The Postoperative Breast: Imaging Findings and Diagnostic Pitfalls After Breast-Conserving Surgery and Oncoplastic Breast Surgery

Breast surgery is the cornerstone of treatment for early breast cancer. Historically, mastectomy and conventional breast-conserving surgery (BCS) were the main surgical techniques for treatment. Now, oncoplastic breast surgery (OBS), introduced in the 1990s, allows for a combination of BCS and reconstructive surgery to excise the cancer while preserving or enhancing the contour of the breast, leading to improved aesthetic results. Although imaging after conventional lumpectomy demonstrates typical postsurgical changes with known evolution patterns over time, OBS procedures show postsurgical changes/fat necrosis in locations other than the lumpectomy site. The purpose of this article is to familiarize radiologists with various types of surgical techniques for removal of breast cancer and to distinguish benign postoperative imaging findings from suspicious findings that warrant further work-up.

Multishot Diffusion-Weighted MRI of the Breasts in the Supine vs. Prone Position

BACKGROUND

Diffusion-weighted imaging (DWI) may allow for breast cancer screening MRI without a contrast injection. Multishot methods improve prone DWI of the breasts but face different challenges in the supine position.

PURPOSE

To establish a multishot DWI (msDWI) protocol for supine breast MRI and to evaluate the performance of supine vs. prone msDWI.

STUDY TYPE

Prospective.

POPULATION

Protocol optimization: 10 healthy women (ages 22-56), supine vs. prone: 24 healthy women (ages 22-62) and five women (ages 29-61) with breast tumors.

FIELD STRENGTH/SEQUENCE

3-T, protocol optimization msDWI: free-breathing (FB) 2-shots, FB 4-shots, respiratory-triggered (RT) 2-shots, RT 4-shots, supine vs. prone: RT 4-shot msDWI, T2-weighted fast-spin echo.

ASSESSMENT

Protocol optimization and supine vs. prone: three observers performed an image quality assessment of sharpness, aliasing, distortion (vs. T2), perceived SNR, and overall image quality (scale of 1-5). Apparent diffusion coefficients (ADCs) in fibroglandular tissue (FGT) and breast tumors were measured.

STATISTICAL TESTS

Effect of study variables on dichotomized ratings (4/5 vs. 1/2/3) and FGT ADCs were assessed with mixed-effects logistic regression. Interobserver agreement utilized Gwet's agreement coefficient (AC). Lesion ADCs were assessed by Bland-Altman analysis and concordance correlation (ρc ). P value <0.05 was considered statistically significant.

RESULTS

Protocol optimization: 4-shots significantly improved sharpness and distortion; RT significantly improved sharpness, aliasing, perceived SNR, and overall image quality. FGT ADCs were not significantly different between shots (P = 0.812), FB vs. RT (P = 0.591), or side (P = 0.574). Supine vs. prone: supine images were rated significantly higher for sharpness, aliasing, and overall image quality. FGT ADCs were significantly higher supine; lesion ADCs were highly correlated (ρc  = 0.92).

DATA CONCLUSION

Based on image quality, supine msDWI outperformed prone msDWI. Lesion ADCs were highly correlated between the two positions, while FGT ADCs were higher in the supine position.

EVIDENCE LEVEL

2.

TECHNICAL EFFICACY

Stage 1.

Adaptations of Breast Imaging Centers to the COVID-19 Pandemic: A Survey of California and Texas

OBJECTIVE

To determine the early impact of the COVID-19 pandemic on breast imaging centers in California and Texas and compare regional differences.

METHODS

An 11-item survey was emailed to American College of Radiology accredited breast imaging facilities in California and Texas in August 2020. A question subset addressed March-April government restrictions on elective services ("during the shutdown" and "after reopening"). Comparisons were made between states with chi-square and Fisher's tests, and timeframes with McNemar's and paired t-tests.

RESULTS

There were 54 respondents (54/240, 23%, 26 California, 28 Texas). Imaging volumes fell during the shutdown and remained below pre-pandemic levels after reopening, with reduction in screening greatest (ultrasound 12% of baseline, mammography 13%, MRI 23%), followed by diagnostic MRI (43%), procedures (44%), and diagnostics (45%). California reported higher volumes during the shutdown (procedures, MRI) and after reopening (diagnostics, procedures, MRI) versus Texas (P = 0.001-0.02). Most screened patients (52/54, 96% symptoms and 42/54, 78% temperatures), and 100% (53/53) modified check-in and check-out. Reading rooms or physician work were altered for social distancing (31/54, 57%). Physician mask (45/48, 94%), gown (15/48, 31%), eyewear (22/48, 46%), and face shield (22/48, 46%) use during procedures increased after reopening versus pre-pandemic (P < 0.001-0.03). Physician (47/54, 87%) and staff (45/53, 85%) financial impacts were common, but none reported terminations.

CONCLUSION

Breast imaging volumes during the early pandemic fell more severely in Texas than in California. Safety measures and financial impacts on physicians and staff were similar in both states.

A behavioral training protocol using visual perceptual learning to improve a visual skill

We describe a behavioral training protocol using visual perceptual learning (VPL) to improve visual detection skills in non-experts for subtle mammographic lesions indicative of breast cancer. This protocol can be adapted for the professional training of experts (radiologists) or to improve visual skills for other tasks, such as the detection of targets in photo or video surveillance.

For complete details on the use and execution of this protocol, please refer to Frank et al. (2020a).

•

Behavioral training using VPL induces long-lasting improvements of a visual skill

•

Training should be conducted using detailed feedback about response accuracy

•

Training can be conducted with minimal technical equipment

•

VPL protocol can be used for clinical or other professional training

Impact of the COVID-19 Pandemic on Breast Imaging Education

Objective

To determine the impact of the COVID-19 pandemic on breast imaging education.

Methods

A 22-item survey addressing four themes during the early pandemic (time on service, structured education, clinical training, future plans) was emailed to Society of Breast Imaging members and members-in-training in July 2020. Responses were compared using McNemar's and Mann-Whitney U tests; a general linear model was used for multivariate analysis.

Results

Of 136 responses (136/2824, 4.8%), 96 U.S. responses from radiologists with trainees, residents, and fellows were included. Clinical exposure declined during the early pandemic, with almost no medical students on service (66/67, 99%) and fewer clinical days for residents (78/89, 88%) and fellows (48/68, 71%). Conferences shifted to remote live format (57/78, 73%), with some canceled (15/78, 19%). Compared to pre-pandemic, resident diagnostic (75/78, 96% vs 26/78, 33%) (P < 0.001) and procedural (73/78, 94% vs 21/78, 27%) (P < 0.001) participation fell, as did fellow diagnostic (60/61, 98% vs 47/61, 77%) (P = 0.001) and procedural (60/61, 98% vs 43/61, 70%) (P < 0.001) participation. Most thought that the pandemic negatively influenced resident and fellow screening (64/77, 83% and 43/60, 72%, respectively), diagnostic (66/77, 86% and 37/60, 62%), and procedural (71/77, 92% and 37/61, 61%) education. However, a majority thought that decreased time on service (36/67, 54%) and patient contact (46/79, 58%) would not change residents' pursuit of a breast imaging fellowship.

Conclusion

The pandemic has had a largely negative impact on breast imaging education, with reduction in exposure to all aspects of breast imaging. However, this may not affect career decisions.

Diffusion-weighted double-echo steady-state with a three-dimensional cones trajectory for non-contrast-enhanced breast MRI

The image quality limitations of echo-planar diffusion-weighted imaging (DWI) are an obstacle to its widespread adoption in the breast. Steady-state DWI is an alternative DWI method with more robust image quality but its contrast for imaging breast cancer is not well-understood. The aim of this study was to develop and evaluate diffusion-weighted double-echo steady-state imaging with a three-dimensional cones trajectory (DW-DESS-Cones) as an alternative to conventional DWI for non-contrast-enhanced MRI in the breast. This prospective study included 28 women undergoing clinically indicated breast MRI and six asymptomatic volunteers. In vivo studies were performed at 3 T and included DW-DESS-Cones, DW-DESS-Cartesian, DWI, and CE-MRI acquisitions. Phantom experiments (diffusion phantom, High Precision Devices) and simulations were performed to establish framework for contrast of DW-DESS-Cones in comparison to DWI in the breast. Motion artifacts of DW-DESS-Cones were measured with artifact-to-noise ratio in volunteers and patients. Lesion-to-fibroglandular tissue signal ratios were measured, lesions were categorized as hyperintense or hypointense, and an image quality observer study was performed in DW-DESS-Cones and DWI in patients. Effect of DW-DESS-Cones method on motion artifacts was tested by mixed-effects generalized linear model. Effect of DW-DESS-Cones on signal in phantom was tested by quadratic regression. Correlation was calculated between DW-DESS-Cones and DWI lesion-to-fibroglandular tissue signal ratios. Inter-observer agreement was assessed with Gwet's AC. Simulations predicted hyperintensity of lesions with DW-DESS-Cones but at a 3% to 67% lower degree than with DWI. Motion artifacts were reduced with DW-DESS-Cones versus DW-DESS-Cartesian (p < 0.05). Lesion-to-fibroglandular tissue signal ratios were not correlated between DW-DESS-Cones and DWI (r = 0.25, p = 0.38). Concordant hyperintensity/hypointensity was observed between DW-DESS-Cones and DWI in 11/14 lesions. DW-DESS-Cones improved sharpness, distortion, and overall image quality versus DWI. DW-DESS-Cones may be able to eliminate motion artifacts in the breast allowing for investigation of higher degrees of steady-state diffusion weighting. Malignant breast lesions in DW-DESS-Cones demonstrated hyperintensity with respect to surrounding tissue without an injection of contrast. LEVEL OF EVIDENCE: 2. TECHNICAL EFFICACY STAGE: 1.

Supervised Learning Occurs in Visual Perceptual Learning of Complex Natural Images

There have been long-standing debates regarding whether supervised or unsupervised learning mechanisms are involved in visual perceptual learning (VPL) [1-14]. However, these debates have been based on the effects of simple feedback only about response accuracy in detection or discrimination tasks of low-level visual features such as orientation [15-22]. Here, we examined whether the content of response feedback plays a critical role for the acquisition and long-term retention of VPL of complex natural images. We trained three groups of human subjects (n = 72 in total) to better detect "grouped microcalcifications" or "architectural distortion" lesions (referred to as calcification and distortion in the following) in mammograms either with no trial-by-trial feedback, partial trial-by-trial feedback (response correctness only), or detailed trial-by-trial feedback (response correctness and target location). Distortion lesions consist of more complex visual structures than calcification lesions [23-26]. We found that partial feedback is necessary for VPL of calcifications, whereas detailed feedback is required for VPL of distortions. Furthermore, detailed feedback during training is necessary for VPL of distortion and calcification lesions to be retained for 6 months. These results show that although supervised learning is heavily involved in VPL of complex natural images, the extent of supervision for VPL varies across different types of complex natural images. Such differential requirements for VPL to improve the detectability of lesions in mammograms are potentially informative for the professional training of radiologists.

DCE-MRI parameters have potential to predict response of locally advanced breast cancer patients to neoadjuvant chemotherapy and hyperthermia: a pilot study

Combined therapies represent a staple of modern medicine. For women treated with neoadjuvant chemotherapy (NA ChT) for locally advanced breast cancer (LABC), early determination of whether the patient will fail to respond can enable the use of alternative, more beneficial therapies. This is even more desirable when the combined therapy includes hyperthermia (HT), an efficient way to improve drug delivery, however, more costly and time consuming. There is data showing that this goal can be achieved using magnetic resonance imaging (MRI) with contrast agent (CA) enhancement. This work for the first time proposes combining the information extracted from pre-treatment MR imaging into a morpho-physiological tumour score (MPTS) with the hypothesis that this score will increase the prognostic efficacy, compared to each of its MR-derived components: morphological (derived from the shape of the tumour enhancement) and physiological (derived from the CA enhancement variance dynamics parameters). The MPTS was correlated with response as determined by both pathologic residual tumour and MRI imaging, and was shown to have potential to predict response. The MPTS was extracted from pre-treatment MRI parameters, so independent of the combined therapy used.

PURPOSE

To use a novel morpho-physiological tumour score (MPTS) generated from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to predict response to treatment.

MATERIALS AND METHODS

A protocol was designed to acquire DCE-MRI images of 20 locally advanced breast cancer (LABC) patients treated with neoadjuvant chemotherapy (NA ChT) and hyperthermia (HT). Imaging was done over 30 min following bolus injection of gadopentetate-based contrast agent. Parametric maps were generated by fitting the signal intensity to a double exponential curve and were used to derive a morphological characterisation of the lesions. Enhancement-variance dynamics parameters, wash-in and wash-out parameters (WiP, WoP), were extracted. The morphological characterisation and the WiP and WoP were combined into a MPTS with the intent of achieving better prognostic efficacy. The MPTS was correlated with response to NA therapy as determined by pathological residual tumour and MRI imaging.

RESULTS

The contrast agent in all tumours typically peaked in the first 1-4 min. The tumours' WiP and WoP varied considerably. The MPTS was highly correlated with whether the patients had a pathological response. This scoring system has a specificity of 78% and a sensitivity of 91% for predicting response to NA chemotherapy. The kappa was 0.69 with a 95% confidence interval of [0.38, 1] and a p-value of 0.002.

CONCLUSIONS

This pilot study shows that the MPTS derived using pre-treatment MRI images has the potential to predict response to NA ChT and HT in LABC patients. Further prospective studies are needed to confirm the validity of these results.

FDG PET, PET/CT, and breast cancer imaging

Currently, the clinical role of positron emission tomography (PET) and PET/computed tomography (CT) in patients with breast cancer is to provide additional information in select scenarios in which results of conventional imaging are indeterminate or of limited utility. There is currently no clinical role for fluorodeoxyglucose (FDG) PET in detection of breast cancer or evaluation of axillary lymph nodes, but these are areas of active research. FDG PET is complementary to conventional staging procedures and should not be a replacement for either bone scintigraphy or diagnostic CT. FDG PET and PET/CT have been shown to be particularly useful in the restaging of breast cancer, in evaluation of response to therapy, and as a problem-solving method when results of conventional imaging are equivocal. In these situations, FDG PET often demonstrates locoregional or unsuspected distant disease that affects management. PET has demonstrated a particular capability for evaluation of chemotherapy response in both patients with locally advanced breast carcinoma and those with metastatic disease.

Cancer yield of probably benign breast MR examinations

PURPOSE

To evaluate the cancer yield, frequency of use, and follow-up compliance of breast MR examinations assessed as "probably benign."

MATERIALS AND METHODS

We retrospectively reviewed our MR database of 809 consecutive examinations between January 2003 and June 2004. We identified all examinations that ultimately received an MR breast imaging reporting and data system (BI-RADS) 3 assessment and recommendation for a short-interval follow-up MR with or without an antecedent targeted ultrasound. The clinical indication for breast MR, date of the follow-up examination, follow-up assessment, and any pathology findings through June 2005 were collected from clinical records and radiology and pathology reports. Frequency of BI-RADS 3 use, follow-up compliance, and cancer yield were calculated.

RESULTS

A total of 160 out of 809 (20%) examinations comprise the study population. A total of 100 out of 160 (63%) women returned for the recommended follow-up MR, in which three out of 100 (3%) were upgraded to BI-RADS 4 with biopsy recommended. One patient underwent biopsy and the result was benign. A total of seven out of 160 (4%) underwent mastectomy in lieu of MR for known cancer elsewhere in the breast. One out of seven mastectomy specimens contained malignancy that corresponded to the probably benign finding, resulting in a cancer yield of one out of 160 (0.6%).

CONCLUSION

Our data suggest that follow-up MR is a valid alternative to biopsy for MR BI-RADS 3 lesions.

Evolving concepts in the management of lobular neoplasia

Lobular neoplasia broadly defines the spectrum of changes within the lobule, ranging from atypical lobular hyperplasia (ALH) to lobular carcinoma in situ (LCIS). This continuum of lesions is associated with an increased risk for developing subsequent invasive breast cancer, with the magnitude of that risk corresponding to the degree of proliferative change. The associated risk for developing invasive breast cancer after a diagnosis of lobular neoplasia is multicentric, bilateral, and equal in both breasts. Lobular neoplasia itself may transform into invasive carcinoma, although the frequency of this occurrence is unknown. Thus, lobular neoplasia is a risk factor for invasive breast cancer and may be a precursor lesion in unusual circumstances. The management of ALH and LCIS depends on the setting in which they are encountered. When ALH and LCIS are diagnosed after core needle breast biopsy, wire localization for surgical excision is required for definitive diagnosis because rates of histologic underestimation approach those of atypical ductal hyperplasia (ADH). When diagnosed on surgical biopsy, ALH and LCIS generally do not require further intervention, even when present at a surgical margin. However, bilateral breast cancer risk must be considered, especially when patients have a family history of breast cancer. In selected situations, bilateral prophylactic mastectomy with or without reconstruction may be considered when atypical hyperplasia or LCIS is diagnosed. Although this reduces risk for developing subsequent breast carcinoma by 90%, patients selected for prophylactic mastectomy represent a small subgroup of lobular neoplasia patients and generally have other risk factors, such as strong family history or evidence of genetic predisposition.

Streaming detection for evaluation of indeterminate sonographic breast masses: a pilot study

OBJECTIVE

Streaming detection is a novel sonography technique that uses ultrasonic energy to induce movement in cyst fluid that is detected on Doppler sonography. This pilot study evaluates the utility of streaming detection for differentiating cysts from solid masses in breast lesions that are indeterminate on sonography.

SUBJECTS AND METHODS

Thirty-nine lesions-11 simple cysts and seven solid masses (control group) and 21 masses with indeterminate findings for the diagnosis of a cyst versus a solid lesion (study group)-in 34 patients were evaluated using streaming detection. All lesions underwent cyst aspiration or biopsy (n = 35) or were diagnosed simple cysts (n = 4) on sonography. Lesion size and depth were recorded. Streaming detection software was placed on conventional sonography units. Acoustic pulses were focused on the lesion, and if fluid movement was generated, it was seen on the spectral Doppler display as velocity away from the transducer. Lesions were then aspirated or underwent biopsy, and the viscosity of the aspirated fluid was recorded. The sensitivity and specificity of the technique and the effect of cyst size, cyst depth, and fluid viscosity in diagnosing fluid-filled cysts were assessed.

RESULTS

Overall, 31 cysts and eight solid masses (seven benign, one carcinoma) were diagnosed in the study and control groups. Aspiration of indeterminate lesions resulted in 20 cysts and one solid mass. Lesions ranged in size from 4 to 47 mm and in depth from 4 to 29 mm. In the control group, streaming detection correctly showed nine of the 11 simple cysts (sensitivity, 82%; positive predictive value, 100%), and acoustic streaming was absent in all seven solid masses (specificity, 100%; negative predictive value, 78%). Of the indeterminate lesions, streaming detection allowed correct identification of 10 of 20 cysts (sensitivity, 50%; positive predictive value, 100%). Acoustic streaming was not detected in the one solid study group lesion. Neither cyst size or depth nor fluid viscosity had a significant effect on the ability to detect fluid.

CONCLUSION

The streaming detection technique improved differentiation of cysts from solid masses in indeterminate lesions and has potential for reducing the number of recommended cyst aspirations for the diagnosis of indeterminate breast masses.

MRI-guided vacuum-assisted breast biopsy with a handheld portable biopsy system

OBJECTIVE

The purpose of this study was to evaluate a compact portable 10-gauge handheld battery-operated vacuum-assisted biopsy system for MRI-guided breast biopsy.

CONCLUSION

The compact portable battery-operated biopsy system can be used successfully for MRI-guided core breast biopsy and is an alternative to current systems.

Screening women at high risk for breast cancer with mammography and magnetic resonance imaging

BACKGROUND

The authors compared the performance of screening mammography versus magnetic resonance imaging (MRI) in women at genetically high risk for breast cancer.

METHODS

The authors conducted an international prospective study of screening mammography and MRI in asymptomatic, genetically high-risk women age >/= 25 years. Women with a history of breast cancer were eligible for a contralateral screening if they had been diagnosed within 5 years or a bilateral screening if they had been diagnosed > 5 years previously. All examinations (MRI, mammography, and clinical breast examination [CBE]) were performed within 90 days of each other.

RESULTS

In total, 390 eligible women were enrolled by 13 sites, and 367 women completed all study examinations. Imaging evaluations recommended 38 biopsies, and 27 biopsies were performed, resulting in 4 cancers diagnosed for an overall 1.1% cancer yield (95% confidence interval [95%CI], 0.3-2.8%). MRI detected all four cancers, whereas mammography detected one cancer. The diagnostic yield of mammography was 0.3% (95%CI, 0.01-1.5%). The yield of cancer by MRI alone was 0.8% (95%CI, - 0.3-2.0%). The biopsy recommendation rates for MRI and mammography were 8.5% (95%CI, 5.8-11.8%) and 2.2% (95%CI, 0.1-4.3%).

CONCLUSIONS

Screening MRI in high-risk women was capable of detecting mammographically and clinically occult breast cancer. Screening MRI resulted in 22 of 367 of women (6%) who had negative mammogram and negative CBE examinations undergoing biopsy, resulting in 3 additional cancers detected. MRI also resulted in 19 (5%) false-positive outcomes, which resulted in benign biopsies.

BI-RADS for sonography: positive and negative predictive values of sonographic features

OBJECTIVE

The purpose of this study was to assess the positive predictive value (PPV) and negative predictive value (NPV) of features described in the new sonographic BI-RADS lexicon for evaluating solid masses with known histologic diagnoses.

MATERIALS AND METHODS

Sonograms of 403 solid lesions were analyzed by one of three dedicated breast radiologists. Each lesion was described using features from the sonographic BI-RADS lexicon. Lesion description and biopsy results were correlated. PPV and NPV were calculated.

RESULTS

Histologic results showed that 141 (35%) of 403 masses were malignant. Sonographic BI-RADS descriptors showing high predictive value for malignancy include spiculated margin (86%, 19/22), irregular shape (62%, 102/164), and nonparallel orientation (69%, 75/109). Sonographic BI-RADS descriptors highly predictive of benign lesions include circumscribed margin (90%, 160/178), parallel orientation (78%, 228/294), and oval shape (84%, 200/237). For the sonographic BI-RADS features of mass margin, shape, orientation, lesion boundary, echo pattern, and posterior acoustic features, descriptors chosen were significantly (p < 0.001) different for malignant and benign masses.

CONCLUSION

Descriptors from the new sonographic BI-RADS lexicon can be useful in differentiating benign from malignant solid masses.

Comparison of recall and cancer detection rates for immediate versus batch interpretation of screening mammograms

PURPOSE

To retrospectively compare recall and cancer detection rates between immediate and subsequent batch methods for interpretation of screening mammograms.

MATERIALS AND METHODS

Institutional review board approval was obtained, and informed consent was waived. Retrospective analysis was performed for 8698 screening mammograms obtained between January 1 and October 31, 2001, which were interpreted either immediately (n = 4113) or subsequently with batch method (n = 4585). Data were collected from data reporting system and patient billing records. Patients with high risk factors were excluded; 3441 patients were in the immediate group, and 3932 were in the batch group. The two groups were compared with respect to age, breast density, and availability of comparison films with Wilcoxon rank sum test. Recall rates and cancer detection rates for each group were determined and compared with Pearson chi(2) test; false-negative rates were compared with Fischer exact test.

RESULTS

A significant difference (P < .001) was noted in recall rates between immediate (18%) and batch (14%) groups; however, no significant difference (P = .7) was noted in cancer detection rates (immediate, 0.5%; batch, 0.4%). Mean age of patients was 56.8 years (age range, 21-96 years) in the immediate group and 56.2 years (age range 24-98 years) in the batch group (P = .02). Comparison of breast densities between groups indicates no statistically significant difference (P = .4). The batch group had significantly fewer comparison mammograms (3106 [79%]) available than the immediate group (2856 [83%]) (P < .001). There was no significant difference in false-negative rates between the immediate group (0.1%) and the batch group (0.1%) (P > .99).

CONCLUSION

Immediate interpretation of screening mammograms resulted in a statistically significant increase in recalls and additional clinical work-ups of perceived abnormalities; however, no significant difference in cancer detection rate was detected between groups.

Stereotactic breast biopsy of noncalcified lesions: a cost-minimization analysis comparing 14-gauge multipass automated core biopsy to 14- and 11-gauge vacuum-assisted biopsy

A decision model was used to compare the relative costs of the 14-gauge automated gun technique to the 14-gauge and 11-gauge vacuum-assisted techniques for stereotactic biopsy of noncalcified breast lesions. Probability and cost variables were estimated from clinical experience with 76 automated gun biopsies, seventy-eight 14-gauge vacuum-assisted biopsies and thirty-nine 11-gauge vacuum-assisted biopsies. The 14-gauge automated gun was the preferred strategy from a cost standpoint: the 14-gauge vacuum technique was 1.19 times more expensive, and the 11-gauge was 1.22 times more expensive.

Accuracy of segmentation of a commercial computer-aided detection system for mammography

PURPOSE

To assess the accuracy of segmentation in a commercially available computer-aided detection (CAD) system.

MATERIALS AND METHODS

Approval for this study was obtained from the authors' institutional review board. Informed consent was not required by the board for this review, as data were stripped of patient identifiers. Two thousand twenty mammograms from 507 women were analyzed with the hardware and software of a commercial CAD system. The accuracy of the segmentation process was determined semiquantitatively and categorized as near perfect if the skin line of the breast was accurately detected, acceptable if only subcutaneous fat was excluded, or unacceptable if any breast parenchyma was excluded from consideration. The accuracy of segmentation was compared for different breast densities and film sizes by using logistic regression (P < .05).

RESULTS

Overall, segmentation was near perfect or acceptable in almost 96.8% of images. However, segmentation defects were significantly more common in mammograms with heterogeneously dense breast tissue (8% unacceptable) than in those with fatty replaced (0% unacceptable), scattered (1.2% unacceptable), or extremely dense (1.8% unacceptable) breast parenchyma (P < .05). For images with unacceptable segmentation, the average percentage of breast parenchyma excluded was almost 25% (range, 5%-100%), with no significant differences among breast densities.

CONCLUSION

For one commercial CAD system, segmentation was usually near perfect or acceptable but was unacceptable more than five times more frequently for mammograms of breasts with heterogeneously dense parenchyma than for those with all other breast densities. On average, one-quarter of the breast parenchyma was excluded from CAD analysis for images with unacceptable segmentation.

Computer-Aided Detection of Amorphous Calcifications

OBJECTIVE

Computer-aided detection (CAD) systems have been used successfully to detect malignant calcifications on mammography, with sensitivities ranging from 86% to 99%. Amorphous calcifications are a subset of small indistinct calcifications of intermediate concern that have a 20% likelihood of being malignant and that are frequently overlooked on mammography. The purpose of our study was to determine the sensitivity of one commercially available CAD system for detecting amorphous calcifications.

MATERIALS AND METHODS

A commercially available CAD system evaluated mammograms of 82 patients with 85 mammographically detected and histologically sampled groups of amorphous calcifications (21 malignant, 14 high risk, and 50 benign). The sensitivity of the system for detecting the calcifications on at least one image of the two-view mammographic examination (case sensitivity) and on each individual mammographic image (image sensitivity) was determined. Findings were correlated with results from large core needle biopsy or surgical excision in each case.

RESULTS

The CAD system detected amorphous calcifications in 43 of 85 cases (case sensitivity, 51%) and in 59 of 146 mammographic images (image sensitivity, 40%). The case sensitivities by histologic outcome were 57% for malignant calcifications, 29% for high-risk calcifications, and 54% for benign calcifications. An average of 2.0 false-positive marks were displayed per case.

CONCLUSION

The CAD sensitivity for malignant amorphous calcifications is markedly lower than previously reported for all malignant calcifications. Breast imaging radiologists who use CAD systems should continue to search diligently for these difficult-to-detect lesions.

Detection of Primary Breast Carcinoma with a Dedicated, Large-Field-of-View FDG PET Mammography Device: Initial Experience

PURPOSE

To prospectively assess a dedicated, large field of view positron emission tomography (PET) mammographic device for imaging primary breast carcinoma.

MATERIALS AND METHODS

Institutional review board approval was obtained for this study, and all patients provided written informed consent prior to participation. Subjects were recruited from a cohort of patients in whom diagnostic mammography and/or ultrasonography demonstrated lesions that were highly suggestive of malignancy. Twenty-three patients who met the inclusion criteria were subsequently imaged by using a dedicated PET mammography unit that was developed in conjunction with the Thomas Jefferson National Accelerator Facility (Newport News, Va). One hour after administration of 2.0-2.5 mCi (74.0-93.5 MBq) of fluorodeoxyglucose, 5-minute PET mammography of the affected breast was performed. Images were processed and reconstructed in the transverse craniocaudal and coronal planes. For each lesion, image-guided core-needle biopsy was performed immediately after PET mammography. Conventional mammography results and histologic findings were correlated with PET mammography images. The sensitivity, specificity, negative predictive value, and positive predictive value of PET mammography for demonstrating malignant lesions were calculated.

RESULTS

PET mammography demonstrated 20 focal abnormalities, of which 18 were malignant and two were benign. Both benign lesions represented areas of fat necrosis. Three of 20 malignant lesions demonstrated at conventional mammography were not demonstrated at PET mammography. The overall sensitivity of PET mammography for malignancy was 86% (95% confidence interval: 65%, 95%), with a positive predictive value of 90% (95% confidence interval: 70%, 97%). The calculated specificity was 33% (95% confidence interval: 2%, 79%), and the negative predictive value was 25% (95% confidence interval: 1%, 70%).

CONCLUSION

These pilot data suggest that PET mammography can demonstrate small primary breast malignancies.

Accuracy of a Collagen-Plug Biopsy Site Marking Device Deployed After Stereotactic Core Needle Breast Biopsy

OBJECTIVE

The goal of this study was to compare the accuracy of clip placement of a collagen-plug biopsy marking device with that of the more conventional, previously evaluated metallic tissue-marking clips. SUBJECTS AND METHODS. The placement accuracy of 31 collagen-plug marking devices was compared with the placement accuracy of 43 metallic marker clips deployed at biopsies performed between August 1, 2002, and November 20, 2002. The precision of marker placement was assessed by determining the position of the clip relative to the targeted mammographic lesion. Statistical analysis comparing the distance from the clip to the targeted lesion was performed.

RESULTS

Using a two-group Wilcoxon's rank sum test, we found the clip-to-target distances for the collagen-plug central titanium marker were significantly different from the clip-to-target distances of the conventional metallic marker clips (p = 0.04). There were significantly fewer cases in which the clip-to-target distance was 1 cm or greater on at least one mammographic projection with the collagen-plug marker (5/31) than with the conventional metallic marker clip (19/43) (chi-square test, p = 0.02).

CONCLUSION

The collagen-plug marking device is an effective alternative to existing marker clips, and use of this device may result in fewer cases in which the marker clip is substantially displaced (> or = 1 cm) away from the actual biopsy site.

Accuracy of MRI in the Detection of Residual Breast Cancer After Neoadjuvant Chemotherapy

OBJECTIVE

This study was undertaken to evaluate the ability of MRI to accurately show residual primary breast malignancy in women treated with neoadjuvant chemotherapy.

MATERIALS AND METHODS

Twenty-one patients with locally advanced primary breast carcinoma underwent contrast-enhanced MRI before and after treatment with neoadjuvant anthracycline-based chemotherapy. For each patient, the maximum extent of the MRI abnormality was measured both before and after treatment. These measurements were subsequently compared with physical examination findings and histologic results to determine the ability of MRI to accurately reveal tumor extent after neoadjuvant chemotherapy.

RESULTS

MRI after chemotherapy showed a correlation coefficient of 0.75 with histology, which was better than physical examination (r = 0.61). MRI underestimated the extent of residual tumor in two patients by more than 1 cm (including one false-negative examination), was within 1 cm in 12 of 21 patients, and overestimated tumor extent by more than 1 cm in seven of 21 patients.

CONCLUSION

MRI can show residual malignancy after neoadjuvant chemotherapy better than physical examination, particularly in patients who have not had a complete clinical response to therapy.

Computer-Aided Detection (CAD) in Screening Mammography:Sensitivity of Commercial CAD Systems for Detecting Architectural Distortion

OBJECTIVE

Computer-aided detection (CAD) algorithms have successfully revealed breast masses and microcalcifications on screening mammography. The purpose of our study was to evaluate the sensitivity of commercially available CAD systems for revealing architectural distortion, the third most common appearance of breast cancer.

MATERIALS AND METHODS

Two commercially available CAD systems were used to evaluate screening mammograms obtained in 43 patients with 45 mammographically detected regions of architectural distortion. For each CAD system, we determined the sensitivity for revealing architectural distortion on at least one image of the two-view mammographic examination (case sensitivity) and for each individual mammogram (image sensitivity). Surgical biopsy results were available for each case of architectural distortion.

RESULTS

Architectural distortion was deemed present and actionable by a panel of expert breast imagers in 80 views of the 45 cases. One CAD system detected distortion in 22 of 45 cases of distortion (case sensitivity, 49%) and in 30 of 80 mammograms (image sensitivity, 38%); it displayed 0.7 false-positive marks per image. Another CAD system identified distortion in 15 of 45 cases (case sensitivity, 33%) and 17 of 80 mammograms (image sensitivity, 21%); it displayed 1.27 false-positive marks per image. Sensitivity for malignancy-caused distortion was similar to or lower than sensitivity for all causes of distortion.

CONCLUSION

Fewer than one half of the cases of architectural distortion were detected by the two most widely available CAD systems used for interpretations of screening mammograms. Considerable improvement in the sensitivity of CAD systems is needed for detecting this type of lesion. Practicing breast imagers who use CAD systems should remain vigilant for architectural distortion.

Ultrasound guided pO2 measurement of breast cancer reoxygenation after neoadjuvant chemotherapy and hyperthermia treatment

The objective of this study was to determine whether neoadjuvant chemotherapy in combination with hyperthermia (HT) would improve oxygenation in locally advanced breast tumours. The study describes a new optimized ultrasound guided technique of pO2 measurement using Eppendorf polarographic oxygen probes in 18 stage IIB-III breast cancer patients. Prior to treatment, tumour hypoxia (median pO2<10 mmHg) was present in 11/18 patients (average median pO2=3.2 mmHg). Seven patients had well oxygenated tumours (median pO2 of 48.3 mmHg). Eight patients with hypoxic tumours prior to treatment had a significant improvement (p=0.0008) in tumour pO2 after treatment (pO2 increased to 19.2 mmHg). In three patients, tumours remained hypoxic (average median pO2=4.5 mmHg). The advantages of the ultrasound guided pO2 probe are in the accuracy of the Eppendorf electrode placement in tumour tissue, the ability to monitor electrode movement through the tumour tissue during the measurement and the ability to avoid electrode placement near or in large blood vessels by using colour Doppler imaging. The results of this preliminary study suggest that the combination of neoadjuvant chemotherapy and hyperthermia improves oxygenation in locally advanced breast tumours that are initially hypoxic.

Sonographic detection and sonographically guided biopsy of breast microcalcifications

OBJECTIVE

The purpose of this study was to evaluate the ability of sonography to depict and guide biopsies of mammographically suspicious microcalcifications and to reveal the mammographic features and histologic outcomes of lesions amenable to sonographically guided biopsy.

SUBJECTS AND METHODS

. Suspicious clusters of microcalcifications without other mammographic abnormalities were evaluated on sonography before biopsy and divided into two groups: those with and those without microcalcifications seen on sonography. Sonographically detected lesions underwent sonographically guided biopsy; lesions not seen on sonography underwent mammographically guided biopsy. Imaging features and histologies were correlated, and the positive predictive value of sonography was determined.

RESULTS

Of 111 lesions (105 patients), 26 lesions (23%) were identified and underwent sonographically guided biopsy; 85 lesions (77%) were not identified sonographically. The diameters of microcalcification clusters in the sonographically identified group were significantly larger (p = 0.0005) and contained larger numbers of microcalcification particles (p = 0.038) compared with clusters not identified sonographically. Sonographically identified lesions were seen as masses (77%) or dilated ducts (23%) with echogenic foci. Sonographically identified lesions were more likely to be malignant than those not seen on sonography (69% vs 21%, respectively; p < 0.00002). Of 38 malignant lesions, those visible on sonography were more likely to be invasive than those not seen on sonography (72% vs 28%, respectively; p = 0.018). In malignant lesions undergoing core biopsy and surgical excision, the extent of disease was underestimated less with sonographically guided biopsy (7%, 1/15) than with stereotactic biopsy (33%, 5/15).

CONCLUSION

Suspicious microcalcifications are seen infrequently on sonography (23%) but, when detected, can be successfully biopsied with sonographic guidance and more frequently are malignant and represent invasive cancer than those seen on mammography alone.

Diagnostic accuracy of digital mammography in patients with dense breasts who underwent problem-solving mammography: effects of image processing and lesion type

PURPOSE

To determine effects of lesion type (calcification vs mass) and image processing on radiologist's performance for area under the receiver operating characteristic curve (AUC), sensitivity, and specificity for detection of masses and calcifications with digital mammography in women with mammographically dense breasts.

MATERIALS AND METHODS

This study included 201 women who underwent digital mammography at seven U.S. and Canadian medical centers. Three image-processing algorithms were applied to the digital images, which were acquired with Fischer, General Electric, and Lorad digital mammography units. Eighteen readers participated in the reader study (six readers per algorithm). Baseline values for reader performance with screen-film mammograms were obtained through the additional interpretation of 179 screen-film mammograms. A repeated-measures analysis of covariance allowing unequal slopes was used in each of the nine analyses (AUC, sensitivity, and specificity for each of three machines). Bonferroni correction was used.

RESULTS

Although lesion type did not affect the AUC or sensitivity for Fischer digital images, it did affect specificity (P =.0004). For the General Electric digital images, AUC, sensitivity, and specificity were not affected by lesion type. For Lorad digital images, the results strongly suggested that lesion type affected AUC and sensitivity (P <.0001). None of the three image-processing methods tested affected the AUC, sensitivity, or specificity for the Fischer, General Electric, or Lorad digital images.

CONCLUSION

Findings in this study indicate that radiologist's interpretation accuracy in interpreting digital mammograms depends on lesion type. Interpretation accuracy was not influenced by the image-processing method.

Imaging-guided core needle biopsy of papillary lesions of the breast

OBJECTIVE

Our objective was to assess the incidence of papillary lesions of the breast diagnosed at imaging-guided core needle biopsy and the need for surgical excision after a benign diagnosis.

MATERIALS AND METHODS

This retrospective study included 1374 patients with consecutive suspicious breast lesions that underwent either mammography or sonographically guided large-core needle breast biopsy. Fifty-seven lesions (4%) were classified as papillary lesions. Eleven of the 57 cases were lost to follow-up (n = 6) or had not yet shown 2 years of stability (n = 5) and were excluded from this study. The remaining 46 papillary lesions constitute our study population.

RESULTS

Surgical excision was performed in 17 (37%) of 46 papillary lesions. In the group of patients whose lesions were recommended for excision because carcinoma was identified at core biopsy, surgical excision revealed one false-positive and two true-positive diagnoses. In four cases, histologic diagnoses of the excisional biopsy and the core needle biopsy were discordant. One false-positive finding at core needle biopsy initially was interpreted as invasive ductal carcinoma on the basis of core needle biopsy specimens. In three false-negative findings, the initial diagnosis at core needle biopsy was upgraded after surgical excision. Two cases of papilloma with adjacent atypical ductal hyperplasia and one of atypical papilloma were upgraded to ductal carcinoma in situ after surgical excision. Imaging follow-up was performed in the remaining 29 patients. All lesions were stable or had decreased in size during the 2-year follow-up period. The negative predictive value of core needle biopsy for excluding malignancy among the papillary lesions diagnosed in our study was 93%.

CONCLUSION

When the histologic diagnosis is benign, our data suggest that papillary lesions may be safely managed with imaging follow-up rather than with surgical excision. However, atypical papillary lesions or those associated with atypia require surgical excision because histologic underestimation occurs at a frequency similar to that in other atypical lesions undergoing core needle biopsy.

Malignant lesions initially subjected to short-term mammographic follow-up

PURPOSE

To determine whether systematically evaluated criteria for probably benign lesions were actually applied to lesions placed into that category.

MATERIALS AND METHODS

A search of the mammography database yielded 295 cases that were initially followed up with short-term interval mammography but eventually received a biopsy recommendation for the same breast. Of the 83 malignancies (81 patients) for which mammograms and pathology reports were available for review, 51 malignancies corresponded to the lesions for which short-term follow-up was recommended. Each case was retrospectively reviewed to determine whether the lesion followed up represented the subsequently diagnosed malignancy. Each lesion was characterized with appropriate Breast Imaging Reporting and Data System descriptors, based on the mammographic imaging available when short-term follow-up was first recommended. These characteristics were then used to determine if, in retrospect, the mammographic appearance met previously published criteria for probably benign lesions.

RESULTS

Of the 51 malignancies, 23 (45%) appeared mammographically as microcalcifications, 12 (24%) as masses, four (8%) as architectural distortion, and 12 (24%) as developing densities. None fulfilled strict criteria for a probably benign lesion when reviewed in retrospect. Forty-seven (92%) of 51 lesions had already demonstrated progression at the time of follow-up recommendation.

CONCLUSION

Short-term mammographic follow-up is often recommended for lesions that, in retrospect, do not fulfill established diagnostic criteria for probably benign lesions.

Sonographically guided biopsy of suspicious microcalcifications of the breast: a pilot study

OBJECTIVE

The purpose of this study is to evaluate the use of sonographic guidance for biopsy of mammographically detected suspicious microcalcifications.

SUBJECTS AND METHODS

Twenty-three patients with suspicious microcalcifications detected on mammography (15 associated with masses or distortion; eight with microcalcifications alone) underwent sonographically guided core biopsy (n = 18) or sonographically guided needle localization before excision (n = 5). Microcalcifications were targeted, and specimen radiographs were obtained for each lesion, with the success of the procedure based on identifying microcalcifications on the specimen radiograph. For core biopsies, the number of cores obtained was compared with that in 49 control patients who underwent sonographically guided core biopsy of noncalcified masses.

RESULTS

All 23 lesions (100%) were successfully biopsied under sonographic guidance, with microcalcifications seen on specimen radiographs in each case. Of 18 core biopsies, a mean of 8.7 cores was obtained compared with a mean of 5.5 cores in the control group (p<0.0001). Of 13 lesions sampled with core biopsy that subsequently underwent surgical excision, three (23%) were upgraded from atypical ductal hyperplasia to ductal carcinoma in situ (n = 1) and from ductal carcinoma in situ to invasive carcinoma (n = 2). Mammographically, most lesions contained more than 15 pleomorphic microcalcifications. On sonography, echogenic foci corresponded to microcalcifications in all but two cases in which broader echogenic regions were seen. When no mass or distortion was visible on mammography, sonography showed a mass or dilated ducts with internal echogenic foci.

CONCLUSION

Microcalcifications identifiable on sonography can be successfully biopsied under sonographic guidance. Further study is necessary to determine whether targeting microcalcifications seen sonographically in the mass or duct can improve the rate of underestimation of disease compared with stereotactic core biopsy.

Tissue harmonic imaging sonography of breast lesions: improved margin analysis, conspicuity, and image quality compared to conventional ultrasound

The purpose of this preference study is to determine if tissue harmonic imaging (THI) is preferred over conventional sonography for imaging breast masses. A prospective evaluation of 73 identical image pairs (one obtained with conventional sonography, one with THI sonography) was performed, examining 25 cysts, 36 solid masses, and 12 indeterminate lesions. Each image was evaluated for lesion contrast, margins, and overall image quality using a graduated score. Statistical analysis was performed using a modified t test. For cystic and solid lesions, THI was preferred for lesion conspicuity, margin, and overall quality (P<.001). For indeterminate lesions, THI was significantly preferred for lesion conspicuity and overall quality (P<.05), but the preference for margins was not significant. Overall, THI of breast lesions was significantly preferred for lesion contrast and margin evaluation compared to conventional sonography. This modality deserves further evaluation and may improve detection and evaluation of breast lesions.

Negative predictive value of sonography with mammography in patients with palpable breast lesions

OBJECTIVE

This study was performed to determine the negative predictive value of sonography with mammography in evaluating palpable breast lesions.

MATERIALS AND METHODS

Four hundred twenty patients with 455 palpable breast lesions were retrospectively identified from our mammography database as having negative mammographic and sonographic results. For patients diagnosed with breast cancer, images and medical records were reviewed to determine whether the palpable lesion evaluated on sonography and mammography corresponded to the patient's breast cancer. On the basis of the number of breast cancers that correlated to the palpable areas imaged, the negative predictive value of sonography with mammography was determined.

RESULTS

Sixty-two of the 420 patients in the study group were already diagnosed with breast carcinoma, and eight new carcinomas were diagnosed during the study period. Only one of six ipsilateral cancers corresponded to a palpable lesion that had a negative imaging evaluation. This lesion was diagnosed as an invasive lobular cancer, hard and fixed at physical examination. Imaging and clinical follow-up of the remaining patients showed no abnormality at the sites of previously investigated palpable abnormalities. The mean imaging follow-up was 25 months. The negative predictive value of sonography and mammography in the setting of a palpable lesion was 99.8%.

CONCLUSION

The negative predictive value of sonography with mammography is high, and together these imaging modalities can be reassuring if follow-up is planned when the physical examination is not highly suspicious. However, if the physical examination is suspicious, biopsy should not be delayed.

Metallic clip deployment during stereotactic breast biopsy: retrospective analysis

PURPOSE

To determine the visibility of presumably excised lesions on screen-film mammograms obtained after biopsy and to determine the accuracy of clip deployment on the basis of measurements obtained on routine pre- and postbiopsy mammograms.

MATERIALS AND METHODS

One hundred eleven cases of core-needle biopsy with clip deployment were reviewed. In each, the type of lesion, lesion location, and biopsy approach were recorded. Pre- and postbiopsy images were reviewed, and the distance between the clip and biopsy site was measured. Postbiopsy images were reviewed to determine whether the targeted lesion remained visible.

RESULTS

In 62 (56%) cases, the clip was located within 5 mm of the target on postbiopsy images (craniocaudal and mediolateral), while in 18 (16%), the clip was within 6-10 mm on one projection. However, 31 (28%) clips were more than 1 cm from the target on at least one postbiopsy image. Of the 111 cases, 39 (35%) were malignant or atypical and required excision. Of these, 18 (46%) had clips at least 1 cm from the targeted lesion on at least one projection.

CONCLUSION

Metallic clips placed during core-needle breast biopsy are intended to mark the biopsy site when the visible lesion is excised, in case additional biopsy is required. The data suggest that the position of metallic clips placed during stereotactic core-needle biopsy may differ substantially from the location of the biopsy site. Postbiopsy mammography should be performed in two orthogonal planes to document clip position relative to the biopsy site.

Focal fibrosis: a common breast lesion diagnosed at imaging-guided core biopsy

OBJECTIVE

Focal fibrosis is a benign breast lesion commonly diagnosed by imaging-guided core biopsy. The goal of this study is to determine the frequency of focal fibrosis diagnosed at core biopsy and to describe its imaging features.

MATERIALS AND METHODS

A consecutive series of 894 imaging-guided breast core biopsies were reviewed, and all cases of focal fibrosis were selected. The imaging features of each lesion were characterized. All lesions had been reviewed during radiologic-histologic review sessions to assess for accurate needle positioning and concordant results. Follow-up imaging and histologic data were reviewed to document lesion stability.

RESULTS

Focal fibrosis was diagnosed in 80 (8.9%) of 894 imaging-guided core biopsies: 20 (8.7%) of 229 sonographically guided biopsies and 60 (9.0%) of 665 mammographically guided biopsies. Of 75 mammographically visible lesions, 39 (52%) were masses, 29 (39%) were densities, and seven (9.3%) were clusters of calcifications. Thirty-five hypoechoic lesions were visualized on sonography: 29 (80%) were oval, and six (17%) were irregularly shaped. Six (21%) of the 28 oval masses showed posterior enhancement, four (14%) posterior shadowing, and 19 (68%) neither feature. Fifty-two (65%) of 80 patients with focal fibrosis had routine imaging follow-up; all had stable findings (mean follow-up period, 27 months). No false-negative cases were identified.

CONCLUSION

Focal fibrosis most commonly appears as an enlarging solid mass or developing density on mammography or as an oval mass on sonography. Our data suggest that focal fibrosis accounts for 9% of lesions that undergo imaging-guided core biopsy and that the diagnosis can be accurately reached using imaging-guided biopsy.

Outcome analysis for women undergoing annual versus biennial screening mammography: a review of 24,211 examinations

OBJECTIVE

Our goal was to determine differences in outcome measures between women undergoing annual versus biennial screening mammography.

MATERIALS AND METHODS

A retrospective review of prospectively collected data on 24,211 consecutive screening mammography examinations was performed in women aged 40-79 years, all of whom had undergone previous normal screening mammography. Annual screening and biennial screening were defined as examinations performed 10-14 months and 22-26 months, respectively, after previous normal screening mammography. The rates of recall, biopsy, cancer detection, and interval cancer for annual and biennial screening cohorts were calculated, as were tumor size, lymph node status, and stage of invasive cancer. Interval cancer cases were identified by linkage with a regional tumor registry.

RESULTS

Of the 4306 biennially screened women, 160 were recalled (3.7%), 45 were biopsied (1.0%), and cancer was detected in 19 (0.44%). Of the 19,905 annually screened women, 518 were recalled (2.6%), 150 were biopsied (0.75%), and cancer was detected in 71 (0.36%). Of the 3278 registry-linked biennially screened women, five had interval cancer (0.15%); of the 15,031 registry-linked annually screened women, 10 had interval cancer (0.07%). For biennial screening-detected cancer and interval invasive cancer combined, the median tumor size was 15 mm, 24% had lymph node metastasis, and 29% were stage 2 or higher. For annual screening-detected cancer, these measures were 11 mm, 14% positive nodes, and 17% stage 2+ cancer, respectively.

CONCLUSION

Annual screening mammography results in lower recall rates than does biennial screening (p < .0001). Moreover, annual screening results in the detection of smaller tumors that have a more favorable prognosis (p = .04).

Ability of mammography to reveal nonpalpable breast cancer in women with palpable breast masses

OBJECTIVE

Our goal was to determine the frequency with which mammography reveals nonpalpable malignancies in women with benign palpable masses and to compare these nonpalpable malignancies with the palpable malignancies and nonpalpable malignancies detected in asymptomatic women.

SUBJECTS AND METHODS

This study of nominally asymptomatic women involved 85,399 consecutive mammographic examinations, of which 3459 (4.1%) examinations were performed on women who had palpable masses identified before or at the time of mammography. A medical outcomes audit identified mammographic examinations after which breast cancer was diagnosed and determined selected surrogate measures for mortality reduction for the mammographically detected malignancies.

RESULTS

Of the 3459 examinations in women with palpable masses, 64 cases of cancer were revealed by mammography. Of these, 54 cases involved palpable malignancies (15.6/1000 examinations) and 10 involved nonpalpable malignancies (2.6/1000 examinations). Of the 81,940 examinations in asymptomatic women, 346 cases of nonpalpable cancer were detected (4.2/1000 examinations). Of the 10 cases of nonpalpable cancer detected in women with benign palpable masses, median tumor size was 13.8 mm, 10% had axillary node metastasis, and 10% were stage 2 or higher. The corresponding surrogate measures for cases of nonpalpable cancer detected in asymptomatic women were median tumor size, 13.6 mm; node metastasis, 7%; stage 2 or higher, 14%. The surrogate measures for the 54 palpable malignancies were median tumor size, 23.7 mm; node metastasis, 31%; stage 2 or higher, 63%.

CONCLUSION

The surrogate measures for the nonpalpable malignancies in women with benign palpable lesions resemble those in asymptomatic women and are much more favorable than those of palpable malignancies. Therefore, in women with a palpable breast mass, it is important to use mammography to screen the remainder of both breasts for nonpalpable cancer.

American Nursing Informatics Association role survey

A descriptive study, using a survey approach, was conducted among 48 American Nursing Informatics Association (ANIA) member respondents to determine the nursing informatics role among professional nurses working in the specialty. Members were asked to complete a survey regarding their current position, educational and work experience, continuing education, and work challenges. Although the ages of the informatics nurses parallel the national, range, most have been in the field of nursing informatics for 2.5 to 5 years and in their current position only 1.5 to 2 years. Job responsibilities and challenges indicate common issues and concerns that have implications for the specialty of nursing informatics and nursing in general.

Nonenzymatic glycosylation of proteins and protease activities in granulation tissues in experimental diabetes

Serum proteins and hemoglobins show increased nonenzymatic glycosylation in diabetes mellitus. The measure of glycosylated proteins, particularly hemoglobin, is considered to be a preferred indicator in the control of diabetes. In a study of diabetes and inflammation, we assessed the extent of nonenzymatic glycosylation of proteins of granulation tissue from diabetic rats. Five, seven, and ten days after carrageenan injection, the granuloma proteins were extracted. Nonenzymatic glycosylation was measured in soluble and insoluble granuloma proteins by thiobarbituric acid assay. Protease activities and free amino groups were assayed in soluble extracts. Nonenzymatic glycosylation in soluble proteins of both groups reached a maximum on the seventh day. However, nonenzymatic glycosylation in soluble proteins of the diabetic granulomas was significantly greater than the controls on days five and seven. During the days after granuloma induction, nonenzymatic glycosylation in the insoluble granuloma tissue proteins gradually decreased without any significant differences between controls and diabetics. Significant decreases in the free amino groups in soluble proteins of the diabetic tissues were noted. Greater activities of cathepsins B and D were noted in diabetic tissues over controls. These observations suggest that, in addition to increased proteolysis, increased nonenzymatic glycosylation of tissue proteins could be associated with the impaired process of wound healing in diabetics.

Glycoprotein biosynthesis during inflammation in normal and streptozotocin-induced diabetic rats

Extracellular glycoproteins play an important role in wound healing; yet little is known about glycoprotein biosynthesis and its regulation by insulin in inflammation. Using [1-14C] fucose as a marker, glycoprotein biosynthesis was studied in carrageenan-induced granuloma from diabetic and control rats. Fucose incorporation into glycoproteins was followed for 24 h after an intraperitoneal injection of the label. Radioactivity in trichloroacetic acid precipitable serum glycoproteins and saline-soluble and insoluble glycoproteins was assessed in five-, seven-, and ten-day-old granuloma tissues. Fucose incorporation was higher in soluble glycoproteins (P less than 0.01) at all points in controls than in diabetic granulomas, and peak incorporation was reached in both groups on the seventh day. Incorporation of fucose into insoluble glycoproteins was higher in normals on the seventh day than in diabetics. Liver-, kidney-, and intestine-soluble glycoproteins showed a maximum incorporation on the seventh day, but no difference was noted between diabetic and normal rats. Incorporation of fucose in insoluble glycoproteins showed a gradual decline with the age of granuloma in all tissues from both groups, with the exception of the kidney. In the kidney, fucosylation of insoluble glycoproteins was decreased (P less than 0.01) in diabetics compared to controls. These results indicate an active phase of biosynthesis, with an increase in glycosylation during inflammation that is probably insulin dependent.

Factors influencing referral decisions in physiatry

As the population ages and more emphasis is placed on patient management than on curative exercise, physical medicine gains an important place in medical specialties. This study investigates the referral behavior in physiatry and compares it with referrals to other specialties. From a sample of 159 primary care physicians in the St. Louis metropolitan area who have a high probability of using physical medicine and rehabilitation, a referral model in physiatry was constructed. The results indicate that while the traditional determinants of referral decision play a significant role in influencing the referral behavior in physiatry, there also is a group of variables in physiatry that are significantly different from those of other subspecialties in determining referral process.