Luciano Fernandes Chala

Mammography-based screening program: preliminary results from a first 2-year round in a Brazilian region using mobile and fixed units

BackgroundBreast cancer is the most frequently diagnosed cancer and the leading cause of cancer deaths among women worldwide. The use of mobile mammography units to offer screening to women living in remote areas is a rational strategy to increase the number of women examined. This study aimed to evaluate results from the first 2 years of a government-organized mammography screening program implemented with a mobile unit (MU) and a fixed unit (FU) in a rural county in Brazil. The program offered breast cancer screening to women living in Barretos and the surrounding area.MethodsBased on epidemiologic data, 54 238 women, aged 40 to 69 years, were eligible for breast cancer screening. The study included women examined from April 1, 2003 to March 31, 2005. The chi-square test and Bonferroni correction analyses were used to evaluate the frequencies of tumors and the importance of clinical parameters and tumor characteristics. Significance was set at p < 0.05.ResultsOverall, 17 964 women underwent mammography. This represented 33.1% of eligible women in the area. A mean of 18.6 and 26.3 women per day were examined in the FU and MU, respectively. Seventy six patients were diagnosed with breast cancer (41 (54%) in the MU). This represented 4.2 cases of breast cancer per 1000 examinations. The number of cancers detected was significantly higher in women aged 60 to 69 years than in those aged 50 to 59 years (p < 0.001) or 40 to 49 years (p < 0.001). No difference was observed between women aged 40 to 49 years and those aged 50 to 59 years (p = 0.164). The proportion of tumors in the early (EC 0 and EC I) and advanced (CS III and CS IV) stages of development were 43.4% and 15.8%, respectively.ConclusionsPreliminary results indicate that this mammography screening program is feasible for implementation in a rural Brazilian territory and favor program continuation.

Can Doppler or contrast-enhanced ultrasound analysis add diagnostically important information about the nature of breast lesions?

OBJECTIVES: Despite evidence suggesting that Doppler ultrasonography can help to differentiate between benign and malignant breast lesions, it is rarely applied in clinical practice. The aim of this study was to determine whether certain vascular features of breast masses observed by duplex Doppler and color Doppler ultrasonography (before and/or after microbubble contrast injection) add information to the gray-scale analysis and support the Breast Imaging-Reporting and Data System (BI-RADS) classification. METHODS: Seventy solid lesions were prospectively evaluated with gray-scale ultrasonography, color Doppler ultrasonography, and contrast-enhanced ultrasonography. The morphological analysis and lesion vascularity were correlated with the histological results. RESULTS: Percutaneous core biopsies revealed that 25/70 (17.5%) lesions were malignant, while 45 were benign. Hypervascular lesions with tortuous and central vessels, a resistive index (RI)≥0.73 before contrast injection, and an RI≥0.75 after contrast injection were significantly predictive of malignancy (p<0.001). CONCLUSION: The combination of gray-scale ultrasonography data with unenhanced or enhanced duplex Doppler and color Doppler US data can provide diagnostically useful information. These techniques can be easily implemented because Doppler devices are already present in most health centers.

MRI to Predict Nipple Involvement in Breast Cancer Patients

OBJECTIVE The selection of breast cancer patients as candidates for nipple-sparing mastectomy (NSM) is dependent on the preoperative detection of neoplastic involvement of the nipple-areola complex (NAC). This cross-sectional study was designed to evaluate the accuracy of preoperative breast MRI as a noninvasive method to predict neoplastic involvement of the nipple. MATERIALS AND METHODS We included 165 female breast cancer patients with a surgical plan that included total mastectomy or breast conservation surgery with the removal of the NAC. All patients underwent MRI before surgery on a 1.5-T unit with a 4-channel in vivo dedicated surface breast coil. One radiologist who was blinded to the results of the histologic evaluations of the specimens evaluated the MRI studies. RESULTS Of the 170 mastectomy specimens evaluated, 37 (21.8%) had neoplastic involvement of the NAC. The MRI findings of enhancement between the index lesion and the NAC and of nipple retraction were considered statistically significant predictors of nipple involvement in breast cancer patients (p < 0.01 and p = 0.01, respectively). The negative predictive value of the combination of these MRI findings was 83.3%. CONCLUSION Breast MRI is a safe noninvasive method to preoperatively evaluate breast cancer patients eligible for NSM with a high specificity and a high negative predictive value when enhancement between the index lesion and the nipple and nipple retraction are analyzed.

Observer Variability in the Application of Morphologic and Dynamic Criteria According to the BI-RADS for MRI

To the Editor: Magnetic resonance (MR) imaging of the breast has evolved into an important adjunctive tool in breast imaging for the detection, diagnosis, and staging of breast cancer (1–3). As breast MR has become more available and used, standardization of terminology has become necessary. A standardized terminology was developed by the American College of Radiology (4) to facilitate communication among physicians, to bring uniformity to the interpretation of breast MR and to improve the specificity of the method. To test the reproducibility of the descriptors from the BI-RADS for MR, 109 enhancing lesions (Table 1) were independently interpreted by four radiologists. The observers were grouped into pairs based on their experience. The first pair consisted of radiologists with at least 11 years experience in breast imaging. The second pair consisted of breast-imaging fellows who were at the end of their fellowship program. Before the beginning of the study, all observers reviewed the descriptors proposed by the MR BI-RADS. Only images that showed the enhancing lesion on the dynamic sequence and the T2 images of the corresponding area were displayed for review in the workstation. The observers detailed the morphologic and dynamic descriptors, final assessment categories and management recommendations for each enhancement, initially without clinical or other imaging modalities information. For the dynamic analysis, each observer traced the curve at the moment of the review. Then, clinical and other imaging modalities information was made available and the observers described the final assessment and recommendations again. The final assessment category 1 was not included, because all the examinations displayed enhancement. Associated features were not independently evaluated, although the presence of any suspicious associated features might have influenced the radiologists’ final assessment. BI-RADS final categories 2 and 3 were combined for the analysis and considered a negative study. The final categories 0, 4, 5 or 6 were considered positive. Kappa statistics were calculated to assess the proportion of agreement beyond that expected by chance (Table 2). The moderate agreement obtained among the experienced observers for mass morphology could reflect the familiarity with the mammographic and sonographic descriptors. Despite the association reported in the literature between rim enhancement and malignancy and nonenhancing septa and fibroadenoma, we could not measure the agreement for these two descriptors because not all observers used them to characterize the masses. This could reflect difficulty to correctly apply terms that are unique to MR or could be associated with the fact that the ‘‘mass-internal enhancement’’ could be divided into two major subgroups: homogeneous and heterogeneous. And specific terms as dark internal septation or rim enhancement were substituted for a more broad definition under the heterogeneous type of enhancement, artificially increasing the concordance for this descriptor. Greater discordance among all observers was measured for the distribution of non-mass enhancements. This could be related to the fact that the non-mass categorization is exclusive to MR. Ikeda et al. demonstrated that readers agreed more when they were asked to use familiar rather than unfamiliar terms (5). Also, there is some overlap among the descriptors for non-mass distribution; this could decrease the degree of concordance, because the descriptors could be erroneously used as synonyms. In order to avoid misuse of the terms, the ductal and segmental descriptors could Address correspondence and reprint requests to: Paula de Camargo Moraes, Rua Saturno, 420, Zip code 015031-030, Aclimação – São Paulo, SP, Brazil, or e-mail: moraespc@terra.com.br.

Nonnecrotizing systemic granulomatous panniculitis involving the breast: imaging correlation of a breast cancer mimicker.

2Departamento de Anatomia Patologica do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil. anniculitis is an inflammatory process of the subcutaneous tissue. Immunologic, traumatic, metabolic, paraneoplastic, and infectious causes have been implicated, and in some cases, the condition is idiopathic [1]. Panniculitis typically involves the subcutaneous tissue of the lower extremities but can affect fat tissue in other locations, such as the viscera. Breast involvement is rare and can be mistaken for cancer at clinical examination and on imaging studies. Most of the cases of breast involvement described in the literature have been reported as a component of WeberChristian disease [2, 3]. We report the clinical, mammographic, sonographic, and MRI features and course of disease of a patient with chronic nonnecrotizing systemic panniculitis affecting the breasts.

Breast Cancer Screening: Updated Recommendations of the Brazilian College of Radiology and Diagnostic Imaging, Brazilian Breast Disease Society, and Brazilian Federation of Gynecological and Obstetrical Associations

1Coordinator of the National Mammography Commission, Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR), São Paulo, SP, Brazil 2Member of the National Mammography Commission, Representative of the Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR), São Paulo, SP, Brazil 3Member of the National Mammography Commission, Representative of the Sociedade Brasileira de Mastologia (SBM), São Paulo, SP, Brazil 4Member of the National Mammography Commission, Representative of the Federação Brasileira das Associações de Ginecologia e Obstetrícia (Febrasgo), Rio de Janeiro, RJ, Brazil

Breast cancer screening: updated recommendations of the Brazilian College of Radiology and Diagnostic Imaging, Brazilian Breast Disease Society, and Brazilian Federation of Gynecological and Obstetrical Associations

Objective To present the current recommendations for breast cancer screening in Brazil, as devised by the Brazilian College of Radiology and Diagnostic Imaging, the Brazilian Breast Disease Society, and the Brazilian Federation of Gynecological and Obstetrical Associations. Materials and methods We analyzed scientific studies available in the Medline and Lilacs databases. In the absence of evidence, the recommendations reflected the consensus of a panel of experts. Recommendations Annual mammography screening is recommended for women 40-74 years of age. Among women ≥ 75 years of age, annual mammography screening should be reserved for those with an expected survival > 7 years. Complementary ultrasound should be considered for women with dense breasts. Complementary magnetic resonance imaging is recommended for women at high risk. When available, an advanced form of mammography known as tomosynthesis can be considered as a means of screening for breast cancer.

Abstract P4-02-04: Magnetic resonance imaging to predict nipple involvement in breast cancer patients

Introduction. The implementation of Nipple-Sparing Mastectomy (NSM) as a treatment option for selected cases of breast cancer has risen great interest among breast surgeons. The preservation of the nipple-areola complex (NAC) can lead to extremely favorable psychological effects in breast cancer patients treated with this type of procedure. However, to ensure the oncologic safety of this technique it is of utmost importance to evaluate the likelihood of NAC involvement pre-operatively. In this study we evaluate the contribution of Breast Magnetic Resonance Imaging (MRI) in predicting the involvement in the NAC in breast cancer patients. Materials and Methods: We studied 170 mastectomy specimens from 165 breast cancer patients (five patients had bilateral disease) affected by Ductal Carcinoma in situ (DCIS)(n=19) or Invasive Ductal Carcinoma (n=151), stages I, II or IIIA. Every patient was pre-operatively studied using a 1.5 Tesla, 4-channel in vivo dedicated surface breast coil MRI. The parameters we investigated were: type of index lesion enhancement pattern (nodular or non-nodular), size of the index lesion, enhancement between the index lesion and the NAC, enhancement of the nipple, thickening of the areola, nipple retraction and size of the nipple in comparison with the contra-lateral nipple. The retro-areolar area and papilla were evaluated in histological sections of 4μm to identify DCIS and Invasive Ductal or Lobular carcinomas. One radiologist, blinded to the result of the histological evaluation of the papillae, performed the evaluation of the MRIs. Results. In univariate analysis, type of lesion enhancement in MRI, enhancement between index lesion and the papilla, distance between the index lesion and the papilla, enhancement of the papilla and nipple retraction had a statistically significant correlation with neoplastic involvement of the NAC (p Conclusion. We can conclude that the probability of the NAC being cancer-free is around 90% when there is no enhancement between the index lesion and the nipple, and there is no retraction of the nipple in the pre-operative MRI study of the breast. Citation Format: Piato JR, Chala LF, Alves-Jales RD, Doria MT, Mota BS, Messias AP, Goncalves R, Mano MS, Soares JM, de Barros N, Filassi JR, Baracat EC. Magnetic resonance imaging to predict nipple involvement in breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-02-04.