Tanya W. Stephens

Surgical decision making and factors determining a diagnosis of breast carcinoma in women presenting with nipple discharge

BACKGROUND There is no consensus about the use of the various diagnostic tests and surgical procedures available to confirm or rule out breast cancer in patients presenting with nipple discharge. This study was designed to identify patient and nipple-discharge characteristics associated with the diagnosis of breast cancer and to determine the utility of mammography, sonography, ductography, and cytology in surgical decision making in patients presenting with pathologic nipple discharge. STUDY DESIGN We reviewed the medical records of all patients who presented with nipple discharge at our institution between August 1993 and September 2000. Patient and nipple-discharge characteristics and findings on imaging studies and cytologic examination were analyzed. RESULTS A total of 146 patients presented at our institution with nipple discharge during the study period. Of these, 52 had clinically benign discharge and were managed without surgical intervention; 94 patients had pathologic discharge and underwent a biopsy procedure for histologic diagnosis, treatment, or both. Logistic regression analysis identified mammographic (relative risk [RR] = 10.47, 95% confidence interval [CI] 2.36 to 46.39, p = 0.0002) and sonographic (RR = 5.54, 95% CI 1.27 to 25.40, p = 0.028) abnormalities as independent factors associated with a malignant diagnosis. Nineteen cancers, 62 papillomas, and 13 other benign lesions were identified among the patients with pathologic discharge. In 3 patients with cancer (15.8%) and 30 patients with a papilloma (48.4%), ductography was the only means of identifying lesions to be resected. Patients who underwent ductography-guided operation (n = 42, 50%) or any surgical procedure including a localization study (n = 66, 78.6%) were significantly more likely than patients who underwent central duct excision alone to have a specific underlying lesion identified (p = 0.045 and p = 0.033, respectively). CONCLUSIONS Abnormalities on mammography and sonography in patients with nipple discharge should alert physicians to the possibility of a breast cancer diagnosis. In patients with pathologic discharge with normal findings on physical examination and other imaging studies, ductography might be the only means of localizing and resecting breast lesions associated with nipple discharge.

The Many Faces of Fat Necrosis in the Breast

OBJECTIVE This article describes the manifestations of fat necrosis on mammography, sonography, and MRI and correlates the imaging findings with the pathologic findings. CONCLUSION On imaging studies, the appearance of fat necrosis ranges from typically benign to worrisome for malignancy. Mammography is more specific than sonography, and emphasis should be placed on mammography in making the diagnosis of fat necrosis. In selected cases, MRI may be helpful in showing findings consistent with fat necrosis.

Primary Breast Cancer in Men: Clinical, Imaging, and Pathologic Findings in 57 Patients

OBJECTIVE The purpose of our study was to describe the imaging findings in primary breast cancer in men. MATERIALS AND METHODS Male patients from a single pathology database with the histologic diagnosis of breast cancer who had undergone preoperative mammography or sonography were included in this study. The mammograms and sonograms were retrospectively reviewed according to the American College of Radiology BI-RADS lexicon. Patients who did not have films available but had imaging reports available for review were also included. Sonograms of the regional nodal basins, including axillary, infraclavicular, internal mammary, and supraclavicular regions, were noted. Histopathology subtype of breast cancer and axillary nodal status were documented. RESULTS A total of 57 patients with imaging and 187 patients without imaging were included. The median age was 62 years (range, 19-80 years). Forty-nine patients had undergone both mammography and sonography; six, mammography alone; and two, sonography alone. Ninety-five percent (54/57) of patients presented with a palpable mass and 4% (2/57) with nipple inversion. At mammography, 69% (38/55) of cancers showed a mass; 29% (16/55), mass with microcalcifications; and 2% (1/55), microcalcifications. Gynecomastia was noted in 22 (40%) of 55 patients. Mammographic features included an irregular mass with spiculated or indistinct margins. Calcifications were typically pleomorphic and segmental. Sonographic features were typically an irregular mass with microlobulated margins. Axillary nodal involvement was present in 47% of patients. Most cancers were ductal carcinoma, either invasive or in situ. CONCLUSION Breast cancer in men characteristically presents as an irregular subareolar mass with spiculated or indistinct margins on mammography and can be associated with calcifications and gynecomastia. Sonography has a role in regional staging of lymph nodes.

Microcalcification detectability for four mammographic detectors: Flat‐panel, CCD, CR, and screen/film

Amorphous silicon/cesium iodide (a-Si:H/CsI:Tl) flat-panel (FP)-based full-field digital mammography systems have recently become commercially available for clinical use. Some investigations on physical properties and imaging characteristics of these types of detectors have been conducted and reported. In this perception study, a phantom containing simulated microcalcifications (microCs) of various sizes was imaged with four detector systems: a FP system, a small field-of-view charge coupled device (CCD) system, a high resolution computed radiography (CR) system, and a conventional mammography screen/film (SF) system. The images were reviewed by mammographers as well as nonradiologist participants. Scores reflecting confidence ratings were given and recorded for each detection task. The results were used to determine the average confidence-rating scores for the four imaging systems. Receiver operating characteristics (ROC) analysis was also performed to evaluate and compare the overall detection accuracy for the four detector systems. For calcifications of 125-140 microm in size, the FP system was found to have the best performance with the highest confidence-rating scores and the greatest detection accuracy (Az = 0.9) in the ROC analysis. The SF system was ranked second while the CCD system outperformed the CR system. The p values obtained by applying a Student t-test to the results of the ROC analysis indicate that the differences between any two systems are statistically significant (p<0.005). Differences in microC detectability for the large (150-160 microm) and small (112-125 microm) size microC groups showed a wider range of p values (not all p values are smaller than 0.005, ranging from 0.6 to <0.001) compared to the p values obtained for the medium (125-140 microm) size microC group. Using the p values to assess the statistical significance, the use of the average confidence-rating scores was not as significant as the use of the ROC analysis p value for p value.

Timed efficiency of interpretation of digital and film-screen screening mammograms.

OBJECTIVE Our objective was to compare interpretation speeds for digital and film-screen screening mammograms to test whether other variables might affect interpretation times and thus contribute to the apparent difference in interpretation speed between digital mammograms and film-screen mammograms, and to test whether the use of digital rather than film comparison studies might result in significant time savings. MATERIALS AND METHODS Four readers were timed in the course of actual clinical interpretation of digital mammograms and film-screen mammograms. Interpretation times were compared for subgroups of studies based on the interpretation of the study by BI-RADS code, the number of images, the presence or absence of comparison studies and the type of comparison study, and whether the radiologist personally selected and hung additional films; the same comparisons were made among individual readers. RESULTS For all four readers, mean interpretation times were longer for digital mammograms than for film-screen mammograms, with differences ranging from 76 to 202 seconds. The difference in interpretation speed between digital and film-screen mammograms was independent of other variables. Digital mammogram interpretation times were significantly longer than film-screen mammogram interpretation times regardless of whether the digital mammograms were matched with film or digital comparison studies. CONCLUSION In screening mammography interpretation, digital mammograms take longer to read than film-screen mammograms, independent of other variables. Exclusive use of digital comparison studies may not cause interpretation times to drop enough to approach the interpretation time required for film-screen mammograms.

Snakules: A Model-Based Active Contour Algorithm for the Annotation of Spicules on Mammography

We have developed a novel, model-based active contour algorithm, termed “snakules”, for the annotation of spicules on mammography. At each suspect spiculated mass location that has been identified by either a radiologist or a computer-aided detection (CADe) algorithm, we deploy snakules that are converging open-ended active contours also known as snakes. The set of convergent snakules have the ability to deform, grow and adapt to the true spicules in the image, by an attractive process of curve evolution and motion that optimizes the local matching energy. Starting from a natural set of automatically detected candidate points, snakules are deployed in the region around a suspect spiculated mass location. Statistics of prior physical measurements of spiculated masses on mammography are used in the process of detecting the set of candidate points. Observer studies with experienced radiologists to evaluate the performance of snakules demonstrate the potential of the algorithm as an image analysis technique to improve the specificity of CADe algorithms and as a CADe prompting tool.

Measuring Intra- and Inter-Observer Agreement in Identifying and Localizing Structures in Medical Images

Inter- and intra-observer variability exists in any measurements made on medical images. There are two sources of variability. The first occurs when the observers identify and localize the object of interest, and the second happens when the observers make appropriate measurement on the object of interest. A number of statistical methods are available to quantify the degree of agreement between measurements made by different observers. However, little has been done to develop metrics for quantifying the variability in identifying and localizing the objects of interest prior to measurement. In this paper, we propose to use the complex wavelet structural similarity index (CW-SSIM) method to measure the variability in identifying and localizing structures on images. Performance comparisons using simulated images as well as real mammography images demonstrate the effectiveness and robustness of the CW-SSIM method.

Myeloid sarcoma of the urinary bladder and epididymis as a primary manifestation of acute myeloid leukemia with inv(16)

Myeloid sarcoma (MS) of the lower urinary tract is rare. We describe a 47-year-old man with hematuria, who was subsequently found to have MS involving bladder and epididymis. The neoplasm was composed predominantly of blasts that expressed CD68, CD117, myeloperoxidase, and lysozyme, with occasional immature eosinophils. Although blood and bone marrow examinations showed no morphologic evidence of leukemia, conventional cytogenetic studies of marrow demonstrated inv(16)(p13q22) in 4 of 20 metaphases; fluorescence in situ hybridization of the bladder neoplasm also showed inv(16). Following chemotherapy, the patient has been in complete remission for 32 months. In our literature review, we identified 7 cases of MS involving bladder, only 3 without evidence of an associated myeloid neoplasm in marrow, none with cytogenetic data. A high index of suspicion is required to establish the diagnosis of MS involving bladder. Cytogenetic analysis is useful for both demonstrating minimal marrow disease and classifying MS in paraffin-embedded tissue sections.

Rosai-Dorfman Disease of the Breast

1All authors: Division of Diagnostic Imaging, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 57, Houston, TX 77030. Address correspondence to G. J. Whitman (gwhitman@di.mdacc.tmc.edu). 53-year-old woman presented with an ill-defined mass in the left breast on screening mammography. There was no evidence of a palpable abnormality, skin changes, or nipple discharge. Laboratory tests revealed a mild normocytic anemia and an elevated erythrocyte sedimentation rate. Mammography (Fig. 1A) of the left breast showed a 1.5-cm high-density mass with indistinct margins in the 7:00 position, 8 cm from the nipple. Sonography (Fig. 1B) showed an ill-defined, hypoechoic mass, which correlated with the mammographic finding. A sonographyguided needle core biopsy was performed, followed by a stereotactic vacuum-assisted core biopsy. Histopathology (Fig. 1C) revealed a polymorphous infiltrate of histiocytes, mature-appearing lymphocytes, and plasma cells surrounded by areas of fibrosis. The histiocytes were large with round nuclei, a single eosinophilic nucleolus, and abundant pale cytoplasm. Many of the histiocytes contained lymphocytes in cytoplasmic vacuoles, a finding referred to as emperipolesis. Immunohistochemical stains performed on fixed, paraffin-embedded tissue sections showed that the histiocytes expressed S-100 protein, A

Challenges in Mammography: Part 1, Artifacts in Digital Mammography

OBJECTIVE Early detection of breast cancer is directly related to the radiologists ability to detect abnormalities visible only on mammograms. Artifacts on mammograms reduce image quality and may present clinical and technical difficulties for the radiologist, mammography technologist, medical physicist, and equipment service personnel. CONCLUSION In this article, we will illustrate the appearance of artifacts in full field digital mammography, review the causes of these artifacts, and discuss methods to eliminate artifacts in digital mammography.