MRI features of inflammatory breast cancer

Diffuse unilateral MRI breast entities

Many benign and malignant breast entities can present with diffuse unilateral magnetic resonance imaging (MRI) findings. The unilateral breast findings can be broken down into three broad categories including asymmetric diffuse masses/non-mass enhancement (NME), diffuse unilateral skin thickening, and diffuse asymmetric background enhancement. Although correlation with clinical history is always necessary, biopsy is often needed to make a definitive diagnosis. There are some findings on MRI which can help narrow the differential including morphology, distribution, T2W signal, enhancement kinetics, and associated skin thickening. Malignant entities which will be discussed in this review include ductal carcinoma in situ, invasive ductal carcinoma, invasive lobular carcinoma, Paget disease, inflammatory breast cancer, and locally advanced breast cancer. Benign entities which will be discussed in this review include idiopathic granulomatous mastitis (IGM), infectious mastitis, pseudoangiomatous stromal hyperplasia, giant fibroadenoma, early and late radiation changes, unilateral breast feeding, and central venous obstruction, all which have varied MRI appearances. It is important for radiologists to be familiar with the common entities that can present with diffuse asymmetric unilateral MRI breast findings to ensure the correct diagnosis and management is undertaken.

Magnetic resonance imaging findings for inflammatory mastitis of unknown etiology

Inflammatory mastitis of unknown etiology includes the entities periductal mastitis and idiopathic granulomatous mastitis. These relatively uncommon processes usually affect women of childbearing age. They usually present as a palpable mass that is painful on palpation. These lesions have an insidious clinical course and are difficult to diagnose. In some cases, they can resemble malignant disease, especially in some very developed cases where they can resemble inflammatory carcinoma. When considered all together in the appropriate clinical context, the magnetic resonance imaging signs enable us to approach a specific diagnosis. These entities share clinical and radiological characteristics with malignant processes, so biopsies are fundamental to rule out malignancy.

New Strategies for Locally Advanced Breast Cancer: A Review of Inflammatory Breast Cancer and Nonresponders

This review explores the new strategies around the management of locally advanced breast cancer (LABC), particularly for nonresponsive tumors and/or initially unresectable tumors at diagnosis, inclusive of inflammatory breast cancer. Nonresponders to neoadjuvant systemic therapy present a unique clinical challenge. Emerging medical therapeutics as well as considerations for use of radiotherapy and/or surgery in this setting are discussed. Specifically, the use of neoadjuvant radiotherapy for LABC and lymphedema prevention with lymphatic reconstruction following axillary lymph node dissection are reviewed.

Radiation for inflammatory breast cancer: Updates

Inflammatory breast cancer (IBC) is a diagnosis based on a constellation of clinical features of edema (peau d'orange) of a third or more of the skin of the breast with a palpable border and a rapid onset of breast erythema. Incidence of IBC has increased over time, although it still makes up only 1-4% of all breast cancer diagnoses. Despite recent encouraging data on clinical outcomes, the published local-regional control rates remain consistently lower than the rates for non-IBC. In this review, we focus on radiotherapy, provide a framework for multi-disciplinary care for IBC, describe local-regional treatment techniques for IBC; highlight new directions in the management of patients with metastatic IBC and offer an introduction to future directions regarding the optimal treatment and management of IBC.

A Case of Bilateral Inflammatory Breast Cancer

Inflammatory breast cancer (IBC) is an aggressive form of breast carcinoma. Bilateral occurrences of IBC within a short time frame are rare, particularly without significant surgical intervention. This case presents a patient with contralateral recurrence of IBC less than a year after the initial diagnosis. A 39-year-old female was diagnosed with stage IV inflammatory breast cancer in her left breast. Less than a year later, extensive disease was found in her right breast. The patient had received incomplete treatment for the left IBC due to barriers to accessing care. Imaging confirmed the presence of inflammatory breast cancer in the contralateral breast, along with regional adenopathy and metastases. The patient began a chemotherapy regimen similar to her previous treatment. This case highlights the uncommon occurrence of contralateral recurrence of IBC and the hypothesized mechanism of lymphatic spread, suggesting local metastasis rather than a new primary tumor. The patient's incomplete treatment and lack of surgical intervention likely contributed to the development of contralateral IBC. The case underscores the importance of magnetic resonance imaging (MRI) in evaluating soft tissue and lymphatic changes in IBC. Barriers to care negatively impact prognosis, emphasizing the need for timely follow-up, diagnostic imaging, and oncologic therapy for successful treatment.

Inflammatory Skin Change From a Small 0.9 cm Primary Breast Cancer Not Seen on Initial Imaging: A Case Report

Most inflammatory breast cancers are caused by invasive ductal cell carcinomas that arise from mammary epithelial cells lining the breast ducts. Typically, in these cancers, radiological signs are conspicuous, and a diagnosis is made after standard mammographic imaging or ultrasound. We report the case of a 54-year-old female who presented to a mammography clinic with right-sided breast pain and swelling. Upon physical examination, there was no palpable mass. Ultrasound and mammogram findings included mild skin thickening, normal-sized but irregularly shaped axillary lymph nodes, and no breast mass. Due to the presence of inflammatory changes (skin thickening) and abnormal lymph nodes but no obvious mass, an MRI was done to find the primary mass after a core needle biopsy of one lymph node showed metastatic ductal disease. In this patient, a 0.9 cm mass was found at the right 8:00 position on MRI. A second-look ultrasound was then performed and the mass was identified, followed by an ultrasound-guided core biopsy. The biopsy showed an invasive ductal cell carcinoma. In most cases, inflammatory breast cancer is associated with larger tumor sizes. However, a subset of patients with inflammatory breast cancer may present with a small primary breast tumor that causes inflammatory changes. Here, we present a rare case of inflammatory breast cancer associated with a small breast mass measuring less than 1 cm in size.

Monocyte MRI Relaxation Rates Are Regulated by Extracellular Iron and Hepcidin

Many chronic inflammatory conditions are mediated by an increase in the number of monocytes in peripheral circulation, differentiation of monocytes to macrophages, and different macrophage subpopulations during pro- and anti-inflammatory stages of tissue injury. When hepcidin secretion is stimulated during inflammation, the iron export protein ferroportin is targeted for degradation on a limited number of cell types, including monocytes and macrophages. Such changes in monocyte iron metabolism raise the possibility of non-invasively tracking the activity of these immune cells using magnetic resonance imaging (MRI). We hypothesized that hepcidin-mediated changes in monocyte iron regulation influence both cellular iron content and MRI relaxation rates. In response to varying conditions of extracellular iron supplementation, ferroportin protein levels in human THP-1 monocytes decreased two- to eightfold, consistent with paracrine/autocrine regulation of iron export. Following hepcidin treatment, ferroportin protein levels further decreased two- to fourfold. This was accompanied by an approximately twofold increase in total transverse relaxation rate, R₂*, compared to non-supplemented cells. A positive correlation between total cellular iron content and R₂* improved from moderate to strong in the presence of hepcidin. These findings suggest that hepcidin-mediated changes detected in monocytes using MRI could be valuable for in vivo cell tracking of inflammatory responses.

Imaging Modalities in Inflammatory Breast Cancer (IBC) Diagnosis: A Computer-Aided Diagnosis System Using Bilateral Mammography Images

Inflammatory breast cancer (IBC) is an aggressive type of breast cancer. It leads to a significantly shorter survival than other types of breast cancer in the U.S. The American Joint Committee on Cancer (AJCC) defines the diagnosis based on specific criteria. However, the clinical presentation of IBC in North Africa (Egypt, Morocco, and Tunisia) does not agree, in many cases, with the AJCC criteria. Healthcare providers with expertise in IBC diagnosis are limited because of the rare nature of the disease. This paper reviewed current imaging modalities for IBC diagnosis and proposed a computer-aided diagnosis system using bilateral mammograms for early and improved diagnosis. The National Institute of Cancer in Egypt provided the image dataset consisting of IBC and non-IBC cancer cases. Type 1 and Type 2 fuzzy logic classifiers use the IBC markers that the expert team identified and extracted carefully. As this research is a pioneering work in its field, we focused on breast skin thickening, its percentage, the level of nipple retraction, bilateral breast density asymmetry, and the ratio of the breast density of both breasts in bilateral digital mammogram images. Granulomatous mastitis cases are not included in the dataset. The system's performance is evaluated according to the accuracy, recall, precision, F1 score, and area under the curve. The system achieved accuracy in the range of 92.3-100%.

Unilateral primary breast edema: Can T2-weighted images meet the diagnostic challenge?

Background

Unilateral primary breast edema may pose a diagnostic challenge. Excluding malignant etiologies is of utmost importance and may require the use of dynamic MRI examination as a problem solver. Yet, the enhancement pattern of benign and malignant disorders associated with edematous breasts may overlap, and this may add to the dilemma. So, our aim in the current study was to assess the role of T2-weighted MR imaging as a problem-solving sequence in differentiating benign from malignant causes of the edematous breast.

Results

In the current prospective study, 65/96 cases were benign and 31/96 cases were malignant. By the individual analysis of the signal intensity in T2-weighted imaging of MRI examination, there was a significant correlation between low T2 signal intensity lesion and malignant etiology of breast edema with a resultant higher sensitivity of 83.87% and a higher specificity of 98.46% as compared to the contrast-enhanced series, which achieved a sensitivity of 80.65% and a specificity of 20.00%. The combined assessment of T2 WI and the contrast-enhanced series yielded a higher sensitivity of 100% and a specificity of 98.46%.

Conclusions

T2WI is a problem-solving sequence in the evaluation of the primary edematous breast, yielding a significant added value in the diagnostic approach and improving the overall diagnostic performance of dynamic contrast-enhanced MRI.

MRI Changes in Breast Skin Following Preoperative Therapy for Patients with Inflammatory Breast Cancer

RATIONALE AND OBJECTIVES

Preoperative systemic therapy (PST) followed by mastectomy and radiation improves survival for patients with inflammatory breast cancer (IBC). Residual disease within the skin post-PST adversely impacts surgical outcome and risk of local-regional recurrence (LRR). We aimed to assess magnetic resonance imaging (MRI) breast skin changes post-PST with pathologic response and its impact on surgical resectability.

MATERIALS AND METHODS

We retrospectively reviewed 152 baseline and post-PST breast MRIs of 76 patients with IBC. Using the ACR-BIRADS MRI lexicon, we correlated skin thickness, qualitative enhancement, and kinetic analysis with pathologic response in the skin at mastectomy.

RESULTS

Baseline MRI showed skin thickening in all 76 patients, 75/76 (99%) showed skin enhancement, 54/75 (72%) had medium/fast initial kinetics, usually with persistent delayed kinetics in 49/54 (91%). Following PST, 66/76 (87%) had residual skin thickening with 64/76 (84%) showing a decrease; 33/76 (43%) had persistent enhancement. The median thickness post-PST was 4.7 mm with residual tumor in the skin, and 3.0 mm without residual tumor (p = 0.008). Regardless of pathologic response, the majority of patients had persistent skin thickening on MRI following PST (100% [14/14] with residual tumor and 84% [52/62] without residual tumor). There was no association between post-PST skin thickness on breast MRI and rate of LRR.

CONCLUSION

Patients with IBC have skin thickening and enhancement on baseline breast MRI, with a statistically significant reduction in skin thickness following successful PST. Despite persistent skin changes on MRI, patients achieving a partial or complete parenchymal response to PST may proceed to mastectomy with low LRR rates.

Breast metastases of eccrine porocarcinoma

Eccrine porocarcinoma is a rare skin adnexal malignant neoplasm that may arise from a pre-existing benign eccrine poroma or without a predisposing factor. It is a highly invasive neoplasm and has a strong metastatic potential. The most frequently affected organs are the lymph nodes and rarely solid organs such as the liver, lungs and breast. We report a case of a woman with a history of surgically treated eccrine porocarcinoma that a year later presented with multiple lesions in both breasts and axillary lymphadenopathies. After a detailed imaging investigation, the diagnosis of metastatic lesions from porocarcinoma was made. To our knowledge, until the moment, only one case of breast metastasis of eccrine porocarcinoma has been reported in the literature.

A Complex Radiomic Signature in Luminal Breast Cancer from a Weighted Statistical Framework: A Pilot Study

Radiomics is rapidly advancing in precision diagnostics and cancer treatment. However, there are several challenges that need to be addressed before translation to clinical use. This study presents an ad-hoc weighted statistical framework to explore radiomic biomarkers for a better characterization of the radiogenomic phenotypes in breast cancer. Thirty-six female patients with breast cancer were enrolled in this study. Radiomic features were extracted from MRI and PET imaging techniques for malignant and healthy lesions in each patient. To reduce within-subject bias, the ratio of radiomic features extracted from both lesions was calculated for each patient. Radiomic features were further normalized, comparing the z-score, quantile, and whitening normalization methods to reduce between-subjects bias. After feature reduction by Spearman’s correlation, a methodological approach based on a principal component analysis (PCA) was applied. The results were compared and validated on twenty-seven patients to investigate the tumor grade, Ki-67 index, and molecular cancer subtypes using classification methods (LogitBoost, random forest, and linear discriminant analysis). The classification techniques achieved high area-under-the-curve values with one PC that was calculated by normalizing the radiomic features via the quantile method. This pilot study helped us to establish a robust framework of analysis to generate a combined radiomic signature, which may lead to more precise breast cancer prognosis.

Delayed presentation of inflammatory breast carcinoma during the COVID-19 pandemic

Background

Breast cancer may present with distinct cutaneous manifestations that may be paraneoplastic or secondary to direct skin infiltration, distant skin metastases, or dermal lymphatic tumor embolization (inflammatory breast carcinoma).

Case report

A 51-year-old Asian woman visited the emergency care department during the outbreak of COVID-19 in Northern Italy. About 6 months before, she had noted the onset of right breast swelling accompanied by skin redness and itching. She never consulted a physician, and, over time, the local skin condition progressed to a large scaly plaque covering the entire breast surface including the nipple. At presentation, abduction of the right upper limb was impaired due to severe shoulder pain. CT scan showed the presence of bilateral breast masses with necrotic and colliquative features, and multiple skeletal, nodal, pulmonary, and brain images suggestive of metastases. An ultrasound-guided core biopsy of the contralateral breast showed grade 2 non-special type infiltrating carcinoma. The patient was referred to the breast oncology unit and is currently being treated with aromatase inhibitors and chemotherapy.

Conclusion

The COVID-19 pandemic has disrupted the entire spectrum of oncological care including breast cancer. Hopefully, telemedicine will contribute to increase patients' confidence and will provide earlier diagnosis and treatment while minimizing the risk of contagion.

Primary Breast Angiosarcoma: Utilisation of Pre-surgical Magnetic Resonance Imaging (MRI) for Accurate Tumour Characterization and Planning - A Case Report and Literature Review

BACKGROUND

Primary breast angiosarcoma is a rare malignancy with non-specific clinical and radiological findings.

CASE REPORT

A 30-year-old lady presented with left breast pain and lumpiness for over one year. She has had several breast ultrasounds (US) and was treated for acute mastitis and abscess. Subsequently, in view of the rapid growth of the lump and worsening pain, she was re-investigated with US, elastography, digital breast tomosynthesis (DBT) and MRI. MRI raised the suspicion of angiosarcoma. The diagnosis was confirmed after biopsy and she underwent mastectomy.

DISCUSSION

Literature review on imaging findings of breast angiosarcoma, especially on MRI, is discussed. MRI features showed heterogeneous low signal intensity on T1 and high signal intensity on T2. Dynamic contrast enhancement (DCE) features included either early enhancement with or without washout in the delayed phase, and some reported central areas of non-enhancement.

CONCLUSION

This case report emphasises on the importance of MRI in clinching the diagnosis of breast angiosarcoma, and hence, should be offered sooner to prevent diagnostic delay.

Magnetic resonance imaging in the evaluation of pathologic nipple discharge: indications and imaging findings

Pathologic nipple discharge (PND) is typically unilateral, spontaneous, involves a single duct, and is serous or bloody in appearance. In patients with PND, breast MRI can be helpful as an additional diagnostic tool when conventional imaging with mammogram and ultrasound are negative. MRI is able to detect the etiology of nipple discharge in 56-61% of cases when initial imaging with mammogram and ultrasound are negative. Advantages to using MRI in evaluation of PND include good visualization of the retroareolar breast and better evaluation of posterior lesions which may not be well evaluated on mammograms and galactograms. It is also less invasive compared to central duct excision. Papillomas and nipple adenomas are benign breast masses that can cause PND and are well visualized on MRI. Ductal ectasia, and infectious etiologies such as mastitis, abscess, and fistulas are additional benign causes of PND that are well evaluated with MRI. MRI is also excellent for evaluation of malignant causes of PND including Paget's disease, ductal carcinoma in-situ and invasive carcinoma. MRI's high negative predictive value of 87-98.2% is helpful in excluding malignant etiologies of PND.

Mastitis and More: A Pictorial Review of the Red, Swollen, and Painful Breast

Clinically, acute mastitis presents as a red, swollen, and painful breast. Targeted ultrasound can be performed to evaluate the extent of infection and for an underlying abscess. Noncomplicated mastitis or a small fluid collection may respond to oral antibiotics without further intervention, but a larger or more complex abscess may require single or serial percutaneous aspiration. Breast infections, particularly those complicated by an abscess, can have a prolonged clinical course, and close follow-up is required. Since the clinical presentation and imaging features of acute infectious mastitis can overlap with other etiologies, such as inflammatory breast cancer and idiopathic granulomatous mastitis, a percutaneous biopsy may be indicated to accurately diagnose patients.

Locoregional Management of Inflammatory Breast Cancer

Purpose of Review

Inflammatory breast cancer (IBC) is a biologically aggressive subtype with a high risk for rapid local progression and early distant metastasis. We review the updated data for optimal locoregional management of IBC, including areas of active controversy.

Recent Findings

Advancements in tri-modality therapies have improved survival among IBC patients in recent years; however, the risk of locoregional and distant recurrence remains high, particularly in triple-negative IBC. Data to support de-escalation of surgery or radiotherapy is limited, and the recommended treatment approach for non-metastatic IBC remains preoperative systemic therapy (PST), modified radical mastectomy (MRM), and adjuvant radiotherapy in all patients. For patients with de novo metastatic disease, locoregional intervention may be appropriate.

Summary

Optimal locoregional management of IBC remains PST followed by MRM and adjuvant radiotherapy. With increasingly effective systemic therapies, research to identify a subset of patients who may benefit from de-escalation of locoregional therapies is warranted.

Introduction of a New Staging System of Breast Cancer for Radiologists: An Emphasis on the Prognostic Stage

In 2017, the American Joint Committee on Cancer announced the 8th edition of its cancer staging system. For breast cancer, the most significant change in the staging system is the incorporation of biomarkers into the anatomic staging to create prognostic stages. Different prognostic stages are assigned to tumors with the same anatomic stages according to the tumor grade, hormone receptor (estrogen receptor; progesterone receptor) status, and HER2 status. A Clinical Prognostic Stage is assigned to all patients regardless of the type of therapy used; in contrast, a Pathologic Prognosis Stage is assigned to patients in whom surgery is the initial treatment. In a few situations, low Oncotype DX recurrence scores can change the prognostic stage. The radiologists need to understand the importance of the biologic factors that can influence cancer staging.

Distinct epidemiological profiles associated with inflammatory breast cancer (IBC): A comprehensive analysis of the IBC registry at The University of Texas MD Anderson Cancer Center

Background

To date, studies on inflammatory breast cancer (IBC) lack comprehensive epidemiological data. We analyzed detailed prospectively collected clinical and epidemiological data from the IBC Registry at The University of Texas MD Anderson Cancer Center.

Methods

Patients with IBC (n = 248) were consecutively diagnosed and prospectively enrolled between November 2006 and April 2013. All patients were newly diagnosed and at least 18 years old. Secondary IBC was excluded. Overall 160 variables were collected and evaluated including sociodemographics, anthropometrics, tobacco and alcohol consumption, reproductive variables, and family history data.

Results

Mean age at diagnosis was 51.6 (±11.5 SD) years, and the majority of patients were White (77.8%). A mean BMI ≥ 25 kg/m², irrespective of menopausal status, was observed in 80.2% of all patients, with 82.6% of African Americans being obese. Approximately 42.2% of patients were ever smokers, and 91% reported ever being pregnant. A history of breastfeeding was reported in 54% of patients, with significant differences between ethnic groups in favor of White women (P<0.0001). Other reproductive factors such as use of birth control pills & hormone replacement therapy were also more frequently associated with White women compare to other ethnic groups (P < 0.05). In the multivariate Cox proportional hazard analysis, African American or Hispanic ethnicity, not having breastfed, higher clinical stage, and TNBC subtype were associated with shorter survival.

Conclusion

Our data suggest that IBC is associated with distinct epidemiological profiles. This information could assist in targeting patients with specific preventive strategies based on their modifiable behavioral patterns.

Inflammatory Breast Cancer: What to Know About This Unique, Aggressive Breast Cancer

Inflammatory breast cancer (IBC) is a rare form of breast cancer that accounts for only 2% to 4% of all breast cancer cases. Despite its low incidence, IBC contributes to 7% to 10% of breast cancer caused mortality. Despite ongoing international efforts to formulate better diagnosis, treatment, and research, the survival of patients with IBC has not been significantly improved, and there are no therapeutic agents that specifically target IBC to date. The authors present a comprehensive overview that aims to assess the present and new management strategies of IBC.

International Consensus on the Clinical Management of Inflammatory Breast Cancer from the Morgan Welch Inflammatory Breast Cancer Research Program 10th Anniversary Conference

National and international experts in inflammatory breast cancer (IBC) from high-volume centers treating IBC recently convened at the 10th Anniversary Conference of the Morgan Welch Inflammatory Breast Cancer Research Program at The University of Texas MD Anderson Cancer Center in Houston Texas. A consensus on the clinical management of patients with IBC was discussed, summarized, and subsequently reviewed. All participants at the conference (patients, advocates, researchers, trainees, and clinicians) were queried using the MDRing electronic survey on key management issues. A summary of the expert consensus and participant voting is presented. Bilateral breast and nodal evaluation, breast magnetic resonance imaging, positron emission tomography/computed tomography, and medical photographs were endorsed as optimal. Neoadjuvant systemic therapy, modified radical mastectomy and level I and II ipsilateral axillary node dissection, post-mastectomy radiotherapy, adjuvant targeted therapy and hormonal therapy as indicated, and delayed reconstruction were agreed-upon fundamental premises of standard non-protocol-based treatment for IBC. Consideration for local-regional therapy in de novo stage IV IBC was endorsed to provide local control whenever feasible. Variation across centers and special circumstances were discussed.

Incidence of inflammatory breast cancer in patients with clinical inflammatory breast symptoms

BACKGROUND

To describe a large cohort of women with non-puerperal inflammatory breast and to identify characteristics of inflammatory breast cancer.

METHODS

All patients consulting for inflammatory breast syndrome in the breast unit of our tertiary University hospital between September 2013 and December 2015 were prospectively included. We excluded women who were pregnant or in the postpartum period. Patients underwent systematic clinical examination and imaging (breast ultrasonography and mammography). A biopsy was performed if the clinician suspected a malignant lesion of the breast. Clinicopathologic and radiologic data were registered. Statistics were performed using R (3.0.2 version) software.

RESULTS

Among the 76 patients screened and included, 38 (50%) had a malignant lesion at final diagnosis, 21 (27.6%) were diagnosed with infectious disease and 17 (22.4%) with inflammatory disease of the breast. When compared to patients with benign disease, patients with a malignant lesion were significantly older (p = 0.022, CI95% 1.78-14.7), had a significantly bigger palpable mass (p<0.001, CI 95% 22.8-58.9), were more likely to have skin thickening (p = 0.05) and had more suspicious lymph nodes at clinical examination (p<0.001, CI 95% 2.72-65.3). Precise limits on ultrasonography were significantly associated with benign lesions. The presence of a mass (p = 0.04), micro calcifications (p = 0.04) or of focal asymmetry (p<0.001, CI95% 1.3-618) on mammography was significantly associated with malignant disease.

CONCLUSION

Inflammatory breast cancer was common in our cohort of women consulting for inflammatory breast syndrome. Identifying these patients with high-risk malignancy is crucial in the management of an inflammatory breast.

Evaluating pathologic response of breast cancer to neoadjuvant chemotherapy with computer-extracted features from contrast-enhanced ultrasound videos

PURPOSE

To extract quantitative perfusion and texture features with computer assistance from contrast-enhanced ultrasound (CEUS) videos of breast cancer before and after neoadjuvant chemotherapy (NAC), and to evaluate pathologic response to NAC with these features.

METHODS

Forty-two CEUS videos with 140,484 images were acquired from 21 breast cancer patients pre- and post-NAC. Time-intensity curve (TIC) features were calculated including the difference between area under TIC within a tumor and that within a computer-detected reference region (AUT_T-R). Four texture features were extracted including Homogeneity and Contrast. All patients were identified as pathologic responders by Miller and Payne criteria. The features between pre- and post-treatment in these responders were statistically compared, and the discrimination between pre- and post-treatment cancers was assessed with a receiver operating characteristic (ROC) curve.

RESULTS

Compared with the pre-treatment cancers, the post-treatment cancers had significantly lower Homogeneity (p<0.001) and AUT_T-R (p=0.014), as well as higher Contrast (p<0.001), indicating the intratumoral contrast enhancement decreased and became more heterogeneous after NAC in responders. The combination of Homogeneity and AUT_T-R achieved an accuracy of 90.5% and area under ROC curve of 0.946 for discrimination between pre- and post-chemotherapy cancers without cross validation. The accuracy still reached as high as 85.7% under leave-one-out cross validation.

CONCLUSIONS

The computer-extracted CEUS features show reduced and more heterogeneous neovascularization of cancer after NAC. The features achieve high accuracy for discriminating between pre- and post-chemotherapy cancers in responders and thus are potentially valuable for tumor response evaluation in clinical practice.

An unexpected diagnosis of breast malignancy

Inflammatory breast cancer constitutes 5% of all breast cancer diagnoses. Diagnosis is based on clinical signs including skin changes, erythema and oedema, together with rapid progression and involvement of more than one-third of the affected breast. It is an aggressive tumour with great metastatic potential, metastases being present in 30% of patients at first presentation. Primary non-Hodgkin's lymphoma of the breast is rare but is well reported. It accounts for 0.5% of all breast malignancies and 1% of all non-Hodgkin's diagnoses. Prognosis of primary breast lymphoma varies depending on the stage of disease with stage IE having a 5-year survival rate of 78-83% and stage IIE having a 5-year survival rate of 20-57%. We present a rare case of non-Hodgkin's lymphoma mimicking an inflammatory breast cancer. The aim of this case report is to highlight an unusual presentation of non-Hodgkin's lymphoma and the diagnostic difficulties that arise.

The use of ultrasonography and digital mammography in women under 40 years with symptomatic breast cancer: a 7-year Irish experience

BACKGROUND

Breast cancer in women under 40 years of age is rare and typically presents symptomatically. The optimal imaging modality for this patient group is controversial. Most women undergo ultrasonography with/without mammography. Young women typically have dense breasts, which can obscure the features of malignancy on film mammography, however, initial studies have suggested that digital mammography may have a more accurate diagnostic performance in younger women. Ultrasound generally performs well in this age group, although it is poor at detecting carcinoma in situ (DCIS).

AIMS

To evaluate the comparative diagnostic performance of ultrasonography and digital mammography in the initial diagnostic evaluation of women under 40 years of age with symptomatic breast cancer.

METHODS

Retrospective review of all women under the age of 40 years managed at our symptomatic breast cancer unit from January 2009 to December 2015.

RESULTS

There were 120 patients that met the inclusion criteria for this study. The sensitivity of ultrasonography and digital mammography for breast cancer in this patient group was 95.8 and 87.5 %, respectively. The patients with a false negative mammographic examination were more likely to have dense breasts (p < 0.01). Five patients had a false negative ultrasonographic examination, withal of whom were diagnosed with DCIS detected by mammography.

CONCLUSION

This study demonstrates the superior sensitivity of ultrasound for breast cancer in women under the age of 40 years, however, the results show that digital mammography has an important complimentary role in the comprehensive assessment of these patients, particularly in the diagnosis of DCIS.

[Exploration of breast inflammation excluding pregnancy and breastfeeding: Guidelines]

Breast inflammation, excluding breast-feeding and pregnancy, is a rare breast pathology. We conducted a PubMed database search of all studies focusing on mastitis or breast inflammation exploration. While the most frequent aetiologies are infectious and inflammatory, inflammatory breast cancer can be diagnosed (LE2). Aetiologic diagnostic is difficult due to the absence of any clinical and imaging specific signs (LE3). The presence of mass, suspect lymph nodes or skin thickening in a woman older than 40 years old should orient toward inflammatory breast cancer (LE3). A suspect lesion must lead to perform a biopsy under sonography (grade A). In the absence of evidence for a malignant pathology after initial evaluation, we recommend starting an antibiotic treatment (grade C) with a clinical follow-up at the end of the treatment (grade B). If the symptoms persist, we recommend a new imaging (± MRI) (grade C) and a biopsy (grade C). Benign inflammatory pathologies may require a biopsy to exclude an inflammatory breast cancer and precise the diagnosis. Their specific management and treatment are presented in detail in the following chapters and may involve steroids.

The Third International Inflammatory Breast Cancer Conference

Inflammatory breast cancer (IBC) is the most aggressive and deadly form of breast cancer. Disease-specific research and conferences have been organized since 2008 with the intent to bring together experts in various disciplines. This report focus on the Third International IBC Conference held in Philadelphia on December 2012.

Fat suppression strategies in MR imaging of breast cancer at 3.0 T: comparison of the two-point Dixon technique and the frequency selective inversion method

PURPOSE

To compare two fat suppression methods in contrast-enhanced MR imaging of breast cancer at 3.0 T: the two-point Dixon method and the frequency selective inversion method.

MATERIALS AND METHODS

Forty female patients with breast cancer underwent contrast-enhanced three-dimensional T1-weighted MR imaging at 3.0 T. Both the two-point Dixon method and the frequency selective inversion method were applied. Quantitative analyses of the residual fat signal-to-noise ratio and the contrast noise ratio (CNR) of lesion-to-breast parenchyma, lesion-to-fat, and parenchyma-to-fat were performed. Qualitative analyses of the uniformity of fat suppression, image contrast, and the visibility of breast lesions and axillary metastatic adenopathy were performed.

RESULTS

The signal-to-noise ratio was significantly lower in the two-point Dixon method (P < 0.001). All CNR values were significantly higher in the two-point Dixon method (P < 0.001 and P = 0.001, respectively). According to qualitative analysis, both the uniformity of fat suppression and image contrast with the two-point Dixon method were significantly higher (P < 0.001 and P = 0.002, respectively). Visibility of breast lesions and metastatic adenopathy was significantly better in the two-point Dixon method (P < 0.001 and P = 0.03, respectively).

CONCLUSION

The two-point Dixon method suppressed the fat signal more potently and improved contrast and visibility of the breast lesions and axillary adenopathy.

¹⁸F-FDG PET/CT imaging versus dynamic contrast-enhanced CT for staging and prognosis of inflammatory breast cancer

PURPOSE

Inflammatory breast cancer (IBC) is the most aggressive type of breast cancer with a poor prognosis. Locoregional staging is based on dynamic contrast-enhanced (DCE) CT or MRI. The aim of this study was to compare the performances of FDG PET/CT and DCE CT in locoregional staging of IBC and to assess their respective prognostic values.

METHODS

The study group comprised 50 women (median age: 51 ± 11 years) followed in our institution for IBC who underwent FDG PET/CT and DCE CT scans (median interval 5 ± 9 days). CT enhancement parameters were net maximal enhancement, net early enhancement and perfusion.

RESULTS

The PET/CT scans showed intense FDG uptake in all primary tumours. Concordance rate between PET/CT and DCE CT for breast tumour localization was 92%. No significant correlation was found between SUVmax and CT enhancement parameters in primary tumours (p > 0.6). PET/CT and DCE CT results were poorly correlated for skin infiltration (kappa = 0.19). Ipsilateral foci of increased axillary FDG uptake were found in 47 patients (median SUV: 7.9 ± 5.4), whereas enlarged axillary lymph nodes were observed on DCE CT in 43 patients. Results for axillary node involvement were fairly well correlated (kappa = 0.55). Nineteen patients (38%) were found to be metastatic on PET/CT scan with a significant shorter progression-free survival than patients without distant lesions (p = 0.01). In the primary tumour, no statistically significant difference was observed between high and moderate tumour FDG uptake on survival, using an SUVmax cut-off of 5 (p = 0.7 and 0.9), or between high and low tumour enhancement on DCE CT (p > 0.8).

CONCLUSION

FDG PET/CT imaging provided additional information concerning locoregional involvement to that provided by DCE CT on and allowed detection of distant metastases in the same whole-body procedure. Tumour FDG uptake or CT enhancement parameters were not correlated and were not found to have any prognostic value.

Percutaneous biopsies: indications and techniques

Breast inflammation is a difficult clinical problem as it can result from a variety of causes: specific or non-specific infectious mastitis, which may or may not be complicated, primary or secondary inflammatory mastitis or inflammatory cancer. The main objective of radiology is to eliminate an inflammatory cancer. Other objectives are to characterise an inflammatory condition (where the clinical context is valuable in guiding diagnosis but which often requires a micro- or macrobiopsy) or to obtain a microorganism in cases of complicated infectious mastitis (a diagnostic procedure but also comprising the first stage of treatment). Whether for bacteriological or histological purposes, percutaneous samples therefore play a large part in the diagnostic procedure, other than in the clinical context of pregnancy where mastitis is more easily diagnosed because of its frequency. The guidance method is usually ultrasound, and the needle chosen will depend on the radiological or ultrasound signal: puncture with an 18G needle will be used for a bacteriological sample, microbiopsy of a mass or lymph nodes, or macrobiopsy in the case of microcalcifications.

Imaging inflammatory breast cancer

Carcinomatous mastitis is a severe form of breast cancer and its diagnosis is essentially clinical and histological. The first examination to perform is still mammography, not only to provide evidence supporting this diagnosis but also to search for a primary intramammary lesion and assess local/regional spread. It is essential to study the contralateral breast for bilaterality. Ultrasound also provides evidence supporting inflammation, but appears to be better for detecting masses and analysing lymph node areas. The role of MRI is debatable, both from a diagnostic point of view and for monitoring during treatment, and should be reserved for selected cases. An optimal, initial radiological assessment will enable the patient to be monitored during neoadjuvant chemotherapy.