BI-RADS descriptors for mammographically detected microcalcifications verified by histopathology after needle-localized open breast biopsy

Tattoo Pigment in an Intramammary Lymph Node Mimicking Breast Malignancy

There are many patterns of microcalcification in mammography. Distinguishing between these patterns can be challenging. A malignant cause needs to be assessed through further diagnostic workup. We present a case of a 36-year-old BRCA1 mutation carrier, presenting with a small mass containing calcification on her screening mammogram. A vacuum-assisted biopsy under tomosynthesis guidance was performed and demonstrated an intramammary lymph node showing prominent extracellular black pigment. To our knowledge, this is the first case report of tattoo pigment mimicking breast malignancy on mammography.

Comprehensive quantitative malignant risk prediction of pure grouped amorphous calcifications: clinico-mammographic nomogram

BACKGROUND

Pure grouped amorphous calcifications are classified as Breast Imaging Reporting and Data System (BI-RADS) category 4B suspicious calcifications and recommended for biopsy. However, the biopsies often reveal benign findings, especially in screening mammograms (92.4-97.2%).

METHODS

Mammograms of 699 pure grouped amorphous calcifications with final pathological results were analyzed in this retrospective study. The maximum span (MS) of the group of calcifications and the MS of the parallel/vertical direction of the mammary duct (MPS/MVS) were measured, and the MPS to MVS ratio was calculated. Based on the MS and ratio, 2 prediction nomograms with other clinic-mammographic features were developed. The discrimination performance of the models was assessed and compared by the area under the receiver operating characteristic curve (AUC). Scatterplots were created to determine the cutoff values with fewer misdiagnoses of malignant calcifications and fewer false positives.

RESULTS

Ultimately, 2 prediction models were successfully developed based on the 4 risk factors of age, purpose of the mammogram, whether multiple or single calcifications, and the MS [odds ratio (OR) =1.06, P=0.02]/ratio (OR =6.05, P<0.001). Both models had good discrimination. The ratio model performed better than the MS model in the training cohort (AUC of 0.875 and 0.834, respectively, P=0.003) and validation cohort (AUC 0.908 and 0.867, respectively, P=0.047). For the group with probably benign calcifications (as detected by the ratio nomogram), the malignancy rates were 2.7% [95% confidence interval (CI): 1.00% to 6.53%] and 1.19% (95% CI: 0.06% to 7.37%) in the training and validation cohorts, respectively, and 44.12% and 47.70% of benign biopsies were detected in the training and validation cohorts, respectively.

CONCLUSIONS

The clinico-mammographic quantitative malignancy risk prediction nomogram showed favorable discrimination and calibration performance. The ratio model showed better diagnostic efficiency than the MS model, and identified >40% of benign biopsies.

Computational FEM Model and Phantom Validation of Microwave Ablation for Segmental Microcalcifications in Breasts Using a Coaxial Double-Slot Antenna

Introduction

Cancer is the second leading cause of death worldwide. Breast cancer is the second most common cause of cancer-related mortality, accounting for 11.6% of the total number of deaths. The main treatments for this disease are surgical removal of the tumor, radiotherapy, and chemotherapy. Recently, different minimally invasive technologies have been applied (e.g., emission of electromagnetic waves, thermal and chemical means) to overcome the important side effects of these treatment modalities. The objective of this study was to develop and evaluate a predictive computational model of microwave ablation.

Materials and Methods

The predictive computational model of microwave ablation was constructed by means of a dual-slot coaxial antenna. The model was compared with an experiment performed using a breast phantom, which emulates the dielectric properties of breast tissue with segmental microcalcifications. The standing wave ratio (SWR) was obtained for both methods to make a comparison and determine the feasibility of applying electromagnetic ablation to premalignant lesions in breasts. Specifically, for the analysis of segmental microcalcifications, a breast phantom with segmental microcalcifications was developed and two computational models were performed under the same conditions (except for blood perfusion, which was excluded in one of the models).

Results

The SWR was obtained by triplicate experiments in the phantom, and the measurements had a difference of 0.191 between the minimum and maximum SWR values, implying a change of power reflection of 0.8%. The average of the three measurements was compared with the simulation that did not consider blood perfusion. The comparison yielded a change of 0.104, representing a 0.2% change in power reflection. Discussion. Both experimentation in phantom and simulations demonstrated that ablation therapy can be performed using this antenna. However, an additional optimization procedure is warranted to increase the efficiency of the antenna.

New advance in breast cancer pathology and imaging

The improvement of knowledge concerning the pathology of breast cancer could provide the rationale for the development of new imaging diagnostic protocols. Indeed, as for the microcalcifications, new histopathological markers can be used as target for in vivo early detection of breast cancer lesions by using molecular imaging techniques such as positron emission tomography. Specifically, the mutual contribution of these medical specialties can ‘nourish’ the dream of a personalized medicine that takes into account the intrinsic variability of breast cancer. In this review, we report the main discoveries concerning breast cancer pathology highlighting the possible cooperation between the departments of anatomic pathology and imaging diagnostics.

Characterization of Breast Microcalcifications Using a New Ultrasound Image-Processing Technique

OBJECTIVES

To evaluate a new commercial image-processing technique (MicroPure; Toshiba America Medical Systems, Tustin, CA) for detection and characterization of breast microcalcifications in patients undergoing stereotactic or ultrasound-guided biopsies using mammography as the reference standard.

METHODS

One hundred female patients, with a total of 104 lesions, scheduled for an image-guided biopsy of an area with breast microcalcifications (identified on a prior mammogram) underwent MicroPure examinations of the breast using an Aplio XG scanner (Toshiba America Medical Systems) with a broad-bandwidth linear array. MicroPure combines nonlinear imaging and speckle suppression to mark suspected calcifications as white spots in a blue overlay image. Four independent and blinded readers (2 radiologists and 2 physicists) analyzed 208 digital clips consisting of dual grayscale ultrasound and MicroPure imaging, counting the number of microcalcifications seen with MicroPure. The observers also assessed the level of suspicion on a qualitative, visual analog, 6-point scale from 0 (no findings) over 1 (benign) to 5 (malignant).

RESULTS

The mean number of microcalcifications ± SD seen was 6.3 ± 3.5, whereas mammography saw 28.9 ± 24.6 (P = .66). When the MicroPure level of suspicion scores were compared with pathologic results using a receiver operating characteristic curve analysis, the areas under the curve ranged from 0.54 to 0.59. Nonetheless, malignant cases were seen to have significantly more microcalcifications than benign cases (mean number of microcalcifications, 6.9 ± 5.1 versus 5.3 ± 3.7; P = .02).

CONCLUSIONS

MicroPure can be used to identify areas with breast microcalcifications but cannot effectively characterize such areas. Instead, MicroPure may represent a new imaging method for guiding a biopsy to areas of microcalcifications.

Ultrasound Detection of Microcalcifications in Surgical Breast Specimens

The objective was to evaluate a commercial image processing technique (MicroPure, Canon Medical Systems, Tustin, CA, USA) for detection of microcalcifications in breast surgical specimens. Twenty women scheduled for surgical excision of an area with breast calcifications were enrolled, their surgical specimens underwent grayscale ultrasound (US) and MicroPure examination using an Aplio XG scanner (Canon). Four independent and blinded readers analyzed 54 US and 54 MicroPure digital clips to determine the number of calcifications and scored image quality and artifacts on a 10-point scale. All readers saw significantly more microcalcifications with MicroPure than with US, 14.0 ± 12.0 versus 3.0 ± 3.2 (p <0.0001). Three readers preferred MicroPure image quality over that of US (p <0.009) and vice versa for one reader (p = 0.003). Three readers saw fewer Cooper's ligament artifacts with MicroPure than with US (p <0.0001); one reader saw no significance difference between them (p = 0.58). In conclusion MicroPure identified more breast microcalcifications than grayscale US in ex vivo surgical breast specimens.

Suspicious amorphous microcalcifications detected on full-field digital mammography: correlation with histopathology

Objective

To evaluate suspicious amorphous calcifications diagnosed on full-field digital mammography (FFDM) and establish correlations with histopathology findings.

Materials and Methods

This was a retrospective study of 78 suspicious amorphous calcifications (all classified as BI-RADS^® 4) detected on FFDM. Vacuum-assisted breast biopsy (VABB) was performed. The histopathological classification of VABB core samples was as follows: pB2 (benign); pB3 (uncertain malignant potential); pB4 (suspicion of malignancy); and pB5 (malignant). Treatment was recommended for pB5 lesions. To rule out malignancy, surgical excision was recommended for pB3 and pB4 lesions. Patients not submitted to surgery were followed for at least 6 months.

Results

Among the 78 amorphous calcifications evaluated, the histopathological analysis indicated that 8 (10.3%) were malignant/suspicious (6 classified as pB5 and 2 classified as pB4) and 36 (46.2%) were benign (classified as pB2). The remaining 34 lesions (43.6%) were classified as pB3: 33.3% were precursor lesions (atypical ductal hyperplasia, lobular neoplasia, or flat epithelial atypia) and 10.3% were high-risk lesions. For the pB3 lesions, the underestimation rate was zero.

Conclusion

The diagnosis of precursor lesions (excluding atypical ductal hyperplasia, which can be pB4 depending on the severity and extent of the lesion) should not necessarily be considered indicative of underestimation of malignancy. Suspicious amorphous calcifications correlated more often with precursor lesions than with malignant lesions, at a ratio of 3:1.

MRI and comparison mammography: a worthy diagnostic alliance for breast microcalcifications?

BACKGROUND

There is a lack of data concerning diagnostic performance of magnetic resonance imaging (MRI) in patients with new or increasing microcalcifications.

PURPOSE

To evaluate suspicious microcalcifications by using comparison mammography, MRI, and a combination of both methods.

MATERIAL AND METHODS

Our study group consisted of 55 patients with mammographically detected BI-RADS (Breast Imaging Reporting and Data System) 3-5 microcalcifications for whom comparison mammograms were available. All patients underwent breast MRI before SVAB (stereotactic vacuum-assisted biopsy). Diagnostic performances of comparison mammography and MRI were evaluated, as well as the combination of the respective imaging findings.

RESULTS

Of the 55 microcalcification cases, 35 showed progression and 20 were stable between interval screenings. The negative predictive value (NPV) of comparison mammography was 100%, whereas the NPV of MRI was 92%. However, the specificity of combination of findings was 97%, significantly higher than the 42% specificity of comparison mammography (P < 0.001). Additionally, the positive predictive value of combination of findings was 93% versus 44% of comparison mammography (P = 0.001).

CONCLUSION

A biopsy is recommended when MRI positive lesion corresponding the area of new or increasing mammographic microcalcifications is detected. Patients with stable microcalcifications can continue follow-up mammography, regardless of MRI result.

Hook Wire Localization Procedure and Early Detection of Breast Cancer - Our Experience

AIM:

The purpose of this study is to describe our experience with needle localization technique in diagnosing small breast cancers.

MATERIAL AND METHODS:

This retrospective study included a hundred and twenty patients’ with impalpable breast lesions and they underwent wire localization. All patients had mammography, ultrasound exam and pathohystological results. We use Mammomat Inspiration Siemens digital unit for diagnosing mammography, machine - Lorad Affinity with fenestrated compressive pad for wire localization and ultrasound machine Acuson X300 with linear array probe 10 MhZ. We use two types of wire: Bard hook wire and Kopans breast lesion localization needle, Cook. Comparative radiologic and pathologic data were collected and analyzed.

RESULTS:

In 120 asymptomatic women, 68 malignancies and 52 benign findings were detected with mammography and ultrasound. The mean age for patients with malignancy was 58.6 years. According BI-RADS classification for mammography the distribution is our group was: BI-RADS 3 was presented in 6 (8.82%) patients, BI-RADS 4 was presented in 56 (82.35%) patients and BI-RADS 5 was present in 6 (8.82%) of the patients. Most wire localizations were performed under mammographic guidance in 58 from 68 patients with malignant lesions (85.29%) and with ultrasound in 10 (14.7%). According the mammographic findings patients with mass on mammograms were 29 (42.65%), mass with calcifications 9 (13.23%), calcifications 20 (29.41%) and architectural distortions or asymmetry 10 (14.71%).

CONCLUSION:

Wire localization is a well established technique for the management of impalpable breast lesions.

Changing patterns of microcalcification on screening mammography for prediction of breast cancer

BACKGROUND

The presence of microcalcification on mammography is one of the earliest signs in breast cancer detection. However, it is difficult to distinguish malignant calcifications from benign calcifications. The aim of this study is to evaluate correlation between changing patterns of microcalcification on screening mammography and malignant breast lesions.

METHODS

Medical records and diagnostic images of 67 women who had previously undergone at least two digital mammograms at least 6 months apart and underwent mammography-guided needle localization and surgical excision between 2011 and 2013 were retrospectively reviewed and analyzed.

RESULTS

Breast cancer was detected in the surgical specimens of 20 patients (29.9 %). Annual change of extent of microcalcification on mammography showed statistically significant correlation with pathologic outcome (P = 0.023). The changing pattern of new appearance or increased extent of microcalcification on mammography had positive predictive value of 54.8 % for breast cancer, and it was a statistically significant predictor for breast cancer (P = 0.012). Shape or number change of microcalcification without increased extent had less accurate predictive value for breast cancer, particularly in women younger than 50 years (P < 0.001).

CONCLUSIONS

This study showed that the pattern of increased extent of microcalcification on screening mammography was a significant predictor for breast cancer. We suggest that mammography-guided needle localization and surgical excision should be considered when increased extent of microcalcification is observed on screening mammography and closed follow-up without pathologic confirmation can be permitted if absence of extension of microcalcification was confirmed in women younger than 50 years.

Breast microcalcifications: the lesions in anatomical pathology

Microcalcifications are actually indirect signs of pathological processes, and only a few of these processes may be correctly correlated to the morphologic pattern of calcifications. This is true of the microcalcifications typically classified as benign by the 4th edition of the BI-RADS Atlas, except for round and punctuate microcalcifications. This is also the case of polymorphous fine and linear fine microcalcifications most often, but not exclusively, associated with DCIS with necrosis. For other types of microcalcifications, other parameters are analyzed in a more global approach: the associated clinical or mammographical signs; the context, especially genetic; the spatial distribution; the number; the evolution over time. The radiologist should compare the images with the anatomy of the terminal ductal-lobular unit, from where most cancers arise, and estimates the risk by taking into account the clinical context and the antecedents.

Breast cancer risk prediction model: a nomogram based on common mammographic screening findings

OBJECTIVES

To develop a prediction model for breast cancer based on common mammographic findings on screening mammograms aiming to reduce reader variability in assigning BI-RADS.

METHODS

We retrospectively reviewed 352 positive screening mammograms of women participating in the Dutch screening programme (Nijmegen region, 2006-2008). The following mammographic findings were assessed by consensus reading of three expert radiologists: masses and mass density, calcifications, architectural distortion, focal asymmetry and mammographic density, and BI-RADS. Data on age, diagnostic workup and final diagnosis were collected from patient records. Multivariate logistic regression analyses were used to build a breast cancer prediction model, presented as a nomogram.

RESULTS

Breast cancer was diagnosed in 108 cases (31 %). The highest positive predictive value (PPV) was found for spiculated masses (96 %) and the lowest for well-defined masses (10 %). Characteristics included in the nomogram are age, mass, calcifications, architectural distortion and focal asymmetry.

CONCLUSION

With our nomogram we developed a tool assisting screening radiologists in determining the chance of malignancy based on mammographic findings. We propose cutoff values for assigning BI-RADS in the Dutch programme based on our nomogram, which will need to be validated in future research. These values can easily be adapted for use in other screening programmes.

KEY POINTS

• There is substantial reader variability in assigning BI-RADS in mammographic screening. • There are no strict guidelines linking mammographic findings to BI-RADS categories. • We developed a model (nomogram) predicting the presence of breast cancer. • Our nomogram is based on common findings on positive screening mammograms. • The nomogram aims to assist screening radiologists in assigning BI-RADS categories.

New image processing technique for evaluating breast microcalcifications: a comparative study

OBJECTIVES

The purpose of this study was to evaluate a new commercial image processing technique (MicroPure; Toshiba America Medical Systems, Tustin, CA) for identifying breast microcalcifications compared to gray scale ultrasound imaging (US) using mammography as the reference standard.

METHODS

Twenty women, with breast calcifications identified mammographically, underwent gray scale US and MicroPure examinations of the breast. Still images and digital clips of the target area were acquired using gray scale US and MicroPure (at 3 different sensitivity levels: 0, 1, and 2). The images were analyzed by 4 independent and blinded readers (2 radiologists and 2 physicists) to determine the number of calcifications as well as to score image quality and artifacts.

RESULTS

For all 4 readers, there were significantly more calcifications seen with MicroPure (at the 2 highest sensitivity levels) compared to gray scale US (P < .009). Agreement between readers consistently increased from gray scale US to MicroPure imaging (gray scale intraclass correlation coefficient, 0.02-0.44; versus MicroPure intraclass correlation coefficient, 0.34-0.71). The agreement improved between mammography and MicroPure (13.2%-28.3%) when compared with mammography and gray scale US (1.7%-5.2%); the 2 radiologists saw a bigger improvement. Two readers preferred the MicroPure image quality over gray scale US (P < .001) and vice versa for the other 2 readers(P < .001). All 4 readers saw fewer artifacts with MicroPure (at level 2) than with gray scale US (P < .02).

CONCLUSIONS

MicroPure imaging identified significantly more breast microcalcifications than gray scale US.