Sebastião Piato

Appearence of breast masses on sonoelastography with special focus on the diagnosis of fibroadenomas

The aim of this study was to show and correlate the imaging features of breast masses, especially fibroadenomas, using sonoelastography. Two hundred thirty-five patients with 302 breast lesions referred for core needle biopsy participated in the study. All lesions appearing as solid masses on conventional US were included. Out of the included lesions (270), 115 (42.6%) corresponded to histologically confirmed fibroadenomas and 155 (57.4%) to lesions with histologically confirmed diagnoses other than fibroadenomas. These were further subdivided into fibrocystic changes, lesions with low malignancy potential, and malignant lesions. Fibroadenomas were also divided according to histological presentation into three subgroups to allow comparative study based on elastographic scores. All lesions were classified using a four-point scoring system based on ultrasound elastography imaging characteristics. Different presentations were observed for elastographic scores according to histological presentation of fibroadenomas, whereby fibroadenomas with benign characteristics tended to have elastographic classification similar to fibrocystic changes, and complex and hypercellular fibroadenomas had classifications similar to harder lesions. Fibroadenomas are generally classified as category 3 in the BI-RADS® lexicon and are the most commonly found lesions in breast biopsies. Sonoelastography can provide additional information to conventional studies and be used as an auxiliary tool in assessing these masses in clinical practice.

Correlation of cyclooxygenase-2 and aromatase immunohistochemical expression in invasive ductal carcinoma, ductal carcinoma in situ, and adjacent normal epithelium

SummaryThe purpose of our study was to evaluate the correlation between cyclooxygenase-2 (COX-2) and aromatase immunohistochemical expression in ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) present in the same breast, as well as in adjacent stroma and normal epithelium, we still correlated with nuclear grade, histologic grade, presence or absence of comedonecrosis, tumor size, and age at diagnosis. Forty-seven cases were evaluated through the use of anti-aromatase and anti-COX-2 polyclonal antibodies. Making the correlation of COX-2 and aromatase expression, we observed that COX-2 expression in IDC was correlated with aromatase expression in IDC (p<0.001), DCIS (p<0.001), normal epithelium (p=0.024), and stroma tumor (p<0.001). When the correlation was made between COX-2 expression in DCIS with aromatase, we observed positive correlation in IDC (p<0.001), DCIS (p<0.001), normal epithelium (p=0.013), and stroma tumor (p<0.001). In the correlative analysis of COX-2 expression in normal epithelium with aromatase in different evaluated tissues, we observed the following statistical results: IDC (p<0.001), DCIS (p<0.001), normal epithelium (p=0.005), and stroma tumor (p=0.047). Our results demonstrate the high correlation between COX-2 and aromatase expression in IDC, DCIS and normal epithelium, showing the importance of these two enzymes in the induction, promotion and progression of breast cancer.

Valores preditivos das categorias 3, 4 e 5 do sistema BI-RADS em lesões mamárias nodulares não-palpáveis avaliadas por mamografia, ultra-sonografia e ressonância magnética

OBJECTIVE: To evaluate the predictive value of BI-RADS™ categories 3, 4 and 5 in non-palpable breast masses assessed by mammography, ultrasound and magnetic resonance imaging MATERIALS AND METHODS: Twenty-nine patients with BI-RADS categories 3, 4 and 5 nonpalpable breast masses identified by mammograms were submitted to complementary ultrasound and magnetic resonance imaging studies, besides excisional biopsy. In total, 30 biopsies were performed. The lesions as well as their respective BI-RADS classification into 3, 4 and 5 were correlated with the histopathological results. The predictive values calculation was made by means of specific mathematical equations. RESULTS: Negative predictive values for category 3 were: mammography, 69.23%; ultrasound, 70.58%; and magnetic resonance imaging, 100%. Positive predictive values for category 4 were: mammography, 63.63%; ultrasound, 50%; and magnetic resonance imaging, 30.76%. For category 5, positive predictive values were: mammography and ultrasound, 100%; and magnetic resonance imaging, 92.85%. CONCLUSION: For category 3, the negative predictive value of magnetic resonance imaging was high, and for categories 4 and 5, the positive predictive values of the three modalities were moderate.OBJECTIVE: To evaluate the predictive value of BI-RADS™ categories 3, 4 and 5 in non-palpable breast masses assessed by mammography, ultrasound and magnetic resonance imaging MATERIALS AND METHODS: Twenty-nine patients with BI-RADS categories 3, 4 and 5 nonpalpable breast masses identified by mammograms were submitted to complementary ultrasound and magnetic resonance imaging studies, besides excisional biopsy. In total, 30 biopsies were performed. The lesions as well as their respective BI-RADS classification into 3, 4 and 5 were correlated with the histopathological results. The predictive values calculation was made by means of specific mathematical equations. RESULTS: Negative predictive values for category 3 were: mammography, 69.23%; ultrasound, 70.58%; and magnetic resonance imaging, 100%. Positive predictive values for category 4 were: mammography, 63.63%; ultrasound, 50%; and magnetic resonance imaging, 30.76%. For category 5, positive predictive values were: mammography and ultrasound, 100%; and magnetic resonance imaging, 92.85%. CONCLUSION: For category 3, the negative predictive value of magnetic resonance imaging was high, and for categories 4 and 5, the positive predictive values of the three modalities were moderate.

Apresentação das lesões mamárias císticas à ultra-sonografia utilizando a elastografia

OBJECTIVE: To demonstrate the most frequent features of cystic breast lesions at ultrasound elastography, discussing the applicability of this method. MATERIALS AND METHODS: The present casuistic included 150 patients referred for percutaneous breast biopsy of 175 lesions. Histologically diagnosed solid lesions (153 lesions) were excluded; lesions histologically diagnosed as cystic (22 lesions), including complicated cysts, papillary lesions, inflammatory lesions, typical columnar cell hyperplasia and duct ectasia were retrospectively classified by means of elastography, according to a scoring system developed by the authors, with categories ranging between 1 and 4. RESULTS: Thirteen (59%) of the 22 lesions evaluated corresponded to cysts, one (4.6%) to duct ectasia, two (9.2%) to inflammatory lesions, five (22.6%) to papillary lesions, and one (4.6%) to columnar cell hyperplasia. The scoring system was applied with the following results: 17 category 2 lesions, four category 3 lesions, one category 4 lesion, and none category 1 lesion, with a 95% specificity. CONCLUSION: Different features of cystic breast lesions are demonstrated by elastography according to histological results, representing a useful and easily applicable method for differentiating benign from malignant breast lesions.

Diagnostic underestimation of atypical ductal hyperplasia and ductal carcinoma in situ at percutaneous core needle and vacuum-assisted biopsies of the breast in a Brazilian reference institution

Objective To determine the rates of diagnostic underestimation at stereotactic percutaneous core needle biopsies (CNB) and vacuum-assisted biopsies (VABB) of nonpalpable breast lesions, with histopathological results of atypical ductal hyperplasia (ADH) or ductal carcinoma in situ (DCIS) subsequently submitted to surgical excision. As a secondary objective, the frequency of ADH and DCIS was determined for the cases submitted to biopsy. Materials and Methods Retrospective review of 40 cases with diagnosis of ADH or DCIS on the basis of biopsies performed between February 2011 and July 2013, subsequently submitted to surgery, whose histopathological reports were available in the internal information system. Biopsy results were compared with those observed at surgery and the underestimation rate was calculated by means of specific mathematical equations. Results The underestimation rate at CNB was 50% for ADH and 28.57% for DCIS, and at VABB it was 25% for ADH and 14.28% for DCIS. ADH represented 10.25% of all cases undergoing biopsy, whereas DCIS accounted for 23.91%. Conclusion The diagnostic underestimation rate at CNB is two times the rate at VABB. Certainty that the target has been achieved is not the sole determining factor for a reliable diagnosis. Removal of more than 50% of the target lesion should further reduce the risk of underestimation.

Elastography: Theory into Clinical Practice

To the Editor:Ultrasonography has increasingly been consideredas a useful tool for the diagnosis and management ofbreast lesions (1). With the introduction of highfre-quency digital transducers ranging from 7 to 14 mHz,it is now possible to assess the morphology of theselesions and to categorize them according to the criteria suggested by the most recent BIRADS lexicon (2).However, the study of undetermined masses remains agreat challenge as these lesions present benign sonographic features but no additional data that allowthem to be classified as benign (3). Trials are beingconducted using complementary diagnostic methodsthat allow the categorization of theses masses asbenign, probably benign or suspicious for malignancyand in this context elastography is a promising devel-opment (47).The ultrasound elastography study represents anextension of the most ancient tool used in medicine,i.e., palpation, where the physician assesses the shapeand rigidity of the target organ (8). When externalpressure is applied (stress) onto a target area, thispressure causes tissue deformation (strain). Using specific softwares, tissue deformation is expressed ascolor variation on the ultrasound and may be n usefultool, particularly for the study of breast lesions basedon the assumption that malignant lesions tend to be510 times more rigid than benign (47).This technique was first described by JonathanOphir et al. (4) during the 1990s. Currently, there aretwo main research lines to determine ultrasound elas-tography clinical applicability. The first line ofresearch is based on the assessment of the mass sizebefore and after compressing the target areas with theuse of a software that makes soft lesions appearlighter and rigid lesions appear darker, and in whichmalignant lesions tend to appear more evident thanthe benign lesions (5,6). The other research line isbased on the use of a software that applies a differentcolor spectrum to tissues according to their rigidity,ranging from red to soft tissues, green to intermediatetissues, and dark blue to rigid tissues (Figs. 1 and 2)(7). There is no consensus as to which is the best technique or a classification defining its clinical application, which main limitations are the interobservervariability described in previous studies and how compression should be performed for the study.In a recent study conducted at Santa Casa deMiserico´rdia de Sa˜o Paulo and Centro de TomografiaComputadorizada (CTCGeˆnese) using the ultrasoundsystem Sonix SP (Ultrasonix Medical Corporation,Vancouver, BC, Canada) with multifrequency linearprobes of 514 MHz, and a special software designedfor the device, 256 lesions were evaluated based onthe color spectrum variability. Lesions were classified,using a 4point scoring system developed by theauthors, in two phases: during compression and afterdecompression (almost static compressions). From 256lesions, 215 were benign and 41 malignant; the positive predictive value was 81.8%, the negative predictive value was 97.17%, sensibility was 85.71%,specificity was 96.26%, and the diagnostic accuracywas 94.53%. When compared with conventionalultrasound, a significant improvement in the ability ofobservers to distinguish benign from malignant lesionswas observed (Fig. 3). Through the comparison ofimages during compression and after decompression,it is possible to create parameters to compare thebehavior of target lesions with the adjacent breast tis-sue. The variation in lesion size seen during the studywas not considered a good diagnostic criterion as themargins were not well defined during the dynamicstudy and this was believed to have contributed forthe interobserver variability described in previousseries.The main application of elastography is in the complementary study of undetermined masses, usuallyclassified as BIRADS 3, which mainly comprise complicated cysts, fibroadenomas, and carcinomas withatypical appearance. These lesions are often source ofanxiety, stress, and fear for patients who frequentlyend up choosing to have a biopsy to histologically

Cyclooxygenase-2 and human epidermal growth factor receptor type 2 (HER-2) expression simultaneously in invasive and in situ breast ductal carcinoma

CONTEXT AND OBJECTIVE Cyclooxygenase-2 (COX-2) and human epidermal growth factor receptor type 2 (HER-2) are associated with tumorigenesis. Studies have shown that HER-2 can regulate COX-2 expression. The aim of this study was to evaluate the correlation between COX-2 and HER-2 expression in normal breast epithelium and in ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) present in the same breast. DESIGN AND SETTING Cross-sectional study at the Mastology Unit of the Department of Gynecology and Obstetrics, Santa Casa de Misericórdia de São Paulo Hospital. METHODS COX-2 and HER-2 were detected using immunohistochemistry on 100 tissue fragments. HER-2 > +2 was subjected to fluorescence in situ hybridization (FISH). RESULTS COX-2 expression was detected in 87%, 85% and 75% of IDC, DCIS and normal epithelium, respectively. HER-2 expression was detected in 34% of IDC and 34% of DCIS. COX-2 in DCIS correlated with HER-2 in IDC (P = 0.049) and DCIS (P = 0.049). COX-2 in normal epithelium correlated with HER-2 in IDC (P = 0.046) and DCIS (P = 0.046). COX-2 in IDC was not associated with HER-2 (P = 0.235). Comparison between COX-2 and HER-2 in DCIS showed that there was a statistically significant difference with regard to nuclear grades II and III and presence of comedonecrosis (P < 0.001). In IDC, there was significant expression with nuclear grades II and III and histological grade II (P < 0.001). CONCLUSIONS Our findings provide evidence that HER-2 and COX-2 regulate each other.

Proposta de sistematização do estudo elastográfico de lesões mamárias pela ultrassonografia

OBJECTIVE: Proposal of systematization for the elastographic study in the ultrasound routine. METHODS: Evaluation was made of 308 patients forwarded to the breast intervention service in the CTC-Genesis from May 1, 2007 to March 1, 2008 to perform percutaneous breast biopsy. Prior to the percutaneous biopsy, an ultrasound study and an elastography were performed. Lesions were primarily analyzed and classified according to the Bi-Rads® lexicon criteria by the conventional ultrasound scan (B mode). The elastography was then performed and analyzed in accordance with the systematization proposed by the authors, using images obtained during compression and after decompression of the area of interest. Lesions were classified following the system developed by the authors using a four-point scale, where scores (1) and (2) were considered benign, score (3) probably benign and score (4) suspicion of malignancy. Results obtained by the two methods were compared with the histological results using the areas within the ROC (receiver operator curves) curves. RESULTS: The area within the curve for elastography was of 0.952 with a confidence interval between 0.910 and 0.966, error of 0.023, and of 0.867 with a confidence interval between 0.823 and 0.903, error of 0.0333 for the ultrasound. When the areas were compared, a difference between the curves of 0.026 was observed, which was statistically significant. CONCLUSION: This work shows the systematization of the elastographic study using information obtained during compression and after decompression of the ultrasound scan sample, thus showing that elastography might enhance the assessment of risk of malignancy for lesions characterized by the ultrasound.

Predictive values of BI-RADS® magnetic resonance imaging (MRI) in the detection of breast ductal carcinoma in situ (DCIS)

PURPOSE The purpose of this study was to evaluate BI-RADS indicators in the detection of DCIS by MRI. MATERIALS AND METHODS Prospective observational study that started in 2014 and lasted 24 months. A total of 110 consecutive patients were evaluated, who presented with suspicious or highly suspicious microcalcifications on screening mammography (BI-RADS categories 4 and 5) and underwent stereotactic-guided breast biopsy, having had an MRI scan performed prior to biopsy. RESULTS Altogether, 38 cases were characterized as positive for malignancy, of which 25 were DCIS and 13 were invasive ductal carcinoma cases. MRI had a sensitivity of 96%; specificity of 75.67%; positive predictive value (PPV) for DCIS detection of 57.14%; negative predictive value (NPV) in the detection of DCIS of 98.24%; and an accuracy of 80.80%. CONCLUSION BI-RADS as a tool for the detection of DCIS by MRI is a powerful instrument whose sensitivity was higher when compared to that observed for mammography in the literature. Likewise, the PPV obtained by MRI was higher than that observed in the present study for mammography, and the high NPV obtained on MRI scans can provide early evidence to discourage breast biopsy in selected cases.

Comparison of Fetal Nuchal Fold Thickness Measurements by Two- and Three-Dimensional Ultrasonography (3DXI Multislice View).

Purpose. To compare the measurements of fetal nuchal fold (NF) thickness by two-dimensional (2D) and three-dimensional (3D) ultrasonography using the three-dimensional extended imaging (3DXI). Methods. A cross-sectional study was performed with 60 healthy pregnant women with a gestational age between 16 and 20 weeks and 6 days. The 2D-NF measurements were made as the distance from the outer skull bone to the outer skin surface in the transverse axial image in the suboccipital-bregmatic plane of the head. For the 3D we employed the 3DXI multislice view software, in which 3 × 2 tomographic planes was displayed on the screen and the distance between the tomographic slices was 0.5 mm. Maximum, minimum, mean, and standard deviation were calculated for 2D and 3D ultrasonography, as well the maximum and minimum, mean, and standard deviation for the difference between both methods. The Wilcoxon signed-rank test was used to compare the two different techniques. Results. 2D-NF showed a mean of thickness of 3.52 ± 0.95 mm (1.69–7.14). The mean of 3D-NF was 3.90 ± 1.02 mm (2.13–7.72). The mean difference between the methods was 0.38 mm, with a maximum difference of 3.12 mm. Conclusion. The NF thickness measurements obtained by 3D ultrasonography were significantly larger than those detected with 2D ultrasonography.