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This prospective single-center study enrolled 50 women with 51 contrast-enhanced mammography (CEM)-enhancing lesions that lacked a sonographic or mammographic correlate. Trial participants underwent CEM-guided biopsy. Biopsy was technically successful for 46 lesions and was not performed for five nonvisualized lesions (all nonmass enhancement), yielding a cancellation rate of 9.8%. Mean biopsy time was 16.6 minutes. All biopsies revealed concordant pathology (25 benign, 10 high-risk, 11 malignant). No non-visualized or benign lesion yielded malignancy at follow-up.

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INTRODUCTION: Cytomegalovirus (CMV) is a common intrauterine infection and the developing nervous system is a frequent target, suffering a range of injuries from subclinical to catastrophic. CASE PRESENTATION: A 20-week gestational age fetus was found to have a large echogenic focus in one cerebral hemisphere. Congenital CMV infection was identified by amniocentesis and maternal serology. Postmortem examination of the brain revealed massive intracerebral hemorrhage as the correlate for the sonographic finding. The microscopic examination of the brain was also striking for extensive polymicrogyria, a high burden of CMV, and abundant angiocentric CMV pathology. DISCUSSION AND CONCLUSION: Catastrophic intracerebral hemorrhage has not been previously reported in association with congenital CMV infection. The present case expands the range of potential injuries to the developing brain in congenital CMV infection and raises the possibility of a direct vascular injury.

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BACKGROUND AND PURPOSE: To quantify intra-fraction tumor motion using imageguidance and implanted fiducial markers to determine if a 5 mm planning-target-volume (PTV) margin is sufficient for early stage breast cancer patients receiving neoadjuvant stereotactic ablative radiotherapy (SABR). MATERIALS AND METHODS: A HydroMark© (Mammotome) fiducial was implanted at the time of biopsy adjacent to the tumor. Sixty-one patients with 62 tumours were treated prone using a 5 mm PTV margin. Motion was quantified using two methods (separate patient groups): 1) difference in 3D fiducial position pre- and post-treatment cone-beam CTs (CBCTs) in 18 patients receiving 21 Gy/1fraction (fx); 2) acquiring 2D triggered-kVimages to quantify 3D intra-fraction motion using a 2D-to-3D estimation method for 44 tumours receiving 21 Gy/1fx (n = 22) or 30 Gy/3fx (n = 22). For 2), motion was quantified by calculating the magnitude of intra-fraction positional deviation from the pretreatment CBCT. PTV margins were derived using van Herkian analysis. RESULTS: The average ± standard deviation magnitude of motion across patients was 1.3 ± 1.15 mm Left/Right (L/R), 1.0 ± 0.9 mm Inferiorly/Superiorly (I/S), and 1.8 ± 1.5 mm Anteriorly/Posteriorly (A/P). 85/105 (81%) treatment fractions had dominant anterior motion. 6/62patients (9.7%) had mean intra-fraction motion during any fraction > 5 mm in any direction, with 4 in the anterior direction. Estimated PTV margins for single and three-fx patients in the L/R, I/S, and A/P directions were 6.0x4.1x5.9 mm and 4.5x2.9x4.3 mm, respectively. CONCLUSION: Our results suggest that a 5 mm PTV margin is sufficient for the I/S and A/P directions if a lateral kV image is acquired immediately before treatment. For the L/R direction, either further immobilization or a larger margin is required.

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PURPOSE: To determine the effect of dose fractionation and time delay post-neoadjuvant stereotactic ablative radiotherapy (SABR) on dynamic contrast-enhanced (DCE)-MRI parameters in early stage breast cancer patients. MATERIALS AND METHODS: DCE-MRI was acquired in 17 patients pre- and post-SABR. Five patients were imaged 6-7 days post-21 Gy/1fraction (group 1), six 16-19 days post-21 Gy/1fraction (group 2), and six 16-18 days post-30 Gy/3 fractions every other day (group 3). DCE-MRI scans were performed using half the clinical dose of contrast agent. Changes in the surrounding tissue were quantified using a signal-enhancement threshold metric that characterizes changes in signal-enhancement volume (SEV). Tumour response was quantified using Ktrans and ve (Tofts model) pre- and post-SABR. Significance was assessed using a Wilcoxin signed-rank test. RESULTS: All group 1 and 4/6 group 2 patients' SEV increased post-SABR. All group 3 patients' SEV decreased. The mean Ktrans increased for group 1 by 76% (p = 0.043) while group 2 and 3 decreased 15% (p = 0.028) and 34% (p = 0.028), respectively. For ve, there was no significant change in Group 1 (p = 0.35). Groups 2 showed an increase of 24% (p = 0.043), and Group 3 trended toward an increase (23%, p = 0.08). CONCLUSION: Kinetic parameters measured 2.5 weeks post-SABR in both single fraction and three fraction groups were indicative of response but only the single fraction protocol led to enhancement in the surrounding tissue. Our results also suggest that DCE-MRI one-week post-SABR may be too early for response assessment, at least for single fraction SABR, whereas 2.5 weeks appears sufficiently long to minimize confounding acute effects.

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PURPOSE: To evaluate whether concurrent neoadjuvant radiation added to standard chemotherapy could increase the pathologic complete response (pCR) to treatment for locally advanced breast cancer (LABC). METHODS AND MATERIALS: This prospective phase 2 trial recruited 32 LABC patients from 2009 to 2011. Patients received neoadjuvant every-3-weekly 5-fluorouracil (500 mg/m2), epirubicin (100 mg/m2), and cyclophosphamide (500 mg/m2) for 3 cycles, followed by weekly docetaxel (35 mg/m2) for 9 cycles. Regional radiation (45 Gy/25 plus 5.4 Gy/5) was delivered concurrently with docetaxel, then modified radical mastectomy. Patients were matched post hoc by a blinded statistician to a concurrent cohort treated with neoadjuvant chemotherapy, modified radical mastectomy, and adjuvant regional radiation. RESULTS: Thirty of 32 patients completed treatment. Twenty-seven were successfully matched by propensity score to 81 control patients by age, stage, and molecular subtype. The concurrent chemoradiation produced a significant increase in pCR (14% vs 22%, P<.001) but no statistically significant difference in disease-free and overall survival at 3 years (respectively, 69% vs 81%, P=.186, hazard ratio 0.51; and 74% vs 89%, P=.162, hazard ratio 0.46). Toxicity included 25% of patients with grade 3 pneumonitis and 25% of patients with dermatitis, and 1 death. CONCLUSIONS: Concurrent neoadjuvant radiation added to radiosensitizing chemotherapy significantly improved pCR. A prospective randomized clinical trial is warranted to exploit the improved response seen with concurrent therapy but using another radio-sensitizing taxane, to better minimize treatment-related toxicity and determine its impact on overall survival.

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