Role of high frequency ultrasonography in the evaluation of palpable breast masses in Chinese women: alternative to mammography?

We prospectively assessed the accuracy of high resolution breast ultrasonography in the diagnosis of palpable breast masses in comparison to clinical palpation and x-ray mammography. Four hundred and eight Chinese women with palpable breast lumps had clinical assessment followed by ultrasonography of the breast, mammography (for women over 35 years), and fine needle aspiration cytology. Excisional biopsy or surgery was performed for suggestive lesions. The clinical, mammographic and ultrasound diagnoses were compared with the final pathologic diagnosis. In the determination of whether a lesion was malignant, the sensitivity, specificity, and positive predictive values were 97%, 97%, and 85%, respectively, for ultrasonography; 92%, 94%, and 84%, respectively, for mammography; and 88%, 92%, and 67%, respectively, for clinical evaluation. The specificity for combined clinical palpation and ultrasonography was higher (99%) than that for combined clinical palpation and mammography (96%). Addition of ultrasonography to combined clinical palpation and mammography increased specificity. Mammography in addition to combined clinical palpation and ultrasonography did not significantly improve the sensitivity, specificity, or positive predictive value. This limited usefulness raises the question as to whether it should be eliminated in the workup of a palpable mass in the average Chinese patient. Its main advantage is the detection of extended foci of carcinoma in situ related to a palpable mass, which often is undetected by ultrasonography.     

The evaluation of common breast problems

The most common breast problems for which women consult a physician are breast pain, nipple discharge and a palpable mass. Most women with these complaints have benign breast disease. Breast pain alone is rarely a presenting symptom of cancer, and imaging studies should be reserved for use in women who fall within usual screening guidelines. A nipple discharge can be characterized as physiologic or pathologic based on the findings of the history and physical examination. A pathologic discharge is an indication for terminal duct excision. A dominant breast mass requires histologic diagnosis. A breast cyst can be diagnosed and treated by aspiration. The management of a solid mass depends on the degree of clinical suspicion and the patient's age.     

Imaging of the breast: techniques and results

Procedures for imaging of the breast have increased in number substantially in the past 30 years. Mammography, currently the most important breast imaging technique, was introduced at the Mayo Clinic in 1961. In 1988, more than 36,000 mammographic procedures were done. Breast ultrasonography is also a valuable examination, particularly for determining whether mass lesions are cystic or solid. The use of mammography for screening is increasing. Screening mammography allows the detection of breast cancer before it is palpable and while it is still in a stage known as minimal breast cancer. Lesions metastatic to axillary lymph nodes are less common in women with nonpalpable breast cancers than in women with palpable lesions. Nondiagnostic mammography should not delay the biopsy of a mass that is suspicious on physical examination. A special breast imaging center for performance of screening studies and evaluation of breast problems has been established at the Mayo Clinic.     

Sonographic Appearances of Benign and Malignant Male Breast Disease With Mammographic and Pathologic Correlation

Objective. Imaging of the male breast is most often performed for the evaluation of a clinical abnormality such as breast enlargement or tenderness, a palpable mass, nipple skin changes, or nipple discharge. Most breast lesions encountered in men are benign. Malignant breast lesions are less frequent; breast cancer accounts for less than 1% of all male cancers in the United States. The initial imaging evaluation of a finding in the male breast is performed with mammography. Sonography is frequently used as an adjunct to mammography but is less often used as the primary imaging modality. The objective of this article is to provide readers with a thorough review of the sonographic appearances of benign and malignant male breast disease. Methods. We reviewed our institution's case database to identify male patients who underwent mammography, sonography, and subsequent biopsy of a breast lesion. These cases were collected and reviewed to select the best imaging examples. Results. A spectrum of benign and malignant male breast disease is presented with corresponding sonographic, mammographic, and pathologic imaging. For each entity, the salient imaging findings and typical clinical presentation are discussed. Conclusions. Most studies in the literature have reported on the mammographic and sonographic imaging features of primary breast carcinoma in men. However, very little has been reported on the sonographic appearance of benign and malignant male breast conditions. Recognition and correct identification of pathologic male breast entities on sonography is essential to determine appropriate management recommendations and avoid unnecessary biopsies.     

Nipple fluid cytology

With increasing emphasis on public awareness of breast cancer and screening mammography, more women seek consultation for breast symptoms, including nipple discharge. The presence of nipple discharge is distressing for the patient; however, its origin is fortunately most often benign. Nipple discharge associated with a recognizable mass requires sampling and surgical excision. Currently, clinical breast examination, cytology, ductography, mammogram, and ultrasound are commonly used to evaluate patients who have nipple discharge. Ductal lavage and ductoscopy, in association with emerging new technology, may be of help in increasing the sensitivity of nipple fluid cytology. In addition, nipple fluid cytology may offer a new way to study the spectrum of premalignant breast lesions, and to identify women at risk for breast cancer.     

原发性淋巴瘤的超声声像图及钼靶X线摄影特征分析

目的分析原发性淋巴瘤的超声声像图及钼靶X线摄影特征。方法回顾性分析13例经病理证实的原发性淋巴瘤患者的临床资料、超声声像图及钼靶X线摄影图像。结果 13例患者共15个病灶,9例伴有患侧腋窝淋巴结肿大,均为单侧发生非霍奇金淋巴瘤。13例患者行超声检查,9例行钼靶X线摄影检查。超声声像图多表现为:卵圆形(7/15)或分叶状(5/15)、边界清晰(10/15)低回声为主的肿块,部分肿块(7/15)伴后方回声增高,均未见肿块周围蟹足样改变、高回声晕环、后方回声衰减及肿块内钙化。多数肿块(11/15)内见丰富的动脉血流信号。钼靶X线摄影多表现为:卵圆形(5/8)或分叶状(3/8)的边界清晰(7/8)和高密度(7/8)肿块。2例乳腺腺体较致密,未见明确肿块,均未见毛刺、钙化、皮肤增厚及乳头凹陷。结论原发性淋巴瘤的超声及钼靶X线摄影表现均无特异性。在结合超声声像图肿块血流信号特征考虑恶性可能,而钼靶X线摄影表现为良性或不典型乳腺癌者应考虑到乳腺原发性淋巴瘤可能,进一步进行组织学活检以明确乳腺原发性淋巴瘤的诊断。     

Screening for breast cancer: current recommendations and future directions

Breast cancer is one of the most significant health concerns in the United States. Recent reviews have questioned the value of traditional breast cancer screening methods. Breast self-examination has been shown not to improve cancer-specific or all-cause mortality in large studies, but it is commonly advocated as a noninvasive screen. Patients who choose to perform self-examination should be trained in appropriate technique and follow-up. The contribution of the clinical breast examination to early detection is difficult to determine, but studies show that sensitivity is highly dependent on time taken to do the examination. Up to 10 percent of cancers are mammographically silent but evident on clinical breast examination. The U.S. Preventive Services Task Force recommends mammography for women older than 40 years who are in good health, but physicians should consider that sensitivity is lower for younger women. Digital mammography is somewhat more sensitive in younger women and women with dense breasts, but outcome studies are lacking. Although magnetic resonance imaging shows promise as a screening tool in some high-risk women, it is not currently recommended for general screening because of high false-positive rates and cost. The American Cancer Society recommends annual magnetic resonance imaging as an adjunct to screening mammography in high-risk women 30 years and older.     

The role of magnetic resonance imaging in screening women at high risk of breast cancer

Most women at very high risk of breast cancer because of a mutation in the genes BRCA1 or BRCA2, or a very strong family history of breast cancer, opt for intensive breast screening rather than bilateral prophylactic mastectomy. Annual screening mammography has low sensitivity in this population in part because of the greater breast density and faster tumor growth of younger women, resulting in cancers being detected at a suboptimal stage. In 11 prospective comparative studies, the addition of annual contrast-enhanced magnetic resonance imaging (MRI) of the breast to mammography demonstrated more than 90% sensitivity, more than twice that of mammography alone. False-positive rates were higher with the addition of MRI, but specificity improved on successive rounds of screening. Although survival data are not yet available, the stage distribution of these tumors predicts a significant reduction in breast cancer mortality rate compared with that of screening without MRI. Accordingly, annual MRI plus mammography is now the standard of care for screening women aged 30 years or older who are known or likely to have inherited a strong predisposition to breast cancer (based on the above evidence) and for women who received radiation therapy to the chest before the age of 30 years (based on expert opinion). Further research is necessary to define the optimal screening schedule for different subgroups. Formal studies of other high-risk populations (eg, biopsy showing lobular neoplasia or atypical ductal hyperplasia, dense breasts, and personal history of breast cancer at a young age) should be done before MRI screening is routinely adopted for these women.     

Evaluation of 1294 Female Patients with Breast Pain: A Retrospective Study

Introduction

Mastalgia, or breast pain, is one of the most important complaints referred to outpatient clinics. The objective of this study was to evaluate the factors causing mastalgia. All patients who presented to our clinic with complaints of mastalgia were assessed along with their type of mastalgia symptoms, menopausal status, and radiology results.

Methods

A total of 3157 patients with mastalgia complaints visited our clinic between January 2015 and February 2018. Only 1294 of them were retrospectively screened. Age, sex, menopausal (premenopausal, postmenopausal) status, mastalgia type (cyclic, non-cyclic), and imaging findings of the patients were examined.

Results

The mean age was 43.8?±?11.8 (13–86) years, with 453 (35%) patients younger than 40 years and 841 (65%) older than 40. Cyclic mastalgia was found in 207 (16%) patients, and non-cyclic mastalgia was seen in 1087 (84%) patients. A total of 786 (60.7%) patients were premenopausal, and 508 (39.3%) were postmenopausal. Mammography was used in 545 (42.1%) patients; 1190 (92.0%) women had breast ultrasonography.

Conclusion

Although breast pain is a common symptom in women who are referred to breast outpatient clinics, we concluded that patients who complain of mastalgia should not be afraid of cancer. Despite this and for reassurance, clinical imaging may be necessary to alleviate these patients’ suspicions.

     

Myofibroblastoma of the breast in postmenopausal women: Two case reports with imaging findings and review of the literature

Myofibroblastoma is a rare benign mesenchymal tumor of the breast, which tends to affect postmenopausal women and older men. It usually presents as a unilateral, well-circumscribed, firm, nontender, and freely mobile mass. We report two cases of myofibroblastoma in postmenopausal women with the imaging findings of mammography, ultrasonography, computed tomography, ¹⁸F-Fluorodeoxyglucose-positron emission tomography computed tomography, and pathologic findings and review the relevant literature.     

Sonographic Features of Gynecomastia

Objective. The purpose of this study was to identify sonographic features of gynecomastia. Methods. .A retrospective analysis was performed on all male patients with breast symptoms imaged with breast sonography over a 5‐year period. Breast sonograms in 158 men were jointly reviewed by 3 investigators. Sonograms were assessed for the presence or absence of a mass: (1) if mass present, (a) location of the mass, (b) vascularity, (c), axis, (d) appearance of posterior tissues, and (e) tissue echo texture; and (2) if mass absent, anteroposterior (AP) depth at the nipple (increased if >1 cm). Results. Of the 237 men with breast symptoms, 79 with only mammography were excluded. Of the 158 who had sonography with or without mammography, 5 without gynecomastia were also excluded. A total of 153 men included in the study presented with pain (n = 38), a lump (n = 95), both pain and a lump (n = 17), or nipple discharge (n = 3). Nine of 153 with gynecomastia had a biopsy. A total of 219 sonographic examinations were performed, which revealed 73 masses (33%): 20 (27%) nodular, 20 (27%) poorly defined, and 33 (45%) flame shaped. All masses were retroareolar, with 57 (78%) hypoechoic, 54 (73%) avascular, 60 (82%) parallel to the chest wall, and 47 (64%) without posterior enhancement or shadowing. Of the 146 without masses (67%), 141 (97%) had increased AP depth at the nipple. Conclusions. Gynecomastia is a clinical diagnosis, and mammography is the primary imaging modality when indicated. However, if sonography is used when mammography is declined or when mammography is inconclusive, it is important to recognize the various described patterns of gynecomastia to avoid unnecessary biopsy based on sonographic findings.     

Microcalcifications of non-palpable breast lesions detected by ultrasonography: correlation with mammography and histopathology.

OBJECTIVES: Microcalcifications are generally not demonstrated well on ultrasonography. In this study, we attempted to demonstrate the usefulness of high-resolution ultrasonography in the detection of microcalcifications associated with non-palpable breast cancers. DESIGN: Fourteen patients with non-palpable breast lesions in whom microcalcifications were detected or suspected by ultrasonography and one patient in whom microcalcifications were detected on mammography only were included in the study. Mammography and analysis of biopsy specimens were performed in each patient and the findings were correlated with the ultrasonographic findings. Ultrasonography and mammography were performed independently by different physicians at different times. RESULTS: In three patients < or = 30 years of age, who were not at high risk of breast cancer and who had no evidence of cancer on palpation, high-resolution ultrasonography clearly showed microcalcifications but no mass. Two of these patients had ductal carcinoma in situ and one had small invasive carcinoma with extensive comedocarcinoma. Among the other 12 patients with non-palpable breast lesions, ultrasonography detected microcalcifications accurately in six and suggested possible microcalcifications in a further four. Microcalcifications in all of these ten patients were confirmed by mammography thereafter. Four of these ten patients had ductal carcinoma in situ, with or without invasive carcinoma. Of the remaining two patients, one demonstrated false-positive findings and one false-negative findings on ultrasound. On high-resolution ultrasonography, microcalcifications produced the appearance of twinkling stars (bright dots in different planes) in a dark sky (contrasted against ill-defined hypoechoic patches), corresponding on histopathology to groups of expanded ducts with increased cell density with or without necrosis. CONCLUSION: High-resolution ultrasonography may be used for detection of microcalcifications in non-palpable breast lesions. Ultrasonography is helpful in screening for early breast cancers, especially in young patients who are at risk for breast cancer and in whom mammography is not usually carried out.     

Breast masses. In-office evaluation with diagnostic triad

Using the diagnostic triad of clinical breast examination, fine-needle aspiration, and mammography, primary care physicians can make an in-office definitive diagnosis in 90% of women presenting with a dominant breast mass. The remaining 10% should undergo open surgical biopsy. This diagnostic-triad approach is accurate, efficient, and cost-effective, and it does not require additional lengthy training, expensive equipment, or complex technology. In the case of breast cancer, the woman and her family can be immediately counseled and quickly prepared for consulting appointments and appropriate treatment options.     

How should we screen for breast cancer? Mammography, ultrasonography, MRI

Of the imaging techniques currently available to evaluate women for breast disease, mammography remains the mainstay of breast cancer screening, but recent guidelines have included magnetic resonance imaging (MRI) for the screening of some women at high risk. Whole-breast ultrasonography for screening has not been established as useful and so should not be offered routinely to patients.     

Glycogen-rich clear cell carcinoma of the breast: a case report

Glycogen-rich clear cell carcinoma (GRCC) of the breast is a rare malignant breast tumor. We recently encountered a case of GRCC and report our imaging findings here. The patient was a 49-year-old woman with a mass in her right breast. Mammographic study showed no definite mass shadow because the breast was dense. No calcifications were identified. Ultrasonography disclosed a hypoechoic mass that had a diameter of 1.3 cm, partially irregular borders, heterogeneous internal echoes, and posterior acoustic enhancement, suggesting an invasive carcinoma. Histologic study of core needle biopsy specimens showed a solid proliferation of large clear carcinoma cells, suggestive of a ductal carcinoma. The carcinoma cells possessed clear cytoplasm larger than that typical of ductal carcinoma cells. Breast-conserving surgery was performed with axillary sentinel lymph node biopsy. Macroscopically, the tumor was a solid, white-yellow mass with fairly well defined margins. Histologic examination of the tumor showed a characteristic feature of GRCC: the tumor cells were positive for estrogen receptor but negative for progesterone receptor and Her 2, and the sentinel lymph node was histologically negative. The patient remains well and has had no clinical recurrence of the disease after 2.5 years of follow-up without radiotherapy or adjuvant therapy. Noteworthy is the usefulness of mammography and ultrasonography, which should be used as complementary imaging tools.     

Sonographic evaluation of focal asymmetric density of the breast

The purpose of this study was to examine the role of sonography in the evaluation of a focal asymmetric density of the breast in patients who subsequently underwent biopsy for this finding. During a 30-month period, the clinical, sonographic, and pathologic findings were retrospectively reviewed in 36 women who underwent biopsy for a focal asymmetric density of the breast after mammographic and sonographic workup. Sonographic evaluation of a focal asymmetric density of the breast in 36 women demonstrated a solid mass in 15, a suspected complicated cyst in two, echogenic tissue in nine women, and no focal sonographic change in 10. Excisional biopsy of the focal asymmetric density revealed infiltrating ductal cancer in seven patients (19.4%: 7/36). Two of these seven patients with breast cancer had no focal abnormality at sonographic examination. Twenty-nine patients had benign pathologic findings. In this retrospective study, the negative predictive value of sonography for breast cancer in a patient with a focal asymmetric density undergoing biopsy was found to be 89.4% (17/19). Sonographic evaluation of a focal asymmetric density is helpful, particularly to identify an underlying mass. When sonography demonstrates echogenic tissue corresponding to the focal asymmetric density, a benign process is likely; however, absence of a corresponding focal finding does not exclude malignancy. Therefore, although the negative predictive value of sonography for breast cancer in a patient with a focal asymmetric density is high, biopsy is still indicated for this mammographic finding when it is new, enlarging, or palpable, even in the absence of a suspicious sonographic finding.     

老年女性乳腺癌的临床特征及超声诊断价值

目的探讨老年女性乳腺癌的临床特征及超声诊断价值。 方法回顾性选取2015年6月至2019年12月就诊于北京协和医院乳腺外科行乳腺病灶手术获得明确病理诊断的≥70岁的老年女性288例，共计298个病灶，获取完整的临床、病理及超声影像资料。分析纳入对象的临床表现、病理特征，应用诊断试验四格表计算超声对老年女性乳腺良、恶性病灶及不同就诊原因患者良、恶性病灶的诊断效能，以及对腋窝淋巴结转移的诊断效能。 结果288例患者中，自行触及肿块189例（65.63%）、乳头溢液23例（7.99%）、体检（临床查体、影像学检查）发现肿块76例（26.39%）。298个病灶中，恶性病灶272个（91.28%），良性病灶26个（8.72%）。263例乳腺癌患者中，160例（60.84%）行乳腺肿块局部扩大切除术，71例（27.00%）行乳腺癌改良根治术，31例（11.79%）行乳腺肿块局部扩大切除术及前哨淋巴结活检或腋窝淋巴结清扫术，1例（0.38%）行全乳切除术。其中237例初诊患者术后病理T分期为T1 127例（53.59%），T2 79例（33.33%）。超声对老年女性乳腺癌的诊断敏感度、特异度和准确性分别为95.59%、50.00%和91.61%，其中超声对以肿块为主诉（包括自行触及和体检筛查发现）患者乳腺癌的诊断准确性（94.53%）高于主诉为乳头溢液患者的诊断准确性（58.33%）。102例乳腺癌患者接受了腋窝淋巴结处理，其中45例病理证实为腋窝淋巴结转移。术前超声对于腋窝转移性淋巴结诊断的敏感度、特异度和准确性分别为93.33%、73.68%、82.35%。 结论老年乳腺癌患者大多数因临床症状就诊，肿瘤分期晚。超声对以肿块为主诉的老年乳腺癌患者的诊断准确性较高，但对乳头溢液患者的诊断准确性仍有待提高。超声术前评估对老年乳腺癌患者腋窝淋巴结临床治疗方式的选择有重要价值。     

超声对乳头溢液性病变的诊断价值

目的:探讨高频超声探头对乳头溢液性病变的应用及诊断价值。方法:用7.5MHz电子线阵探头对32例乳头溢液患者进行乳腺超声检查,记录病变部位及导管或腺体内异常,同时常规行乳腺专科查体和钼靶X线检查,诊断结果与术后病理对照比较。结果:32例中导管内病变27例、导管外病变4例、囊性增生1例。超声对乳头溢液性病变的检出率为90.6%,诊断符合率为75.9%,与钼靶X线的检出率(37.5%)比较有显著性差异(P<0.05),尤其对导管内病变更显著。结论:超声可作为乳头溢液性病变尤其是导管内病变的无创性首要检诊手段。     

Sonographic,magnetic resonance imaging,and mammographic assessments of preoperative size of breast cancer.

High resolution sonographic (39 cases), magnetic resonance imaging (32 cases), and mammographic (35 cases) measurements of preoperative size of breast cancer were correlated with the pathologic size in 39 patients with breast carcinoma to determine the most accurate imaging technique for breast cancer size. There were nine T1, 21 T2, four T3, and four T4 tumors. Sonographic and magnetic resonance imaging measurements of tumor size demonstrated correlation coefficients of 0.92 and 0.93, respectively, both of which were superior to that of mammography (0.84). Sonographic tumor size evaluation thus is shown to be equivalent to magnetic resonance imaging in this study. Three of nine (33%), four of seven (57%), and four of eight (50%) T1 tumors would have been overstaged by ultrasonography, magnetic resonance imaging, and mammography, respectively. Three of 21 (14.3%), one of 16 (6.3%), and two of 18 (11.1%) T2 tumors would have been understaged by ultrasonography, magnetic resonance imaging, and mammography, respectively. We therefore found ultrasonography to be of value in the diagnosis and staging of breast cancer.     

Breast Abscess After Nipple Piercing

The purpose of this series was to review the spectrum of clinical and sonographic features associated with infection after nipple piercing. Between 2002 and 2010, 6 patients presented to our breast center with a breast abscess after nipple piercing. A retrospective analysis of the imaging findings was performed with clinical and pathologic correlation. Patients with breast infections after nipple piercing tend to be young, and the timing since piercing varies from 2 weeks to 17 months. Sonography showed a complex or hypoechoic mass in 5 of 6 patients. Treatment of breast abscesses included surgical incision and drainage, percutaneous drainage, and antibiotic therapy. Surgical evacuation is commonly performed; however, sonographically guided aspiration may be an appropriate management strategy.