The accuracy of breast ultrasound in the evaluation of clinically benign discrete, symptomatic breast lumps

INTRODUCTION

Recent reports have suggested that breast ultrasound (US) is of value in distinguishing malignant from benign processes. The aim of this study was to establish the accuracy of US in detecting invasive malignancy in clinically benign, discrete, symptomatic breast lumps.

METHODS

The US appearances of 205 clinically benign breast masses were documented prospectively and prior to mammography by one radiologist (AJE). The US appearances were then correlated with the fine needle aspiration (FNA), core biopsy and surgical findings and compared with the mammographic findings.

RESULTS

The US findings were normal 72 (35%), simple cyst 63 (31%), solid benign 51 (25%), solid indeterminate 15 (7%) and solid malignant four (2%). Ultrasound characterized 13 (93%) of the 14 patients found to have invasive carcinoma as indeterminate or malignant. No patients with normal or simple cyst US findings had invasive malignancy. Ultrasound had significantly better accuracy (97% vs 87%, P < 0.02) sensitivity (93% vs 57%, P < 0.05) and negative predictive value (99% vs 92%, P < 0.002) than mammography in the detection of invasive carcinoma when indeterminate and malignant imaging findings were taken as positive.

CONCLUSION

US is a useful adjunct to FNA/core biopsy in confirming the nature of symptomatic, clinically benign breast masses and is superior to mammography in this clinical setting.

Screening women aged less than 50 years with a family history of breast cancer

Family history is an important breast cancer risk factor and is a common reason for referral to specialist breast clinics for consideration of breast screening. The aims of this study were to determine cancer detection rates and prognostic features of breast cancers identified in women aged less than 50 years at increased risk of breast cancer who attend a Family History Breast Screening Clinic (FHC). Between January 1988 and December 1995, 1371 asymptomatic women aged less than 50 years underwent annual clinical breast examination and biennial mammography due to a family history of breast cancer. A total of 29 cancers (23 invasive and 6 in situ) were detected or presented as interval cancer during a mean follow-up of 22 months (range 0-96 months). This gave a relative risk for invasive breast cancer in this high-risk group of 5 when compared with an age-matched female population in the U.K. The cancer screening detection rates were similar to those of women aged 50 years or over undergoing population screening in the NHS Breast Screening Programme (NHSBSP)--FHC prevalent screen 8 per 1000 screening visits versus NHSBSP 6.5 per 1000, FHC incident screen 3.3 per 1000 screening visits versus NHSBSP 3.8 per 1000. A higher proportion of in situ cancers were detected in the FHC screened group compared with cancers identified in symptomatic patients from an age-matched risk group (21% versus 4%). No differences were demonstrated for invasive tumour size, grade or lymph node stage between symptomatic and screened women. The early results of this study suggests that young women at risk of breast cancer due to a family history may benefit from regular breast screening due to the early detection of in situ lesions.

The role of ultrasound in breast cancer screening. A consensus statement by the European Group for Breast Cancer Screening

The members of the European Group for Breast Cancer Screening have considered the use of ultrasound in breast diagnosis and breast cancer screening. After wide consultation and a detailed literature review, the consensus of the Group on the role of ultrasound is as follows: current evidence indicates that ultrasound of the breast is an important adjunct to mammography and clinical examination in the further assessment of both palpable and impalpable breast abnormalities. However, the use of ultrasound in population screening of asymptomatic women is associated with unacceptably high rates of both false positive and false negative outcomes. At present there is little evidence to support the use of ultrasound in population breast cancer screening at any age.

Radiological features of papillary carcinoma of the breast

Seventeen patients with papillary carcinoma of the breast were analysed with respect to the radiological findings by three experienced breast radiologists. The most frequent mammographic appearance of papillary tumours was of an ill-defined (70%) and lobulated (60%) mass and at ultrasound as a well-defined (76%), inhomogeneous (62%) and hypoechoic (92%) lesion. Histopathological subtypes of encysted papillary carcinoma, encysted papillary carcinoma with an invasive focus and invasive papillary carcinomas could not be predicted from the radiological features, although invasive tumours tended to be larger at presentation than the other subtypes.

Routine audit of breast fine needle aspiration (FNA) cytology specimens and aspirator inadequate rates

In an attempt to improve the quality of the breast FNA specimens we instigated a continuing audit of this procedure in this hospital. All FNAs since 1990 have had the following recorded: mode of aspiration, e.g. freehand or image guided, patient presentation (screening or symptomatic), patient diagnostic category, cytological diagnosis and final histological diagnosis. Aspirator performance was assessed by means of the inadequate aspiration rate (IR) of FNAs performed on patients with a final diagnosis of cancer (FDC) and diagnostic category A patients (clinically or radiologically malignant lesions). An ongoing annual review of the performance of all the aspirators was undertaken, all of whom received individual feedback. Counselling and further training were offered where indicated by poor performance. Over the period 1990-1995 a total of 13537 FNAs were performed by 27 aspirators. The IR on category A and FDC cases over this period was 16.0% and 18.1%. The best performance achieved by an aspirator in a calendar year was an IR of 3.6% with no inadequate specimens in either FDC or category A lesions, and the best performance over the entire period was an average IR of 11.75% and 14.25% for FDC and category A groups, respectively. The overall IR on category A patients ranged from 15.9% to 23.8% and on FDC cases from 12.2% to 21.7%. There was a significant improvement in individual junior aspirator performance when their first year was compared with their last year on the unit. In some cases a deterioration in intra-aspirator performance was observed, from an IR of 6% to 33%. The overall IR rate of the unit remained stable for FDC patients, 15.5% in 1990 compared with 15.1% in 1995. This appeared to be largely due to a high proportion of the aspirations being performed by experienced personnel with consistent IRs. However, concealed within the overall rate there were some poor performers who benefited from counselling and/or further training. These results indicate an important role for audit in identifying poor aspirators who benefit from targeted training and advice, thereby improving the quality of FNA specimens, and ultimately patient care.

The effect of hormone replacement therapy on recall rate in the National Health Service Breast Screening Programme

PURPOSE

Hormone replacement therapy (HRT) can lead to an increase in the density of breast parenchyma on mammography and to the development of mammographically visible cysts and fibroadenomas. These changes may obscure features indicative of benign processes or mimic those of a carcinoma on screening mammography. This study was designed to assess the effect of HRT usage on the recall rate of women attending for routine breast screening.

METHOD

Details of HRT usage were taken from 5699 consecutive women aged 49-64 attending for breast screening. Mammograms were read without knowledge of HRT usage and recall for assessment details collected.

RESULTS

A significant fall in recall rate was seen between the prevalent and incident screens in women not taking HRT (P < 0.016). This fall was not present in women taking HRT. The recall rate for the incident screen of women on HRT was 37% higher than that for women who did not take HRT; however the positive predive value for cancer of recall was lower at 3.7% compared to 12.9%.

CONCLUSION

These results indicate that the recall rate for incident screening is likely to be higher in women on HRT. This increase in assessment will lead to increased cost and anxiety in the screened population.

The detection of ductal carcinoma in situ at mammographic screening enables the diagnosis of small, grade 3 invasive tumours

This study was carried out to assess the frequency of ductal carcinoma in situ (DCIS) occurring within and surrounding grade 3 invasive tumours and the effect of its detection on size and nodal stage of invasive carcinomas at mammographic detection. Grade 3 tumours with either no associated DCIS or DCIS only within the invasive component were significantly larger in size than tumours with surrounding DCIS (P < 0.02) and were less likely to be under or equal to 10 mm in size (0% or 13% vs 30% respectively, P < 0.02). Tumours with mammographic calcification were more likely to be less than or equal to 10 mm in size than non-calcific tumours (32% vs 11% respectively, P < 0.05). This was because of the high frequency of tumours less than or equal to 10 mm in size in the linear/branching calcification group. Tumours showing calcification without a mass also appear to be a group with good prognostic features, with a mean size of 13 mm, 33% being 10 mm or less in size and only 17% being node positive. We have found that the presence of surrounding DCIS enables earlier detection of grade 3 invasive carcinomas because of the presence of mammographically visible calcification. Detection of calcification suggestive of DCIS should remain an important part of mammographic screening.

The impact of core-biopsy on pre-operative diagnosis rate of screen detected breast cancers

The UK breast screening Surgical Quality Assurance guidelines suggest a target for pre-operative diagnosis of screen detected cancer of over 70%. Core biopsy was introduced in our breast screening assessment clinics in April 1994 and this study reports the impact of introducing core biopsy on the pre-operative diagnosis rate. Between April 1994 and March 1995, 100 cancers were detected. Results of fine needle aspiration cytology and core biopsies were studied to assess the contribution of each to the pre-operative diagnosis rate of cancer and comparison made with results from the previous 2 years. After introducing core biopsy pre-operative diagnosis rates rose from 72% to 90% (P < 0.0002) leading to a 64% reduction in diagnostic biopsies for screen detected cancer. Malignant results were obtained in 61% of first FNA (similar to previous years) and 74% of first core biopsies (combined 87%). Repeat FNA/core diagnosed three further cancers increasing the final pre-operative diagnosis rate to 90%. Final pathological examination after surgical excision demonstrated an increase in the preoperative detection of DCIS from 39% to 82% (P < 0.01) and invasive disease from 80% to 92% (P < 0.02). The introduction of core biopsy has significantly improved our management of screen detected breast cancer.

Pure mucinous breast cancer-mammographic and ultrasound findings

Aim to describe the mammographic and ultrasonographic features of pure mucinous breast cancer.

PATIENTS AND METHODS

The mammographic features of 15 patients and ultrasonographic features of seven patients with pure mucinous breast cancer were reviewed retrospectively by three experienced breast radiologists.

RESULTS

The commonest mammographic appearance was of a poorly defined (86%) lobulated (71%) mass which could contain calcification (14%). A well defined mass (14%) and suspicious calcifications without a mass (7%) were also seen. Ultrasound showed a mass lesion in all seven cases which was either hypoechoic (86%) or mixed echogenicity (14%); 86% had a heterogeneous internal echo pattern; 71% showed distal enhancement while none showed distal attenuation.

CONCLUSION

The imaging features of pure mucinous cancer are different from more common types of breast carcinoma. It is possible to misinterpret the appearances of this slow growing tumour as a benign lesion due to rarity of speculation on mammography and distal attenuation on ultrasonography. Most cases do, however, show other features suggesting malignancy.

Screening interval breast cancers: mammographic features and prognosis factors

PURPOSE

To review the mammographic features of screening interval breast cancers and to compare the tumor size, histologic grade, and lymph node involvement with those in screening-detected and unscreened symptomatic cancers.

MATERIALS AND METHODS

Screening mammography was performed in 72,773 women aged 50-64 years. Ninety interval cancers were identified in 89 women. The mammographic and histopathologic features of these cancers were analyzed.

RESULTS

At review of the screening mammograms, interval cancers were classified into four groups: 51 true-positive, 20 false-negative, seven mammographically occult, and 12 unclassified. The most common missed abnormality in the false-negative cases was architectural distortion. Interval cancers were larger, of higher grade, and more likely to have lymph node involvement than screening-detected tumors and were of similar size, histologic grade, and stage of lymph node involvement as symptomatic tumors.

CONCLUSION

Prognosis in interval cancers is similar to that in symptomatic, unscreened tumors and statistically significantly worse than that in screening-detected cancers.

The positive predictive value of mammographic signs: a review of 425 non-palpable breast lesions

The sensitivity of mammography in cancer detection needs to be high but is also important to achieve a high diagnostic specificity to avoid the morbidity associated with unnecessary surgical biopsy. We have reviewed the mammographic features of non-palpable breast lesions to identify factors which may improve the specificity of mammographic interpretation and reduce the number of open surgical biopsies for benign lesions. Four hundred and twenty-five surgical biopsies of non-palpable breast lesions were performed following image-guided localization between January 1987 and April 1994. The mammographic features of these lesions were reviewed and correlated with their histology. Two hundred and twenty-five of the excised lesions were malignant and 200 were benign giving a benign to malignant ratio of 0.88:1 and a positive predictive value (PPV) for malignancy of 53%. Pre-operative fine needle aspiration cytology was performed in 359 cases (84%). The PPV for the various mammographic abnormalities following the assessment process ranged from 4% for well defined masses to 94% for spiculate masses. The PPV for all microcalcifications was 45%. For impalpable lesions it is our policy to recommend surgical excision of all spiculate masses, parenchymal deformities and high risk microcalcifications. Ill defined masses are managed according to fine needle aspiration cytology (FNAC) and/or core biopsy results. Masses which are entirely well-defined are regarded as benign and are not recalled for assessment unless they are new or enlarging. Needle core biopsy has been added to our preoperative assessment of mammographically indeterminate microcalcifications with the aim of reducing the number of benign surgical biopsies.

Thrombolysis theraphy in patients with femoropopliteal synthetic graft occulsions

BACKGROUND

The aim of this study was to evaluate the efficiency of thrombolysis in the presence of an occluded femoropopliteal synthetic graft.

PATIENTS AND METHODS

Over a 3-year period, 46 occluded femoropopliteral grafts were treated with urokinase and reconstruction. The cases were divided into three groups: group 1 (n=25), complete thrombolysis followed by reconstruction or angioplasty or both; group 2 (n=5), complete thrombolysis alone; and group 3 (n=16), failure of thrombolysis requiring reconstruction or leading to amputation. Patients were completely observed after treatment for more than 1 year.

RESULTS

There are no fatal complications among patients with thrombolytic therapy. In group 1, the 3-year patency rates were 12% and the 3-year limb salvage rates were 77%. In group 2, the 3-year patency rates and the limb salvage rates were 20% and 80%, respectively. The group 3 patency rates and the limb salvage were 8% and 40%, respectively. The best results were achieved in patients who had thrombolysis followed by reconstruction (group 1) and in those who had thrombolysis alone (group 2). limb salvage was poor in patients with failure of lytic therapy regardless of the reconstruction (P<0.01).

CONCLUSION

The use of intra-arterial urokinase followed by secondary vascular reconstructive procedures was studied. The patient with synthetic graft occlusion still has a reasonably favorable prognosis for long-term limb salvage when thrombolysis is successful.

Is ipsilateral mammography worthwhile in Paget's disease of the breast?

AIMS

To identify the clinical value of pre-operative ipsilateral mammography in patients with Paget's disease of the breast.

METHOD

The mammograms and histological data of 27 patients with Paget's disease and 60 patients with symptomatic DCIS without Paget's disease were reviewed and compared.

RESULTS

Forty-four percent of patients with Paget's disease had normal mammograms. Mammography did not discriminate between DCIS and invasive disease, and could not predict DCIS sub-type. DCIS was large cell in 80% of patients with Paget's disease. Given that large cell DCIS in non Paget's patients is normally visible mammographically, the large proportion of Paget's patients with normal mammography is difficult to explain, but could be due to the small size of the lesions. Comparison of the Paget's and non-Paget's groups showed that large cell solid disease was more common, small cell cribriform less common and normal mammography more common in the Paget's group. Given that mastectomy is the treatment of choice, the only clinical value of ipsilateral mammography in our unit would be to allow image guided core biopsy of any detected mammographic abnormalities to determine the presence of invasive disease prior to surgery, thus indicating the need for node sampling pre-operatively rather than as a delayed procedure. This study also confirms that mammography is of little help in deciding if breast conserving surgery is appropriate for individual cases of Paget's disease of the nipple due to the insensitivity of mammography in showing the site of disease.

Case report: fibromatosis of the breast in a male patient

Fibromatosis of the breast is an uncommon disease, although several series of this condition in females have been reported in the literature. We present the first case to be described in a male patient.

Relationship of runoff vessels to results following thrombolysis and revascularization for synthetic graft occlusions

The objective of this study was to evaluate the relation between runoff vessels and the prognosis in patients who have had an occlusion of a previously placed peripheral arterial bypass graft. Over a 4-year period 77 occluded synthetic grafts were treated with urokinase and reconstruction after angiographic study. Follow-up ranged from 1 to 1627 days. The cases were divided into three groups according to the number of patent tibial vessels. Group I consisted of patients who had no vessel runoff. Group II consisted of patients who had single vessel runoff. Group III consisted of patients who had two or three runoff vessels. In Group I, the 1, 2, and 3-year patency rates were 35.8%, 8.9%, and 8.9%; and the limb salvage rates were 50.2%, 40.2%, and 40.2% for 1, 2, and 3 years, respectively. The Group II patency rates were 31.2%, 26.0%, and 13.0% and the limb salvage rates were 72.3%, 62.9%, and 62.9%. The Group III patency rates were 50.0%, 26.1%, and 20.9%; and the limb salvage rates were 93.1%, 79.1%, and 79.1%. There is no statistically significant difference in patency rates among any of the groups. The limb salvage rate was significantly increased in Group III, compared to I (P < 0.01) and Group II (P < 0.05), and in Group II, compared to Group I (P < 0.05). These results indicate that the higher rate of limb salvage in this study statistically correlated with the number of runoff vessels.

Mammographic features of invasive lobular and invasive ductal carcinoma of the breast: a comparative analysis

The mammographic appearances of 86 invasive lobular carcinomas were compared with those of 86 invasive ductal carcinomas of no special type matched for age, size and stage. There was no significant difference in the frequency of a mammographic abnormality consistent with malignancy between the lobular carcinoma (90%) and ductal carcinoma (96%) groups. A spiculate mass was the commonest feature in both groups (69% and 63%, respectively). There were no differences in the imaging features of masses in the two groups. In the lobular carcinoma group any mammographic abnormality was more likely to be seen on only one view and calcifications were less frequently observed. Multiple lesions were more frequent in the ductal carcinoma group. However, although these differences appeared to reach statistical significance, as they were only apparent in a study with a large number of comparisons, it is unlikely that these differences are practically significant. Analysis of the lobular invasive group failed to demonstrate any significant differences in the imaging features of the classical and mixed sub-types, a spiculate mass being the most common single abnormality in both. No mammographic differences of practical use to distinguish invasive lobular from invasive ductal carcinoma of no special type were demonstrated.

Thrombolysis of peripheral graft occlusion in patients with hypertension

The objective of this study was to evaluate the effect of hypertension on the use of thrombolytic therapy in patients with occluded synthetic peripheral bypass grafts. Thrombolysis with urokinase was performed in 44 cases of occluded lower extremity bypass grafts. The cases were divided into two groups: Group I consisted of patients currently being treated for hypertension. Group II consisted of patients without a history of hypertension. A comparison of pre- or intra-lytic data revealed that there was no significant difference in each group. Complications occurred in 15 (32.6%) out of 46 cases. There was no significant increase in complication when the risk factors were compared. In Group I, the one, two, and three year patency rates were 42.7%, 23.0%, and 7.7% and the limb salvage rates were 93.3%, 73.9%, and 73.9% for one, two, and three years respectively. The Group II patency rates were 70.6%, 41.6%, and 41.6% and the limb salvage rates were 94.1%, 86.9%, and 86.9%. The patency rate was significantly reduced when Group I was compared to Group II (p < 0.05). There was no statistically significant difference in limb salvage rates between Groups I and II. In conclusion, hypertension is one of the important risk factors that reduce the patency rate after thrombolytic therapy in patients with peripheral arterial bypass graft.

ABC of breast diseases. Screening for breast cancer

Images

The radiological appearances of invasive cribriform carcinoma of the breast. Nottingham Breast Team

Invasive cribriform carcinoma (ICC) of the breast is characterized by a cribriform histological architecture. It is rare, accounting for 0.6% of breast cancers in Nottingham and has an excellent prognosis. Its radiological features have not been previously described. Preoperative mammograms were available in eight cases (6 symptomatic, 2 screen-detected) and preoperative ultrasound examinations in four. The tumour was mammographically occult in four (50%) cases. The four tumours which were visible on mammography all showed as a large (20-35 mm) spiculated mass and two contained a few flecks of punctate calcification. The ultrasound appearances were not entirely typical of breast carcinoma. Three of four showed an ill-defined, inhomogeneous solid mass, but without the distal acoustic attenuation found in 60-97% of other forms of breast carcinoma. We conclude that ICC has imaging characteristics distinct from tubular carcinoma, which is its closest histological analogue.

Correlations between the mammographic features of ductal carcinoma in situ (DCIS) and C-erbB-2 oncogene expression. Nottingham Breast Team

PURPOSE

C-erbB-2 oncogene expression is found in 60% of DCIS cases. C-erbB-2 expression in DCIS has been shown to correlate with comedo subtype, large cell size, lymphoid infiltrate, nuclear pleomorphism, multinucleation and high mitotic rate. These findings have led to the suggestion that the subgroup of DCIS that expresses c-erbB-2 may be a biologically definable category with prognostic significance. The purpose of this study was to identify any differences in the mammographic appearances between DCIS which expresses c-erbB-2 and DCIS that does not express this oncogene.

MATERIALS AND METHODS

C-erbB-2 staining characteristics and preoperative mammograms were available for review in 126 patients with pure DCIS. All the mammograms were reviewed by a radiologist knowing the patient had DCIS but without any further pathological or immunohistochemical information.

RESULTS

C-erbB-2 positive DCIS showed the following features more commonly than c-erbB-2 negative disease: calcification (65 of 71 (92%) vs 28 of 39 (72%), P < 0.01), ductal distribution of calcification (51 of 65 (78%) vs 16 of 28 (57%), P < 0.05), rod-shaped calcification (53 of 65 (82%) vs 15 of 28 (54%), P < 0.01) and granular calcification (63 of 65 (97%) vs 24 of 28 (86%), P < 0.05). C-erbB-2 negative DCIS more commonly showed an abnormal mammogram without calcification than c-erbB-2 positive disease (11 of 39 (28%) vs 6 of 71 (8%), P < 0.01).

CONCLUSION

We have demonstrated significant differences in the mammographic features of c-erbB-2 positive and negative disease. As c-erbB-2 expression has been shown to correlate with aggressive histological features, the differences in the mammographic appearances between c-erbB-2 positive and c-erbB-2 negative DCIS may be of practical value.

Evaluation of multiple vascular reconstructive procedures with synthetic graft occlusions

The objective of this study was to evaluate the efficiency of multiple vascular reconstructive procedures in the presence of an occluded synthetic graft. Over a four year period seventy-seven occluded synthetic grafts were treated with urokinase and reconstruction. Follow-up ranged from 1 to 1627 days (4 years, 5 1/2 months). Kaplan-Meier and generalized Wilcoxon test were used to determine patency and limb salvage rates. The cases were divided into three groups according to the number of previous reconstructive events. Group I consisted of patients that had undergone one previous vascular reconstructive procedure. Group II consisted of patients that had undergone two previous vascular reconstructive procedures. Group III consisted of patients who had undergone three or more previous reconstructive procedures. In Group I, the one, two, and three year patency rates were 48.6%, 34.7%, and 26.0% and the limb salvage rates were 76.2%, 67.9%, and 67.9% for one, two, and three years respectively. The Group II patency rates were 41.9%, 24.4%, and 16.3% and the limb salvage rates were 73.7%, 66.3%, and 66.3%. The Group III patency rates were 31.8%, 5.5%, and 5.5% and the limb salvage rates were 76.6%, 54.8%, and 54.8%. The patency rate was significantly reduced when Group III was compared to Group I (p < 0.01). There was no statistically significant difference in limb salvage rates between any of the groups. These results indicate that the number of secondary vascular reconstructive procedures combined with thrombolysis had no correlation with the prognosis of limb salvage.(ABSTRACT TRUNCATED AT 250 WORDS)