Ultrasonography alone for diagnosis of breast cancer in women under 40

Introduction

Recent guidelines suggest that ultrasonography should be used as the primary imaging modality in women under 40 years of age with mammography being offered if further imaging is required. The aim of this study was to assess the adequacy of ultrasonography and the utility of mammography in this patient group by reviewing the role these imaging techniques had in the diagnosis of breast cancer in our unit.

Methods

All breast cancers diagnosed in patients 39 years or younger from June 2009 to June 2011 were reviewed. This was a retrospective review of presentation, clinical findings, imaging modality (ultrasonography, mammography, magnetic resonance imaging [MRI]) and histology. Mammography was the primary imaging modality until May 2011 in women between 35 and 39 years of age. Both invasive and intraductal carcinoma were included in the study but lobular carcinoma in situ was excluded.

Results

A total of 2,495 patients were referred to the symptomatic breast clinic in this age group during the study period. Thirty women were identified with either invasive cancer (n=27) or ductal carcinoma in situ (n=3). Twenty-eight patients underwent mammography, graded as uncertain, suspicious or malignant in the majority. Malignancy was missed in one patient. All 30 patients underwent ultrasonography, reported as uncertain, suspicious or malignant, an indication for diagnostic core biopsy. Ultrasonography alone did not miss any cancers but did fail to detect multifocal disease in one patient.

Conclusions

In this study group, ultrasonography was reliable as the primary imaging modality for women under 40, identifying all cancers in this cohort. Mammography and/or MRI remain essential adjuncts to accurately determine multifocality and/or the extent of disease.     

Adequacy of diagnostic tests and surgical management of symptomatic invasive lobular carcinoma of the breast

Introduction

Invasive lobular carcinoma (ILC) presents diagnostic and therapeutic challenges as it produces subtle radiological changes. It has been suggested that it is not suitable for breast conserving surgery (BCS). The aim of this study was to ascertain the diagnostic adequacy of modern mammography and ultrasonography in the context of a fast track symptomatic diagnostic clinic in the UK. It also sought to compare the mastectomy, re-excision and BCS rates for ILC with those for invasive ductal carcinoma (IDC).

Methods

A retrospective analysis of prospectively collected data was carried out on all new symptomatic cancers presenting to the one-stop diagnostic clinic of a single breast unit between 1998 and 2007.

Results

Compared with IDC, ILC was significantly larger at presentation (46mm vs 25mm), needed re-excision after BCS more often (38.8% vs 22.3%) and required mastectomy more frequently (58.8% vs 40.8%). Although mammography performs poorly in diagnosing ILC compared with IDC, when combined with ultrasonography, sensitivity of the combined imaging was not significantly different between these two histological types.

Conclusions

Provided ultrasonography is performed, standard radiological imaging is adequate for initial diagnosis of symptomatically presenting ILC but some additional preoperative workup should clearly be employed to reduce the higher number of reoperations for this histological type.     

Combined fine-needle aspiration,physical examination and mammography in the diagnosis of palpable breast masses: their relation to outcome for women with primary breast cancer

Objective

To examine the combined and individual predictive values of fine-needle aspiration (FNA), physical examination (PE) of the breast and mammography (the “triple test”) in diagnosing breast cancer in relation to the results of open surgical biopsy.

Design

A study of the records of patients who received both FNA and open surgical biopsy for the same palpable breast lump. The results of diagnostic assessment and open surgical biopsy were categorized as positive or negative. Concordance (percentage of tests found to be correct at biopsy), sensitivity, specificity (percentage of patients without breast cancer for whom the diagnostic test was negative) and positive predictive value (percentage of patients with a positive test found to have breast cancer) were determined for the triple test for each diagnostic modality. In addition, prognostic variables (tumour size, node positivity, estrogen and progesterone receptor status) and outcomes were assessed in patients with a diagnosis of breast cancer.

Setting

A university-affiliated general hospital with a special focus on women’s health.

Patients

Of 290 patients who had both FNA and open surgical biopsy, 191 underwent all three diagnostic procedures.

Main Outcome Measures

The diagnostic accuracy of FNA, PE and mammography to permit preoperative definitive therapy or to allow observation without mandating open surgical biopsy.

Results

In 81 patients all three diagnostic modalities were in agreement for a diagnosis of either benign or malignant disease; the concordance for the triple test was 98.8%, specificity was 100% and sensitivity was 95.5%. Nodal status, tumour size and outcome were similar whether or not the triple test was positive, but, interestingly, when the triple-test results were positive, estrogen (p < 0.05) and progesterone (p < 0.03) receptor values were more likely to be negative.

Conclusions

When all three diagnostic modalities were in agreement for a diagnosis of malignant disease, the combination of FNA, PE and mammography had excellent concordance with the results of open surgical biopsy, and in this situation definitive treatment may be carried out. If all three modalities are in agreement for a diagnosis of benign disease, a period of close observation with repetition of FNA may be safely entertained. Lack of concordance of the three diagnostic modalities mandates biopsy. Triple-test positivity does not predict a worse outcome.     

Relation between clinical and mammographic diagnosis of breast problems and the cancer/biopsy rate

Objective

To determine the sensitivity of mammographic and clinical assessment of breast problems, independent of one another, on the ratio of cancers found to biopsies performed (cancer/biopsy rate).

Design

A review of diagnoses from prospectively recorded and independently assessed clinical and mammographic examinations.

Setting

The breast clinic in a university-affiliated hospital.

Patients

Patients were considered in two age groups — under 50 years and 50 years and over; 1251 patients underwent breast biopsy between September 1976 and November 1994 after clinical assessment and mammography.

Main Outcome Measure

The cancer diagnosis rate found on biopsy as a result of clinical and mammographic findings.

Results

In both age groups, mammography was significantly (p < 0.001) more sensitive than clinical assessment in cancer diagnosis but gave a significantly (p < 0.0001) higher rate of false-positive results. The cancer diagnosis rate was highest when lesions were assessed both clinically and mammographically as malignant but was of diagnostic benefit only to women in the under-50-year age group. The cancer rate was 12% when both assessments indicated a benign process and only 2% in women under age 50 years with clinically benign conditions who did not have mammography. Twenty-one percent of the biopsies were obtained in women with clinically normal breasts because of a mammographic abnormality and 17% of all the cancers found were clinically occult.

Conclusions

The sensitivity of clinical assessment, particularly in premenopausal women is low and the false-positive mammography rate is high, but the cancer/biopsy rate is sufficiently high to warrant breast biopsy if either diagnostic modality suggests a cancer. When neither modality suggests cancer, the cancer/biopsy rate is 12% in both age groups.     

A Comparison of Conventional Ultrasonography and Arthrosonography in the Assessment of Cuff Integrity after Rotator Cuff Repair

Background

This study was designed to perform conventional ultrasonography, magnetic resonance arthrography (MRA) and arthrosonography exams after rotator cuff repair to compare the results of conventional ultrasonography and arthrosonography with those of MRA as the gold standard.

Methods

We prospectively studied 42 consecutive patients (14 males, 28 females; average age, 59.4 years) who received arthroscopic rotator cuff repair due to full-thickness tears of the supraspinatus tendon from 2008 to 2010. The integrity assessment of the repaired rotator cuff was performed 6 months postoperatively using conventional ultrasonography, MRA, and arthrosonography.

Results

The diagnostic accuracy of the conventional ultrasonography compared to MRA was 78.6% and the McNemar test results were 0.016 in full-thickness tear and 0.077 in partial-thickness tear. The diagnostic accuracy of arthrosonography compared to MRA was 92.9% and the McNemar test results were 0.998 in full-thickness tear and 0.875 in partial-thickness tear.

Conclusions

It was found that the integrity assessment of the repaired rotator cuff by ultrasonography must be guarded against and that arthrosonography is an effective alternative method in the postoperative integrity assessment. Also, an arthrosonography seems to be a suitable modality to replace the conventional ultrasonography.     

Laparoscopic Repair of a Right Paraduodenal Hernia

Background and Objectives:

Right paraduodenal hernia (PDH) results from a primitive gut malrotation. The resultant jejunal mesenteric defect posterior to the superior mesenteric vessels allows decompressed jejunum to herniate retroperitoneally. PDH make up 53% of all internal hernias, but account for only 0.2% to 5.8% of all cases of intestinal obstruction. In addition, PDH exhibits male and left-sided predominance. Ours is the second report to describe the preoperative diagnosis and totally laparoscopic repair of a right PDH.

Methods:

We report the case of a 26-year-old female with symptoms suggestive of partial small bowel obstruction and a 6-year history of intermittent abdominal pain. Physical examination demonstrated lower quadrant tenderness. Plain abdominal radiographs and ultrasonography were nondiagnostic. Contrasted computed tomography of the abdomen revealed jejunum encased within the right upper quadrant suspicious for right PDH.

Results:

The patient underwent successful laparoscopic right PDH repair and was discharged home on postoperative day 1 without late sequelae.

Conclusions:

In the outpatient setting, clinical suspicion and comprehensive radiological investigation permit preoperative diagnosis of right PDH. In acute situations, clinical presentation, plain radiographs, and then diagnostic laparoscopy may be an expeditious diagnostic algorithm. Subsequent laparoscopic repair of right PDH is feasible and may shorten hospital length of stay.     

Postmenopausal Breast Tuberculosis – Report of 4 Cases

Background

Breast tuberculosis is an uncommon disease even in countries where the incidence of tuberculosis is high.

Case Report

This is a case series concerning 4 postmenopausal breast tuberculosis cases encountered in Moulay Youssef Hospital between January 2007 and December 2010. Breast tuberculosis represents 0.25% of all hospitalized tuberculosis patients in our department. The mean age of our patients was 62.5 ± 5.8 years. Clinical findings were heterogeneous; 1 case was multifocal tuberculosis, and another case was coexistent tuberculosis and malignancy of the breast. Mammography and ultrasonography findings were suspicious for malignancy in all 4 cases. Fine needle aspiration was negative in 3 cases. The diagnosis was made in all patients by histological examination of biopsy specimens, which revealed typical tuberculous lesions. Anti-tuberculosis therapy formed the mainstay of treatment.

Conclusion

The clinical and radiological features of mammary tuberculosis can be very confusing and easily mistaken for breast cancer. Symptoms suggestive of tuberculosis warrant a biopsy to exclude possible cancer.     

Lobular Breast Cancer in a Male Patient with a Previous History of Irradiation Due to Hodgkin's Disease

Background

Male breast cancer is rare and represents less than 1% of all breast cancers. Considering the fact that the male breast most often does not consist of lobules and acini, lobular carcinoma of the male breast is exceptionally rare.

Case Report

In this paper we present a unique case of alveolar variant of lobular male breast cancer in a 56-year-old patient.

Conclusion

According to our knowledge this is the first presentation of an alveolar variant of lobular male breast cancer that appeared 14 years after chemo- and radiotherapy for the treatment of Hodgkin''s disease.     

Bilateral Axillo-Breast Approach Robotic Thyroidectomy (BABA RT) Does Not Interfere with Breast Image Follow-Up

Background

Bilateral axillo-breast approach robotic thyroidectomy (BABA RT) is frequently performed and has excellent cosmetic results. However, there has been concern that subcutaneous tunneling in construction of the operation field might interfere with subsequent breast imaging. In this study, we evaluated whether BABA RT interferes with breast imaging by evaluating serial perioperative results of mammography and ultrasonography.

Methods

We selected female patients who underwent BABA RT between 2008 and 2012, and who also had mammography or ultrasonography pre- and postoperatively, and compared the results of pre- and postoperative imaging. The results of mammography and ultrasonography were reported according to the Breast Imaging Reporting and Data System (BIRADS).

Results

A total of 175 nodules from 108 female patients were analyzed. The mean age of the patients was 42.9 ± 9.7 years, and the median follow-up period was 34.1 months. Ninety-four patients (87.0%) underwent total thyroidectomy, and 101 patients (93.5%) had malignant thyroid disease. After BABA RT, mammography and ultrasonography were performed an average of 2.9 ± 2.0 times and 3.3 ± 2.0 times per person, respectively. Six patients required breast intervention according to mammography or ultrasonography after BABA RT, and all procedures were successfully conducted.

Conclusions

BABA RT did not cause diagnostic difficulties such as poor sonic window in subsequent breast imaging studies. Routine breast imaging studies for breast nodule follow-up could be performed without difficulties resulting from BABA RT.

     

The influence of clinicopathological features on the predictive accuracy of conventional breast imaging in determining the extent of screen-detected high-grade pure ductal carcinoma in situ

INTRODUCTION

The extent of calcified ductal carcinoma in situ (DCIS) detected by screening mammography is a determinant for treatment with breast conserving surgery (BCS). However, DCIS may be uncalcified and almost a quarter of patients with DCIS treated initially by BCS either require a second operation or are found to have unexpected invasive disease following surgery. Identification of these cases might guide selective implementation of additional diagnostic procedures.

METHODS

A retrospective review of patients with a preoperative diagnosis of pure high-grade DCIS at the Southampton and Salisbury Breast Screening Unit over a ten-year period was carried out. Mammograms were reviewed independently by a consultant radiologist and additional factors including the Breast Imaging Reporting and Data System (BI-RADS®) breast density score, DCIS extent and disease location within the breast recorded.

RESULTS

Unexpected invasive disease was found in 35 of 144 patients (24%). Within our unit the re-excision rate for all screen-detected DCIS is currently 23% but for patients included in this study with high-grade DCIS the re-excision rate was 39% (34/87). The extent of DCIS (p=0.008) and lack of expression of the oestrogen receptor (ER) predicted the requirement for re-excision in both univariate (p=0.004) and multivariate analysis (p=0.005).

CONCLUSIONS

High-grade DCIS may be focally uncalcified, leading to underestimation of disease extent, which might be related to ER status. Invasive foci associated with high-grade DCIS are often mammographically occult. Exploration of additional biomarkers and targeted use of further diagnostic techniques may improve the preoperative staging of DCIS.     

The use of pre-operative computed tomography in the assessment of the acute abdomen

INTRODUCTION

While there are a lot of data on the accuracy of computed tomography (CT) in diagnosing specific causes of an acute abdomen, there is very little information on the accuracy of CT in the acute general surgical admissions workload. We look at the diagnostic accuracy of CT in patients presenting with an acute abdomen who ultimately required a laparotomy.

METHODS

Patients who underwent an emergency laparotomy between 2008 and 2010 at Eastbourne District General Hospital with pre-operative CT on the same admission were included in the study. The CT report was compared with the laparotomy and histology findings and, where a discrepancy existed, the original imaging was reviewed by a senior consultant blinded to the original report and laparotomy findings.

RESULTS

A total of 196 emergency laparotomies were performed over the 2–year period, with 112 patients undergoing pre-operative CT. Fifteen patients were excluded from the study due to missing notes. In the remaining 97 patients, 80 CT reports correlated with the final operative diagnosis, giving a diagnostic accuracy of 82%. Of these, the on-call registrar was the initial reporter in 37 scans, with a diagnostic accuracy of 78%. On review of the CT by a second consultant, this increased to 90 correlations, yielding an accuracy of 93%. Delay between CT and the operation did not significantly alter diagnostic accuracy, nor was there any statistically significant reduction in accuracy in reports issued by on-call registrars.

CONCLUSIONS

On first reporting, CT misses 18% of diagnoses that ultimately require operative intervention. Reducing the threshold for obtaining a second consultant radiologist review significantly improves the diagnostic accuracy to 93%.     

Ultrasonography aids decision-making in children with abdominal pain

INTRODUCTION

Although regular clinical assessment of the acute abdomen is considered best practice, ultrasonography confirming the presence of appendicitis will add to the decision-making process. The aim of this study was to assess the accuracy of ultrasonography and its usefulness in diagnosing acute appendicitis in a regional paediatric surgical institution.

METHODS

Retrospectively and in this order, radiology, theatre and histopathology databases were searched for patients who had presented with acute abdominal pain, patients who had undergone an appendicectomy and all appendix specimens over a two-year period. The databases were cross-referenced against each other.

RESULTS

A total of 273 non-incidental appendicectomies were performed over the study period. The negative appendicectomy rate was 16.5% and the perforation rate 23.7%. Thirty-nine per cent of children undergoing an appendicectomy had at least one pre-operative ultrasound scan. Ultrasonography as a diagnostic tool for acute appendicitis in children had a sensitivity of 83.3%, a specificity of 97.4 %, a positive predictive value of 92.1% and a negative predictive value of 94.0%.

CONCLUSIONS

Ultrasonography is used liberally to aid in the decision making process of equivocal and complicated cases of acute appendicitis and it achieves good measures of accuracy. As a diagnostic tool it is unique in its ability to positively predict as well as exclude. A high negative predictive value suggests that more patients could be managed on an outpatient basis following a negative scan.     

Clinical and surgical management of unilateral prepubertal gynecomastia

INTRODUCTION

Gynecomastia is the benign proliferation of the glandular tissue in the male breast. This condition is thought to be caused by the imbalance between estrogen action relative to androgen action at the breast tissue level. Bilateral gynecomastia is frequently found in the neonatal period, early in puberty, and with increasing age. Prepubertal unilateral gynecomastia in the absence of endocrine abnormalities is extremely rare, with only a few cases in literature.

PRESENTATION OF CASE

We present an otherwise healthy boy of 12 years old with unilateral breast masses. No abnormalities were found on ultrasonography and on all endocrine parameters. Treatment consisted in a new “modified” Webster technique.

DISCUSSION

The results confirmed validity of this technique in terms of esthetic and functional results, and patient satisfaction. Atypical presentations of gynecomastia are often not recognized. The main pathophysiology of gynecomastia is alteration in the balance between the stimulatory effect of estrogen and the inhibitory effects of androgens on the development of the breast. If there is no causal treatment, surgical resection is the therapy of first choice.

CONCLUSION

The exact mechanism of unilateral gynecomastia formation in our case is unclear. The evaluation of unilateral gynecomastia can therefore be complex. In conclusion, the surgical treatment of unilateral gynecomastia requires an individual approach, based on an appropriate diagnostic algorithm.     

Population-Based Effects of Mammography Screening in Bavaria on the Distribution of TNM-T Categories with Respect to Different Histological Subgroups

Background

Organized mammography screening was implemented in Bavaria in 2003, with a target population of about 1.5 million women (aged 50–69 years). We evaluated the population-based effects of mammography screening on the distribution of tumor-node-metastasis (TNM)-T categories with regard to different histological subgroups of breast cancer.

Patients and Methods

Women diagnosed with breast cancer between 2002 and 2008 were included. The annual age-specific incidence rates separated by T category were calculated for different histological subgroups and plotted against time. Time trends were analyzed not only in the screening population but also based on women aged 15–49 and ≥70 years, respectively. Furthermore, correlation coefficients were calculated in order to evaluate the possible association between participation rate and incidence of certain TNM-T categories.

Results

With ductal carcinomas, the incidence of early-stage tumors shows a strong increase in the screening population and a significant correlation with the participation rate, whereas with lobular carcinomas there is a stagnation of incidence in women aged 50–69 years irrespective of TNM-T category.

Conclusions

Short-term effects of mammography screening can already be demonstrated. However, depending on breast cancer type, not all women appear to benefit from screening. The expected long-term reduction of breast cancer mortality remains to be seen.     

Influence of MRI field strength on clinical decision making in knee cartilage injury – A case study

Objective:

To increase clinicians’ awareness of the differences in image resolution and potential diagnostic accuracy between small and large-field MR Scanners. To present an example of a clinical decision making challenge in how to proceed when knee MRI and clinical findings don’t agree.

Clinical Features:

A 38 year old female mountain biker presented with knee pain and clinical features strongly suggestive of a torn meniscus or loose bodies. An initial MRI using a small field strength (0.18T) scanner was reported as normal. Her clinical presentation was suspicious enough that a repeat MRI on a high-field (1.5T) scanner was ordered. The second MRI included high resolution 3D volumetric imaging which revealed cartilage damage and loose bodies.

Intervention and Outcome:

The patient was treated with arthroscopic surgery which confirmed the presence of meniscal and chondral injury and resulted in notable improvement in the patient’s symptoms.

Conclusion:

Clinicians should consider scanner quality and diagnostic accuracy before discounting strongly suggestive clinical history and examination findings when MRIs are reported as normal.     

Granulomatous Mastitis: A Spectrum of Disease

Summary

Background

Granulomatous disease within the breast can result from a variety of causes.

Patients and Methods

We present 3 cases of this condition with 3 different underlying diagnoses.

Results

Each case was initially labelled as idiopathic granulomatous mastitis, although this was proven not to be correct on further investigation.

Conclusion

Clearly, identifying the correct underlying diagnosis is essential in granulomatous breast lesions as the treatment varies widely depending on the underlying aetiology. Effective communication and feedback in the context of the multidisciplinary team are vital to the diagnostic process in such challenging cases.Key Words: Granulomatous mastitis, Breast     

Role of specimen US for predicting resection margin status in breast conserving therapy

Aim

To assess the diagnostic accuracy of specimen ultrasound (US) for predicting resection margin status in women undergoing breast conserving therapy for US-detected cancer, having the histological findings as the reference standard.

Patients and methods

A total of 132 consecutive patients (age range, 34–87 years; mean, 51 years) underwent breast-conserving surgery for US-detected invasive breast cancer. All surgical specimens underwent US examination. The presence of lesion within the specimen and its distance from the specimen margins were assessed considering a threshold distance between the lesion and specimen margins of 10 mm. US findings were then compared with the pathological ones and specimen US. Sensitivity, specificity, diagnostic accuracy, positive (PPV) and negative predictive values (NPV) for predicting histological margin status were evaluated, having the histological findings as the reference standard.

Results

The histological examination detected invasive ductal carcinoma in 96/132 (73%) cases, invasive lobular carcinoma in 32/132 (24%), mucinous carcinoma in 4/132 (3%). The pathological margin analysis revealed 96/132 (73%) negative margins and 36 (27%) close/positive margins. US examination detected all 132 breast lesions within the surgical specimens. 110 (83%) negative margins and 22 (17%) positive margins were found on US. Sensitivity, specificity, diagnostic accuracy, PPV and NPV of 44%, 94%, 80%, 73% and 82%, respectively, were found for specimen US.

Conclusions

Specimen US represents a time and cost saving imaging tool for evaluating the presence of US detected-breast lesion within surgical specimen and for predicting the histological margin status.     

The impact of surgeon-based ultrasonography for parathyroid disease on a British endocrine surgical practice

INTRODUCTION

Surgeon-based ultrasonography (SUS) for parathyroid disease has not been widely adopted by British endocrine surgeons despite reports worldwide of accuracy in parathyroid localisation equivalent or superior to radiology-based ultrasonography (RUS). The aim of this study was to determine whether SUS might benefit parathyroid surgical practice in a British endocrine unit.

METHODS

Following an audit to establish the accuracy of RUS and technetium sestamibi (MIBI) in 54 patients, the accuracy of parathyroid localisation by SUS and RUS was compared prospectively with operative findings in 65 patients undergoing surgery for primary hyperparathyroidism (pHPT).

RESULTS

The sensitivity of RUS (40%) was below and MIBI (57%) was within the range of published results in the audit phase. The sensitivity (64%), negative predictive value (86%) and accuracy (86%) of SUS were significantly greater than RUS (37%, 77% and 78% respectively). SUS significantly increased the concordance of parathyroid localisation with MIBI (58% versus 32% with RUS).

CONCLUSIONS

SUS improves parathyroid localisation in a British endocrine surgical practice. It is a useful adjunct to parathyroid practice, particularly in centres without a dedicated parathyroid radiologist, and enables more patients with pHPT to benefit from minimally invasive surgery.     

Invasive Lobular Carcinoma of the Male Breast: A Rare Histology in an Uncommon Disease

Summary

Background

Breast cancer in men is an uncommon disease. Nearly all cases of male breast cancer originate in the terminal ductulolobular unit, with exceedingly rare reports of lobular carcinoma in men. Invasive lobular cancer is found in no more than 1-2% of male breast cancer cases. Most of what is known about this disease is in the form of approximately 30 case reports in the literature.

Case Report

We report the case of a 52-year-old man who presented at our institution with a lump in his left breast. Ultrasound-guided biopsy revealed an invasive lobular cancer. The rare histological type was confirmed by the result of the histological examination of the mastectomy specimen. The treatment was completed by dose dense chemotherapy, radiation, and endocrine therapy.

Conclusion

Even though lobular structures are quite infrequent in the normal male, sporadic cases of invasive lobular breast cancer have been described. A short overview will be given in this case report.Key Words: Male breast cancer, Lobular carcinoma, Rare histology