Laurie Margolies

Breast Cancer in Male-to-Female Transsexuals: Use of Breast Imaging for Detection

OBJECTIVE The purposes of this article are to describe two cases of breast cancer in male-to-female transsexuals and to review eight cases previously reported in the literature. CONCLUSION Breast cancer occurs in male-to-female transsexuals who receive high doses of exogenous estrogen and develop breast tissue histologically identical to that of a biologically female breast. This exposure to estrogen results in increased risk of breast cancer. The first patient described is a male-to-female transsexual with screening-detected ductal carcinoma in situ and a family history of breast cancer. The other patient is a male-to-female transsexual with invasive ductal carcinoma that was occult on diagnostic digital mammographic and ultrasound findings but visualized on digital breast tomosynthesis and breast MR images. The analysis of the eight previously reported cases showed that breast cancer in male-to-female transsexuals occurs at a younger age and is more frequently estrogen receptor negative than breast cancer in others born biologically male. Screening for breast cancer in male-to-female transsexuals should be undertaken for those with additional risk factors (e.g., family history, BRCA2 mutation, Klinefelter syndrome) and should be available to those who desire screening, preferably in a clinical trial.

Dense Breast Tissue Notification: Impact on Women’s Perceived Risk, Anxiety, and Intentions for Future Breast Cancer Screening

PURPOSE The aim of this study was to explore how women respond to the wording of dense breast tissue notifications, which are increasingly required by state law after mammography. The specific aims were to (1) determine whether perceived lifetime risk for breast cancer and intentions to undergo mammography increase after reviewing a sample notification, (2) explore individual difference variables (eg, minority status, insurance coverage) that may influence intentions for additional ultrasound screening, and (3) assess whether anxiety mediates the relationship between perceived risk and screening intentions. METHODS A total of 184 women aged >40 years in the United States were recruited from Amazon Mechanical Turk to respond to a dense breast tissue notification as if they had personally received it. RESULTS After reviewing a notification, women reported greater perceived risk (d = 0.67) and intentions to undergo mammography (d = 0.25) than before. Most women intended to undergo additional ultrasound screening, although to a lesser extent when ultrasound was covered by insurance than when it was not (d = 1.03). All screening intentions were lower in women with ambiguity aversion, a tendency to avoid tests without medical consensus, and those who preferred an active decision-making role. Anxiety mediated the relationship between perceived breast cancer risk and all screening intentions. CONCLUSIONS Women who receive dense breast tissue notifications may generally increase their breast cancer screening intentions; however, intention strength varies depending on internal (eg, ambiguity aversion) and external (eg, insurance for ultrasound) factors. Although perceived risk increases after notification, it is anxiety that drives womens intentions for future screening.

The chest radiologist's role in invasive breast cancer detection

PURPOSE To assess the ability of chest CT to identify patients needing further evaluation of the breasts. METHODS IRB approval was obtained with a waiver of consent. Women with chest CT and mammogram within 12months formed the cohort. A breast assessment and recommendation CT score (BARCS) analogous to mammographic BI-RADS was created and compared to the mammogram BI-RADS. RESULTS BARCS and mammographic BI-RADS management recommendations were concordant for 77.1%. 11 invasive cancers were detected; all by mammogram while CT missed 2. CONCLUSION BARCS score should be studied in prospective trials. Chest CT might be the earliest opportunity to detect breast cancer.

Incremental Role of Mammography in the Evaluation of Gynecomastia in Men Who Have Undergone Chest CT

OBJECTIVE The purpose of this study was to determine whether additional breast imaging is clinically valuable in the evaluation of patients with gynecomastia incidentally observed on CT of the chest. MATERIALS AND METHODS In a retrospective analysis, 62 men were identified who had a mammographic diagnosis of gynecomastia and had also undergone CT within 8 months (median, 2 months). We compared the imaging findings of both modalities and correlated them with the clinical outcome. RESULTS Gynecomastia was statistically significantly larger on mammograms than on CT images; however, there was a high level of concordance in morphologic features and distribution of gynecomastia between mammography and CT. In only one case was gynecomastia evident on mammographic but not CT images, owing to cachexia. Two of the 62 men had ductal carcinoma, which was obscured by gynecomastia. Both of these patients had symptoms suggesting malignancy. CONCLUSION The appearance of gynecomastia on CT scans and mammograms was highly correlated. Mammography performed within 8 months of CT is unlikely to reveal cancer unless there is a suspicious clinical finding or a breast mass eccentric to the nipple. Men with clinical symptoms of gynecomastia do not need additional imaging with mammography to confirm the diagnosis if they have undergone recent cross-sectional imaging.

The general radiologist's role in breast cancer risk assessment: breast density measurement on chest CT☆

To determine if general radiologists can accurately measure breast density on low-dose chest computed tomographic (CT) scans, two board-certified radiologists with expertise in mammography and CT scan interpretation, and seven general radiologists performed retrospective review of 100 womens low-dose chest CT scans. CT breast density grade based on Breast Imaging Reporting and Data System grades was independently assigned for each case. Kappa statistic was used to compare agreement between the expert consensus grading and those of the general radiologists. Kappa statistics were 0.61-0.88 for the seven radiologists, showing substantial to excellent agreement and leading to the conclusion that general radiologists can be trained to determine breast density on chest CT.

Early discussion of breast density and supplemental breast cancer screening: is it possible?

The purpose of this study is to determine whether it is possible to make breast cancer screening more efficient in those with dense breasts. Over 12 states require that patients with dense breasts receive notification about their breast density in lay letters that are sent after the screening mammogram. Some of these letters advise patients to speak with their primary care providers about the possibility of supplemental breast cancer screening. We sought to determine whether primary care providers can discuss breast density and recommend supplemental breast cancer screening using the density of the previous mammography. This would reduce the burden of additional appointments and might increase the number of patients choosing to have supplemental screening. The mammographic breast density of 250 consecutive patients from May 2011 to September 2011 was compared with the immediate prior mammogram. Patients whose prior mammograms were more than 36 months prior or less than 8 months prior to the current exam were excluded, leaving 217 patients. The proportion of patients with breast density change was analyzed. The concordance of breast density between the two exams was assessed and the effects of patient age and the length of time between mammograms were examined. The breast density of the current and most recent prior mammogram was stable for 86.6% of patients. Neither age nor length of time between mammograms affected concordance. Primary care providers can decrease the need for multiple appointments and decrease patient anxiety by discussing breast density and screening choices prior to the patients screening mammography. The great majority of patients will receive the correct information about their breast density by using a prior report.

Mammographic Screening for Breast Cancer: 2010

Recently, the US Preventive Services Task Force (USPSTF) guidelines concerning analog screening mammography were revised. Despite the breast cancer death rate falling by 30% since 1990 and mammography receiving the lions share of credit for the decrease, the USPSTF no longer advises routine screening mammography for women aged 40-49. Biennial screening is advised for those aged 50-74. The USPSTF did not make a recommendation regarding screening those aged > or = 75. The recommendations do not cover digital mammography. It is necessary for primary care providers to understand the data so they can assist patients making decisions about breast cancer screening.

Cellular fibroadenoma on Core needle biopsy: management recommendations for the radiologist

INTRODUCTION Cellular fibroadenomas (CFA) are difficult to distinguish from phyllodes tumor (PT) at biopsy. This studys purpose was to determine what CFA characteristics were associated with recommendations to follow-up or excise and if the current algorithm was correct. MATERIALS AND METHODS Databases from 2002 to 2014 were reviewed. Mass characteristics and post biopsy recommendations were recorded. RESULTS 81 CFAs were diagnosed; 19 cellular and 62 with slightly cellular stroma. 21 masses were surgically excised with 2 PTs diagnosed. CONCLUSION Larger mass size and increased histologic cellularity were associated with excision recommendation, but only clinical growth was associated with PT.

Breast Magnetic Resonance Imaging: An Overview for Nonradiologists

Magnetic resonance imaging is a major component of breast imaging. Many studies have shown that magnetic resonance imaging is the most sensitive imaging method for detecting invasive breast cancer in comparison with mammography, ultrasound, and clinical breast examinations. Evidence-based clinical indications for breast magnetic resonance imaging include screening patients at high risk for breast cancer, including those with breast/ovarian cancer genes (BRCA1 and BRCA2), those who are untested first-degree relatives of carriers of these genes, those whose lifetime risk of developing breast cancer is 20% to 25% or greater, those who had chest radiation when they were 10 to 30 years old, and those who have or are first-degree relatives of people with Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome. Breast magnetic resonance imaging is performed in conjunction with mammography and does not replace mammography. Outside of the screening population, utilization of breast magnetic resonance imaging for newly diagnosed breast cancer patients and its use as a problem-solving technique for equivocal mammographic or clinical findings remain controversial. An understanding of the current evidence facilitates appropriate utilization of this important medical resource. This article discusses indications for ordering breast magnetic resonance imaging and how to read the breast magnetic resonance imaging report and understand the lexicon used.

Fully automated breast density assessment from low-dose chest CT

Breast cancer is the most common cancer diagnosed among US women and the second leading cause of cancer death 1 . Breast density is an independent risk factor for breast cancer and more than 25 states mandate its reporting to patients as part of the lay mammogram report 2 . Recent publications have demonstrated that breast density measured from low-dose chest CT (LDCT) correlates well with that measured from mammograms and MRIs 3-4 , thereby providing valuable information for many women who have undergone LDCT but not recent mammograms. A fully automated framework for breast density assessment from LDCT is presented in this paper. The whole breast region is first segmented using an anatomy-orientated novel approach based on the propagation of muscle fronts for separating the fibroglandular tissue from the underlying muscles. The fibroglandular tissue regions are then identified from the segmented whole breast and the percentage density is calculated based on the volume ratio of the fibroglandular tissue to the local whole breast region. The breast region segmentation framework was validated with 1270 LDCT scans, with 96.1% satisfactory outcomes based on visual inspection. The density assessment was evaluated by comparing with BI-RADS density grades established by an experienced radiologist in 100 randomly selected LDCT scans of female subjects. The continuous breast density measurement was shown to be consistent with the reference subjective grading, with the Spearman’s rank correlation 0.91 (p-value < 0.001). After converting the continuous density to categorical grades, the automated density assessment was congruous with the radiologist’s reading in 91% cases.