Digital breast tomosynthesis (DBT) occult breast cancers: clinical, radiological and histopathological features.
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1 Digital breast tomosynthesis (DBT) occult breast cancers: clinical, radiological and histopathological features. Poster No.: C-1707 Congress: ECR 2015 Type: Scientific Exhibit Authors: V. Vinci 1, A. Iqbal 2, D. R. Evans 2, R. K. Wasan 2, J. Goligher 2, C. Keywords: DOI: Peacock 2, R. Rahim 2, K. Satchithananda 2, M. J. Michell 2 ; 1 Rome/ IT, 2 London/UK Breast, Mammography, Ultrasound, MR, Diagnostic procedure, Cancer /ecr2015/C-1707 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 10
2 Aims and objectives Tomosynthesis represents a relatively new technique within the field of breast imaging. Screening trials using Tomosynthesis in association with digital mammography (DM) have already shown some important improvements with increased cancer detection rates and decreased recall rates [1-2]. Moreover, since it partially overcomes the masking effect seen with mammography due to tissue superimposition [3], it also showed interesting results in the evaluation of women with dense breasts [4], where DM showed a reduced accuracy. However, considering its recent introduction, yet many studies are needed to define the potential role of DBT as well as its limitation; in this regard, this retrospective study aims to analyse a series of occult tumors on DBT, and to study the histopathological clinical and imaging features. Page 2 of 10
3 Methods and materials We retrospectively included in this study 16 cases of proven breast cancers, which were reported as normal on DBT and digital mammography (DM). These cases were collected from assessment and symptomatic clinics. All DBT were read by Radiologists experienced in DBT interpretation. The electronic medical records were reviewed to collect clinical history, additional imaging data and biopsy results Page 3 of 10
4 Results The average age was 50 years (range 34 to 79ys). All patients were symptomatic and the clinical examination score was P3/indeterminate. Ultrasound (US) was able to detect lesions in all cases, average size was 17mm; three cases appeared as parenchymal distortion (fig 1-2), four lesions as well defined masses (fig 3) and the remaining nine cases were classified as ill-defined masses (fig 4). The mammographic parenchyma pattern was dense ( BIRAD 4) in seven cases and glandular (BIRAD 3) in nine cases. The US score was U3/indeterminate in six cases (fig 1) and U4/suspicious for malignancy in the remaining ten cases(fig 2-4). All cases underwent an US guided biopsy showing high grade (grade 2/3) invasive ductal carcinoma in thirteen cases and high grade (grade 2/3) invasive lobular carcinoma in three cases. All lesions were visible on MRI, showing typical features suggestive of malignancy, such as parenchymal distortion in T2 weighted sequences and rapid and early enhancement Page 4 of 10
5 Images for this section: Fig. 1: 42 years old woman presenting with a papable lump in the right breast at 9 O' Clock position. Mammogramm projection of the right breast in the MLO view (fig a ) and CC view (fig b), as well as DBT MLO (fig c) and CC view (fig d), demonstrate a dense breast (BIRAD 4) with no focal abnormalities seen. Fig e corresponds to the US imaging of the symptomatic area and shows an area of altered echogenichity, however not suspicious for malignancy, (UK score U3). Fig f and g show the corresponding findings on MRI (white arrow), which demonstrate a spiculated mass on T2 weighted sequences (fig f) with increased enhancement compared to the surrounding glandular tissue as seen on T1 weighted sequences with Fat saturation acquired 2 minutes after contrast injection (fig g). The histology showed an Invasive Lobular Cancer grade 2. Breast Radiology Department, King's College Hospital, London, UK Page 5 of 10
6 Fig. 2: 48 years old woman presenting with a papable lump in the upper outer quadrant of the left breast. Mammogramm projection of the left breast in the CC view (fig a ) and MLO view (fig b), as well as DBT MLO (fig c) and laterally extended CC view (fig d), demonstrate a glandular breast (BIRAD 3) with no focal abnormalities seen. Fig g and h corresponds to the US imaging of the symptomatic area, which show highly suspicious features of malignancy (UK score U5), such as an ill defined hypoechoic mass, with heterogeneous echogenicity, and some pheriferal vascular flow on color doppler (fig g). Fig e and f show the corresponding findings on MRI, an enhancing mass in the lateral part of the left breast as seen on T1 weighted sequences with Fat saturation acquired 2 minutes after contrast injection (fig e) and the corresponding subtracted images (fig f), with the corresponding subtle finding of a spiculated mass on the T2 weighted image shown on the enlarged box. The hystology showed an Invasive Lobular Cancer grade 2. Page 6 of 10
7 Breast Radiology Department, King's College Hospital, London, UK Fig. 3: 46 years old woman presenting with a papable lump in the 12 O' Clock position of the right breast. Mammogramm projection of the right breast in the CC view (fig a ) and MLO view (fig b), as well as DBT CC (fig c) and MLO view (fig d), demonstrate a glandular breast (BIRAD 3) with no focal abnormalities seen. Fig g and h corresponds to the US imaging of the symptomatic area and the outer region of the breast, which show several Hypoechoic masses, highly suspicious for malignancies (UK score U4). Fig e and f correspond to two different axial planes of the breast showing heterogenously enhancing tumour spread to the entire right breast (T1 weighted sequence with fat saturation acquired 2 minutes after contrast injection). The final hystology on the surgical specimen showed a multifocal Invasive Ductal Cancer grade 3. Breast Radiology Department, King's College Hospital, London, UK Page 7 of 10
8 Fig. 4: 36 years old woman presenting with a papable lump in the outer part of the left breast. Mammogramm projection of the left breast in the CC view (fig a ) and MLO view (fig b), as well as DBT CC (fig c) and MLO view (fig d), demonstrate a mixed glandular breast (BIRAD 3) with no focal abnormalities seen. Fig g and h corresponds to the US imaging of the symptomatic area and the outer region of the breast, which show several hypoechoic masses, surrounded by an altered echogenicity of the glandular tissue, highly suspicious for malignancies (UK score U5). Fig e and f correspond to two different axial planes of the breast showing heterogenously enanching tumour in the lateral ascpect of the left breast, the right breast showed some benign scattered background enhancement (T1 weighted sequence with fat saturation acquired 2 minutes after contrast injection). The final histology on the surgical specimen showed a multifocal Invasive Ductal Cancer grade 3 Breast Radiology Department, King's College Hospital, London, UK Page 8 of 10
9 Conclusion In summary, cancers which are undetected on DBT are typically high grade and occur in dense parenchyma. In these cases, MRI should be used for accurate local staging. Page 9 of 10
10 References 1. Ciatto S, Houssami N, Bernardi D, et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol 2013;14(7): Skaane P, Bandos AI, Gullien R, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology 2013;267(1): Kopans DB. Digital breast tomosynthesis from concept to clinical care. AJR Am J Roentgenol 2014;202(2): Christoph I. Lee, Mucahit Cevik, Oguzhan Alagoz, et al. Comparative Effectiveness of Combined Digital Mammography and Tomosynthesis Screening for Women with Dense Breasts. Radiology Oct 13: Page 10 of 10
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