Palpable solid breast masses: retrospective single- and multimodality evaluation of 201 lesions

The diagnostic virtues and limitations of single- and multimodality testing in the evaluation of solid palpable breast masses were studied. Two hundred one consecutive patients who had a solid palpable breast mass and who underwent biopsy between September 1982 and July 1986 were included for blinded retrospective analysis of their physical examination, mammographic, ultrasonographic (US), thermographic, and pathologic characteristics. Benign breast disease was diagnosed histologically in 106 women, while carcinoma was established in 95. The sensitivities of physical examination, mammography, US, and thermography were 0.88, 0.94, 0.78, and 0.49, respectively. US alone had the highest sensitivity in correct diagnosis of a benign solid breast mass and had the highest accuracy (0.84). Use of four modalities increased the preoperative diagnostic true-positive rate to 0.97, with some decline in specificity. Multimodality testing seems particularly beneficial in pre- and perimenopausal patients.     

Automated breast sonography using a 7.5-MHz PVDF transducer: preliminary clinical evaluation. Work in progress

Breast ultrasound imaging performed with an automated machine was carried out in 89 patients, and images obtained with a conventional ceramic single-focus 4-MHz transducer and a 7.5-MHz polyvinylidene fluoride (PVDF) transducer were compared. The 7.5-MHz PVDF transducer improved overall image quality in 77% of patients and had equal penetration in 83%. It yielded greatly increased diagnostic information in 43% of 81 masses and improved visualization of calcification in 57% of 14 lesions in which calcium was visible on mammograms.     

Nonpalpable breast masses: evaluation by US elastography.

OBJECTIVE: To compare the diagnostic performances of conventional ultrasound (US) and US elastography for the differentiation of nonpalpable breast masses, and to evaluate whether elastography is helpful at reducing the number of benign biopsies, using histological analysis as a reference standard. MATERIALS AND METHODS: Conventional US and real-time elastographic images were obtained for 100 women who had been scheduled for a US-guided core biopsy of 100 nonpalpable breast masses (83 benign, 17 malignant). Two experienced radiologists unaware of the biopsy and clinical findings analyzed conventional US and elastographic images by consensus, and classified lesions based on degree of suspicion regarding the probability of malignancy. Results were evaluated by receiver operating characteristic curve analysis. In addition, the authors investigated whether a subset of lesions was categorized as suspicious by conventional US, but as benign by elastography. RESULTS: Areas under the ROC curves (Az values) were 0.901 for conventional US and 0.916 for elastography (p = 0.808). For BI-RADS category 4a lesions, 44% (22 of 50) had an elasticity score of 1 and all were found to be benign. CONCLUSION: Elastography was found to have a diagnostic performance comparable to that of conventional US for the differentiation of nonpalpable breast masses. The authors conclude that BI-RADS category 4a lesions with an elasticity score of 1 probably do not require biopsy.     

高频超声对男性乳腺肿块的诊断价值

目的 探索男性乳腺肿块的超声诊断特征.方法 回顾性分析经手术病理证实的男性乳腺肿块35例,对良恶性乳腺肿块的超声大小、形态、钙化点、内部血流信号、腋下淋巴结等指标进行对比分析.结果 超声检查恶性肿瘤大小(2.5±0.3)em,良性肿块(2.2±0.4)cm,Wilcoxon秩和检验P=0.6339;超声扫查恶性肿瘤形态不规则5例(50％),而良性肿块形态不规则9例(36％),Fisher's确切概率检验P =0.4736;恶性肿瘤纵横比＞1者5例(50％)、良性肿块1例(4％),P=0.004;恶性肿瘤内部钙化灶者6例(60％),良性肿块均未见钙化点(0％)P＜0.001;彩色多普勒血流显像(CDFI)恶性肿瘤内部血流信号丰富者7例(70％),而良性肿块仅4例(16％),P=0.0039;恶性肿瘤RI＞0.6者4例(57％),良性肿块2例(20％)P=0.1618;恶性肿瘤腋下淋巴结肿大者4例(40％),良性肿块2例(8％),P=0.0428.结论 男性乳腺癌超声特征表现为形态不规则,纵横比＞1,内部钙化灶,血流信号丰富,腋下淋巴结肿大.高频超声对男性乳腺肿块诊断有重要价值.     

Intrauterine growth retardation: evaluation by magnetic resonance. Work in progress

Eleven high risk fetuses between 32 and 37 menstrual weeks gestational age were examined by magnetic resonance (MR) imaging. Serial obstetrical sonograms, birth weights, and serial postnatal examinations were obtained in all subjects. Sagittal MR spin echo images obtained using TR = 0.5 sec and TE = 28 msec were useful for assessing subcutaneous fat. Prospective estimates of fetal fat stores correlated with neonatal outcome better than sonographic measurements of fetal growth parameters or actual birth weight. MR appears to be a safe and useful technique that offers information complementary to obstetrical sonography when IUGR is suspected.     

Precise intraoperative location of gastrointestinal bleeding with a hand-held counter. Work in progress

The nuclear medicine bleeding scan is frequently insufficient to locate sites of bleeding precisely, in spite of its great sensitivity. A small, hand-held Geiger-Müller counter, placed directly on exposed intestine in the operating room, enables precise location of the probable bleeding site. In three patients, the technique allowed a minimal amount of intestine to be resected, distinguished between large- and small-intestinal hemorrhage, and eliminated other foci as sites of bleeding.     

Frequency-demodulated US: evaluation in the liver. Work in progress

Frequency modulated (FM) imaging is a new ultrasound (US) modality that uses pulse-echo signal instantaneous frequency in addition to the conventional envelope information. Eight features of the FM image in nondiseased livers are described. The technique is evaluated in a study of 34 patients with biopsy-proved diffuse liver disease. Visual grading of FM US image features shows good correlation with levels of biopsy-graded hepatic fibrosis. Patients with diffuse parenchymal liver disease often exhibit evidence of the abnormality when FM liver imaging is used, while such evidence is not as well demonstrated with conventional envelope (AM) imaging.     

M-mode sonography of the caudal spinal cord in patients with meningomyelocele. Work in progress.

The authors prospectively studied movement patterns of the spinal cord in 46 patients (aged 0.5-16 years) with meningomyelocele but without major neurologic deficits. Three different motion patients were observed. Reduced mobility correlated with a higher risk of developing secondary tethered cord syndrome after a mean observation time of 15 months. This technique may be helpful in identifying patients for early surgery.     

Color Doppler signals from breast tumors. Work in progress

The color Doppler signals in 60 patients with breast masses were assessed subjectively, and a regional grading method was developed for quantitation of displayed blood vessel density. Among 21 patients with breast carcinoma, moderate or high flow was demonstrated in all but one, with an average of 0.5 vessels per square centimeter and color pixels occupying 12.2% of the image area. Among 33 patients with benign disorders, no flow was demonstrated in 25 and slight to moderate flow was seen in five, with an average of 0.01 vessels per square centimeter, occupying 0.8% of the image area. Cancers as small as 10 mm in diameter were positive for flow. High-velocity flow was seen only in malignancies; it was observed in four cases and may have been due to arteriovenous shunting. Flow was less readily detected in recurrent tumors; two of seven tumors were weakly positive. Color Doppler shows promise as an adjunct to ultrasound imaging in the differential diagnosis of breast lesions.     

Work in progress. Intra-arterial digital subtraction angiography: evaluation in 150 patients

As part of an ongoing study comparing digital subtraction angiography (DSA) with conventional film-screen angiography, 150 patients were examined with arterial contrast material injections and digital filming techniques alone or combined with conventional angiography. Of 247 injections, the DSA study was good or excellent in 236, approaching the quality of conventional angiography for visualization of vessels greater than 1 mm in size. Advantages included improved vascular detail in selected areas such as the skull base, visualization of minimal contrast concentration in diseased vessels or postoperatively, and imaging of vessels distal to stenoses without the hazards of selective catheterization. DSA permitted rapid positioning under fluoroscopic control, instantaneous viewing of subtracted images, and reduced technologist time and film costs. Contrast material volume was reduced by 40 to 60%, allowing multiple studies in one sitting and study of patients with renal compromise.     

Common carotid artery bifurcation: evaluation with spiral CT. Work in progress.

To determine the utility of spiral computed tomography (CT) in evaluation of carotid artery stenosis, spiral CT images of 20 patients were compared with images obtained with conventional angiography (20 patients), ultrasound (US) (15 patients), and magnetic resonance (MR) angiography (six patients). The category of stenosis was determined for each internal carotid artery on the basis of the percentage of narrowing: mild = less than 30%, moderate = 30%-69%, and severe = 70%-99%. Occlusions were also noted. The degree of carotid stenosis determined with spiral CT correlated with that determined with conventional angiography in 92% of cases, with that determined with US in 97% of cases, and with that determined with MR angiography in 100% of cases. Calcifications and large ulcers were also well delineated. Spiral CT provided an accurate anatomic depiction of the carotid bifurcation, which could be helpful in preoperative evaluation. The major disadvantage of the technique was the need to postprocess data to remove veins, calcifications, and bone structures from the images.     

Comparative value of 99mTc-sestamibi scintimammography and sonography in the diagnostic workup of breast masses

OBJECTIVE: This study was conducted to assess the relative roles of 99mTc-sestamibi scintimammography and sonography in the evaluation of breast lesions that are indeterminate or suspicious on mammography or clinical examination. SUBJECTS AND METHODS: Twenty-five patients with 33 biopsy-proven breast lesions underwent both scintimammography and sonography. Lesions were categorized as benign or requiring biopsy on the basis of the absence or presence of a focus of increased activity on scintimammography and the shape, orientation, and echogenicity of the lesion on sonography. RESULTS: Sensitivity and specificity in detecting breast cancer were 92% and 95%, respectively, for scintimammography and 100% and 48%, respectively, for sonography. The higher specificity of scintimammography was statistically significant (p < 0.01). CONCLUSION: Although the overall accuracy of 99mTc-sestamibi scintimammography in the diagnosis of breast cancer was high, it has several disadvantages in comparison with sonography. Scintimammography has a slightly higher false-negative rate for breast cancer, is unable to reveal cysts, is more expensive, takes longer to perform, and involves ionizing radiation. For these reasons, scintimammography with 99mTc-sestamibi is unlikely to either replace sonography or be frequently used in addition to sonography.     

Recurrent breast cancer: stereotaxic localization for fine-needle aspiration biopsy. Work in progress.

The efficacy of stereotaxic localization for fine-needle aspiration biopsy in the detection of recurrent cancer manifested as calcifications on mammograms was evaluated in 43 patients that had been treated with local resection and radiation therapy. Six patients had malignant aspirates and one had an atypical aspirate; examination of the surgical specimens revealed all seven of these to be malignant. Thirteen patients underwent surgical biopsies, the results of which were malignant in seven and benign in six. The remaining 30 patients were followed up with mammography. The follow-up mammograms were obtained at 6-month intervals and demonstrated no change in appearance. On the basis of this initial experience, stereotaxic localization for aspiration biopsy offers the potential to accurately distinguish benign from malignant lesions.     

Occult breast masses: use of a mammographic localizing grid for US evaluation.

To determine if there was a problem of misidentification of mammographically detected masses with freehand ultrasound (US), the authors examined 50 mammographically distinct masses in 47 patients who were scheduled to undergo needle localization. In only six cases were the masses to be localized in an area of the breast that contained other mammographic opacities that could have led to problems of identification. The patients were first studied with freehand US. Results were then compared with those subsequently obtained with a fenestrated mammographic compression grid to guide the US evaluation. Needle localization was then performed. In five of 50 cases, masses detected with freehand US and initially believed to correspond to the mammographically detected mass were subsequently found to represent different areas of the breast when US was used with the compression grid. These results suggest that the potential for misidentification of masses with freehand US is real and that a mammographic grid localization device can be used to overcome this problem.     

Palpable asymmetrical thickening of the breast: a clinical, radiological and pathological study

While management protocols for a discrete palpable breast lump are standardized in most centres, the approach to an area of palpable asymmetrical thickening in the breast has seldom been addressed. A diagnostic algorithm for palpable asymmetrical thickening of the breast was prospectively evaluated in 116 Oriental women, followed by a retrospective review of their mammograms and histology specimens. Most women (86%) were pre-menopausal and 82% complained of a lump. The thickening eventually resolved spontaneously in 93 (80%) women. None of these 93 women developed cancer at a median follow-up of 41 months. A total of 9 (7.8%) cancers were found in the series of 116 women, including two with a lobular component. The occurrence of cancer was more likely when the woman was older than 43 years or when the thickening was marked (p<0.04). Mammographic review showed correlation of the palpable thickening with localized increase in breast tissue density and/or microcalcifications in 18% of cases. Histology review suggested fibrosis as an explanation for the clinical presentation. Although most cases of thickening tend to resolve with time, a significant number of cancers present in this way. A diagnostic approach with early and liberal imaging and biopsy for high risk women is required.     

Late sequelae of percutaneous nephrolithotomy: evaluation by high-resolution sonography and colour-coded sonography

We examined 50 asymptomatic patients 6–60 months after percutaneous nephrolithotomy (PCNL) by high-resolution sonography and additional colour-coded sonography and compared our results with the preoperative sonograms and the operative records. No lesions of larger vessels were detected, either arteriovenous fistulate or pseudoaneurysms. Avascular band-shaped hyperechoic parenchymal stripes were found in 17 of 50 patients (35%). As these did not appear in the preoperative sonograms, and as the stripes were in the same orientation as the neprrostomy canal, we believe them to be scar tissue. Correspondence to: R. Knapp