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.     

Critical review of 215 cases of non-palpable mammary lesions]

PURPOSE: The natural history of human breast cancer shows that lesion size correlates directly with nodal metastases and distant spread. Nodal metastases are found in only 6% of cases in the preclinical stage of the tumor and therefore imaging must detect a breast cancer before it becomes palpable. We reviewed 215 nonpalpable breast lesions studied in the last 10 years to assess observers performance and ultimately improve the interpretation of suspicious mammograms, evaluating "cost" in terms of the ratio between benign and malignant lesions (B/M). MATERIAL AND METHODS: From 1988 to October 1998, two hundred and fifteen women with nonpalpable breast lesions suspected at mammography were examined. The lesions were removed after stereotaxic or US location and a radiograph of the surgical specimen was always performed. Mammographic patterns were interpreted retrospectively by two blinded radiologist experienced in breast imaging and specialized in locating nonpalpable breast lesions. Mammographic patterns were classified as poorly/highly suspicious calcifications, regular/irregular masses, spiculated masses, masses with calcifications and parenchymal distortions. Radiographic findings were compared with surgical results and the data used to calculate the B/M, positive predictive value (PPV) for malignancy and the trend of operator's performance. RESULTS: Modern techniques permit to detect a very high number of in situ breast carcinomas. Nineteen of 22 lesions (86%) were detected by mammography as highly suspicious calcifications, 2/22 as spiculated masses and 1/22 as a mass with calcifications. No in situ carcinoma was detected as an irregular mass. All regular masses were proven to be benign at histology. B/M analysis showed a decreasing trend (from 1.94 in the first 3 years to .57 in 1994-96, to .83 in 1997-98) and an overall value of .90. The PPV for malignancy was 83.33% for spiculated masses, 65.5% for highly suspicious calcifications, 63.63% for irregular masses, 47.05% for masses with more or less dysmorphic calcifications, 32.65% for poorly suspicious calcifications, 8.33% for parenchymal distortions and 0% for regular masses. DISCUSSION AND CONCLUSIONS: All spiculated masses and highly suspicious calcifications and microcalcifications should be removed. Biopsy is recommended in parenchymal distortions, despite its low predictive value for malignancy, because these lesions are uncommon and the cost of biopsy is therefore acceptable. Needle aspiration or long-term monitoring can be reconsidered for irregular masses and poorly suspicious microcalcifications. Finally, relative to possible different interpretations of mammographic patterns by center and operator's experience, we suggest that the PPV for every single pattern be continually reassessed based on personal case records rather than on literature data. This holds true especially for microcalcifications.     

Stereotactic vacuum-assisted breast biopsy: results, follow-up and correlation with radiological suspicion

PURPOSE: The purpose of this study was to assess the accuracy and clinical usefulness of stereotactic vacuum-assisted biopsy (VAB) for diagnosing suspicious, nonpalpable, only mammographically detectable breast lesions. MATERIALS AND METHODS: We retrospectively evaluated the results of percutaneous stereotactic VAB with 11-gauge needles performed over a period of 34 months on 228 nonpalpable suspicious breast lesions detectable on mammography only [Breast Imaging Reporting and Data System (BI-RADS) 3: 25.9%; BI-RADS 4: 67.1%; BI-RADS 5: 7%]. The imaging histological concordance was ascertained for each lesion. In cases of discordance, repeat biopsy or surgical excision were recommended; in cases of benign lesions, we urged a follow-up of at least 6 months and for borderline and malignant lesions a surgical excision. We also evaluated concordance between VAB results and subsequent examinations (surgical excision or followup). RESULTS: VAB demonstrated 123 (54%) benign lesions (with six cases of imaging-histological discordance), 26 (11.4%) borderline lesions and 79 (34.6%) malignant lesions. We obtained a suitable post-VAB mammographic or histological evaluation for 78 benign lesions, 17 borderline lesions and 76 malignant lesions, with one (1.3%) false negative (FN) case, two (11.8%) underestimations of borderline lesions, 14 (18.4%) underestimations of malignant lesions and no (0%) false positive cases. We did not observe any postbiopsy complications or scars. CONCLUSIONS: Percutaneous histological VAB with an 11-gauge needle proved to be, as reported in previous studies, a reliable method for diagnosing nonpalpable, mammographically detectable only breast lesions, with an underestimation rate lower than core biopsy and a FN rate similar to that of surgical biopsy, without any significant complications.     

A multicenter study for the evaluation of the diagnostic efficiency of mammography and echography in nonpalpable breast neoplasms]

The Breast Section of the Italian Society of Radiology set up a cooperative study which included 17 Departments of Radiology and Breast Diagnosis in order to evaluate the diagnostic accuracy of US versus mammography in nonpalpable breast lesions. From January 1, 1989 to december 31, 1990, 400 nonpalpable breast lesions (142 benign lesions, 59 in situ and 199 infiltrating carcinomas) were detected by mammography and/or US; they had questionable/suspicious findings which called for further investigation by means of cytology and/or histology. US proved much less sensitive in non-palpable carcinomas than mammography (49.2% vs 93.8%), also in younger women, and failed to detect 50% of the benign/malignant nonpalpable lesions identified by mammography. US sensitivity was directly related to lesion diameter and probe frequency: 38.7% in infiltrating carcinomas < or = 5 mm vs 56.8% in those > 10 mm; 12% in the patients examined with a 5-MHz probe vs 57.7% in those examined with a > or = 7.5-MHz probe. Furthermore, the most significant US patterns of nonpalpable lesion were irregular contours, posterior attenuation and irregular internal echoes, while an irregular skin line and Cooper ligaments had no significant relation with carcinoma. Thus, breast US cannot be used as a screening test on asymptomatic patients not even on young women with radiologically dense breasts. On the contrary, US performed with high-frequency probes is useful in the assessment of nonpalpable lesions identified by mammography, and allows, in many cases, US-guided cytology and preoperative localization.     

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.     

Papillary lesions of the breast: diagnostic imaging and contribution of percutaneous needle biopsy with 14G needle

PURPOSE: To evaluate the presence of suggestive mammographic, US, color-Doppler, RM findings of 33 PLB and to show the accuracy of the large-core biopsy in evaluating these lesions. MATERIAL AND METHODS: A retrospective review of imaging-guided large-core biopsy of 860 consecutive lesions revealed that PLB were diagnosed in 31/33 cases and 3 were suspicious papillary lesions. Surgical correlation was available for all these lesions. Mammography and US were performed in all patients, Color-Doppler in 13/33 and MR in 10/33. RESULTS: Histological findings by percutaneous biopsy demonstrated 26 (79%) benign, 3 (9%) atypical, and 4 (12%) malignant lesions. Histological findings after surgery confirmed the diagnosis for benign and malignant lesions, while of the 3 atypical lesions, 1 was benign and 2 were malignant. One encysted papillary carcinoma in situ at core-biopsy was classified as invasive papillary carcinoma after surgery. PLB were usually found (52%) in subareolar location and the mean size was 17 mm (range 5-60 mm). The most frequent mammographic appearance of benign PLB was of a well-defined (71%), oval (53%) mass. The microcalcifications had variable features; they were isolated in 3/27 (15%) cases and associated with masses in 4/27 (20%). The mammographic finding of papillary carcinoma was of a well-defined (50%) or ill-defined, oval (50%) or lobulated (50%) mass, but never of a spiculated mass. US finding of the benign PLB most commonly showed a well-defined (84%), oval (84%), complex solid/cystic (52%) mass with frequently (60%) posterior enhancement. US finding of papillary carcinoma was of a well-defined (50%) or ill-defined (50%), oval (50%) or lobulated (50%) mass, most commonly solid-inhomogenous-hypoechoic. Color-Doppler showed high blood flow in 8/10 benign PLB and in 2/3 malignant PLB. Contrast-enhanced MR imaging demonstrated usually well-circumscribed, round masses (71%). The intensity/time curve showed marked focal enhancement (peak signal intensity over 70% at the first minute) in both benign and malignant lesions. DISCUSSION: Often the patients with PBL were symptomatic (for presence of nipple discharge or palpable mass). 31/33 papillary lesions identified at the subsequent imaging-guided large-core biopsy and in the 3/33 remaining lesions percutaneous core-biopsy required a subsequent surgical biopsy for the atypical papillary lesions. US proved to have the highest sensitivity, showing the suggestive feature of a frond-like mass within a dilated duct, and color-Doppler demonstrated high blood flow (which should be considered in differential diagnosis of galactocele). Mammographic finding of papillary lesions was often consistent with benign lesions (fibroadenoma, cyst). MR confirmed the high vascularization of these lesions, showing marked enhancement of the solid component. CONCLUSIONS: US, with Color-Doppler, proved to be the most useful examination for the identification and demonstration of the solid component of these lesions, which, observed further diagnostic investigation. As no definite mammographic, sonographic or RM pattern could be identified to differentiate between benign and malignant PLB, core-biopsy was required. Percutaneous biopsy has shown to be reliable in the diagnosis of benign and malignant PLB (without any false negative): infact, any atypical lesions require surgical examination. The framing of benign and malignant PLB with imaging and core-biopsy was useful because the frequent association of benign PLB with concurrent or subsequent breast carcinoma suggests surgical excision and radiological follow-up.     

Nonpalpable breast cancer: mammographic appearance as predictor of histologic type.

PURPOSE: To investigate the association between mammographic appearance and histologic diagnosis of nonpalpable breast cancers. MATERIALS AND METHODS: Mammographic characteristics of 317 consecutive clinically nonpalpable breast cancers in patients treated with breast-conserving surgery were reviewed. Malignant lesions were categorized as spiculated masses, other lesions, calcifications, and combined findings. Calcifications were characterized as amorphous, pleomorphic, or fine linear and branching. Logistic regression was used for the evaluation. Odds ratios (ORs) represent the magnitude of the association between a histologic diagnosis and a mammographic finding. RESULTS: Spiculated mass without calcifications (n = 150) and calcifications alone (n = 79) accounted for three of four cancers. A spiculated mass without calcifications was strongly associated with invasive cancers (OR = 12). Calcifications alone were strongly associated with ductal carcinoma in situ (DCIS) (OR = 19). In a decreasing order, the following invasive cancers were each associated with spiculated lesions without calcifications: ductal carcinoma grade 1 (OR = 28), ductal carcinoma grade 2 (OR = 17), lobular carcinoma (OR = 11), and ductal carcinoma grade 3 (OR = 4.6). Fine linear and branching calcifications alone were associated with not only DCIS nuclear grades 3 (OR = 17) and 2 (OR = 9.7) but also with invasive ductal carcinoma grade 3 (OR = 13). CONCLUSION: Mammographic appearance can be a predictor of histologic diagnosis in three of four nonpalpable breast cancers.     

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.     

Ultrasonographic evaluation of invasive lobular carcinoma.

PURPOSE: To compare ultrasonographic (US) and mammographic findings and tumor size measurements of invasive lobular carcinoma (ILC). MATERIAL AND METHODS: US diagnoses and mammographic findings were compared in 95 patients with pure ILC, including 46 palpable and 49 nonpalpable tumors. The diameters of tumors measured by mammography, US, and pathology were compared in 70 of the 95 patients using scatter plots and correlation analysis. RESULTS: Eighty-two (86.3%) of the ILCs were correctly diagnosed as malignant tumor, 5 (5.3%) were diagnosed as focal abnormality, and only 2 patients had normal findings on US. The most common mammographic findings were a spiculated mass (57%) and a focal asymmetric density (15%). US correctly diagnosed 8 of 12 patients with normal or equivocal mammographic findings. The correlation of tumor size assessment on imaging and pathology revealed that US measurements including the "halo" (r=0.69) was superior to that of mammography (r=0.59). ILCs larger than 30 mm were heavily underestimated by both methods. CONCLUSION: Malignant tumor was diagnosed on US in most of the patients with ILC. US tumor measurement including the "halo" predicted tumor size most accurately. The correlation between imaging measurements and tumor diameter on histology was lower for ILCs than reported for populations of mixed carcinomas.     

US of mammographically detected clustered microcalcifications

PURPOSE: To determine whether ultrasonography (US) can depict breast masses associated with mammographically detected clustered microcalcifications and whether the visibility at US is different between benign and malignant lesions. MATERIALS AND METHODS: Ninety-four patients with 100 mammographically detected microcalcification clusters prospectively underwent US with a 10- or 12-MHz transducer before mammographically guided presurgical hook-wire localization. The visibility of breast masses at US was correlated with histologic and mammographic findings. RESULTS: Surgical biopsy revealed 62 benign lesions, 30 intraductal cancers, and eight invasive cancers. At US, breast masses associated with microcalcifications were seen in 45 (45%) of 100 cases. US depicted more breast masses associated with malignant (31 [82%] of 38) than with benign (14 [23%] of 62) microcalcifications (P: <.001). In malignant microcalcification clusters larger than 10 mm, US depicted associated breast masses in all 25 cases. There was no statistically significant difference in shape and distribution of calcific particles, as well as in breast composition, at mammography between US visible and invisible groups. CONCLUSION: Given a known mammographic location, US with a high-frequency transducer can depict breast masses associated with malignant microcalcifications, particularly clusters larger than 10 mm. US can be used to visualize large clusters of microcalcifications that have a very high suspicion of malignancy.     

High-resolution scintimammography: a pilot study.

This study evaluated a novel high-resolution breast-specific gamma camera (HRBGC) for the detection of suggestive breast lesions. METHODS: Fifty patients (with 58 breast lesions) for whom a scintimammogram was clinically indicated were prospectively evaluated with a general-purpose gamma camera and a novel HRBGC prototype. The results of conventional and high-resolution nuclear studies were prospectively classified as negative (normal or benign) or positive (suggestive or malignant) by 2 radiologists who were unaware of the mammographic and histologic results. All of the included lesions were confirmed by pathology. RESULTS: There were 30 benign and 28 malignant lesions. The sensitivity for detection of breast cancer was 64.3% (18/28) with the conventional camera and 78.6% (22/28) with the HRBGC. The specificity with both systems was 93.3% (28/30). For the 18 nonpalpable lesions, sensitivity was 55.5% (10/18) and 72.2% (13/18) with the general-purpose camera and the HRBGC, respectively. For lesions < or = 1 cm, 7 of 15 were detected with the general-purpose camera and 10 of 15 with the HRBGC. Four lesions (median size, 8.5 mm) were detected only with the HRBGC and were missed by the conventional camera. CONCLUSION: Evaluation of indeterminate breast lesions with an HRBGC results in improved sensitivity for the detection of cancer, with greater improvement shown for nonpalpable and < or =1-cm lesions.     

Atypical ductal hyperplasia: can some lesions be defined as probably benign after stereotactic 11-gauge vacuum-assisted biopsy,eliminating the recommendation for surgical excision?

PURPOSE: To determine if a subset of atypical ductal hyperplasia (ADH) lesions diagnosed at 11-gauge, directional, vacuum-assisted, prone, stereotactic biopsy fit the "probably benign" definition of a less than 2% chance of being carcinoma at subsequent surgical excision. MATERIALS AND METHODS: Clinical, mammographic, and stereotactic biopsy features in 104 consecutive nonpalpable ADH lesions were correlated with the presence of carcinoma at lumpectomy. The results were analyzed with chi(2) statistic, with P <.05 indicative of significant difference. RESULTS: Surgical excision revealed carcinoma in 22 (21%) of 104 ADH lesions. The lowest incidences of carcinoma (each P <.02) were 16% (15 of 92) in patients with no personal history of breast carcinoma, 13% (nine of 67) when maximum lesion diameter was less than 10 mm, and 8% (three of 36) when 100% of the mammographic lesion was removed at stereotactic biopsy. CONCLUSION: No clinical, mammographic, or biopsy features alone or in combination could be used to define a substantial subset of probably benign lesions with a less than 2% chance of carcinoma at lumpectomy.     

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.     

磁共振DWI检查在肺内良恶性病变鉴别诊断中的价值

目的:探讨磁共振DWI检查中ADC值和LSR值对肺内良恶性病变的鉴别诊断价值。方法:收集经肺部CT检查发现肺部大于1cm结节或肿块的55名患者,所有患者均行磁共振常规检查和DWI(b=600s/mm^2)扫描,分析肺内良恶性病变ADC值和LSR值的特点。结果 :ADC值和LSR值诊断肺内良恶性病变ROC曲线下面积为0.787和0.783,最佳诊断阈值为1.53×10^-3mm^2/s和1.075。ADC值和LSR值诊断肺内良恶性病变的灵敏度分别为79.1%和72.1%,特异度分别为73.3%和86.7%,两者之间灵敏度与特异度差异没有统计学意义(P=0.44,0.48);将ADC值和LSR值联合诊断肺内良恶性病变的灵敏度为93.0%,高于任何单一的诊断方法(P=0.04,0.0077);特异度为73.3%,与单一诊断之间比较,差异没有统计学意义(P=1,0.48)。ADC值、LSR值以及ADC值联合LSR值诊断肺内良恶性病变的阳性预测值、阴性预测值、阳性似然比、阴性似然比、约登指数和准确率分别为87.2%,57.9%,2.96,0.29,52.4%,77.6%;93.9%,52.0%,5.4,0.32,58.8%,75.9%;90.9%,78.6%,3.48,0.23,66.3%,87.9%。结论:磁共振DWI检查对鉴别肺内良恶性病变具有诊断价值,将ADC值和LSR值联合起来诊断的灵敏度高于单一诊断方式。     

Role of US-guided fine-needle aspiration with on-site cytopathologic evaluation in management of nonpalpable breast lesions

RATIONALE AND OBJECTIVES: The purpose of this study was to evaluate the accuracy of ultrasound (US)-guided fine-needle aspiration (FNA), with radiographic follow-up or surgical excision, in conjunction with on-site cytopathologic support in the management of nonpalpable breast lesions. MATERIALS AND METHODS: The findings of 266 consecutive mammographically or sonographically identified, nonpalpable lesions (228 patients) that underwent US-guided FNA were examined retrospectively. Clustered microcalcifications did not undergo biopsy with this method. Patients who underwent follow-up excisional biopsy or mammography with a duration of at least 24 months were included in the study. RESULTS: In all, 117 lesions met criteria for inclusion, of which 85 (73%) were diagnosed as benign at cytopathologic evaluation and underwent mammographic follow-up of at least 24 months (range, 24-67 months; mean, 36 months). Thirty-two lesions (27%) had either malignant or atypical cytopathologic findings, for which surgery was recommended. Eleven (9%) of the 32 had malignant cytopathologic findings from initial US-guided FNA, which were confirmed at surgical excision. The remaining 21 lesions (18%) were diagnosed as atypical on the basis of US-guided FNA results. Of these, 18 lesions underwent excisional biopsy: Two were diagnosed as carcinoma (not otherwise specified), and 16 were diagnosed with a variety of benign disorders. The remaining three patients with atypical lesions chose mammographic follow-up rather than surgical diagnosis, and their conditions have remained stable for more than 24 months. Of the 85 benign cases, one changed during follow-up (12 months) and underwent repeat biopsy, with malignancy noted. The sensitivity of US-guided FNA in identifying malignant lesions was 93% (13 of 14), and the specificity of a benign finding was 100% (102 of 102). The positive and negative predictive values of US-guided FNA supported by on-site cytopathologic evaluation were 100% (13 of 13) and 99% (102 of 103), respectively. CONCLUSION: Supported by appropriately trained on-site cytopathologists and in conjunction with follow-up mammography, US-guided FNA appears to be efficacious in the management of patients with abnormal radiographic findings. It is quick, relatively inexpensive, and minimally invasive, and, in the presence of competent cytopathologists, should be the modality of choice.     

Stereotaxic cytologic examination of non-palpable lesions of the breast. Experience with 791 consecutive cases

The authors report on 791 consecutive cases undergoing stereotaxic cytology for nonpalpable lesions detected at mammography. Histologic diagnosis (malignant = 179, benign = 107) or mammographic follow-up after at least one year (benign = 275) was available in 561 cases. The overall inadequacy rate of stereotaxic cytology was 0.21, and dependent on lesion type (benign = 0.25, malignant = 0.13 p less than 0.001) and on sampling operator experience (range 0.17-0.31, p less than 0.001). Sensitivity (dubious + positive, after exclusion of inadequates) was 0.83 and dependent on histologic type (infiltrating = 0.87, intraductal = 0.68). Specificity (negative/benign, after exclusion of inadequates) was 0.96. Stereotaxic cytology helped in reducing the number of unnecessary benign biopsies and the biopsy ratio was 0.6 benign to 1 malignant biopsy. In cases with moderate suspicion at mammography the radiologist felt reassured by negative cytology and advised mammographic control rather than surgical biopsy. Cytology was determinant in advising surgical biopsy in 9 cancer cases whereas the absence of cytologic positivity contributed to diagnostic delay in 2 cancer cases. Overall, stereotaxic cytology allowed a relevant reduction of unnecessary benign biopsies and should be routinely employed in the diagnostic work-up of nonpalpable lesions detected at mammography.     

High-spatial-resolution MR imaging of focal breast masses: interpretation model based on kinetic and morphological parameters

PURPOSE: To assess a new interpretation model combining kinetic pattern and morphologic characteristics using high-spatial-resolution MR imaging. MATERIALS AND METHODS: Breast MR imaging was performed in 58 patients with 63 pathologically proved focal breast masses (49 malignant and 14 benign). MR imaging was performed on a 1.5-Tesla system using the volumetric interpolated breath-hold examination (VIBE) sequence. Morphological parameters were lesion shape, mass margin, rim enhancement (RE), enhancing internal septations, and internal signal on T2-weighted images. Lesion shape/margin was classified into four categories as follows: smooth (smooth/round or smooth/oval), lobulated (lobular shape), irregular (irregular margin or irregular shape), and spiculated (spiculated margin). RE was sub-classified as early RE at 60 sec and delayed RE at 4 min. Strongly high signal and the presence of internal black septations were evaluated over the entire lesion on T2-weighted images. The kinetic parameter was visually assessed as follows: washout, plateau, and progressive. RESULTS: The most frequent types of lesion shape/margin in the malignant lesions were irregular (47%) and spiculated (43%), whereas 13 of the benign lesions had smooth or lobular margins (93%). The most frequent characteristics in breast cancers with lobulated configuration were washout pattern (80%), whereas 78% of the lobulated benign lesions were negative for visual washout. The positive predictive value (PPV) was 98% (49/50). CONCLUSION: "Washout with enhancing septations" is thought be specific for carcinoma with a lobulated configuration (80%). A combination of morphological criteria (including lesion shape/margins, strongly high signal on T2-weighted images) and visual washout is useful for differentiating between benign and malignant lesions.     

The correlation of mammographic-and histologic patterns of breast cancers in BRCA1 gene mutation carriers, compared to age-matched sporadic controls

Breast cancers in BRCA1 gene mutation carriers often have specific histologic features: grade III tumors with pushing margins. Our purpose was to compare the mammographic and histologic features of breast cancers in carriers with those in age-matched sporadic controls. The features of breast cancers in 27 BRCA1 carriers found during annual surveillance were compared to those in 107 age-matched sporadic controls. The carriers had no (classic) spiculated mammographic lesions, a high percentage of well-defined masses and hardly any masses with microcalcifications, whereas the controls had significantly fewer well-defined ones and only in 27% spiculated lesions on the mammogram. The well-defined mammographic tumors correlated in 83% of the carriers and in 70% of the controls with histologic circumscribed tumor margins. Spiculated mammographic lesions in the controls were in 90% grade I or II tumors. DCIS with or without infiltration was seen in 22% of the carriers and in 45% of the controls. In conclusion, breast cancers diagnosed in BRCA1 carriers do not have classic malignant mammographic features. A minority of the young sporadic controls show the classic malignant lesion on the mammogram. Both carriers and controls generally show a good correlation between their mammographic- and histologic tumor pattern.     

Sonographic criteria for differentiation of benign and malignant solid breast lesions: size is of value

PURPOSE: The purpose of this study was to evaluate whether lesion size may influence the value of sonographic findings in the differential diagnosis between benign or malignant breast lesions. MATERIALS AND METHODS: Sonographic features of 256 histologically confirmed (148 benign, 108 malignant) breast lesions were retrospectively and independently reviewed by three radiologists unaware of mammographic findings and pathology results. Each lesion was assessed for several sonographic features and assigned a level of suspicion. Logistic modelling defined the predictive value of each sonographic feature per se and in relation to lesion size. The k statistic (k) evaluated interobserver agreement in lesion classification. The accuracy of breast sonography in characterising solid lesions was also evaluated. RESULTS: Analysis of the sonographic features predictive of malignant disease, taken as a whole, showed that only irregular margins and marked hypoechogenicity maintain their predictive value independent of lesion size. When lesion size is considered, the other features remain significant only for lesions larger than 7 mm. Interobserver agreement for sonographic suspicion, when calculated not taking into account lesion size, was good or excellent whereas it was reduced for lesions smaller than 7 mm. Accuracy of breast sonography improved when evaluating lesions larger than 7 mm. CONCLUSIONS: Lesion size influences the value of sonographic findings in distinguishing benign from malignant lesions. The usually adopted criteria in sonography have a significantly lower accuracy in characterisation of small lesions.