Sclerosing adenosis: mammographic and ultrasonographic findings with clinical and histopathological correlation

OBJECTIVE: To evaluate the mammographic and ultrasonographic findings of sclerosing adenosis, a relatively uncommon entity which may sometimes mimic carcinoma. MATERIALS AND METHODS: A retrospective review of the records of 33,700 women, who have undergone mammographic examination at our institution between January 1985 and July 2001 revealed 43 histopathologically proven sclerosing adenosis. The history, physical examination, mammographic and ultrasonographic findings were analyzed in all patients. In 30 patients, the nonpalpable lesions were preoperatively localized by the needle-hookwire system under the guidance of mammography (n=22) or ultrasonography (US) (n=8). Radiological features were correlated with histopathological findings. RESULTS: The age of the patients varied between 32 and 55 years (mean, 43.7 years). Only two patients had a family history of breast cancer. In six patients, the presenting complaint was mastalgia. A palpable mass was present in 13 cases. The mammographic findings were; microcalcifications in 24 (55.8%) (clustered in 22, diffuse in two), mass in five (11.6%), asymmetric focal density in three (6.9%), and focal architectural distortion in three (6.9%) patients. Four of the masses were irregularly contoured, while one was well-circumscribed. On US, focal acoustic shadowing without a mass configuration was noted in the three patients who showed asymmetrical focal density on mammography. In eight patients, who showed normal mammograms, a solid mass was detected on US. Two masses had discrete well-circumscribed oval or lobulated contours, while six showed microlobulation and irregularity. In one case, the irregularly contoured mass had marked posterior acoustic shadowing. Two of the three patients, who had focal architectural distortion on mammograms, had an irregularly contoured solid mass, while the third presented as focal acoustic shadowing without a mass configuration. CONCLUSION: Sclerosing adenosis mostly presents as a nonpalpable lesion with different mammographic and sonographic appearances. The most common finding is microcalcifications on mammograms. Awareness of the possible imaging features will enable us to consider sclerosing adenosis in the differential diagnosis. The radiological features may sometimes mimic malignancy, so histopathologic examination is mandatory for definite diagnosis.     

Mammography in women with axillary lymphadenopathy and normal breasts on physical examination: value in detecting occult breast carcinoma.

OBJECTIVE. The purpose of this study was to determine the value of mammography in detecting occult carcinoma in patients with axillary adenopathy and normal breasts on physical examination. MATERIALS AND METHODS. We analyzed the results of mammography performed in 17 patients; all women had palpable axillary lymphadenopathy of unknown origin and all had normal breasts on physical examination. RESULTS. In 10 of the 17 patients, mammographic findings were abnormal. The mammographic finding of axillary adenopathy in seven patients was inconsequential because the nodes were evident on physical examination. Three patients had abnormal mammographic findings that were potentially significant, including one with a poorly defined mass suggestive of breast carcinoma, one with a subcutaneous nodule, and one with parenchymal breast edema. Two of 17 patients had an occult breast cancer. In only one of the patients was the cancer detected on mammography. The other patient had undergone prior left mastectomy and was thought to have metastases to the right axilla from the contralateral breast. Mammographic findings in this latter patient were normal. CONCLUSION. While occult breast carcinoma was relatively common in our series (two of 17 patients), the ability to detect the tumor with mammography was disappointing (one of two patients). This may be explained by the fact that one postmastectomy patient with occult carcinoma had metastatic disease to the contralateral axilla and a normal remaining breast, which was pathologically confirmed at mastectomy. Our experience suggests that mammography is valuable in patients with normal breasts on physical examination who have primary carcinoma involving ipsilateral axillary lymph nodes. The procedure should be included in the diagnostic evaluation of patients with axillary adenopathy in order to detect the unusual case of occult breast carcinoma.     

Variability in the interpretation of ultrasonography in patients with palpable noncalcified breast tumors

PURPOSE: To analyze interobserver variability of ultrasonography (US) as an adjunct to mammography in patients with palpable noncalcified breast tumors. MATERIAL AND METHODS: Mammographic, US, and combined reading of 200 patients with palpable noncalcified breast masses were performed independently by four experienced radiologists. Nonneoplastic abnormalities and mammographically obvious cancers were excluded. Receiver operating characteristic (ROC) analysis based on 115 tumors was carried out for mammography, US, and both combined for each radiologist. The US diagnoses of the 45 cancers excluded from ROC analysis and the 55 cancers included were compared. RESULTS: One radiologist revealed a significantly higher diagnostic performance with US than with mammography. Combined reading showed the highest performance for all observers, but the improvement as compared with mammography was significant for only two. Higher accuracy on combined reading was mainly caused by correct upgrading of tumors with benign or indeterminate mammographic findings. One radiologist had benefit of US for downgrading of tumors. All four radiologists made a malignant US diagnosis twice as often in mammographically obvious cancers than in mammographically nonconclusive tumors. CONCLUSION: Radiologists differ substantially in interpretation of breast imaging. Combined reading offers the highest diagnostic accuracy mainly by correct upgrading of tumors on US. The role of US for downgrading tumors is operator-dependent.     

Palpable breast thickening: role of mammography and US in cancer detection

PURPOSE: To determine the frequency of breast carcinoma and ascertain the diagnostic yield of mammography and breast ultrasonography (US) in the detection of breast carcinoma in women with palpable breast thickening. MATERIALS AND METHODS: One hundred twenty-three consecutive cases of breast thickening (103 patients) during a 1-year period were reviewed. Experienced breast examiners prospectively identified patients with breast thickening. Results of diagnostic mammographic work-up, breast US, breast biopsy, and clinical follow-up were retrospectively reviewed. RESULTS: Six (5%) of 123 cases had a diagnosis of breast carcinoma; five (83%) of the six had invasive carcinoma. Mammography was performed in all cases, US in 77 (63%) cases. Mammographic sensitivity for invasive cancer detection was 60% (three of five cases), specificity was 94% (102 of 108 cases), and negative predictive value was 97% (102 of 105 cases). Sensitivity of US alone was 100% (two of two cases), specificity was 96% (65 of 68 cases), and negative predictive value was 100% (65 of 65 cases). The combined negative predictive value of mammography and US was 100%. Patients with prior biopsies at the site of palpable thickening accounted for most false-negative mammograms. Median time to initiate follow-up of patients in whom biopsy was not performed was 14 months. CONCLUSION: Breast cancer was discovered in 5% of women with palpable breast thickening. Women with negative mammograms and US scans are at low risk for cancer but should, in our opinion, be followed up at short-term intervals with clinical examination and imaging if biopsy is not elected by their surgeon or clinician.     

Ultrasound-guided core needle biopsy as an initial diagnostic test for palpable breast masses.

PURPOSE: To determine the role of ultrasound (US)-guided core needle biopsy as an initial diagnostic test for palpable breast masses. MATERIALS AND METHODS: Ninety-eight consecutive patients, each with a palpable breast mass, were referred for US-guided core biopsy by a multidisciplinary team of physicians who specialize in the care of breast diseases. All palpable breast masses were clearly visible on high-resolution US. Ninety-nine core needle biopsies were performed under local anesthesia with use of freehand technique, mostly in an outpatient setting. Core needle path through each mass was documented in two orthogonal sections. A mean of 3.4 tissue core samples (range, 1-7) were obtained in each patient. RESULTS: Core needle biopsy resulted in the diagnosis of 66 malignancies, two cases of atypical ductal hyperplasia (ADH), and 30 benign diseases of the breast. Surgery with curative intent was performed in 63 breast malignancies and excisional biopsies were performed for 10 benign diseases (two cases of ADH and eight benign lesions). Twenty-five breast masses were managed nonoperatively: chemotherapy was performed in three locally advanced breast cancers and 3-year follow-up was conducted for 22 benign lesions. Malignancies were correctly diagnosed in all cases. No malignancy was discovered at surgery or during clinical follow-up of ADH and no benign breast lesions were diagnosed by core needle biopsy. US-guided core needle biopsy is 100% sensitive and specific for palpable breast malignancies, with no false-positive results. A puncture site ecchymosis was the only morbidity or complication noted. CONCLUSION: US-guided core needle biopsy is a safe and accurate first diagnostic test for palpable breast masses that require tissue proof.     

Diagnostic value of ultrasonography in patients with palpable mammographically noncalcified breast tumors

PURPOSE: To analyze the diagnostic accuracy of mammography, ultrasonography (US), and both methods combined in evaluation of palpable noncalcified breast tumors. MATERIAL AND METHODS: Mammograms and sonograms of 200 patients with palpable noncalcified breast masses were retrospectively analyzed independently by four experienced radiologists in 3 sessions: Mammography or US interpretations in the first two and combined reading in the last session. Nonneoplastic abnormalities and mammographically obvious cancers were excluded. Receiver operating characteristic (ROC) analyses were performed for 115 (60 benign and 55 malignant) tumors and subgroups according to tissue density and tumor size. A single ROC curve for each diagnostic test was obtained by pooling the individual ratings. The area under the ROC curve was used as a measure of diagnostic performance. RESULTS: US revealed significantly higher diagnostic performance than mammography for tumors larger than 2 cm. Combined reading showed significantly higher performance than mammography except for tumors smaller than 2 cm. The performance of all three tests was reduced in dense parenchyma, and significantly so for mammographic and combined interpretation. CONCLUSION: The accuracy of US in patients with palpable mammographically noncalcified and not obviously malignant breast tumors is lower than reported for mixed sample populations. The accuracy of US may be influenced by breast parenchyma density. Combined reading offers the highest diagnostic accuracy.     

Breast masses: removal of all US evidence during biopsy by using a handheld vacuum-assisted device--initial experience

PURPOSE: To assess the effects of removal of all ultrasonographic (US) evidence of breast lesions by using a vacuum-assisted biopsy (VAB) device. MATERIALS AND METHODS: Thirty-four women with breast masses underwent US-guided biopsy with an 11-gauge VAB device, with which removal of all evidence of the lesion was attempted. Histologic findings were compared with results of surgery and follow-up imaging. Patient tolerance and perceptions of the procedure and the ability of the procedure to eliminate a palpable finding were evaluated with questionnaires and findings at follow-up physical examination. RESULTS: The biopsy protocol was completed in all cases. Twenty-six benign lesions (76%) and eight malignancies (24%) were diagnosed. After VAB, 10 patients (29%) underwent surgery on the basis of histologic findings of invasive carcinoma (n = 7), ductal carcinoma in situ (n = 1), lobular neoplasia (n = 1), or atypical ductal hyperplasia (n = 1). VAB resulted in complete excision of four of 10 lesions: two of eight malignancies and two of two benign lesions. Among 21 patients with benign lesions who underwent 6-month follow-up imaging, eight (38%) had a definite residual mass. At 6-month follow-up examination, VAB was seen to have eliminated the palpable abnormality in seven (88%) of eight patients with initially palpable benign masses. Thirty-two patients (94%) described no or mild pain during biopsy, and 33 patients (97%) rated care as excellent. CONCLUSION: After removal of all US evidence of breast masses with a VAB device, there was a substantial probability that residual lesion that was not visualized during the procedure would later be found at surgery or follow-up imaging. A palpable mass (< or =1.2 cm in mean diameter) was eliminated in 88% of cases, and patient tolerance and perceptions of the procedure were favorable.     

Usefulness of mammography and sonography in women less than 35 years of age

Indications, clinical history, mammographic findings, and clinical outcome were reviewed in 1,016 women younger than 35 years who underwent mammography during an 8-year period. The indications for mammography were a palpable mass in 454 (44.7%), findings at routine screening in 237 (23.3%), lumpiness in 29 (14.9%), unilateral nipple discharge in seven (3.5%), localized breast tenderness in six (5.1%), adenopathy in three (1.9%), diffuse tenderness in two (2.9%), bilateral nipple discharge in two (1.5%), and miscellaneous in four (2.2%). In 405 women (39.9%), at least two-thirds of the breast tissue was radiodense; however, in 299 (29.4%) women the breast was predominantly fatty, allowing for excellent mammograms. Six women had carcinomas: Mammographic findings prompted biopsy in one patient, indicated a benign-appearing mass (found to be solid at sonography or aspiration) in three patients with a palpable mass (contributing to delay in biopsy in two), and were negative in two. Sonography was performed in 389 women and was useful in preventing unnecessary biopsy of cysts but was not useful in differentiating benign from malignant solid masses. Younger women with persistent localized breast symptoms should undergo a tailored mammographic examination, but negative findings or findings of a benign lesion should not preclude biopsy of a palpable solid mass.     

Tubulolobular carcinoma of the breast: clinical, mammographic and sonographic findings

PURPOSE: To determine and quantitate radiologic characteristics of tubulolobular carcinoma of the breast and to report clinical and pathologic findings. MATERIALS AND METHODS: A retrospective review of records of 2872 women who received a diagnosis of breast carcinoma between January 1988 and January 2006 revealed 26 histopathologically proven tubulolobular carcinoma of the breast. Analysis included history; findings at physical examination, mammography, and sonography (US) at the time of diagnosis and in postoperative follow-up, and histopathological results. RESULTS: At physical examination, palpable mass was present in 85% (n=22) of the patients. The mammographic findings were mass in 17 (65%), asymmetric focal density in 2 (8%), architectural distortion in 2 (8%) and negative mammograms in 5 (19%) of the 26 patients. US depicted 25 masses in 24 patients, all of which were hypoechoic, with spiculated (n=13) or microlobulated (n=12) margins. The cancer was clinically occult in 12% (n=3), mammographically occult in 19% (n=5), and radiologically occult in 4% (n=1) of the patients. Histologically, the mean size of the tumor was 1.7cm and 18 (69%) patients were node negative. CONCLUSION: Tubulolobular carcinoma of the breast usually manifests clinically as a firm, immobile mass and mammographically as a spiculated or ill-defined, irregular, isodense mass without microcalcifications. Common findings on sonography include a homogeneously hypoechoic, spiculated or microlobulated mass with posterior acoustic shadowing or normal acoustic transmission. Tubulolobular carcinoma should be included in the differential diagnosis for breast masses with these imaging features.     

Benign breast lesions: ultrasound detection and diagnosis

Experience with 2500 patients over age 30 studied by physical examination, x-ray mammography, and sonography enabled definition of several specific clinical situations in which sonography adds meaningful diagnostic information not provided by either of the other examinations. These include: palpable breast masses for cyst-solid differentiation; nonpalpable mammographic masses for cyst-solid differentiation; and women with a symptomatic area in the breast that shows only uniformly dense fibro-glandular tissue on x-ray mammograms. For women with radiographically dense breasts who have no breast symptoms, abnormal physical findings, or mammographic lesions, sonography will identify many benign cysts and also some benign solid lesions, but at best only rarely (none of the 587 cases in this study) will it detect an otherwise occult breast cancer. Our data suggest that sonography should not be a substitute for physical examination and mammography in women over age 30, but rather that in three specific clinical situations it can be a valuable addition to the standard diagnostic evaluation.     

Tubular carcinoma of the breast: mammographic, sonographic, clinical and pathologic findings

PURPOSE: To determine and quantitate the radiological characteristics of tubular carcinoma of the breast, to report clinical and pathologic findings and to define findings at follow-up. MATERIALS AND METHODS: A retrospective review of records of 2872 women who received a diagnosis of breast carcinoma between January 1988 and January 2006 revealed 32 histopathologically proven pure tubular carcinoma of the breast. Analysis included history; findings at physical examination, mammography, and sonography (US) at the time of diagnosis and in postoperative follow-up and histopathological results. RESULTS: Fifty-nine percent of the patients (n=19) presented with a palpable mass. The mammographic findings were a mass in 23 (72%), a mass with microcalcifications in 2 (6%), asymmetric focal density in 1 (3%), architectural distortion in 1 (3%) and negative in 5 (16%) of the 32 patients. Most (96%) masses had spiculated margins. US depicted 30 masses in 29 patients, all of which were hypoechoic, mostly (n=27, 90%) with posterior acoustic shadowing. The cancer was clinically occult in 41% (n=13), mammographically occult in 16% (n=5), and sonographically occult in 6% (n=2) of the patients. Histologically, the tumor was multifocal in 3% (n=1) of the patients. Four (13%) patients developed contralateral breast carcinoma at follow-up. CONCLUSION: Tubular carcinoma has a variety of presentations, but it is mostly seen on mammography as a small spiculated mass, and on sonography as an irregular mass with posterior acoustic shadowing. Although tubular carcinoma is known as a well-differentiated tumor with excellent prognosis, the mammographic follow-up of the contralateral breast is important.     

Follow-up of palpable circumscribed noncalcified solid breast masses at mammography and US: can biopsy be averted?

PURPOSE: To determine whether palpable noncalcified solid breast masses with benign morphology at mammography and ultrasonography (US) can be managed similarly to nonpalpable probably benign lesions (Breast Imaging Reporting and Data System [BI-RADS] category 3)-that is, with periodic imaging surveillance-and to determine whether biopsy can be averted in these lesions. MATERIALS AND METHODS: No institutional review board approval or patient consent was required. This retrospective analysis, based on final imaging reports, included 152 patients (age range, 28-77 years; mean age, 48.3 years) with 157 palpable noncalcified solid masses that were classified as probably benign at initial mammography and US. Of 152 patients, 108 underwent follow-up with mammography and US (6-month intervals for 2 years, then 12-month intervals). The remaining 44 patients underwent surgical or needle biopsy after initial imaging. Lesions were analyzed at initial and follow-up examinations. Statistical analysis included Student t test and corresponding exact 95% confidence intervals. RESULTS: In 108 patients who underwent follow-up only, 112 lesions were palpable. In 102 (94.4%) of 108 patients, masses remained stable during follow-up. Lesions were followed for at least 2 years (mean, 4.1 years; range, 2-7 years). In six (5.6%) patients, palpable lesions increased in size during follow-up; these lesions were benign at subsequent open biopsy. No breast carcinoma was diagnosed in the 44 patients with 45 palpable lesions who underwent biopsy after initial imaging. Of 157 lesions, no malignant tumors were observed (exact one-sided 95% confidence interval: 0%, 1.95%). CONCLUSION: The data strongly suggest that palpable noncalcified solid breast masses with benign morphology at mammography and US can be managed similarly to nonpalpable BI-RADS category 3 lesions, with short-term follow-up (6-month intervals for 2 years). More data, based on a larger series, are required to determine whether this conclusion is correct.     

Multifocal,multicentric, and contralateral breast cancers: bilateral whole-breast US in the preoperative evaluation of patients

PURPOSE: To evaluate the efficacy of preoperative bilateral whole-breast ultrasonography (US) in the detection of additional multifocal, multicentric, and contralateral cancers and the effect of US information on therapeutic decisions. MATERIALS AND METHODS: Two hundred one patients who had newly diagnosed breast cancer or who were suspected of having breast cancer underwent US examination of the ipsilateral and contralateral breasts with a 10-, 12-, or 13-MHz transducer. All solid lesions found at US alone were classified according to level of suspicion and were selected for biopsy. The US results were compared with mammographic findings. Sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: In ipsilateral breasts, US depicted 194 (97%) of 201 foci of invasive cancer and 52 (75%) of 69 foci of ductal carcinoma in situ (DCIS), whereas mammography and physical examination depicted 173 (86%) foci of invasive cancer and 56 (81%) foci of DCIS. In the contralateral breast, US depicted 11 (92%) of 12 foci of invasive cancer and four (57%) of seven foci of DCIS, whereas mammography and physical examination depicted six (50%) foci of invasive cancer and five (71%) foci of DCIS. Overall, US depicted mammographically and clinically unsuspected multifocal or multicentric cancers in 28 patients (14%) and contralateral cancer in eight patients (4%). On the basis of these US findings, therapy was correctly changed in 32 patients (16%). The sensitivity, specificity, and positive and negative predictive values of prospective classification of 77 solid lesions detected at US alone were 100% (36 of 36), 51% (21 of 41), 64% (36 of 56), and 100% (21 of 21), respectively. CONCLUSION: Bilateral whole-breast US complements mammography in the preoperative evaluation of patients with breast cancer.     

Specificity of mammography and US in the evaluation of a palpable abnormality: retrospective review

PURPOSE: To determine the number of patients who received a diagnosis of breast cancer after having an area of clinical concern at presentation and combined negative mammographic and ultrasonographic (US) findings. MATERIALS AND METHODS: During a 4-year period, 829 patients with a palpable abnormality at presentation and combined negative mammographic and US findings were identified. The number of women who went on to receive a diagnosis of breast cancer was determined retrospectively. The authors searched the breast imaging database and the pathology database, sent a contact letter to the referring physicians, and linked their data to the State Cancer Registry. They also analyzed the breast parenchymal density among all patients who had more than 2 years of follow-up. RESULTS: Of the 829 women, 374 had follow-up information. Two-hundred thirty-three patients had negative imaging findings with more than 2 years of follow-up. The other 141 women were presumed to be cancer free, as they were not identified by the State Cancer Registry. Six (2.6%) of the 233 women had a diagnosis of breast cancer in the area of the palpable abnormality. The six cancers were diagnosed among the 156 women who had radiographically dense breast tissue (Breast Imaging Reporting and Data System category 3 or 4). Among the 77 women with predominantly fatty tissues, no cancers were diagnosed. CONCLUSION: A negative mammographic and US finding of a palpable abnormality does not exclude breast cancer, but the likelihood of breast cancer is low, approximately 2.6%-2.7%. It may be higher if the breast tissues are dense and lower if they are predominantly fatty.     

Breast conservation therapy in patients with mammographically undetected breast cancer.

The authors reviewed their experience with 542 patients with breast cancer who were treated with conservative surgery and radiation therapy (CSRT) and analyzed the outcome in those patients whose tumors could not be detected with mammography. Fifty-five of the patients (10.1%) had a palpable, pathologically confirmed breast carcinoma and a negative preoperative mammogram. Routine follow-up included annual mammography and physical examination. The local recurrence, 5-year actuarial survival, and 5-year disease-free survival rates for these 55 patients did not differ significantly from those for patients with positive mammograms. There were six cases of local breast recurrence in this subgroup. Four of five cases were visible on mammograms (one patient did not undergo mammography at the time of recurrence); two of the cases were detected with mammography alone following physical examination with negative results. The authors conclude that patients with palpable but mammographically occult early-stage breast cancer are suitable candidates for CSRT and that mammography is a mandatory part of follow-up of conservatively treated patients.     

Effects of fine-needle aspiration on the US appearance of the breast.

Fine-needle aspiration (FNA) of normal breast tissue or benign lesions can cause changes that suggest malignancy at ultrasound (US) examination. Serial US studies showed that three of 17 patients developed signs mimicking malignancy following FNA of palpable breast lumps. A second group of 14 patients had US signs of malignancy in palpable lumps following recent FNA. Nine patients with benign lesions were unnecessarily worried, since the appearance was probably due to FNA. Diagnosis of malignancy was delayed in one of five patients because the US appearance was attributed to the FNA in the presence of false-negative cytologic findings. FNA of normal breast tissue or benign masses produced tissue changes in 18% of cases that altered the US appearance from normal or benign to possibly malignant. The changes took up to 4 months to subside. If US is clinically indicated, it should be performed before FNA.     

Paget's disease of the breast: clinical, mammographic, sonographic and pathologic findings in 52 cases

PURPOSE: To determine and quantitate radiologic characteristics of Paget's disease of the breast and to report clinical and pathologic findings. MATERIALS AND METHODS: A retrospective review of records of 2872 women who received a diagnosis of breast carcinoma between January 1988 and January 2006 revealed 52 histologically proved Paget's disease of the breast. Analysis included history, findings at physical examination, mammography and sonography (US) and histologic type of Paget's disease. RESULTS: At physical examination, palpable mass (n=33, 63%), nipple erythema-eczema-ulceration (n=17, 33%) and blood-stained nipple discharge (n=5, 10%) were noted. Among 17 patients who had clinically evident Paget's disease, the mammographic findings were isolated microcalcifications in 3 (18%), mass associated with microcalcifications in 5 (29%), mass in 2 (12%) and negative in 7 (41%) patients. In the 35 patients with clinically inevident Paget's disease, these mammographic findings were 43% (n=15), 34% (n=12), 20% (n=7) and 3% (n=1), respectively. US depicted 43 masses in 35 patients, all of which were lobulated or irregularly contoured, mostly (n=41, 95%) without posterior acoustic shadowing. The cancer was clinically occult in 10% (n=5), mammographically occult in 15% (n=8) and radiologically occult in 13% (n=7) of the 52 patients. Histologically, the tumor was multifocal and/or multicentric in 11 (21%) patients. CONCLUSION: The clinical features of Paget's disease are characteristic and should alert the clinician to the likelihood of an underlying carcinoma, which should be evaluated radiologically. However, as Paget's disease is primarily a clinical diagnosis and mammograms may be negative, screening programs without clinical examination may result with delay in diagnosis. As a result, both clinical and imaging findings are complementary and should be correlated to confirm or exclude a diagnosis of Paget's disease.     

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.     

Adnexal masses in women with breast cancer: US findings with clinical and histopathologic correlation

PURPOSE: To correlate ultrasonographic (US), clinical, and histopathologic findings in patients with breast cancer who underwent surgery for adnexal masses evident at US. MATERIALS AND METHODS: A database search yielded 54 patients with breast cancer and with adnexal masses at US and histopathologic examinations. Clinical, US, and histopathologic findings were correlated. RESULTS: Forty (74%) patients had benign adnexal masses, and 14 (26%) had malignant masses; three patients had both benign and malignant ovarian masses. Seven patients had primary ovarian cancer, and seven had breast metastases to the ovary. All breast metastases to the ovary were bilateral solid masses at histopathologic examination and occurred in women with stage IV breast carcinoma at the time of US. Eleven ovaries with breast metastases were solid at US. The remaining three ovaries with breast metastases had cystic components at US because of hemorrhage or coexistent benign ovarian cysts. Four of seven patients with primary ovarian carcinoma had bilateral ovarian tumors, and seven of 11 ovarian carcinomas were predominantly cystic at US. No patient with primary ovarian carcinoma had stage IV breast cancer. CONCLUSION: In this small series, half the ovarian malignancies in patients with breast cancer were primary ovarian carcinomas and half were breast metastases to the ovary. Breast metastases to the ovary most frequently are bilateral solid masses at US and are associated with stage IV disease at the time of US.