Rebecca Leddy

Assessing the role of ultrasound in predicting the biological behavior of breast cancer.

OBJECTIVE The purpose of this article is to correlate various ultrasound features of breast cancer with tumor grade, and with estrogen, progesterone, and ERRB2 (formerly HER2) receptor status as well as to assess the predictive value of these features. MATERIALS AND METHODS The features of breast cancers found by using ultrasound between January 2010 and June 2011 were reviewed for tumor size, margins, and posterior acoustic features. The tumor margins were classified into spiculated, angular, indistinct, lobulated or microlobulated, and circumscribed. The posterior acoustic features were classified into shadowing, enhancement, mixed pattern, and no change. The individual features were correlated with the estrogen receptor (ER)-progesterone receptor (PR) and ERRB2 receptor status and tumor grade. RESULTS Among 160 patients with breast cancer, 102 (63.8%) were ER-positive/PR-positive, 32 (20.0%) were ER-positive/PR-negative, and 26 (16.3%) were ER-negative/PR-negative (22 were triple-negative). Tumors with posterior shadowing have greater than nine times the odds of having ER-positive findings (95% CI, 2.09-40.81; p = 0.011) and greater than 13 times the odds of having a lower-grade tumor (I or II vs III; 95% CI, 4.90-36.54; p < 0.001) than those without posterior shadowing. Tumors with posterior enhancement have greater than eight times the odds of having at least one negative receptor (95% CI, 3.97-18.11; p < 0.001) and 24 times the odds of having a high-grade tumor (95% CI, 9.91-58.14; p < 0.001) than those without posterior enhancement. CONCLUSION The presence of posterior shadowing is strongly associated with an ER-positive and low-grade tumor, whereas the presence of posterior enhancement is strongly associated with a high-grade tumor and with moderate risk of being receptor negative.

Review of Metaplastic Carcinoma of the Breast: Imaging Findings and Pathologic Features

Metaplastic carcinoma (MPC), an uncommon but often aggressive breast cancer, can be challenging to differentiate from other types of breast cancer and even benign lesions based on the imaging appearance. It has a variable pathology classification system. These types of tumors are generally rapidly growing palpable masses. MPCs on imaging can present with imaging features similar to invasive ductal carcinoma and probably even benign lesions. The purpose of this article is to review MPC of the breast including the pathology subtypes, imaging features, and imaging pathology correlations. By understanding the clinical picture, pathology, and overlap in imaging characteristics of MPC with invasive ductal carcinoma and probably benign lesions can assist in diagnosing these difficult malignancies.

Comparative accuracy of preoperative tumor size assessment on mammography, sonography, and MRI: Is the accuracy affected by breast density or cancer subtype?

To compare the accuracy of preoperative breast tumor size measurements obtained on three imaging modalities (mammography [MM], sonography [US], and MRI) with those obtained on final pathologic examination for different breast densities and various tumor types.

Correlation of sonographic features of invasive ductal mammary carcinoma with age, tumor grade, and hormone-receptor status.

To determine whether presenting sonographic features of invasive ductal carcinomas (IDC) are associated with patient age, tumor histologic grade, and hormonal receptor status.

Effects of Changes in BI-RADS Density Assessment Guidelines (Fourth Versus Fifth Edition) on Breast Density Assessment: Intra- and Interreader Agreements and Density Distribution.

OBJECTIVE The objective of our study was to determine intra- and interreader agreements for density assessment using the fifth edition of the BI-RADS guidelines and to compare with those for density assessment using the fourth edition of the BI-RADS guidelines. MATERIALS AND METHODS Five radiologists assessed breast density four times in 104 mammographic examinations: twice using the fourth edition of the BI-RADS guidelines and twice using the fifth edition. The intra- and interreader agreements for density assessment based on each guideline were determined and compared. The density distribution pattern under each of the four BI-RADS density categories using each guideline was also noted and compared. RESULTS The intrareader agreement for density assessment using the fifth-edition criteria was lower than that using the fourth-edition criteria (p = 0.0179). The overall intrareader agreement (weighted kappa) using the old criteria was 0.84 (95% CI, 0.80-0.87), and the individual intrareader agreement values in five readers ranged from 0.78 (95% CI, 0.69-0.88) to 0.92 (95% CI, 0.87-0.97). The overall intrareader agreement using the new BI-RADS criteria was 0.77 (95% CI, 0.73-0.81), and the individual intrareader agreement values in five readers ranged from 0.74 (95% CI, 0.64-0.84) to 0.99 (95% CI, 0.98-1.00). The interreader agreement values obtained using the fifth-edition criteria were also lower than those obtained using the fourth-edition criteria (p = 0.006). The overall interreader agreement using the old BI-RADS criteria was 0.65 (95% CI, 0.61-0.69), whereas the overall interreader agreement using the new BI-RADS criteria was 0.57 (95% CI, 0.53-0.61). Overall a higher number of dense assessments were given when the fifth-edition guidelines were used (p < 0.0001). CONCLUSION Compared with the intra- and interreader agreements obtained using the fourth edition of the BI-RADS guidelines, the intra- and interreader agreements were lower using the fifth-edition guidelines. An increased number of dense assessments were given when the fifth-edition guidelines were used.

Mammographic detection of breast arterial calcification as an independent predictor of coronary atherosclerotic disease in a single ethnic cohort of African American women

OBJECTIVE Accumulating data on predominantly Caucasian women suggests an association between breast arterial calcification (BAC) and coronary artery disease (CAD). We sought to comprehensively examine the correlation between mammographic BAC and CAD endpoints detected by cardiac computed tomography (CCT) in African American (AA) women. METHODS Consecutive AA women who underwent digital screening mammography and CCT were identified. In blinded fashion, mammographic and CCT studies were reviewed. Patient-related pertinent covariates were assessed. RESULTS Two-hundred-four AA women (median age, 52.5 years) were included. BAC was present in 42 women (20.6%). BAC was significantly associated with coronary artery calcium score >100 (odds ratio [OR], 7.66; 95% confidence interval [CI], 2.75-21.29; P < 0.001), atherosclerotic luminal narrowing (OR, 9.99; CI, 3.65-27.32; P < 0.001), and stenosis ≥50% (OR, 5.48; CI, 1.97-15.23; P = 0.001) by CCT. CONCLUSION In AA women, BAC is associated with increased probability of coronary calcification, atherosclerosis, and CAD on CCT.

Role of Breast Ultrasound and Mammography in Evaluating Patients Presenting with Focal Breast Pain in the Absence of a Palpable Lump

To determine if ultrasound and/or mammography is helpful in detecting breast cancers in patients presenting with focal breast pain. Patients who presented between February 2008 and April 2011 with focal breast pain without a lump were included in the study. The mammographic and US findings were retrospectively reviewed. BIRADS 0, 4, and 5 were considered positive on mammogram while BIRADS 4 and 5 were considered positive on US. The efficacy of mammogram‐alone, ultrasound‐alone, and in combination to detect breast cancer was evaluated. The performance of mammography for detecting any mass lesions that were present on subsequent US was also evaluated. A total of 257 patients were evaluated with US and 206 (80.1%) of these also had mammograms prior to the US. Cancer incidence was 1.2% (n = 3). The sensitivity, specificity, PPV, and NPV of mammogram‐alone and US‐alone for detection of breast cancer in these patients were 100%, 87.6%, 10.7%, 100% and 100%, 92.5%, 13.6%, and 100%, respectively, while for combined mammogram and US was 100%, 83.7%, 8.3%, and 100%. The sensitivity, specificity, PPV, and NPV of mammogram for identifying an underlying suspicious mass lesion that was subsequently detected by US was 58%, 91%, 39%, and 95%. The NPV of a BIRADS 1 mammogram for any underlying mass lesion was 75%. Addition of an ultrasound to a mammogram did not detect additional cancers; likely due to low cancer incidence in these patients. However, US detected underlying mass lesions in 25% cases with a BIRADS 1 mammogram result.

Primary Sarcoid of the Breast with Incidental Malignancy

Breast sarcoidosis is rare and usually presents in patients with known sarcoid involving other organ systems. In the breast, sarcoidosis may mimic malignancy which must be excluded by core biopsy. We report a very unusual case of primary breast sarcoidosis with incidentally discovered breast carcinoma. The roles of mammography, ultrasound, and MRI in the diagnosis as well as other potential differential diagnosis are discussed.

Asymptomatic Incidental Ductal Carcinoma in situ in a Male Breast Presenting with Contralateral Gynecomastia

Ductal carcinoma in situ (DCIS) in males is rare and usually presents with symptoms on the affected side, such as, palpable mass or bloody nipple discharge. Even as DCIS has been reported in conjunction with gynecomastia in the same breast, we report an unusual case of a 62-year-old Caucasian male, with no family history of breast cancer, who presented with symptomatic side gynecomastia, and was incidentally found to have DCIS in a completely asymptomatic left breast. To the best of our knowledge, this case is the first report in literature of asymptomatic, incidentally discovered DCIS in a male patient.

Mammographic and Sonographic Characteristics of a Cavernous Hemangioma in a Male Patient

Vascular tumors of the breast, including benign hemangiomas, are infrequently encountered. These lesions are especially rare in the male breast, with only several case reports in the literature. We report a case of a pathologically diagnosed cavernous hemangioma in a male breast and describe the imaging characteristics.