Ellen Shaw de Paredes

UNUSUAL BREAST LESIONS : RADIOLOGIC-PATHOLOGIC CORRELATION

Unusual lesions of the breast can present a diagnostic challenge. These lesions include systemic diseases, benign tumors, and primary and metastatic malignancies. Lymphadenopathy is the most common mammographic finding associated with collagen vascular disease. Wegener granulomatosis may manifest as an irregular, high-density mass simulating breast cancer. Diabetic fibrous mastopathy manifests at mammography as very dense breast tissue and at ultrasonography (US) as an irregular, hypoechoic mass with striking posterior acoustic shadowing simulating malignancy. Fibromatosis simulates malignancy at mammography as an irregularly shaped, uncalcified, high-density mass and at US as an irregular, hypoechoic mass with posterior acoustic shadowing. At US, granular cell tumor may manifest as a solid, poorly marginated mass with marked posterior acoustic shadowing or may appear more benign. At mammography, hamartomas are typically well-circumscribed, round to oval masses with a thin, radiopaque pseudocapsule; at US, they manifest as a sharply defined, heterogeneous oval mass or as normal glandular tissue. Phyllodes tumor manifests at mammography as a large, well-circumscribed oval or lobulated mass; at US, it usually manifests as an inhomogeneous, solid-appearing mass. At mammography, primary breast lymphoma manifests as a relatively circumscribed mass or a solitary, indistinctly marginated, uncalcified mass. Metastatic lesions may manifest mammographically as single or multiple masses or as diffuse skin thickening; at US, they tend to have circumscribed margins with low-level internal echoes. Radiologists should be familiar with the characteristic mammographic appearances of these lesions and should consider benign and systemic causes in the differential diagnosis when malignant-appearing findings are encountered.

The Relationship between Psychosocial Factors and Breast Cancer: Some Unexpected Results

A growing body of research suggests a link between psychosocial factors and breast cancer. Research in this area often contains methodological problems, however, such as small sample size, inadequate comparison groups, omission of important control variables, inclusion of only a few psychosocial variables, and failure to analyze moderating effects. To overcome these problems, the present study examined the link between breast cancer and multiple psychosocial variables (life events, coping, Type A behavior pattern, availability of social support) among 1,052 women with and without breast cancer. After controlling for history of breast cancer and age, we found very few significant relationships between psychosocial variables and breast cancer. Furthermore, the relationship between life events and breast cancer was not moderated by coping, Type A, or availability of social support. Methodological and substantive reasons for these findings are discussed.

Imaging and Management of Breast Masses During Pregnancy and Lactation

▪ Abstract: Detection and management of breast abnormalities that develop during pregnancy and lactation is difficult for both the clinician and the radiologist. This article reviews the hormonal and physiologic effects on the breast during pregnancy and lactation. Breast masses that occur in pregnant or lactating patients, including pregnancy‐associated breast cancer, are discussed and the corresponding ultrasound and mammographic findings are presented. Finally, a rationale for the imaging evaluation and management of the pregnant or lactating patient with a breast mass are presented. ▪

Interventional breast procedures

The capability to provide histologic diagnoses of nonpalpable lesions by performance of percutaneous needle biopsy has revolutionized breast imaging in the past decade. The radiologist who performs percutaneous breast biopsies assumes an increased level of responsibility for the patient regarding patient selection, lesion selection, performance of the biopsy procedure, interpretation of results, and patient follow-up. With variable and increasingly numerous options for the biopsy of breast lesions, careful attention must be paid to the selection of patients and types of lesions for different procedures. Critical technical considerations affect whether biopsy of a lesion can be optimally performed percutaneously, and these considerations must be factored into the recommendations for patient treatment. In addition, a limited preprocedural clinical assessment of the patient will allow a safer procedure to be performed expeditiously. Most breast abnormalities classified by using the ACR Lexicon as 4 (suggestive) or 5 (highly suggestive, likely malignant) are suitable for either percutaneous breast needle biopsy or needle localization and excisional biopsy. In general, those lesions classified as 3 (probably benign) carry a recommendation for early follow-up and not biopsy, because the likelihood of malignancy is small. A particular advantage of percutaneous biopsy is in the diagnosis of multicentric breast cancer. Core biopsy is less invasive and less costly than surgical biopsy, and it can be used to demonstrate multicentric disease, saving the patient a two-step surgery. However, several lesions are better treated by excision than by percutaneous biopsy. Among these are architectural distortion or loosely arranged, segmental or regional microcalcifications. For nonpalpable breast lesions visualized on mammography, sonography, or both, imaging-guided localization is required for precise needle placement either for wire localization or for percutaneous breast biopsy. The selection of which modality to use for guidance depends on (1) the adequacy of visualization of the lesion by the modality used, (2) the position of the lesion, (3) the ease of positioning the patient, (4) the skill of the operator, (5) the need to reduce radiation exposure, (6) the overall patient condition, and (7) size of the lesion. Fine-needle aspiration biopsy (FNAB) has a high sensitivity and specificity in the diagnosis of palpable breast lesions when the procedure is properly performed and interpreted. Variable results have been achieved with FNAB of nonpalpable breast lesions under imaging guidance. Three critical components are necessary to achieve reliable results by using FNAB. These include the following: (1) accuracy in needle placement, (2) skill in performance of FNAB, and (3) expert cytopathologic analysis. Accurate preoperative needle localization of nonpalpable breast lesions allows the radiologist to guide the surgeon performing an open biopsy and helps to ensure that the surgical procedure can be performed quickly and can be accomplished with the best possible cosmetic result for the patient. Lesions selected for needle localization and biopsy should undergo a complete tailored imaging evaluation before the needle localization is scheduled. Specimen radiography should be performed for all nonpalpable lesions. Once the lesion has been identified on specimen radiography, the radiologist can assist the pathologist in identifying the lesion microscopically by marking the lesion within the surgical specimen. We cover the technical and interpretative aspects of percutaneous breast biopsy and needle localization for surgical biopsy.

Columnar Cell Lesions of the Breast: Mammographic Findings with Histopathologic Correlation

Because of advances in mammography and a concomitant rise in the number of breast biopsies being performed for mammographically detected abnormalities, increasing numbers of columnar cell lesions (CCLs) are being described by pathologists. However, these lesions can be challenging to manage, since their classification has changed over time and only limited research has been conducted regarding their clinical significance. CCLs may be characterized by a single layer of columnar cells (columnar cell change [CCC]), multiple layers with stratification and apical tufting (columnar cell hyperplasia [CCH]), or monomorphic cells with cytologic atypia (flat epithelial atypia [FEA]). The differentiation between CCC, CCH, and FEA is clinically significant: CCC and CCH are considered benign lesions, whereas FEA can be associated with, and even a precursor to, low-grade ductal carcinoma in situ and atypical ductal hyperplasia. Therefore, the identification of FEA at core biopsy should prompt excision of the remaining portion of the lesion.

Evaluation of stereotactic core needle biopsy (SCNB) of the breast at a single institution

Stereotactic core needle biopsy (SCNB) has become a popular method for diagnosis of occult breast abnormalities. There are few large series of SCNB from a single institution. Data on patients undergoing SCNB for mammographic abnormalities were collected prospectively over 43 months at a university hospital. Mammographic findings were categorized as benign, probably benign, indeterminate, suspicious or malignant. For lesions with SCNB pathology that were non-diagnostic, showed atypical hyperplasia or malignancy (in situ or invasive), or were discordant with the pre-biopsy mammogram findings, surgical excision was recommended. Subsequent surgical pathology was reviewed. All remaining lesions were followed mammographically after SCNB. SCNB was performed on 692 lesions in 607 patients. There were 79 malignancies, for a positive SCNB rate of 11.4%. The 349 SCNB performed for benign, probably benign and indeterminate lesions on mammography had a positive SCNB rate of only 4%. Surgery was recommended for 127 (18.3%) lesions, while 565 (81.6%) were followed mammographically after SCNB. A compliance rate of 61% for at least one follow-up mammogram was obtained, with a median follow-up of 17.2 months and with no cancers found. The sensitivity for malignancy with SCNB was 93%. SCNB provides a minimally invasive method to assess mammographic abnormalities. Abnormalities considered radiographically to be other than malignant or suspicious yielded few cancers. In this series a low positive SCNB rate resulted in no false negatives on mammographic follow-up. The optimal positive biopsy rate for SCNB is debatable.

Breast disease: The radiologist's expanding role

The role of the diagnostic radiologist in breast cancer has expanded during the eight-decade history of breast imaging. The radiologists role now encompasses both breast cancer diagnosis and treatment. This article traces the expansion of the radiologists role through the history of mammography. The current roles of the radiologist in breast cancer diagnosis are discussed, including screening mammography in the asymptomatic patient, problem-solving breast imaging, breast ultrasound, and galactography. The radiologists roles in breast cancer treatment that are discussed include preoperative needle localization, percutaneous breast biopsy, and evaluation of the postoperative breast.

A controlled phantom study of a noise equalization algorithm for detecting microcalcifications in digital mammograms.

We report on some extensions and further developments of a well-known microcalcification detection algorithm based on adaptive noise equalization. Tissue equivalent phantom images with and without labeled microcalcifications were subjected to this algorithm, and analyses of results revealed some shortcomings in the approach. Particularly, it was observed that the method of estimating the width of distributions in the feature space was based on assumptions which resulted in the loss of similarity preservation characteristics. A modification involving a change of estimator statistic was made, and the modified approach was tested on the same phantom images. Other modifications for improving detectability such as downsampling and use of alternate local contrast filters were also tested. The results indicate that these modifications yield improvements in detectability, while extending the generality of the approach. Extensions to real mammograms and further directions of research are discussed.

Evaluation of a Digital Spot Mammographic Unit Using a Contrast Detail Phantom

The utilization of charged-coupled device detectors (CCD) for digital mammography is an area of active investigation. Smaller field detectors are commercially available and are increasingly utilized on mammographic units to guide stereotactic breast biopsies. Advantages of digital mammography include the following: a wide dynamic range, improved contrast, increased signal to noise ratio, and improved efficiency in image acquisition through a near real-time operation (1,2,3).

Combined galactography and stereotactic core needle breast biopsy for diagnosis of intraductal lesions

The diagnosis of intraductal breast lesions detected during galactography performed for spontaneous nipple discharge traditionally has been obtained by performing subsequent needle localization and surgical excision. Galactography followed by stereotactic core needle breast biopsy offers a less invasive alternative for arriving at a diagnosis in many patients. This article describes our technique for combined galactography and stereotactic core needle breast biopsy. We also discuss the use of stereotactic core needle breast biopsy versus needle localization with surgical excision and the advantages and applications of our use of combined galactography and stereotactic core needle breast biopsy. In most cases, no mammographic abnormalities, other than the occasional dilated duct or segmental microcalcifications, are present in patients with spontaneous nipple discharge. Galactography, or ductography, usually is performed to evaluate the various causes of nipple discharge.1 Galactography is used to determine whether there is an intraductal lesion causing the nipple discharge, and to identify the location of the intraductal filling defect for surgical planning. Nipple discharge from multiple ducts is seen more often in the setting of duct ectasia or fibrocystic change. These entities usually present with bilateral cloudy yellow or greenish discharge that must be expressed from the nipple1 (Table 1). Intraductal papillomas most commonly present with spontaneous, unilateral nipple discharge that is bloody, serous, or clear, from a single duct. However, because some breast cancers also can present in this fashion,1 further evaluation of this type of spontaneous, uniorificial nipple discharge is indicated. The indication for galactography is the presence of a spontaneous, serous, serosanguineous, or bloody nipple discharge. Typically, such discharge is uniorificial and unilateral. However, these more suspicious types of discharge occasionally may occur simultaneously with a more benign, multiorificial, bilateral nipple discharge.