Fernando Collado-Mesa

An ecological analysis of childhood-onset type 1 diabetes incidence and prevalence in Latin America

OBJECTIVE To explore, for Latin America, by means of an ecological correlation analysis, the possible relationships between both the incidence and prevalence of childhood type 1 diabetes and selected hypothesized etiological factors, including race/ethnicity, geographical latitude, breastfeeding rates, per capita milk supply and coffee consumption, and wealth-related indicators such as infant mortality rate, life expectancy at birth, and national human development index. METHODS Recently published data on incidence and prevalence of type 1 diabetes in children < or = 14 years of age in Latin American countries were utilized. Risk indicators were selected based on existing genetic and environmental hypotheses. Indicator data were obtained from publicly available resources. Spearman correlation coefficients were used to measure the association between both incidence and prevalence of type 1 diabetes and the selected indicators. RESULTS A strong negative correlation was found between the proportion of Amerindians in a countrys population and both incidence (r = -0.75; P = 0.008) and estimated prevalence (r = -0.78; P < 0.0001) of childhood type 1 diabetes. The per capita supply of milk showed a strong positive correlation with both incidence (r = 0.70; P = 0.025) and prevalence (r = 0.55; P = 0.018). Wealth-related indicators correlated with prevalence but not with incidence. CONCLUSIONS Our results suggest that the presence of the Amerindian component of the population in Latin America provides protection against childhood-onset type 1 diabetes. Our results also confirm the association previously reported in other countries and regions of the world of type 1 diabetes and milk consumption. Further studies are needed to develop and test potential genetic and environmental hypotheses that could help to better understand the interplay between genetic susceptibility and environment in type 1 diabetes across different ethnic groups.

A community-based breast cancer screening program for medically underserved women: its effect on disease stage at diagnosis and on hazard of death

OBJECTIVE Earlier studies by this research team found that medically underserved minority women in the Miami-Dade County area of the state of Florida, United States, were in need of breast cancer screening and that there were problems with availability, accessibility, and acceptability of services. In response, a community-based comprehensive breast cancer screening program called the Early Detection Program (EDP) was developed. The specific purpose of this study was to assess the effect that EDP participation had on stage at diagnosis and on hazard of death. METHODS Existing data from the Florida Cancer Data System (FCDS), a statewide cancer registry, were linked with data from the EDP. In December 1998 we assembled a multiethnic (African-American, black Hispanic, white Hispanic, and white non-Hispanic) retrospective cohort with the following inclusion criteria: all women aged 40 and older with breast cancer diagnosed and staged at University of Miami/Jackson Memorial Medical Center (which is located in the city of Miami, Florida) from January 1987 through December 1997. EDP participants were medically underserved, that is, they resided in lower socioeconomic areas and/or had limited or no health insurance to cover medical costs. Subjects identified as EDP participants were compared to nonparticipants with respect to disease stage at diagnosis and hazard of death. Logistic regression and Cox regression models were used for analysis. RESULTS EDP participants were 2.4 times as likely (95% confidence interval = 1.71 to 3.43) to present with a diagnosis of localized cancer as were nonparticipants, even after controlling for race and age at diagnosis. EDP participation was independently associated with both earlier diagnosis and reduced hazard of death. CONCLUSIONS Participation in the EDP increases the likelihood of early detection of breast cancer and reduces the hazard of death for medically underserved women in the Miami-Dade County area of Florida. Interestingly, white Hispanics showed a better survival than did both African-Americans and white non-Hispanics. Our research also demonstrates the value of utilizing existing cancer registry data to evaluate a community-based program such as the EDP.

Contralateral Intramammary Silicone Lymphadenitis in a Patient with an Intact Standard Dual-Lumen Breast Implant in the Opposite Reconstructed Breast

Silicone lymphadenopathy is a recognized complication of silicone gel implant rupture; the ipsilateral axillary lymph nodes are most commonly involved. We report imaging findings on a range of different imaging modalities and biopsy results in a case of biopsy-proven silicone lymphadenitis involving contralateral intramammary and axillary lymph nodes in a patient with an intact standard dual-lumen breast implant in the opposite reconstructed breast. This case demonstrates that in a patient with disrupted lymph drainage due to prior mastectomy and axillary node dissection for breast cancer treatment, silicone particles can migrate in a retrograde fashion via the ipsilateral internal mammary lymph nodes and reach not only the contralateral axilla but also the outer quadrants of the contralateral breast, even in the presence of an intact breast implant.

Solitary neurofibroma of the breast

Neurofibromas are slow-growing, painless, benign nerve-sheath tumors. They occur most commonly in the dermis and subcutis and are rarely found in the breast. We report a rare case of a solitary neurofibroma of the breast in a 61-year-old asymptomatic woman.

Resident and Fellow Education Feature: US Evaluation of Axillary Lymph Nodes

1From the Breast Imaging Section, Department of Radiology, University of Miami Sylvester Comprehensive Cancer Center, 1475 NW 12th Ave, Miami, FL 33136. Received April 14, 2013; revision requested November 18; revision received March 13, 2014; accepted July 23. All authors have disclosed no relevant relationships. Address correspondence to J.M.N. (e-mail: jnet@med.miami.edu). The full digital presentation is available online.

Primary neuroendocrine carcinoma of the breast: report of 2 cases and literature review

Neuroendocrine tumors of the breast are very rare accounting for less than 0.1% of all breast cancers and less than 1% of all neuroendocrine tumors. Focal neuroendocrine differentiation can be found in different histologic types of breast carcinoma including in situ and invasive ductal or invasive lobular. However, primary neuroendocrine carcinoma of the breast requires the expression of neuroendocrine markers in more than 50% of the cell population, the presence of ductal carcinoma in situ, and the absence of clinical evidence of concurrent primary neuroendocrine carcinoma of any other organ. Reports discussing the imaging characteristics of this rare carcinoma in different breast imaging modalities are scarce. We present 2 cases of primary neuroendocrine carcinoma of the breast for which mammography, ultrasound, and magnetic resonance imaging findings and pathology findings are described. A review of the medical literature on this particular topic was performed, and the results are presented.

Utility of supplemental screening with breast ultrasound in asymptomatic women with dense breast tissue who are not at high risk for breast cancer

Objective: To assess the results of an initial round of supplemental screening with hand-held bilateral breast ultrasound following a negative screening mammogram in asymptomatic women with dense breast tissue who are not at high risk for breast cancer. Materials and Methods: A retrospective, Health Insurance Portability and Accountability Act compliant, Institutional Research Board approved study was performed at a single academic tertiary breast center. Informed consent was waived. A systematic review of the breast imaging center database was conducted to identify and retrieve data for all asymptomatic women, who were found to have heterogeneously dense or extremely dense breast tissue on screening bilateral mammograms performed from July 1, 2010 through June 30, 2012 and who received a mammographic final assessment American College of Radiologys (ACR) Breast Imaging Reporting and Data System (BI-RADS) category 1 or BI-RADS category 2. Hand-held screening ultrasound was performed initially by a technologist followed by a radiologist. Chi-square and t-test were used and statistical significance was considered at P < 0.05. Results: A total of 1210 women were identified. Of these, 394 underwent the offered supplemental screening ultrasound. BI-RADS category 1 or 2 was assigned to 323 women (81.9%). BI-RADS category 3 was assigned to 50 women (12.9%). A total of 26 biopsies/aspirations were recommended and performed in 26 women (6.6%). The most common finding for which biopsy was recommended was a solid mass (88.5%) with an average size of 0.9 cm (0.5–1.7 cm). Most frequent pathology result was fibroadenoma (60.8%). No carcinoma was found. Conclusion: Our data support the reported occurrence of a relatively high number of false positives at supplemental screening with breast ultrasound following a negative screening mammogram in asymptomatic women with dense breast tissue, who are not at a high risk of developing breast cancer, and suggests that caution is necessary in establishing wide implementation of this type of supplemental screening for all women with dense breast tissue without considering other risk factors for breast cancer.

Diagnostic Performance of CT Attenuation Values of Focal 18F-FDG Avid Breast Lesions Detected on Whole-Body PET-CT in Postoperative Breast Cancer Patients

To assess whether CT attenuation values help in differentiating benign from malignant etiology of focal 18F‐FDG avid breast lesions detected on whole‐body PET/CT exam in postoperative breast cancer patients. Institutional review board approval and waived informed consent were obtained for this HIPAA‐compliant retrospective study. Between January 2009 and July 2011, a total of 85 patients had 97 focal 18F‐FDG avid breast lesions on whole‐body PET/CT. Of these, 54 (56%) lesions were biopsy‐proven primary invasive breast carcinoma that had not undergone treatment at the time of PET/CT, 35 (36%) were benign lesions, and 8 were locally recurrent breast carcinoma. Mean attenuation values were retrospectively measured in Hounsfield units (HU) for the correlative lesion on the CT portion of the exam. Receiver‐operating characteristic curves (ROC) were calculated to determine the optimal cutoff values of HU that would best discriminate between benign and malignant lesions. Interobserver agreement for measured mean attenuation values was assessed by calculating the intraclass correlation coefficient (ICC). Mean HU for the benign lesions group and the local recurrence lesions group was −11.0 ± 30.3 versus 32.9 ± 6.87 (p < 0.0002). ROC curve analysis comparing benign breast lesions to local recurrence lesions found an optimal cutoff value of 17 HU (area under curve = 0.982, p < 0.0001, Sensitivity = 100%, Specificity = 89%). ICC with regard to interobserver agreement in measuring the mean HU of the benign lesions was 0.84 (95% confidence interval 0.64–0.93) and for the malignant lesions was 0.88 (95% confidence interval 0.77–0.94). A CT attenuation threshold value of less than 17 HU suggests benign etiology of focal 18FDG avid breast lesions in postoperative breast cancer patients. If confirmed by additional studies, these findings may provide additional information to guide the treating physician regarding decisions for supplementary imaging or the need to biopsy.

Palpable solid breast masses with probably benign sonographic features: can biopsy be avoided?

To the Editor: New palpable breast masses have traditionally been recommended for tissue diagnosis, regardless of their imaging features. With the establishment of specific sonographic criteria for benign and malignant features of solid masses (1), radiologists have increasingly debated the question of whether biopsy is necessary for every new palpable solid breast mass. Although studies have been published establishing the validity of short-term follow-up rather than biopsy for solid masses with benign features on sonography (2–5), in our experience, biopsy rather than imaging follow-up continues to occur. This question was a recent forum topic on the Society of Breast Imaging’s website (http://www.sbi-online.org/forum.cfm), indicating that even among dedicated breast imagers there still may not be consensus opinion on this topic. We performed a retrospective study with Institutional Review Board approval to assess this issue in the setting of a Breast Imaging Center within a Community Cancer Center. All subjects were retrospectively identified by searching the medical records and computer data base for cases of new and palpable masses with probably benign features on imaging (BI-RADS category 3) that were upgraded to BI-RADS category 4A because of their new and palpable nature, and that were recommended for image-guided biopsy between November 2007 and June 2009. All breast ultrasound examinations were performed by technologists specialized in Breast ultrasound with 6–13 years of experience, using 10–14 MHz linear array transducers. For the purpose of this study, ultrasound features suggesting probably benign morphology included the following: homogeneous echotexture, oval or macrolobulated shape, parallel orientation, thin circumscribed margins, no posterior acoustic shadowing, and lack of any characteristically malignant features (1,6). A total of 41 patients had a total of 41 palpable masses having imaging features corresponding to BI-RADS category 3 (Fig. 1). Because of their new and palpable nature, these masses were upgraded to BI-RADS category 4A (2–10% chance of malignancy (7)) with a recommendation for biopsy. All patients were women with a mean age of 38.6 years (range 18–86). Nine patients were younger than 30 years of age. The palpable masses ranged in size from 0.4 to 2.6 cm. A total of 33 patients were evaluated with a combination of mammography and ultrasound. In these patients, 13 (39%) of lesions were identified by ultrasound only and demonstrated no visible abnormality at the site of palpable concern on the correlative diagnostic mammogram. Of those patients without a corresponding mammographic abnormality, 11 (85%) had heterogeneously dense or extremely dense breast tissue on mammography. Thirty-two (78%) of masses were described as oval; less frequent descriptors included round and lobulated. Thirty-one (76%) of masses were described as circumscribed. All of the masses underwent ultrasound-guided needle biopsy