Active Surveillance for Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ

Atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) are relatively common breast lesions on the same spectrum of disease. Atypical ductal hyperblasia is a nonmalignant, high-risk lesion, and DCIS is a noninvasive malignancy. While a benefit of screening mammography is early cancer detection, it also leads to increased biopsy diagnosis of noninvasive lesions. Previously, treatment guidelines for both entities included surgical excision because of the risk of upgrade to invasive cancer after surgery and risk of progression to invasive cancer for DCIS. However, this universal management approach is not optimal for all patients because most lesions are not upgraded after surgery. Furthermore, some DCIS lesions do not progress to clinically significant invasive cancer. Overtreatment of high-risk lesions and DCIS is considered a burden on patients and clinicians and is a strain on the health care system. Extensive research has identified many potential histologic, clinical, and imaging factors that may predict ADH and DCIS upgrade and thereby help clinicians select which patients should undergo surgery and which may be appropriate for active surveillance (AS) with imaging. Additionally, multiple clinical trials are currently underway to evaluate whether AS for DCIS is feasible for a select group of patients. Recent advances in MRI, artificial intelligence, and molecular markers may also have an important role to play in stratifying patients and delineating best management guidelines. This review article discusses the available evidence regarding the feasibility and limitations of AS for ADH and DCIS, as well as recent advances in patient risk stratification.

Impact of Longitudinal Focused Academic Time on Resident Scholarly Activity

RATIONALE AND OBJECTIVES

Meeting the Accreditation Council for Graduate Medical Education scholarly activity requirement can be challenging for residents. Time to engage in research is one of the commonly perceived barriers. To address this barrier, our residency program implemented a focused academic time initiative of a half day per week that can be taken while on rotation. At the end of the third year of implementation, we assessed the effectiveness of this initiative on the productivity of resident scholarly activity.

MATERIALS AND METHODS

Radiology resident scholarly activity submitted to the Accreditation Council for Graduate Medical Education web-based Accreditation Data System were reviewed and compared to the three academic years before (July 1, 2012-June 30, 2015) and three academic years after (July 1, 2015-June 30, 2018) implementing the focused research time. The types of scholarly activity, which consisted of peer-reviewed journal publications, national conference presentations, and textbook chapters were captured. PubMed-Indexed for MEDLINE (PMID) number was used to confirm publications. Descriptive statistics were used to analyze the data.

RESULTS

The total number of residents per year, ranging between 37-40, was similar between the academic years 2012-2015 (116 residents total) and 2015-2018 (117 residents total). After initiating focused academic time, the number of publications increased from 45 to 75 (67%), presentations at conferences increased from 112 to 128 (14%), the number of textbook chapters increased from 4 to 15 (275%), and total number of first author publications by residents increased from 21 to 28 (33% increase).

CONCLUSION

Longitudinal focused academic time of half a day per week increased productivity of scholarly activity among our radiology residents.

Preserving Radiology Resident Education During the COVID-19 Pandemic: The Simulated Daily Readout

RATIONALE AND OBJECTIVES

The educational value of the daily resident readout, a vital component of resident training, has been markedly diminished due to a significant decrease in imaging volume and case mix diversity. The goal of this study was to create a "simulated" daily readout (SDR) to restore the educational value of the daily readout.

MATERIALS AND METHODS

To create the SDR the following tasks were performed; selection of cases for a daily worklist for each resident rotation, comprising a combination of normal and abnormal cases; determination of the correct number of cases and the appropriate mix of imaging modalities for each worklist; development of an "educational" environment consisting of separate "instances" of both our Picture Archive Communication System and reporting systems; and the anonymization of all of the cases on the worklists. Surveys of both residents and faculty involved in the SDR were performed to assess its effectiveness.

RESULTS

Thirty-two residents participated in the SDR. The daily worklists for the first 20 days of the SDR included 3682 cases. An average of 480 cases per day was dictated by the residents. Surveys of the residents and the faculty involved in the SDR demonstrated that both agreed that the SDR effectively mimics a resident's daily work on rotations and preserves resident education during the Coronavirus Disease 2019 crisis.

CONCLUSION

The development of the SDR provided an effective method of preserving the educational value of the daily readout experience of radiology residents, despite severe decreases in imaging exam volume and case mix diversity during the Coronavirus Disease 2019 pandemic.

Optimizing 1.5-Tesla and 3-Tesla dynamic contrast-enhanced magnetic resonance imaging of the breasts

The technical requirements for magnetic resonance imaging (MRI) of the breasts are challenging because high temporal and high spatial resolution are necessary. This article describes the necessary equipment and pulse sequences for performing a high-quality study. Although imaging at 3-Tesla (T) has a higher signal-to-noise ratio, the protocol needs to be modified from the 1.5-T system to provide optimal imaging. The article presents the requirements for performing breast MRI and discusses techniques to ensure high-quality examinations on 1.5-T and 3-T systems.

Image presentation. Sonographic appearances of benign and malignant male breast disease with mammographic and pathologic correlation

OBJECTIVE

Imaging of the male breast is most often performed for the evaluation of a clinical abnormality such as breast enlargement or tenderness, a palpable mass, nipple skin changes, or nipple discharge. Most breast lesions encountered in men are benign. Malignant breast lesions are less frequent; breast cancer accounts for less than 1% of all male cancers in the United States. The initial imaging evaluation of a finding in the male breast is performed with mammography. Sonography is frequently used as an adjunct to mammography but is less often used as the primary imaging modality. The objective of this article is to provide readers with a thorough review of the sonographic appearances of benign and malignant male breast disease.

METHODS

We reviewed our institution's case database to identify male patients who underwent mammography, sonography, and subsequent biopsy of a breast lesion. These cases were collected and reviewed to select the best imaging examples.

RESULTS

A spectrum of benign and malignant male breast disease is presented with corresponding sonographic, mammographic, and pathologic imaging. For each entity, the salient imaging findings and typical clinical presentation are discussed.

CONCLUSIONS

Most studies in the literature have reported on the mammographic and sonographic imaging features of primary breast carcinoma in men. However, very little has been reported on the sonographic appearance of benign and malignant male breast conditions. Recognition and correct identification of pathologic male breast entities on sonography is essential to determine appropriate management recommendations and avoid unnecessary biopsies.

Microinvasive ductal carcinoma in situ: clinical presentation, imaging features, pathologic findings, and outcome

OBJECTIVE

The purpose of our study was to describe the clinical features, imaging characteristics, pathologic findings and outcome of microinvasive ductal carcinoma in situ (DCISM).

MATERIALS AND METHODS

The records of 21 women diagnosed with microinvasive ductal carcinoma in situ (DCISM) from November 1993 to September 2006 were retrospectively reviewed. The clinical presentation, imaging and histopathologic features, and clinical follow-up were reviewed.

RESULTS

The 21 lesions all occurred in women with a mean age of 56 years (range, 27-79 years). Clinical findings were present in ten (48%): 10 with palpable masses, four with associated nipple discharge. Mean lesion size was 21mm (range, 9-65mm). The lesion size in 62% was 15mm or smaller. Mammographic findings were calcifications only in nine (43%) and an associated or other finding in nine (43%) [mass (n=7), asymmetry (n=1), architectural distortion (n=1)]. Three lesions were mammographically occult. Sonographic findings available in 11 lesions showed a solid hypoechoic mass in 10 cases (eight irregular in shape, one round, one oval). One lesion was not seen on sonography. On histopathologic examination, all lesions were diagnosed as DCISM, with a focus of invasive carcinoma less than or equal to 1mm in diameter within an area of DCIS. Sixteen (76%) lesions were high nuclear grade, four (19%) were intermediate and one was low grade (5%). Sixteen (76%) had the presence of necrosis. Positivity for ER and PR was noted in 75% and 38%. Nodal metastasis was present in one case with axillary lymph node dissection. Mean follow-up time for 16 women was 36 months without evidence of local or systemic recurrence. One patient developed a second primary in the contralateral breast 3 years later.

CONCLUSION

The clinical presentation and radiologic appearance of a mass are commonly encountered in DCISM lesions (48% and 57%, respectively), irrespective of lesion size, mimicking findings seen in invasive carcinoma. Despite its potential for nodal metastasis (5% in our series), mean follow-up at 36 months was good with no evidence of local or systemic recurrence at follow-up. Knowledge of these clinical and imaging findings in DCISM lesions may alert the clinician to the possibility of microinvasion and guide appropriate management.

Fine-needle aspiration biopsy of benign adenomyoepithelioma of the breast: radiologic and pathologic correlation in four cases

Benign adenomyoepithelioma of the breast is a rare tumor in which the cytologic findings have been described in only a few cases. While benign, the imaging and pathologic features may be mistaken for malignancy. We report the aspiration biopsy findings in four cases of adenomyoepithelioma with radiologic and histologic correlation. Cytopathologists should familiarize themselves with this entity to avoid a misdiagnosis of carcinoma.

Papillary Lesions of the Breast at Percutaneous Core-Needle Biopsy

PURPOSE

To retrospectively review the imaging and histologic findings in patients in whom a benign papillary lesion was diagnosed at core-needle breast biopsy.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board at each institution; patient consent was not required. The study was HIPAA compliant. The authors reviewed the findings from 42 patients (age range, 26-76 years; mean age, 54.3 years) with 43 benign papillary lesions diagnosed at core-needle biopsy. Thirty-six (84%) of the 43 lesions were surgically excised, and seven (16%) were followed up with long-term imaging. The authors assessed the radiographic findings, the histologic findings at core-needle biopsy, and the findings at subsequent surgical excision or imaging follow-up. Statistical analysis was performed on a per-patient basis and included the Blyth-Still-Casella procedure to construct exact 95% confidence intervals (CIs) and the Fisher exact test.

RESULTS

At core-needle biopsy, lesions were diagnosed as papilloma (n = 29), sclerosing papilloma (n = 8), and benign papillary lesions not otherwise specified (n = 6). For the 36 lesions that were surgically excised, histologic follow-up showed no residual lesion in 10, intraductal papilloma in 14, intraductal papillomatosis in two, papilloma with adjacent foci of atypical ductal hyperplasia (ADH) in eight, and well-differentiated papillary ductal carcinoma in situ (DCIS) in two. Mammographic follow-up in the remaining seven lesions revealed stable calcifications in five (at 28-55 months) and no residual lesion in two (at 26-29 months). In nine of the 42 patients (21%), the diagnosis was upgraded to either ADH or DCIS (exact two-sided 95% CI = 11.4%, 36.4%).

CONCLUSION

The results strongly suggest that papillary lesions diagnosed as benign at core-needle biopsy should be surgically excised because a substantial number of lesions were upgraded to ADH and DCIS at excision.

Invasive ductal carcinoma with fibrotic focus: mammographic and sonographic findings with histopathologic correlation

OBJECTIVE

We sought to define the imaging findings of invasive ductal carcinoma with fibrotic focus and its associated histopathologic correlation.

CONCLUSION

Radiologists should be aware of the imaging characteristics of this newly described entity because of the significant prognostic implications and perhaps to prompt the pathologist to assess for the presence of a fibrotic focus at excision.

Adenoid cystic carcinoma of the breast diagnosed by fine-needle aspiration

Fine-needle aspiration cytology remains a useful tool for preoperative diagnosis of breast lesions. We describe a case of adenoid cystic carcinoma (ACC) of the breast detected by ultrasound-guided fine-needle aspiration (FNA). Subsequent histopathology corroborated the diagnosis. ACC is a rare but distinctive neoplasm of the breast that can be accurately diagnosed by FNA. Its infrequent presentation, favorable prognosis, and relatively conservative management in the breast prompt us to reinforce its features.

Pseudoangiomatous Stromal Hyperplasia of the Breast: Sonographic Features with Histopathologic Correlation

The objective of this study was to evaluate the spectrum of sonographic findings in pseudoangiomatous stromal hyperplasia (PASH) of the breast when it presents as a tumoral mass with pathologic correlation. Breast sonogram studies of 13 patients with 13 pathologically proven PASH lesions were retrospectively reviewed. The morphologic characteristics of the lesions as seen on ultrasound were evaluated and correlated with histopathologic findings. Sonography demonstrated most lesions, 11 of 13, to be hypoechoic in echotexture. One lesion was isoechoic in echotexture, also demonstrating small internal cysts, and one was predominantly hyperechoic. Two of the 11 hypoechoic lesions also demonstrated a complex heterogeneous pattern with a central hypoechoic area and a peripheral echogenic rim. All lesions were oval in shape with the long axis of the lesion parallel to the chest wall. None of the lesions demonstrated posterior acoustic shadowing. PASH lesions of the breast have a varied sonographic appearance. Knowledge of the spectrum of morphologic features shown on sonography can be helpful in the diagnosis of this entity.

An Unusual Presentation of Neurofibromatosis of the Breast

Patients with neurofibromatosis type I or von Recklinghausen disease develop neurofibromas in the subcutaneous tissues, including the breast. There are two German reports of massive neurofibromatosis of the breast, but few reports of massive neurofibromatosis of the breast in the English literature. We present an unusual case of neurofibromatosis of the breast with large neurofibromas predominantly noted protruding from both nipple-areolar complexes.

Calcifications associated with lactational changes of the breast: mammographic findings with histologic correlation

OBJECTIVE

We sought to describe the mammographic appearance of calcifications associated with histologically confirmed lactational changes of the breast.

CONCLUSION

Calcifications associated with lactational changes of the breast may have a suspicious appearance on mammography. These calcifications may be identified on a patient's original screening mammogram or may be a new finding on an annual screening examination. Correlating a clinical history of recent lactation or a postpartum state is important in establishing a concordance between the mammographic and histologic findings. However, despite the benign nature of these calcifications, biopsy is recommended because of their suspicious morphologic features.

Papillary lesions of the breast: evaluation with stereotactic directional vacuum-assisted biopsy

PURPOSE

To evaluate the use of stereotactic directional vacuum-assisted biopsy (SDVAB) in diagnosing and managing papillary lesions of the breast.

MATERIALS AND METHODS

The authors retrospectively reviewed the mammographic and histopathologic findings of 26 cases in which papillary lesions were diagnosed at SDVAB. In all cases, subsequent surgical excision (n = 20) or long-term imaging follow-up (n = 6) was performed and correlated with findings at SDVAB.

RESULTS

SDVAB of 26 lesions yielded tissue that was classified as benign in 12, atypical in six, and malignant in eight. Of the 12 lesions that were diagnosed as histologically benign at SDVAB, six were surgically excised. Of these six lesions, five yielded benign correlative results. The sixth lesion was thought to be discordant with the imaging findings, and was surgically excised and determined to be malignant. Of the six benign lesions that were not surgically sampled for biopsy, five decreased in size and one was not seen at radiographic follow-up. Of the six lesions diagnosed as atypical at SDVAB that were surgically excised, one was benign and five were atypical. None proved to be malignant. Of the eight lesions diagnosed as malignant at SDVAB, surgical excision demonstrated ductal carcinoma in situ in all eight; two also had foci of invasive carcinoma.

CONCLUSION

Benign and malignant papillary lesions of the breast can be reliably diagnosed at SDVAB when the SDVAB results correlate with the imaging findings. However, the extent of malignant papillary disease may be underestimated at SDVAB; in our study, invasive carcinoma was later discovered in 25% of patients with this diagnosis.

Stereotaxic aspiration biopsy in the evaluation of mammographically detected clustered microcalcification

BACKGROUND

Stereotaxic fine-needle aspiration biopsy (SFNA) of mammographically detected nonpalpable lesions of the breast provides accurate diagnosis and may eliminate many unnecessary excisional biopsies of areas of microcalcification.

METHODS

SFNA of microcalcification of indeterminate radiologic significance was performed on 125 patients (1991-1994), yielding 130 specimens (2 sites in 2 patients and bilateral aspirations in 3 patients). Stereotaxic localization was performed, and samples from within the area of microcalcification were obtained using 22-gauge needles. Smears stained with a Giemsa-type stain were prepared and studied by a cytopathologist during the procedure to determine the adequacy of each specimen.

RESULTS

Of 130 specimens, 104 (80%) were cytologically benign, 13 (10%) were atypical, 6 (4.6%) were suspicious, and 7 (5.3%) were malignant. All malignant diagnoses were confirmed by subsequent operative biopsy. Follow-up was available in 74 of 104 benign cases (71%): surgical excisions (all benign) in 8 cases and follow-up mammograms at 6 months to 5.8 years in 66 cases (no radiologic change in 64 cases and 2 [1.9%] cases with new radiologic findings [SFNAs of the new radiographic abnormality revealed adenocarcinoma in both]).

CONCLUSIONS

SFNA is a reliable and cost-effective method of evaluating indeterminate microcalcification; however, mammographic follow-up is indicated because of the possibility of subsequent and independent cancers.

Stimulation of glucose transport in Clone 9 cells by exposure to alkaline pH

Incubation of a rat liver cell line (Clone 9) for 2 h at pH 8.5 was found to result in a profound (5- to 8-fold) stimulation of cytochalasin B-inhibitable glucose transport. The enhancement of glucose transport after exposure to elevated external pH (achieved by lowering the CO2 tension in a bicarbonate-containing medium) was demonstrable within 15 min, was half-maximal at pH 8.0, and was near-maximal at pH 8.6. Intracellular pH rose linearly with incremental changes in external pH, from pH 7.45 to 8.6 with a slope of 0.6. The increase in transport activity in response to incubation at alkaline pH was accompanied by a parallel increase in lactate production and persisted for more than an hour after external pH was restored to normal. During the latter period, intracellular glucose concentration (less than 10% of that of the external medium under control conditions) increased greater than 10-fold to approximate that in the extracellular medium. Incubation of these cells at pH 8.5 for 2 h resulted in a complete resistance of cell ATP levels to challenge with 5 mM cyanide, suggesting that the adaptive facilitation of glucose transport was of sufficient magnitude to permit a marked stimulation of glycolytic ATP synthesis on inhibition of oxidative phosphorylation. The enhancement of glucose transport was attributable to an increase in the maximum velocity (Vmax) rather than to any change in the Michaelis constant (Km) for transport and was not prevented by cycloheximide. It is concluded that the marked stimulation of glucose transport resulting from exposure of these "low-glucose" cells to alkaline pH reflects either an increase in the abundance of functional glucose transporters in the plasma membrane or an increase in their catalytic turnover rate.

Enhanced glucose transport in response to inhibition of respiration in Clone 9 cells

An acceleration of ATP synthesis by anaerobic glycolysis provides important compensation for interference with respiration in a variety of cells. Effective compensation for an inhibition of respiration, however, can occur in cells in which glucose entry is rate limiting only if sufficient glucose becomes available through an enhancement of transport. We present here a detailed study of the effects of inhibition of respiration in Clone 9 cells, a continuous cell line characterized by low internal glucose concentrations (less than 10% that of the external medium) and minimal stores of glycogen. Exposure of these cells to 5 mM cyanide results in a 90% fall in cell ATP and a twofold rise in cell Na+ within 20 min. By the end of 1 h, however, there is a 4.5- to 7-fold increase in cytochalasin B-inhibitable glucose transport that is accompanied by a parallel increase in the rate of lactate production, a partial recovery of cell ATP, and no further rise in cell Na+. The acute fall in ATP resulting from a submaximally effective concentration of cyanide (0.5 mM) is moreover followed by a time-dependent recovery of cell ATP to near-normal levels and subsequent resistance to challenge with even 5 mM cyanide. The stimulation of facilitative glucose transport resulting from exposure to cyanide is attributable to an increase in maximal velocity rather than to a change in Km and persists for more than 2 h after removal of the inhibitor. These results demonstrate that, in these cells characterized by low internal glucose concentrations, regulation of glucose entry is of central importance in ATP homeostasis and that a major component of the adaptive response to an inhibition of respiration is a time-dependent increase in glucose transport.