Ellen Kao

Breast imaging reporting and data system lexicon for US: interobserver agreement for assessment of breast masses.

PURPOSE To retrospectively evaluate the interobserver agreement of radiologists who used the Breast Imaging Reporting and Data System (BI-RADS) lexicon to characterize and categorize ultrasonographic (US) features of breast masses. MATERIALS AND METHODS No institutional review board approval or patient consent was required. Five breast radiologists retrospectively independently evaluated 267 breast masses (113 benign and 154 malignant masses in 267 patients) by using the BI-RADS US lexicon. Reviewers were blinded to mammographic images, medical history, and pathologic findings. Interobserver agreement was assessed with the Aickin revised kappa statistic. RESULTS Interobserver agreement varied from fair for evaluation of mass margins (kappa = 0.36) to moderate for evaluation of lesion boundary (kappa = 0.48), echo pattern (kappa = 0.58), and posterior acoustic features (kappa = 0.47) to substantial for evaluation of mass orientation (kappa = 0.70) and shape (kappa = 0.64). For small (< or =0.7 cm; n = 49) or malignant (n = 154) masses, low concordance was noted for margin descriptors (kappa = 0.30 and 0.28, respectively) and BI-RADS category (kappa = 0.21 and 0.26, respectively). Overall, only fair agreement was obtained for BI-RADS category (kappa = 0.30). Agreement for subdivisions 4a, 4b, and 4c of BI-RADS category 4 was fair (kappa = 0.33), fair (kappa = 0.32), and poor (kappa = 0.17), respectively. CONCLUSION Reproducibility of US BI-RADS terminology is good except for margin evaluation. A trend toward lower concordance was noted for the evaluation of small masses and malignant lesions. Classification into subdivisions 4a, 4b, and 4c was poorly reproducible.

Sonographic and Mammographic Appearances of Breast Hemangioma

OBJECTIVE The purpose of our study was to retrospectively evaluate the clinical, imaging, and pathologic findings of breast hemangiomas in 16 patients. CONCLUSION A mass displaying an oval or lobular shape with well-circumscribed or microlobulated margins on mammography and sonography, and in a superficial location, should alert the radiologist to the possible diagnosis of hemangioma. Imaging-guided biopsy appears sufficiently reliable to rule out any malignant or premalignant component and to avoid a surgical excision if doing so is clinically appropriate.

Tissue Harmonic Imaging, Frequency Compound Imaging, and Conventional Imaging Use and Benefit in Breast Sonography

The purpose of this study was to evaluate different sonographic settings (tissue harmonic, frequency compounding, and conventional imaging) and to determine which setting optimizes breast lesion detection and lesion characterization.

Flat Epithelial Atypia of the Breast: Pathological-Radiological Correlation

OBJECTIVE This study was undertaken to determine the prevalence of flat epithelial atypia at ultrasound-guided and stereotactically guided needle biopsies, to describe the mammographic and sonographic features of flat epithelial atypia, and to determine the significance of lesions diagnosed as flat epithelial atypia at imaging-guided needle biopsies. MATERIALS AND METHODS Retrospective review of a database of 1369 consecutive sonographically and stereotactically guided needle biopsies performed during a 12-month period yielded 33 lesions with flat epithelial atypia as the most severe pathologic entity (32 patients). Two radiologists retrospectively reviewed the imaging presentation, by combined consensus, according to the BI-RADS lexicon. RESULTS Twenty-two of 33 flat epithelial atypia diagnoses (67%) were obtained under stereotactic guidance, and 11 (33%) were obtained under sonographic guidance. Six patients had synchronous breast cancer. Flat epithelial atypia lesions presented mammographically most often as microcalcifications (20/33 [61%]) distributed in a cluster (14/20 [70%]) with amorphous morphology (13/20 [65%]). Sonographically, flat epithelial atypia lesions appeared most often as masses (9/11 [82%]), with an irregular shape (6/9 [67%]), microlobulated margins (5/9 [56%]), and hypoechoic or complex echotexture (7/9 [78%]). Twenty-eight of 33 lesions (85%) were surgically excised, confirming the flat epithelial atypia diagnosis in 11 of the 28 lesions (39%), yielding carcinoma in four (14%) and atypical ductal hyperplasia in six (21%). Columnar cell changes without atypia were diagnosed in four lesions (14%), and lobular carcinoma in situ was diagnosed in three lesions (11%). CONCLUSION Mammographic and sonographic presentation of flat epithelial atypia is not specific (clustered amorphous microcalcifications and irregular, hypoechoic or complex masses). Given the underestimation rate of malignancy, surgical excision should be considered when imaging-guided biopsy yields flat epithelial atypia.

Contribution of Tissue Harmonic Imaging and Frequency Compound Imaging in Interventional Breast Sonography

Objective. The purpose of this study was to retrospectively compare conventional imaging, frequency compound imaging (CI), and tissue harmonic imaging (THI) in interventional breast sonography. Methods. Institutional Review Board approval and patient informed consent were not required. The authors reviewed 104 sonographically guided breast procedures in 83 patients. For each biopsy, 4 images obtained with conventional imaging, frequency CI at 10 and 14 MHz (CI10 and CI14), and THI were graded independently by 2 radiologists for lesion conspicuity, needle conspicuity, lesion and needle conspicuity, and overall image quality. Frequency CI at 10 MHz, CI14, and THI were compared with conventional imaging. Different clinical scenarios (fatty versus glandular background, fine needle versus core needle, and oblique versus horizontal needle direction) were evaluated. Results. Statistical analysis showed that for overall image quality, CI10 was the best setting (odds ratios [OR], 3.67 and 7.48). For lesion conspicuity, CI14 (OR, 3.55) and THI (OR, 1.77) improved lesion visibility in a fatty background, whereas THI (OR, 0.26) was very limited in a glandular background. For needle conspicuity, no setting was better than conventional, whereas THI was the least valuable setting (OR, 0.011 and 0.049). For lesion and needle conspicuity, CI10 showed significantly better results than conventional for a dense background (P = .0268 and .4028; OR, 2.435 and 1.383) with 1 reviewer, whereas THI was the least valuable setting (OR, 0.014 and 0.042). Conclusions. Conventional imaging provided the best assessment of lesion and needle conspicuity. Frequency compounding is a useful setting for dense breast and for fine‐needle aspiration. Tissue harmonic imaging has a role in the visualization of a lesion against a fatty background but is of limited value in needle visualization.

Spontaneous Thrombosis of Pseudoaneurysm of the Breast Related to Core Biopsy

WEB This is a Web exclusive article. ore needle biopsy is being used increasingly for the diagnosis of breast masses. It is considered an alternative to surgical biopsy, and the rate of complications is relatively low. The most frequently encountered complication is hematoma [1]. Iatrogenic pseudoaneurysm is a rare complication. We report a case of pseudoaneurysm occurring after 14-gauge core needle biopsy. Spontaneous thrombosis of the pseudoaneurysm occurred over a period of 3 weeks after the biopsy.

Sonography of Postexcision Specimens of Nonpalpable Breast Lesions: Value, Limitations, and Description of a Method

OBJECTIVE The objective of our study was to retrospectively review our experience regarding the value of sonography in identifying a nonpalpable mass within a surgically excised specimen and in assessing the surgical margins in cases of malignancy. MATERIALS AND METHODS One hundred four lumpectomies were performed in 99 consecutive patients with 131 nonpalpable breast lesions after sonographically guided needle localization. All 104 surgical specimens were scanned on sonography, and 86 specimen radiographs were obtained. Visualization of the lesion on sonography was compared with specimen radiographs and histologic findings. Sonographic margin status was classified as negative (shortest distance between tumor and specimen margin, > 0.2 cm) or positive (shortest distance between tumor and specimen margin, 0.2 cm) and was compared with pathology results. RESULTS Specimen sonography showed 95.4% (125/131) of the excised abnormalities; nonfatty background and a lesion size of greater than 0.5 cm contributed significantly to the success of specimen sonography. Four of six lesions missed on sonography were identified on specimen radiography. Among 81 malignant specimens, sonography identified 38 specimens with positive margins and 43 with negative margins. Pathologic examination revealed eight false-positive and 10 false-negative results (21% false-positive rate and 23.2% false-negative rate). CONCLUSION Specimen sonography is an effective procedure for identifying the presence of the lesion within the specimen; however, it is of limited value in cases of small hypoechoic lesions against a fatty background. Assessment of margins is limited by both false-positive and false-negative results.

Transmural colonic ischemia: clinical features and computed tomography findings

Our purpose was to describe the computed tomography features of transmural colonic ischemia in correlation with clinical, laboratory and histopathological findings of 14 patients who underwent colectomy (9 female and 5 male; mean age, 68 years). Seven patients died (50%). Transmural necrosis involved the right colon in 10 patients (10/14, or 72%). Eleven patients showed thickened colonic wall (11/14, or 79%), 10 pneumatosis (10/14, or 71%), 5 gas in the portal venous system (5/14, or 36%), and 14 fat stranding (14/14, or 100%).

Retroareolar Carcinomas in Breast Ultrasound: Pearls and Pitfalls

Breast Ultrasound (US) is an important tool for both screening and diagnostic examinations. Although breast US has benefitted from significant recent technical improvements, its use for the retroareolar region is known to be more challenging than for other locations. The retroareolar location was defined by Giess et al. in 1998 as the region where any lesion is situated at less than two cm from the nipple and/or involves the nipple-areolar complex on mammogram. Understanding of the complex anatomy and physiology of the nipple-areolar region is important to avoid misinterpretation and misdiagnosis. The ability for the breast imager to manage difficulties related to the retroareolar area is paramount by adjusting settings (compounding, frequency, Doppler) and utilizing specific manoeuvers. Cases illustrating difficulties encountered in diagnosis of retroareolar carcinomas are presented.

Imaging features and conspicuity of invasive lobular carcinomas on digital breast tomosynthesis

OBJECTIVE To review the imaging features of invasive lobular carcinoma (ILC) seen on digital breast tomosynthesis (DBT) in comparison with invasive ductal carcinoma (IDC), and to evaluate whether DBT could improve conspicuity and tumour size assessment of ILC in comparison with digital mammography (DM). METHODS Institutional review board with waiver of informed consent was obtained for this retrospective study. Patients with ILC or IDC who underwent DBT and DM at the time of diagnosis were included. DM and DBT images were reviewed in consensus by two breast radiologists in order to assess imaging features, conspicuity and maximum tumour diameter of ILC and IDC. Pathology on the surgical specimen was considered the standard of reference for assessment of tumour size. RESULTS 43 patients (20 patients with ILC and 23 patients with IDC) were included. On DBT, compared with IDC, ILC presented less frequently as masses (40% vs 78%) (p = 0.01) and more frequently as isolated distortion (20% vs 0%) (p = 0.03). ILC presented more often as asymmetries (60%) than masses (20%) on DM (p = 0.02) but not on DBT (35% vs 40%; p = 1.00). Conspicuity of ILC was significantly higher on DBT than on DM (p = 0.002), while the difference between the two techniques was not significant for IDC (p = 0.2). Regarding ILC, concordance in tumour size measurement between DBT and pathology was fair (intraclass correlation coefficient = 0.24). CONCLUSION ILC rarely presented as dense masses but frequently demonstrated architectural distortion on DBT. DBT increased lesion conspicuity but failed to accurately assess tumour size of ILC. Advances in knowledge: (1) This study describes specific features of ILC on DBT. (2) It shows that DBT can improve conspicuity of ILC.