Annette I. Joe

Does digital mammography increase detection of high-risk breast lesions presenting as calcifications?

OBJECTIVE The objective of our study was to evaluate whether the transition from film-screen mammography (FSM) to digital mammography (DM) was associated with increased detection of high-risk breast lesions. MATERIALS AND METHODS A retrospective search identified 142 cases of atypia or lobular neoplasia (LN) diagnosed in women with mammographic calcifications between January 2004 and August 2010. We excluded lesions upgraded to cancer at excisional biopsy, lesions in women with ipsilateral cancer within 2 years of mammography, and lesions that presented as a mass only. The cases included in the cohort were 82 (57.7%) cases of atypical ductal hyperplasia; 17 (12%) atypical lobular hyperplasia; 25 (17.6%) lobular carcinoma in situ (LCIS); 12 (8.5%) atypia and LCIS; and six (4.2%) other atypia. The institution transitioned from predominantly performing FSM in 2004 to performing only DM by 2010. Pathology was interpreted by breast pathologists. The annual detection rate was calculated by dividing the number of high-risk lesions by mammography volume. RESULTS Of the 142 cases of atypia or LN, 52 (36.6%) were detected using FSM and 90 (63.4%) were detected using DM. The detection rate was higher with DM (1.24/1000 mammographic studies) than FSM (0.37/1000 mammographic studies). The detection rate by year ranged between 0.21 and 0.64 per 1000 mammographic studies for FSM and between 0.32 and 1.49 per 1000 mammographic studies for DM. The median size of the calcifications was 8 mm on DM and 7 mm on FSM. The most common appearance was clustered amorphous or indistinct calcifications on both FSM and DM. CONCLUSION The transition from FSM to DM was associated with a threefold increase in the detection rate of high-risk lesions. Improved detection may allow enhanced screening, risk reduction treatment, and possibly breast cancer prevention. However, increased detection of high-risk lesions may also result in oversurveillance and treatment.

Sonographically-guided metallic marker placement at time of wire localization for intraductal or cystic lesions: a method to verify lesion retrieval.

RATIONALE AND OBJECTIVES To propose deploying a metallic marker using sonographic guidance immediately before wire localization for excisional biopsy to identify intraductal or complex cystic lesions at specimen radiography. MATERIALS AND METHODS Institutional review board approval was obtained for this study and is Health Insurance Portability and Accountability Act compliant. The clinical, radiographic, and pathologic records of 21 patients, ages 21-78 years, with 22 intraductal or complex cystic masses who underwent excisional biopsy with wire localization immediately after sonographically-guided marker placement were reviewed. The procedure mammogram, ultrasound, and specimen radiographs were reviewed and evaluated for the presence of a metallic marker, lesion, or both. Pathology of all specimens was recorded and reviewed for concordance. RESULTS Twenty-one (95%) of the markers were visualized on specimen radiographs. No lesions were apparent on specimen radiographs. Mammographic findings in 17 were negative (17/22; 77%); 3 circumscribed or partially obscured masses (3/22; 14%), 1 focal asymmetry (1/22; 5%), and 1 architectural distortion (5%) were also seen. Sonographic findings were 12 intraductal masses (12/22; 55%) and 10 complex cystic masses (10/22; 45%). Median and average size of all lesions were 9 mm (intraductal masses: median, 6 mm, mean, 7; complex cystic masses: median, 10 mm, mean, 11). All lesions were benign and all pathology was concordant with imaging findings. CONCLUSIONS Given the high rate of marker retrieval on specimen radiography and pathologic concordance, marker placement at the time of wire localization is an efficient way to confirm retrieval of intraductal or complex cystic lesions.

Costs of Achieving High Patient Compliance After Recall from Screening Mammography

OBJECTIVE The purpose of our study was to document the hidden costs in achieving high recall patient compliance from an off-site screening mammography program. MATERIALS AND METHODS This study was approved by our institutional review board. At our institution, no patient was placed in final BI-RADS assessment category 3, 4, or 5 without a diagnostic study. Each incomplete study, in addition to the formal report, was flagged on the day sheet, letters were sent to the referring physician and patient, and an incomplete computer code was added. Working from the day sheets, a clerk contacted the patient by telephone within 2 working days to schedule the diagnostic study. Diagnostic slots were purposely left open to accommodate these cases. An ongoing computer tickler file of incomplete codes provided a further check. A time study of clerical performance with recalled patients was measured prospectively for 100 consecutive cases. RESULTS For the years 2002-2004, 4,025 (13%) of 30,286 screening patients were recalled for diagnostic mammography. After an average of 2.2 telephone calls per patient, (3.64 minutes of clerical time), 3,977 of 4,005 patients returned for a diagnostic study. Forty-eight of 4,025 initially noncompliant patients received an average of six telephone calls (4.7 minutes) and a registered letter. One of the 28 initially noncompliant patients went on to biopsy that revealed a breast cancer. Patient compliance was 4,005 (99.5%) of 4,025. The additional cost for this program was

Ensuring Excision of Intraductal Lesions: Marker Placement at Time of Ductography

4,724 divided by 30,286 screening patients, or 16 cents per screening patient. CONCLUSION The radiology department assumed responsibility for contacting patients who needed recall for additional diagnostic imaging. Using strict documentation of the incomplete breast imaging evaluations, computer checks, clerical support, and prompt scheduling, we achieved 99.5% compliance. The additional cost was small, 16 cents per screening patient.

Use of Screening Mammography to Detect Occult Malignancy in Autologous Breast Reconstructions: A 15-year Experience

RATIONALE AND OBJECTIVES To propose grid coordinate marker placement for patients with suspicious ductogram findings occult on routine workup. To compare the success of marker placement and wire localization (WL) with ductogram-guided WL. MATERIALS AND METHODS A retrospective search of radiology records identified all patients referred for ductography between January 2001 and May 2008. Results for 16 patients referred for ductogram-guided WL and 5 patients with grid coordinate marker placement at the time of ductography and subsequent WL were reviewed. Surgical pathology results and clinical follow-up were reviewed for concordance. RESULTS Nine of 16 patients (56.3%) underwent successful ductogram-guided WL. Eight of nine patients had papillomas, one of which also had atypical ductal hyperplasia (ADH). One of nine patients had ectatic ducts with inspisated debris. Seven patients who failed ductogram-guided WL eventually underwent open surgical biopsy. Four of seven patients had papillomas, one of which also had lobular carcinoma in situ. Remaining patients had ADH (1/7) and fibrocystic changes with chronic inflammation (3/7). All five (100%) patients with grid coordinate marker placement underwent successful WL and marker excision. Pathology results included three papillomas, papillary intraductal hyperplasia, and fibrocystic change. CONCLUSION Grid coordinate marker placement at the time of abnormal ductogram provided an accurate method of localizing ductal abnormalities that are occult on routine workup, thus facilitating future WL. Marker placement obviated the need for repeat ductogram on the day of surgery and ensured surgical removal of the ductogram abnormality.

Availability of prior mammograms affects incomplete report rates in mobile screening mammography

Purpose To examine how often screening mammography depicts clinically occult malignancy in breast reconstruction with autologous myocutaneous flaps (AMFs). Materials and Methods Between January 1, 2000, and July 15, 2015, the authors retrospectively identified 515 women who had undergone mammography of 618 AMFs and who had at least 1 year of clinical follow-up. Of the 618 AMFs, 485 (78.5%) were performed after mastectomy for cancer and 133 (21.5%) were performed after prophylactic mastectomy. Medical records were used to determine the frequency, histopathologic characteristics, presentation, time to recurrence, and detection modality of malignancy. Cancer detection rate (CDR), sensitivity, specificity, positive predictive value, and false-positive biopsy rate were calculated. Results An average of 6.7 screening mammograms (range, 1-16) were obtained over 15.5 years. The frequency of local-regional recurrence (LRR) was 3.9% (20 of 515 women; 95% confidence interval [CI]: 2.2%, 5.6%); all LRRs were invasive, and none were detected in the breast mound after prophylactic mastectomy. Of the 20 women with LRR, 13 (65%) were screened annually before the diagnosis. Seven of those 13 women (54%) had clinically occult LRR, and mammography depicted five. Five of the six clinically evident recurrences (83%) were interval cancers. The median time between reconstruction and first recurrence was 4.4 years (range, 0.8-16.2 years). The CDR per AMF was 1.5 per 1000 screening mammograms (five of 3358; 95% CI: 0.18, 2.8) after mastectomy for cancer and 0 of 1000 examinations (0 of 805 mammograms; 95% CI: 0, 5) after prophylactic mastectomy. Sensitivity, specificity, positive predictive value, and false-positive biopsy rate were 42% (five of 12), 99.4% (4125 of 4151), 16% (five of 31), and 0.6% (26 of 4151), respectively. Conclusion The CDR of screening mammography (1.5 per 1000 screening mammograms) of the AMF after mastectomy for cancer is comparable to that for one native breast of an age-matched woman. Screening mammography adds little value after prophylactic mastectomy.

Harms of Restrictive Risk-Based Mammographic Breast Cancer Screening

PurposeMobile mammography can improve access to screening mammography in rural areas and underserved populations. We evaluated the frequency of incomplete reports in mobile mammography screening and the relationships between prior mammograms and recall rates.MethodsThe frequency of incomplete mammogram reports, the subgroups of those needing prior comparison mammograms, recalls for additional imaging, and availability of prior mammograms of a mobile screening mammography unit were compared with fixed site mammography from January 1, 2007 through December 31, 2009. All mobile unit mammograms were full field digital mammography (FFDM). Differences between rates of recall, incomplete reports, and availability of prior mammograms were calculated using the Chi-Square statistic.ResultsOf 2640 mobile mammography cases, 21.9% (578) reports were incomplete, versus 15.2% (7653) (p ≤ 0.001) of 50325 fixed site reports. Of incomplete cases, recall for additional imaging occurred among 8.3% (218) of mobile mammography reports versus 11.3% (5708) (p ≤ 0.001) of fixed site reports. Prior mammograms were needed among 13.6% (360) of mobile mammography versus 3.9% (1945) (p ≤ 0.001) of fixed site reports. Mobile mammography recall rate varied with availability of prior mammograms: 16.0% (54) when no prior mammograms, 7.6% (127) when prior mammograms were elsewhere but unavailable and 5.9% (37) when prior FFDM were immediately available (p ≤ 0.001).ConclusionsIncomplete reports were more frequent in mobile mammography than the fixed site. The availability of prior comparison mammograms at time of interpretation decreased the rate of incomplete mammogram reports. Recall rates were higher without prior comparison mammograms and lowest when comparison FFDM mammograms were available.

Imaging DCIS: Digital/Film-Screening Mammography, Tomosynthesis, MRI, Ultrasonography

OBJECTIVE The objective of this study was to determine if restrictive risk-based mammographic screening could miss breast cancers that population-based screening could detect. MATERIALS AND METHODS Through a retrospective search of records at a single institution, we identified 552 screen-detected breast cancers in 533 patients. All in situ and invasive breast cancers detected at screening between January 1, 2011, and December 31, 2014, were included. Medical records were reviewed for history, pathology, cancer size, nodal status, breast density, and mammographic findings. Mammograms were interpreted by one of 14 breast imaging radiologists with 3-30 years of experience, all of whom were certified according to the Mammography Quality Standards Act. Patient ages ranged from 36 to 88 years (mean, 61 years). The breast cancer risks evaluated were family history of breast cancer and dense breast tissue. Positive family history was defined as a first-degree relative with breast cancer. Dense breast parenchyma was either heterogeneously or extremely dense. RESULTS Group 1 consisted of the 76.7% (409/533) of patients who had no personal history of breast cancer. Of these patients, 75.6% (309/409) had no family history of breast cancer, and 56% (229/409) had nondense breasts. Group 2 consisted of the 16.7% (89/533) of patients who were 40-49 years old. Of these patients, 79.8% (71/89) had no family history of breast cancer, and 30.3% (27/89) had nondense breasts. Ductal carcinoma in situ made up 34.6% (191/552) of the cancers; 65.4% (361/552) were invasive. The median size of the invasive cancers was 11 mm. Of the screen-detected breast cancers, 63.8% (352/552) were minimal cancers. CONCLUSION Many screen-detected breast cancers occurred in women without dense tissue or a family history of breast cancer. Exclusive use of restrictive risk-based screening could result in delayed cancer detection for many women.

Breast fibroadenomas in the pediatric population: common and uncommon sonographic findings

Ductal carcinoma in situ (DCIS) can be visualized by multiple imaging modalities including mammography, digital breast tomosynthesis (DBT), ultrasound, and breast magnetic resonance imaging (MRI). It can manifest as a mass or architectural distortion; however, it most commonly presents as suspicious calcifications. Fine linear or fine linear branching calcifications in a segmental distribution have the highest risk of malignancy. Most mammographic calcifications are benign; however, those which are malignant are usually associated with DCIS. The transition from film screen to digital mammography has resulted in an increase in the diagnosis of DCIS because of digital mammography’s higher detection rate for calcifications.