Intramammary incidental findings on staging computer tomography

Contrast-Enhanced Chest Computed Tomography for In-Breast Recurrence Detection: Clinical and Imaging Predictors of Visibility

Purpose: Routine surveillance chest CT is not recommended by current guidelines; however, its use has been increasing with improved accessibility. This study aimed to evaluate the utility of surveillance contrast-enhanced chest computed tomography (CT) in detecting in-breast recurrence among survivors, focusing on imaging and clinicopathological features that enhance tumor visibility. Additionally, this study sought to determine which patient populations may derive benefit from contrast-enhanced chest CT. Materials and Methods: A retrospective analysis was conducted on records of patients diagnosed with in-breast recurrence through biopsy during follow-up after breast cancer surgery between January 2016 and August 2022. Patients who underwent contrast-enhanced chest CT within one month of diagnosis were included. Two radiologists reviewed the chest CT scans for breast cancer lesions by consensus, and their findings were validated by two other radiologists blinded to tumor locations. Statistical analyses were performed to evaluate associations among clinicopathological factors, image features, and visibility. Results: Eighty-nine recurrent tumors in 85 patients were included. Fifty-eight recurrent tumors were identified by radiologists who were not blinded. The blinded radiologists independently identified 50 and 56 recurrences, with substantial inter-observer agreement (κ-value = 0.768, p < 0.001). The visible group had a significantly higher rate of invasive ductal carcinoma (IDC) compared to the non-visible group (81.0% vs. 54.8%, p = 0.002). Additionally, the visible group exhibited larger tumors than the non-visible group (mean ± SD: 1.9 ± 1.5 cm vs. 1.3 ± 0.6 cm, p = 0.018). Tumors located in fatty backgrounds demonstrated significantly greater visibility on chest CT than those in glandular backgrounds (67.2% vs. 16.1%, p < 0.001). Recurrent breast cancer was also more frequently visible on chest CT in patients who had undergone mastectomy compared to those who had received breast-conserving surgery (p < 0.001). Conclusions: Contrast-enhanced chest CT can aid in the detection of in-breast recurrence, particularly in patients who have undergone mastectomy, as a complementary imaging modality. Tumors in fatty backgrounds, large tumors, mass-type tumors, and IDCs are better visible on chest CT.

Assignment of the biological value of solid breast masses based on quantitative evaluations of spectral CT examinations using electron density mapping, Zeffective mapping and iodine mapping

OBJECTIVE

We aimed to asses, in a clinical setting, whether the newly available quantitative evaluation of electron density (ED) in spectral CT examinations of the breast provide information on the biological identity of solid breast masses and whether ED maps yield added value to the diagnostic information of iodine maps and Zeff maps calculated from the same CT image datasets.

METHODS

All patients at the University Breast Cancer Center who underwent a clinically indicated Dual Layer Computed Tomography (DLCT) examination for staging of invasive breast cancer from 2018 to 2020 were prospectively included. Iodine concentration maps, Zeff maps and ED maps were automatically reconstructed from the DLCT datasets. Region of interest (ROI) based evaluations in the breast target lesions and in the aorta were performed semi-automatically in identical anatomical positions using dedicated evaluation software. Case-by-case evaluations were carried independently by 2 of 4 radiologists for each examination, respectively. Statistical analysis derived from the ROIs was done by calculating ROC/AUC curves and Youden indices.

RESULTS

The evaluations comprised 166 DLCT examinations. In the ED maps the measurements in the breast target lesions yielded Youden cutpoints of 104.0% (reader 1) and 103.8% (reader 2) resulting in AUCs of 0.63 and 0.67 at the empirical cutpoints. The variables "Zeff" and "iodine content" derived from the target lesions showed superior diagnostical results, with a Youden cutpoint of 8.0 mg/ml in the iodine maps and cutpoints of 1.1/1.2 in the Zeff maps the AUCs ranging from 0.84 to 0.85 (p = 0.023 to <0.000). The computational combination of Zeff and ED measurements in the target lesions yielded a slight AUC increase (readers 1: 0.85-0.87; readers 2: 0.84-0.94). The ratios of the measured values in the target lesions normalized to the values measured in the aorta showed comparable results. The AUCs of ED derived from the cutpoints showed inferior results to those derived from the Zeff maps and iodine maps (ED: 0.64 and 0.66 for reader 1 and 2; Zeff: 0.86 for both readers; iodine content: 0.89 and 0.86 for reader 1 and 2, respectively). The computational combination of the ED results and the Zeff measurements did not lead to a clinically relevant diagnostic gain with AUCs ranging from 0.86 to 0.88.

CONCLUSIONS

Quantitative assessments of Zeff, iodine content and ED all targeting the physical and chemical aspects of iodine uptake in solid breast masses confirmed diagnostically robust cutpoints for the differentiation of benign and malignant findings (Zeff < 7.7, iodine content of <0.8 mg/ml). The evaluations of the ED did not indicate any added diagnostic value beyond the quantitative assessments of Zeff and iodine content. Further research is warranted to develop suitable clinical indications for the use of ED maps.

Incidental Breast Findings on Computed Tomography and MR Imaging

Computed tomography (CT) and magnetic resonance (MR) imaging may demonstrate a wide variety of incidental findings in the breast, including primary breast carcinoma, the second most common cancer in women. It important to recognize the spectrum of pathologic conditions in order to properly assess the need for further workup. Some findings may be diagnosed as benign on the basis of CT/ MR imaging and clinical history alone, whereas others will require evaluation with dedicated breast imaging and possibly biopsy. This article serves to guide radiologists' management of the wide spectrum of incidental breast findings encountered on cross-sectional imaging.

Incidence and outcomes of incidental breast lesions detected on cross-sectional imaging examinations

The aim of this study was to determine the frequency and outcomes of incidental breast lesions detected on nonbreast specific cross-sectional imaging examinations. A retrospective review of the medical records was performed to identify all patients without a known history of breast cancer, who had an incidentally discovered breast lesion detected on a nonbreast imaging examination performed at our institution between September 2008 and August 2012 for this IRB-approved, HIPAA compliant study. Outcomes of the incidental lesions were determined by follow-up with dedicated breast imaging (mammography, breast ultrasound, and/or breast MRI) or results of biopsy, if performed. Imaging modality of detection, imaging features, patient age, patient location at the time of the nonbreast imaging examination, type of follow-up, and final outcome were recorded. Rates of malignancy were also calculated, and comparison was made across the different cross-sectional imaging modalities. Kruskal-Wallis and Fisher's exact tests were used to identify factors associated with an increased rate of malignancy. Logistic regression was used to model the risk of malignancy as a function of continuous predictors (such as patient age or lesion size); odds ratios and 95% confidence intervals were obtained. A total of 292 patients with incidental breast lesions were identified, 242 of whom had incidental lesions were noted on computed tomography (CT) studies, 25 on magnetic resonance imaging (MRI), and 25 on positron emission tomography (PET). Although most of the incidental breast lesions were detected on CT examinations, PET studies had the highest rate of detection of incidental breast lesions per number of studies performed (rate of incidental breast lesion detection on PET studies was 0.29%, compared to 0.10% for CT and 0.01% for MRI). Of the 121 of 292 (41%) patients who received dedicated breast imaging work-up at our institution, 40 of 121 (33%) underwent biopsy and 25 of 121 (21%) had malignancy. There was a significantly increased rate of malignancy in older patients (odds ratio: 1.05, 95% CI: 1.02-1.093; P = .006). Additionally, patients with PET-detected incidental breast lesions had a significantly higher rate of malignancy (55%), compared to patients with CT-detected (35%) and MRI-detected (8%) incidental breast lesions (P = .038). The rate of malignancy upon follow-up of incidental breast lesions detected on nonbreast imaging examinations in this retrospective study was 21%, supporting the importance of emphasizing further work-up of all incidentally detected breast lesions with dedicated breast imaging. Additionally, we found that PET examinations had the highest rate of detection of incidental breast lesions and the highest rate of malignancy, which suggests that PET examinations may be more specific for predicting the likelihood of malignancy of incidental breast lesions, compared to CT and MRI.

[Imaging findings of intramammary malignant lymphoproliferative disease]

Intramammary manifestation of lymphoproliferative disease is rare. The radiological evaluation follows in most cases the clinical suspicion and therefore the radiologist takes an important place in diagnostics. The aim of this work is to demonstrate typical radiological patterns of this rare entity with multimodal cases and to sensitize for it. The differential diagnosis to other breast tumors, especially primary breast carcinoma, can be radiologically difficult, so the suspicious lesion must be histologically verified by biopsy.

Extrapulmonary neoplasms in lung cancer screening

A significant reduction in lung cancer specific mortality rate was demonstrated by the National Lung Screening Trial (NLST) in participants who had annual low-dose computed tomography (LDCT) screening. In addition to early detection of lung cancer, lung cancer screening (LCS) provides an opportunity to detect cardiovascular disease, pulmonary disease (such as chronic obstructive pulmonary disease and interstitial lung disease), and extrapulmonary neoplasms, such as thyroid, breast, kidney, liver, esophageal, pancreatic and mediastinal tumors. Considering the fact that 22.3% of the certified deaths in the computed tomography (CT) arm of the NLST trial were due to extrapulmonary malignancies, compared to 22.9% of deaths from lung cancer, it is possible that early diagnosis and treatment of clinically significant incidental findings may further decrease morbidity and mortality in screening participants. In this article we review prevalence, clinical relevance and management of incidentally detected extrapulmonary malignancies.

[Imaging diagnostics of breast metastases from extramammary tumors]

Breast metastases of solid extramammary tumors are very rare in comparison to primary malignancies of the breast and account for only 0.33-6.3% of all malignant neoplasms of the breast. The most common primary tumors are malignant melanoma, distant sarcomas, lung cancer, ovarian cancer, renal cell cancer and thyroid cancer in decreasing order of frequency. This review article summarizes the clinical features and the different imaging findings of breast metastases from different extramammary solid tumors. Breast metastases are often incidental findings in computed tomography (CT) or positron emission tomography CT (PET-CT) imaging. Mammography shows two different imaging patterns, namely focal lesions and diffuse architectural distortion with skin thickening. Breast metastases presenting as focal masses usually occur as solitary and more rarely as multiple round lesions with a smooth edge boundary. Associated calcifications are rare findings. Diffuse architectural distortion with skin thickening is more common in breast metastases from most gastric tumors, ovarian cancer and rhabdomyosarcoma. Using ultrasound most lesions are hypoechoic, oval or round with smooth boundaries and posterior acoustic enhancement. The magnetic resonance imaging (MRI) criteria of breast metastases show an inconstant signal behavior that cannot be safely classified as benign or malignant. In summary, in patients with known malignancies the presence of breast metastases should be considered even with imposing clinically and radiologically benign findings.

Incidental findings in the skeletal musculature on computed tomography

OBJECTIVE

The purpose of this study was to analyze intramuscular incidental findings identified on CT in a large patient cohort.

METHODS

In the time period from 2010 to 2015, a total of 44,794 patients with several diagnoses were investigated by CT. Only those patients who underwent body CT including the neck, thorax, abdomen and pelvic regions after the i.v. application of a contrast medium were involved in the study. There were 4085 patients. On further analysis, only patients with intramuscular findings (IFs) incidentally detected on CT were included. Osseous or soft-tissue lesions with invasion into the musculature were excluded from the study. Patients with known or clinically suspicious muscle disorders were also excluded. Overall, 639 (15.64% of the 4085 analyzed cases) patients, 253 females and 386 males, with mean age 72.43 ± 12.02 years, were identified. Collected data were evaluated by means of descriptive statistics.

RESULTS

In the 639 patients, 917 IFs were identified. More often, several benign disorders were diagnosed (n = 803, 87.6%). There were hernias (33.5%), atrophy of different muscles (22%), lipomas (21%), intramuscular calcifications (8.7%), bursitis (1.2%) and intramuscular bleeding (1.1%). Malignant IFs (n = 114, 12.4%) included intramuscular metastases (11.9%) and lymphomas (0.6%). Most frequently, the identified IFs were localized in the abdominal wall musculature, paravertebral and gluteal muscles. In 657 cases (71.6% of all IFs), the identified muscle findings were not diagnosed by the radiologist who initially assessed the investigation.

CONCLUSION

CT can detect different incidental disorders within the skeletal musculature. Most of them were benign. However, malignant lesions can also occur. Therefore, skeletal muscles should be carefully evaluated on CT performed for other reasons. Advances in knowledge: IFs occur in 15.6% of CT investigations. Benign findings represent 87.6% and malignant lesions can be identified in 12.4%.

Intramammary Findings on CT of the Chest - a Review of Normal Anatomy and Possible Findings

Computed tomography (CT) is a frequently performed examination in women of all ages. In all thoracic CT examinations of the chest at least parts of the breasts are included. Therefore incidental breast pathology may be observed. It has been suggested that one out of 250 women undergoing chest CT will show a malignant incidental breast lesion. Given the high number of performed chest CT examinations, this contributes to a significant number of malignancies. In this review, after a brief discussion of the value of computed tomography in breast imaging, normal and pathologic findings are discussed to create awareness of this potential “black box” on chest CT.

Thrombotic events as incidental finding on computed tomography in intensive care unit patients

INTRODUCTION

Intensive care unit (ICU) patients are a risk group to develop thrombosis and/or thromboembolism. The purpose of this study was to analyze the frequency and localization of clinically silent thrombotic events (TE) detected on CT.

MATERIALS AND METHODS

From 2006 to 2013 a total of 370 patients from the ICU of our university clinic were investigated by postcontrast CT. In all cases CT was performed for detecting septic foci. There were 135 women and 235 men. CT scans included cervical, thoracic, abdominal, and pelvic regions. CT images of all patients were re-interpreted by 2 radiologists by consensus. Only thromboses detected for the first time on CT were included into the analysis. Collected data were evaluated by means of descriptive statistics. Frequencies and localizations of TE in surgical and non surgical patients were analyzed by Chi-square test. Significance level was p<0.05.

RESULTS

In 31.9% several TE were diagnosed. There were venous thrombosis (89.8%), cardiac thrombus (2.6%), and pulmonary embolism (7.6%). More often jugular veins were affected followed by brachiocephalic veins, and iliac veins. The frequency of TE in surgical patients was 31.1%, and 32.1% in non surgical patients. Patients after surgery had more often thrombosis of extremities veins in comparison to non surgical patients. In 61.9% of all TE the identified thrombotic complications were not diagnosed at the time of CT investigations.

CONCLUSION

TE can be identified in 31.9% of ICU patients as incidental finding on CT. There were venous thromboses, pulmonary embolism, and cardiac thrombus. Most frequently neck and thoracic veins were affected. 61.9% of all TE were not diagnosed at the time of CT investigations. Radiologists should check carefully CT scans for presence of different TE.

Costs associated with evaluation of incidental breast lesions identified on computed tomography

OBJECTIVE

The purpose of this study was to calculate the costs associated with the evaluation of breast incidentalomas (BI) identified on CT.

METHODS

All CT scans of the thorax performed at the radiological department of the University Hospital of the Martin-Luther-University Halle-Wittenberg between the years 2006 and 2014 were reanalysed retrospectively. 111 patients with BI were identified. The radiological and clinical reports of these cases were examined, and the costs of all further diagnostic procedures performed to clarify the detected BI were calculated.

RESULTS

In 31 (27.9%) of the 111 patients, BI were not further investigated. Of the remaining 80 (72.1%) cases of BI, primary breast carcinoma was diagnosed in 10 (12.5%) cases, breast involvement by lymphoma in 7 (8.8%) cases, intramammary metastases in 19 (23.7%) cases and different benign findings in 44 (55.0%) cases. The total costs associated with clarification of BI in our institution (n = 53) amounted to €14,045.71. The costs per BI were €265.01 and per newly identified breast cancer €1560.63.

CONCLUSION

Breast lesions incidentally detected on CT should be categorized as major incidental findings because of the high frequency of malignancy. The radiologist should carefully evaluate the breast on CT images and all identified BI should be clarified. The clarification of BI is associated with a low economic burden in comparison with screening programmes for primary breast cancer.

ADVANCES IN KNOWLEDGE

The radiologist should carefully evaluate the breast on CT and all identified BI should be clarified. The evaluation of BI is associated with a low economic burden.

Incidental Breast Lesions Detected on Computed Thorax Tomography

OBJECTIVE

Although mammography is the primary imaging method of the breast, incidental benign and malignant breast lesions are increasingly being detected on computed tomographies (CTs) performed to detect different pathologies. Therefore, the detection and accurate identification of these lesions is important. In this study, we aimed to evaluate the frequency, morphological features, and results of incidental breast lesions on CTs performed for the detection of extramammarian pathologies.

MATERIALS AND METHODS

Incidental breast lesions on CTs performed in our department between 2011 and 2013 were evaluated. Patients who had previously diagnosed breast lesions were excluded from the study. The inclusion criteria were histopathologic diagnose and being followed-up for at least 2 years.

RESULTS

The study population consisted of 33 women whose mean age was 55±1.38 (37-78) years. Of the 33 women, 12 (36%) had malignant and 21 (64%) had benign or normal findings. The most common malignant lesion was invasive ductal carcinoma, and the most common benign lesion was fibroadenoma. Ill-defined contour and lymphadenopathy in malignant lesions and well-defined contour in benign lesions were the most important CT findings.

CONCLUSION

Breast must be carefully evaluated if it is included in the scans. An accurate report of breast lesions gives an opportunity for early diagnosis and treatment.

Clinically Relevant Cardiovascular Findings Detected on Staging Computed Tomography in Patients with Several Malignancies

We evaluated the frequency and subtypes of clinically relevant cardiovascular (CV) findings identified on staging computed tomography (CT) in a large sample. Patients (n = 5026) with different malignant diseases were staged by CT. Clinically relevant CV findings (CRCFs) were included into the study. The CRCFs were defined as cardiac aneurysm, cardiac thrombus, venous thrombosis, arterial thrombosis, arterial dissection, pulmonary thromboembolism, arterial dissection, and dislocation of venous ports/central venous catheters. The CRCFs were identified in 342 patients (6.8% of all patients). Overall, 491 CRCFs were identified in the patients (1.4 per patient). In 203 (59.4%) patients, 1 CRCF; in 129, 2 (37.7%) CRCFs; and in 10 (2.9%) cases, 3 CRCFs were detected. There were incidental venous thrombosis (n = 298, 60.7% of all CRCFs), pulmonary thromboembolism (n = 84, 17.1%), arterial aneurysms (n = 44, 8.9%), arterial thrombosis (n = 43, 8.8%), heart thrombus (n = 15, 3.1%), arterial dissection (n = 3, 0.6%), heart aneurysms (n = 2, 0.4%), and port catheter dislocation (n = 2, 0.4%). The identified CRCF can be associated with potential hazardous complications. The CV system should be carefully evaluated in staging CT investigations.

Non-osseous incidental findings in low-dose whole-body CT in patients with multiple myeloma

OBJECTIVE

The purpose of this study was to identify the frequency and grading of non-osseous incidental findings (NOIF) in non-contrast whole-body low-dose CT (LDCT) in patients with multiple myeloma.

METHODS

In the time period from 2010 to 2013, 93 patients with multiple myeloma were staged by non-contrast whole-body LDCT at our radiological department. LDCT images were analysed retrospectively for NOIF, which also included unsuspected extramedullary manifestation of multiple myeloma. All NOIF were classified as major or clinically significant, moderate or possibly clinically significant and minor or not clinically significant. Medical records were analysed regarding further investigation and follow-up of the identified NOIF.

RESULTS

In the 93 patients, 295 NOIF were identified (on average, 3.2 NOIF per patient). Most of the NOIF (52.4%) were not clinically significant, 25.8% of the NOIF were possibly clinically significant and 21.8% of the NOIF were clinically significant. Clinically significant NOIF were investigated further by CT after intravenous administration of contrast medium and/or by ultrasound or MRI. In 34 of these cases, extramedullary relapse of myeloma, occult carcinoma or infectious/septic incidental findings were diagnosed (11.5% of all NOIF). In the remaining 10.3% of the NOIF classified as clinically significant, various benign lesions were diagnosed.

CONCLUSION

LDCT detected various non-osseous lesions in patients with multiple myeloma. 36.6% of the patients had clinically significant NOIF. Therefore, LDCT examinations in patients with multiple myeloma should be evaluated carefully for the presence of NOIF.

ADVANCES IN KNOWLEDGE

LDCT identified several NOIF. A total of 36.6% of patients with multiple myeloma had clinically significant NOIF. Radiologists should analyse LDCT examinations in patients with multiple myeloma not only for bone lesions, but also for lesions in other organs.

Comparison between incidental malignant and benign breast lesions detected by computed tomography: a systematic review

INTRODUCTION

With increasing use of CT for a variety of diagnostic pathways, breast incidentalomas will be identified more frequently. Therefore, it is important for radiologists to know typical CT appearances of malignant and benign breast lesions. The aim of this study was to compare radiological features of benign and malignant incidental breast findings on CT reported in the literature.

METHODS

A search for appropriate studies published between 1988 and 2012 yielded five results with a total of 214 patients/257 lesions. Morphological features of the described breast masses, such as shape, margins, enhancement, axillary lymphadenopathy and calcifications, were analysed.

RESULTS

The prevalence of incidental breast carcinoma varied from 9.2% to 60.9% of the lesions. The frequency of benign lesions was 30.4-71.8%. The remaining incidental findings were intramammary metastases and primary or secondary breast lymphomas. Malignant lesions were larger in size, were round in shape and demonstrated a higher density compared with benign lesions. There was no significant difference in the margin characteristics of the masses between the groups. The morphological features previously postulated as typical for malignancy turned out to be non-specific.

CONCLUSIONS

Benign and malign breast incidentalomas are not safely distinguished from each other on standard chest CT. Therefore, all breast incidentalomas should be evaluated by further radiological/histological investigations.