Standardised or individualised X-ray tube angle for mediolateral oblique projection in digital mammography?

IntroductionWe aimed to investigate whether there were any differences in positioning criteria related to the presentation of the pectoralis major muscle (pectoral muscle) for women of different heights using a standardized 60° X-ray tube angle for mammograms in mediolateral oblique (MLO) projection.MethodsData from MLO mammograms of right breasts of 45,193 women screened in BreastScreen Norway 2016–2019 were used. The positioning criteria were related to the pectoral muscle length (measure A and measure B), width and shape and considered adequate or inadequate depending on the degree of fulfilling the criteria. Data associated with the pectoral muscle were extracted from Volpara, an automated software for breast density assessment. Information on height was obtained from a self-reported questionnaire received by the women together with the invitation to attend the screening program. Women were divided into three groups based on the height percentiles (P) in the Norwegian growth curves: < 25th percentile (<P25th: ≤163 cm), 25th-75th percentile (P25–P75th: 164–170 cm), and >75th percentile (>P75th: >170 cm). Logistic regression was used to analyse the odds of adequate pectoral muscle length A and B, and shape, adjusting each model for screening technique and equipment model. Results were presented with odds ratios (OR) and 95% confidence intervals (CI).ResultsMean age of the screened women was 61.5 (SD = 4.8) years. The adequate measure for the pectoral muscle length A was obtained for 25.9% (11,724/45,193), length B for 76.3% (34,489/45,193), width for 75.0% (33,894/45,193) and shape for 97.6% (44,118/45,193) of the mammograms. Adjusted odds of an adequate pectoral muscle length A were lower for women of <P25th (OR = 0.90, 95% CI: 0.86–0.95) compared to women of P25-75th. Odds of an adequate pectoral muscle length B were lower for women of <P25th (OR = 0.88, 95% CI 0.84–0.93) and higher for women of >P75th (OR = 1.08, 95% CI 1.02–1.14) compared to women of P25-75. Odds of an adequate pectoral muscle shape were higher for women of <P25th (OR = 1.14, 95%CI 1.08–1.19) and lower for women of >P75th (OR = 0.92, 95% CI 0.87–0.97) compared to women of P25-75th.ConclusionThe 60° X-ray tube angle might suit most of the female population offered mammographic screening in Norway, but women of a relatively low height (163 cm or lower) might benefit from an X-ray tube angle less than 60-degrees.Implications for practiceUsing 60° X-ray tube angle for the MLO mammograms in BreastScreen Norway fit the majority of the participating women. More research is needed to change the protocol associated with the tube angle for women shorter than 163 cm.     

Mammography: Correlation of pectoral muscle width and the length in the mediolateral oblique view of the breast

PurposeTo investigate the relationship between the width and length of the pectoral muscle in the mediolateral oblique mammogram of the breast.MethodMammograms reviewed for this study were performed on women undergoing routine mammographic screening with BreastScreen NSW South West, Australia. The study included a total of 2800 randomly selected mediolateral oblique mammograms from examinations taken between July 2004 and September 2006. Measurements of the width and length of the pectoral muscle were recorded.ResultsNo statistically significant difference was demonstrated between the mean values for right and left width (p = 0.5293) or length (p = 0.2079). Matched pair analysis demonstrated a statistically significant difference width, (p = 0.0069) and length, (p = 0.0369). No relationship could be demonstrated between the width and length of the pectoral muscle, (p = 0.0701).ConclusionThe inability to determine a relationship between the width and length of the pectoral muscle suggests that these criteria should be assessed independently of each other. This new understanding of the presentation of the pectoral muscle will enable clinically relevant redevelopment of current image evaluation systems to include statistically supported mean performance values. Further research is needed to explore the relationship of width and length to other key image evaluation criteria used in mammography image quality evaluation.     

MRI findings of muscle involvement in idiopathic hypereosinophilic syndrome

A 40-year-old white man presented with fever, muscle pain, skin nodules and persistent hypereosinophilia over a period of 1 year. In addition, he had ventricular arrhythmias with episodes of tachycardia. Besides a lack of response to antiparasitic therapy, laboratory and pathological data excluded the diagnosis of trichinosis or any other parasitic infection. The patient's course of the disease over the previous 1¹/₂ years was compatible with hypereosinophilic syndrome. In a muscle biopsy several eosinophilic perivascular and leucocytic intravascular infiltrates were found, indicative of muscle involvement by the disease. This is a report on the MRI findings of muscle involvement in idiopathic hypereosinophilic syndrome. Reveived: 29 December 1997; Revision received: 9 March 1998; Accepted: 20 April 1998     

Fibrosarcoma of the breast: mammographic findings in five cases.

The mammographic features of fibrosarcoma of the breast, a rare malignant tumor, have not been described. Accordingly, we reviewed the mammograms, pathology reports, and medical records of five women with this tumor. All cases had surgical biopsies and a diagnosis made by histologic evaluation. The age of the patients ranged from 48 to 79 years. Histologically, three of the five fibrosarcomas were thought to have arisen from phyllodes tumor, and four were palpable. On mammograms, the tumors were dense masses with largely indistinct margins, ranging from 1.5 to 7.0 cm in diameter. One contained calcified osseous elements suggesting osseous trabeculae. Although the osseous trabeculae in that tumor strongly suggested sarcoma, most of the tumors had a nonspecific appearance on mammograms. Fibrosarcomas of the breast have a nonspecific mammographic appearance. Surgical biopsy and histologic evaluation are necessary for definitive diagnosis.     

Breast cancer in women 35 years old or younger: clinical and mammographic features

The purpose of our work was to describe the clinical and mammographic patterns of breast cancer in women aged 35 years old or less. From 1980 to 1985, 92 women 35 years old or younger were treated in our institution for breast cancer. Their mammograms were reviewed to determine the breast density and to describe the mammographic lesion. The clinical examination found a palpable breast mass (n = 84), nipple discharge (n = 2), axillary lymph node involvement (n = 3), metastasis (n = 1) or was normal (n = 2). The mammograms exhibited dense (n = 59), mixed dense/fatty (n = 29) or fatty (n = 4) parenchymal breast. The mammograms showed opacity with well-defined (n = 13) or ill-defined borders (n = 34), spiculated opacity (n = 11), architectural distortion (n = 9), isolated clusters of microcalcifications (n = 13) or were normal (n = 18). The diagnosis of breast cancer in young womensis difficult, because mammographic accuracy is less reliable and benign disease is far more prevalent.     

Stereotactic 14G core biopsy of non-palpable breast cancer: what is the relationship between the number of core samples taken and the sensitivity for detection of malignancy?

AIM: Percutaneous 14-gauge core biopsy (CB) guided by digital stereotactic mammography is now an established technique in the investigation of women with non-palpable suspicious mammographic lesions. Diagnostic sensitivity of CB is affected both by the nature of the mammographic abnormality and by the number of core samples taken. METHODS AND RESULTS: A retrospective review of 500 women who have undergone CB in our institution showed that in 235 cases, invasive or non-invasive carcinoma was found on final surgical histology. Correlation between CB result and surgical histology revealed a significant increase in sensitivity for the diagnosis of malignancy if a larger number of cores were taken (84.3% for two cores and 90.2% for five cores vs. 97.9% for six or more cores). This trend was maintained when patients were subdivided according to mammographic abnormality, either soft tissue mass or microcalcifications. The effect on diagnostic sensitivity of increasing the number of tissue cores obtained was most pronounced in patients with microcalcifications graded as low or moderately suspicious for malignancy (70.1% for two cores and 79.1% for five cores vs 94.0% for six or more cores). The presence of an invasive component in a malignant lesion was correctly diagnosed using CB in 79.2% overall if at least six cores were taken. If the mammographic lesion was a soft tissue mass, this figure rose to 95.7%, but was only 35.7% if the visible lesion was composed of microcalcifications alone. CONCLUSION: Our series confirms the reliability of stereotactic CB in the diagnosis of breast carcinoma. Diagnostic sensitivity is improved by increasing the number of cores taken (to six or more), particularly in women with mammographic microcalcifications of an equivocal nature.     

Fibrous nodules found at large-core needle biopsy of the breast: imaging features

PURPOSE: To describe the imaging and histologic features of large-core needle biopsy (LCNB) specimens of fibrous nodules. MATERIALS AND METHODS: Of 853 breast masses in which LCNB was performed, 38 (4%) revealed histologic findings of fibrous nodules. Repeat biopsy was performed in 16 lesions (surgical excision, 13 lesions; repeat LCNB, three lesions). The mammographic and ultrasonographic findings in these 16 cases, the histologic LCNB findings, and the repeat biopsy findings were retrospectively reviewed. RESULTS: Repeat biopsy findings confirmed the diagnosis of fibrous nodules in 15 of the 16 masses. In one mass, repeat LCNB findings showed a fibroadenoma. The imaging features of the fibrous nodules varied. Five nodules (33%) manifested as masses with indistinct margins; six (40%), as circumscribed masses. In four cases (27%), imaging suggested malignancy. None were calcified masses. An additional 22 masses had circumscribed or indistinct borders and were diagnosed with LCNB as fibrous nodules. None of these masses had suspicious findings, and repeat biopsy was not performed. CONCLUSION: Fibrous nodules usually manifest as masses with circumscribed or indistinct margins but can have findings suggestive of malignancy. LCNB can reveal histologic findings consistent with this diagnosis. In all masses in which repeat biopsy was performed, the diagnosis of a fibrous nodule was confirmed or another benign stromal lesion was diagnosed.     

Mammography image quality: Model for predicting compliance with posterior nipple line criterion

Purpose

To develop a model using measurements of pectoral muscle width and length together with the acceptability of the posterior nipple line criteria (PNL) to predict the acceptability of the presentation of the pectoral muscle in the mediolateral oblique view of the breast.

Method

A total of 400 mediolateral oblique mammogram images were randomly selected from BreastScreen NSW South West, Australia. Measurements of length and width of the pectoral muscle and the acceptability of the pectoral muscle position relative to the PNL were recorded. Data analysis involved logistic regression and ROC analysis to test the predictors of width and length and the performance of the model. The model was then used to predict the outcome of acceptable or unacceptable PNL criterion for each case.

Results

The estimated odds ratio for an increase of 10 mm was 1.98 (CI = 1.68, 2.34) for the length predictor and 2.14 (CI = 1.56, 2.93) for the width predictor. A cut off point of 0.6083 was derived from the training set and applied with the developed model to the test set. The area under the ROC curve was 0.9339 demonstrating an accurate model.

Conclusion

This paper describes a model to predict the acceptability of the PNL criterion using the width and length of the pectoral muscle. This model could be used in the automated assessment of image quality which has the potential to enhance the consistency in mammographic image quality evaluation. Optimising image quality contributes to increased accuracy in radiological interpretation, which maximises the early detection of breast cancer and potentially reduces mortality rates.     

Post-lumpectomy breast calcifications: Can original tumor features assist in determining need for biopsy?

ObjectiveThe objective of our study was to determine whether, in the digital era, imaging features of a primary breast tumor can be used to influence the decision to biopsy ipsilateral breast calcifications that occur following surgery in women treated with breast conservation surgery (BCS).Materials and methodsWe retrospectively identified women treated with BCS who subsequently developed suspicious calcifications in the treated breast (BI-RADS 4 or 5) from January 2012 – December 2018. Only cases with histopathological diagnosis by stereotactic or surgical biopsy were included. Pathology reports were reviewed, and biopsy results were considered malignant if invasive carcinoma or ductal carcinoma in situ (DCIS) was found. All other results were considered benign.Fisher's exact test was done comparing frequencies of malignancy between those patients whose original tumor had calcifications versus those whose original tumors were not calcified.ResultsOf 90 women with suspicious calcifications on a post-BCS mammogram, 65 (72.2%) were biopsy proven benign and 25 (27.8%) were malignant. The original tumor presented without calcifications in 39 patients (43%), and 51 (57%) had calcifications with or without associated mass, focal asymmetry, or architectural distortion. New calcifications were less likely to be malignant if the original tumor presented without calcifications (5/39; 12.8%) as compared to original tumors with calcifications (20/51; 38.5%) [p-value < 0.05].ConclusionNew calcifications after BCS are significantly less likely to be malignant if the original tumor presented without calcifications. However, with a PPV of 12.8%, even calcifications in a patient with a non-calcified primary tumor require biopsy.     

Stereotaxic needle-core biopsy and fine-needle aspiration biopsy in the diagnosis of nonpalpable breast lesions: controversies and future prospects

Objective: To determine the advantages and limitations of a combined stereotaxic fine-needle aspiration biopsy and needle-core biopsy in the diagnosis of 353 nonpalpable breast lesions with special attention given to the collection of follow-up data. Methods and material: 353 nonpalpable breast lesions underwent ‘one pass’ stereotaxic fine-needle aspiration (21 gauge needle) and needle-core biopsy (18 gauge needle) at our institution from January 1990 to October 1993. Stereotaxic biopsies were carried out by means of an ‘add-on unit’. Surgical biopsy was usually recommended for highly suspicious radiologic patterns and/or needle biopsy reports classified as atypical or malignant. In all other cases mammographic follow-up was advised at 6 months and then annually for 3 years. The data were collected retrospectively during September 1995 (theoretical average follow-up of greater than 3 years). Results: Following the combined needle biopsy technique procedure, surgery was recommended for 83 lesions. Fifty-four cancers were associated to these suspicious lesions. Because of changing radiological or clinical pattern during follow-up (mean follow-up: 22 months), 11 cancers were detected among the 270 lesions initially considered not to need surgery. Forty-three percent of the 65 malignant lesions were initially read as having less than highly suspicious mammographic features. There was no significant difference between the sensitivity and the specificity of one pass fine-needle aspiration biopsy (57% and 96% respectively) and needle-core biopsy (60% and 97% respectively), but noncontributive samples were not included in the false negative diagnoses and atypical samples were included in the true positive diagnoses. Of the 11 missed cancers, nine were manifested initially by clusters of calcifications. Our diagnostic approach was significantly less sensitive (P = 0.006) and less specific (P = 0.032) in cases of clusters of calcifications (31% false negative diagnoses) than in cases of soft-tissue masses (5.5% false negative diagnoses). In this study, an average delay in diagnosis of 22 months was responsible for a significantly increased percentage of axillary node positive invasive cancer (P < 0.001) and six of the 11 missed cancers were palpable at the time of the delayed diagnosis. For the nine cancers initially manifested by calcifications, the 22 months delay in diagnosis was responsible for a nonsignificant increase of microinvasive type at the expense of carcinoma in situ. Conclusion: Our enthusiasm with the sensitivity of this double stereotaxic needle sampling has been tempered by the results of this reanalysis in the light of a mean theoretical follow-up of three years. Our diagnostic approach was adequate in the presence of soft-tissue masses but not valid in the presence of clustered calcifications. When dealing with calcifications, multiple samplings must be done in order to improve the sensitivity of the diagnosis. Furthermore, this study does not favour the theory that the majority of mammographically detected cancers are indolent and highlights the poor sensitivity of the mammographic follow-up of nonpalpable lesions.     

Mammographic appearance of calcifications as a predictor of intraductal carcinoma histologic subtype

We reviewed 109 consecutive cases of intraductal carcinoma to evaluate the association between histologic subtype (comedo = 35, non-comedo = 71, mixed = 3) and calcification type, as assessed by histology (amorphous vs. crystalline) or by mammography (coarsely granular, irregular shape, linear, branching vs. fine granular, irregular, or more or less regular oval or circular forms). Calcifications were microscopically or mammographically detected in 90.8% and 76.1% of cases, respectively, and a significant association was found between microscopic (amorphous) and mammographic (coarse granular, linear, branching) calcified types and histologic comedo subtypes (P <0.001). Nevertheless, accurate prediction of the histologic subtype on the basis of mammographic calcifications occurred only in 78.3% of cases with calcifications, and in 59.6% of all cases. Mammography is not a reliable method to predict DCIS histologic subtype at the present time. Correspondence to: S. Ciatto     

Mammographic changes in postmenopausal women on hormonal replacement therapy

The purpose of this study was to investigate the extent of the effects of hormonal replacement therapy (HRT) on the mammographic breast pattern in postmenopausal women. In a hospital-based study mammographic examinations of 81 postmenopausal women were evaluated retrospectively, before and after 1–2 years of treatment with oestrogens or a combination of oestrogens and progestagens. Each individual mammographic film was examined separately, and the glandular tissue was classified according to a modified Wolfe classification. In a screening-centre-based study two consecutive mammograms, with a 2-year interval, of 645 women, of whom 70 were using some kind of hormone therapy, were evaluated retrospectively. In the hospital-based study 31% of patients treated with combination HRT showed an increase in fibroglandular tissue compared with only 8.7% in the group treated with oestrogens alone. The difference was statistically significant (p=0.046). In the screening-based study 14.3% of the women using hormonal therapy showed an increase, whereas in the non-users no increase was found (p=1.24×10⁻¹⁰). After beginning HRT many women (between 14 and 25% in our experience) can be expected to undergo a mammographically detectable increase in fibroglandular tissue. Radiologists should be aware of the aetiology of such changes, and can obtain information on HRT most conveniently by having the technologist routinely question each patient.     

Calcified filariasis of the breast: report of four cases

Circumscribed to endemic areas throughout tropical countries, filariasis is a rare and unknown disease in Europe. We report four cases of calcified filariasis involving the breast, supporting the diagnosis on the typical mammographic appearance of the calcified worms and the past history of filarial infection. Few reports have been published in the radiology literature about this infrequent manifestation of the parasitation. The purpose of this article is to show the mammographic characteristics of this disease that soon will be seen frequently in developed countries due to the increasing population from the endemic areas.     

Breast neoplasms detected only with ultrasonography: incidental finding or clinical evidence?

INTRODUCTION: Mammography is the only technique of proven efficacy in the early diagnosis of breast cancer, even though its sensitivity is much lower in breasts that are dense or with a high parenchymal-stromal component. In the past malignant breast nodules detected at US in patients with negative mammographic and physical findings were considered incidental findings, but more recent papers report increasing numbers of breast cancers detected only at US. PURPOSE: We investigated the yield of US performed as a diagnostic complement in asymptomatic women with mammographic findings that were either negative or poorly readable because of dense breast. MATERIAL AND METHODS: We examined 13 women 37 to 55 years old (mean 47): 9 of them were asymptomatic and 4 had poorly specific physical findings. The patients underwent physical examination, mammography, US, microhistologic biopsy with 14G needles under US guidance and surgery. RESULTS: Fourteen breast lesions 7.0-15 mm in diameter were detected only by US. Mammography (2 or 3 standard views) was negative in all cases. The lesions detected only by US (10% of all carcinomas) were typified with US-guided needle biopsy and finally confirmed surgically. DISCUSSION AND CONCLUSIONS: Though obtained in a small series, our results seem to suggest that US should be included in the diagnostic work-up, especially of women with dense breast. Also, any hypoechoic lesion detected at breast US in clinically asymptomatic women with negative mammographic findings should be further investigated with US, needle aspiration or core biopsy to make the final diagnosis.     

Incremental clinical value of ultrasound in men with mammographically confirmed gynecomastia

Purpose

To determine whether ultrasound is of any value in male patients presenting with focal symptoms who have classic features of gynecomastia but no concerning findings on mammography.

Materials and Methods

Over a 3-year period, all male patients who underwent mammographic evaluation were identified in this retrospective study. Patients with a mammographic diagnosis of gynecomastia and subsequent breast ultrasound at a large tertiary academic medical center comprised the study cohort. Men whose ultrasound diagnosis differed from the initial mammographic evaluation were analyzed for both additional benign findings as well as findings that warranted biopsy.

Results

A total of 353 mammograms were obtained from 327 unique patients (ages 18–95, mean 51 years). Of all mammographic examinations, gynecomastia was the sole finding in 73% (259). In those 259 studies, 85% were further evaluated with ultrasound, in which 6 (2.7%) showed additional benign findings, and 4 (1.8%) showed suspicious findings for which biopsy was recommended. No malignancies were detected in those patients. Furthermore, no malignancies were detected in patients whose mammogram revealed only normal fatty parenchyma or only gynecomastia. In all cases of cancer, mammography revealed visible masses.

Conclusion

Judicious use of breast ultrasound in men improves outcome. Our data suggest that targeted ultrasound is of limited value in symptomatic male patients where mammography is negative or reveals only gynecomastia and leads to unnecessary benign biopsies in these patients. When mammography reveals concerning findings, ultrasound adds positively to clinical management.     

Differential diagnosis between fibroadenoma, giant fibroadenoma and phyllodes tumour: sonographic features and core needle biopsy

Purpose

The aim of this study was to analyse mammographic and ultrasound (US) features of fibroadenoma and phyllodes tumour and assess the diagnostic accuracy of mammography, US and US-guided core needle biopsy (CNB) in the differential diagnosis of these two lesions.

Materials and methods

The results of the pathological analysis of excision biopsy of 83 lesions (67 fibroadenomas and 16 phyllodes tumours) were correlated with the findings of mammography, US and US-guided CNB performed on 83 women with a mean age of 45.4 years (range 18?C75 years).

Results

Sensitivity, specificity and positive predictive values compared with histology were 45%, 50% and 79% for mammography, 34%, 69% and 82% for US and 81%, 97% and 87% for US-guided CNB (p=0.001).

Conclusions

The almost complete overlap between mammographic and US parameters of fibroadenomas and phyllodes tumours and the absence of pathognomonic features preclude the differential diagnosis between the two histological types. US-guided CNB is a valuable tool in the differential diagnosis between fibroadenoma and phyllodes tumour.     

Stereotactic Core-Needle Biopsy of Non-Mass Calcifications: Outcome and Accuracy at Long-Term Follow-Up

Objective

To determine, by means of long-term follow-up evaluation, the outcome and accuracy of stereotactic core-needle biopsy (SCNB) of non-mass calcifications observed at mammography, and to analyze the factors contributing to false-negative findings.

Materials and Methods

Using a 14-gauge needle, SCNB was performed in cases involving 271 non-mass calcified lesions observed at mammography in 267 patients aged 23-72 (mean, 47) years. We compared the SCNB results with those of long-term follow-up which included surgery, mammography performed for at least six months, and reference to Korean Cancer Registry listings. We investigated the retrieval rate for calcifications observed at specimen mammography and histologic evaluation, and determined the incidence rate of cancer, sensitivity, and the underestimation rate for SCNB. False-negative cases were evaluated in terms of their mammographic findings, the effect of the operators'' experience, and the retrieval rate for calcifications.

Results

For specimen mammography and histologic evaluation of SCNB, the retrieval rate for calcifications was, respectively, 84% and 77%. At SCNB, 54 of 271 lesions (19.9%) were malignant [carcinoma in situ, 45/54 (83%)], 16 were borderline, and 201 were benign. SCNB showed that the incidence of cancer was 5.0% (6/120) in the benign mammographic category and 31.8% (48/151) in the malignant category. The findings revealed by immediate surgery and by long-term follow-up showed, respectively, that the sensitivity of SCNB was 90% and 82%. For borderline lesions, the underestimation rate was 10%. For false-negative cases, which were more frequent among the first ten cases we studied (p = 0.01), the most frequent mammographic finding was clustered amorphous calcifications. For true-negative and false-negative cases, the retrieval rate for calcifications was similar at specimen mammography (83% and 67%, respectively; p = 0.14) and histologic evaluation (79% and 75%, respectively; p = 0.47).

Conclusion

In this study group, most diagnosed cancers were in-situ lesions, and long-term follow-up showed that the sensitivity of SCNB was 82%. False-negative findings were frequent during the operators'' learning period.     

The significance of circumscribed malignant mammographic masses in the surveillance of BRCA 1/2 gene mutation carriers

Breast cancers in gene mutation carriers may escape mammographic detection because of rapid growth and tumor expansion. Therefore, they may mimic benign lesions on the mammogram. Twenty-nine BRCA 1/2 mutation carriers under surveillance developed 31 breast cancers between 1994 and 2001 at a mean age of 44.2 years. Controls were 63 women with 67 breast cancers in the same period at a mean age of 53.8 years, also under surveillance because of a life time risk of at least 15%. In 26% of the carriers vs. 48% of the controls, mammography was the method that first suspected a malignancy. Seven radiologists performed a retrospective review of the original mammograms to establish technical assessment, with special attention for circumscribed lesions and estimated probability of malignancy. In the mutation carriers seven (23%) circumscribed non-calcified mammographic masses were found and three in the controls (4.5%) P=0.01. These masses were proven to be malignant. In both groups around 70% of these fast-growing circumscribed lesions were detected by the patients. The masses were situated in breasts with a good interpretable breast pattern. BRCA 1/2 mutation carriers had a significantly higher percentage of circumscribed non-calcified mammographic masses that proved to be malignant. These mammographic lesions in women at high risk should be described as at least Birads 0 and worked-up with ultrasound and needle biopsy.     

Vacuum-assisted biopsy diagnosis of atypical ductal hyperplasia and patient management

Purpose

This study sought to evaluate the accuracy of vacuum-assisted biopsy (VAB) in the diagnosis of atypical ductal hyperplasia (ADH) by determining the rate of VAB underestimation compared with definitive histology. In addition, an attempt was made to identify parameters that could help determine the most appropriate patient management.

Materials and methods

We retrospectively reviewed 1,776 VAB procedures performed between November 1999 and January 2008 for suspicious subclinical breast lesions visible only at mammography. A total of 177 patients with a VAB diagnosis of pure ADH were studied. Patients with a diagnosis of ADH associated with other lesions (lobular intraepithelial neoplasia, papilloma), atypical lobular hyperplasia, lobular carcinoma in situ and any lesions with a microhistological diagnosis other than ADH were excluded. Mammographic appearance of lesions was as follows: 152 mostly clustered microcalcifications (86%); five opacities with microcalcifications (3%); 12 single opacities (3%); and eight parenchymal distortions (4%), of which five were without and three were with microcalcifications. In cases underestimated by VAB, we evaluated the extent of ADH within ducts and lobules. Based on results, patients were subdivided into two groups: ??2 ADH foci; >2 ADH foci. Patients were subdivided into two groups: one was referred for surgery and the other for follow-up care. The decision to either perform or not perform surgery was based on combined analysis of the following parameters: patient age; risk factors in the patient??s history; mammographic extent of microcalcifications; complete excision of microcalcifications at VAB; and final Breast Imaging Reporting and Data System (BI-RADS) assessment.

Results

In the first group (n=98), comparison of microhistology with final histology revealed that 19 cases of ADH had been underestimated by VAB. In the second group (n=79), six cases of ADH showed progression of the mammographic abnormality, which was subsequently confirmed by surgical biopsy.

Conclusions

The most relevant parameters affecting the decision to proceed to surgical excision were lesion diameter >7 mm on mammography, >2 ADH foci, incomplete removal of the calcifications and a family and/or personal history of breast cancer. Although there are no definite mammographic predictors of malignancy, a radiological assessment of suspicious lesion in the presence of an additional equivocal parameter always warrants surgical management.