RPS 1602 - Interventional radiology in breast cancer care

Author Block: F. Galati, M. Pasculli, C. Napoletano, V. Rizzo, R. Maroncelli, F. Cicciarelli, M. Nuti, C. Catalano, F. Pediconi; Rome/IT
Purpose: Cryoablation is a minimally-invasive procedure that uses cooling to induce necrosis of the targeted tissue. All other minimally invasive techniques use hyperthermia, which melts cell membranes and causes protein denaturation. In contrast, cryoablation leaves tumor proteins and tumor-associated antigens intact, with the potential to stimulate an anti-tumor immune response. Thus, the purpose of this prospective pilot study was to characterize the immune response induced by tumor cryoablation in blood samples from early breast cancer (BC) patients.
Methods or Background: We enrolled patients with early-stage BC, scheduled for breast surgery, not eligible for neo-adjuvant therapy, and with a cryo-feasible cancer location. Blood samples to assess immune response were taken before (T0) and one week after cryoablation (T1), and before (T2) and one week after (T3) surgery. Analysis of T cell subsets (CD3, CD8, CD4, CD137, and Tregs) and the inflammatory/damage molecule HMGB1 were performed by flow cytometry/ELISA. Circulating cytokines were also analyzed using the Luminex analysis.
Results or Findings: From July 2022 to January 2023, ten patients underwent cryoablation. Analysis of circulating markers of cryo-immunological response revealed a progressive release of HGBM1 after cryoablation (T0-T1, p=0.04) until surgical resection of the primary tumor (T0-T3, p=0.02). Cryoablation followed by surgery also induced a significant decrease in CD137 T cell subsets (total and CD4; p<0.01), and IL4 (T0-T3, p<0.05). Finally, a significant decrease in proliferative Treg cell subsets (Ki67+Tregs; p<0.05) was observed.
Conclusion: In our pilot study, cryoablation induced the release of HMGB1, which acts to activate the primary phases of the immune response, and the decrease of the immunosuppressive Treg subset and the pro-tumoral cytokine IL-4, probably released by CD4CD137 T cells.
Limitations: Although the limited number of patients, cryoablation was a valuable method to enhance the anti-tumor response.
Funding for this study: The study has received funding from the Seed Grant funding programme of the European Society of Radiology (ESR) in collaboration with the European Institute for Biomedical Imaging Research (EIBIR) kindly supported by an unrestricted, non-exclusive grant from GE Healthcare.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The study obtained the approval of the Institutional Review Board of “Sapienza” University of Rome (Ref.6528, approved 24.11.2021).

Author Block: X. Ma; Shanghai/CN
Purpose: To establish a fusion model based on mammography (MG) and magnetic resonance imaging (MRI) for the preoperative differentiation of breast phyllodes tumors (PTs) and fibroadenomas (FAs).
Methods or Background: The clinical data, MG images, and MR images of patients with breast FAs treated in our institution from October 2019 to December 2020, as well as patients with PTs treated from January 2011 to December 2020, were retrospectively collected. Univariate and multivariate logistic regression analyses were conducted to select independent factors and to construct a diagnostic model to differentiate PTs and FAs. The diagnostic performance of the model was evaluated using the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).
Results or Findings: A total of 147 patients with FAs and 138 patients with PTs were included in this study. The results of the multivariate logistic regression analysis showed that patient age, maximum diameter of mass, density on MG images, lobulation on MR images, and time-intensity curve (TIC) were independent factors contributing to the differential diagnosis. Finally, the fusion model showed satisfactory discrimination (area under the curve (AUC) 0.90, 95% CI: 0.86-0.94) and calibration. DCA indicated good clinical benefit, as indicated by most values being within threshold probabilities.
Conclusion: MG and MRI findings help differentiate between FAs and breast PTs preoperatively. The multimodal fusion model was clinically efficacious and beneficial and thus useful for accurate clinical diagnosis and treatment.
Limitations: Our study is a retrospective and single-centre study, so it is necessary to validate the accuracy of the research results through multicentre studies.
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Fudan University Shanghai Cancer Center

Author Block: D. E. Tekcan Sanli¹, G. Esen²; ¹Gaziantep/TR, ²Istanbul/TR
Purpose: To compare the accuracy of radiological tumor sizes obtained by mammography (MMG), ultrasonography (US) and magnetic resonance imaging (MRI) with pathological sizes and to determine whether tumor size measurements change based on molecular subtypes and the presence of accompanying ductal carcinoma in situ (DCIS).
Methods or Background: A total of 559 breast cancer patients diagnosed in 11 university hospitals in Turkey between 2010 and 2022, underwent preoperative MMG, USG, and MRI, and did not receive neoadjuvant chemotherapy (NAC) were included in the study. Tumors were divided into histopathological (in-situ/invasive/ in-situ+invasive (mixed)) and molecular (Luminal A/B/HER2+/triple-) subgroups. Tumor sizes were measured on each modality retrospectively and compared with the pathologic sizes reported in the postoperative pathology reports. Comparison was performed based on histological type (invasive/ in situ/ mixed), and molecular subtypes.
Results or Findings: The highest agreement in invasive tumors was obtained with MRI (MRI:0.831, US:0.769, MMG:0.650). In the presence of DCIS, the agreement was strong with MRI (r:0.770), moderate with MMG and US (r:0.517, r:0.593, respectively). In mixed tumors, agreement was strong with MRI (r:0.817), moderate with US (r:0.656), and low with MMG (r:0.499). Based on molecular subtypes, highest correlation was obtained with US and MRI in HER-2 (+) tumors (r:0.754, r:0.715, respectively), and with MRI in other subtypes (Luminal A-B-triple (-)) with MRI (r:0.856-0.815-0.858; respectively). There was no statistically significant difference in terms of other criteria.
Conclusion: This multicenter study shows that MRI is the most reliable method in preoperative determination of tumor size for both invasive and in-situ tumors and all molecular subtypes.
Limitations: In this retrospective study, the number of patients was sufficient but unbalanced when divided into subgroups. The presence of invasive lobular carcinoma and axillary lymph nodes were not taken into account separately.
Funding for this study: No
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Ethics committee approval is obtained from Acıbadem University. (No:2021-21/29)

Author Block: C. O'Brien, M. R. Common, N. Hambly, N. Ní Mhuircheartaigh, M. Bambrick, D. Duke, N. Healy, E. Downey; Dublin/IE
Purpose: Our retrospective study examines patients referred to a symptomatic breast centre with breast abnormality identified on cross-sectional imaging with special reference to frequency and outcomes.
Methods or Background: All patients presenting to our symptomatic breast centre over a 29-month period (Dec. 21-May 24) were evaluated. Patients referred following detection of breast abnormality on cross-sectional imaging were identified. Results of subsequent breast imaging, image-guided biopsies and histopathology were analysed.
Results or Findings: 13,336 consecutive referrals over a 29-month period were reviewed. 179 female/ 3 male patients, mean age 56.3 years (range 26 -89years), were referred with breast abnormality on cross-sectional imaging. 158/182 (86.8%) were identified on CT, 9/182 (4,9%) on MRI, 14/182 (7.7%) on nuclear medicine, 1/182 (0.5%) on ultrasound. Clinical breast examination was normal in most patients. All patients underwent breast imaging. 75/ 182 (41.2%) patients underwent image guided biopsy. Histopathology results of biopsies were benign in 26/75 (34.7 %), indeterminate (B3) in 5/74 (6.8%) and malignant in 44/75 (58.6%). 2/5 patients with B3 histopathology underwent surgical excision yielding final benign pathology, while 3/5 opted for lesion surveillance. Overall cancer detection rate was 24.2% (44/ 182).
Conclusion: While breast abnormalities detected on cross sectional imaging represent a small subgroup of referrals the cancer detection rate in this cohort is significant. With normal clinical examinations these patients are at risk of delays along the traditional referral pathways based on clinical suspicion of malignancy. Direct referral of these patients to breast radiology ensures prioritisation based on lesion appearance on cross-sectional imaging.
Limitations: Only cross-sectional breast abnormalities of patients referred to the symptomatic breast service were reviewed.
Funding for this study: Nil
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: Approval obtained from the Quality and Safety Directorate team at our institution.

Author Block: G. Sessa, C. Beretta, C. Bozzola, F. Mogavero, C. Parlato, L. Nocetti, G. Ligabue, P. Torricelli, A. Pecchi; Modena/IT
Purpose: This study aims to evaluate the applicability of radiomics analysis to mammographic images of patients diagnosed with triple negative breast cancer (TNBC) in order to identify radiomics features that can differentiate the mutational status of BRCA genes.
Methods or Background: This retrospective study included patients histologically diagnosed with TNBC who performed a mammographic examination between 2010 and 2021.
Mammographic images were reviewed and for each patient the tumor lesions were manually segmented in the mammographic projection where they were better demarcable; a further elliptical ROI (region of interest) of standard size (100 mm2) was drawn in the most homogeneous area of the controlateral healthy gland using the analogue mammographic projection of the same date or, if not available, of the corresponding bilateral mammographic investigation closer to the time of diagnosis. Features from each ROI were extracted with Pyradiomics-3D.
Results or Findings: The population included 50 patients and 51 lesions (12 BRCA+ patients and 13 lesions therein, 38 BRCAwildtype patients and 38 lesions therein).
The lesions included 37 nodules, 3 pathologic microcalcifications and 11 lesions appearing as nodules with contextual microcalcifications.
The segmentation was carried out on the following projections: 24 LCC, 24 RCC, 21 LMLO, 2 LML, 21 RMLO, 2RML.
The first preliminary analysis demonstrated the feasibility of the radiomics study in the population examined. Based on a previous study conducted on DCE-MRI of the same target population, we expect to be able to identify differences in radiomic patterns which represent the fenotipic expression of mutations occurring on a genetic level.
Conclusion: This study demonstrated the feasability of radiomics analysis on diagnostic mammograms of TNBC patients to build a predictive model able to discriminate between carriers and non carriers of BRCA gene mutations.
Limitations: Small population
Funding for this study: No funding received for this study
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The research was approved by the Area Vasta Emilia Nord Est Ethical Committee (463/2020/OSS/AOUMO) SIRER ID 236 - EMENDAMENTO SOSTANZIALE 1.0 (prot. AOU 0008681/22 del 23/03/2022) and informed consent was obtained from all subjects.

Author Block: A. Portaluri¹, F. M. Arico¹, X. Wang², T. Zhang², C. Sofia¹, E. Condorelli¹, F. Catanzariti¹, M. A. Marino¹; ¹Messina/IT, ²Amsterdam/NL
Purpose: To evaluate the performance of a new combined score, CEUS-BI-RADS (CB) score, in differentiating between benign and malignant lesions and in reducing the number of unnecessary breast biopsies.
Methods or Background: 331 women with a new breast lesion scheduled for US-guided biopsy (sonographically assesed as BI-RADS 4 a-c and 5) were enrolled. For each lesion, CEUS examination was performed before the biopsy. 2 single reader (1 high-experienced breast radiologist and 1 trainee) independently assessed all CEUS studies with qualitative analysis, in terms of time and intensity of enhancement, enhancement pattern and size increase after contrast administration, assigning them a CEUS score from 0 to 3. Moreover a score from 1 to 4 was assigned for each BI-RADS category sonographically assesed as BI-RADS 4a, 4b, 4c and 5. Finally a combined score (CB score) was obtained. Descriptive statistics, area under the curve (AUC), receiver operating characteristic (ROC) analysis, sensitivity and specificity were used to investigate the diagnostic performance of the combined approach. Inter-reader reliability was measured using Cohen’s kappa statistics.
Results or Findings: 294 lesions have been found. CB score showed the highest diagnostic performance compared to the CEUS score alone (average AUCs = 0.935 vs 0. 890, p <0.0001), the highest sensitivity (87.9% vs 91.3%) and specificity (75.2% vs 80.7%) . Moderate (κ= 0. 45) agreement was found between the two readers. Finally, CB score would have obviated up to 40% of unnecessary biopsies.
Conclusion: CB score allowed to improve the diagnostic performance of CEUS alone for lesions assesment, reducing the rate of false positives biopsies for both experienced and unexperienced reader.
Limitations: Deeper studies on the application of this score need to be carried out to improve the identification of small tumours that have minimal blood supply.
Funding for this study: None
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: This is a single-center, retrospective study. Ethics committee approval was waived as all Contrast-Enhanced Ultrasound (CEUS) examinations were conducted as part of routine clinical care, following established protocols at our institution. These examinations were clinically indicated prior to biopsy, ensuring that no additional procedures were performed outside the Standard of Care (SOC).

Author Block: S. E. Baldi Giorgi, F. Di Naro, G. Migliaro, F. Pugliese, T. Amadori, S. Vidali, G. Bicchierai, V. Miele, J. Nori; Florence/IT
Purpose: This study aims to evaluate the most effective non-surgical treatment for breast cancer in surgery-ineligible patients, comparing ultrasound-guided Cryoablation combined with hormonal therapy (HT) versus Cryoablation alone and hormonal therapy alone.
Methods or Background: A cohort of 64 patients (mean age 83.4 years) not-suitable for surgery due to comorbidities and/or advanced age was enrolled, with a total of 73 biopsy-confirmed malignant breast lesions. All the lesions were invasive ductal carcinomas (mean size 14.8 mm), hormone-positive and HER2-negative, with no ultrasound-visible lymph node involvement.
Patients were divided into three groups: 36 lesions were treated with Cryoablation and HT, 19 with Cryoablation only and 18 with HT only.
A locoregional staging was performed at baseline with contrast-enhanced-mammography (CEM) and ultrasound, followed by CEM and ultrasound follow-up at 12 months post-treatment. Only patients completing the follow-up were included.
Lesion size was compared at baseline and 12 months after-treatment. Fisher's exact test was used for group comparison.
Results or Findings: Of the 73 lesions, 47 completed the 12-months follow-up: 20 in the Cryoablation-with-HT group, 9 in the Cryoablation-only group, and 18 in the HT-only group. Tumor size reduction was greatest in the Cryoablation-with-HT group (94%, mean reduction of 15.4 mm), followed by Cryoablation-only (82%, mean reduction of 9.7 mm), and HT-only (43%, mean reduction of 4.6 mm).
Tumors with absent or low CEM-enhancement, suggesting residual-disease reduction, were most frequent in the Cryoablation-with-HT group (80%), followed by Cryoablation-only (77.8%), and HT-only (38.9%).
Fisher’s test revealed a significant difference between the Cryoablation-with-HT and the HT-only groups (p<0.0015), expressing the added value of Cryoablation.
Conclusion: Cryoablation with hormonal-therapy significantly reduces tumor size and residual disease more effectively than therapy alone, making it a promising option for patients not-eligible for surgery.
Limitations: No limitations were identified.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The study was approved by Comitato Etico Regione Toscana - Pediatrico (reference number: 165/2024).

Author Block: H. L. Couto¹, C. N. Valadares², B. F. De Paula Ricardo¹, A. N. Soares¹, P. H. Toppa¹, B. A. Coelho³, C. C. Pessoa⁴, N. Sharma⁵, E. Carvalho Pessoa⁴; ¹Belo Horizonte/BR, ²São Paulo/BR, ³Montes Claros/BR, ⁴Botucatu/BR, ⁵Leeds/UK
Purpose: Evaluate vacuum assisted biopsy (VAB) as diagnostic test of LR-DCIS in the context of real-world clinical practice.
Methods or Background: Database analysis of 116 cancers [both invasive breast cancers (IC) and ductal carcinoma in situ (DCIS)] diagnosed by VAB submitted to standard surgical treatment with complete histological data from VAB and surgery from 04/13/2017 to 11/28/2020. The VAB results were matched to the surgical pathology, considered the gold standard. The pathological diagnoses were grouped into malignancies requiring immediate surgical treatment [DCIS with high risk (HR-DCIS) of progression to IC or IC] versus those eligible to active surveillance (LR-DCIS). HR-DCIS/IC were considered positive while LR-DCIS negative results. VAB sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were obtained.
Results or Findings: Median age was 56 (20-91); final median invasive tumor size (T) of 6mm (0,8 – 25) and 8mm (2 – 65) for DCIS; 65.52% were US-guided (70/116) and 44.48% (46/116) stereotactic guided; 42.24% (49/116) were only masses, 26,72% (31/116) masses associated with calcifications and 31.03% (36/116) calcifications. Out of 116 malignancy cases diagnosed by VAB, 15 (12.9%) resulted in LR- DCIS in the biopsy, 10 (8.6%) confirmed LR-DCIS in surgery, and 5 (4.3%) were upgraded to HR-DCIS/IC in surgery. VAB showed 95.28% sensitivity and 100% specificity. The positive predictive value (PPV) was 100%, and the negative predictive value (NPV) was 66.67%. Of the 5 false negatives (FN) LR-DCIS upgraded in surgery: 3 were HR-DCIS and 2 IC (pT1a-bpN0-luminal).
Conclusion: VAB, based in conventional pathology and immunohistochemistry, had an elevated FNR LR-DCIS in real world practice and, if applied, VAB LR-DCIS upgraded cases could be treated by either hormone or radiation therapy isolated or combined counterbalanced by slight reduction of overtreatment.
Limitations: Retrospective data base
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The study was approved by the Ethics Committee of Santa Casa of Belo Horizonte under the number 25761019.8.0000.5138, and all methods were carried out in accordance with national guidelines

Author Block: Ş. Kökten, H. Kılın, N. Voyvoda; Istanbul/TR
Purpose: The touch imprint method is used during the frozen study of sentinel lymph node samples in breast cancer patients and provides a rapid response with high accuracy and ensures the correct management of patients during surgery. Similarly, imprint preparations made from core biopsies can also be helpful in reaching rapid and accurate results. The aim of this study was to determine the diagnostic value and accuracy of the imprint method.
Methods or Background: Between January 2024 and March 2024, patients who were referred to the breast imaging center of our hospital due to a mass in the breast and planned for US-guided core needle biopsy were included in the study. Touch imprint and core biopsy specimens were retrospectively evaluated at different times by the same pathologist. Pathological findings in touch imprint evaluation were classified using the guideline.
Results or Findings: 201 lesions of 178 patients with an average age of 48.05 (min: 16-max 82) were evaluated. Of the 201 lesions, 186 were breast lesions and 15 were axillary lymph nodes. Seven of 186 breast lesions were excluded from the evaluation because touch imprint was defined as insufficient. The sensitivity of touch imprint was calculated as 87.50%, specificity as 89.16%, ppv: 54.66%, npv as 97.95% and accuracy as 88.94%. If we exclude the lymphoma patient, the sensitivity of imprint for lymph node was calculated as 100%, specificity as 83.3%, ppv: 47.27%, npv as 100% and accuracy as 85.5%. When not excluded, the sensitivity of imprint cytology was 88.89%, specificity as 83.33%, ppv: 44.35%, npv as 98.05% and accuracy as 84.06%.
Conclusion: Imprint cytology prepared from core biopsies of breast lesions can provide highly accurate and rapid diagnosis. Thus, treatment can be started without delay.
Limitations: No limitations were identified.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Local ethics committee approval (decision no: 2024/010.99/3/19) was obtained before the study.

Author Block: F. Pugliese, F. Di Naro, G. Migliaro, S. E. Baldi Giorgi, T. Amadori, D. De Benedetto, C. Bellini, V. Miele, J. Nori; Florence/IT
Purpose: To assess the effectiveness of cryoablation (CR) in different subtypes of breast tumors, a cohort of 39 biopsy-proven B5 lesions underwent ultrasound-guided scar biopsy evaluation one year post-treatment.
Methods or Background: From 2022-2023, the B5 lesions comprised 35 invasive ductal carcinoma (IDC), 2 IDC-associated DCIS, and 2 invasive lobular carcinomas. All patients were deemed inoperable for advanced age and comorbidities, leading to their enrollment in an annual follow-up and ultrasound-guided scar biopsy. The study population was stratified into three subgroups: molecular subtype, dimensional cut-off, and growth index.
Results or Findings: These lesions were hormone-responsive, with 19 classified as Luminal A and 20 as Luminal B. The dimensional cutoff ranged to 2.5 cm, with ice ball dimensions tailored to encompass a one-centimeter margin around the lesions. Data analysis revealed notable differences in the efficacy of cryoablation among the various subgroups. When considering Luminal A lesions with ki67>20% the complete ablation rate was 84.2% and for Luminal B it was 90.0%. Conversely, tumors with Ki67 expression ≤20% exhibited higher complete ablation rates, with Luminal A reaching 100% and Luminal B at 84.6%. Additionally, lesions ≤10 mm in size exhibited a higher complete ablation rate of 100% compared to lesions >10 mm, which showed an 80.0% success rate. Histologically, CR was ineffective in achieving complete ablation in DCIS cases, presenting a rate of 0%, but other subtypes demonstrated a higher complete ablation rate at 91.9%. However, none of these differences were statistically significant.
Conclusion: Cryoablation emerges as a promising primary treatment option for breast cancer is a safe and effective nonsurgical alternative to breast-conserving surgery in select patients with unifocal IDC low grade, hormone receptor-positive, and ≤10 mm size
Limitations: No limitations were identified.
Funding for this study: No funding was received for this study
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: The study is retrospective