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Representative examples of MRI-guided breast needle core biopsies showing a characteristic benign complex multicystic lesion lined by apocrine metaplastic epithelium, called “cystic apocrine metaplasia.” This benign lesion was seen in 38% (11/29) of the benign MRI-guided needle core biopsies in this series.
Source publication
The role of MRI in the management of breast carcinoma is rapidly evolving from its initial use for specific indications only to a more widespread use on all women with newly diagnosed early stage breast cancer. However, there are many concerns that such widespread use is premature since detailed correlation of MRI findings with the underlying histo...
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Context 1
... of our benign cases (11/29, 38%) consisted of a specific complex multicystic lesion lined by apocrine metaplastic epithelium, a lesion we called “cystic apocrine metaplasia” ( Figure 1). During the last few years there has been a heightened interest in the application of magnetic resonance imaging (MRI) in the management of breast cancer. Currently, MRI is used as a supplemental tool to complement conventional methods of radiologic and ultrasonographic breast evaluation. A number of appropriate indications for the clinical use of MRI in breast cancer diagnosis and management include clarification of questionable findings on mammography, evaluation and accurate staging of breast tumors in dense breasts, accurate evaluation of specific subtypes of breast carcinomas such as infiltrating lobular carcinoma, assessment of response to preoperative chemotherapy, diagnosis of occult primary breast tumors presenting with axillary nodal involvement, and surveil- lance programs assessing high-risk patients such as breast cancer gene carriers or patients with a history of chest irradiation [1–6]. However, as the use of MRI at the time of new diagnosis of early stage breast cancer is quickly becoming a new standard of care, there is heightened concern that routine use of MRI for preoperative staging may lead to more extensive surgery, while solid evidence for improvement of surgical management, improved rates of local con- trol, or improved overall prognosis is lacking [8–12]. In addition, while in a number of studies the detection of additional foci of breast cancer by MRI in the a ff ected breast is reported to be around 16% (ranging from 6 to 34%) [12, 13], only limited information exists on the histology of the additional lesions that MRI testing falsely identifies as worrisome [14]. In this paper, we report that MRI-guided needle core biopsies of separate lesions in the a ff ected breast of patients with newly diagnosed breast carcinoma show additional foci of malignancy in 20% of cases. A high percentage (66%) of these additional suspicious areas by MRI are benign by histologic examination. More specifically, MRI- guided needle core biopsies seem to target a characteristic complex multicystic lesion lined by apocrine metaplastic epithelium, in over one third of the cases, a lesion we called “cystic apocrine metaplasia.” Our findings suggest that MRI-guided core biopsies result in an important change of detection of additional foci of malignancy in a significant number of cases. In addition, MRI-directed needle core biopsies often target benign lesions with specific histopatho- logic characteristics, namely, a characteristic complex multicystic lesion lined by apocrine epithelium, the so-called “cystic apocrine metaplasia.” We suggest that awareness ...
Citations
... While breast MRI is highly sensitive for the detection of breast cancer, the specificity of breast MRI remains suboptimal; the majority (60%-80%) of all MRI-guided breast biopsies continue to yield benign findings. [2][3][4][5][6][7][8][9] Due to the inherent complexity of reporting breast MRI, combined with heterogeneous breast pathology diagnoses, breast MRI radiology-pathology correlation remains challenging. While prior studies have described the pathologic findings of MRI breast biopsies, often with radiologic correlation, [2][3][4][5][6][7][8][9] there has been variable progress in reducing the number of unnecessary breast MRI-guided biopsies. ...
... [2][3][4][5][6][7][8][9] Due to the inherent complexity of reporting breast MRI, combined with heterogeneous breast pathology diagnoses, breast MRI radiology-pathology correlation remains challenging. While prior studies have described the pathologic findings of MRI breast biopsies, often with radiologic correlation, [2][3][4][5][6][7][8][9] there has been variable progress in reducing the number of unnecessary breast MRI-guided biopsies. Furthermore, no studies have focused on potential variation in the distribution of histologic diagnoses over an extended time period. ...
... 13,14 Cystic apocrine metaplasia is also a relatively common benign finding in MRI-guided breast biopsies, with institutions reporting CAM as representing 10% to 38% of biopsied lesions. 2,6,7,15,16 We have previously shown that CAM should be considered when T2-hyperintense enhancing foci or subcentimeter circumscribed masses (with or without washout kinetics) are seen. 10 During the first quarter (2004-2007) of our study, CAM was the prominent histologic finding in 11% of all MRI biopsies, while in the last quarter (2016-2019), CAM only represented 4% of biopsies. ...
Background
Breast magnetic resonance imaging (MRI) is an important imaging tool for the management of breast cancer patients and for screening women at high risk for breast cancer.
Objectives
To examine long-term trends in the distribution of histologic diagnoses obtained from MRI-guided breast biopsies.
Design
Retrospective analysis.
Methods
We retrospectively reviewed the distribution of histologic diagnoses of MRI-guided breast biopsies from 2004 to 2019. All cases underwent central pathology review and lesions were classified based on the most prominent histologic finding present. Magnetic resonance imaging features were extracted from radiology reports when available and correlated with pathology diagnoses.
Results
Four hundred ninety-four MRI-guided biopsies were performed on 440 patients; overall, 73% of biopsies were benign and 27% were malignant. The annual percentages of benign and malignant diagnoses remained similar throughout the 16-year period. Of the benign entities commonly identified, the percentage of benign papillary and sclerosing lesions detected in the benign biopsies increased significantly (13% in 2004-2011 vs 31% in 2012-2019, P = .03). The mean size of malignant lesions was larger than benign lesions (30.1 mm compared with 14.2 mm, P = .045); otherwise, there were no distinguishing radiologic features between benign and malignant lesions.
Conclusion
The specificity of breast MRI remained constant over a 16-year period; however, there was a shift in the distribution of benign diagnoses with increased detection and biopsy of benign papillary and sclerosing lesions. Monitoring the distribution of breast MRI biopsy diagnoses over time with radiology-pathology correlation might improve the suboptimal specificity of breast MRI.
... However, differences have emerged in both this study and in the published literature. Siziopikou et al. [20] noted "cystic papillary metaplasia," a lesion referred to as "clustered cysts with papillary apocrine metaplasia" in this study, to be frequently seen in their SD standard deviation; IDC invasive ductal carcinoma; ILC invasive lobular carcinoma; CIS ductal carcinoma in situ/pleomorphic lobular carcinoma in situ; NME non-mass enhancement; EM enhancing mass; EF enhancing focus; FGT fibroglandular tissue *7 malignant lesions adjacent to biopsy-proven cancers were excluded + Exact test C Chi-square test; W Wilcoxon rank-sum test [12,14]. Of note, PASH was not specifically investigated as an independent pathologic feature in this study but was frequently observed focally in association with fibrocystic changes, and in particular, columnar cell lesions, an association that has been recognized and is thought to result from hormonally driven epithelial-stromal interaction [21]. ...
Purpose
Breast magnetic resonance imaging (MRI) has high sensitivity but suffers from low specificity, resulting in many benign breast biopsies for MRI-detected lesions. We sought to compare histologic findings between patients who underwent MRI-guided breast biopsy versus biopsy via other imaging modalities as well as to examine features associated with malignancy in the MRI cohort to help inform MRI-biopsy practice.
Methods
A 2-year (2018–2019) retrospective review of breast biopsies at our enterprise was conducted. Biopsies were categorized as stereotactic, ultrasound, MRI, or palpation guided. Pathology was categorized as benign (further divided into nine categories), atypical, or malignant (subdivided into in situ and invasive carcinoma). Pathology was compared between biopsy groups. Clinical, pathologic, and imaging features were compared between pathology groups within the MRI cohort.
Results
5828 biopsies from 4154 patients were reviewed, including 548 MRI-guided biopsies with stratification of MRI-biopsy pathology as follows: 69% benign, 13.8% atypical, and 17.2% malignant. Among benign MRI biopsies, there was higher frequency of “clustered cysts with papillary apocrine metaplasia” (56/548; 10.2%) and lower rate of fibroadenoma/fibroadenomatous change (55/548; 10%) compared to other modalities (158 or 3% and 1144 or 21.7% of 5280 biopsies, respectively). Multivariate analysis revealed indication of breast cancer (p < .0001), ipsilateral cancer (p < .0001) and rapid initial phase kinetics (p = .017) to remain significantly associated with malignant MRI-biopsy pathology.
Conclusions
A concurrent or recent breast cancer diagnosis was most predictive of malignancy on MRI-guided breast biopsy. Combined MRI feature evaluation and radiologic-pathologic concordance activities may allow for prognostic refinement and improved risk stratification.
... [16][17][18][19][20][21][22] Lesions detected by MRI can be categorized broadly by morphology into mass, nonmass, or focus, with nonmass enhancement (NME) being defined as an area of enhancement without an associated space-occupying mass that is distinct from the surrounding background parenchyma. NME has been associated with a wide spectrum of benign and malignant lesions [23][24][25][26][27][28][29][30][31][32][33][34] and over half of nonpalpable invasive carcinomas according to 1 study. 35 Given the overlap between benign and malignant lesions, there may be resultant uncertainty with regard to the concordance between MRI and pathologic findings in such cases. ...
Context.—
Dynamic, contrast-enhanced magnetic resonance imaging (MRI) is a highly sensitive imaging modality used for screening and diagnostic purposes. Nonmass enhancement (NME) is commonly seen on MRI of the breast. However, the pathologic correlates of NME have not been extensively explored. Consequently, concordance between MRI and pathologic findings in such cases may be uncertain and this uncertainty may cause the need for additional procedures.
Objective.—
To examine the histologic alterations that correspond to NME on MRI.
Design.—
We performed a retrospective search for women who underwent breast MRI between March 2014 and December 2016 and identified 130 NME lesions resulting in biopsy. The MRI findings and pathology slides for all cases were reviewed. The follow-up findings on any subsequent excisions were also noted.
Results.—
Among the 130 cases, the core needle biopsy showed 1 or more benign lesions without atypia in 80 cases (62%), atypical lesions in 21 (16%), ductal carcinoma in situ in 22 (17%), and invasive carcinoma in 7 (5%). Review of the imaging features demonstrated some statistically significant differences in lesions that corresponded to malignant lesions as compared with benign alterations, including homogeneous or clumped internal enhancement, type 3 kinetics, and T2 dark signal; however, there was considerable overlap of features between benign and malignant lesions overall. Of 130 cases, 54 (41.5%) underwent subsequent excision with only 6 cases showing a worse lesion on excision.
Conclusions.—
This study illustrates that NME can be associated with benign, atypical, and/or malignant pathology and biopsy remains indicated given the overlap of radiologic features.
... [10][11][12][13][14] Of the correlation studies pertaining to MRI, most are found within the radiology literature, but a few studies appear in pathology sources. [15][16][17][18][19][20] It is important for pathologists to understand this imaging technique and be familiar with the entities that can present as an abnormal enhancing lesion on MRI. The purpose of this study is to identify the spectrum of pathologic changes that present as abnormal enhancing lesions and to determine if any specific MRI pattern correlates with malignant lesions. ...
... Apocrine metaplasia was described as a frequent biopsy finding in MRI-guided biopsies in one study (38%; 11 of 29 cases). 15 However, in our study, 10 cases showed cystic apocrine metaplasia, mostly as one of the findings in the fibrocystic change category, with the exception of 1 case where apocrine metaplasia was the only finding. A recent study showed that increased microvascular density in select benign breast lesions, notably cystic apocrine metaplasia when compared with normal fibroglandular tissue, led to their detection on MRI as an enhancing focus or small mass. ...
Context:
- Breast magnetic resonance imaging (MRI) is now used routinely for high-risk screening and in the evaluation of the extent of disease in newly diagnosed breast cancer patients. Morphologic characteristics and the kinetic pattern largely determine how suspicious a breast lesion is on MRI. Because of its high sensitivity, MRI identifies a large number of suspicious lesions. However, the low to moderate specificity and the additional cost have raised questions regarding its frequent use.
Objectives:
- To identify the pathologic entities that frequently present as suspicious enhancing lesions and to identify specific MRI characteristics that may be predictive of malignancy.
Design:
- One hundred seventy-seven MRI-guided biopsies from 152 patients were included in the study. The indication for MRI, MRI features, pathologic findings, and patient demographics were recorded. The MRI findings and the pathology slides were reviewed by a dedicated breast radiologist and breast pathologists.
Results:
- Seventy-one percent (126 of 177) of MRI-guided breast biopsies were benign, 11% (20 of 177) showed epithelial atypia, and 18% (31 of 177) showed malignancy. The vast majority (84%; 62 of 74) of MRI lesions with persistent kinetics were benign. However, 57% (17 of 30) of lesions with washout kinetics and 65% (62 of 95) of mass lesions were also benign.
Conclusions:
- Magnetic resonance imaging detects malignancies undetected by other imaging modalities but also detects a wide variety of benign lesions. Benign and malignant lesions identified by MRI share similar morphologic and kinetic features, necessitating biopsy for histologic confirmation.
... Other studies have shown that most (60-80%) enhancing lesions recommended for biopsy are ultimately determined to be benign [23,24]. Cystic apocrine metaplasia is a subset of fibrocystic changes featuring discrete clustered cysts that are lined by apocrine epithelium. ...
... Although evidence suggests that gross cysts are related to an increased relative risk of breast cancer [7], current consensus is that these cysts are not associated with breast cancer; they are thus not considered to be precancerous lesions per se [8]. Importantly, apocrine cysts are among the most common findings of magnetic resonance imaging of the breast [9][10][11], which may lead to unnecessary biopsy due to the mimicking of breast neoplasia [12]. The term "apocrine adenosis" has been applied to a range of apocrine proliferations, including deformed lobular units, sclerosing adenosis, radial scars and complex sclerosing lesions. ...
Apocrine morphology in breast is observed in a wide variety of lesions ranging from simple cysts and atypical hyperplasia to invasive metastatic stages of disease. The accurate diagnosis of breast apocrine carcinoma remains controversial, mainly due to the subjectivity of histopathological criteria and the lack of sensitive and specific biomarkers for reliable categorization of this subtype of breast carcinoma. Thus, many efforts are currently being made to identify novel molecular marker signature(s) that can define apocrine carcinoma with high levels of accuracy and reliability, and determine with certainty the true clinical significance of these lesions. The purpose of this article is to review the data on apocrine lesions, with an emphasis on borderline apocrine differentiation. In particular, we address relevant issues in the context of the current state of research on benign and malignant apocrine lesions of the breast, with a focus on parameters for diagnosis and potential-targeted therapeutic options.
... Recently, breast MRI has emerged as a staging tool that can detect otherwise occult malignancy in these patients [1,2,3,5]. Although breast MRI is known to have very high sensitivity in this clinical setting, false positive findings can also occur resulting in a lower specificity [6][7][8]. In patients with newly diagnosed breast malignancy, including Paget's disease of the nipple, any asymmetric enhancement should be considered suspicious for further disease [2], and an MRguided biopsy should be performed to obtain a tissue diagnosis if not seen on a "second-look" ultrasound. ...
Paget’s disease of the nipple is a rare breast malignancy. It is usually, but not always, associated with an underlying ductal carcinoma in situ or invasive ductal carcinoma. Conventional breast imaging studies often fail to detect underlying breast malignancy when present. The following article will discuss the role of breast MRI as a problem solving tool in Paget’s disease of the nipple-areolar complex in patients with no abnormality on clinical examination and normal mammography.
doi:10.4021/jcs80w
MRI-GBB is a safe, simple and fast procedure that can be performed with minimal
training. The biopsy can spare the patient surgical biopsy and may reduce re-surgery rate.
T2-hyperintense lesions in MRI-guided breast biopsies have NPV of 96%. Thus, MRIguided
breast biopsies utilization may be reduced based on our study by around one
third. Thus, the T2W signal intensity of the lesion could aid in reducing the number of MRI
guided breast biopsies resulting in reduced patient's anxiety, treatment delay and cost.
Benign papillary and sclerosing lesions of the breast (intraductal papillomas, complex sclerosing lesions, radial scars) are considered high‐risk lesions due to the potential for upgrade to carcinoma on subsequent surgical excision. Optimal clinical management of such lesions remains unclear due to variable reported upgrade rates. Apocrine metaplasia is a common finding in breast tissue and its role in MRI enhancing lesions is increasingly being recognized. The purpose of this study was to investigate the MRI features of papillary and sclerosing lesions of the breast, evaluate the clinical management and upgrade rate of such lesions, and examine the contribution of apocrine metaplasia to the imaging findings. A 13‐year retrospective review of MRI‐guided biopsies identified 70 MRI‐detected and ‐biopsied papillary and sclerosing lesions. Sixteen lesions without atypia underwent surgical excision; only one case (6%) was upgraded to pleomorphic lobular carcinoma in situ. The majority (64%) of biopsies contained apocrine metaplasia either within or adjacent to the targeted lesion. We found that half of MRI‐detected lesions had T2 hyperintense foci (2‐5 mm) or masses (>5 mm) adjacent to the lesion. Histologic correlation showed apocrine cysts were likely responsible for this imaging finding in 56% of these cases.
