Imaging of breast cancer-related changes after nonsurgical therapy

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.

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.

Case report: Hilar metastasis of breast cancer: A single-center retrospective case-control study

Purpose

The lungs are a common metastatic organ in breast cancer, mainly due to blood metastasis. On imaging, most metastatic lesions show a peripheral round mass in the lung, occasionally with a hilar mass as the primary manifestation, showing burr and lobulation signs. This study aimed to investigate breast cancer patient's clinical characteristics and prognosis with two different metastatic sites in the lung.

Methods

We retrospectively analyzed patients admitted to the First Hospital of Jilin University between 2016 and 2021 diagnosed with breast cancer lung metastases. Forty breast cancer patients with hilar metastases (HM) and 40 patients with peripheral lung metastases (PLM) were matched 1:1 using a pairing method. To analyze the patient's prognosis, the clinical characteristics of patients with two different metastatic sites were compared using the chi-square test, Kaplan-Meier curve, and Cox proportional hazards model.

Results

The median follow-up time was 38 months (2-91 months). The median age of patients with HM was 56 years (25-75 years), and that of patients with PLM was 59 years (44-82 years). The median overall survival (mOS) was 27 months in the HM group and 42 months in the PLM group (p = 0.001). The results of the Cox proportional hazards model showed that the histological grade (hazard ratio = 2.741, 95% confidence interval 1.442-5.208, p = 0.002) was a prognostic factor in the HM group.

Conclusion

The number of young patients in the HM group was higher than that in the PLM group, with higher Ki-67 indexes and histological grades. Most patients had mediastinal lymph node metastasis, with shorter DFI and OS and poor prognosis.

Recurrent Metastatic Breast Cancer in Internal Mammary Lymph Nodes along the Translocated Left Internal Mammary Artery Bypass Graft

Internal mammary lymph node (IMLN) is the second most common site for nodal metastases in breast cancer. The authors present a case of a 58-year-old woman with a history of coronary artery bypass graft surgery 1 year prior who presented with a neck mass. Imaging showed an enlarged IMLN along the course of the translocated left internal mammary artery (LIMA) bypass graft on the surface of the heart, and the patient was later proven to have recurrent breast cancer. To the authors' knowledge, this is the first case report in the literature of a breast cancer recurrence in an IMLN along the postoperative translocated LIMA bypass graft. Keywords: Adults, CT, PET/CT, Breast, Thorax, Lymphatic, Metastases © RSNA, 2021.

Recurrent metastatic breast cancer manifesting as pulmonary tumor thrombotic microangiopathy with interstitial pulmonary fibrosis and infarcts: A clinicopathological correlation

Pulmonary Tumor Thrombotic Microangiopathy (PTTM) is a fatal complication of malignancy characterized by embolization of tumor cells to the pulmonary vasculature leading to a vascular reaction resulting in stenosis and pulmonary hypertension. Because the clinical manifestations of PTTM overlap with those of other entities, premortem diagnosis is challenging. We describe an unusual case of PTTM as the only clinical manifestation of recurrent metastatic breast cancer. A 50 year-old woman presented with hypoxemia and echocardiographic findings consistent with pulmonary hypertension and cor pulmonale. Correlation of premortem pulmonary imaging with autopsy histopathologic findings revealed that ill-defined ground-glass opacities identified on CT angiogram corresponded to areas of cellular interstitial fibrosis and widespread intrapulmonary tumor emboli involving predominantly small-sized arteries with associated florid intimal fibrosis. The radiologic nodularities and scattered peripheral wedge-shaped consolidations corresponded to evolving pulmonary infarcts on histopathology. Although retrospectively, the imaging findings were concordant with a spectrum of increasing severity of tumor embolization and vascular remodeling, the diagnosis of PTTM was not made premortem. PTTM is a rare entity that must be considered in cancer patients with unexplained hypoxemia, pulmonary hypertension and lung opacities on imaging.

Comparative diagnostic accuracy of 18F-FDG PET/CT for breast cancer recurrence

In the last decades, in addition to conventional imaging techniques and magnetic resonance imaging (MRI), ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) has been shown to be relevant in the detection and management of breast cancer recurrence in doubtful cases in selected groups of patients. While there are no conclusive data indicating that imaging tests, including FDG PET/CT, produce a survival benefit in asymptomatic patients, FDG PET/CT can be useful for identifying the site of relapse when traditional imaging methods are equivocal or conflicting and for identifying or confirming isolated loco-regional relapse or isolated metastatic lesions. The present narrative review deals with the potential role of FDG PET in these clinical settings by comparing its accuracy and impact with conventional imaging modalities such as CT, ultrasound, bone scan, ¹⁸F-sodium fluoride PET/CT (¹⁸F-NaF PET/CT) as well as MRI. Patient-focused perspectives in terms of patients' satisfaction and acceptability are also discussed.

Antemortem diagnosis of pulmonary tumor thrombotic microangiopathy in a patient with recurrent breast cancer: a case report

Background

Pulmonary tumor thrombotic microangiopathy (PTTM), a rare complication of advanced cancer, is histologically characterized by tumor embolisms and fibrocellular intimal proliferation of small pulmonary arteries and arterioles. PTTM usually has an extremely poor prognosis, and antemortem diagnosis is very difficult.

Case presentation

A 65-year-old woman with a 5-year history of clinical stage IIA (T2N0M0) invasive ductal carcinoma of the left breast was hospitalized for worsening shortness of breath, hemoptysis, and cough since 2 months. She had previously received neoadjuvant chemotherapy and left mastectomy. Because the cancer cells were positive for human epidermal growth factor receptor 2 (HER2), four cycles of trastuzumab had been administered as adjuvant chemotherapy. On admission, chest computed tomography (CT) showed peripheral consolidations in both the lower lobes and a mediastinal mass. Specimens obtained on video-assisted thoracoscopic surgical biopsy revealed tumor cell embolism, intimal fibrocellular proliferation of small arteries, fibrin thrombi, recanalization, and infarction in the left lower lobe, as well as metastasis to the mediastinal pleura. Immunohistochemical staining of the tumor cells revealed positivity for HER2, and a diagnosis of recurrent breast cancer with PTTM was made. Four cycles of trastuzumab resulted in rapid improvement of her symptoms and CT findings of peripheral consolidations and the mediastinal mass.

Conclusion

An antemortem diagnosis of PTTM was made in a patient with HER2-positive recurrent breast cancer. Trastuzumab was effective for not only breast cancer but also PTTM.