乳腺影像报告与数据系统对临床触诊阴性乳腺病灶分类的价值

目的探讨乳腺影像报告与数据系统(breast imaging reporting and data system,BI-RADS)对于临床触诊阴性乳腺病灶分类的意义及指导乳腺病灶活检的价值。方法由X线摄影发现的触诊阴性乳腺病灶162个,按照美国放射学会制定的第四版BI-RADS对其分类,所有病灶均采用金属线定位活检技术获得组织学诊断。结果全组162个触诊阴性病灶中,确认乳腺癌46个,阳性预测值为28.4%。按照BI-RADS分类,2类病灶11例,其中癌0例;3类病灶55例,癌2例;4类病灶77例,癌29例;5类病灶19例,癌15例;BI-RADS2-5类病灶癌的阳性预测值分别为0%,3.6%,37.7%与78.9%。结论BI-RADS分类大大提高了触诊阴性乳腺病灶影像诊断的特异性,可用于指导活检指征的选择,建议对BI-RADS4类与5类病灶进行活检,以提高触诊阴性乳腺病灶活检的阳性率。     

乳腺X线摄影对临床体检及超声检查阴性、X线摄影可疑病灶用外科干预的指导意义

目的:探讨乳腺影像报告及数据系统(BI-RADS)对临床体检及超声检查阴性、乳腺X线摄影可疑阳性的乳房病灶用外科干预的指导意义。方法:对乳腺X线摄影提示存在可疑病灶,而临床无法扪及明显肿块且超声检查阴性的病人,进行乳腺X线立体定位,作手术活检或真空辅助微创旋切活检,以明确可疑病灶的病理诊断。使用卡方检验或确切概率法检验,比较不同BI-RADS分类间恶性疾病发生率的差异;组间两两比较采用卡方分割法。结果:180例病灶中,BI-RADS分类属4A类者为92例,4B类者为64例,4C类者为24例。有23例病灶证实为恶性病变,其中2例(8.7%)为4A类,9例(39.1%)为4B类,12例(52.3%)为4C类。卡方检验发现,不同BI-RADS分类组之间,恶性病例的发生率有统计学差异(P<0.001)。结论:对于乳腺X线摄影检查为唯一阳性结果的乳腺病灶,BI-RADS分类系统对是否应予外科干预有指导意义。BI-RADS属4A类病灶可行短期随访;属4B或4C类病灶需进一步作外科活检以明确诊断。     

触诊阴性乳腺病灶的诊治体会（附85例分析）

目的探讨触诊阴性乳腺病灶的临床表现特点和诊治方法。方法回顾性分析85例触诊阴性乳腺病灶的临床资料。结果触诊阴性乳腺病灶一般没有明显临床症状，少数有乳房胀痛、乳头溢液（血）或乳房外观改变，临床上诊治相对困难。85例中良性病变69例，占81．2％，恶性病变16例，占18．8％。结论通过超声引导下或X线立体定位针吸细胞学检查、穿刺病理学检查、手术活检以及乳腺导管镜检查对触诊阴性乳腺病灶基本可以做出明确诊断。     

超声弹性成像、X 线钼靶与超声引导下穿刺活检在BI-RADS4类乳腺肿块鉴别诊断中的价值评估

目的:探讨超声弹性成像、X线钼靶与超声引导下穿刺活检在BI-RADS4类乳腺肿块鉴别诊断中的价值。方法:采用回顾性调查方法,对2016年8月—2018年2月手术且病理证实的82例84个乳腺病灶的术前超声弹性成像、X线钼靶与超声引导下穿刺活检结果进行分析,比较超声弹性成像、X线钼靶与超声引导下穿刺活检的良恶性诊断效能。结果:在84个BI-RADS4类乳腺肿块病灶中,恶性48个,良性36个。超声弹性成像的诊断敏感度、特异度、准确度、阳性预测值、阴性预测值、漏诊率、误诊率分别为95.8%(46/48)、94.4%(34/36)、95.2%(80/84)、95.8%(46/48)、94.4%(34/36)、4.17%(2/48)、5.56%(2/36);X线钼靶分别为91.7%(44/48)、88.9%(32/36)、90.5%(76/84)、91.7%(44/48)、88.9%(32/36)、8.33%(4/48)、11.1%(4/36);超声引导下穿刺活检分别为97.9%(47/48)、100.0%(36/36)、98.8%(83/84)、100.0%(47/47)、97.3%(36/37)、2.08%(1/48)、0.00%(0/36)。三种检测方式的诊断效能差异无统计学意义(P0.05),但超声引导下穿刺活检对乳腺病灶定性诊断具有绝对优势。结论:超声引导下穿刺活检在BI-RADS4类乳腺肿块鉴别诊断中的价值最高。     

触诊阴性乳腺病灶定位切除的适应证选择及预后

目的探讨触诊阴性乳腺病灶定位切除的适应证选择及预后。方法回顾性分析我院1998年3月~2007年12月190例女性209个经金属线定位切除的临床触诊阴性乳腺病灶的临床资料,在未知病理诊断的情况下复阅乳腺钼靶片,根据BI-RADS第四版标准分类,计算各类病灶的阳性预测值,并对归并后的良、恶性倾向组的阳性预测值行χ2检验。结果190例共接受209个触诊阴性乳腺病灶的定位切除,54例55个病灶为恶性,阳性预测值为26.3%(55/209),BI-RADS2、3、4和5类病灶的阳性预测值分别为0%(0/21)、5.3%(4/76)、27.0%(20/74)和81.6%(31/38),恶性倾向组的阳性预测值45.5%(51/112)显著高于良性倾向组的4.1%(4/97)(χ2=45.973,P=0.000)。190例中位随访时间59个月(1~118个月)。55个恶性病灶中,0期和Ⅰ期乳腺癌共45个(81.8%),除1例Ⅲ期患者术后出现对侧淋巴结转移外,其余患者无病生存。结论对于BI-RADS4类和5类病灶应积极行定位切除活检,而BI-RADS2类和3类病灶则以定期随诊为主。经定位切除确诊的临床触诊阴性乳腺癌绝大部分为...     

超声引导下MMT与Bard活检针在乳腺触诊阴性的乳腺癌活检诊断中的价值比较

目的:探讨超声引导下麦默通旋切系统(MMT)与传统Bard活检针穿刺对乳腺触诊阴性病灶的乳腺癌诊断价值。方法:选取2014年1月—2016年1月收治的113例经乳腺超声、X线钼靶发现且临床触诊阴性的乳腺病灶进行回顾性分析,共计167个乳腺病灶,其中80例(120个病灶)在超声引导下经MMT旋切活检(MMT组)、33例(47个病灶)采取Bard穿刺活检(Bard组),以术后病理结果作为金标准,对比2种方式的诊断价值。结果:MMT组活检成功率100%,显著高于Bard组的87.23%,差异有统计学意义(P0.05);MMT法活检鉴别诊断临床触诊阴性的乳腺病灶良恶性的灵敏度为96.67%、特异度为97.78%、漏诊率为3.33%、误诊率为2.22%;Bard法活检鉴别诊断临床触诊阴性的乳腺病灶良恶性的灵敏度为83.33%、特异度为92.22%、漏诊率为16.67%、误诊率为7.78%。MMT法活检的并发症率为10.00%,显著低于Bard组的30.30%,差异有统计学意义(P0.05)。结论:超声引导下MMT活检较BARD活检针穿刺对乳腺触诊阴性病灶具有更高的诊断价值。     

乳腺乳头状病变507例临床病理学特点及相关治疗分析

目的 探讨不同种类乳腺乳头状病变的临床特点以及相应的治疗方法。 方法 回顾性分析2013年1月至2015年12月在上海交通大学医学院附属瑞金医院乳腺疾病诊治中心行手术治疗,并经病理学检查证实为乳腺乳头状病变病人的临床资料。 结果 共有507例病人诊断为乳腺乳头状病变,其中导管内乳头状瘤（IP）不伴非典型性增生、IP伴非典型性增生、IP伴原位癌、导管内乳头状癌、包膜内乳头状癌、实性乳头状癌以及浸润性乳头状癌分别为389例（76.7%）、22例（4.3%）、24例（4.7%）、27例（5.3%）、12例（2.4%）、20例（3.9%）和13例（2.6%）。对乳腺良恶性乳头状病变相关临床因素分析发现,乳腺超声、X线检查和磁共振检查的乳腺影像学报告与数据系统（BI-RADS）分类与乳腺乳头状病变性质显著相关,BI-RADS分类为≥4B类提示恶性病变可能性较大（P < 0.05）。对不同乳腺恶性乳头状病变相关临床及治疗方案分析,发现年龄、有无溢液、溢液性状、肿块大小、激素受体状态、Ki-67表达、手术方式及辅助治疗的选择,在上述乳腺恶性乳头状病变病人中差异无统计学意义（P > 0.05）。 结论 IP是乳腺乳头状病变发生率最高的肿瘤;乳腺超声、X线检查和磁共振检查可作为乳腺良恶性乳头状病变早期诊断的方法;不同乳腺恶性乳头状病变发病率较低,其具有相似的临床特征,须待大规模队列数据进一步验证。     

动态增强MRI定性诊断乳腺导管上皮非典型增生

目的 观察动态增强MRI（DCE-MRI）定性诊断乳腺导管上皮非典型增生（ADH）的价值。方法 回顾性分析经穿刺活检或局部切除组织活检诊断的64例乳腺单发ADH患者,以手术病理结果为金标准,比较恶性与良性病变患者临床资料及乳腺X线、DCE-MRI征象,分析DCE-MRI预测乳腺恶性ADH的效能。结果 64例乳腺单发ADH中,28例为恶性（恶性组）,36例非恶性（非恶性组）,组间活检方式、病灶最大径、MRI示乳腺实质背景强化（BPE）、乳腺X线表现差异均有统计学意义（P均<0.1）;将上述因素纳入Logistic多因素回归分析,结果显示仅BPE为乳腺恶性ADH的独立影响因素[OR=7.550,95%CI（1.575,36.197）,P=0.011]。DCE-MRI诊断BI-RADS 4A及以下者27例,其中3例为恶性;4A类以上（4B及4C）37例,25例为恶性,诊断敏感度89.29%（25/28）,特异度66.67%（24/36）,阳性预测值67.57%（25/37）,阴性预测值88.89%（24/27）。结论 DCE-MRI可用于定性诊断乳腺ADH;其所示中重度BPE为术后病理恶性的正相关因素。     

麦默通旋切系统在乳腺临床触诊阴性病灶活检中的应用

目的:探讨麦默通旋切系统在乳腺临床触诊阴性病灶活检中的应用及意义。方法:通过对我院73例乳腺X线摄影及彩超发现的临床触诊阴性乳腺病灶采用麦默通真空辅助旋切活检及BARD穿刺针活检,分析其病理结果。结果:43例麦默通活检病人及30例BARD穿刺活检病人,其活检成功率分别为100%及83.3%,病理符合率分别为100%及84.6%,两组比较有统计学差异(P<0.05)。早期癌比例麦默通组占16.3%,BARD穿刺针组为6.7%,但尚无统计学差异。结论:麦默通微创活检具有微创、安全的特点,诊断灵敏度及特异度更高,可作为临床触诊阴性乳腺病灶活检的首选方法。     

乳腺钼靶X线三维立体定位系统引导下导丝定位活检的临床应用

目的探讨乳腺钼靶X线三维立体定位系统引导下导丝定位手术活检在临床不能触及肿块的乳腺病变中的价值及可行性。 方法回顾性研究2013年4月至2015年10月间收治的乳腺钼靶X线异常女性患者67例,对临床不能触及的乳腺病灶行导丝定位手术活检及病理检查。 结果67例病灶均一次定位成功,发现乳腺癌17例（25.4%）,癌前病变（导管上皮非典型增生及导管内乳头状瘤）13例（19.4%）,其他良性病变37例（55.2%）。影像表现为微钙化灶的46例病例中乳腺恶性病变共16例（34.8%）,癌前病变8例（17.4%）,其他良性病变22例（47.8%）;非钙化组的21例病例中良性病变20例（95.2%）,恶性病变1例（4.8%）。与影像表现为非钙化组比较,对于临床不能触及的乳腺病灶,乳腺钼靶X线影像表现为微钙化时乳腺癌检出率更高（χ²=5.369,P=0.021）。 结论钼靶X线三维立体定位系统引导下导丝定位活检可以发现容易漏诊的早期乳腺癌及癌前病变,该方法简便、准确,值得推广。     

Experience with fine-wire localization breast biopsies for nonpalpable breast lesions detected mammographically

There is evidence to suggest that the early diagnosis and treatment of breast cancer may be associated with a better prognosis. Technical advances such as mammography can detect nonpalpable breast lesions and changes associated with early carcinoma. With fine-wire localization under mammographic control, the surgeon can reliably remove nonpalpable lesions while sparing normal breast tissue. The authors describe the technique for fine-wire localization and removal of lesions and report their experience over 3 years with 262 women who underwent 269 biopsies for nonpalpable lesions. Four subgroups were identified: screened women who had no indication for mammography other than age, women who were referred for mammography by community physicians, a group referred to the Cancer Control Agency of British Columbia and a group referred to the agency for localization biopsy after mammography performed outside the Vancouver area had suggested a malignant lesion. The yield of cancers from biopsies was 10%, 38%, 43% and 26% respectively. The yield was significantly (p less than 0.05) lower for the screened group. Age over 60 years, previous breast cancer and mammographic technique were identified as possible predictors of a positive biopsy. The authors have found fine-wire localization biopsy a safe and reliable method of removing nonpalpable breast lesions.     

高频超声检出并定位不能扪及的乳腺癌

目的：探讨高频超声检出乳腺不能扪及病灶的可行性及其定位活检方法。方法：常规高频超声检查以发现临床不能扪及的病灶．拟诊为肿瘤性病灶则在超声引导下行Hookwire穿刺，并由此引导作手术活检。结果：对980例共1247处不能扪及的病灶进行了超声诊断并引导活检。共计查出乳腺癌115处，上皮不典型增生131处。超声对不能扪及的乳腺癌检查的敏感性、特异性分别为69％和88％，良、恶性诊断符合率为96％；对有活检指征的乳腺癌和癌前期病变检出的敏感性、特异性分别为77％和74％。用本法定位方便、手术顺利地找到病灶并完成活检。结论：高频超声可以检出临床不能扪及的乳腺癌及癌前病变，超声引导穿刺定位方法简便易行。     

X线立体穿刺钢丝标记定位对无体征乳癌的诊断价值

目的 探讨X线立体穿刺钢丝标记定位在无临床体征的早期乳癌中的诊断价值。方法 对29例钼靶X片上有可疑病灶而无任何临床体征的患者,在X线立体定位下穿刺病灶并用金属导丝标记,标记后根据导丝位置切除病灶,并进行快速冰冻活检,明确诊断。结果 29例中9例（31．0％）为癌,20例（69．0％）良性。冰冻切片病理检查与术后石蜡报告结果一致。结论 X线立体穿刺钢丝标记定位活检技术解决了乳腺微小病灶活检术中精确定位的难题,对无临床体征的早期乳癌诊断准确、可靠、实用。     

Hematoma-directed ultrasound-guided breast biopsy

OBJECTIVE AND SUMMARY BACKGROUND DATA: The standard technique for removal of nonpalpable breast lesions is needle localization breast biopsy. Because traumatic hematomas can often be seen with ultrasound, the authors hypothesized that iatrogenically induced hematomas could be used to guide the excision of nonpalpable lesions using ultrasound. METHODS: Twenty patients with nonpalpable breast lesions detected by magnetic resonance imaging only were enrolled in this single-institution trial, approved by the institutional review board. A hematoma consisting of 2 to 5 mL of the patient's own blood was injected into the breast to target the nonpalpable lesion. Intraoperative ultrasound of the hematoma was used to direct the excisional biopsy. RESULTS: The average age of women was 53.8 +/- 10 years. Ninety-five percent of lesions detected by magnetic resonance imaging were localized by hematoma injection. All the hematomas used to recognize targeted lesions were identified at surgery by ultrasound and removed without complication. Eight (40%) of the lesions were malignant, with an average tumor size of 12 +/- 6 mm (range 4-25). The remaining 12 lesions (60%) comprised papillomas, sclerosing adenosis, radial scar, fibroadenoma, and areas of atypical ductal hyperplasia. CONCLUSION: The results of this pilot study show the effectiveness of hematoma-directed ultrasound-guided breast biopsy for nonpalpable lesions seen by magnetic resonance imaging. This new procedure is potentially more comfortable for the patient because no wire or needle is left in the breast. It is technically faster and easier because ultrasound is used to visualize directly the location of the hematoma at surgery and to confirm lesion removal in the operating room by specimen ultrasound. The hematoma can be placed several days before biopsy, easing scheduling, and without fear of the migration that may occur with needle localization. This method may have ready application to mammographically detected lesions.     

Sentinel node biopsy for nonpalpable breast tumors requires a preoperative diagnosis of invasive breast cancer

A sentinel node biopsy done at the time of initial tumor resection allows for a one-stage surgical procedure. In addition, sentinel node identification may be impaired when done after a previous tumor excision. This study evaluates the sentinel node biopsy in patients with nonpalpable breast cancer and assesses whether a sentinel node biopsy for mammographically suspect breast lesions is justified when preoperative needle biopsy is inconclusive for invasive malignancy. A sentinel node biopsy was done in 67 patients with nonpalpable breast lesions after injection of radioactive tracer (intraparenchymal in 35 and subdermal in 32) and blue dye (para-areolar). A preoperative core needle biopsy was positive for malignancy in 42 patients. Thirteen patients had positive cytology or ductal carcinoma in situ (DCIS). In 12 patients the needle biopsy was nondiagnostic, but the lesions remained highly suggestive of malignancy on mammography. Sentinel node biopsy was successful in 64 patients (96%). In these, the sentinel node was both radioactive and blue in 58 patients (91%). Only 4 of 13 patients with positive cytology or DCIS on preoperative needle biopsy and only 5 of 12 patients without a preoperative diagnosis had an invasive cancer after resection. Sentinel nodes were positive for nodal metastases in 9 of 49 patients (18%) with a successful sentinel node biopsy for invasive malignancy. None of the eight patients with DCIS had nodal metastases. The sentinel node procedure avoids the potential morbidity of an axillary dissection in more than 80% of patients with nonpalpable breast cancer. A sentinel node biopsy for mammographically detected suspect breast lesions is not justified without a preoperative histologic diagnosis of invasive breast cancer.     

Nonpalpable breast cancer: needle-localized biopsy for diagnosis and considerations for treatment

Screening mammography as an adjunct to physical examination led to the discovery of 237 radiographically suspicious but nonpalpable breast lesions. Needle localization of the lesion preoperatively in the mammography suite followed by breast biopsy led to the diagnosis of 64 nonpalpable carcinomas, including 25 invasive, 16 minimally invasive, and 23 noninvasive cancers. Noninvasive and minimally invasive cancers were microscopic. Of the invasive lesions, 7 were 10 mm or less in diameter and 14 were 11 to 20 mm in diameter. Noninvasive and minimally invasive cancers tended to occur in younger women (average age 52 and 51 years, respectively), and almost uniformly appeared as clustered calcifications mammographically. Invasive cancers affected an older population (average age 65 years), and the mammographic appearance was that of a mass in the majority of cases. A variety of surgical procedures were carried out subsequent to biopsy to provide definite treatment of these nonpalpable breast cancers. A review of surgical specimens available from these procedures demonstrated a 27 percent incidence of residual disease at the biopsy site. In patients who underwent mastectomy, 34 percent had an unsuspected focus of cancer in another quadrant of the breast and an additional 14 percent had an unsuspected focus of epithelial atypia. No patient with either noninvasive or minimally invasive cancer was found to have axillary lymph node metastases. Twenty-nine percent of patients with invasive tumors demonstrated lymph node metastases in the axilla. Our results demonstrate the efficacy of preoperative needle localization to assist in the biopsy of nonpalpable breast lesions and the diagnosis of a significant number of early breast cancers. The treatment plan for patients with these cancers must address the high incidence of residual disease at the biopsy site, multicentricity, and the proved capacity for invasive lesions to metastasize to the axillary lymph nodes, regardless of the size of the primary tumor.     

Breast biopsy with needle localization: influence of age and mammographic feature on the rate of malignancy in 350 nonpalpable breast lesions

The purpose of this study was to determine the influence of mammographic feature and patient age on the rate of malignancy in nonpalpable breast lesions. During a 3-year period, 305 patients underwent biopsy after needle localization of 350 nonpalpable breast lesions. A total of 66 malignant breast tumors were found (biopsy yield rate, 19%): 23 carcinoma in situ, 43 infiltrating cancer. The biopsy yield rate in women younger than 50 years was 8% (12 of 153) and in women 50 years or older 27% (54 of 197; p less than 0.001). The biopsy yield rate varied with the mammographic feature in both groups of patients and was highest for spicular masses (61%), followed by strongly suspicious calcifications (29%). No cancers were found among well-defined masses or asymmetric densities. Other factors that were associated with high biopsy yield rate were personal or family history of breast cancer and diagnostic, rather than screening, mammography. The results suggest that the rate of malignancy in nonpalpable breast lesions is influenced by several factors, including age of patient and mammographic feature of the lesion. By taking all these factors into account, biopsies can possibly be performed more selectively thereby increasing the cost effectiveness of biopsy for occult breast cancer.     

Early detection of breast carcinoma: a comparison of palpable and nonpalpable lesions.

A retrospective study of 536 needle-localization biopsies of nonpalpable breast lesions and 623 excisional biopsies of palpable breast lesions was performed. Carcinoma was present in 17.9% of needle-localization biopsy specimens and in 11.1% of excisional biopsy specimens. Noninvasive carcinoma constituted 50% of carcinomas detected by needle-localization biopsy and only 7.3% of carcinomas detected by excisional biopsy (p less than 0.005). Invasive carcinoma detected by needle-localization biopsy was associated with axillary lymph node metastasis in 9.8% of patients who had axillary dissection, compared with 37.7% of patients with invasive carcinoma detected by excisional biopsy of a palpable mass (p less than 0.005). Invasive carcinoma detected by needle-localization biopsy was less than 2 cm in size (T1) in 93.5% of biopsy specimens; in contrast, invasive carcinoma detected by excisional biopsy was less than 2 cm in size in only 54.7% of biopsy specimens (p less than 0.005). Nonpalpable breast lesions that proved to be invasive carcinoma were pathologic stage I in 82.9% of patients. Palpable breast lesions that proved to be invasive carcinoma were pathologic stage I in only 47.2% of patients. Survival benefits of mammographic screening and biopsy of nonpalpable lesions are likely the result of detection of invasive carcinoma at an early stage and detection of noninvasive carcinoma that may later develop into or mark increased risk of invasive carcinoma.     

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??Analysis of value of nonpalpable breast lesions by vacuum assisted biopsy JIN Si-li, ZHAO Yi.The Seventh Department of General Surgery, Shengjing Hospital, China Medical Universiry, Shenyang 110004, China
Corresponding author: ZHAO Yi, E-mail: 2597016916@qq.com
Abstract Objective To explore the application of vacuum assisted biopsy (VAB) in nonpalpable breast high-risk lesions. Methods From January 2015 to December 2016, 1641 nonpalpable breast lesions from 518 patients with Encor guided by ultrasound in Shengjing Hospital, China Medical University were analyzed retrospectively. Results Pathological tips show adenosis 610??37.2%??, breast fibroma 163??9.9%??, fibroadenosis 668??40.7%??, mesenchymal cells in active growth 32??2.0%????papillary 25??1.5%????dysplasia 89??5.4%???? mastitis 15??0.9%??, 8 cancer??0.5%?? and others 31??1.9%??. The patients were followed up for 18-24 months??458 (88.4%) cases were followed up successfully. Color Doppler ultrasound was reviewed every 3 months.No recurrence in high-risk patients,no metastasis in malignant patients. Conclusion For nonpalpable breast lesion, the VAB is helpful for the diagnosis and treatment, and is more conductive to the detection of high-risk lesions.