Imaging techniques in breast cancer

Imaging is the mainstay in breast cancer diagnosis, with mammography being the primary screening tool used to detect small/asymptomatic cancers. Symptomatic patients undergo triple assessment which includes a clinical assessment, imaging and, if indicated, an image-guided biopsy for histological diagnosis. We discuss current and emerging breast imaging techniques used in breast cancer care. These include mammography, digital breast tomosynthesis, ultrasound and magnetic resonance. We also discuss image-guided biopsy and miscellaneous image-guided interventions that influence the management of breast cancer care.     

Incidence of abnormal mammograms after reduction mammoplasty: implications for oncoplastic closure

Background

Reduction mammoplasty requires significant tissue dissection, which may impact the interpretation of future mammograms used in breast cancer surveillance. The aim of this study was to define the incidence of abnormal mammography after reduction mammoplasty and to assess the impact of substantial tissue remodeling on interpreting mammography.

Methods

We conducted a single-center retrospective case-control study examining results of postoperative mammography after reduction mammoplasty over a 5-year period.

Results

Between 2001 and 2005, 87 patients underwent breast reduction and had available postoperative mammography. A control group of 30 patients were identified who underwent consultation for breast reduction but did not have surgery. The median time to postoperative mammography was 52 weeks. The incidence of abnormal first postoperative mammogram (Breast Imaging-Reporting and Data System [BIRADS] 0, 3–6) was not significantly different between reduction mammoplasty patients and controls (n = 23, 26% vs 8, 27%, respectively, P = 1.00). Age, postoperative complications, tissue pathology, history of previous breast biopsy, and abnormal preoperative mammography did not significantly predict abnormal postoperative mammogram. Postoperative mammography led to additional imaging in 20 patients (23%) and breast biopsy in 1 patient (1.1%).

Conclusions

Despite the substantial tissue mobilization performed during reduction mammoplasty, postoperative screening mammography does not lead to significantly more imaging or diagnostic interventions when compared with nonoperative controls. This small case-control study suggests that oncoplastic closure techniques should not adversely impact subsequent mammography.     

中国乳腺X线筛查项目中联合应用超声检查的价值

目的：评估在乳腺X线摄片基础上联合应用超声检查在乳腺筛查中的价值。方法：选取复旦大学附属肿瘤医院通过乳腺筛查项目筛查出,并在初筛时同时行乳腺X线摄片和超声检查的40岁以上女性乳腺癌病人。分析单用乳腺X线摄片、单用超声和在乳腺X线摄片基础上联合应用超声在检出恶性病例时的诊断灵敏度,并进一步分析单用乳腺X线摄片和在乳腺X线摄片基础上联合应用超声的诊断灵敏度与年龄及腺体致密度间的关系。结果：筛查发现并符合入组标准的乳腺癌病例共42例,单用乳腺X线摄片、单用超声和在乳腺X线摄片基础上联合应用超声的诊断灵敏度分别为81.0%、64.3%、95.2%,单用乳腺X线摄片和在乳腺X线摄片基础上联合应用超声的诊断灵敏度差异有统计学意义（P〈0.05）。多量型和致密型乳腺,在乳腺X线摄片基础上联合应用超声的诊断灵敏度比单用乳腺X线摄片高,其差异有统计学意义（P〈0.05）,但在年轻女性（50岁以下）中,没有发现差异（P〉0.05）。结论：乳腺X线摄片诊断灵敏度高于乳腺超声检查,在乳腺X线摄片基础上联合应用超声可提高乳腺筛查的诊断灵敏度,在乳腺X线摄片基础上联合应用超声推荐用于腺体密度较高的乳腺筛查。     

Clinically occult breast carcinoma: Diagnostic approaches and role of axillary node dissection

Background: Nonpalpable breast lesions are being detected with increasing frequency with the advent of improved mammographic techniques. Although only 20–30% of these lesions are malignant, definitive diagnosis has usually required a needle-localization excisional biopsy, which is costly and increases the psychological stress on the patient. The purpose of this retrospective study was to determine the sensitivity of ultrasound-guided fine-needle aspiration (FNA) biopsy of nonpalpable breast masses and the incidence of axillary nodal metastases in these subclinical lesions. Methods: Seventy-one patients treated for clinically occult malignant breast tumors between 1985 and 1992 were identified. Charts were reviewed to determine the accuracy of breast ultrasonography in detecting occult mass lesions and whether ultrasound guidance improved the accuracy of FNA biopsy. In addition, the incidence of axillary lymph node involvement was noted. Results: Of the 71 malignant tumors, 35 were in situ and 36 were invasive. The median diameter was 0.5 cm for noninvasive lesions and 0.8 cm for invasive tumors. A mass was seen on mammography in 32 (45%) patients, microcalcifications were seen in 36 (51%), and both a mass and microcalcifications were seen in three (4%). Of the 30 patients who underwent an axillary node dissection, 4 (13%) had disease-positive nodes. Ultrasound-guided FNA was performed in 15 patients with a mass lesion, with a sensitivity of 93%. Conclusions: These results indicate that ultrasound-guided FNA cytologic analysis is an accurate diagnostic technique even in small (<1 cm), mammographically detected breast masses. In addition, the incidence of axillary nodal metastases indicates that an axillary lymph node dissection should be performed in invasive lesions, even those <1 cm in diameter.     

超声检测乳腺癌微小钙化的影响因素及与钼靶X线摄影的对比

【摘要】〓目的〓比较超声与钼靶X线摄影检测乳腺癌微小钙化的一致性,探讨影响超声检测乳腺癌微小钙化的影响因素。方法〓87例乳腺癌行超声及钼靶X线摄影检查,分析二者的乳腺病灶及微小钙化的特点,比较二者检测的一致性,分析超声检测微小钙化的影响因素。结果〓超声对病灶的显示率及诊断恶性的准确率均高于钼靶(χ2=9.911,P=0.002)。二者在微小钙化的检出方面无统计学差异(P>0.05),具有较高的一致性(k=0.652)。以钼靶显示微小钙化作为标准,超声检测微小钙化的敏感度为82.1%,特异度为83.3%,假阳性率16.7%,假阴性率为17.9%。钼靶上微小钙化的大小及密集程度影响其超声检测(P<0.05)。结论〓超声较钼靶X线摄影能更敏感地检测及诊断乳腺恶性病变;超声能有效地检测乳腺癌微小钙化,但易受微小钙化的大小及密集程度的影响。     

Value of 99mTc-MIBI scintimammography in women with impalpable breast lesions seen on mammography.

OBJECTIVE: To find out if 99mTc-methoxyisobutylisonitrile scintimammography (MIBI) is useful in the evaluation of impalpable breast lesions in women referred for biopsy after mammography screening. DESIGN: Observational and prospective study. SETTING: Radiological screening campaign in Spain. PATIENTS: 36 patients referred between September 1997 and June 1998 (37 biopsies) with impalpable breast lesions referred consecutively from a screening campaign. Ages ranged from 50 to 64 years. INTERVENTIONS: Mammography, ultrasound, MIBI, and wire-guided biopsy. MAIN OUTCOME MEASURES AND RESULTS: Mean values for sensitivity, specificity, positive predictive value, and negative predictive value for scintimammography were 78.9, 72.2, 75, and 76.5 respectively (p = 0.002). The logistic regression analysis showed that 99mTc-MIBI scintimammography result predicted (p = 0.003) the risk of breast cancer in this group of patients (odds ratio: 9.75), particularly infiltrating ductal carcinoma. CONCLUSIONS: MIBI scintimammography in patients referred for biopsy after mammography screening does not so much rule out cancer as confirm the diagnosis. Its practical benefit would be not so much avoiding biopsy for these patients as aiding in planning the radicality of their excision.     

Ultrasound-guided biopsy of nonpalpable breast masses by surgeons

Background: Recently, ultrasound (US)-guided needle biopsy has been proposed as an acceptable alternative to open biopsy in women with nonpalpable breast masses. This study evaluated the accuracy of US-guided needle biopsy of nonpalpable breast masses performed by surgeons at the time of the initial clinical examination. Methods: Ultrasound-guided aspiration and/or core biopsy (US-GAB) was performed on 103 patients presenting with a nonpalpable, new, or increasing-size mass detected on mammography. Study patients included those whose US was classified as: fibroadenoma (FA) (n=26), complex cyst (n=32), indeterminate (complex cyst versus solid; N=24), or suspect (n=21). Results: Of the 32 patients with diagnostic US of complex cyst, US-GAB confirmed 27 to be cysts. Twelve additional cysts were aspirated among the 24 indeterminate lesions. Sixteen FA were diagnosed on US-GAB; 11 of these underwent open biopsy and each was demonstrated to be a FA. Fibrocystic/benign-breast change (FBC) was diagnosed on 26 US-GAB; 15 of these underwent open biopsy, which demonstrated three FA and 12 FBC. Nine atypical lesions were diagnosed on US-GAB; six FBC, one papilloma, one FA, and one cancer were demonstrated on open biopsy. Seven cancers were diagnosed on US-GAB and all were confirmed on open biopsy. There were six insufficient specimens from US-GAB; four of these underwent open biopsy, which demonstrated two FA and two FBC. Conclusion: Ultrasound-guided aspiration and/or core biopsy performed by surgeons in conjunction with the initial clinical examination can accurately diagnose nonpalpable, mammographically detected breast masses. Results of this study were presented at the 48th Annual Cancer Symposium of The Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.     

Ten years follow-up of histologically benign calcifications in the breast after vacuum-assisted stereotactic biopsy (VASB): Is additional mammographic follow-up warranted?

ObjectiveThis study assessed the short-term and the long-term breast cancer rate in patients with benign histopathologic results after a vacuum-assisted stereotactic biopsy (VASB) for calcifications.MethodsIn a retrospective cohort study, all consecutive patients who had a benign diagnosis after VASB to analyze breast calcifications. Data of breast cancer development at short-term (four years) and long-term follow-up was gathered. Breast cancer rates in our cohort were compared to the breast cancer incidence in the general population.ResultsOf 1376 patients who underwent VASB to analyze breast calcifications, 823 had a benign histopathologic diagnosis. During short-term follow-up, eight patients developed breast cancer. During the mean long-term follow-up period of 9.3 ± 3.1 years, 22 patients were diagnosed with ipsilateral breast cancer. The incidence rate of breast cancer after benign biopsy was comparable to the rate in the general population.ConclusionIn patients with VASB-confirmed benign calcifications of the breast, we found no excess incidence of ipsilateral breast cancer during ten years follow-up. Therefore, in patients with an increased risk of breast cancer (due to a history of breast cancer or familial risk) annual mammography should be sufficient. Patients with a population-based risk may be monitored via biennial mammography by the national screening program. More frequent screening would provide no benefit.     

Laser therapy for small breast cancers

BACKGROUND: Widespread mammography has resulted in the increased detection of breast cancer <1.5 cm. It may be possible to treat these small tumors with in-situ laser ablation. Prior to ablation tumor size is determined by ultrasound and mammogram. Histologic diagnosis and determination of prognostic factors are obtained from image-guided needle core samples. Invasive and in-situ tumors may be percutaneously ablated by a stereotactically guided laser needle and subsequently evaluated by imaging methods and needle biopsy. METHODS: Fifty-four patients (50 invasive, 4 in-situ); 51 mass, 3 microcalcification; mean diameter 12 (5 to 23) mm were treated by a stereotactically guided 805 nm laser beam via a fiber in a 16G needle delivered to the cancer. One to 8 weeks later the coagulated lesions were surgically removed for pathologic evaluation. In 2 additional patients, the laser-treated tumors were not removed but were monitored by mammography, ultrasonography, and needle core biopsy. RESULTS: None of the patients sustained any adverse effect. The average treatment time was 30 minutes. Pathology analysis revealed a 2.5 to 3.5 hemorrhagic ring surrounding the necrotic tumor. Under steady conditions, in two groups of 14 patients, 93% and 100% of the tumors showed complete destruction, with no residual cancer report. In the 2 unresected cases kept under surveillance for 6 to 24 months, the laser-treated tumors first showed shrinkage, followed by a 2 to 3 cm oil cyst. Fibrosis was demonstrated on needle core biopsies. CONCLUSIONS: Laser energy delivered through a stereotactically guided needle appears to ablate mammographically detected breast cancer. A multicenter clinical trail is planned.     

The role of mammography in detecting breast cancer in augmented breasts

Recent reports suggest that mammographic findings may be compromised in patients who have undergone augmentation mammoplasty. Therefore, early detection of breast cancer by mammography may be obscured. We reviewed records for our patients with breast cancer after augmentation mammoplasty to define further the role and accuracy of mammography. Six patients aged 34 to 52 years (mean, 42 years) had a diagnosis of breast carcinoma 4 to 14 years (mean, 7.2 years) after augmentation mammoplasty. Five patients had preoperative mammographic examinations. Suspicious lesions were seen in 4 patients, and microcalcifications were identified in the fifth. The sixth patient had a normal xeromammogram. Pathological diagnosis was infiltrating ductal carcinoma in 5 patients and intraductal carcinoma in 1. Findings for lymph nodes were negative in 3 patients; 2 others had positive findings in one lymph node, and 1 had positive results in four lymph nodes. Five patients had a suspicious mass that was palpated on self-examination or by the patient's plastic surgeon, and the sixth patient had a routine screening mammogram. Two of 3 patients with positive lymph nodes received adjuvant chemotherapy. This report confirms the role of mammography as a screening tool in making the diagnosis of breast cancer in women who have undergone augmentation mammoplasty. The importance of self-examination and follow-up by the plastic surgeon is stressed. The data suggest that mammography remains an accurate method for detecting breast lesions.     

Occult breast carcinoma in patients undergoing reduction mammaplasty

Seven patients who had breast reduction surgery and whose preoperative physical examinations were unremarkable were found to have brest carcinoma. In the five in whom mastectomy was performed, most closures were difficult, and in one patient bilateral mastectomy was complicated by wound dehiscence. In only one of these seven was it possible to obtain information regarding the hormonal binding status of the tumor cells. These and other sequelae would not have occured had the tumors been diagnosed before operation. Because physical examination alone is not sufficiently sensitive for the diagnosis of breast cancer, we suggest that mammography be included in the evaluation of patients consulting surgeons for breast reduction.     

A Giant Mammary Hamartoma in a Young Breast Cancer Patient

BackgroundHamartomas of the breast are rare benign tumors. Pre- and also postoperative differentiation from other benign or even malignant tumors is challenging.Case PresentationA 36-year-old female presented with a giant tumor of the left breast. The patient had suffered from an early breast cancer of the contralateral right breast the year before, which was treated with breast-conserving therapy, radiation, and endocrine therapy ever since. The hamartoma was classified as BI-RADS 2 in mammography and BI-RADS 4 in ultrasound. On clinical examination, a tumor of nearly 15 cm in size led to an abstruse deformity of the breast and the nipple-areola complex. We found an indolent, grand bulging tumor with an elastic texture directly beneath the skin. A biopsy that had been performed before was compatible with the suspected hamartoma. Because of the remaining diagnostic uncertainties after contralateral breast cancer and the progressive malformation of the left breast, a tumor extirpation utilizing a reduction mammaplasty was performed without complications. Subsequent genetic analyses excluded a loss of PTEN in this patient.ConclusionWe presented the rare case of a 36-year-old woman with a history of breast cancer and a 700-g breast hamartoma. The preoperative and even the postoperative specification of a hamartoma remains challenging, and associations with genetic alterations should be considered.     

结合弹性成像调整超声BI-RADS分级后对乳腺肿块的诊断价值

目的分析超声BI-RADS分级在结合弹性成像并调整分级后对乳腺肿块的诊断价值。 方法回顾性分析2016年1月至12月南方医科大学附属东莞人民医院进行手术或活检获得病理结果的乳腺肿块,比较术前常规超声BI-RADS分级（US-BI-RADS）和结合弹性成像并调整后的BI-RADS分级（UE-BI-RADS）诊断乳腺肿块的价值。 结果US-BI-RADS对3~5级病灶诊断恶性的阳性预测值分别为0.86%、6.80%、26.04%、71.58%、91.25%;UE-BI-RADS分别为0.57%、6.67%、31.91%、79.31%、96.77%。US-BI-RADS诊断乳腺恶性肿瘤的敏感度为82.22%,特异度为88.43%,约登指数为0.71,ROC曲线下面积为0.919;UE-BI-RADS诊断的敏感度为87.18%,特异度为88.98%,约登指数为0.76,ROC曲线下面积为0.941。 结论UE-BI-RADS能提高超声对乳腺恶性病变的诊断价值;对US-BI-RADS 4级以上的病灶,有必要进行弹性成像后调整评分。     

Outcomes of patients with lobular in situ neoplasia of the breast: The role of vacuum-assisted biopsy

ObjectivesTo audit the outcomes of patients with non-pleomorphic lobular in situ neoplasia (LISN) of the breast and clarify the role of vacuum-assisted biopsy (VAB), surgical biopsy and conservative management for this condition.Materials and methodA single-centre retrospective review of hospital databases covering a 14-year period was performed. Patients with LISN as the most pertinent diagnosis on core needle biopsy (CNB), vacuum-assisted biopsy (VABs) or surgical biopsy were identified. The radiological features, histopathological findings and outcome of subsequent annual mammography were recorded.ResultsBetween 1998 and 2012 there were 70 patients with LISN as the most pertinent diagnosis at CNB, VAB or surgery. 52 underwent VAB, typically 18 11-gauge samples. The pathology was upgraded from the preceding 14-gauge CNB in 7 cases. Of 11 patients who underwent surgery after VAB, one (who had undergone a low tissue yield VAB) was upgraded. There were no new breast cancers during a mean annual mammographic follow-up period of 53 months in 40 patients who had VAB with complete radiological-histopathological concordance.ConclusionProvided there is adequate tissue sampling and radiological-pathological concordance, VAB is a safe alternative to open biopsy in the management of non-pleomorphic LISN.     

Imaging Characteristics of Male Breast Disease

Abstract: The purpose of the study was to describe the imaging findings of male breast disease. One hundred and sixty‐four male patients, who underwent mammography and ultrasonography (US) between January 1999 and December 2008, were retrospectively evaluated. Seventy‐five patients (46%) underwent biopsy, and 89 patients (54%) were diagnosed radiologically. The radiologic and pathologic diagnoses in 164 cases of this series were 13 cancers (8%), including one ipsilateral and one contralateral breast cancers, 147 cases of gynecomastia (90%), one fibroadenoma (0.6%), two cases of fibrocystic disease of the breast (1.2%), and one epidermoid inclusion cyst (0.6%). Three mammographic patterns were adequate to describe all 147 cases of gynecomastia in our series: 53 patients (36%) had nodular gynecomastia, 46 patients (31%) had dendritic gynecomastia, and 48 patients (33%) had diffuse gynecomastia. Gynecomastia was unilateral in 65% of cases (n = 95), and bilateral in 35% of cases (n = 52). On physical examination, two of the malignant lesions had no clinic features of malignancy (15%). On mammography, 11 of 13 malignant masses were demonstrated (85%). A mass with microcalcifications was seen on mammograms in one case (9%). The contours of the masses were irregular in nine cases (82%), well‐circumscribed in two cases (18%). The location of the masses was retroareolar in seven cases (64%) and eccentric to the nipple in four cases (36%). The size of the masses varied between 0.5 cm and 5 cm (mean 2.4 cm). Nipple retraction was evident in five cases (45%), and skin thickening in four cases (36%). All of the malignant masses were demonstrated on ultrasound; however, one of them was seen retrospectively after mammography. All of the masses were hypoechoic and solid, the contours were well‐defined and smooth in two masses (15%), and irregular in 11 masses (85%), and five masses (39%) had posterior prominent shadowing. Axillary lymphadenopathia was detected in two cases (15%). One patient had a previous contralateral breast cancer, and one had an ipsilateral. On mammography, breast cancer characteristically exhibits an irregular subareolar mass, nipple retraction, and skin ulceration or thickening, but sometimes breast cancer has a well‐circumscribed contour and punctuated microcalcifications. Ultrasonography is essential and useful for further characterization and helpful for demonstrating lymphadenopathies of the axillary region.     

乳腺髓样癌的超声造影特征与病理对照

目的分析乳腺髓样癌的超声造影特征,并与病理学对照。方法回顾性分析13例乳腺髓样癌患者的超声造影形态学特征,比较造影前后肿块横径、肿块与周围乳腺正常组织的时间-强度曲线定量参数,并进行统计学分析。将超声造影表现与病理表现相对照。结果乳腺髓样癌超声造影显示肿块形态不规则、边界清晰、内部均匀增强分别为10、11、11例,与病理形态学特征相符合。造影前后肿块横径差异无统计学意义(P=0.61),与病理学膨胀性生长方式相符合。与周围乳腺正常组织相比,髓样癌造影剂到达时间和达峰时间显著提前(P=0.034、0.021),峰值强度显著提高(P=0.005),与病理学上病灶内血管密度增高且分布均匀、病灶周边有较大管径血管的特征相符合。结论乳腺髓样癌特征性的超声造影表现有其病理学依据,可作为临床超声诊断和鉴别诊断的依据。     

Magnetic resonance imaging as a diagnostic tool for breast cancer in premenopausal women

BACKGROUND: Screening mammography has led to earlier diagnosis of breast cancer; however, the increased tissue density of young women can complicate mammographic interpretation. We hypothesized that magnetic resonance imaging (MRI) has value in detection of mammographically occult breast cancers, particularly in premenopausal women for whom the sensitivity of mammography is compromised. METHODS: Data were available for 89 women with biopsy-proven breast cancer who had undergone both mammography and breast MRI. Variables evaluated included menopausal status and radiographic findings. Data were analyzed using Fisher's Exact test; P < .05 was considered significant. RESULTS: Of the 89 women in our study, 69 were perimenopausal or postmenopausal and 20 were premenopausal at the time of diagnosis. The malignant lesion was identified on mammography and MRI for a majority of patients. One third of premenopausal women had negative mammography but positive MRI findings. CONCLUSIONS: Our findings support a role for breast MRI in supplementing conventional mammography for early detection of breast cancer in premenopausal women.     

超声引导下mammotome微创旋切乳腺良性肿块的技术探讨

目的 探讨超声引导下mammotome微创旋切治疗乳腺良性肿瘤的临床效果及手术经验.方法 对186例212处乳腺肿块行超声引导下mammotome微创旋切,并评价其诊疗效果.结果 186例患者超声均清楚显示病变.肿块完全切除率为72.0%(134/186),位于胸大肌表面者和位于乳晕附近者完全切除率分别为31.5%(6/19)和33.3%(4/12).0.5cm≤肿块直径≤2.5cm的患者134例,超声显示肿瘤完全切除率88.0%(118/134);2.5cm<直径≤3.0cm的患者38例,超声显示肿瘤完全切除率42.1%(16/38);直径>3.0cm的患者14例,超声显示肿瘤完全切除0例.52例肿块未能完全切除的患者改为开放手术切除.于术后四周进行B超随访,肿块经mammotome完全切除的134例患者均未见肿块残留.其中112例患者术后六个月B超检查随访14.2%(16/112)肿块复发,其中6例开放手术切除,10例再次mammotome微创旋切,六个月后随诊有1例复发改行开放手术.结论 超声引导下mammotome切除乳腺肿块,尤其是小的乳腺肿块,简便、安全、有效.     

Imaging techniques in breast cancer

Imaging plays a critical role in the diagnosis and management of breast cancer. Two-view mammography and ultrasound form the mainstay of breast imaging and are essential components of the triple assessment. Digital mammography is rapidly replacing analogue mammography, and recent advances such as digital tomosynthesis add a third dimension to conventional 2D mammographic images. The versatility of ultrasound allows assessment of the breast and axilla as well as accurately targeted interventions, from the simple diagnostic core biopsy to preoperative tumour localization. It also guides large volume biopsies and excision of certain benign lesions, which in some cases can obviate surgical excision. Newer ultrasound techniques being applied to the breast and axilla include elastography and the use of intradermal microbubbles to guide the radiologist to the sentinel axillary node. Breast MRI is a powerful modality in assessing breast cancer. It can provide accurate information on size and multifocality of lesions, particularly those that are mammographically challenging such as lobular cancers, and it is also used to assess response to neoadjuvant chemotherapy and guide surgical management. CT scans, and in selected cases Positron Emission Tomography, play important roles in the assessment of metastatic disease.