Dianne Georgian-Smith

ULTRASOUND AS A COMPLEMENT TO MAMMOGRAPHY AND BREAST EXAMINATION TO CHARACTERIZE BREAST MASSES

This study was designed to determine if complementary ultrasound (US) imaging and Doppler could decrease the number of biopsies for benign masses. A total of 761 breast masses were sequentially scored on a level of suspicion (LOS) of 1-5, where 1 represented low, and 5 was a high suspicion of malignancy, for mammography, US, and color flow with pulse Doppler (DUS). After biopsy, the results were analyzed using 2 x 2 contingency tables and ROC analysis, for mammography alone and in combination with US and DUS. The addition of US increased the specificity from 51.4% to 66.4% at a prevalence of 31.3% malignancy. ROC analysis showed that the addition of US significantly improved the performance over mammography alone in women < 55 years old (p = 0.049); > 55 years old (p = 0.029); masses < 1 cm (p = 0.016) and masses > 1 cm (p = 0.016). These results show that the addition of US to mammography alone could substantially reduce the number of breast biopsies for benign disease.

Basal Subtype of Invasive Breast Cancer is Associated with a Higher Risk of True Recurrence after Conventional Breast-Conserving Therapy

PURPOSE To determine whether breast cancer subtype is associated with patterns of ipsilateral breast tumor recurrence (IBTR), either true recurrence (TR) or elsewhere local recurrence (ELR), among women with pT1-T2 invasive breast cancer (IBC) who receive breast-conserving therapy (BCT). METHODS AND MATERIALS From Jan 1998 to Dec 2003, 1,223 women with pT1-T2N0-3 IBC were treated with BCT (lumpectomy plus whole-breast radiation). Ninety percent of patients received adjuvant systemic therapy, but none received trastuzumab. Biologic cancer subtypes were approximated by determining estrogen receptor-positive (ER+), progesterone receptor-positive (PR+), and human epidermal growth factor receptor-2-positive (HER-2+) expression, classified as luminal A (ER+ or PR+ and HER-2 negative [HER-2-]), luminal B (ER+ or PR+ and HER-2+), HER-2 (ER- and PR- and HER-2+), and basal (ER- and PR- and HER-2- ) subtypes. Imaging, pathology, and operative reports were reviewed by two physicians independently, including an attending breast radiologist. Readers were blinded to subtype and outcome. TR was defined as IBTR within the same quadrant and within 3 cm of the primary tumor. All others were defined as ELR. RESULTS At a median follow-up of 70 months, 24 patients developed IBTR (5-year cumulative incidence of 1.6%), including 15 TR and 9 ELR patients. At 5 years, basal (4.4%) and HER-2 (9%) subtypes had a significantly higher incidence of TR than luminal B (1.2%) and luminal A (0.2%) subtypes (p < 0.0001). On multivariate analysis, basal subtype (hazard ratio [HR], 4.8, p = 0.01), younger age at diagnosis (HR, 0.97; p = 0.05), and increasing tumor size (HR, 2.1; p = 0.04) were independent predictors of TR. Only younger age (HR, 0.95; p = 0.01) significantly predicted for ELR. CONCLUSIONS Basal and HER-2 subtypes are significantly associated with higher rates of TR among women with pT1-T2 IBC after BCT. Younger age predicts for both TR and ELR. Strategies to reduce TR in basal breast cancers, such as increased boost doses, concomitant radiation and chemotherapy, or targeted therapy agents, should be explored.

Sonography of palpable breast cancer

Because of the increasing use of sonography to rule out cancer in women with palpable breast abnormalities, this study was performed to determine the rate of sonographically occult malignancy in this clinical setting.

Analysis of the Mammographic and Sonographic Features of Pseudoangiomatous Stromal Hyperplasia

OBJECTIVE The purpose of this study was to describe the imaging findings in 149 patients with pseudoangiomatous stromal hyperplasia (PASH) who had undergone at least 4 years of clinical follow-up for detection of subsequent malignancy. CONCLUSION PASH is a common entity that presents with benign imaging features without evidence of subsequent malignant potential. At our institution, in the absence of suspicious features a diagnosis of PASH at core biopsy is considered sufficient, and surgical excision has been obviated.

Controversies on the Management of High-Risk Lesions at Core Biopsy from a Radiology/Pathology Perspective

Readers may feel less than satisfied when they discover that there is no consensus on the appropriate recommendations for follow-up of risk lesions following percutaneous core biopsy. The significance of this article is in the details of the methodologies and results, and much less in the numbers. The overall goal is to emphasize the flaws in current studies.

Factors That Impact the Duration of MRI-Guided Core Needle Biopsy

OBJECTIVE The purpose of our study was to determine which patient-related, target lesion-related, or procedure-related variables impact the duration of MRI-guided core needle breast biopsy. MATERIALS AND METHODS Between July 11, 2006, and September 26, 2007, data were collected for 75 single-target MRI-guided 9-gauge vacuum-assisted core needle biopsy procedures using a grid-guidance technique and performed at a single institution. The following variables were studied: MRI suite occupation time, number of operators, patient age and breast size, target morphology and location, approach to target, equipment used, number of image acquisitions and times the patient was moved in and out of the closed magnet, and occurrence of complications. Statistical analysis was performed using the Students t test, analysis of variance, and Pearsons correlation, with p values < 0.05 considered significant. RESULTS The mean duration was 57.9 minutes (SD, 17.2 minutes; range, 30-109 minutes). None of the patient- or target-related variables significantly impacted the duration, although lesions located in the anterior third of the breast showed a trend to prolong the procedure (p = 0.059). The time to complete a procedure was reduced when the operating radiologist was assisted by a breast imaging fellow-in-training (p = 0.01). Increasing numbers of image acquisitions and times the patient was moved in and out of the magnet significantly lengthened the procedure duration (p = 0.0001 for both). No major complications occurred. Biopsies yielded 16% (12/75) malignant and 84% (63/75) benign diagnoses. CONCLUSION Variables that minimized procedure duration were number of image acquisitions, number of patient insertions or removals from the magnet, and assistance of a breast imaging fellow-in-training. No patient-related or target-related variables impacted procedure time.

The Mammary Hamartoma Appreciation of Additional Imaging Characteristics

Objective. To determine the mammographic and sonographic findings of hamartomas that were not classic on imaging, how pathologists distinguish the hamartoma from benign breast tissue on core samples, and reasons for discrepancies between core and surgical biopsy. Methods. A retrospective review of all image‐recommended core biopsies between 1993 and 2001 was performed. There were 41 cases of hamartomas found on either core or surgical biopsy. The mammographic, sonographic, and pathologic findings were reviewed. Results. Of 41 hamartomas in 38 patients, 18 went on to surgical biopsy. Of these 18 cases, 4 cases of hamartoma on core biopsy were fibroadenoma after excision; 2 cases of hamartoma on core biopsy were confirmed by surgery; and 12 cases of fibrocystic change after core biopsy were hamartoma after surgical biopsy. The 4 cases of fibroadenoma shown at final pathologic examination were excluded from imaging review, leaving 37 cases. In the 20 patients who underwent only core sampling, 23 hamartomas were diagnosed. Seventeen masses were visible on mammography, and 82% were homogeneously dense. Of 36 masses shown on sonography, 86% were uniformly hypoechoic. At histologic examination, only 16% contained fat within the mass. Conclusions. Hamartomas may appear as homogeneously dense, well‐circumscribed masses, varying in appearance from the classically described encapsulated mixed fatty‐fibroglandular mass. Pathologists can make the diagnosis of hamartoma without the presence of adipose tissue but may have difficulty in distinguishing the hamartoma from fibrocystic change. However, if there is radiologic‐pathologic concordance, further surgical excision is not warranted.

Detecting Nonpalpable Recurrent Breast Cancer: The Role of Routine Mammographic Screening of Transverse Rectus Abdominis Myocutaneous Flap Reconstructions

PURPOSE To perform a retrospective cohort study to determine the rates of recall and cancer detection and then to develop a decision analytic model to evaluate the effectiveness of routine screening of transverse rectus abdominis myocutaneous (TRAM) flap reconstructions. MATERIALS AND METHODS This study was approved by the institutional review board, and the methods comply with HIPAA regulations. A retrospective search of the institutional mammographic results database was done to identify bilateral screening mammographic examinations obtained from January 1, 1999, through July 15, 2005. The search included the term TRAM; the recall and cancer detetion rates were then detected. Subsequently, a decision analytic model was constructed to evaluate a hypothetical cohort of women with TRAM flap reconstructions. RESULTS Of 554 mammograms (265 TRAM flap reconstructions), 546 (98.6%) had negative results (Breast Imaging Reporting and Data System category 1 or 2). Eight (1.4%) had positive test results (Breast Imaging Reporting and Data System category 0, 3, 4, or 5). All suspicious lesions underwent biopsy and had benign pathologic results. No interval breast cancers were identified. The detection rate for nonpalpable recurrent breast cancer was 0% (exact 95% confidence interval: 0.0%, 1.4%). According to decision analysis, screening would help detect an estimated 12 additional recurrent cancers per 1000 women screened, providing an additional 1.6 days of life expectancy for the screened cohort. Under base-case conditions, screening of TRAM flap reconstructions is less effective than screening asymptomatic women in their 40s. Sensitivity analysis revealed that a benefit equivalent to that of screening asymptomatic women in their 40s was achievable under conditions related to estimates of screening effectiveness and cancer detection rate. CONCLUSION Routine screening mammography of TRAM flap reconstructions has a very low detection rate for nonpalpable recurrent breast cancer. Decision analysis indicates that screening such women is less effective than screening asymptomatic women in their 40s for primary breast cancer.

Variations in Physician Recommendations for Surgery After Diagnosis of a High-Risk Lesion on Breast Core Needle Biopsy

OBJECTIVE This article focuses on four high-risk lesions: lobular neoplasia, benign papilloma, radial scar, and flat epithelial atypia. Controversies exist in the management after core biopsy of each of these lesions--whether to perform immediate surgical excision so as not to miss an associated malignancy or imaging follow-up because concomitant malignancy is low. This review is staged in two parts per lesion. The first is from data gathered during the last two American Roentgen Ray Society annual meetings from the audience response system querying practice management styles per diagnostic lesion. The second part is a brief review of selected articles recommending either follow-up or surgery. The strengths and weaknesses of each article are discussed. CONCLUSION Our opinion is that neither recommendation, surgical excision or follow-up, is well substantiated in the literature and that our ignorance is not serving the needs of women worldwide. The time is now for a prospective trial.

Radiological reasoning: male breast mass with calcifications.

OBJECTIVE We encountered a mammographically calcified breast mass in a 30-year-old man. It was initially thought to be comedo-type ductal carcinoma in situ because of the dense calcifications, but sonography and MRI suggested a highly vascular lesion. The final pathologic diagnosis was hemangioma. CONCLUSION Vascular tumors of the breast occur infrequently and are even more rare in males. The clinical and radiologic diagnosis of breast hemangioma is often difficult, but different imaging techniques, when used together, can provide important information for differential diagnosis and management. A biopsy is required.