Transillumination in breast cancer detection: screening failures and potential

This prospective study of 1265 women referred to a multimodality breast diagnostic center compares the sensitivity for breast cancer detection of state-of-the-art transillumination light scanning and film-screen mammography. Of 33 biopsy-proven cancers, transillumination light scanning detected 58%, while mammography detected 97% of the cancers. Light scanning did detect 55% of the nonpalpable breast cancers, and 30% of those tumors smaller than 1 cm. Detection of breast cancer by light scanning was affected by breast size, but not architecture, and was directly related to tumor size. Although transillumination light scanning can detect some small curable breast cancers (smaller than 1 cm), it does not do so at a sensitivity adequate for screening. An example is illustrated in which light scanning detected an occult breast cancer before the development of recognizable mammographic changes.     

Light scanning versus mammography in breast cancer detection

Transillumination light scanning of the breast was compared with screen-film mammography in a prospective study of 1,110 women referred to an outpatient imaging department. Each method was interpreted independently of the other but with knowledge of physical examination findings. Of 24 biopsy-proved cancers, 14 (58%) were detected with light scanning and 21 (88%) with mammography. The 77 false-positive light scan examinations were attributed to technical factors and the inability of light scanning to distinguish malignant from benign conditions on the basis of imaging features. Of the ten false-negative light scan examinations, two were retrospectively reclassified as positive, but light scans in the other eight cases remained normal in appearance. The authors conclude that transillumination light scanning is not competitive with mammography as a screening method for breast cancer detection. furthermore, they were unable to identify a select subpopulation of women who might benefit from light scanning as an adjunct to mammography.     

Diagnostic accuracy of 99mTc-sestamibi breast imaging: multicenter trial results.

Although mammography is well established as a first-line tool for breast cancer screening and detection, efforts to develop complementary procedures continue. Observation of 99mTc-sestamibi tumor uptake provided the impetus for its evaluation as an adjunctive technique. This trial's objectives were to determine in a multicenter trial the diagnostic accuracy of 99mTc-sestamibi in women with suspected breast cancer and to investigate factors influencing diagnostic accuracy. METHODS: Our multicenter trial enrolled 673 women (387 with nonpalpable abnormalities; 286 with palpable abnormalities) scheduled for excisional biopsy or mastectomy. Blinded and unblinded interpretations of scintigraphic images were compared with core laboratory established histopathologic diagnoses to define the diagnostic accuracy of 99mTc-sestamibi breast imaging. RESULTS: Blinded readers' diagnostic accuracy was 78%-81%. Inter-reader agreement was excellent, ranging from 95% to 100% (kappa = 0.82-0.99). Overall institutional sensitivity and specificity for 99mTc-sestamibi breast imaging were 75.4% and 82.7%, respectively. In this population with a 40.1% disease prevalence, the positive predictive value was 74.5% and the negative predictive value was 83.4%. The negative predictive value was 94% in patients with a 40% or lower mammographic likelihood of breast cancer. Sensitivity was higher for palpable abnormalities; specificity was higher for nonpalpable abnormalities. Sensitivity was decreased for tumors <1 cm in largest dimension but appeared not to be affected by patient's age. CONCLUSION: As an adjunct to current procedures, 99mTc-sestamibi breast imaging may contribute to patient management decisions in selected populations, including women with dense breasts, mammographically indeterminate lesions >1 cm, and palpable abnormalities.     

Nonpalpable, probably benign lesions: role of follow-up mammography.

Of 21,855 consecutive women prospectively studied with mammography, physical examination, and high-resolution ultrasonography when appropriate, 558 received a diagnosis of nonpalpable, probably benign lesions. Follow-up mammography was recommended for these patients. Characteristically benign lesions and palpable masses were excluded from analysis. The positive predictive value for detection of a nonpalpable, probably benign breast lesion was 0.017. Nine patients ultimately proved to have carcinoma; two of them had noninvasive carcinoma, and two had axillary node metastases. The positive predictive value for detection of a nonpalpable, probably malignant lesion was 0.47. The policy of recommending mammographic surveillance for nonpalpable, probably benign lesions, a viable option for radiologists, has the capability of lowering the rate and therefore the costs of biopsy procedures with negative results.     

Comparison of mammography and transillumination light scanning in the detection of breast lesions

A prospective study was done involving 822 women who had both film screen mammography and a breast transillumination light scan examination. The study population was not randomized; a modified phase-2 study was done. Mammography was superior for detecting malignancy: of the 67 pathologically proved breast cancers, 64 (95.5%) were detected by mammography and 45 (67.2%) were detected by transillumination. Biopsy revealed that 74 patients had benign lesions. In this group of patients, the false-positive rate was 12.2% for light scanning and 79.7% for mammography; however, 117 other patients had false-positive light scans.     

Medical audit of mammography: a simplified alternative.

Assessing radiologists' mammographic interpretation and performing a complete audit of a mammographic practice are notoriously difficult and time consuming. The authors propose a simplified method for accomplishing a satisfactory medical audit. A search of the 1987 pathological reports of St. Michael's Hospital in Toronto yielded 153 patients who underwent excisional biopsy of the breast and for whom preoperatively obtained mammograms were available. The medical records of the patients were reviewed to obtain demographic data, as well as information as to whether the excised lesions had been palpable and the stage of the tumour. The mammograms of the patients were categorized retrospectively by four independent observers. The findings were correlated with the results of the pathological examinations and analysed with receiver-operating characteristic (ROC) curves. Forty-five nonpalpable and 121 palpable lesions were identified, of which 70 were malignant and 96 benign. The positive predictive value of mammography for the nonpalpable lesions was 20%. Three of the 9 nonpalpable cancers and 35 of the 56 palpable ones had metastasized to the axillary lymph nodes. The area under the ROC curves for the four radiologists ranged from 0.84 to 0.89. This audit method in inexpensive and easily applied.     

Periodic mammographic follow-up of probably benign lesions: results in 3,184 consecutive cases

The author prospectively evaluated the value of periodic mammographic surveillance among 3,184 consecutive cases of nonpalpable, probably benign breast lesions detected with mammography. Follow-up consisted of four mammographic examinations during a 3- or 3.5-year period. Clinical outcome was ascertained in each case after the study period, whether or not patients complied with the protocol. Probably benign lesions were subsequently found to be malignant in 17 cases (positive predictive value for cancer, 0.5%). Fifteen of the 17 cancers were identified by means of interval mammographic change prior to development of a palpable mass; all 17 were stage 0 or stage 1 tumors. All 17 women who had cancer currently show no evidence of tumor recurrence (median duration of follow-up, 5 years). These results should help establish the validity of managing mammographically detected, probably benign lesions with periodic mammographic surveillance. By decreasing the number of biopsies of benign lesions and thereby substantially reducing costs, this approach may help overcome a major barrier to widespread use of mammographic screening.     

Negative predictive value of sonography with mammography in patients with palpable breast lesions

OBJECTIVE: This study was performed to determine the negative predictive value of sonography with mammography in evaluating palpable breast lesions. MATERIALS AND METHODS: Four hundred twenty patients with 455 palpable breast lesions were retrospectively identified from our mammography database as having negative mammographic and sonographic results. For patients diagnosed with breast cancer, images and medical records were reviewed to determine whether the palpable lesion evaluated on sonography and mammography corresponded to the patient's breast cancer. On the basis of the number of breast cancers that correlated to the palpable areas imaged, the negative predictive value of sonography with mammography was determined. RESULTS: Sixty-two of the 420 patients in the study group were already diagnosed with breast carcinoma, and eight new carcinomas were diagnosed during the study period. Only one of six ipsilateral cancers corresponded to a palpable lesion that had a negative imaging evaluation. This lesion was diagnosed as an invasive lobular cancer, hard and fixed at physical examination. Imaging and clinical follow-up of the remaining patients showed no abnormality at the sites of previously investigated palpable abnormalities. The mean imaging follow-up was 25 months. The negative predictive value of sonography and mammography in the setting of a palpable lesion was 99.8%. CONCLUSION: The negative predictive value of sonography with mammography is high, and together these imaging modalities can be reassuring if follow-up is planned when the physical examination is not highly suspicious. However, if the physical examination is suspicious, biopsy should not be delayed.     

Cytological and histological studies in stereotactic punctures of non-palpable solid breast lesions]

Cytologic aspiration and core biopsy were performed on 50 nonpalpable breast lesions by using a stereotactic localization technique. Cytologic and histologic results were correlated with mammographic findings and therapeutic decisions were based on the results of both procedures. Representative material was obtained in 100% of the lesions. The sensitivity was 90% and specificity was 97.5%. The predictive values were high except for the predictive value of a negative histologic finding in a suspicious cluster of microcalcifications (50%).     

Revisiting the mammographic follow-up of BI-RADS category 3 lesions

OBJECTIVE: Using data collected for one series during 1987-1989 and data collected for another series during 1996, we sought to compare the frequency of and positive predictive value for carcinoma of the breast in nonpalpable, probably benign lesions that had been detected on and followed up with mammography. MATERIALS AND METHODS: During 1996, mammography was performed in 18,435 women of whom 544 (3.0%) had lesions assigned to Breast Imaging Reporting and Data System (BI-RADS) category 3 for nonpalpable, probably benign lesions. The lesions in the women were assessed as BI-RADS category 3 after the patients had undergone a diagnostic study that included additional imaging, sonography, and a focused physical examination. Patients with BI-RADS category 3 lesions were recommended for mammographic surveillance. A minimum of 2 years of follow-up data was available for 511 patients, our study population. We compared the findings for our study population with those of the previous study. RESULTS: Ninety-seven percent of the follow-up mammograms showed stability or regression of the BI-RADS category 3 lesions. Fourteen patients (3%) had nonpalpable interval progression revealed on mammography and underwent biopsy. The breast cancer detection rate in category 3 lesions among the study population was 0.4% (2/511), which was 14% of the patients who had undergone biopsies because of interval progression of the lesions. The pathologic stage of the cancers in these two patients was T1b N0. CONCLUSION: Compared with the findings from the 1987-1989 study, the frequency of BI-RADS category 3 lesions has remained stable; patient compliance for follow-up has increased; and the positive predictive value of category 3 lesions for cancer has decreased from 1.7% to 0.4% (p = 0.04).     

Mammography and subsequent whole-breast sonography of nonpalpable breast cancers: the importance of radiologic breast density

OBJECTIVE: Our purpose was to determine the contribution of mammography followed by sonography for the detection of nonpalpable breast cancers in Breast Imaging Reporting and Data System (BI-RADS) density grades 1-4 breasts, in grades 1 and 2 breasts, and in grades 3 and 4 breasts. MATERIALS AND METHODS: The results of physical, mammographic, and sonographic examinations performed in 4236 patients were reviewed to determine the sensitivities of mammography and sonography for the detection of nonpalpable breast cancers and to calculate the relative risk for detecting nonpalpable breast cancers using sonography in comparison with mammography in density grades 1-4, grades 1 and 2, and grades 3 and 4 breasts. Sonography was performed after mammographic interpretation. RESULTS: Sensitivities of mammography and subsequent sonography for the detection of nonpalpable breast cancers were 69% and 88% in grades 1-4, 80% and 88% in grades 1 and 2, and 56% and 88% in grades 3 and 4 breasts, respectively. The relative risk for detecting nonpalpable breast cancers using sonography was statistically significantly greater than that for detecting nonpalpable breast cancers using mammography in grades 1-4 (relative risk, 1.29; p = 0.024) and in grades 3 and 4 (relative risk, 1.57; p = 0.013) but not in grades 1 and 2 (relative risk, 1.1; p = 0.445) breasts. CONCLUSION: Sonography is a useful adjunct after mammography for the detection of nonpalpable breast cancer, particularly in the dense breast.     

Nonpalpable breast lesions: accuracy of prebiopsy mammographic diagnosis

Mammograms of 220 patients who underwent spot localization for removal of nonpalpable breast lesions were reviewed for accuracy of interpretation. Results of subsequent biopsy indicated malignancy in 77 cases. The interpretations of mammograms obtained before biopsy were incorrect in 71 cases (27 false-negative and 44 false-positive studies). Among the false-negative cases, 70% of the abnormalities were determined histologically to be noninfiltrative cancers. An aggressive screening program with preoperative localization and biopsy is needed in questionable cases, since mammographic signs of early or nonpalpable malignancy are often subtle and nonspecific.     

Stereotactic fine-needle aspiration for cytologic diagnosis of nonpalpable breast lesions

Fine-needle aspiration for cytologic diagnosis was performed on 219 nonpalpable breast lesions by using a stereotactic localization technique. Cytologic results were correlated with mammographic findings, and therapeutic decisions were based on the results of both procedures. Representative cytologic material was obtained in 74% of the lesions. Strict criteria of representativeness were observed. If only cases with representative cytologic yield are considered, the sensitivity was 93% and the specificity was 97%. The predictive values were high except for the predictive value of a negative cytologic finding in a spiculated lesion (50%). Sampling errors caused by abundant fibrosis, needle deviation, and difficulty in defining the lesion on the stereoscopic views are discussed. Another source of sampling error may be the mixed nature of some lesions consisting of benign and malignant components. Fine-needle aspiration of 219 nonpalpable breast lesions by using a stereotactic localization device yielded representative cytologic samples in 74% of the lesions.     

彩色多普勒超声对良恶性乳腺肿瘤的研究

目的：探讨彩色多普勒超声（ColourDopplerUltrasonography．CDU）在判断乳腺肿物良恶性和腋淋巴结转移的价值。材料和方法：作者分析了58例乳腺实性肿物的彩色多普勒超声和临床怀疑乳腺癌且CDU为阳性的30例病人的腋淋巴结CDU扫查结果。结果：发现34例乳腺癌中26例CDU有阳性表现，而24例良性肿物则均无阳性结果。得出CDU对乳腺癌的敏感性为77％，特异性100％，阳性符合率100％，肿癌直径小于1cm和浸润性小叶癌的CDU阳性率最低。对照术后病理，10例腋淋巴结CDU阳性者均已有淋巴结浸润，另有4例已受累的淋巴结CDU为阴性。CDU对腋淋巴结受累敏感性为71％，特异性100％，阳性符合率100％。结论：CDU对乳腺肿物良恶性以及腋淋巴结转移的判断上有重要的应用价值。     

Nonpalpable breast lesions: evaluation with power Doppler US and a microbubble contrast agent-initial experience

PURPOSE: To evaluate power Doppler ultrasonography (US) performed with a microbubble US contrast agent in the differentiation of nonpalpable breast lesions. MATERIALS AND METHODS: Fifty nonpalpable breast lesions in 50 patients were prospectively evaluated with power Doppler US before and after injection of the contrast agent SH U 508A. Lesion vascularity and the morphology of vessels on US scans were analyzed and were correlated with histologic results. RESULTS: Surgical excision revealed 22 cancers and 28 benign lesions. At nonenhanced power Doppler US, eight (36%) of 22 cancers and four (14%) of 28 benign lesions were vascular. At contrast agent-enhanced power Doppler US, 21 (95%) cancers and six (21%) benign lesions were vascular (P <.001). Irregular vessels were seen in three cancers and one benign lesion at nonenhanced power Doppler US and in 11 cancers and one benign lesion at contrast-enhanced power Doppler US. By using the presence of vascularity in the mass as the diagnostic criterion for malignancy, the sensitivity, specificity, and positive and negative predictive values of power Doppler US changed from 36%, 86%, 67%, and 63%, respectively, to 95%, 79%, 78%, and 96% after contrast agent injection. CONCLUSION: Contrast-enhanced power Doppler US was superior to nonenhanced power Doppler US in the demonstration and characterization of tumor vascularity in nonpalpable breast lesions. Contrast-enhanced power Doppler US may be useful for the differentiation between nonpalpable breast cancers and benign tumors.     

Prediction of aortoiliac stent-graft length: comparison of measurement methods

PURPOSE: To evaluate short-term follow-up of nonpalpable probably benign lesions in a 2-year mammographic screening. MATERIALS AND METHODS: Of 13,790 women aged 45-65 years who underwent first-round screening, 795 (5.8%) underwent short-term mammographic follow-up (every 6 months for 2 years) of nonpalpable probably benign lesions (eg, masses, focal asymmetric densities, and calcifications) previously assessed at an additional imaging evaluation, including ultrasonography. When no changes were found at short-term mammographic follow-up, women were assigned to the 2-year screening interval. Needle localization and surgical biopsy were performed when the lesion progressed (was enlarged or had an increased number or size of calcifications or modification of their initial characteristics). The effectiveness of this approach was evaluated with statistical analysis. RESULTS: Of 795 lesions, 788 (99%) remained stable, and seven (1%) had changes prompting surgical biopsy. Two cancers (0.3%), one microinvasive intraductal carcinoma and one 7-mm invasive ductal carcinoma without positive nodes, were found. Four of the five benign histologic results were probably benign calcifications with progression at short-term follow-up. The sensitivity, specificity, accuracy, and positive and negative predictive values were 100%, 99%, 99%, 29%, and 100%, respectively. CONCLUSION: The benign nature of most nonpalpable probably benign lesions can be typified with short-term mammographic follow-up. This approach permitted identification of a few low-stage carcinomas, but progression in the probably benign calcifications was usually unrelated to malignancy.     

Mammographic and ultrasonographic findings in bilateral breast cancer: a comparative study

To compare the results of mammographic and US examinations in unilateral and bilateral breast cancers in routine clinical work, the files of all patients with 825 preoperative mammograms and 525 preoperative US examinations operated on for primary breast cancer in the Oulu University Hospital from 1983 through 1993 were retrospectively reviewed. The only statistically significant difference noted in the mammographic findings was the false-negative rates in unilateral, bilateral and metachronous second breast cancers (6.8, 16.3 and 23.3 %, respectively). The differences were mainly due to the lower sensitivity of mammography in the detection of palpable bilateral breast cancers. The false-negative rate of US was also significantly higher in bilateral breast cancers (23 %) than in unilateral cancers (11 %), and significantly higher for nonpalpable than palpable cancers in both the bilateral and the unilateral groups. The mammographic failure rates and the difference between these two groups were most pronounced during the early study period, which underscores the importance of experience and dedicated imaging technique. The smaller tumour size at the time of diagnosis and probably the loss of the opposite breast for comparison have contributed to the higher false-negative rates in bilateral breast cancer. Received 25 April 1997; Revision received 1 September 1997; Accepted 6 October 1997     

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.     

MRI 对乳腺 X 线摄影中“局灶性不对称”征象的诊断价值

目的：探讨M RI对X线摄影中乳腺“局灶性不对称”（FAB ）征象的诊断价值。方法回顾性分析经病理证实的46例FAB的M RI形态学特点及动态增强时间‐信号强度曲线（T IC ）的类型。结果在FAB相应区域,M RI检出46例病灶,病理证实良性病变35例,恶性病变11例。其中外形分叶及边缘毛刺的准确度、阳性预测值以及阴性预测值分别为82．61％、66．67％、86．49％和86．96％、85．71％、87．18％。T IC显示：Ⅰ型17例,均为良性;Ⅱ型6例,其中良性4例,恶性2例;Ⅲ型9例,均为恶性。M RI对其良恶性诊断的准确度为86．96％,阳性预测值和阴性预测值分别为81．82％与96．88％。结论 M RI能够准确判断FAB中是否存在潜在病灶,并能较准确地判断其良恶性。     

Breast light scanning: a real-time breast-imaging modality

A total of 450 patients was referred for real time transillumination of both breasts. Of these, 84 were investigated by either cyst aspiration or excisional biopsy within two months of the breast light scan. Fourteen malignant and 70 benign lesions were correctly diagnosed by light scanning preoperatively. X-ray mammography produced four false negative results in this same group of patients. Two of the malignant lesions diagnosed by light scanning were not palpable. Light scanning had a sensitivity of .93 in the detection of breast cancer and a specificity of .89 in this study, following correlation with biopsy or cyst aspiration. Although mammography is still the reference technique in breast screening, real time light scanning by an experienced operator and interpreter should be an important adjunct in any clinic responsible for evaluating breast disease. The technique has the advantage of being safe, painless, noninvasive, and using no ionizing radiation. The technique is also acceptable to patients. It requires no preparation, and examination time rarely exceeds 15 minutes.