Outcome of men presenting with clinical breast problems: the role of mammography and ultrasound

The purpose of this study was to determine the outcome of men presenting with clinical breast problems for breast imaging and to evaluate the role of mammography and ultrasound in the diagnosis of benign and malignant breast problems. We retrospectively reviewed clinical, radiographic, and pathologic records of 165 consecutive symptomatic men presenting to Breast Imaging over a 4 year period. We assessed the clinical indication for referral, mammographic findings, sonographic findings, histologic results, and clinical outcomes. Patients ranged in age from 22 to 96 years. Breast Imaging Reporting and Data System (BI-RADS) category 4 and 5 mammograms and solid sonographic masses were considered suspicious for malignancy. Six of 165 men (4%) had primary breast carcinoma, which were mammographically suspicious in all 6 (100%). Five were invasive ductal carcinoma and one was ductal carcinoma in situ (DCIS). Of 164 mammograms, 20 (12%) were suspicious. Six were cancer and 14 were benign. Clinical follow-up for 2 years or biopsy results were available for 138 of the 165 men (84%). Twelve with benign mammographic findings had benign biopsies. All men with benign mammography not undergoing biopsy were cancer free. Sensitivity for cancer detection (mammography) was 100% and specificity was 90%. Positive predictive value (mammography) was 32% (6 of 19) and the negative predictive value was 100%. Sonography was performed in 68 of the 165 men (41%). Three of three cancers (100%) were solid sonographic masses. There were 9 of 68 false-positive examinations (13%). Sensitivity and negative predictive value for cancer detection (ultrasound) was 100% and specificity was 74%. The most common clinical indication for referral was mass/thickening (56%). Mammography had excellent sensitivity and specificity for breast cancer detection and should be included as the initial imaging examination of men with clinical breast problems. The negative predictive value of 100% for mammography suggests that mammograms read as normal or negative need no further examination if the clinical findings are not suspicious. A normal ultrasound in these men confirms the negative predictive value of a normal mammogram.     

Mammography of women with suspicious breast lumps

We analyzed 342 women who had suspicious breast lumps to determine if preoperative mammography could improve the malignancy yield of biopsy procedures. The number of women with cancer of the breast and false-negative mammogram reports ranged from 11% to 25%, depending on how equivocal mammogram reports were interpreted. Therefore, women with clinically suspicious breast lumps should undergo biopsy regardless of mammographic findings. A significant difference in the mean (+/- SD) predictive value of a positive mammogram existed between women above and below the age of 50 years (80 +/- 8 vs 43 +/- 14) because of the age-specific relative prevalence of benign and malignant disease, and because mammography had difficulty distinguishing between benign and malignant lumps (specificity, 70). Preoperative mammography of women with suspicious breast lumps is indicated to screen for occult carcinoma, to prevent biopsy sampling errors, and to judge the adequacy of lumpectomy if the lesion is malignant.     

Accuracy of combined clinical-mammographic-cytologic diagnosis of dominant breast masses. A prospective study

Excisional biopsy is considered a mandatory part of the workup for patients with dominant breast masses. To evaluate the efficacy of a combined physical, mammographic, and fine-needle aspiration cytologic examination, 113 women were prospectively evaluated. Breast masses were listed as either benign or suspicious/malignant. All patients underwent a subsequent biopsy. Fifty-two (46%) of 113 patients had a malignant mass. The sensitivity and specificity of the individual tests were as follows: 96% and 66% for the physical examination; 94% and 73% for the mammographic examination; 90% and 93% for the fine-needle aspiration cytologic examination. For the 86 patients who underwent all three studies, the 25 patients with benign test results on all three examinations had a benign pathologic result. One (6%) of 18 patients with a single suspicious/malignant test result had cancer, 9 (64%) of 14 patients with two suspicious/malignant test results and 28 (97%) of 29 patients with three suspicious/malignant results also had breast cancer. We conclude that the combined triad of physical, mammographic, and fine-needle aspiration cytologic examinations is highly accurate in the diagnosis of breast masses, and patients in whom all three examination results are benign can be safely observed, obviating the need for an open biopsy.     

Wire-guided biopsies of nonpalpable breast lesions

The purpose of this study was to review the results of mammographic wire-guided biopsies of nonpalpable breast lesions and the features of the lesions in the preoperative examinations. Sixty women, mean age 50.2 years (range 31 to 74), underwent a wire-guided biopsy of the lesion. Twenty-nine patients had preoperative fine needle aspiration of the lesion. The radiographic diagnosis was correct in 33 patients (55%); 25 had breast cancer and 8 patients had a benign lesion. In 9 of the 14 patients with clustered microcalcifications in mammography and in 13 of the 15 patients with a mass noted in mammography, the cytological examination was correct. Nonpalpable mammographic masses with regular borders and normal fine needle aspiration examination do not require biopsy. In malignant mammographic appearances associated with a normal fine needle aspiration examination, biopsy of the lesion should always be done.     

Comparison between sonography and mammography for breast cancer diagnosis in oriental women after augmentation mammaplasty

Augmentation mammaplasty has become more popular in Taiwan. Therefore, clinical imaging is necessary to evaluate those patients who develop breast cancers. The purpose of this study was to evaluate the detection of breast diseases after augmentation mammaplasty by means of mammography and sonography. A retrospective follow-up study and analysis of diagnostic methods including mammography, sonography, physical examination, and aspiration cytology was conducted on 105 patients who underwent augmentation mammaplasty at Kaohsiung Medical University Hospital between 1989 and 2001. A total of 105 patients were identified in this study, and mean follow-up was 4 years. Two tumors from 8 cancer patients were visible on standard mammograms, and seven tumors were diagnosed as cancer by sonography. One of 15 benign breast tumors was interpreted as a suspected cancer, and 7 tumors were interpreted as normal findings on mammograms. Fourteen of 15 benign breast tumors were diagnosed correctly except for one suspicious case examined by sonography. Sonography showed the highest rate of diagnostic accuracy (91.3%) and mammograms had the lowest rate (73.9%). The accuracy rate of physical examination was 73.9%, and aspiration cytology was 90.0% accurate. This study affirms that sonography is a more useful diagnostic tool than mammography in Taiwanese women who have undergone augmentation mammaplasty.     

Breast saving therapy: diagnostic problems in after care

From 1.1.1977 through 31.12.1985 two hundred seventy-five patients with stages pTis, pT1-2, pN0-1, cM0 breast cancer were treated by breast-conserving therapy. Six patients (2%) were lost to follow-up. Fifty-four patients developed significant subcutaneous or parenchymal induration in the treated breast. The induration was considered clinically suspicious for recurrence in 30/54 and non-suspicious in 24/54. Of the 30 suspicious indurations mammography was diagnostic or suggestive of recurrence in 12 (40%), and the diagnosis of recurrence could be confirmed microscopically in 16 (53%). Mammography showed no pathologic findings in 14/30 (42%) patients with suspicious indurations, and in 12/30 (40%) the impression of benignity was also confirmed microscopically. In patients whose mammograms were diagnostic or suggestive of tumor, malignancy was demonstrated by pathologic examination in all cases. In 21/24 (87.5%) clinically benign indurations no tumor could be found on microscopic examination. Twenty of these patients had a normal mammogram, and in only 1 of these was a recurrence discovered incidentally during a cosmetic operation. Four of the 24 patients with clinically benign indurations had pathologic mammograms, and in 2 of these the diagnosis of recurrence was established histologically. - The rate of agreement between suspicious clinical and mammographic or microscopic findings was about 50%, whereas the correlation for clinically benign indurations was greater than 80%.     

Negative predictive value of sonography and mammography in patients with focal breast pain

The purpose of this study was to determine the negative predictive value of mammography and sonography in a population of patients with focal breast pain referred for imaging evaluation. Eighty-six consecutive patients with focal breast pain in the absence of a breast mass were retrospectively identified from an imaging database. The electronic inpatient and outpatient records for the 86 patients were reviewed. For patients who were diagnosed with breast cancer, pathology reports were reviewed to determine whether the painful area corresponded to the patient's cancer. In addition, patient records were linked to the institution's cancer registry. Of the 86 patients, 26 patients were lost to follow-up and did not appear in the institution's cancer registry. Four patients were diagnosed with breast carcinoma, two of whom had incidental cancers that were detected mammographically by microcalcifications and were separate from and unrelated to the area of pain. Seven patients underwent biopsy at the site of breast pain with benign diagnosis. Imaging and clinical follow-up for the 51 patients with benign or negative imaging at the site of pain showed no abnormality with a mean follow-up of 26.5 months. The negative predictive value of mammography and sonography in patients with breast pain was 100%. The negative predictive value of mammography and sonography for focal breast pain is high. Negative mammography and sonography can be reassuring to the treating clinician if follow-up is planned when physical examination is not suspicious. However, if physical examination is suspicious, biopsy should not be delayed.     

The utility of breast MRI as a problem-solving tool

Breast magnetic resonance imaging (MRI) is routinely used as a problem-solving tool, but its benefit for this indication remains unclear. The records of 3001 consecutive breast MR examinations between January 1, 2003 and June 6, 2007 were reviewed to identify all those performed for the clinical indication of problem solving. Details of clinical presentation, mammography and ultrasound (US) findings, follow-up recommendations, and pathology outcomes were recorded. Benign versus malignant outcomes were determined by biopsy or 12 months of follow-up imaging and linkage with the regional tumor registry. Problem solving was the clinical indication for 204 of 3001 (7%) of all examinations. Forty-two of 204 examinations (21%) had suspicious or highly suspicious MRI assessments with recommendation for biopsy and 62 of 204 (79%) examinations were assessed as negative, benign, or probably benign. Thirty-six biopsies were performed based on MRI findings and 14 cancers were diagnosed. Biopsy was indicated for 11 of 14 (79%) cancers based on suspicious mammographic or US findings identified prior to MRI. One incidental cancer was detected by MRI alone in a patient at high risk for breast cancer, and two cancers were detected in patients with suspicious nipple discharge and negative mammogram and US. A single false-negative MRI occurred in a patient whose evaluation for a palpable lump prompted biopsy. Problem-solving breast MRI rarely identifies otherwise occult cancer and can be falsely negative in patients with suspicious findings on mammogram and US. Until the benefits and risks of problem-solving MRI are clarified, it should be used judiciously.     

Use and abuse of mammography in the early diagnosis of breast cancer

In the 8 years before 1980, 3958 women were examined in the St. Michael's Hospital breast clinic in Toronto. Of 302 women with breast cancer, 87 (29%) had normal mammograms. Breast cancer was found in 34 after at least one clinical and mammographic examination had given normal results. Of these, 6 (18%) cancers were detected only by mammography while, paradoxically, 23 (68%) were detected only by clinical examination. Normal mammograms are significantly (p less than 0.001) more frequent in young women with breast cancer and in those with small palpable breast cancers. Mammography is most productive when used as a routine study in older women who have clinically normal breasts. All women should start having them around the age of 40 to 45 years. How often they should be repeated is debatable. There is no evidence that they should be repeated annually. Under 35 years of age mammography for any reason is unrewarding. Biopsy of a breast lump that is solid on aspiration should never be delayed because of a normal mammogram. Biopsy of a radiologically suspicious lesion in the breast should never be delayed because the findings on clinical examination are normal.     

Stereotaxic localization for fine-needle aspiration breast biopsy. Initial experience with 300 patients.

The efficacy of stereotaxic aspiration biopsy was evaluated in 300 consecutive patients with nonpalpable mammographic lesions. Sixty-eight patients (23%) had suspicious or malignant aspirates; all cases were proved malignant by subsequent examination of operative specimens. Two hundred sixteen patients (72%) had benign aspirates. Of these, 65 were confirmed by operation and 151 had subsequent mammography at 6- and 12-month intervals with no demonstrable mammographic change. In 10 instances (3%), the aspirates were atypical, and in six (2%), nondiagnostic. Biopsy specimens were obtained in all 16 instances, and eight were malignant. The sensitivity of stereotaxic breast aspiration for the diagnosis of cancer was 96%, and the specificity was 100%. Our experience confirms the efficacy of stereotaxic aspiration for the initial evaluation of mammographically detected, nonpalpable lesions.     

Breast biopsy for calcifications in nonpalpable breast lesions. A prospective study

We prospectively studied 239 consecutive patients who underwent breast biopsy for 277 nonpalpable lesions characterized by mammographic microcalcifications. Clinical and mammographic characteristics were correlated with histologic findings in an attempt to identify patients more likely to have early breast cancer. The distribution of clinical risk factors was equal between patients with benign or malignant outcomes. The predominant Wolfe pattern on mammography was P2 (38%); however, no relationship was observed between the Wolfe pattern and malignancy. A marked correlation was observed between malignancy and small lesions, more than 15 calcifications, and calcifications in a linear or branching pattern. Twenty-four percent (n = 67) of the biopsy specimens contained either ductal or lobular breast cancer. This study highlights the necessity of an aggressive approach toward suspicious calcifications found by mammography.     

Is mammography overused in male patients?

There is no agreed protocol for the use of mammography in evaluating the male breast. As a result, the tendency is to use the mammography more often than required. In order to define the role of mammography in men, we carried out a retrospective analysis of all male patients referred to the breast clinic with a history of breast lump between January 2001 and December 2003. The impact of mammography in the evaluation of male breast cancer cases was studied. A total of 220 male patients were referred to the breast clinic during this period. Of these, 134 men had a mammographic examination, with majority (96%) being performed prior to their consultation with the breast clinician as per the clinic protocol. Nine patients under the age of 35 years also had a mammographic evaluation. There were 4 cases of breast cancer diagnosed during this period. Breast cancer was suspected in all patients on clinical examination and was confirmed by biopsy. Breast cancer in men can be suspected on clinical examination in the majority of cases. Mammography appears unnecessary in most men and should not be used as a routine imaging procedure. One should consider imaging only those with clinically suspicious breast lumps to avoid unnecessary imaging particularly in young male patients.     

Comparative Value of Mammography,Fine-Needle Aspiration Biopsy,and Core Biopsy in the Diagnosis of Invasive Lobular Carcinoma

Abstract: Invasive lobular carcinoma of the breast (ILC) is a lesion often cited as being more difficult to diagnose than invasive ductal carcinoma. Our objective was to assess the role of mammography, fine-needle aspiration biopsy (FNAB) and large core needle biopsy (LCNB) in the diagnosis of invasive lobular carcinoma of the breast. We reviewed 1,074 consecutive patients with invasive cancers of the breast, of which 102 (9%) were ILC. All the patients with ILC had mammography, 66 had FNAB, and 15 had LCNB performed. Of the patients with ILC, 95 of 102 (93%) had an abnormal mammogram. Seven patients (7%) had a negative mammogram. The most common radiographic finding in patients with ILC was a spiculated mass (42%). The average size of the cancers detected by mammography was 1.17 cm, with no significant effect of size on the ability to detect cancer based on its mammographic presentation for p > .05. Sixty-six patients had FNAB, with a postive diagnosis of cancer in 27 (41%) and suspicious or atypical aspiration in 20 patients (30%). Nineteen patients (28%) had false-negative aspirates. There was no significant difference in size for patients whose cytology demonstrated malignant, suspicious, atypical, or benign aspirates, F (4,56) = 1.01, p > .05. For the fifteen patients who had LCNB, a definitive diagnosis of ILC was made in 13 cases (87%), with another patient having a diagnosis that was “suspicious” for ILC. One patient had a false-negative LCNB. ILC can be detected by mammography, in most instances. FNAB may fail to diagnose this cancer, particularly if the cancer is of low nuclear grade. The lack of reliability of FNAB for diagnosis of ILC, which may occur in some cases is due to the discontinuous infiltrative pattern and the intrinsic cytologic characteristics of this cancer. LCNB is a complementary diagnostic procedure when the FNAB is nondiagnostic to demonstrate the presence of ILC. In the presence of a dominant mass by palpation and a clinical suspicion of the presence of ILC, a negative mammography or a benign FNA should not preclude a surgical biopsy.     

Sonographic Evaluation of Clinically Palpable Breast Cancers Invisible on Mammography

Abstract: The purpose of this study was to determine the utility of sonography in the evaluation of palpable breast cancers invisible on mammography. A retrospective review of the pathology department's database was used to identify patients with palpable breast cancers. Consecutive patients that had excision between January 1992 and September 1997 were included. Mammograms and breast ultrasounds were reviewed retrospectively and correlated with pathologic and surgical findings. During the study period 298 women presented with a palpable breast cancer for imaging at our institution. Of these, 38 cancers (12.8%) were not seen on mammography. In 32 patients where no mammographic abnormality was found, ultrasound was able to detect a mass corresponding to the area of clinical concern. Histologic tumor types included 30 invasive ductal carcinomas, 5 ductal carcinomas in situ, and 3 invasive lobular carcinomas. Mammographic density was mild with scattered fibroglandular densities in 2 (5%), heterogeneously dense in 12 (32%), and extremely dense in 24 (63%). Thirty-one masses (97%) were hypoechoic and 1 (3%) was echogenic. Lesion margins were irregular in 23 (72%), lobulated in 5 (16%), and well-circumscribed in 4 (12%). In this group of patients the combination of mammography and ultrasound of the mass demonstrated 99% of the palpable cancers. In patients presenting with a breast mass on physical examination in whom mammography fails to demonstrate an abnormality, supplemental ultrasound is helpful in most instances to further characterize the lesion.     

The Diagnostic Accuracy of Mammography and Ultrasound in the Evaluation of Male Breast Disease: A New Algorithm

Summary

Background

The purpose of this study was to define the diagnostic accuracy of mammography and ultrasound in the evaluation of male breast disease, and to suggest a diagnostic protocol for male breast disease.

Material and Methods

We retrospectively reviewed clinical, radiographic, and pathologic records of 75 patients. Breast Imaging Reporting and Data System (BI-RADS) category 4-5 mammograms and ultrasonograms were suggested as suspicious for malignancy.

Results

Of the 75 patients, 23 (31%) were considered to have suspicious lesions by mammography and/or ultrasonography. 13 of the patients were shown to have breast cancer. The remaining 52 (69%) were referred for biopsy by clinicians; all of the biopsy specimens were benign (gynecomastia). The accuracy data of mammography and ultrasonography are: sensitivity, 69 and 100%; specificity, 87 and 97%; positive predictive value, 53 and 87%; negative predictive value, 93 and 100%; and accuracy, 84 and 97%, respectively.

Conclusion

We suggest a new diagnostic algorithm for the evaluation of male breast disease in which ultrasonography may be used to evaluate palpable abnormalities as the first diagnostic tool of choice. To use and to trust imaging would decrease the number of false-positive biopsies that would be generated by physical examination alone.Key Words: Male breast cancer, Ultrasound, Mammography     

Aspiration cytology is superior to Tru-Cut needle biopsy in establishing the diagnosis of clinically suspicious breast masses.

Eighty-one consecutive patients with breast masses clinically suspicious for malignancy were evaluated prospectively. There were 31 benign lesions and 50 malignancies. Clinical diagnosis was correct in 85% (2.5% false negative, 12.5% false positive). Mammography was diagnostic in 52.8% (31.5% false negative, 15.7% false positive). Needle biopsy was accurate in 78.9% (21.1% false negative, 0% false positive). Aspiration cytology was diagnostic in 96.2% (3.8% false negative, 0% false positive). Statistical comparison of all four tests revealed that aspiration cytology was slightly more accurate than physical examination for all lesions (p = 0.07), but significantly more accurate for benign lesions (p = 0.005). Overall, aspiration cytology was significantly more accurate than mammography (p = 0.000001) and needle biopsy (p = 0.008). Only one minor complication, a superficial infection, occurred with aspiration cytology and needle biopsy. Thin-needle aspiration cytology is a benign procedure that appears to be superior to physical examination, mammography, and needle biopsy in establishing the diagnosis of clinically suspicious breast masses.     

The diagnostic accuracy of mammography in the evaluation of male breast disease.

BACKGROUND: The role of mammography in the evaluation of male patients presenting with breast disease is controversial. This controversy is a function of the lack of specific data concerning the diagnostic accuracy of mammography when used in this clinical setting. The purpose of this study was to define the diagnostic accuracy of mammography in the evaluation of male breast disease. METHODS: One hundred and four prebiopsy mammograms from 100 patients with tissue diagnoses were read blindly by two independent radiologists, and placed into one of five predetermined categories: definitely malignant, possibly malignant, gynecomastia, benign mass, and normal. Radiologic/pathologic correlation was performed and the sensitivity (Sn), specificity (Sp), positive (Ppv) and negative predictive value (Npv), and accuracy (Ac) for each of the mammographic diagnostic category determined. RESULTS: The pathologic diagnoses were 12 cancers, including 1 patient with bilateral breast cancer, 70 cases of gynecomastia, 16 benign masses, and 6 normals. The accuracy data for the mammographic diagnostic categories are as follows: malignant (combined definitely and possibly malignant), Sn 92%, Sp 90%, Ppv 55%, Npv 99%, Ac 90%; and overall benignity (combined gynecomastia, benign mass, and normal), Sn 90%, Sp 92%, Ppv 99%, Npv 55%, Ac 90%. Six cancers (50%) coexisted with gynecomastia. CONCLUSIONS: Mammography can accurately distinguish between malignant and benign male breast disease. Although not a replacement for clinical examination, its routine use could substantially reduce the need for biopsy in patients whose mammograms and clinical examination suggest benign disease.     

The influence of knowledge of mammography findings on the accuracy of breast ultrasound in symptomatic women

Breast ultrasound is generally interpreted with knowledge of the mammographic examination. This study examined the influence of knowledge of mammography findings on the accuracy of ultrasound in women with breast symptoms. Subjects were sampled from all women 25-55 years of age consecutively attending a breast clinic. This included all 240 women shown to have breast cancer and 240 age-matched women shown not to have cancer. Ultrasound films were prospectively reviewed and reported by two radiologists independent of each other and in a blinded manner. A two-phase design was used. In the first phase, the radiologists provided an opinion on the ultrasound films. In the second phase, the ultrasound films were reread with consideration of the corresponding mammographic examination. The accuracy of reading the ultrasound with and without knowledge of the findings on mammography was compared using sensitivity and specificity, and receiver operating characteristics (ROC) curves. Reporting the ultrasound with knowledge of mammography (compared to without mammography) improved sensitivity and reduced specificity for both radiologists. For one reader, sensitivity increased from 77.5% to 86.7% (p = 0.0002) and specificity decreased from 89.7% to 85.4% (p = 0.04). For the other reader, sensitivity increased from 81.3% to 87.5% (p = 0.0023) and specificity decreased from 87.1% to 85.0% (p = 0.27). ROC curves for both radiologists showed that reporting ultrasound with knowledge of mammography resulted in small (about 3%), but significant improvement in the area under the ROC curve. Our study indicates that knowledge of the findings of mammography improves the interpretation of breast ultrasound in symptomatic women.     

BREASTAID: Clinical results from early development of a clinical decision rule for palpable solid breast masses

OBJECTIVE: To develop a clinical decision rule (entitled BREASTAID) that will predict the probability of malignancy in women with palpable solid breast masses. SUMMARY BACKGROUND DATA: Currently, 80% of open breast biopsies are benign, resulting in excessive economic, psychologic, and physical morbidity. METHODS: A total of 452 solid breast masses were evaluated in a surgical breast clinic between November 1994 and February 1998. Breast cancer status was defined histologically as ductal carcinoma in situ or invasive cancer. Noncancer status included benign histology, mass resolution, or stability at 12-month follow-up. Data were collected on risk factors, clinical breast examination, mammography, and cytology results. Three multiple logistic regression models were used to generate the probability of cancer at 3 logical steps in the workup; Bayes' theorem was applied in a stepwise fashion to generate a final probability of cancer. RESULTS: A model incorporating only clinical breast examination and mammography resulted in an excessive number of either missed cases or biopsies compared with one that included cytology. Using a cut-point of 4%, this latter BREASTAID model had 97.6% sensitivity and 85.1% specificity. Compared with triple diagnosis, BREASTAID would have reduced the open biopsy rate from 39.8% (180 of 452) to 22.3% (101 of 452), improving the diagnostic yield from 22.7% to 40.6%. CONCLUSIONS: This study convincingly demonstrates that at minimum, clinical, radiologic, and cytologic evaluations are required to accurately evaluate a solid breast mass. BREASTAID has the potential to minimize the number of open biopsies performed while allowing safe triage to follow-up. Before widespread application, further validation studies are required.