Benign adenomatous kidney neoplasms in children with polycythemia: imaging findings

PURPOSE

To correlate pathologic, computed tomographic (CT), and ultrasound (US) characteristics of nephrogenic adenofibromas and embryonal adenomas (uncommon pediatric renal tumors) in children.

MATERIALS AND METHODS

Medical records and imaging and pathologic findings were reviewed in three children (aged 6 1/2, 7, and 11 years) with adenomatous renal tumors and polycythemia. Specimens were reviewed at the National Wilms Tumor Study Pathology Center (Loma Linda, Calif).

RESULTS

All tumors were smaller than 3 cm in greatest dimension. They were hyperechoic on US scans and had high attenuation on unenhanced CT scans. Two patients underwent nephrectomy for initial diagnosis of Wilms tumor. The third underwent local excision. At pathologic examination, embryonal-appearing adenomatous epithelial cells were found to form tubules and papillae with abundant psammomatous calcifications. Two masses were classified as embryonal adenomas and one as nephrogenic adenofibroma.

CONCLUSION

Increased attenuation on CT scans and increased echogenicity on US scans of renal adenomatous tumors are distinctive findings that may reflect the presence of tubulopapillary structures and psammomatous calcifications.

[Transvaginal ultrasonography and nuclear magnetic resonance. Comparison of techniques in the evaluation of ovarian lesions]

A total of 53 patients were included in this study, aged between 21 and 72 years old and hospitalised with the diagnosis of ovarian tumour. All patients underwent a clinical examination, ultrasonography and NMR prior to surgery. The findings of ultrasonography and NMR were correlated with histological results in order to evaluate the value of these methods in the differential diagnosis of benign and malignant ovarian tumours. Histological tests revealed 46 benign tumours, 3 borderline cases and 4 malignant growths. Transvaginal ultrasonography revealed precisely 47 out of 53 ovarian tumours, and NMR 49 out of 53. The main limitation of both techniques was the tendency to overestimate ovarian lesions (specificity: ultrasonography 89%, NMR 93%). As far as concerns the identification of malignant lesions NMR does not appear to offer significant advantages in comparison to ultrasonography (sensitivity 85% ultrasonography = NMR).

Doppler sonography of adnexal masses: the predictive value of the pulsatility index in benign and malignant disease

OBJECTIVE

The purpose of this study was to determine whether pulsed Doppler sonography can be used to distinguish between benign and malignant adnexal masses on the basis of pulsatility index.

SUBJECTS AND METHODS

In an 18-month period, all patients in whom an adnexal mass was detected at sonography had further evaluation of the mass by color and pulsed Doppler sonography. Ninety-nine patients with 102 masses that were surgically removed were included in the study. The pulsatility indexes were calculated from the reproducible spectral waveforms generated from flow centrally or peripherally within or immediately adjacent to the mass. Each lesion was categorized on the basis of its gray scale morphologic features as typically benign or indeterminate/malignant in appearance.

RESULTS

Of the 102 adnexal masses, 89 were benign and 13 were malignant. In seven of the 89 benign lesions, no flow could be detected, and these were excluded from analysis. Of the remaining 82 benign lesions, 65 showed pulsatility indexes consistently equal to or greater than 1.0, and 17 showed pulsatility indexes of less than 1.0. Ten of the 13 malignant lesions had pulsatility indexes consistently less than 1.0, and three primary malignant tumors had their lowest pulsatility indexes ranging between 1.1 and 1.8. Sixty-five of the 68 masses with pulsatility indexes equal to or greater than 1.0 were benign, for a positive predictive value of 96% for benign disease. Ten of the 27 masses with pulsatility indexes of less than 1.0 were malignant, for a positive predictive value of 37% for malignant disease. Forty-five masses were detected in perimenopausal and postmenopausal patients. In this group, the pulsatility index had a positive predictive value of 88% for benign disease and 47% for malignant disease. In this study, 45 of 49 masses that had a typically benign sonographic appearance had pulsatility indexes equal to or greater than 1.0. All 49 masses had benign histology. In the remaining 46 masses with an indeterminate/malignant sonographic appearance, 20 of 23 with pulsatility indexes equal to or greater than 1.0 were benign, and 10 of 23 with pulsatility indexes of less than 1.0 were malignant.

CONCLUSION

Our results show a high positive predictive value of high-impedance flow in benign adnexal disease and a predominance of low-impedance flow in malignant adnexal disease. However, the pulsatility indexes showed considerable overlap between benign and malignant lesions, indicating that Doppler sonography has severe limitations in the differentiation of benign from malignant adnexal disease on the basis of low-impedance flow (pulsatility index < 1.0).

Endovaginal sonographic appearance of benign ovarian masses

This article illustrates the different appearances of benign ovarian and paraovarian masses at endovaginal sonography. A retrospective study was performed of the records for 118 patients with 140 surgically proved benign adnexal masses, including dermoid cysts (n = 27), endometriomas (n = 40), epithelial inclusion cysts (n = 14), serous cystadenomas (n = 11), mucinous cystadenomas (n = 14), fibromas (n = 11), cystadenofibromas (n = 12), paratubal cysts (n = 5), hydrosalpinges (n = 3), and tubo-ovarian abscesses (n = 3). Preoperative diagnosis was made in 96% of the dermoid cysts on the basis of a hyperechoic attenuating component or multiple small horizontal interfaces and in 100% of uncomplicated fibromas on the basis of a hypoechoic attenuating mass. There was an overlap among the endovaginal sonographic appearances of the other condition.

Oxygenation of mammary tumors as evaluated by ultrasound-guided computerized-pO2-histography

The average pO2 in breast carcinomas in situ is significantly lower than that in the normal breast tissue. The mean pO2 value for benign breast tumors is significantly higher than that of the breast cancers but lies significantly lower than the corresponding normal breast. No significant differences are found in the mean pO2 values when comparing cancers of different stages and histology. A decrease in the mean pO2 value is measured from the periphery to the center of the breast tumors investigated. The average pO2 values for pre- and postmenopausal patients differ significantly. The described method provides a reliable assessment of tissue pO2 in situ with a minimum of discomfort. Due to extensive inter tumor heterogeneity, prediction of pO2 values for tumors of same stage and same histology is not possible, so that measurement of individual tumor is mandatory for determining therapy response.

Breast diseases: color Doppler US in differential diagnosis

PURPOSE

To subjectively and semiquantitatively evaluate color Doppler signals on images of breast lesions.

MATERIALS AND METHODS

A 5-MHz ultrasound (US) system was used to examine 210 new breast lesions. Signals were evaluated subjectively with an analog scale. A semiquantitative scoring system involved analysis of the average number of vessels per square centimeter and average density of color pixels.

RESULTS

Vessels were detected in 57 of 58 cancers (mean, 0.11 vessels per square centimeter, occupying 1.76% of the scan area). Color Doppler scores had no correlation with conventional prognostic indicators such as lymph node status or survival. Fewer vessels per square centimeter (mean, 0.06) occupying a smaller area (mean, 0.41%) were detected in the five fibroadenomas (n = 36) that showed color Doppler signals. Most cases (99 of 104 [96%]) of benign breast changes had no color Doppler signals.

CONCLUSION

Color Doppler signals in a lesion otherwise thought to be benign should prompt a biopsy, while the absence of signals in an indeterminate lesion is reassuring.

[Whole body positron emission tomography in breast cancer]

The value of whole body positron emission tomography using F-18 2-deoxy-2-fluoro-d-glucose in primary work-up and follow-up was prospectively evaluated in 37 patients with primary or metastatic breast cancer. From 20 primary breast masses 15 from 16 malignant and 4 from 4 benign lesions confirmed by biopsy, were detected. In 3 out of 21 patients in correlation to morphologic imaging, respectively biopsy, no metastatic disease was not identified. Generally speaking, whole body positron emission tomography appears to be a suitable diagnostic staging tool in breast cancer.

[The value of ultrasonography in benign breast diseases]

In recent years breast scans have been widely used for the precise diagnosis of breast cancer. However, the value of this diagnostic tool is debatable in comparison to mammography in women of a childbearing age who often present a dense youthful breast. The role of clinical examination as a screening process is also examined. In the light of these findings the Authors evaluated the role played by ultrasonography in breast cancer, and in particular benign breast tumours, in a group of outpatients attending the clinic. The technique used was relatively simple: the scan in the department used for gynecological and obstetrical ultrasonography was fitted with a 5 MHz probe and was used to perform all the scans. In addition, a Kiteco space maintainer was used for ultrasonography of soft tissue. Scans were performed at a distance of 0.5 cm. The Authors examined 107 patients with benign breast tumours using ultrasonography. They evaluated the morphology, dimensions, edges and internal echo-structure of pathological formations and adjacent areas. The value of breast ultrasonography emerges from an analysis of the results both in the study of the glandular structure and in the differentiation between cystic and solid type lesions which are not always diagnosed during clinical examination. A total of 59 fibroadenoma, 44 cysts, 2 lipoma and 2 phylloids were diagnosed. Fibroadenomas had smooth edges in 98.4% of cases and were lobulate in 1.6%. In 100% of cases the fibroadenomas diagnosed presented fine internal homogeneous echoes with a lower echogenicity than that of surrounding glandular tissue.(ABSTRACT TRUNCATED AT 250 WORDS)

[The echo-dense edge and hyper-reflective spikes: sensitive criteria for malignant processes in breast ultrasound]

At the Department of Gynaecology of the RWTH-Aachen, 110 patients with palpatory and/or mammographic suspect findings were sonographically examined. By using a high resolution 10 MHz-probe with a freely mobile transducer, a new method of differential diagnostic criteria was established, pertaining to the edge of the tumour. The high echogenetic halo and the hyperdense spikes proved to be most important differential diagnostic tools in assessing sonographically suspect tumours.

An improved technique for needle localized biopsy of occult lesions of the breast

The current retrospective study reports the results of the 98 outpatient procedures using a modified version of needle localized excisional biopsies of occult lesions of the breast at a community hospital. Intraoperative fluoroscopy is used to direct a second needle placement along the dissection tract to localize more accurately the intraglandular lesion. The medical records of 88 patients who underwent this procedure between 1989 and 1991 were reviewed. A detailed description of the procedure used as well as clinical data from roentgenographic, histologic and operative reports are given. Benign histologic findings were reported in 80.6 percent of the instances, with fibrocystic disease accounting for most (66 of 79) of the benign diagnoses. Primary malignancy was found in 18 biopsies, with noninfiltrating ductal carcinoma being the most prevalent (n = 8). Infiltrating ductal carcinoma was found six times, infiltrating lobular carcinoma was found three times and a combination of noninfiltrating ductal and noninfiltrating lobular carcinoma was found once. Metastasis to axillary lymph nodes was found twice. One lesion of the breast was large cell lymphoma. Mass lesions accounted for 46 of the 98 lesions and calcifications accounted for the remaining 52. Thirteen of the 18 primary lesions that proved to be malignant presented as calcifications, whereas five presented as a mass. Infiltrating carcinoma, however, was more likely to be associated with mass lesions than with calcifications--all five malignant mass lesions were infiltrating, whereas of the 13 lesions with calcifications, four were infiltrating. Failure to confirm the removal of the lesion roentgenographically occurred once, but there were no other complications to this technique. Additionally, a circumareolar incision was used in 64.7 percent of the procedures and 76.5 percent of the procedures were done using local anesthesia and intravenous sedation. We conclude that the technique introduced herein is a simple, highly reliable means to localize accurately nonpalpable lesions of the breast using a combination of fluoroscopy and needle localization that allows a better cosmetic result.

Breast ultrasonography

Ultrasound of the breast has a role both as the primary and as an ancillary modality in the work-up of breast abnormalities. Its main role is to differentiate cystic from solid abnormalities and to thereby guide further work-up and intervention. Only the diagnosis of a simple cyst will obviate the need for further evaluation or therapy. Doppler ultrasonography of breast lesions may give further information in the future, although this is currently not employed in clinical practice. Various types of ultrasound examinations may yield useful information in the patient with breast cancer or in women with breast prostheses.

[Ultrasonic examination of the breast]

Ultrasonography can be a valuable adjunct to mammography in the evaluation of breast pathology. Breast sonography can differentiate a cyst from a tumour. Fibroadenomas and carcinomas can often present characteristic ultrasonic features but, as a rule, ultrasonography does not give a confident diagnosis of benign or malignant tumour. Ultrasound-guided needle biopsies and preoperative localization of non-palpable lesions can be performed. Breast sonography should be regarded as an adjunct to mammography. The practical role of ultrasonography in a breast-imaging centre will depend on the quality of the triple diagnostics.

Enlarging fibroadenoma in a postmenopausal woman: case report

The authors describe mammographic and pathologic evidence of the growth of a fibroadenoma in an 82-year-old obese woman, 44 years after menopause, who had never been treated with hormone therapy. The patient's obesity is hypothesized as the causal factor for increased estrogen levels leading to growth of the fibroadenoma.

Enlarging occult fibroadenomas

From July 1, 1989, through June 30, 1991, 1,218 preoperative wire-localization breast biopsies were performed at one institution. In this group, 254 (21%) of the abnormalities were fibroadenomas, 26 of which had enlarged or developed in the interval between routine or short-interval follow-up mammography. This interval growth was noted in 21 premenopausal women and in five who were postmenopausal and receiving oral estrogen supplementation.

Ultrasonic attenuation in fibroadenoma of the breast

Fifteen patients are described who attended out Breast Screening Programme, and were found to have sclerosed fibroadenomas, the imaging of which raised the possibility of carcinoma. In six of these a reflective zone between a mass lesion and distal acoustic shadowing might have been used to infer the benign diagnosis.

Pathologic correlation in mammographically directed breast biopsies

In a series of 1137 diagnostic breast biopsy specimens in a 2-year period, nearly half (n = 534) underwent specimen mammography. Calcifications were found in 48% of the specimen mammograms. In a quarter of the cases, calcification was a marker either for carcinoma or a significant precursor lesion. Moreover, in the majority of these malignancies, calcifications were markers of preinvasive carcinoma. In another quarter of cases, some form of proliferative ductal hyperplasia accounted for calcifications, and in the remainder, cysts and miscellaneous other conditions accounted for calcifications. The yield of malignancy was much lower in noncalcified specimens (12%). A nodular or asymmetric density proved to be a fibroadenoma in 30% of cases. However, the majority of cases had less well-defined changes, probably representing some form of lobular fibrosis. We found submission of a duplicate specimen mammogram with the breast biopsy specimen to pathology to be a significant adjunct to correlation. The abnormal area is marked on the mammogram by the radiologist for the pathologist. This is particularly helpful for localizing noncalcified stromal abnormalities. Calcifications are most easily and reliably isolated by serial slicing and performing another radiograph of the slices.

[Doppler ultrasound differentiation of benign and malignant breast tumors]

Before surgery we studied the blood flow in and around 59 breast tumours (35 malignant and 24 benign) and investigated a correlation with the histology. The most decisive factors were the maximum end-diastolic frequency B (probability greater than magnitude of z = 0.0009) and the mean frequency F mean (probability greater than magnitude of z = 0.0017). The maximum systolic frequency A, the resistance index Ri, the diastolic angle W and the pulsatility index Pi showed less significant differences between malignant and benign histological types. In a retrospective survey, we tried to confirm the definitive histology by our Doppler results. In this, we failed in 17.14%--of malignant cases and in 33.33% in the cases of benign tumours.

MR imaging of the breast with Gd-DTPA enhancement: comparison with mammography and ultrasonography

The accuracy of MR imaging with Gd-DTPA enhancement was compared with mammography and ultrasonography in 52 patients with clinically palpable benign and malignant breast masses (36 carcinomas, 2 malignant phyllodes tumors, 7 fibroadenomas, 7 cysts). On dynamic MR imaging, carcinomas and fibroadenomas were discriminated by their different dynamic enhancement profiles. In carcinomas, signal intensity increased rapidly, reaching a peak or plateau within 2 min after the injection of contrast medium. In fibroadenomas, signal intensity showed a much slower continuous increase without ceasing until about 8 min after injection. Malignant phyllodes tumors showed a dynamic enhancement profile identical to that of benign fibroadenomas. MR imaging correctly identified 84% of malignant tumors, 86% of fibroadenomas, and 100% of cysts, and was substantially more accurate in tissue characterization than mammography. The results of ultrasonography were highly similar to those of MR imaging. However, no single modality was infallible, and the three modalities were complementary rather than competitive. Considering the high cost and long examination time of MR imaging, mammography supplemented by ultrasonography seems to be the method of choice in the diagnosis of breast lesions. Nevertheless, MR imaging can add important information when the results of mammography and ultrasonography are insufficient or contradictory.

Ultrasound tissue characterization of breast biopsy specimens

Results of measurements of ultrasound speed and absorption coefficients in the range 3 to 8 MHz in breast tissues at 37 C are reported and analyzed in attempts to identify a set of ultrasound parameters capable of discriminating normal, benign, and malignant tissues. We analyzed 118 tissue regions, comprising 47 normal, 55 benign, and 16 malignant by straight-line fitting of frequency dependence of attenuation. Data for ten additional regions, for a total of 128, became available and were added to the cohort when we subsequently fitted quadratic curves. Sound speed consistently emerged as the variable with greatest discriminating power, particularly for separating normal from benign and malignant tissue. Great difficulty was encountered in discriminating benign from malignant, even when the jackknife technique was used. More success was found with classification and regression trees (CART), although results were sensitive to assigned misclassification costs. Best results from straight-line fits were obtained when discriminating malignant from combined normal/benign data after randomly assigning 75 percent of the data to the learning set and 25 percent to the test set. Then, 23 out of 25 normal/benign and 4 out of 4 malignant cases in the test set were correctly classified. With quadratic fitting, best results were obtained in the three-class case--the false positive rate for malignancy was reduced to zero in the learning (0/31) and test (0/10) sets. Nevertheless, the false negative rate increased to 13 out of 31 (42 percent) in the learning set, while attaining zero (0/4) in the test set.

[Importance of early diagnosis in the improvement of prognosis in breast carcinoma: non-palpable lesions. Preliminary results]

There are still marked differences in the current indications for breast screening proposed by the various international school of oncology. Epidemiological data to the effect that breast screening in asymptomatic women aged over 50 reduces the death rate due to breast cancer now appears to be widely accepted, but an analogous finding for women aged between 40-49 has not yet been confirmed. Following a brief analysis of the most important breast screening programmes carried out to date, the Authors report the preliminary results regarding the identification and biopsy of non-palpable breast lesions during the course of a screening programme in 1986 by the Dept. of Cancer Surgery. Of a total of 1128 breast scans in asymptomatic patients aged between 40 and 73, 24 suspect (1.9%) non-palpable lesions were found of which 5 (20.8%) proved to be carcinomas.

The predictive value of needle localization mammographically assisted biopsy of the breast

This study was done to review critically the experience at the University of California at San Diego in needle localization mammographic biopsy of the breast with regard to use and accuracy in identifying early carcinoma of the breast. Ninety-seven patients underwent needle localization mammographic biopsy of the breast between 1985 and 1987. Indications for this procedure included the presence of microcalcifications or a mass shown on mammographic examination, or both, in conjunction with physical examination which did not define a discrete abnormality in the area. Mammographic, demographic, pathologic, hormone receptor data and staging information were recorded and processed on the MicroVax II computer (Digital Equipment Corporation). Twenty-four per cent of lesions with needle localization mammographic assisted biopsy proved to be malignant. Sixteen lesions were diagnosed as an infiltrating ductal carcinoma and ten of these had an accompanying intraductal carcinoma. Over-all, intraductal carcinoma was present in 16 of the 23 specimens diagnosed as malignant. At biopsy, the margins were clear in 17 of 23, and vascular invasion was present in only one patient with an infiltrating lobular carcinoma. Five were tumor in situ, 12 were stage 1 and five were stage 2 (staging information was not available in one instance). Hormone receptor data were available in 17 of 23 specimens. Estrogen receptors were positive in 13 and progesterone receptors were positive in six. The smallest preinvasive malignant lesion was 4 millimeters, as seen on the mammogram, and the smallest free-standing invasive lesion was 8 millimeters. Preinvasive lesions (intraductal) presented as microcalcifications in 80 per cent. Invasive lesions presented as either a mass (n = 9) or as a mass and microcalcifications (n = 5) in 81 per cent. All five lesions presenting as both a mass and microcalcifications on mammogram proved to be malignant. Multifocal lesions on mammographic examination which proved to be malignant were multifocal pathologically in only 50 per cent. Needle localization mammographic biopsy is useful in detecting early carcinoma of the breast. Biopsy should be done on lesions presenting on mammogram as both a mass and microcalcifications and not observed. Focality of lesions on mammogram does not correlate with focality on biopsy and may be misleading as criteria for operative planning.