Objective: To assess the efficacy of contrast-enhanced mammography (CEM) in differentiating benign from malignant breast lesions in Asian patients with bloody nipple discharge (BND). Methods: This retrospective study included 58 women with BND (mean age: 51.7 years) who underwent standardized CEM at institutions in Taiwan and Singapore. Lesion characteristics (size, enhancement, conspicuity, shape, margins) were evaluated on CEM by blinded radiologists. Non-enhanced mammography (MMG) and ultrasound (US) within a defined timeframe were compared for diagnostic accuracy. Benign or malignant status was confirmed by biopsy or 2-year imaging follow-up. Results: Malignancy was found in 29 of 58 lesions (50.0%), with ductal carcinoma in situ (DCIS) being the most common. CEM demonstrated a 100% negative predictive value (NPV) for non-enhancing lesions. Significant predictors of malignancy on multivariate analysis include enhancing lesions of size ≥ 1.5 cm (p-value 0.025) and suspicious morphological features (irregular/spiculated margins, irregular shape, segmental/linear NME distribution) (p-value < 0.001). CEM outperformed MMG (sensitivity: 58.6%) and US (sensitivity: 79.3%), achieving a sensitivity of 100% and the highest diagnostic accuracy at 81.3%. Additionally, a CEM size cut-off of 1.5 cm yielded a sensitivity of 73.5% and a specificity of 84.3%. Conclusions: CEM effectively differentiates benign from malignant lesions in patients with BND, improving diagnostic accuracy and potentially reducing unnecessary interventions.

Architectural distortion (AD) is the third most common abnormality detected on mammograms. In the absence of an accurate non-invasive tool to evaluate ADs, clinical management often requires surgical excision for histological diagnosis. This problem is expected to worsen with the growing use of digital breast tomosynthesis (DBT) and the resultant increasing detection of ADs. There is therefore a great clinical need for a diagnostic imaging tool to complement non-enhanced mammography for the evaluation of AD. Contrast-enhanced mammography (CEM) is an emerging breast imaging method that uses contrast media and the principle of dual-energy subtraction to evaluate vascularity of suspicious breast lesions. CEM, a cost-effective alternative to breast magnetic resonance imaging (MRI), can be used to evaluate AD by juxtaposing CEM images with non-enhanced mammograms for comparison. In this review, the authors aim to provide readers with an overview of the interpretation of AD on CEM using imaging examples. Relevant imaging features of CEM and their respective significance will be matched with information from a literature review. Finally, the authors would like to highlight the added value of CEM in relevant clinical applications in the assessment of AD.

Objective To evaluate the impact of pre-operative contrast-enhanced mammography (CEM) in breast cancer patients with dense breasts. Methods We conducted a retrospective review of 232 histologically proven breast cancers in 200 women (mean age: 53.4 years ± 10.2) who underwent pre-surgical CEM imaging across two Asian institutions (Singapore and Taiwan). Majority (95.5%) of patients had dense breast tissue (BI-RADS category C or D). Surgical decision was recorded in a simulated blinded multi-disciplinary team setting on two separate scenarios: (i) pre-CEM setting with standard imaging, and clinical and histopathological results; and (ii) post-CEM setting with new imaging and corresponding histological findings from CEM. Alterations in surgical plan (if any) because of CEM imaging were recorded. Predictors CEM of patients who benefitted from surgical plan alterations were evaluated using logistic regression. Results CEM resulted in altered surgical plans in 36 (18%) of 200 patients in this study. CEM discovered clinically significant larger tumor size or extent in 24 (12%) patients and additional tumors in 12 (6%) patients. CEM also detected additional benign/false-positive lesions in 13 (6.5%) of the 200 patients. Significant predictors of patients who benefitted from surgical alterations found on multivariate analysis were pre-CEM surgical decision for upfront breast conservation (OR, 7.7; 95% CI, 1.9-32.1; p = 0.005), architectural distortion on mammograms (OR, 7.6; 95% CI, 1.3–42.9; p = .022), and tumor size of ≥ 1.5 cm (OR, 1.5; 95% CI, 1.0-2.2; p = .034). Conclusion CEM is an effective imaging technique for pre-surgical planning for Asian breast cancer patients with dense breasts. Key Points • CEM significantly altered surgical plans in 18% (nearly 1 in 5) of this Asian study cohort with dense breasts. • Significant patient and imaging predictors for surgical plan alteration include (i) patients considered for upfront breast-conserving surgery; (ii) architectural distortion lesions; and (iii) tumor size of ≥ 1.5 cm. • Additional false-positive/benign lesions detected through CEM were uncommon, affecting only 6.5% of the study cohort.

Invasive lobular carcinoma (ILC) has a greater tendency to metastasize to the peritoneum, retroperitoneum, and gastrointestinal (GI) tract as compared to invasive carcinoma of no special type (NST). Like primary ILC in the breast, ILC metastases are frequently infiltrative and hypometabolic, rather than mass forming and hypermetabolic in nature. This renders them difficult to detect on conventional and metabolic imaging studies. As a result, intra-abdominal ILC metastases are often detected late, with patients presenting with clinical complications such as liver failure, hydronephrosis, or bowel obstruction. In patients with known history of ILC, certain imaging features are very suggestive of infiltrative metastatic ILC. These include retroperitoneal or peritoneal nodularity and linitis plastica appearance of the bowel. Recognition of linitis plastica on imaging should prompt deep or repeat biopsies. In this pictorial review, the authors aim to familiarize readers with imaging features and pitfalls for evaluation of intra-abdominal metastatic ILC. Awareness of these will allow the radiologist to assess these patients with a high index of suspicion and aid detection of metastatic disease. Also, this can direct histopathology and immunohistochemical staining to obtain the correct diagnosis in suspected metastatic disease.

The Breast JournalVolume 26, Issue 11 p. 2260-2262 BREAST IMAGES An elusive diagnosis of IgG4-related sclerosing mastitis Amos H. S. Tan MBBS, Corresponding Author Amos H. S. Tan MBBS Amos_hs_tan@nuhs.edu.sg orcid.org/0000-0002-1729-803X Departments of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore Correspondence Amos H. S. Tan, Department of Diagnostic Imaging, National University Hospital, 1E Kent Ridge Rd, Singapore 119228. Email: Amos_hs_tan@nuhs.edu.sgSearch for more papers by this authorSwee Tian Quek MBBS, FRCR, FAMS, Swee Tian Quek MBBS, FRCR, FAMS orcid.org/0000-0001-7561-7492 Departments of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SingaporeSearch for more papers by this authorPavel Singh MBBS, FRCR, M.Med, Pavel Singh MBBS, FRCR, M.Med orcid.org/0000-0003-1109-0876 Departments of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SingaporeSearch for more papers by this authorThomas Choudary Putti MBBS, MD, Thomas Choudary Putti MBBS, MD orcid.org/0000-0001-8791-7257 Department of Pathology, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SingaporeSearch for more papers by this authorPremilla Gopinathan Pillay MBBS, FRCR, Premilla Gopinathan Pillay MBBS, FRCR Departments of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SingaporeSearch for more papers by this authorFelicity Jane Pool MBChB, FRANZCR, Felicity Jane Pool MBChB, FRANZCR orcid.org/0000-0002-3575-8853 Departments of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SingaporeSearch for more papers by this authorPooja Jagmohan MBBS, MD, FRCR, Pooja Jagmohan MBBS, MD, FRCR orcid.org/0000-0001-8491-0375 Departments of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SingaporeSearch for more papers by this author Amos H. S. Tan MBBS, Corresponding Author Amos H. S. Tan MBBS Amos_hs_tan@nuhs.edu.sg orcid.org/0000-0002-1729-803X Departments of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore Correspondence Amos H. S. Tan, Department of Diagnostic Imaging, National University Hospital, 1E Kent Ridge Rd, Singapore 119228. Email: Amos_hs_tan@nuhs.edu.sgSearch for more papers by this authorSwee Tian Quek MBBS, FRCR, FAMS, Swee Tian Quek MBBS, FRCR, FAMS orcid.org/0000-0001-7561-7492 Departments of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SingaporeSearch for more papers by this authorPavel Singh MBBS, FRCR, M.Med, Pavel Singh MBBS, FRCR, M.Med orcid.org/0000-0003-1109-0876 Departments of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SingaporeSearch for more papers by this authorThomas Choudary Putti MBBS, MD, Thomas Choudary Putti MBBS, MD orcid.org/0000-0001-8791-7257 Department of Pathology, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SingaporeSearch for more papers by this authorPremilla Gopinathan Pillay MBBS, FRCR, Premilla Gopinathan Pillay MBBS, FRCR Departments of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SingaporeSearch for more papers by this authorFelicity Jane Pool MBChB, FRANZCR, Felicity Jane Pool MBChB, FRANZCR orcid.org/0000-0002-3575-8853 Departments of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SingaporeSearch for more papers by this authorPooja Jagmohan MBBS, MD, FRCR, Pooja Jagmohan MBBS, MD, FRCR orcid.org/0000-0001-8491-0375 Departments of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SingaporeSearch for more papers by this author First published: 29 September 2020 https://doi.org/10.1111/tbj.14066Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume26, Issue11November 2020Pages 2260-2262 RelatedInformation

Objective To develop a risk predictor model in evaluation of tomosynthesis-detected architectural distortion (AD) based on characteristics of contrast-enhanced digital mammography (CEDM). Methods Ninety-four AD lesions on CEDM in combination with tomosynthesis were retrospectively reviewed from 92 consecutive women (mean age, 52.4 years ± 7.9) with abnormal diagnostic or screening mammography. CEDM results were correlated with histology of ADs using cross-tabulation for statistical analysis. Predictors for risk of malignancy from CEDM characteristics (background parenchyma enhancement, degree of AD enhancement, enhancing morphology, size of enhancement, and enhancing spiculations) and patient’s age were evaluated using logistic regression. We propose a sum score, termed AD score (ADS), for risk stratification and corresponding suggested BI-RADS category. Results Thirty-three of ninety-four (35.1%) of detected AD lesions were malignant. The sensitivity, specificity, PPV, and NPV of CEDM in evaluation of malignant AD are 100%, 42.6%, 48.5%, and 100%, respectively. Absence of AD enhancement on CEDM is highly indicative of no underlying malignancy. On multivariate analysis, the predictors on CEDM with statistical significance are (1) marked intensity of AD enhancement (OR, 22.6; 95%CI 3.1, 166.6; p = .002); and (2) presence of enhancing spiculations (OR, 9.1; 95%CI 2.2, 36.5; p = .002). A prediction model whose scores (ADS) given by ranking of OR of all predictors with AUC of 0.934 and Brier score of 0.0956 was developed. Conclusion ADS-based lesion characterization on CEDM enables risk assessment of tomosynthesis-detected AD lesions. Key Points • Architecture distortions presenting with marked enhancement intensity and presence of enhancing spiculations are highly associated with risk of malignancy. • Absence of architecture distortion enhancement in minimal or mild background parenchyma enhancement on CEDM indicates low risk of breast malignancy (NPV = 100%).

The Breast JournalVolume 26, Issue 5 p. 1050-1051 BREAST IMAGES Malignant phyllodes tumor of the male breast Pooja Jagmohan MBBS, MD, FRCR, Corresponding Author Pooja Jagmohan MBBS, MD, FRCR poojajagmohan@gmail.com jagmohan_pooja@nuhs.edu.sg orcid.org/0000-0001-8491-0375 Department of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore Correspondence Pooja Jagmohan, Department of Diagnostic Imaging, NUH, 1E Kent Ridge Rd, 119228, Singapore. Emails: poojajagmohan@gmail.com, jagmohan_pooja@nuhs.edu.sgSearch for more papers by this authorHidayah Saleh Habib Almaskeen MBBS, Saudi Board (Radiology), Hidayah Saleh Habib Almaskeen MBBS, Saudi Board (Radiology) Department of Radiology, Maternity and Children Hospital, Dammam, Saudi ArabiaSearch for more papers by this authorPremilla Gopinathan Pillay MBBS, FRCR, Premilla Gopinathan Pillay MBBS, FRCR Department of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, SingaporeSearch for more papers by this authorYonggeng Goh MBChB, M.Med, FRCR, MCI, Yonggeng Goh MBChB, M.Med, FRCR, MCI Department of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, SingaporeSearch for more papers by this authorPavel Singh MBBS, FRCR, M.Med, Pavel Singh MBBS, FRCR, M.Med Department of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, SingaporeSearch for more papers by this authorLuke Ern-Wei Tay MBBS, Luke Ern-Wei Tay MBBS Department of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, SingaporeSearch for more papers by this authorThomas Choudary Putti MBBS, MD(Path), Diplomate (American Board), Thomas Choudary Putti MBBS, MD(Path), Diplomate (American Board) Department of Pathology, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, SingaporeSearch for more papers by this authorSwee Tian Quek MBBS, FRCR, FAMS, Swee Tian Quek MBBS, FRCR, FAMS Department of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, SingaporeSearch for more papers by this author Pooja Jagmohan MBBS, MD, FRCR, Corresponding Author Pooja Jagmohan MBBS, MD, FRCR poojajagmohan@gmail.com jagmohan_pooja@nuhs.edu.sg orcid.org/0000-0001-8491-0375 Department of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore Correspondence Pooja Jagmohan, Department of Diagnostic Imaging, NUH, 1E Kent Ridge Rd, 119228, Singapore. Emails: poojajagmohan@gmail.com, jagmohan_pooja@nuhs.edu.sgSearch for more papers by this authorHidayah Saleh Habib Almaskeen MBBS, Saudi Board (Radiology), Hidayah Saleh Habib Almaskeen MBBS, Saudi Board (Radiology) Department of Radiology, Maternity and Children Hospital, Dammam, Saudi ArabiaSearch for more papers by this authorPremilla Gopinathan Pillay MBBS, FRCR, Premilla Gopinathan Pillay MBBS, FRCR Department of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, SingaporeSearch for more papers by this authorYonggeng Goh MBChB, M.Med, FRCR, MCI, Yonggeng Goh MBChB, M.Med, FRCR, MCI Department of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, SingaporeSearch for more papers by this authorPavel Singh MBBS, FRCR, M.Med, Pavel Singh MBBS, FRCR, M.Med Department of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, SingaporeSearch for more papers by this authorLuke Ern-Wei Tay MBBS, Luke Ern-Wei Tay MBBS Department of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, SingaporeSearch for more papers by this authorThomas Choudary Putti MBBS, MD(Path), Diplomate (American Board), Thomas Choudary Putti MBBS, MD(Path), Diplomate (American Board) Department of Pathology, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, SingaporeSearch for more papers by this authorSwee Tian Quek MBBS, FRCR, FAMS, Swee Tian Quek MBBS, FRCR, FAMS Department of Diagnostic Imaging, National University Hospital and Yong Loo Lin School of Medicine, National University of Singapore, SingaporeSearch for more papers by this author First published: 26 December 2019 https://doi.org/10.1111/tbj.13710Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume26, Issue5May 2020Pages 1050-1051 RelatedInformation

PURPOSE: To determine the accuracy of a handheld ultrasound-guided optoacoustic tomography (US-OT) probe developed for human deep-tissue imaging in ex vivo assessment of tumor margins postlumpectomy. METHODS: A custom-built two-dimensional (2D) US-OT-handheld probe was used to scan 15 lumpectomy breast specimens. Optoacoustic signals acquired at multiple wavelengths between 700 and 1100 nm were reconstructed using model linear algorithm, followed by spectral unmixing for lipid and deoxyhemoglobin (Hb). Distribution maps of lipid and Hb on the anterior, posterior, superior, inferior, medial, and lateral margins of the specimens were inspected for margin involvement, and results were correlated with histopathologic findings. The agreement in tumor margin assessment between US-OT and histopathology was determined using the Bland-Altman plot. Accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of margin assessment using US-OT were calculated. RESULTS: Ninety margins (6 x 15 specimens) were assessed. The US-OT probe resolved blood vessels and lipid up to a depth of 6 mm. Negative and positive margins were discriminated by marked differences in the distribution patterns of lipid and Hb. US-OT assessments were concordant with histopathologic findings in 87 of 89 margins assessed (one margin was uninterpretable and excluded), with diagnostic accuracy of 97.9% (kappa 0.79). The sensitivity, specificity, PPV, and NPV were 100% (4/4), 97.6% (83/85), 66.7% (4/6), and 100% (83/83), respectively. CONCLUSION: US-OT was capable of providing distribution maps of lipid and Hb in lumpectomy specimens that predicted tumor margins with high sensitivity and specificity, making it a potential tool for intraoperative tumor margin assessment.

Multispectral optoacoustic tomography (MSOT) is an innovative state-of-the-art imaging modality that has gained popularity for in vivo breast imaging in recent years. Combining high-resolution images with endogenous differentiation of biochemical contents, MSOT could be an accurate ex vivo imaging modality for assessment of tumor margins during breast-conserving surgery to reduce margin positivity rates. Accurate intraoperative assessment of margins could lead to more precise surgery, allowing a smaller volume of breast tissue to be removed without compromising the resection margins. To the authors' knowledge, there has been no ex vivo study conducted to this day that uses MSOT in the assessment of breast tumor margins after lumpectomy. Hence, we would like to present the first case of breast tumor margin assessment using MSOT in a 55-year-old patient who underwent breast-conserving surgery for invasive ductal carcinoma. (C) 2018 The Authors. Published by Elsevier Inc.

Poster: ECR 2016 / C-1204 / High risk lesions of the breast : Review of the current diagnostic and management strategies by: Jagmohan, F. J. Pool, P. G. Pillay, S. Dhanda, S. T. Quek; singapore/SG