Erkin Aribal

Survey on a mammographic screening program in Istanbul, Turkey.

Abstract:  Breast cancers in Turkey tend to be diagnosed at advanced stages due to lack of organized comprehensive mammographic screening. In this study, factors associated with having a mammogram among healthy women of screening age in Bahcesehir county, a region in Istanbul, were investigated to assess the feasibility of organized breast cancer screening in Turkey. In this cross‐sectional study, 659 healthy women aged between 40 and 69 years were surveyed. A multiple‐choice questionnaire was used to obtain information regarding patient demographics, family history of cancer, and patient knowledge on mammographic screening. Factors associated with increased likelihood of having a mammogram included age older than 50 (OR = 1.75; 95% CI = 1.23–2.49), higher educational level (high school or university graduate; OR = 1.55; 95% CI = 1.07–2.25), and undergoing periodic gynecologic examinations (OR = 5.53; 95% CI = 3.88–7.89). Women aged between 40 and 49 years, who were most likely to have a mammogram within the last 2 years were characterized by a higher educational level (OR = 1.94; 95% CI = 1.14–3.31), periodic gynecologic examinations (OR = 4.06; 95% CI = 2.53–6.51), and a first or second degree family history of breast cancer (OR = 2.2; 95% CI = 1.06–4.50). In contrast, women aged between 50 and 69 years were more likely to have undergone mammography within the previous 2 years if they also had undergone periodic gynecologic examinations (OR = 8.63; 5.04–14.77). Our findings suggest that women of lower educational level and those who do not undergo routine wellness visits with their gynecologist will need to be specifically targeted for educational outreach to achieve broad screening compliance within the population.

Her-2/neu gene amplification compared with HER-2/neu protein overexpression on ultrasound guided core-needle biopsy specimens of breast carcinoma.

Genomic amplification and oncoprotein overexpression of Her-2/neu was studied on ultrasound core needle biopsy specimens of the infiltrative ductal carcinomas of the breast. We performed “two colour” fluorescence in situ hybridization (FISH) for Her-2/neu and chromosome 17 and compared the FISH results with the immunohistochemical overexpression of Her-2/neu protein by 2 antibodies (DAKO HercepTest and the BioGenex monoclonal antibody AM 134-5M). Furthermore, following radical mastectomy with axillary dissection, Her-2/neu status of the patients were compared with the well known histopathological prognostic factors such as histologic grade, tumor stage, lympho/ vascular invasion, surgical margin status and Paget’s disease. Amplification was demonstrated 27% of the cases. Her-2/neu protein overexpression was detected in 47% and 80% of the cases with CB11 and HercepTest respectively. We revealed statistically significant association between the tumor, oncoprotein expression and oncogene amplification (p<0.05). The results of our study showed that combination of IHC and FISH methods enhances the evaluation of tumor genetics at both gene and protein level for the analysis of Her-2/neu in breast carcinoma.

Apocrine Differentiation in Invasive Pleomorphic Lobular Carcinoma with In Situ Ductal and Lobular Apocrine Carcinoma: Case Report

Invasive pleomorphic lobular carcinoma (PLC) is a distinctive aggressive subtype of invasive lobular carcinomas (ILC). We report one case of PLC with in situ PLC and ductal carcinoma in situ with apocrine features.

Successful First Round Results of a Turkish Breast Cancer Screening Program with Mammography in Bahcesehir, Istanbul

BACKGROUND The Bahcesehir Breast Cancer Screening Project is the first organized population based breast cancer mammographic screening project in Turkey. The objective of this prospective observational study was to demonstrate the feasibility of a screening program in a developing country and to determine the appropriate age (40 or 50 years old) to start with screening in Turkish women. MATERIALS AND METHODS Between January 2009 to December 2010, a total of 3,758 women aged 40-69 years were recruited in this prospective study. Screening was conducted biannually, and five rounds were planned. After clinical breast examination (CBE), two-view mammograms were obtained. True positivity, false positivity, positive predictive values (PPV) according to ACR, cancer detection rate, minimal cancer detection rate, axillary node positivity and recall rate were calculated. Breast ultrasound and biopsy were performed in suspicious cases. RESULTS Breast biopsy was performed in 55 patients, and 18 cancers were detected in the first round. The overall cancer detection rate was 4.8 per 1,000 women. Most of the screened women (54%) and detected cancers (56%) were in women aged 40- 49. Ductal carcinoma in situ (DCIS) and stage I cancer and axillary node positivity rates were 22%, 61%, and 16.6%, respectively. The positive predictivity for biopsy was 32.7%, whereas the overall recall rate was 18.4 %. CONCLUSIONS Preliminary results of the study suggest that population based organized screening are feasible and age of onset of mammographic screening should be 40 years in Turkey.

Diagnostic performance of diffusion tensor imaging parameters in breast cancer and correlation with the prognostic factors

To evaluate the diagnostic performances of the diffusion tensor imaging (DTI) parameters in the diagnosis of breast cancer and to investigate the variations in DTI parameters according to the breast cancer biomarkers.

The value of ultrasound elastography in differentiation of malignancy in thyroid nodules.

We aimed to determine the value of ultrasound elastography (US-E) using carotid artery pulsation in differentiation of malignant and benign thyroid nodules. One hundred ten nodules were evaluated by US-E, and stiffness scores were compared to biopsy results. When cutoff for malignancy was determined as score 4, sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 95%, 40%, and 100%, respectively. We suggest fine needle aspiration biopsy to be performed in all score 4 nodules, while biopsy may be unnecessary in score 1 nodules. Benign biopsy result in a score 4 nodule should suggest radiological-pathological disagreement, and repeat biopsy should be recommended.

Multiparametric breast MRI with 3T: Effectivity of combination of contrast enhanced MRI, DWI and 1H single voxel spectroscopy in differentiation of Breast tumors.

OBJECTIVES To evaluate the diagnostic accuracy of dynamic contrast enhanced breast MRI (DCE-MRI) combined with diffusion weighted imaging (DWI) and 1H single-voxel magnetic resonance spectroscopy (1HMRS) in differentiating malignant from benign breast lesions. METHODS One hundred twenty-nine patients with 138 lesions were included in the study. Multiparametric MRI of the breast was performed with a 3T unit. A DWI is followed by DCE-MRI and 1HMRS. All lesions were biopsied within one week after MRI. Histopathologic findings were accepted as the standard of reference. Probability of malignancy was assessed according to BI-RADS for DCE-MRI. ADC values were measured for DWI and choline peaks were assessed using a semi-quantitative method in 1HMRS. Two blinded radiologists evaluated findings in consensus. Diagnostic performance of DCE-MRI, DWI and 1HMRS alone or in combination for multiparametric imaging were statistically evaluated. RESULTS Histopathology revealed malignancy in 54.4% of lesions (75/138). DCE-MRI showed the highest AUC (0.978), sensitivity (97.33%) and specificity (88.89%) compared to DWI and 1HMRS. Sensitivity was 100% when a positive result from any one of three techniques was accepted as malignancy, albeit with a trade-off for 65.1% specificity. Highest specificity (98.4%) was attained when all three techniques were required to be positive, though with a lower sensitivity (82.7%) as trade-off. Logistic regression analysis confirmed significant association with DCE-MRI (p<0.001) and 1H MRS (p=0.009) but not with DWI (p=0.127). There was one case of fat necrosis which was false positive in all three techniques. CONCLUSIONS Multiparametric imaging with combination of DCE-MRI, DWI and 1HMRS does not improve, and may even reduce the diagnostic accuracy of breast MRI. Although, the specificity may be improved with a trade-off for lower sensitivity, we have not set a convenient algorithm for the combined use of these techniques.

Myoepithelial differentiation in breast carcinoma

BACKGROUND The aim of presenting this work is to describe a matrix producing carcinoma with anaplastic myoepithelial cell foci, with the coexistence of in situ myoepithelial carcinoma which originated from a sclerosing adenosis. CASE REPORT A 51-year-old perimenopausal woman presented with a hard irregular lump in her left breast. After histological confirmation of malignancy, the patient underwent a modified radical mastectomy. The tumor was composed of a sclerosed fibroadenoma and preexisting sclerosing adenosis with poorly differentiated overt carcinoma within the cartilaginous matrix. There were foci of ordinary, intermediate-grade carcinoma in situ and myoepithelial carcinoma in situ. RESULTS We performed immunohistochemistry by the streptavidin-biotin horseradish peroxidase method. Estrogen receptor and progesterone receptor were negative, and so was c-erbB-2. Both the invasive and the in situ components were positive for CK7, CK19, CK14, vimentin, smooth muscle actin, nerve growth factor receptor, and epidermal growth factor receptor. By contrast, CK5/6 immunoexpression was found only in the in situ component. Negativity was found for p63 and CD10 within the tumor. While cytoplasmic bcl-2 immunoexpression was detected in some of the tumor cells of the invasive component, intranuclear p53 expression was found to be positive not only in the invasive component but also in the in situ component of the tumor. CONCLUSION The histopathological findings and the immunohistochemistry results support the derivation of the tumor from myoepithelial cells.

Volume Navigation Technique for Ultrasound-Guided Biopsy of Breast Lesions Detected Only at MRI

OBJECTIVE The purpose of this study is to assess the utility of a volume navigation technique (VNT) for ultrasound-guided biopsy of MRI-detected, but sonographically ambiguous or occult, breast lesions. SUBJECTS AND METHODS Within a recruitment period of 13 months (January 1, 2014, through February 1, 2015), 22 patients with 26 BI-RADS category 4 or 5 lesions that were detected at MRI but missed at second-look ultrasound were reimaged using a rapid sequence and a flexible body coil in a 3-T MRI scanner. Patients were supine, with three skin markers placed on the breasts. MRI volume data were coregistered to real-time ultrasound in a dedicated platform, and MRI-detected lesions (six masses, 11 nonmass enhancements, eight foci, and one architectural distortion) were sought using VNT-guided ultrasound. Five needle biopsy specimens were obtained either from each sonographically detected lesion (n = 11) or from VNT-guided sonographically localized breast volume corresponding to the MRI-detected, but still ultrasound-occult, lesions (n = 15). RESULTS Histopathologic analysis revealed 18 benign and six malignant lesions. The remaining two lesions, both of which appeared as masses at MRI, were high risk and were upgraded to carcinoma after excisional biopsy. All malignant lesions underwent curative surgery; the final histopathologic diagnoses remained unchanged. Of the six malignant lesions, one was a mass, three were nonmass enhancements, and two were enhancing foci at MRI. Three malignant lesions were occult at ultrasound, and three were discerned as subtle hypoechoic changes. No benign lesion was sonographically visualized as a mass, and none progressed, with 56% disappearing at MRI performed during the follow-up period (mean, 14 months). CONCLUSION Coregistration of MRI and real-time ultrasound enables sonographic localization of breast lesions detected at MRI only. VNT is a feasible alternative to MRI-guided biopsy of ultrasound-occult breast lesions.

Quantitative differentiation of breast lesions at 3T diffusion‐weighted imaging (DWI) using the ratio of distributed diffusion coefficient (DDC)

To investigate the accuracy of diffusion coefficients and diffusion coefficient ratios of breast lesions and of glandular breast tissue from mono‐ and stretched‐exponential models for quantitative diagnosis in diffusion‐weighted magnetic resonance imaging (MRI).