Clinical value of mammography for symptomatic women 35 years of age and younger

Objective: This retrospective observational study was designed to answer the following question: Is mammography clinically effective in the evaluation of women ≤35 years old with breast symptoms or findings? Study Design: A retrospective review was undertaken of 1908 consecutive initial mammogram reports of symptomatic women ≤35 years old who came to a referral breast clinic. The clinic records were analyzed for the working diagnoses and management plans before and after the input of the initial mammogram reports. Results: Of the 4160 initial mammograms of women who came (1992-1995) to the Breast Diagnostic Center at Women’s and Children Hospital, Los Angeles, Calif, 1908 were of women ≤35 years old. The mammogram reports were reviewed and tabulated by age group for mammography recommendations. The working diagnoses and management plans in the center’s charts were retrospectively evaluated before and after the mammogram reports to ascertain whether the mammogram reports altered clinical management in this patient population and age group. No clinically unsuspected cancers were perceived by mammography performed at the center in women ≤35 years old. (All of the 23 invasive cancers were palpable and had prior diagnoses after fine-needle aspiration biopsy.) The initial mammogram reports did not change the working diagnosis or clinical management of these cases in this patient population and clinic setting. Ultrasonography was recommended by the radiologists in 37% of the study cases. Conclusions: Routine initial mammography was not cost-effective or clinically beneficial in the evaluation of breast symptoms or findings and management of the cases of women ≤35 years old who came to our center. (Am J Obstet Gynecol 1999;180:1484-90.)     

Effects of hormone replacement therapy regimens on mammographic breast density: the role of progestins

AIM: To evaluate the effects of different regimens of hormone replacement therapy (HRT) on mammographic breast density. METHODS: Mammograms of 113 healthy postmenopausal women who were on different HRT regimens were evaluated retrospectively. All women had a baseline mammography and at least one mammogram after at least 12 months of HRT. Four parenchymal patterns were considered mammographically. Quantification of density changes that occurred on follow-up mammograms was done qualitatively and with reference to densities on baseline mammograms. RESULTS: Sixty women were treated with a continuous estrogen-progestin combination; 16 with a cyclic estrogen-progestin combination and 37 were with estrogen only. Twenty-six women had increased mammographic density after HRT. Mammographic density increase was detected in 23 women (38.3%) of the continuous estrogen-progestin combination group, two women (12.5%) of the cyclic estrogen-progestin combination group and one woman (2.7%) of the estrogen-only group. Mammographic density increase was more common among women in the continuous estrogen-progestin combination group than the other groups and this difference was found to be statistically significant (P < 0.001). Breast density increase was observed in 18 of 30 women (60%) with higher doses of progestin compared to 5 of 30 women (16.7%) with lower dose (P < 0.05). CONCLUSIONS: Postmenopausal HRT may increase mammographic breast density. Breast density appears to be mostly affected by higher doses and continuous administration of progestin.     

Breast evaluation and diagnosis by obstetrician-gynecologists. Survey of practice patterns.

Surveys of the obstetrician-gynecologists attending the breast disease postgraduate courses at the 1988 and 1990 American College of Obstetricians and Gynecologists annual clinical meetings report a high level of practice involvement in breast disease evaluation and cancer screening for their patients. A consistently high percentage stated they performed regular clinical breast examinations, documented the examinations with a diagram in the medical record, gave breast self-examination instruction, advised screening mammography following the American College of Obstetricians and Gynecologists guidelines, utilized a patient tracking system for follow-up and referred patients with undiagnosed dominant breast masses. Most stated that they did breast cyst aspiration; those who did not mostly referred their patients for cyst aspiration. The accurate and cost- and time-effective office technique of fine needle aspiration of palpable dominant solid breast mass continues to be underutilized even though the procedure has been proven effective and accurate in the cytologic diagnosis of benign and malignant breast neoplasms. Instruction in the technique of fine needle aspiration of palpable breast cysts and solid masses is available in many clinics, workshops and postgraduate courses.     

Lack of utility in clinical practice of cytologic examination of nonbloody cyst fluid from palpable breast cysts

OBJECTIVE: This study was undertaken to answer the following question: Does cytologic evaluation of nonbloody fluid aspirated from breast cysts contribute to appropriate clinical management? STUDY DESIGN: A retrospective review of palpable breast cyst fluid cytologic reports and associated medical records was undertaken to determine whether the cytologic findings affected patient management. Breast cyst size, fluid volume, fluid color, and patient age were abstracted from 689 medical records (1988-1999) of women whose palpable cysts had been aspirated at the Breast Diagnostic Center, Women's and Children's Hospital, Los Angeles. These observations were correlated with the fluid cytologic reports. RESULTS: Except for frankly bloody fluid, all breast fluid cytologic reports listed the results as acellular, inadequate for cytologic diagnosis, or no malignant cells identified. CONCLUSION: In clinical practice only frankly bloody fluid should be submitted for cytologic analysis. All other cyst fluid should be discarded.     

Palpable abnormalities of the breast not requiring excisional biopsy.

The evaluation of a patient with a palpable abnormality of the breast typically includes physical examination, mammography and fine needle aspiration biopsy (FNAB) with cytologic interpretation of the aspirate. If the findings of these three diagnostic modalities are negative for malignancy, the current standard of care is to proceed to surgical biopsy to confirm the benign nature of the lesion. The current study was done to identify a subset of patients who could be safely observed without surgical (histologic) biopsy. These patients fulfilled specified criteria on physical examination, mammogram and needle sensation when the FNAB needle entered the lesion. Results of the cytologic studies of the FNAB were used as a corroborative rather than as a diagnostic test. Of 305 patients with mammary abnormalities, 106 were identified with "subsuspicious" lesions. Seven of the latter patients underwent surgical biopsy, four because the results of cytologic studies of FNAB revealed cytologic atypia. One of the four patients had infiltrating ductal carcinoma. All other patients have had follow-up evaluation for a mean of 61 months (range of 43 to 74 months). No carcinomas have developed at the subsuspicious site. The current study is the first to clearly define a subset of patients with palpable abnormalities of the breast who do not require surgical biopsy.     

Ultrasound-guided biopsy of non-palpable breast lesions: correlation with the results of fine-needle aspiration biopsy

PURPOSE: The purpose of this study was the clinical evaluation of ultrasound-guided biopsy in comparison with ultrasound-guided fine-needle aspiration biopsy of identical, non-palpable breast lesions. MATERIALS AND METHODS: From August 1997 until July 1998, 73 ultrasound-guided biopsies were performed in 66 patients with non-palpable lesions of the breast. In 18 patients (age 33-77 years) with 20 non-palpable lesions, fine-needle aspiration biopsy (20-G needle) and biopsy (18-G biopsy needle) were performed on a single occasion. This was the patient selection of our retrospective study. RESULTS: One malignant neoplasm was found among the 20 biopsied lesions, while the remaining 19 lesions were of a benign nature. In 20% of the cases, the material obtained by fine-needle biopsy was not sufficient for a cytologic diagnosis, while biopsy allowed a diagnosis in 19/20 cases. No complications were observed. CONCLUSIONS: Ultrasound-guided biopsy using an 18-G needle is a suitable method for the evaluation of non-palpable lesions that are only visible on ultrasound. It represents an attractive alternative to fine-needle aspiration in the absence of experienced cytologic diagnosticians.     

Comparison of needle aspiration cytologic diagnosis with excisional biopsy tissue diagnosis of palpable tumors of the breast in a community hospital.

Fine needle aspiration cytologic examination has not extensively been used in our hospital in the work-up evaluation of solid tumors of the breast and its reliability as a basis on which to perform definitive treatment of carcinoma of the breast was in question. One hundred and five aspiration cytologic specimens were obtained from palpable solid tumors of the breast just prior to excisional biopsy. Specimens were numbered and submitted to three different staff pathologists for diagnosis in a single blind manner. Results were then compared with tissue diagnosis of the same tumors. Of 105 specimens taken at biopsy of the breast, 28 malignant lesions were diagnosed on the final tissue report. Of those, ten were diagnosed as malignant (Class V), two were highly suspicious (Class IV) and six were insufficient specimens (Class O). Of those diagnosed as class IV and V by the results of cytologic examination, all were malignant on permanent section for a specificity of 100 per cent and a sensitivity of 36 per cent. The cytologic diagnoses of Classes I, II and III did not correlate with any histologic report, benign or malignant. Malignant growths were misdiagnosed by cytologic examination in 36 per cent and missed because of inadequate specimens in 28 per cent. We believe that a Class V cytologic finding is sufficient basis on which to perform definitive treatment of carcinoma of the breast provided rigid criteria are used. There is a learning curve associated with this diagnostic modality.     

Place de l’imagerie dans le diagnotic des cancers du sein bilatéraux synchrones

ObjectiveTo investigate the role of imaging procedures in the diagnosis of synchronous bilateral breast cancer (SBBC)Patients and methodsThe patient group consisted of consecutive women undergoing managed for SBBC in our institution between January 2006 and July 2012. We defined SBBC as bilateral breast tumors diagnosed simultaneously or up to 3 months after initial diagnosis. Clinical data included comorbidities, BMI (kg/m²), preoperative breast imaging modalities used and their findings.ResultsOf the 2322 patients with newly diagnosed breast cancer treated on the study period, 46 patients with the diagnosis of SBBC were enrolled to the study. A total of 41.3% patients had family history of breast cancer. A total of 56.52% had clinical symptoms. The most frequent situation of diagnosis (32.6%) was the association of a palpable tumor and a contralateral radiologic abnormality. MRI permitted the diagnosis of 19.6% occult contralateral lesions.Discussion and conclusionClinical examination and conventional imaging procedures (mammography and sonography) detects the majority (76%) of synchronous contralateral breast cancers. A family history of breast cancer, a multifocal breast tumor or the presence of an invasive lobular carcinoma should be arguments for the realization of a breat MRI to eliminate contralateral malignancy.     

Fine-needle biopsy of the breast in the material of Gynecology and Obstetrics Hospital in Walbrzych

OBJECTIVES: Since the year of 2000 we have done more than 500 fine-needle aspiration biopsies in our hospital. DESIGN: The main cause was a breast lesion interpreted as suspicion of cancer in ultrasonography or mammography and its verification between benign tumor and a cancer. MATERIALS AND METHODS: 508 women with clinical findings of breast tumor were qualified for fine-needle biopsy procedure. RESULTS: The most common diagnosis was a benign cystic tumor found in 183 cases and the second one--fibro-cystic mastopathy (132 cases). Surgical operation of the breast was performed in 32 cases. In 17 we found breast cancer and in 14 the diagnosis was suspicion of breast cancer. CONCLUSIONS: Fine-needle biopsy is valuable for diagnosis of breast cancer and can be easily learned and used by the clinician. It's safe, cost-effective, and accurate technique, which has no counter-indications and causes little discomfort. Results are available in a short time so the decision about the necessity for excisional biopsy or mastectomy is made quickly.     

A prospective study of double diagnosis of nonpalpable lesions of the breast.

Approximately three-fourths of open biopsies of the breast performed for mammographically detected suspicious lesions are shown histologically to be benign. Under the narrow conditions described herein, stereotaxic fine-needle aspiration (FNA) can identify these lesions with an accuracy of more than 90 per cent and a false-negative rate of 5 per cent. In an effort to reduce this failure rate, the mammographic appearance and stereotaxic FNA results of these lesions each were given scores on a scale of zero (benign) to five (malignant), to derive an over-all risk score prospectively applied to 264 suspicious occult lesions of the breast prior to open, biopsy. While all 264 lesions could be assigned a mammographic score, adequate tissue for assignment of a cytologic score could be obtained from 150 lesions. Of the 150 evaluable lesions, 53 were malignant and 97 were benign, historically. With a total score of two as the threshold for open biopsy, 21 of 150 (14 per cent) were proved to be benign, with no false-negative findings. If the total threshold score mandating an open biopsy was raised to four, the comparable figures were 61 of 150 (40 per cent) benign lesions and two false-negative instances of carcinoma in situ. Provided adequate tissue is aspirated for cytologic examination, we conclude that this algorithm has practical value in the management of nonpalpable lesions of the breast in that it can reliably identify a fraction of the benign lesions and spare these patients an operation.     

Paget’s disease of the nipple diagnosed by MRI

Background: Paget’s disease of the breast is a rare manifestation of breast carcinoma. Case report: The patient presented with a red lesion of the left nipple–areola complex. Breast physical examination, ultrasonography and mammography were normal bilaterally. Magnetic resonance imaging (MRI) correctly depicted Paget’s disease of the nipple. Before surgery the patient underwent biopsy of the lesion that showed Paget’s disease of the breast associated with an underlying ductal carcinoma in situ. The patient underwent left mastectomy and unilateral axillary lymph node dissection. The patient refused the breast-conserving surgery because she was afraid that she could have a recurrence of the carcinoma. Microscopy of the lesion confirmed the MRI diagnosis. Conclusion: MRI was very useful and accurate to diagnose Paget’s disease of the breast without palpable mass, ultrasonographic and mammographic findings.     

Metastatic cervical carcinoma to the breast.

Metastatic disease to the breast is often an unexpected diagnosis in a female who presents with a breast mass. The most important factor suggesting the appropriate diagnosis is a history of cancer. Correlation of mammographic and ultrasonographic findings may also raise the possibility of a metastatic mass. A well-defined, noncalcified dense mass on film-screen mammography, which also shows low-level homogeneous echoes without posterior acoustic enhancement, suggests the diagnosis. It is important that the diagnosis be made by fine needle aspiration or excisional biopsy so as to expedite appropriate therapy.     

Mastopatía fibroquística. Aspectos controvertidos

ObjectivesTo elucidate the most controversial features of fibrocystic breast disease, which is highly prevalent.MethodsWe reviewed the literature on the topic.ResultsIn fibrocystic breast disease, the diagnostic method of choice is ultrasound, which shows similar characteristics to those in cystic tumors but with differences in number and maximum diameter. With dominant, or separate, nodules, ultrasound can be used to determine whether the lesion is cystic or solid. In cystic lesions, fine-needle aspiration can be used; in solid lesions, core needle biopsy can be employed. No active treatment is required if there is mastalgia and nodularity without a dominant nodule, or if diffusely nodular breasts are painless.Conclusions1. There is no risk of malignancy in simple fibrocystic breast disease but proliferative mastopathy with atypical cells has a relative risk of 4-5. 2. The diagnostic technique of choice for differentiating simple from complex cysts is ultrasound, which can also be used for monitoring and as a guide when aspirating the cyst. 3. When there are clinical and radiologic signs suspicious for malignancy (BI-RADS 3) or suggestive of malignancy (BI-RADS 4 and 5), the first step is fine-needle aspiration or core needle biopsy, or both. 4. Asymptomatic fibrocystic breast disease does not require follow-up, while symptomatic disease can be monitored with ultrasound and/or mammography.     

Breast cysts--diagnostic and therapeutic management and risk for subsequent development of breast carcinoma

Cystic breast disease is a relatively widespread pathological condition in the female sex, it has an incidence of around 7% and predominantly affects women aged between 35 and 50 year old. The diagnosis is based on the standardised protocol including breast examination, mammography, fine-needle aspiration cytology and pneumocystography. While the majority of cysts can be managed by simple aspiration, a small percentage (0.3-1.4%) are malignant. The clinical and pathological features of 7 cases of intracystic carcinoma of the breast which are 0.73% of all cases of cystic breast disease between 1996-2001, are considered in the present article.     

The significance of mammographic findings after breast-conserving therapy for carcinoma of the breast

Mammographic changes after lumpectomy, axillary dissection and irradiation are common and unpredictable. To study the significance of these changes at the first follow-up mammogram, we retrospectively reviewed reports of 172 women treated in this manner between 1979 and 1988. The mean follow-up time was 50 months. Eight patients had recurrences in the same breast, while 13 patients had carcinoma develop in the opposite breast. The mean time of follow-up mammograms was 11 months (range of one to 48 months). Twenty-six patients had a normal mammogram, while 146 patients had some changes within the irradiated breast. Thirty-one patients had suspicious findings--a mass, speculation or new microcalcifications. None of these 31 patients had carcinoma confirmed by biopsy or follow-up examination. Of eight patients with recurrence in the same breast, six had a biopsy because of findings on physical examination, while two had changes from previous mammograms. The mean time to recurrence was 50 months (range of 24 to 81 months). We conclude that mammographic changes in the irradiated breast are common after lumpectomy and irradiation for carcinoma of the breast. A baseline mammogram should be done six months after irradiation is completed. Changes that occur at this time should be considered secondary to surgical treatment and irradiation and are not an indication for immediate biopsy. These findings should be reconfirmed by a mammogram performed one year after irradiation to prove that these changes are stable. Physical examination and yearly mammography of both breasts are imperative in the follow-up evaluation of patients treated in this manner.     

Cytologic findings of aspiration of tumors of the breast

Fine needle aspiration biopsy for cytologic diagnosis has been shown to be an effective adjunct to the clinical evaluation of masses of the breast by physical examination and mammography. In addition to adequately decompressing cystic masses, the procedure has been beneficial in obtaining a pathologic interpretation of any mass that is to be observed. Preoperative knowledge of the malignant nature of a mass of the breast allows the physician to investigate more selectively the possibility of metastatic disease and to consider more intelligently treatment options. Furthermore, the psychologic agony of the unknown for the patient and her family is avoided. Although histologic confirmation is always recommended before proceeding with mastectomy, a positive cytologic diagnosis can suffice when clinically advanced carcinoma is present or when there are medical contraindications to surgical treatment. Because of the false-negative rate of aspiration cytologic diagnosis, all clinically malignant or suspicious masses should have a biopsy in the face of benign cytology. This point cannot be over emphasized and is particularly pertinent to those patients in whom high risk factors of carcinoma of the breast are present. Inconclusive aspirates should be repeated or a biopsy of the mass should be done.     

Technique and guidelines for needle localization biopsy of nonpalpable lesions of the breast

The advances made in mammography, including its accuracy, safety and publicity, will lead to an increasing number of biopsies of the breast after needle localization. The surgeon must carefully evaluate the mammograms and orient the location of the tip of the wire with respect to the mammographic abnormality and the exact location within the breast. The technique described has been used in more than 600 instances. It has led to the detection of cancer in 20 per cent of nonpalpable suspicious mammographic findings. It is well tolerated, readily accomplished, cost effective and accurate.     

Aspiration of the breast and nipple discharge cytology

Between 1 January 1974 and 30 June 1984, 1,003 specimens obtained from the breast were submitted for cytologic evaluation to the Department of Pathology at the Waterbury Hospital Health Center. Eighty-eight per cent were obtained by fine needle aspiration of a palpable mass; the remainder were smears of nipple discharges. Precytologic and postcytologic clinical data were available for 80 per cent of the specimens. In the fine needle aspiration group, there were 219 instances of proved carcinomas; 79 per cent of these had either positive or suspicious cytologic findings. Seventy-five per cent of the patients with positive cytologic results underwent mastectomy without prior histologic confirmation of the needle aspiration and all were confirmed as malignant growths. There were 41 false-negative aspirates which were reviewed in detail. The cytologic slides of 24 of the 41 false-negative aspirates were available for re-evaluation by a second, independent cytopathologist. Only one was thought to have been misread initially; the remainder appeared to have been falsely negative for technical reasons related to aspiration or fixation technique or tumor size less than 1 centimeter. There was one false-positive finding in a patient who was found to have fat necrosis at biopsy. Results of nipple discharge cytology were less accurate. Positive or suspicious cytology was found in only five of 11 proved instances of carcinomas. There was one false-positive and five false-negative results in this group. We conclude that needle aspiration of palpable masses of the breast is an accurate, cost effective procedure which is readily adaptable to a community hospital, provided that a pathologist with an interest in cytology is available.     

Enhancement of true-positive rates for nonpalpable carcinoma of the breast through mammographic selection.

A retrospective review of 332 needle localization biopsies for nonpalpable mammographic abnormalities was performed. Twenty-one invasive and 12 noninvasive carcinomas were identified in this population, for a true positive biopsy rate of 10 percent. A review of all needle localization mammograms performed on these patients by a radiologist specializing in mammography identified 225 mammograms with a low probability of malignancy. In this group, there were four in situ and six invasive carcinomas (true positive biopsy rate of 4 percent). In the remaining 107 mammograms with a high probability of malignancy, there were eight in situ and 15 invasive carcinomas (true positive biopsy rate of 21.4 percent). In the low probability group, fine needle aspiration or excisional biopsy were recommended for six of the ten neoplasms and follow-up mammograms at three to six months for the remaining four (two in situ and two invasive carcinomas). Using selectivity, 225 biopsies could have been avoided at a savings of $97,368 (Canadian dollars) in fees for physicians alone while still identifying 29 of 33 neoplasms (87 percent of all neoplasms) and possibly delaying diagnosis for three to six months or longer in four of 33 neoplasms (13 percent, two in situ and two invasive) for which follow-up mammograms were recommended.     

Mammography of breast carcinoma: experience of 108 cases.

Mammography is the radiographic imaging of the breast and includes screen-film mammography and xeromammography. From September 1987 to March 1990, 108 patients with breast carcinoma received mammographic examinations at Chang Gung Memorial Hospital. The spectrum of mammographic appearance included mass abnormalities (50.9%), calcifications (10.2%), a combination of mass abnormalities and calcifications (25%), asymmetrical increased density (4.6%), and parenchymal distortion (1.9%). The remaining 7.4% of the lesions lacked any radiologic sign of malignancy and primarily appeared as dense breast on the mammogram. In this series, mammography had a sensitivity of 86.1%, a specificity of 77.3% and a positive predictive value of 67.4%. Recognition of these mammographic appearances is beneficial in detecting breast carcinoma and in establishing a correct diagnosis. In addition, knowing the abilities, as well as limitations, of mammography will optimize the efficacy of this examining modality.