Dimitra Koulocheri

The current status of positron emission mammography in breast cancer diagnosis

Mammography is currently the standard breast cancer screening procedure, even though it is constrained by low specificity in the detection of malignancy and low sensitivity in women with dense breast tissue. Modern imaging modalities, such as magnetic resonance imaging (MRI), have been developed in an effort to replace or complement mammography, because the early detection of breast cancer is critical for efficient treatment and long-term survival of patients. Nuclear medicine imaging technology has been introduced in the field of oncology with the development of positron emission tomography (PET), positron emission tomography/computed tomography (PET/CT) and, ultimately, positron emission mammography (PEM). PET offers the advantage of precise diagnosis, by measuring metabolism with the use of a radiotracer and identifying changes at the cellular level. PET/CT imaging allows for a more accurate assessment by merging the anatomic localization to the functional image. However, both techniques have not yet been established as diagnostic tools in early breast cancer detection, primarily because of low sensitivity, especially for sub-centimeter and low-grade tumors. PEM, a breast-specific device with increased spatial resolution, has been developed in order to overcome these limitations. It has demonstrated higher detectability than PET/CT and comparable or better sensitivity than MRI. The ability to target the lesions visible in PEM with PEM-guided breast biopsy systems adds to its usability in the early diagnosis of breast cancer. The results from recent studies summarized in this review indicate that PEM may prove to be a useful first-line diagnostic tool, although further evaluation and improvement are required.

Diagnosing papillary lesions using vacuum-assisted breast biopsy: should conservative or surgical management follow?

Background: This study evaluates the underestimation rate of papilloma lesions diagnosed with vacuum-assisted breast biopsy (VABB), taking into consideration the greater volume excised. Patients and Methods: 56 women with a diagnosis of a papilloma lesion after VABB (Mammotest; Fischer Imaging, Denver, CO, USA) were evaluated. At least 24 cores were excised in all cases (mean 74, range 24–96 cores) and a preoperative diagnosis was established. Subsequently, open surgery using hook-wire localization followed. A second, postoperative diagnosis was independently and blindly made. The association between the pathological types and Breast Imaging Report and Data System (BI-RADS) classification, as well as the discrepancy between preoperative and postoperative diagnoses, was evaluated. Results: The underestimation rate of papillary lesions was 3.6%. When the papillary lesions did not coexist preoperatively with any other precursor breast lesions, the underestimation rate was 0%. The underestimation rate did not differ with age, BI-RADS category or type of lesion. Conclusion: Conservative management of patients with a papillary lesion diagnosis may follow when the extended VABB protocol is adopted and a great tissue volume is excised. However, when diagnosing a coexisting papillary lesion with a precursor breast lesion, open surgery should follow, given the high probability of a postoperative cancer diagnosis.

Bilateral synchronous breast carcinomas followed by a metastasis to the gallbladder: a case report.

BackgroundBreast cancer is usually associated with metastases to lungs, bones and liver. Breast carcinoma metastasizing to the gallbladder is very rare.Case presentationA 59-year-old woman presented with bilateral synchronous breast lesions. A palpable, retroareolar solid lesion of diameter equal to 5 cm was present in the right breast, and a newly developed, non-palpable lesion with microcalcifications (diameter equal to 0.7 cm) was present in the upper outer quadrant of the left breast. Modified radical mastectomy was performed on the right breast and lumpectomy after hook-wire localization was performed on the left breast, combined with lymph node dissection in both sides. The pathological examination revealed invasive lobular carcinoma grade II in the right breast and invasive ductal carcinoma grade I in the left breast. Chemotherapy, radiation therapy, trastuzumab and letrozole were appropriately administered. At her 18-month follow-up, the patient was free of symptoms; the imaging tests (chest CT, abdominal U/S, bone scan), biochemical tests, blood cell count and tumor markers were also normal. At the 20th month after surgery however, the patient developed symptoms of cholecystitis and underwent cholecystectomy. The histopathological examination revealed metastasis of the lobular carcinoma to the gallbladder.ConclusionThis extremely rare case confirms on a single patient the results of large series having demonstrated the preferential metastasis of lobular breast cancer to the gallbladder. Symptoms of cholecystitis should not be neglected in such patients, as they might indicate metastasis to the gallbladder.

Complications of percutaneous stereotactic vacuum assisted breast biopsy system utilizing radio frequency

OBJECTIVE The Breast Lesion Excision System (BLES) is a novel, automatic breast biopsy device that utilizes radiofrequency to excise suspicious non-palpable mammographic lesions. The purpose of the present prospective study is to report and evaluate the complications of this new technique. MATERIALS AND METHODS In a two year period, we used the BLES device in 132 consecutive patients (134 procedures) with non-palpable mammographic lesions. The inclusion criteria consisted of suspicious microcalcifications, solid lesions and asymmetric density. In order to retrieve an intact biopsy specimen, we used the 12mm, 15mm or 20mm tissue basket under local anesthesia, depending on the size of the lesion. Complications were recorded and classified as immediate if occurring during or shortly after the procedure, or late, if occurring in the post-procedure days. RESULTS The procedure was considered successful in all cases, with mammographic confirmation of appropriate excision of the targeted lesion. Although, in a single case the basket initially failed to deploy. Immediate complications were encountered in 11 patients, with minor hemorrhage being the most common (n=6). 17 patients suffered late complications, in seven of whom delayed wound healing was observed. Overall, 27 patients suffered Grade 1 complications (20.14%), one patient experienced a Grade 2 complication while no patients encountered Grade 3-5 complications. CONCLUSIONS According to our experience, the BLES device is an efficient and safe breast biopsy method, with low complication rates, which are minor in their majority. It appears to be a very promising alternative to other, minimally invasive, breast biopsy techniques.

Downgrading BIRADS 3 to BIRADS 2 category using a computer-aided microcalcification analysis and risk assessment system for early breast cancer

This paper explores the potential of a computer-aided diagnosis system to discriminate the real benign microcalcifications among a specific subset of 109 patients with BIRADS 3 mammograms who had undergone biopsy, thus making it possible to downgrade them to BIRADS 2 category. The system detected and quantified critical features of microcalcifications and classified them on a risk percentage scale for malignancy. The system successfully detected all cancers. Nevertheless, it suggested biopsy for 11/15 atypical lesions. Finally, the system characterized as definitely benign (BIRADS 2) 29/88 benign lesions, previously assigned to BIRADS 3, and thus achieved a reduction of 33% in unnecessary biopsies.

Hematoma after Vacuum-Assisted Breast Biopsy: Are Interleukins Predictors?

Background: Hematoma is the main complication of vacuum-assisted breast biopsy (VABB). This study aims to evaluate the associations between interleukin (IL)-1α, IL-1β and IL-6 and hematoma progression. Methods: This study included 36 women who underwent VABB (11G). After VABB, mammograms were obtained from these patients and the maximum diameter of the hematomas was measured. The hematoma progression / occurrence of organized hematomas was followed up for the subsequent 30 days. Venous samples were collected peripherally at 3 time points: prior, at the end, and 1 h after the end of the VABB procedure. Enzyme-linked immunosorbent assays were used for the determination of serum IL-1α, IL-1β and IL-6 levels. Results: 2/36 hematomas were eventually organized within the follow-up period. In these cases, IL-6 had been significantly higher 1 h after the end of VABB (5.70 ± 0.18 vs. 1.73 ± 1.01 pg/ml; p = 0.019, Mann-Whitney-Wilcoxon test for independent samples). No statistically significant associations existed concerning IL-1α and IL-1β. The association between the size of a hematoma on the mammogram and the subsequent organization did not reach statistical significance. Conclusions: Elevated IL-6 at 1 h after the end of VABB might point to subsequent organization of the hematoma and the need for appropriate action.

Secondary breast lymphoma diagnosed by vacuum-assisted breast biopsy: a case report

IntroductionBreast lymphoma, either as a manifestation of primary extranodal disease or as secondary involvement, is a rare malignancy, and its diagnosis, prognosis, and treatment have not been clearly defined. On the other hand, Vacuum-assisted breast biopsy (VABB) is a minimally invasive technique with ever-growing use for the diagnosis of mammographically detected, non-palpable breast lesions.Case presentationA symptom-free, 56-year-old woman presented with a non-palpable BI-RADS 4B lesion without microcalcifications. She had a positive family history for breast cancer and a history of atypical ductal hyperplasia in the ipsilateral breast four years ago. She reported having been treated for non-Hodgkin lymphoma 12 years ago. With the suspicion of breast cancer, mammographically guided VABB with 11-gauge probe (on the stereotactic Fishers table) was performed. VABB made the diagnosis of a non-Hodgkin, grade II, B-cell germinal-center lymphoma. VABB yielded enough tissue for immunohistochemistry/WHO classification.ConclusionThis is the first case in the literature demonstrating the successful diagnosis of breast lymphoma by VABB, irrespectively of the level of clinical suspicion. It should be stressed that VABB was able to yield enough tissue for WHO classification. In general, lymphoma should never be omitted in the differential diagnosis, since no pathognomonic radiologic findings exist for its diagnosis.

Beta-thalassemia major: does it confer particularities to the breast?

To the Editor: Beta-thalassemia, an autosomal recessive disorder, was first described by Cooley and Lee (1) and characterized by reduced synthesis of beta-globin chain. In the past, children with beta -thalassemia rarely survived beyond adolescence (2). The improved expectancy and quality of life in bthalassemic patients due to introduction in the late 1970s of regular optimum red blood cell transfusions and almost daily subcutaneous iron chelation therapy gave on the surface health problems in this population that is breast cancer/breast-related issues that were not present on the past. The aim of the present study was to evaluate whether or not beta-thalassemia major confers particularities to the breast taking into consideration clinical and laboratory parameters. The population of this study consisted of women with confirmed diagnosis of beta-thalassemia major (2). All women presented to our breast unit for their first screening mammogram. The findings of the mammogram (breast density according to ACR and BIRADS category) were independently classified by two specialist radiologists (3). The BI-RADS category 0 was referred to as “uninformative” throughout the manuscript (4), so as to ensure direct interpretability of the findings in the clinical practice. Women not using hormone replacement therapy (HRT) were excluded from this study. As a result, 66 women were eligible for inclusion in this study. For all patients the following data were retrieved from patient’s chart review: age, age at first transfusion, age at first chelation, history of breast cancer in a first degree relative, age at menarche, pharmaceutical induction of menarche, intense exercise (5). All patients were routinely evaluated by a diabetologist, who established the diagnosis of diabetes mellitus (6). At the time of mammogram Body mass index (kg/m) was calculated. Descriptive statistics were calculated for all collected parameters. Concerning categorization of variables, it is worth mentioning that BI-RADS status was treated as a binary variable (0: uninformative, 1: informative i.e., BIRADS 1, 2, 3 in our sample). American College of Radiology breast density category was set as the main factor of the analysis. At the univariate analysis, nonparametric tests (Mann–Whitney –Wilcoxon test for independent samples or Spearman’s rank correlation coefficient) were implemented. At the multivariate analysis, ordinal logistic regression was performed due to the nature of the dependent variable (ACR is an ordinal variable). In the final model, only the statistically significant variables were retained. The satisfaction of the proportionality-of-odds assumption was evaluated with the appropriate likelihood ratio test. Statistical analysis was performed with STATA 11.1 statistical software (Stata Corporation, College Station, TX). The features of the study sample are presented in detail in Table 1. At the univariate analysis ACR was significantly associated with uninformative BI-RADS (ACR mean SD, 3.5 0.6 for uninformative BIRADS versus 2.2 0.6 for informative BI-RADS, p < 0.0001, MWW). ACR was inversely associated with the presence of diabetes mellitus (2.2 0.4 for women with diabetes versus 2.9 0.9 for women without diabetes, p = 0.002, MWW) and serum ferritin levels (Spearman’s rho = 0.320, p = 0.009). On the other hand, no association was detected between ACR and age (Spearman’s rho = 0.087, p = 0.489), age at first transfusion (Spearman’s rho = 0.146, p = 0.243), age at first chelation (Spearman’s rho = 0.137, p = 0.274), age at menarche (Spearman’s rho = 0.013, p = 0.915), pharmaceutical induction of menarche (2.3 0.7 for women with pharmaceutical induction versus 2.7 0.8 for women without pharmaceutical induction, p = 0.184, MWW), intense exercise every week (2.7 0.9 for women exercising intensely versus 2.6 0.8 for women not exercising intensely, p = 0.739, MWW). Worthy of note, the Address correspondence and reprint requests to: George C. Zografos, Department of Surgery, University of Athens, 101, Vas Sofias Ave, Ampelokipi, Athens 11521, Greece, or e-mail: gzografo@med.uoa.gr.

Vacuum-assisted breast biopsy in close proximity to the skin: a case report

IntroductionVacuum-assisted breast biopsy is a minimally invasive technique used increasingly for the assessment of mammographically detected, non-palpable breast lesions. The effectiveness of vacuum-assisted breast biopsy has been demonstrated on lesions both with and without microcalcifications. Given that the position of the lesion represents a major factor in stereotactic vacuum-assisted breast biopsy, targeting lesions in close proximity to the skin (superficial lesions) has been described as a problematic issue.Case presentationA 53-year-old woman presented with a newly developed, non-palpable lesion in her left breast. The lesion consisted of widely spread microcalcifications located approximately 5 mm from the skin. The lesion was isoechoic on ultrasound examination. Vacuum-assisted breast biopsy was scheduled (on the Fischers table, using 11-gauge probes, under local anaesthesia). The vacuum-assisted breast biopsy probe was inserted antidiametrically into the breast, the probe reached the lesion and effort was made to excise the microcalcifications. As only a small proportion of the microcalcifications were excised an accurate diagnosis could not be expected. However, with the probe having entered the breast antidiametrically, the probe tip underlying the skin could be palpated. Following the palpation of the tip, the exact point was marked by a pen, the probe was removed and the patient was transferred to the surgery room to have the remaining lesion removed by a spindle-form excision under local anaesthesia. The mammogram of the removed specimen confirmed the total excision of the suspicious microcalcifications.ConclusionIsoechoic superficial lesions can be localized with a hook-wire and open breast biopsy under general or local anaesthesia can be performed. However, vacuum-assisted breast biopsy might offer an alternative solution and serve as an alternative approach to localize the lesion. The clinical significance of the present exploratory effort remains to be assessed in the future.

Cores with microcalcifications in DCIS diagnosis: how many cores make the difference?

Dear Editor, In a recently published issue of Eur Radiol, Poellinger et al. presented interesting data with respect to the specimens containing microcalcifications in patients with DCIS [1]. Their conclusion underlining the importance of cores with microcalcifications in DCIS diagnosis is in line with our previously published results [2]. However, we believe that certain, additional limitations of the study by Poellinger et al. are worth addressing and discussing. In the population of Poellinger et al. the underestimation rate was equal to 8/35 (22.9%); indeed, this may be relevant to the number of cores excised. The authors have excised 12 cores per lesion. However, in our setting, as described in a double blind study, the excision of more cores (extended protocol, up to 96 cores) results in a reduced underestimation rate of DCIS [3]. Interestingly enough, according to our newest results, the underestimation rate following the implementation of the extended protocol is equal to 2/37 (5.4%), i.e., significantly lower than that reported by Poellinger et al. [2/37 vs. 8/35, Pearson’s chi-square (1) = 4.58, p=0.032]. In light of the above, the graphic representations might be worth extending above 12 cores. The plateau presented might be misleading as the probability of diagnosing DCIS [p(DCIS)] equal to 1 does not represent optimal diagnosis; instead, the plateau described corresponds rather to the 27/35 probability (not underestimated cases), leaving further perspectives open for discussion. Additionally, an interesting phenomenon that is also worth mentioning is the role of cores without microcalcifications in the diagnosing evaluation of DCIS. Cox et al. have reported the existence of higher grade DCIS in such cores [4], whereas our setting has permitted the demonstration of an invasive component in the latter. In conclusion, the study by Poellinger et al. provides valuable insight into the role of specimens containing microcalcifications in the histological examination of DCIS; however, further studies adopting comparative design with the inclusion of extended protocols seem desirable.