was significantly associated with ER staining of the tumor (log‐rank = 0.028). Our findings suggest that hormone receptor negativity may explain the more aggressive behavior of pure IMPC compared to mixed cases. Besides, longer survival period of patients with ER positivity, and the relationship of hormone status and c‐erb‐B2 overexpression and local recurrence further support favorable prognostic value of hormone receptors in invasive breast cancer.     

Comparative Long‐term Study of a Large Series of Patients with Invasive Ductal Carcinoma and Invasive Lobular Carcinoma. Loco‐Regional Recurrence,Metastasis, and Survival

Our aim was to compare histologic and immunohistochemical features, surgical treatment and clinical course, including disease recurrence, distant metastases, and mortality between patients with invasive ductal carcinoma (IDC) or invasive lobular carcinoma (ILC). We included 1,745 patients operated for 1,789 breast tumors, with 1,639 IDC (1,600 patients) and 145 patients with ILC and 150 breast tumors. The median follow‐up was 76 months. ILC was significantly more likely to be associated with a favorable phenotype. Prevalence of contralateral breast cancer was slightly higher for ILC patients than for IDC patients (4.0% versus 3.2%; p = n.s). ILC was more likely multifocal, estrogen receptor positive, Human Epidermal Growth Factor Receptor‐2 (HER2) negative, and with lower proliferative index compared to IDC. Considering conservative surgery, ILC patients required more frequently re‐excision and/or mastectomy. Prevalence of stage IIB and III stages were significantly more frequent in ILC patients than in IDC patients (37.4% versus 25.3%, p = 0.006). Positive nodes were significantly more frequent in the ILC patients (44.6% versus 37.0%, p = 0.04). After adjustment for tumor size and nodal status, frequencies of recurrence/metastasis, disease‐free and specific survival were similar among patients with IDC and patients with ILC. In conclusion, women with ILC do not have worse clinical outcomes than their counterparts with IDC. Management decisions should be based on individual patient and tumor biologic characteristics rather than on lobular versus ductal histology.     

Sentinel node biopsy in ductal carcinoma in situ of the breast: Never justified?

Sentinel lymph node biopsy for ductal carcinoma in situ (DCIS) of the breast is not standard of care. However, nodal involvement for DCIS patients is reported. Aim of our study was to identify preoperative features predictive of nodal involvement in DCIS patients. We have retrospectively reviewed 175 patients with a preoperative diagnosis of DCIS following a vacuum‐assisted breast biopsy, and undergoing surgery with sentinel node biopsy. Variables distribution was compared between patients upstaged to invasive cancer at final pathology and patients with a confirmed DCIS, and between positive vs negative sentinel node patients. Univariate and multivariate analyses were performed for risk of a positive node. Lymph node biopsy was positive in 13 (7.4%) patients, with 8 (61.5%) macrometastases and 5 (38.5%) micrometastases. In these patients, Breast Imaging Reporting and Data System (BI‐RADS) index >4 (OR 4.69, 95% CI 1.282‐17.224, P = .02), lesion extension ≥20 mm (OR 4.25, 95% CI 1.255‐14.447, P = .02), multifocal disease (OR 4.12, 95% CI 0.987‐17.174, P = .05), comedo type (OR 3.54, 95% CI 1.044‐11.969, P = .04), and upstaging (OR 4.56, 95% CI 1.080‐19.249, P = .04) were all predictive of nodal involvement, although upstaging could not be predicted preoperatively. By multivariate analysis, the only independent factor predictive for positive sentinel node was multifocal disease (OR 5.14, 95% CI 1.015‐26.066, P < .05). A preoperative diagnosis of DCIS, also including advanced biopsy systems such as vacuum‐assisted breast biopsy, may be not always sufficient to exclude patients from sentinel node biopsy. DCIS patients with associated BI‐RADS >4, lesion extension ≥20 mm, comedo type, and above all multifocal disease should be considered for axillary evaluation.     

Evaluating the frequency of upgrade to malignancy following surgical excision of high‐risk breast lesions and ductal carcinoma in situ identified by core needle biopsy

Excision of high‐risk breast lesions (HRL) continues to be standard of care. Previous studies have shown that HRLs can be upgraded to carcinoma in situ (CIS) or invasive carcinoma (IC) upon excision. A single institution retrospective review was conducted to determine the rate of upgrade of HRLs and ductal carcinoma in situ (DCIS) identified on image‐guided biopsy upon excision. Eight hundred and fifty‐seven patients who underwent core needle biopsy (CNB) following the detection of suspicious lesions (BI‐RADS IV) on mammograms were identified. HRLs and DCIS warranting subsequent surgical excision were found in 129 of 857 patients (15.1%). Overall, 19.6% (10/51) of DCIS, 52.4% (11/21) of ADH, and 17.6% (3/17) of papillomas were upgraded on surgical excision. A statistically significant difference was found between the concordant and discordant groups regarding the number of cores obtained (P = 0.01) and the needle size used to retrieve specimens on CNB (P = 0.01). This study reveals an upgrade rate of 26.7% of HRLs and DCIS diagnosed by CNB on surgical excision and emphasizes the continued use of large bore needles with an adequate number of core specimens when investigating a suspicious breast lesion.     

Comparison of the diagnostic accuracy of a vacuum-assisted percutaneous intact specimen sampling device to a vacuum-assisted core needle sampling device for breast biopsy: initial experience

The objective of this research was to determine whether biopsy of the breast using a percutaneous intact specimen sampling device influences the underestimation rate of ductal carcinoma in situ (DCIS) compared to a vacuum-assisted core needle biopsy (VACNB) device. This study was a retrospective comparison of two series of 800 consecutive patients that underwent stereotactic biopsy of the breast for mammographic lesions presenting as microcalcifications classified by our institution as Breast Imaging Reporting and Data System (BI-RADS) 4 or 5. In the first series of patients (n = 800), a VACNB device was used; in the second series (n = 800), a vacuum-assisted percutaneous intact specimen biopsy (VAPIB) device was used. Initial diagnoses were made from the histopathologic examination of the tissue retrieved at biopsy. Lesions presenting as DCIS or atypical ductal hyperplasia (ADH) after percutaneous biopsy were then compared to the histopathologic analysis of specimens retrieved at surgical biopsy. DCIS upgrades were defined as cases in which the diagnosis of the stereotactic biopsy was DCIS and the diagnosis of the subsequent surgical excision was infiltrating ductal carcinoma (IDC). ADH upgrades were defined as cases in which the diagnosis of the stereotactic biopsy specimen was ADH and the diagnosis of the surgical excision was DCIS, lobular carcinoma in situ (LCIS), or IDC. The lesions retrieved by both biopsy techniques yielded a similar pathology distribution. Underestimation of DCIS occurred less frequently (p = 0.06) in the biopsy samples taken using the intact biopsy device (1/31, 3.2%) as compared to biopsy samples taken using the core needle biopsy device (7/36, 19.4%). No significant adverse events were reported. Breast biopsy can be performed safely and accurately using a vacuum-assisted percutaneous intact specimen sampling device. In this study, such a device trended toward fewer underestimations of DCIS at biopsy compared to the vacuum-assisted core needle sampling biopsy method.     

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.     

Sentinel node procedure is warranted in ductal carcinoma in situ with high risk of occult invasive carcinoma and microinvasive carcinoma treated by mastectomy

Abstract:  Axillary lymph node dissection in patients with ductal carcinoma in situ (DCIS) of the breast is not warranted because DCIS has no metastatic potential. However, the risk of microinvasive carcinoma (MIC) exists in large DCIS treated by mastectomy. The aim of this series is to evaluate the incidence of lymph node metastases in DCIS and DCIS-MIC. We analyzed retrospectively patients treated in six French cancer centers for pure DCIS or DCIS-MIC. Surgical procedures were lumpectomy or mastectomy associated with an axillary sentinel node (SN) procedure. We included 161 patients suffering from pure DCIS (116/161, 72%) or DCIS-MIC (45/161, 28%). Mean age was 56 years (32–78). We observed underestimation between core biopsy and histological result in 43/142 cases (30%). These data show an association between lesion size, solid subtype, high-grade DCIS, and underestimation. Forty-eight breast conservative procedures were performed and 113 mastectomies (70%). SN procedure was performed using blue dye, technetium, or both. In our series, we selected patients with a high risk of occult invasive carcinoma: high grade (55%), mean size (27 mm), and mastectomy (112). Six SN were found positive (3.7%). In the five patients treated with complete axillary dissection, the SN was the only positive node. SN in DCIS is an interesting procedure but not necessary for all patients. We need to focus on the subgroup with or a high risk of occult MIC: extensive calcifications or palpable mass, DCIS diagnosed by core biopsy and underestimation, multifocality, high grade, large tumor size, MIC, and mastectomy.     

Magnetic Resonance Imaging in Patients Diagnosed With Ductal Carcinoma-In-Situ: Value in the Diagnosis of Residual Disease,Occult Invasion,and Multicentricity

Background: Although magnetic resonance imaging (MRI) has been shown to be a sensitive imaging tool for invasive breast cancers, its utility in ductal carcinoma-in-situ (DCIS) of the breast remains controversial. We studied the performance of MRI in patients with known DCIS for assessment of residual disease, occult invasion, and multicentricity to determine the clinical role of MRI in this setting.Methods: Fifty-one patients with biopsy-proven DCIS underwent contrast-enhanced MRI before surgical treatment. Pre-, early post-, and late postcontrast three-dimensional gradient echo images were obtained and MRI findings were correlated with histopathology. When possible, the performance of MRI and mammography was compared.Results: The accuracy of MRI was 88% in predicting residual disease, 82% in predicting invasive disease, and 90% in predicting multicentricity. The performance of MRI was equivalent in the core biopsy group when compared with the surgical biopsy group. For occult invasion only, MRI and mammography were equivalent. However, overall, MRI was more sensitive and had a higher negative predictive value than mammography.Conclusions:MRI of DCIS can serve as a useful adjunct to mammography by providing a more accurate assessment of the extent of residual or multicentric disease. The performance of MRI is not significantly affected by antecedent surgical excision. MRI may be particularly valuable if preoperatively negative.     

Atypical ductal hyperplasia on core needle biopsy: Surgical outcomes of 200 consecutive cases from a high-volume breast program

Atypical ductal hyperplasia (ADH) is an indication for excisional biopsy to rule out occult breast cancer. We analyzed pathological findings on excisional biopsy for ADH diagnosed in a high volume breast center equipped with digital tomosynthesis. Two hundred consecutive patients were diagnosed with ADH on core biopsy with radiographic concordance followed by excisional biopsy. On excisional biopsy, 33 patients (16.5%) were diagnosed with DCIS or invasive breast cancer. Patients with a concurrent diagnosis of papilloma had a higher risk of upstaging on both univariate and multivariate analysis (41.7% vs. 14.9%, p=0.015). No other statistically significant predictors of upgrading were identified (p>0.05).