Mammographic features and correlation with biopsy findings using 11-gauge stereotactic vacuum-assisted breast biopsy (SVABB)

Stereotactic breast biopsies: Radiological-pathological concordance in a South African referral unit

Background: Stereotactic breast biopsies have become the gold standard for tissue diagnosis in non-palpable, sonographically occult breast abnormalities seen on mammogram. Only limited data exist in South Africa on the correlation between imaging findings and stereotactic biopsy histology.Objectives: To describe the mammographic findings and histological diagnosis in patients who underwent stereotactic breast biopsy at a referral hospital. In addition, to evaluate the proportion of malignancy in each Breast Imaging Reporting and Data System (BI-RADS) category.Method: A retrospective review of stereotactic breast biopsies was performed. Imaging characteristics (including BI-RADS category) and histological diagnosis were recorded. Using histopathology, cases were classified as benign, high-risk or malignant.Results: A total of 131 biopsies, from 123 patients, were included in the study. Most biopsies were performed on asymptomatic patients (79.3%, 104/131). The majority were categorised as BI-RADS 4 and demonstrated calcifications. Histology revealed a malignant diagnosis in 40 (30.5%) patients, a high-risk lesion in 8 (6.1%) patients and a benign diagnosis in 83 (63.4%) patients. There was a stepwise increase in the proportion of malignancy from BI-RADS category 3 to 5. When compared with surgical histology, the stereotactic biopsies demonstrated an overall ductal carcinoma in situ (DCIS) underestimation rate of 10.3%.Conclusion: Despite resource restrictions, stereotactic breast biopsies performed in a South African context produce radiological-pathological concordance in keeping with BI-RADS guidelines, as well as with local and international studies.

The diagnostic value of MRI for architectural distortion categorized as BI-RADS category 3-4 by mammography

BACKGROUND

Architectural distortion is a common mammographic sign that can be benign or malignant. This study investigated the diagnostic value of magnetic resonance imaging (MRI) for architectural distortions that were category 3-4 under the breast imaging reporting and data system (BI-RADS) by mammography.

METHODS

We retrospectively analyzed 219 pathologically confirmed lesions in 208 patients who had BI-RADS category 3-4 architectural distortion in mammography images. Two radiologists described and categorized the architectural distortion and assigned the BI-RADS categories to the corresponding lesions on MRI images. Using the postoperative pathological diagnosis as the gold standard, we performed receiver operating characteristic (ROC) analysis for the efficacy of mammography and MRI in differentiating patients with benign or malignant lesions.

RESULTS

Totally 151 benign lesions and 68 malignant lesions were confirmed. According to the full-field digital mammography (FFDM), 82 lesions were in BI-RADS category 3, 104 lesions in 4A, 29 lesions in 4B, and 4 lesions in 4C. The positive predictive values of FFDM for BI-RADS categories 3, 4A, 4B, and 4C were 13.4% (11/82), 27.9% (29/104), 82.8% (24/29), and 100.0% (4/4), respectively. According to MRI, 59 lesions were in BI-RADS categories 1-2, 87 lesions in 3, 39 lesions in 4, and 34 lesions in 5, with their positive predictive values being 0.0% (0/58), 2.3% (2/87), 89.7% (35/39), and 100.0% (34/34), respectively. The area under the ROC curve (AUC) of breast benign and malignant lesions differentiated by FFDM was 0.647, and the diagnostic sensitivity, specificity, and Youden index were 86.3%, 41.7%, and 0.280, respectively. The AUC of FFDM combined with dynamic contrast-enhanced MRI (DCE-MRI) in differentiating breast benign vs. malignant lesions was 0.851, and the diagnostic sensitivity, specificity, and Youden index were 89.2%, 80.7%, and 0.699, respectively. The AUC of FFDM combined with DCE-MRI and the apparent diffusion coefficient (ADC) in differentiating benign vs. malignant lesions was 0.983, and the diagnostic sensitivity, specificity, and Youden index were 98.1%, 97.5%, and 0.956, respectively.

CONCLUSIONS

MRI can improve the diagnostic efficiency of mammography in diagnosing BI-RADS category 3-4 architectural distortions and can help in the qualitative diagnosis of architectural distortion lesions.

Evaluation of the positive predictive value (PPV3) of ACR BI-RADS category 4 and 5 based on the outcomes of Invasive Diagnostic Office in an outpatient clinic

PURPOSE

The American College of Radiology (ACR) BI-RADS classification is the applicable for breast lesion assessment. BI-RADS categories 4 and 5 need to be followed by biopsy. The aim of our study was to evaluate the tissue biopsy-proven positive predictive value (PPV3) for BI-RADS 4 (and its subcategories) and for BI-RADS 5, and BI-RADS distribution, in comparison to ACR assumptions and literature.

MATERIAL AND METHODS

We retrospectively analysed biopsies performed in our outpatient clinic in 2017. Our target group of patients consisted of 797 patients at the average age of 52 years.

RESULTS

BI-RADS 5 constituted 12% of cases (95 cases), and BI-RADS 4 88% (698 cases). Within BI-RADS 4 subdivisions there were 359 cases in 4a (45.3%), 215 in 4b (27%), and 124 in 4c (15.6%). Overall PPV3 was 34.8%. BI-RADS 5 category PPV3 number was 97.89%. In category BI-RADS 4 the values of PPV3 equalled 26.22% without subdivision and 3.6%, 27.9%, and 88.7% for subcategories BI-RADS 4a, 4b, and 4c, respectively.

CONCLUSIONS

BI-RADS categorisation by radiologists in the studied group matches the literature data according to achieved PPV and BI-RADS percentage distribution. The stratification of cancer risk among categories was proven with Mann-Whitney U test p value < 0.005. There was a statistically important unaccepted difference of PPV3 between core biopsy and vacuum-assisted biopsy, which needs further investigation.

Evaluation of an Automated Information Extraction Tool for Imaging Data Elements to Populate a Breast Cancer Screening Registry

Breast cancer screening is central to early breast cancer detection. Identifying and monitoring process measures for screening is a focus of the National Cancer Institute's Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) initiative, which requires participating centers to report structured data across the cancer screening continuum. We evaluate the accuracy of automated information extraction of imaging findings from radiology reports, which are available as unstructured text. We present prevalence estimates of imaging findings for breast imaging received by women who obtained care in a primary care network participating in PROSPR (n = 139,953 radiology reports) and compared automatically extracted data elements to a "gold standard" based on manual review for a validation sample of 941 randomly selected radiology reports, including mammograms, digital breast tomosynthesis, ultrasound, and magnetic resonance imaging (MRI). The prevalence of imaging findings vary by data element and modality (e.g., suspicious calcification noted in 2.6% of screening mammograms, 12.1% of diagnostic mammograms, and 9.4% of tomosynthesis exams). In the validation sample, the accuracy of identifying imaging findings, including suspicious calcifications, masses, and architectural distortion (on mammogram and tomosynthesis); masses, cysts, non-mass enhancement, and enhancing foci (on MRI); and masses and cysts (on ultrasound), range from 0.8 to1.0 for recall, precision, and F-measure. Information extraction tools can be used for accurate documentation of imaging findings as structured data elements from text reports for a variety of breast imaging modalities. These data can be used to populate screening registries to help elucidate more effective breast cancer screening processes.

Adjunctive targeted contrast-enhanced ultrasonography for the work-up of Breast Imaging Reporting and Data System category 3 and 4 lesions

INTRODUCTION

The assessment and management of Breast Imaging Reporting and Data System category 3 and 4 lesions (BI-RADS 3 and 4 lesions respectively) present numerous challenges for breast radiologists and physicians due to the ambiguity in the classification guidelines. Different imaging modalities have been investigated for their ability to provide additional aid in classification and management. The aim of this study was to evaluate the utility of targeted contrast-enhanced ultrasonography (CEUS) as an adjunctive modality to mammography plus conventional ultrasound (MG + US) in the decision of whether further diagnostic work-up is needed for BI-RADS 3 and 4 lesions.

METHODS

A total of 37 MG + US-detected BI-RADS 3 lesions and 60 MG + US-detected BI-RADS 4 lesions were analysed by targeted CEUS and biopsied. The effectiveness of CEUS in distinguishing benign from malignant entities among the breast lesions was evaluated by using the histological results of biopsied samples as the gold standard.

RESULTS

Two BI-RADS 3 and 14 BI-RADS 4 lesions were diagnosed as true-positive findings by targeted CEUS, with negative predictive values (NPVs) of 100% and 89.2% respectively.

CONCLUSIONS

Owing to the high NPV of targeted CEUS, a negative diagnosis of MG + US-detected BI-RADS 3 lesions by targeted CEUS can be helpful in avoiding unnecessary biopsies. However, targeted CEUS cannot be used to exclude patients with BI-RADS 4 lesions from further diagnostic work-up.

Using the 3-tiered system for categorizing workup of incidental thyroid nodules detected on CT, MRI, or PET/CT: how many cancers would be missed?

BACKGROUND

A 3-tiered system has been proposed by radiologists for the reporting and workup of incidental thyroid nodules (ITN) detected on computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography/computed tomography (PET/CT). It has been shown to reduce the workup rate, but there remains concern about missed malignancies. This study aims at estimating the proportion of incidental cancers that would be missed relative to all thyroid cancers if the 3-tiered system were applied to ITN seen on CT, MRI, or PET/CT. We also aim to characterize these missed incidental cancers by histology and tumor stage.

METHODS

A retrospective review was performed of 680 consecutive patients with thyroid cancer who underwent surgery between January 2003 and December 2012. Medical records were reviewed to identify incidental thyroid cancers detected on imaging. Patients with incidental cancers detected on CT, MRI, or PET/CT were categorized according to the system as 3-tiered system-positive and 3-tiered system-negative. The system recommends that only 3-tiered system-positive ITN undergo further workup with ultrasound. Three-tiered system-negative cancers were the cancers that would have been missed if the system were used in practice. These tumors are described by tumor type, size, and stage to determine the potential impact if the 3-tiered system were adopted.

RESULTS

One hundred and one patients had imaging-detected incidental cancers, of whom 64 met the inclusion criteria and were originally detected on CT, MRI, or PET/CT. Eight were 3-tiered system-negative, which represents 13% of the 64 incidental cancers that could be categorized and 1.2% of all thyroid cancers treated at our institution in the 10-year period. Three-tiered system-negative tumors were all papillary in histology and had a median size of 12 mm (interquartile range 10-12 mm). Six tumors (75%) were American Joint Committee on Cancer (AJCC) stage I, one was AJCC stage II, and one was AJCC stage III at diagnosis.

CONCLUSIONS

Based on thyroid cancers diagnosed during a decade, incidental malignancies missed by the 3-tiered system represent 1.2% of all thyroid malignancies. Three-tiered system-negative incidental cancers were all small papillary cancers. Given that few cancers would be missed and most are less aggressive, we propose that the 3-tiered system could be adopted in clinical practice to guide the workup of ITN identified on CT, MRI, and PET/CT.

Comparison of clinicopathological findings among patients whose mammography results were classified as category 4 subgroups of the BI-RADS

OBJECTIVE:

Our aim is to compare mammographic, demographic and clinicopathological characteristics of patients whose mammographies were classified as subgroups of BI-RADS 4 category (Breast Imaging – Reporting and Data System).

METHODS:

In total, 103 patients with mammography (Senographe 600t Senix HF; General Electric, Moulineaux, France) results classified as BI-RADS 4 were included in the study. Demographic data (age, menopause, and family history) were recorded. All data were compared among BI-RADS 4 subgroups.

RESULTS:

In all, 68.9% (71/103), 7.8% (8/103) and 23.3% (24/103) the patients were in groups BI-RADS 4A, 4B and 4C, respectively. The incidence of malignancy was higher in Groups 4B and 4C than in Group 4A (p<0.05), but similar in Groups 4B and 4C (p>0.05). Mean age was lower in Group 4B than in Groups 4A and 4C (p<0.05). A positive family history was more common in Group 4A than in Group 4B (p=0.025). The frequency of menopausal patients was greater in Groups 4A and 4C than in Group 4B (p=0.021, and 0.003, respectively).

METHODS:

The rate of malignancy was higher in Groups 4B, and 4C than in Group 4A. A positive family history was more common in Group 4A than in Group 4C. Groups 4A, and 4C patients tended to be older and were more likely to be menopausal than Group 4B patients.

Evaluation of the role of dynamic contrast-enhanced MR imaging for patients with BI-RADS 3-4 microcalcifications

Objective

The purpose of study was to prospectively evaluate the diagnostic performance of dynamic contrast-enhanced MR imaging in the differentiation of malignant lesions from benign ones in patients with BI-RADS 3–4 microcalcifications detected by mammography.

Materials and Methods

93 women with 100 microcalcifications had undergone breast MRI from June 2010 to July 2013. Subsequently, 91 received open biopsy and 2 received stereotactic vacuum-assisted biopsy. All results were compared with histological findings. The PPV, NPV and area under curve (AUC) of the mammography and breast MRI were calculated.

Results

There were 31 (31.0%) BI-RADS 3 microcalcifications and 69 (69.0%) BI-RADS 4. The PPV and NPV of mammography is 65.2% (45/69) and 90.3% (28/31). The PPV and NPV of breast MRI was 90.2% (46/51) and 95.9% (47/49). Among 31 BI-RADS 3 microcalcifications, the PPV and NPV of breast MRI was 100% (3/3) and 100% (28/28). Among 69 BI-RADS 4 microcalcifications, the PPV and NPV of breast MRI was 89.6% (43/48) and 90.5% (19/21). The AUC of mammography and breast MRI assessment were 0.738 (95% CI, 0.639–0.837) and 0.931 (95% CI, 0.874–0.988) (p<0.05).

Conclusion

Dynamic contrast-enhanced MR imaging of breast is able to be applied to predict the risk of malignance before follow-up for BI-RADS 3 microcalcifications and biopsy for BI-RADS 4 microcalcifications.

A comprehensive methodology for determining the most informative mammographic features

This study aims to determine the most informative mammographic features for breast cancer diagnosis using mutual information (MI) analysis. Our Health Insurance Portability and Accountability Act-approved database consists of 44,397 consecutive structured mammography reports for 20,375 patients collected from 2005 to 2008. The reports include demographic risk factors (age, family and personal history of breast cancer, and use of hormone therapy) and mammographic features from the Breast Imaging Reporting and Data System lexicon. We calculated MI using Shannon's entropy measure for each feature with respect to the outcome (benign/malignant using a cancer registry match as reference standard). In order to evaluate the validity of the MI rankings of features, we trained and tested naïve Bayes classifiers on the feature with tenfold cross-validation, and measured the predictive ability using area under the ROC curve (AUC). We used a bootstrapping approach to assess the distributional properties of our estimates, and the DeLong method to compare AUC. Based on MI, we found that mass margins and mass shape were the most informative features for breast cancer diagnosis. Calcification morphology, mass density, and calcification distribution provided predictive information for distinguishing benign and malignant breast findings. Breast composition, associated findings, and special cases provided little information in this task. We also found that the rankings of mammographic features with MI and AUC were generally consistent. MI analysis provides a framework to determine the value of different mammographic features in the pursuit of optimal (i.e., accurate and efficient) breast cancer diagnosis.

Positive predictive values of Breast Imaging Reporting and Data System (BI-RADS®) categories 3, 4 and 5 in breast lesions submitted to percutaneous biopsy

Objective To evaluate the BI-RADS as a predictive factor of suspicion for malignancy in breast lesions by correlating radiological with histological results and calculating the positive predictive value for categories 3, 4 and 5 in a breast cancer reference center in the city of São Paulo. Materials and Methods Retrospective, analytical and cross-sectional study including 725 patients with mammographic and/or sonographic findings classified as BI-RADS categories 3, 4 and 5 who were referred to the authors' institution to undergo percutaneous biopsy. The tests results were reviewed and the positive predictive value was calculated by means of a specific mathematical equation. Results Positive predictive values found for categories 3, 4 and 5 were respectively the following: 0.74%, 33.08% and 92.95%, for cases submitted to ultrasound-guided biopsy, and 0.00%, 14.90% and 100% for cases submitted to stereotactic biopsy. Conclusion The present study demonstrated high suspicion for malignancy in lesions classified as category 5 and low risk for category 3. As regards category 4, the need for systematic biopsies was observed.

An observer study for a computer-aided reading protocol (CARP) in the screening environment for digital mammography

RATIONALE AND OBJECTIVES

The aims of this study were to investigate improving work flow efficiency by shortening the reading time of digital mammograms using a computer-aided reading protocol (CARP) in the screening environment and to increase detection sensitivity using CARP, compared to the current protocol, commonly referred to as the quadrant view (QV).

MATERIALS AND METHODS

A total of 200 cases were selected for a receiver-operating characteristic (ROC) study to evaluate two image display work flows, CARP and QV, in the screening environment. A Web-based tool was developed for scoring, reporting, and statistical analysis. Cases were scored for and stratified by difficulty. A total of six radiologists of differing levels of training ranging from dedicated mammographers to senior radiology residents participated. Each was timed while interpreting the 200 cases in groups of 50, first using QV and then, after a washout period, using CARP. The data were analyzed using ROC and κ analysis. Interpretation times were also assessed.

RESULTS

Using QV, readers' average area under the ROC curve was 0.68 (range, 0.54-0.73). Using CARP, readers' average area under the ROC curve was 0.71 (range, 0.66-0.75). There was no statistically significant difference in reader performance using either work flow. However, there was a statistically significant reduction in the average interpretation time of negative cases from 64.7 seconds using QV to 58.8 seconds using CARP.

CONCLUSIONS

CARP determines the display order of regions of interest depending on computer-aided detection findings. This is a variation of traditional computer-aided detection for digital mammography that has the potential to reduce interpretation times of studies with negative findings without significantly affecting sensitivity, thus allowing improved work flow efficiency in the screening environment, in which, in most settings, the majority of cases are negative.

BI-RADS categorisation of 2,708 consecutive nonpalpable breast lesions in patients referred to a dedicated breast care unit

OBJECTIVES

To determine the malignancy rate of nonpalpable breast lesions, categorised according to the Breast Imaging Reporting and Data System (BI-RADS) classification in the setting of a Breast Care Unit.

METHODS

All nonpalpable breast lesions from consecutive patients referred to a dedicated Breast Care Unit were prospectively reviewed and classified into 5 BI-RADS assessment categories (0, 2, 3, 4, and 5).

RESULTS

A total of 2708 lesions were diagnosed by mammography (71.6%), ultrasound (8.7%), mammography and ultrasound (19.5%), or MRI (0.2%). The distribution of the lesions by BI-RADS category was: 152 in category 0 (5.6%), 56 in category 2 (2.1%), 742 in category 3 (27.4%), 1523 in category 4 (56.2%) and 235 in category 5 (8.7%). Histology revealed 570 malignant lesions (32.9%), 152 high-risk lesions (8.8%), and 1010 benign lesions (58.3%). Malignancy was detected in 17 (2.3%) category 3 lesions, 364 (23.9%) category 4 lesions and 185 (78.7%) category 5 lesions. Median follow-up was 36.9 months.

CONCLUSION

This pragmatic study reflects the assessment and management of breast impalpable abnormalities referred for care to a specialized Breast Unit. Multidisciplinary evaluation with BI-RADS classification accurately predicts malignancy, and reflects the quality of management. This assessment should be encouraged in community practice appraisal.

Use of BI-RADS 3-probably benign category in the American College of Radiology Imaging Network Digital Mammographic Imaging Screening Trial

PURPOSE

To determine (a) how often the Breast Imaging Reporting and Data System (BI-RADS) category 3 was used in the American College of Radiology Imaging Network (ACRIN) Digital Mammographic Imaging Screening Trial (DMIST), either at the time of screening mammography or after work-up, (b) how often subjects actually returned for the recommended follow-up examination, and (c) the rate and stages of any malignancies subsequently found in subjects for whom short-term interval follow-up was recommended.

MATERIALS AND METHODS

This study was approved by the Institutional Review Board at all institutions where subjects were enrolled. All subjects participating in DMIST gave informed consent and the study was HIPAA-compliant. A total of 47,599 DMIST-eligible and evaluable subjects, all of whom consented to undergo both digital and screen-film mammography, were included in this analysis. Cases referred for short-term interval follow-up based on digital, screen-film, or both imaging examinations were determined. Compliance with the recommendations and the final outcome (malignancy diagnosis at biopsy or no malignancy confirmed through follow-up) of each evaluable case were determined.

RESULTS

A total of 1114 of the 47,599 (2.34%) subjects had tumors assigned a BI-RADS 3 category and were recommended to undergo short-interval follow-up. In this study, 791 of 1114 (71%) of the subjects were compliant with the recommendation and returned for short-interval follow-up. Of the women who did not return for short-interval follow-up, 70% (226 of 323) did return for their next annual mammography. Among all subjects whose tumors were assigned a BI-RADS 3 category either at screening mammography or after additional work-up, nine of 1114 (0.81%) were found to have cancer. Of the nine biopsy-proved cancers, six were invasive cancers and three were ductal carcinoma in situ stage Tis-T1c. The invasive cancers were all less than 2 cm in size.

CONCLUSION

In DMIST, radiologists used the BI-RADS 3 classification infrequently (2.3% of patients). Tumors assigned a BI-RADS 3 category had a low rate of malignancy. The relatively high rate of noncompliance with short-interval follow-up recommendations (323 of 1114, or 29%) supports prior recommendations that radiologists thoroughly evaluate lesions before placing them in this category.

A nomogram to predict for malignant diagnosis of BI-RADS Category 4 breast lesions

BACKGROUND AND OBJECTIVE

BI-RADS Category classification is the most powerful predictor of breast cancer (BC). However, BI-RADS Category 4 lesions are associated with a highly variable rate of BC. The purpose of this study was to develop and validate a nomogram for the prediction of individual probability of BC in patients with BI-RADS Category 4 lesions.

METHODS

The study included all patients with BI-RADS Category 4 lesions at screening mammogram, who underwent diagnostic cytology or biopsy and, as needed, surgery or follow-up. Univariate and multivariate logistic regression analyses were used to develop the model and build the nomogram. This nomogram was evaluated on a training set of 170 patients treated at IGR Cancer Center, Paris, France. Nomogram performance was evaluated on an external independent dataset of 188 patients from MDA Cancer Center, Houston, Texas.

RESULTS

A total of 51 (28.5%) patients in the training set and 73 (42.4%) patients in the validation set were diagnosed with BC. The final, most informative, nomogram included information on patient age (P = 0.04), palpable tumor (P = 0.002), menopausal status (P = 0.32), lesion size (P = 0.81), HRT (P = 0.09), and Gail risk (P = 0.58). The predictive accuracy of the nomogram was 0.716, respectively. The concordance index of the model was 0.66 in the validation set.

CONCLUSION

The nomogram based on clinical and radiological findings may help inform the patients before surgical explorations, to decrease the number of missed cancer cases but currently cannot replace FNA or biopsy.

Valor preditivo positivo das categorias 3, 4 e 5 do Breast Imaging Reporting and Data System (BI-RADS®)

OBJETIVO: O objetivo deste trabalho foi avaliar o BI-RADS® como fator preditivo de suspeição de malignidade em lesões mamárias não palpáveis nas categorias 3, 4 e 5, correlacionando as mamografias com os resultados histopatológicos através do cálculo do valor preditivo positivo do exame mamográfico. MATERIAIS E MÉTODOS: Trezentas e setenta e uma pacientes encaminhadas a um serviço de referência em tratamento de câncer em Teresina, PI, para realização de exames histopatológicos em mama no período de julho de 2005 a março de 2008, por terem mamografia de categorias 3, 4 ou 5, tiveram seus exames revisados. Das 371 pacientes, 265 foram submetidas a biópsia por agulha grossa e 106, a marcação pré-cirúrgica. RESULTADOS: Em relação às mamografias, 11,32% foram classificadas como categoria 3, 76,28% como categoria 4 e 12,4% como categoria 5. Os resultados histológicos demonstraram 24% de exames positivos para malignidade. Os valores preditivos positivos das categorias 3, 4 e 5 foram, respectivamente, de 7,14%, 16,96% e 82,61%. Foram calculados os valores preditivos positivos, separadamente, para as biópsias percutâneas (7,14%, 15,76%, 76,47%) e para as marcações pré-cirúrgicas (7,14%, 20%, 100%). CONCLUSÃO: Achados malignos foram subestimados pelo laudo radiológico e houve superestimação de achados benignos, o que resultou na realização desnecessária de alguns procedimentos invasivos.

Accuracy of classification of breast ultrasound findings based on criteria used for BI-RADS

OBJECTIVE

To assess the accuracy of categorization of breast ultrasound findings based on scoring for malignancy using the sonographic breast imaging-reporting and data system (BI-RADS).

METHODS

Breast ultrasound was performed in 2462 patients between 2001 and 2004 at our unit. Sonographic findings were scored using analog criteria as in BI-RADS for breast ultrasound (mass shape, margin, orientation, posterior acoustic features, lesion boundary, echo pattern). Each lesion was described using these features and classified into categories 1 to 5 according to the BI-RADS for breast ultrasound. Categorization and biopsy results were compared.

RESULTS

In twenty-two (0.9%) patients breast ultrasound could not be evaluated because of extreme density of tissue. Normal breast ultrasound belonging to Category 1 was found in 871 (35.4%) patients. Simple cysts classified as Category 2 were observed in 712 (28.9%) women. In 491 (19.9%) patients, apparently benign solid masses (Category 3) were found. Suspicious masses were observed in 225 (9.1%) women and masses highly suggestive of malignancy were found in 141 (5.7%) patients (Categories 4 and 5, respectively). Histological examinations were available from 84 (17.1%) masses that had been classified by BI-RADS as Category 3, in 97 (43.1%) from Category 4 and 106 (75.2%) from Category 5. Accordingly, the rate of malignant findings was 1.2% (n = 1) in Category 3, 17% (n = 16) in Category 4 and 94% (n = 100) in Category 5.

CONCLUSION

Scoring breast ultrasound findings for malignancy based on criteria used for BI-RADS breast ultrasound has a high accuracy, comparable to that obtained by BI-RADS for mammography.

Vacuum-assisted breast biopsy in close proximity to the skin: a case report

Introduction

Vacuum-assisted breast biopsy is a minimally invasive technique used increasingly for the assessment of mammographically detected, non-palpable breast lesions. The effectiveness of vacuum-assisted breast biopsy has been demonstrated on lesions both with and without microcalcifications. Given that the position of the lesion represents a major factor in stereotactic vacuum-assisted breast biopsy, targeting lesions in close proximity to the skin (superficial lesions) has been described as a problematic issue.

Case presentation

A 53-year-old woman presented with a newly developed, non-palpable lesion in her left breast. The lesion consisted of widely spread microcalcifications located approximately 5 mm from the skin. The lesion was isoechoic on ultrasound examination. Vacuum-assisted breast biopsy was scheduled (on the Fischer's table, using 11-gauge probes, under local anaesthesia). The vacuum-assisted breast biopsy probe was inserted antidiametrically into the breast, the probe reached the lesion and effort was made to excise the microcalcifications. As only a small proportion of the microcalcifications were excised an accurate diagnosis could not be expected. However, with the probe having entered the breast antidiametrically, the probe tip underlying the skin could be palpated. Following the palpation of the tip, the exact point was marked by a pen, the probe was removed and the patient was transferred to the surgery room to have the remaining lesion removed by a spindle-form excision under local anaesthesia. The mammogram of the removed specimen confirmed the total excision of the suspicious microcalcifications.

Conclusion

Isoechoic superficial lesions can be localized with a hook-wire and open breast biopsy under general or local anaesthesia can be performed. However, vacuum-assisted breast biopsy might offer an alternative solution and serve as an alternative approach to localize the lesion. The clinical significance of the present exploratory effort remains to be assessed in the future.

A prospective pilot clinical trial evaluating the utility of a dynamic near-infrared imaging device for characterizing suspicious breast lesions

Introduction

Characterizing and differentiating between malignant tumors, benign tumors, and normal breast tissue is increasingly important in the patient presenting with breast problems. Near-infrared diffuse optical imaging and spectroscopy is capable of measuring multiple physiologic parameters of biological tissue systems and may have clinical applications for assessing the development and progression of neoplastic processes, including breast cancer. The currently available application of near-infrared imaging technology for the breast, however, is compromised by low spatial resolution, tissue heterogeneity, and interpatient variation.

Materials and methods

We tested a dynamic near-infrared imaging schema for the characterization of suspicious breast lesions identified on diagnostic clinical ultrasound. A portable handheld near-infrared tissue imaging device (P-Scan; ViOptix Inc., Fremont, CA, USA) was utilized. An external mechanical compression force was applied to breast tissue. The tissue oxygen saturation and hemoglobin concentration were recorded simultaneously by the handheld near-infrared imaging device. Twelve categories of dynamic tissue parameters were derived based on real-time measurements of the tissue hemoglobin concentration and the oxygen saturation.

Results

Fifty suspicious breast lesions were evaluated in 48 patients. Statistical analyses were carried out on 36 out of 50 datasets that satisfied our inclusion criteria. Suspicious breast lesions identified on diagnostic clinical ultrasound had lower oxygenation and higher hemoglobin concentration than the surrounding normal breast tissue. Furthermore, histopathologic-proven malignant breast tumors had a lower differential hemoglobin contrast (that is, the difference of hemoglobin concentration variability between the suspicious breast lesion and the normal breast parenchyma located remotely elsewhere within the ipsilateral breast) as compared with histopathologic-proven benign breast lesions.

Conclusion

The proposed dynamic near-infrared imaging schema has the potential to differentiate benign processes from those of malignant breast tumors. Further development and refinement of the dynamic imaging device and additional subsequent clinical testing are necessary for optimizing the accuracy of detection.

Breast Imaging Reporting and Data System - BI-RADS®: valor preditivo positivo das categorias 3, 4 e 5. revisão sistemática da literatura

OBJETIVO: Avaliar artigos, na literatura, que verificam o valor preditivo positivo das categorias 3, 4 e 5 do Breast Imaging Reporting and Data System (BI-RADS®). MATERIAIS E MÉTODOS: Foi realizada pesquisa na base de dados Medline utilizando os termos "predictive value" e "BI-RADS". Foram incluídos 11 artigos nesta revisão. RESULTADOS: O valor preditivo positivo das categorias 3, 4 e 5 variou entre 0% e 8%, 4% e 62%, 54% e 100%, respectivamente. Três artigos avaliaram, concomitantemente, os critérios morfológicos das lesões que apresentaram maior valor preditivo positivo na mamografia, sendo nódulo espiculado o critério com maior valor preditivo positivo. CONCLUSÃO: Houve grande variabilidade do valor preditivo positivo das categorias 3, 4 e 5 do BI-RADS® em todos os estudos, porém foram identificadas diferenças metodológicas que limitaram a comparação desses estudos.

Is zero underestimation feasible? Extended Vacuum-Assisted Breast Biopsy in solid lesions - a blind study

BACKGROUND

Vacuum-Assisted Breast Biopsy (VABB) is effective for the preoperative diagnosis of non-palpable mammographic solid lesions. The main disadvantage is underestimation, which might render the management of atypical ductal hyperplasia (ADH), and ductal carcinoma in situ (DCIS) difficult. This study aims to develop and assess a modified way of performing VABB.

PATIENTS AND METHODS

A total of 107 women with non-palpable mammographic breast solid tumors BI-RADS 3 and 4 underwent VABB with 11G, on the stereotactic Fischer's table. 54 women were allocated to the recommended protocol and 24 cores were obtained according to the consensus meeting in Nordesterdt (1 offset-main target in the middle of the lesion and one offset inside). 53 women were randomly allocated to the extended protocol and 96 cores were excised (one offset-main target in the middle of the lesion and 7 peripheral offsets). A preoperative diagnosis was established. Women with a preoperative diagnosis of precursor/preinvasive/invasive lesion underwent open surgery. A second pathologist, blind to the preoperative results and to the protocol made the postoperative diagnosis. The percentage of the surface excised via VABB was retrospectively calculated on the mammogram. The discrepancy between preoperative and postoperative diagnoses along with the protocol adopted and the volume removed were evaluated by Fisher's exact test and Mann-Whitney-Wilcoxon test, respectively.

RESULTS

Irrespectively of the protocol adopted, 82.2% of the lesions were benign. 14.0% of the lesions were malignancies (5.1% of BI-RADS 3, 5.3% of BI-RADS 4A, 25% of BI-RADS 4B, and 83.3% of BI-RADS 4C lesions). 3.7% of the biopsies were precursor lesions. There was no evidence of underestimation in either protocols. In the standard protocol, the preoperative/postoperative diagnoses were identical. In the extended protocol, the postoperative diagnosis was less severe than the preoperative in 55.5% of cases (55.5% vs. 0%, p = 0.029), and preoperative ADH was totally removed. The phenomenon of discrepancy between diagnoses was associated with larger volume removed (8.20 +/- 1.10 vs. 3.32 +/- 3.50 cm3, p = 0.037) and higher removed percentage of the lesion (97.83 +/- 4.86% vs. 74.34 +/- 23.43%, p = 0.024)

CONCLUSION

The extended protocol seems to totally excise precursor lesions, with minimal underestimation. This might possibly point to a modified management of ADH lesions.

Imprint cytology on microcalcifications excised by vacuum-assisted breast biopsy: a rapid preliminary diagnosis

BACKGROUND

To evaluate imprint cytology in the context of specimens with microcalcifications derived from Vacuum-Assisted Breast Biopsy (VABB).

PATIENTS AND METHODS

A total of 93 women with microcalcifications BI-RADS 3 and 4 underwent VABB and imprint samples were examined. VABB was performed on Fischer's table using 11-gauge Mammotome vacuum probes. A mammogram of the cores after the procedure confirmed the excision of microcalcifications. For the application of imprint cytology, the cores with microcalcifications confirmed by mammogram were gently rolled against glass microscope slides and thus imprint smears were made. For rapid preliminary diagnosis Diff-Quick stain, modified Papanicolaou stain and May Grunwald Giemsa were used. Afterwards, the core was dipped into a CytoRich Red Collection fluid for a few seconds in order to obtain samples with the use of the specimen wash. After the completion of cytological procedures, the core was prepared for routine histological study. The pathologist was blind to the preliminary cytological results. The cytological and pathological diagnoses were comparatively evaluated.

RESULTS

According to the pathological examination, 73 lesions were benign, 15 lesions were carcinomas (12 ductal carcinomas in situ, 3 invasive ductal carcinomas), and 5 lesions were precursor: 3 cases of atypical ductal hyperplasia (ADH) and 2 cases of lobular neoplasia (LN). The observed sensitivity and specificity of the cytological imprints for cancer were 100% (one-sided, 97.5% CI: 78.2%-100%). Only one case of ADH could be detected by imprint cytology. Neither of the two LN cases was detected by the imprints. The imprints were uninformative in 11 out of 93 cases (11.8%). There was no uninformative case among women with malignancy.

CONCLUSION

Imprint cytology provides a rapid, accurate preliminary diagnosis in a few minutes. This method might contribute to the diagnosis of early breast cancer and possibly attenuates patients' anxiety.

Treatment of dysfunctional uterine bleeding in the perimenopause: the effects of adding combined estradiol/norethisterone acetate therapy to goserelin acetate treatment--a randomized, placebo-controlled, double-blind trial

OBJECTIVE

To assess the effects of adding combined estradiol/norethisterone acetate therapy (CENT) to goserelin acetate treatment (GA) of dysfunctional uterine bleeding (DUB) in perimenopausal women.

METHODS

In a randomized, placebo-controlled, double-blind trial followed by an open follow-up study, 31 perimenopausal women with DUB were recruited from gynecological outpatient departments of two Dutch hospitals and randomized for treatment with either GA/placebo or GA/CENT for 6 months followed by 18 months of GA/CENT for all. The main outcome measures were abdominal pain, number of bleeding days, double-layer endometrial thickness (DET), Greene climacteric score (GCS), visual analog scale for well-being, bone mineral density (BMD) and mammographic density (BI-RAD score).

RESULTS

Abdominal pain, number of bleeding days and DET decreased in both groups, the between-group difference in decrease not being statistically significant. GCS initially showed significant improvement in the GA/CENT group. BMD decreased significantly in the GA/placebo group (-4.1%) compared with the GA/CENT group (-0.3%). Another 18 months of GA/CENT did not result in a lasting difference in BMD between groups. BI-RAD scores did not differ significantly between or within the two groups.

CONCLUSIONS

Adding CENT to GA treatment for DUB in perimenopausal women initially prevented BMD loss and improved climacteric complaints, while having no negative impact on vaginal bleeding, abdominal pain or BI-RAD scores. However, prolonged treatment did not result in a lasting prevention of bone loss.

Non-palpable breast carcinomas: Correlation of mammographically detected malignant-appearing microcalcifications and epidermal growth factor receptor (EGFR) family expression

Malignant-appearing microcalcifications (MAMCs) represent one of the earliest mammographic findings of non-palpable breast carcinomas (NPBCs). In the present study, we have evaluated the expression of all EGFR family members in NPBCs and its possible association with MAMCs. Three hundred and fifty patients with non-palpable suspicious breast lesions detected during screening mammography were studied. EGFR family proteins' expression was found to be present since the preclinical phase of breast carcinomas and was strongly correlated (except HER-3) with MAMCs. The co-expression pattern of EGFR family members combined with other molecular prognostic factors and the mammographic appearance might predict the natural history of NPBCs.

Dynamic contrast-enhanced MR imaging in screening detected microcalcification lesions of the breast: is there any value?

PURPOSE

To prospectively evaluate whether dynamic contrast-enhanced magnetic resonance (MR) imaging findings can help predict the presence of malignancy when screening detected microcalcification lesions, and its contribution to patient management of stereotactic vacuum-assisted breast biopsy (SVAB).

MATERIALS AND METHODS

Dynamic contrast-enhanced breast MR imaging was performed when screening 100 detected microcalcification lesions not visualized by ultrasonography with 11-gauge SVAB. Definitive surgery was performed on all patients with the biopsy resulting in the diagnosis of breast cancer or atypical ductal hyperplasia (ADH). Positive predictive values (PPVs) and negative predictive values (NPVs) were calculated on the basis of a BI-RADS (Breast Imaging Reporting and Data System) category and the absence or presence of contrast uptake in the area of microcalcification.

RESULTS

The BI-RADS mammography category correlated with the diagnosis of breast cancer (ADH excluded): category 3 = 7% (4/55); category 4 = 48% (13/27); category 5 = 94% (17/18). After dynamic contrast-enhanced MR imaging, three of four malignancies with BI-RADS mammography category 3 were diagnosed as true positive. Therefore, the PPV of BI-RADS mammography category 3 with MR imaging was 1.8% (1/55). The PPV of contrast uptake of MR imaging was 86% (32/37), significantly higher than the 67% (30/45) PPV of BI-RADS mammography 4 and 5 (P = 0.033). The NPV of BI-RADS mammography 3 was 93% (51/55) versus 97% (61/63) NPV of MR imaging (P = 0.167).

CONCLUSION

In the evaluation of screening detected microcalcification lesions, dynamic contrast-enhanced breast MR imaging provides additional information with high PPV and NPV, and may therefore offer an alternative to SVAB for women who do not want to undergo SVAB with equivocal findings following full diagnostic mammographic assessment, but breast MR imaging with imperfect PPV and NPV cannot replace SVAB.

CLINICAL RELEVANCE

Dynamic contrast-enhanced breast MR imaging can demonstrate malignant microcalcifications detected by screening mammography and can be recommended in the evaluation of equivocal microcalcifications prior to SVAB.