Iraj Khalkhali

Bilateral Orbital Metastases as the Presenting Finding in a Male Patient with Breast Cancer: A Case Report and Review of the Literature

Abstract: Breast cancer in men has traditionally been thought to be substantially different from that in women. As more becomes known about this relatively rare entity, the similarities between genders become more striking than the differences. Carcinoma of the male breast is an uncommon disease occurring in less than 1% of all breast cancers. Male breast carcinoma is staged similarly to female breast cancer using the American Joint Committee Clinical Staging System. As in women, axillary nodal status is the strongest predictor of outcome. Distant metastasis to bones, soft tissue, lungs, and liver have been widely reported in men with breast cancer. This case report provides a rather rare presentation of a man with breast carcinoma with bilateral orbital metastasis as an initial clinical presentation.

THE ROLE OF NUCLEAR MEDICINE IN BREAST CANCER DETECTION: Functional Breast Imaging

Mammography remains the imaging modality of choice in detection of early, nonpalpable breast cancer. Scintimammography using SPECT, however, may prove to be a very useful adjunct to a nondiagnostic or difficult mammogram. Further prospective studies have to be designed so that the specific clinical applications of this technique are more defined. As with any new imaging procedure, special care to obtain high-quality scintimammographic studies and sufficient training of staff to perform and interpret the imaging are necessary.

Improved scintimammography using a high-resolution camera mounted on an upright mammography gantry

Abstract 99m Tc-sestamibi scintimammography (SMM) is a useful adjunct to conventional X-ray mammography (XMM) for the assessment of breast cancer. An increasing number of studies has emphasized fair sensitivity values for the detection of tumors >1xa0cm, compared to XMM, particularly in situations where high glandular breast densities make mammographic interpretation difficult. In addition, SMM has demonstrated high specificity for cancer, compared to various functional and anatomic imaging modalities. However, large field-of-view (FOV) gamma cameras are difficult to position close to the breasts, which decreases spatial resolution and subsequently, the sensitivity of detection for tumors 2 FOV and an array of 2×2×6xa0mm 3 discrete crystals coupled to a photon-sensitive photomultiplier tube readout. This camera is mounted on a mammography gantry allowing upright imaging, medial positioning and use of breast compression. Preliminary data indicates significant enhancement of spatial resolution by comparison with standard imaging in the first 10 patients. Larger series will be needed to conclude on sensitivity/specificity issues.

Examining the Role of Screening Mammography in Men at Moderate Risk for Breast Cancer: Two Illustrative Cases

To the Editor: Male breast cancer is rare, comprising less than 1% of all breast cancers (1). In 2015, only 2,350 new cases of breast cancer are expected to be diagnosed in men (2). Although the overall prognosis for male breast cancer is similar to that for females, the diagnosis is often made at later stages (3). This is thought to be due to several factors, including the absence of breast cancer screening in men. Breast cancer screening would not be advantageous for men at average risk given the rarity of the disease (1). However, there may be a subset of men with elevated risk who might benefit from periodic clinical breast examination (CBE) and possibly annual screening mammography. We report two cases of breast cancer in men with moderate risk factors to highlight potential gaps in screening guidelines. A 51-year-old African-American male-to-female transsexual presented with a self-detected right breast palpable lump. At age 2, the patient underwent bilateral orchiectomy for undescended testes. She reported using estrogen injections since age 14. Her family history was significant for a maternal grandmother and aunt with breast cancer. Examination confirmed periareolar nodularity without adenopathy. Mammography revealed suspicious microcalcifications. Stereotactic-guided core biopsy yielded ductal carcinoma in situ (DCIS) with intermediate nuclear grade and comedonecrosis. The patient underwent bilateral skin sparing mastectomies and right sentinel lymph node biopsy. Final pathology showed multifocal DCIS and a 1 cm focus of moderately differentiated invasive ductal carcinoma with negative margins and sentinel nodes, Stage IA (pT1bN0M0). The tumor was negative for both hormone receptors and human epidermal growth factor receptor 2 (HER2)/neu. Adjuvant chemotherapy was recommended, and she was advised to discontinue estrogen therapy. The patient tested negative for a BRCA mutation. A 44-year-old African-American male with 47XXY Klinefelter syndrome (KS) presented with a left breast mass, and a history of bilateral gynecomastia. He had no contributory family history. Examination revealed a retroareolar left breast mass, without adenopathy. Genital exam was significant for bilateral atrophic testes. A corresponding spiculated mass was visualized on mammography, and ultrasound showed a hypoechoic mass with irregular margins. Core needle biopsy revealed moderately differentiated infiltrating ductal carcinoma that was strongly hormone receptor positive and HER2/neu negative. The patient underwent left simple mastectomy with sentinel lymph node biopsy and concurrent completion axillary dissection after nodal metastasis was evident on frozen section. Final pathology showed moderately differentiated infiltrating ductal carcinoma, with metastasis to one of 18 nodes, Stage IIB (pT2N1M0). He underwent adjuvant chemoand radiotherapy, as well as antiestrogen therapy. There are several risk factors for the development of breast cancer in men. The most significant of these is a mutation in the BRCA tumor suppressor genes, with BRCA2 mutations leading to 80–100 times increased risk (4). More moderate risk factors include KS, testicular disorders, and exogenous estrogen use. KS is characterized by hypogonadism and gynecomastia, and is associated with as high as 50 times increased risk of male breast cancer, likely due to the high ratio of serum estrogen-to-testosterone and elevated gonadotropins (3,5,6). Testicular disorders such as undescended testes, mumps orchitis, orchiectomy, and testicular injury have also been implicated due to resultant relative androgen deficiency (6). Having Address correspondence and reprint requests to: Iraj Khalkhali, MD, Department of Radiology, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, CA 90509, USA, or e-mail: irajkhalkhali@ gmail.com

Indium-111 labelled pooled human immunoglobulin imaging to monitor the efficacy of specific therapy for Pneumocystis carinii pneumonia

Functional imaging is ideally suited to monitoring the effect of specific therapy on disease processes. In this pilot study five patients with AIDS and Pneumocystis carinii pneumonia (PCP) were imaged with Indium-111 labelled pooled human immunoglobulin (111In-HIG) during infection and after therapy for PCP. The lung activity of t t tln-HIG, measured as a lung/heart ratio, was calculated in a study performed during infection with PCP and after therapy. In all five patients the lung/heart ratio of t t 1ln-HIG was reduced after treatment. The mean reduction in heart/lung ratio was 27% (range 12%-53%). If these results are confirmed by a larger study, 11In-HIG will be useful in monitoring the response of PCP to therapy in patients with AIDS.

Scintimammography for the Diagnosis of Breast Cancer

Since the 1990s, there has been a steady decrease in the death rate from breast cancer in the United States, much of which can be attributed to earlier detection from physical examination and screening x-ray mammography (XMM). Several techniques, including scintimammography (SMM), have been proposed

The Role of Imaging in the Evaluation of Focal Mastalgia

Breast pain, also known as mastalgia or mastodynia, is a commonly encountered symptom in clinical practice. It causes significant patient anxiety and is frequently cited as the primary reason for a woman to seek medical attention. Breast pain was the primary indication for 47% of breast-related visits in a 10-year study of women enrolled in a large health maintenance organization (1). Despite the prevalence of the symptom, breast pain associated with cancer is uncommon and is classically described as unilateral, localized, and noncyclic in nature. Mammography and ultrasound are often used to evaluate noncyclical focal breast pain. However, the cancer yield is low in the setting of a normal clinical breast examination and the true role of imaging studies is not clearly defined. The National Comprehensive Cancer Network does not address mastalgia in their Breast Cancer Screening and Diagnosis Clinical Practice Guidelines, despite detailing the appropriate diagnostic evaluation of other breast symptoms such as palpable mass, nipple discharge, asymmetric thickening/nodularity, and skin changes (2). In this issue of The Breast Journal, Leddy et al. examined the role of mammography and ultrasound in the evaluation of patients with focal breast pain. Their study results support those of previous investigators demonstrating the very high sensitivity and negative predictive value of mammography and ultrasound for the detection of breast cancer (3). The results of this study provide further evidence that if the clinical findings and breast imaging results are normal or benign, women can be reassured that the likelihood of their focal breast pain representing malignancy is effectively zero. In these patients, tissue sampling with fine-needle aspiration biopsy, core biopsy, or surgical biopsy is therefore not warranted. Given the very low likelihood of breast cancer in women presenting with breast pain in the absence of abnormalities on clinical examination, the use of breast imaging in this patient population has at times been controversial (4). The cancer incidence was 1.2% in the patient cohort examined by Leddy et al., which is a similar percentage compared to previous publications. The American College of Radiology (ACR) practice guidelines state that diagnostic mammography “may be appropriate for patients with persistent focal areas of pain or tenderness” (5). Furthermore, the ACR guidelines for breast sonography are worded without specific reference to focal pain, citing that ultrasound is indicated in the “evaluation and characterization of palpable masses and other breast related signs and/or symptoms” (6). For patients presenting with localized persistent breast pain at our institution, our imaging protocol depends on the age of the patient. For women 40 years of age and older presenting with persistent focal breast pain, we employ mammography as the initial examination, with adjunct ultrasound targeted specifically to the area of concern. For women younger than age 40, we use ultrasound as the initial, and often only, imaging modality. In this younger patient population, adjunct mammography is reserved for certain high-risk cases such as those with a suspicious lesion identified on ultrasound, or those with a known BRCA gene mutation, a primary relative diagnosed with breast cancer at an age under 50 years, or other risk factor indicating early mammography. We perform therapeutic aspiration of cysts using sonographic guidance for symptomatic relief of pain and/or psychological reassurance if requested by the patient. The reasons for using ultrasound as the primary imaging modality in younger women include the low incidence of breast cancer in this age group, the desire to limit radiation exposure associated with mammography, as well as the higher sensitivity of ultrasound compared with mammography in young women. The criteria for “young” had historically been considered Address correspondence and reprint requests to: Babak N. Kalantari, MD, Department of Radiology, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, CA 90509, USA, or e-mail: bkalantari@dhs.lacounty.gov

Requirements for effective functional breast imaging

Abstract Most nuclear medicine physicists were trained on devices aimed at functional neuroimaging. The clinical goals of brain-centered devices differ dramatically from the parameters needed to be useful in the breast clinic. We will discuss similarities and differences that impact on design considerations, and describe our latest generation of positron emission mammography and intraoperative products. • Source of physiologic contrast : Clinical neuroimaging depends on flow agents to detect the presence of breaks in the blood–brain barrier. Breast flow agents are nonspecific, and may miss preinvasive lesions. • Resolution : Brain cancers are generally diagnosed at late stages, so resolution is not so critical. Detecting early breast cancers, and specifying margins for surgery requires 3xa0mm spatial resolution or better. • Prevalence : Primary brain cancer is uncommon, and lesions mimicking brain cancer are rare. Primary breast cancer is common, and benign lesions are even more common, so specificity and biopsy capability are very important. • Anatomic references : Brain structure is standard, while breast structure is highly variable, requiring immobilization/compression for physiologic imaging and biopsy. • Surgery : Complete cancer resections for brain are very rare, but are possible for breast with appropriate imaging guidance, implying the need for rapid and reliable imaging. nTo summarize, the breast clinic needs a rapid and highly sensitive method of assessing breast physiology, compatible with biopsy and surgery. Positron emission mammography devices, in handheld and X-ray platform based configurations, are ideal for this mission.

Utility of short-interval follow-up mammography after a benign-concordant stereotactic breast biopsy result

BACKGROUNDnThere is currently no clear consensus recommendation for the use of short-interval follow-up mammography after a benign-concordant breast biopsy (BCBB), and practice patterns vary widely. The objectives of this study were to evaluate whether a short-interval follow-up mammogram provided clinical utility after stereotactic BCBB and to examine the costs associated with this surveillance strategy.nnnMETHODSnA retrospective review of women who underwent a stereotactic breast biopsy yielding benign-concordant results between January 2005 and October 2014 was performed to evaluate findings on subsequent imaging, to calculate compliance with recommended short-interval imaging, and to examine whether subsequent imaging revealed an abnormality at the site of the initial stereotactic BCBB. A cost analysis was performed utilizing Medicare reimbursement rates to calculate projected and actual costs of short-interval follow-up imaging after stereotactic BCBB.nnnRESULTSnOf the 470 stereotactic BCBB performed, a short-interval mammogram was completed in 207 (44.0%), 9 (4.3%) of which had suspicious mammographic findings at the initial biopsy site, and 6 subsequently underwent biopsy, with none resulting in malignant or high-risk pathology. The cost of short-interval mammographic follow-up (nu202f=u202f207) was calculated at

Diagnostic Accuracy of 99mTc-Sestamibi Breast Imaging: Multicenter Trial Results

28,541.16.nnnCONCLUSIONSnThis study provides evidence that 6-month follow-up mammography has low clinical utility and unnecessarily increases costs after stereotactic BCBB. A safe and more cost-effective strategy may be resumption of routine mammography at 12 months post-biopsy.