Value of Hand-held Ultrasound in the Differential Diagnosis and Accurate Breast Imaging Reporting and Data System Subclassification of Complex Cystic and Solid Breast Lesions

To explore the value of hand-held ultrasound (HHUS) for diagnosing complex cystic and solid breast lesions, 472 pathologically proven lesions were analyzed. The lesions were divided into four types based on ultrasound features. Positive predictive values (PPVs) for lesion types and risk factor performances were assessed. Furthermore, HHUS and mammography (MAM) performances were compared: 27 lesions missed in MAM were detected in HHUS. Ultrasound feature analysis revealed higher PPVs for type III and IV lesions than for type I and II lesions. In patients older than 51 y, a type III or IV lesion with a diameter greater than 18 mm, an irregular shape, a non-parallel orientation, an uncircumscribed margin, calcification, vascularity and abnormal axillary lymph nodes were suggestive of malignancy; the area under the curve reached 0.869. Thus, ultrasound is useful in diagnosing complex cystic and solid breast lesions, which should be categorized as Breast Imaging Reporting and Data System (BI-RADS) 4B or 4C.

Serum Prolactin Levels in Women with Gross Cystic Breast Disease

Serum prolactin (PRL) concentrations at baseline and after TRH stimulation were determined in 15 healthy women and in 51 premenopausal patients suffering from Gross Cystic Breast Disease. All women were in the luteal phase of the menstrual cycle and patients were divided into three groups according to cyst type at presentation. Basal hormone levels were within the normal range in the control group and in the three cystic breast disease groups. The maximum PRL response to TRH stimulation was significantly higher (p < 0.001) in patients with type I cysts (low Na+/K+ intracystic ratio and apocrine epithelium) than in patients with type II cysts (high Na+/K+ intracystic ratio and flattened epithelium), type III cysts (intermediate Na+/K+ intracystic ratio and mixed epithelium) and in normal women. Serum PRL concentrations corresponding to samples obtained 60 and 90 minutes after stimulation remained higher in the first group of patients. These results led us to consider the existence of an altered central regulation of PRL secretion in patients with type I cysts at presentation.

Computer-aided diagnosis of breast masses using quantified BI-RADS findings

The information from radiologists was utilized in the proposed computer-aided diagnosis (CAD) for breast tumor classification. The ultrasound (US) database used in this study contained 166 benign and 78 malignant masses. For each mass, six quantitative feature sets were used to describe the radiologists' grading of six Breast Imaging Reporting and Data System (BI-RADS) categories including shape, orientation, margins, lesion boundary, echo pattern, and posterior acoustic features on breast US. The descriptive abilities were between 76% and 82% and the predicted descriptors were then used for tumor classification. Using receiver operating characteristic curve for evaluation, the area under curve (AUC) of the proposed CAD was slightly better than that of a conventional CAD based on the combination of all quantitative features (0.96 vs. 0.93, p=0.18). The partial AUC over 90% sensitivity of the proposed CAD was significantly better than that of the conventional CAD (0.90 vs. 0.76, p<0.05). In conclusion, the computer-aided analysis with qualitative information from radiologists showed a promising result for breast tumor classification.

Typical and unusual sonoelastographic patterns of breast cystic lesions: impact on BI-RADS classification

PURPOSE

To describe the sonoelastographic appearance of breast cysts (simple, complicated-cysts with sedimentation and complex-cysts with internal solid parts). To assess the influence of sonoelastography on the BI-RADS classification of complicated cysts.

MATERIALS AND METHODS

A prospective study was conducted and all cysts diagnosed by the same radiologist between May 2007 and July 2008 in our breast unit were included. Each lesion was assessed according to BI-RADS and the Tsukuba elasticity score using a Hitachi 8500 US device. Cytology or histopathology was obtained for complicated and complex cysts.

RESULTS

49 simple, 43 complicated and 14 complex cysts were detected. The elasticity patterns were divided into 4 categories: typical BGR (blue-green-red) pattern, appearance similar to that described for solid. lesions, variants of BGR, an inverse score of 3. The BGR pattern was predominant in breast cysts. Atypical elasticity patterns were mostly associated with complicated and complex cysts. BI-RADS classification of complicated cysts before and after elastography showed a statistically significant difference in terms of final category assessment (most of the complicated cysts were downgraded to BI-RADS 2 after elastography).

CONCLUSION

Being aware of the wide spectrum of elastographic patterns of breast cysts and considering elastography when assessing the BI-RADS category of complicated cysts may lead radiologists to better patient management.

Multicenter study of ultrasound real-time tissue elastography in 779 cases for the assessment of breast lesions: improved diagnostic performance by combining the BI-RADS®-US classification system with sonoelastography

PURPOSE

Hitachi real-time tissue elastography (HI-RTE) is an ultrasound technique that facilitates the estimation of tissue elasticity. Our study evaluates whether sonoelastography improves the differentiation of benign and malignant breast lesions.

MATERIALS AND METHODS

In a multicenter approach sonoelastography of focal breast lesions was carried out in 779 patients with subsequent histological confirmation. We present data from 3 study centers (Berlin, Bielefeld, Homburg/Saar) focusing on the sensitivity (SE), specificity (SP) and the positive (PPV) and negative predictive value (NPV) of sonoelastography. In addition we performed an analysis of the diagnostic performance, expressed by the pretest and posttest probability of disease (POD), in BI-RADS®-US 3 or 4 lesions as these categories can imply both malignant and benign lesions and a more precise prediction would be a preferable aim.

RESULTS

Sonoelastography demonstrated an improved SP (89.5 %) and an excellent PPV (86.8 %) compared to B-mode ultrasound (76.1 % and 77.2 %). Especially in dense breasts ACR III-IV, the SP was even higher (92.8 %). In BI-RADS-US 3 lesions, a suspicious elastogram significantly modified the POD from 8.3 % to a posttest POD of 45.5 %. In BI-RADS-US 4 lesions, we found a pretest POD of 56.6 %. The posttest POD changed significantly to 24.2 % with a normal elastogram and to 81.5 % with a suspicious elastogram.

CONCLUSION

Our data demonstrates that the complementary use of sonoelastography definitely improves the performance in breast diagnostics. Finally we present a protocol of how sonoelastography can be integrated into our daily practice.

Computer aided classification system for breast ultrasound based on Breast Imaging Reporting and Data System (BI-RADS)

Clinically, the ultrasound findings are evaluated by its sonographic characteristics and then assigned to assessment categories according to the definitions of Breast Imaging Reporting and Data System (BI-RADS) developed by the American College of Radiology. In this study, a computer-aided classification (CAC) system was proposed to classify the masses into assessment categories 3, 4 and 5, which simulated the clinical diagnosis of radiologists. Compared with current computer-aided diagnosis systems, the proposed CAC system classifies the indeterminate cases into BI-RADS category 4 for further diagnosis. Six hundred twenty-six cases were collected from three ultrasound systems and confirmed by pathology and retrospectively classified into categories 3, 4 and 5 by radiologists. The multinomial logistic regression model was trained as the CAC system for predicting the assessment category from the computerized BI-RADS features and from a set of machine-dependent factors. By using the machine-dependent factors to indicate the adopted ultrasound systems, the same regression model could be applied for the cases acquired from different ultrasound systems. A basic CAC system was trained by using the classification result of radiologists. A weighted CAC system, to improve the capacity of the basic CAC system in differentiating benign from malignant lesions, was trained by adding the pathologic result. Between the radiologists and the basic CAC system, a substantial agreement was indicated by Cohen's kappa statistic and the differences in either the performance indices or the A(Z) of receiver operating characteristic (ROC) analysis were not statistically significant. For the weighted CAC system, the performance indices accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 73.00% (457 of 626), 98.17% (215 of 219), 59.46% (242 of 407), 56.58% (215 of 380) and 98.37% (242 of 246), respectively; the A(Z) was 0.94; and the correlation with the radiologists was also substantial agreement. The indices accuracy and specificity of weighted CAC system, compared with those of the radiologists, were improved by 5.91% and 8.85%, respectively and the indices of sensitivity and NPV, compared with those of a conventional CAD system, were improved by 10.5% and 5.21%, respectively; all improvements were statistically significant. To classify the mass into BI-RADS assessment categories by the CAC system is feasible. Moreover, the proposed CAC system is flexible because it can be used to diagnose the cases acquired from different ultrasound systems.

Is grading of breast fibrosis with mammography feasible?

PURPOSE

To establish a grading system for mammographic fibrosis and correlate it with clinical fibrosis.

PATIENTS AND METHODS

Analogous to the LENT/SOMA scale a four-tiered scoring scale of breast fibrosis in mammography (G0 = absent, G1 = barely increased density, G2 = definitely increased density to G3 = very marked density) was established by two observers in a group of 16 patients. Reference mammograms were selected. Independently and blinded to clinical results, three observers scored the fibrosis in mammograms of further 31 patients examined by one radiation oncologist in a cross-sectional follow-up study. Pretreatment parenchyma density was judged according to the American College of Radiology (ACR). Interobserver correlation of mammography scoring as well as correlation of mammography and clinical findings were calculated with Cohen's weighted kappa. All patients had breast-conserving surgery and axillary resection for breast carcinoma T1-2N0-1. The breast was irradiated to a median reference dose of 55 Gy (range 50-60 Gy) with 2 Gy five times weekly or 2.5 Gy four times weekly. Two patients received chemotherapy, 14 patients tamoxifen. Median age was 55 years, median follow-up 8 years (4-15 years).

RESULTS

14 of 31 patients had clinical fibrosis, twelve G1 and two G2. In mammography, mild fibrosis (G1) was seen in 12/12/18 patients (observer 1/2/3) and moderate fibrosis (G2) in 9/10/2 patients. Interobserver correlation for observers 1 and 2 who had developed the score was fair (Cohen's weighted kappa 0.64, 95% confidence interval 0.4-0.88). However, it was weak for observer 3 (0.36 and 0.42, respectively) who relied on reference mammograms only. Independent interobserver correlation of pretreatment breast density was good for all observers (Cohen's weighted kappa 0.73-0.8). The correlation of fibrosis by mammography and palpation was weak (Cohen's weighted kappa 0.32-0.42).

CONCLUSION

Grading fibrosis as depicted by mammography is possible, especially if observers prepare by jointly analyzing a training group. It may be useful to study treatment effects, e. g., of fractionation or drugs, because retrospective and repeated analysis is possible. The correlation of mammography with clinical grading should be further evaluated with more objective clinical reference tools.

[Fibrocystic mastopathy and cancer of the breast. About 111 cases]

OBJECTIVE

Our aim was to identify the predictive factors of degeneration of the fibrocystic mastopathy.

METHODS

This work is a retrospective survey of 111 observations of isolated fibrocystic mastopathies or associated to a breast cancer among 542 women admitted for tumor of the breast during one period of 13 active years from 1991 to 2003. The diagnosis has been gotten by anatomo-pathologic exam in 95.5% (106 cas) on the operative piece and 4.5% (5 cas) on a material of biopsy.

RESULTS

The fibrocystic mastopathy represented 30% of the set of the benign tumors of the breast. They were associated to a breast cancer in 45 cases (40.5%). The isolated benign fibrocystic mastopathy was observed in 66 cases with a middle age of 37 years, whereas the shapes associated to a breast carcinoma were noted in 45 cases. The middle age was 53 years. The non proliferative fibrocystic mastopathy is the most frequent histological type and represent 54.6% of the cases. The proliferative form with atypies was observed at 21 women (46.8%). The carcinoma the more frequently associated to the fibrocystic mastopathy was the infiltrating canalled carcinoma in 91% of cases, with a predominance of the II rank (SBR).

CONCLUSION

The discovery of a mastopathy must search a luteal failure and risk factors of breast cancer notably a proliferative shape of mastopathy with atypies.

Profile of breast lesions among women with positive biopsy findings in Yemen

This study described the profile of breast pathology based on records from a reference histopathology laboratory in Yemen of 773 women with positive biopsy or mastectomy findings. Cancers were classified according to the International classification of diseases for oncology. Benign lesions were found in 79.9% of cases. Fibroadenoma was the most prevalent lesion (30.0%) with a mean age at presentation of 22.2 years, followed by fibrocystic disease (27.4%) and breast inflammation (13.1%). Invasive carcinoma was found in 155 cases (20.1%), at a mean age of 44.7 years.

Multimodality computerized diagnosis of breast lesions using mammography and sonography

RATIONALE AND OBJECTIVES

The purpose of this study is to investigate the use of computer-extracted features of lesions imaged by means of two modalities, mammography and breast ultrasound, in the computerized classification of breast lesions.

MATERIAL AND METHODS

We performed computerized analysis on a database of 97 patients with a total of 100 lesions (40 malignant, 40 benign solid, and 20 cystic lesions). Mammograms and ultrasound images were available for these breast lesions. There was an average of three mammographic images and two ultrasound images per lesion. Based on seed points indicated by a radiologist, the computer automatically segmented lesions from the parenchymal background and automatically extracted a set of characteristic features for each lesion. For each feature, its value averaged over all images pertaining to a given lesion was input to a Bayesian neural network for classification. We also investigated different approaches to combine image-based features into this by-lesion analysis. In that analysis, mean, maximum, and minimum feature values were considered for all images representing a lesion. We considered performance by using a leave-one-lesion-out approach, based on image features from mammography alone (two to five features), ultrasound alone (three to four features), and a combination of features from both modalities (three to five features total).

RESULTS

For the classification task of distinguishing cancer from other abnormalities in a lesion-based analysis by using a single modality, areas under the receiver operating characteristic curves (A(z) values) increased significantly when the computer selected the manner (mean, minimum, or maximum) in which image-based features were combined into lesion-based features. The highest performance was found for lesion-based analysis and automated feature selection from mean, maximum, and minimum values of features from both modalities (resulting in a total of four features being used). That A(z) value for the task of distinguishing cancer was 0.92, showing a statistically significant increase over that achieved with features from either mammography or ultrasound alone.

CONCLUSION

Computerized classification of cancer significantly improved when lesion features from both modalities were combined. Classification performance depended on specific methods for combining features from multiple images per lesion. These results are encouraging and warrant further exploration of computerized methods for multimodality imaging.

Time-domain optical mammography SoftScan: initial results

RATIONALE AND OBJECTIVES

Near-infrared (NIR) technology appears promising as a noninvasive technique for breast cancer screening and diagnosis. The technology capitalizes on the relative transparency of human tissue in this spectral range and its sensitivity to the main components of the breast: water, lipid, and hemoglobin. In this study, the authors report quantitative measurements of these components and the functional contrast between healthy and diseased tissue.

MATERIALS AND METHODS

A four-wavelength time domain optical imaging system was used to perform noninvasive NIR measurements in the breast of 49 women both pre- and postmenopausal, ages 24-80. Algorithms based on a diffusive model of light transport provided absolute bulk and local values of breast constituent concentrations.

RESULTS

Important variations in the functional and structural NIR properties of the breast were observed. Demographics trend were noticed in accordance with breast physiology. In the 23 cases imaged with suspicious masses, the optical images were consistent with the mammographic findings. Substantial contrast between masses and adjacent tissue is observed. Moreover, consistent differences between malign and benign cases are found with optical imaging.

CONCLUSION

The results of this pilot study illustrate the sensitivity of optical techniques to the composition of the breast. In addition, preliminary data suggest that benign and malignant tumors can potentially be noninvasively differentiated with optical imaging. Moreover, statistically significant discrimination based on deoxy-hemoglobin content between malign and benign cases was found with optical imaging (P = .0184, one-tailed t test).

[Clinical research on relationship between angiogensis and TCM syndrome type of cyclomastopathy]

OBJECTIVE

To study the relationship between angiogensis and TCM Syndrome type of cyclomastopathy (CMP) to investigate the objective standardization of TCM Syndrome diagnosis of the disease.

METHODS

One hundred and forty patients with CMP were divided into three groups according to TCM syndrome typing. The pathological type, grade and expressions of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF) and microvascular density (MVD) in mammary biopsy were observed.

RESULTS

The expressions of VEGF, bFGF and MVD was different in CMP patients of different TCM types and pathological grades (P < 0.05). The proportion of atypical proliferation, the count of MVD and the expression of VEGF and bFGF were higher in patients of phlegm and stasis type than those in Gan stagnation caused Qistagnation type and Chong and Ren meridians disorder type.

CONCLUSION

TCM Syndrome type of CMP patients is related with vascular activity and grade of angiogensis. The pathological characteristics of mammary tissue and expression of VEGF, bFGF and MVD can be regarded as the objective indexes of TCM typing and clinical efficacy evaluation for CMP.

A case-control study of risk factors for fibrocystic breast conditions: Shanghai Nutrition and Breast Disease Study, China, 1995-2000

This study was conducted to identify reproductive and dietary factors associated with benign proliferative mammary epithelial cell changes. Subjects were women enrolled in a randomized trial of breast self-examination in Shanghai, China. Women who developed fibrocystic breast conditions classified as nonproliferative (175 women), proliferative (181 women), or proliferative with atypia (33 women) between 1995 and 2000 and 1,070 unaffected trial participants were administered general risk factor and food frequency questionnaires. Conditional logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals. High parity and consumption of fresh fruits and vegetables were more strongly associated with a reduced risk of proliferative and atypical lesions than with nonproliferative conditions. For the fourth quartile of consumption versus the first, odds ratios for lesions diagnosed as nonproliferative, proliferative, and proliferative with atypia were 0.4 (95% confidence interval (CI): 0.2, 0.7), 0.2 (95% CI: 0.1, 0.4), and 0.1 (95% CI: 0.03, 0.5), respectively, for fruit intake and 0.6 (95% CI: 0.3, 1.1), 0.4 (95% CI: 0.2, 0.7), and 0.1 (95% CI: 0.1, 0.9), respectively, for vegetable intake. Reduced but nonsignificant risks in relation to soy products were observed for proliferative and atypical lesions. No single nutrient or botanical family was appreciably more strongly associated with proliferative conditions than with nonproliferative conditions, after results were controlled for total fruit and vegetable consumption. A diet rich in fruits and vegetables may reduce cellular proliferation in the mammary epithelium; this is one mechanism by which such a diet could reduce risk of breast cancer.

Computer-aided classification of BI-RADS category 3 breast lesions

PURPOSE

To evaluate a system for computer-aided classification (CAC) of lesions assigned to Breast Imaging Reporting and Data System (BI-RADS) category 3 at conventional mammographic interpretation.

MATERIALS AND METHODS

A CAC system was used to analyze 106 cases of lesions (42 malignant) that at blinded retrospective interpretation were assigned to BI-RADS category 3 by at least two of four radiologists. The CAC system automatically extracted from the digitized mammograms quantitative features that characterized the lesions. The system then used a classification scheme to score the lesions by the likelihood of their malignancy on the basis of these features. The classification scheme was trained with 646 pathologically proved cases (323 malignant), and the results were tested with receiver operating characteristic (ROC) analysis by using the jackknife method. Sensitivity, specificity, positive predictive value, and accuracy were calculated. Category 3 lesions were stratified among BI-RADS categories 2-5 according to CAC-assigned lesion score, and this classification was compared with the results of pathologic analysis.

RESULTS

Jackknife analysis of CAC results in the training data set yielded a sensitivity of 94%, specificity of 78%, positive predictive value of 81%, and area under the ROC curve of 0.90. Of the 42 malignant lesions that had been classified at conventional interpretation as probably benign, nine were assigned by the CAC system to BI-RADS category 4, and 29 were assigned to category 5. The CAC system correctly upgraded the BI-RADS classification of these 38 lesions (sensitivity, 90%) and incorrectly upgraded the classification of only 20 benign lesions (specificity, 69%).

CONCLUSION

The CAC system scored 38 of the 42 malignant lesions initially assigned to BI-RADS category 3 as BI-RADS category 4 or 5, and thus correctly upgraded the category in 90% of these lesions.

[Columnar lesions: a frequent diagnosis in breast pathology!]

Lesions characterized by the presence of columnar epithelial cells lining the terminal duct lobular units (TDLUs) of the breast are being encountered with increasing frequency in breast biopsies performed because of the presence of mammographic microcalcifications. Those lesions in the large majority of the cases are benign. They should be classified into two categories: columnar cell change or columnar cell hyperplasia. Their specific immunophenotype (ER and PR +, Bc12 +) distinguish them from apocrine lesions. Some of them present in addition, cytologic atypia or architectural atypia. When architectural atypia is associated, a careful search for atypical ductal hyperplasia or for low grade DCIS needs to be performed, especially on vacuum assisted macrobiopsies for an appropriate management of the patient.

Aspiration biopsy of mammary lesions with abundant extracellular mucinous material. Review of 43 cases with surgical follow-up

We reviewed 43 fine-needle aspiration biopsy (FNAB) smears with abundant extracellular mucinous material to determine whether accurate classification of mucinous lesions is achievable on FNAB: 26 had carcinoma (pure colloid carcinoma [CCA], 23; mixed CCA/invasive ductal carcinoma [IDC], 3); 17 had benign lesions on follow-up (benign MLL, 6; fibrocystic change [FCC], 6; myxoid fibroadenoma [MFA], 5). All carcinomas were identified correctly as malignant on FNAB. The initial cytologic diagnoses in benign cases were benign in 8, atypical in 8, and "suspicious" for carcinoma in 1. CCAs were moderate to markedly cellular with mild to moderate atypia and lacked oval bare nuclei. Marked nuclear atypia was confined predominantly to cases with mixed CCA/IDC. A distinct feature of CCA was thin-walled capillaries. FCCs and benign MLLs had overlapping cytologic features and showed variable cellularity and no or mild atypia. MFAs were markedly cellular with dyscohesion and variable atypia; stromal fragments and oval bare nuclei were present in every case. Mucinous lesions can be divided into 2 categories by FNAB: those that are adenocarcinomas and those that are not. CCAs have distinctive features that allow a definitive diagnosis on FNAB. Unnecessary surgery can be avoided in MFA by careful evaluation of smear characteristics. Cytologic features of FCC and MLL overlap. Owing to the documented association of MLL with carcinoma, we recommend that lesions that cannot be classified definitively as adenocarcinoma or MFA be considered for conservative excision, even in the absence of atypia.

Cystic lesions of the breast: sonographic-pathologic correlation

PURPOSE

To understand the pathologic basis for sonographic features of cystic lesions of the breast and determine appropriate assessment and management recommendations for these lesions based on sonographic appearance.

MATERIALS AND METHODS

From a database of 2,072 image-guided procedures performed from July 1995 through September 2001, 150 cystic lesions were identified. Diagnosis was established with fine-needle aspiration (n = 55), 14-gauge core-needle biopsy (n = 81), or both (n = 14). Excision was performed for all malignant (n = 18) and atypical (n = 2) lesions and for 11 benign lesions, which recurred or enlarged at follow-up. Imaging follow-up was available for 92 of 119 benign lesions. Targeted sonography was performed with high-frequency (10-MHz center frequency) transducers. Imaging and histopathologic, cytologic, and/or microbiologic findings were reviewed. Lesions were categorized as simple cysts, complicated cysts (imperceptible wall, acoustic enhancement, low-level echoes), clustered microcysts, cystic masses with a thick (perceptible) wall and/or thick (> or =0.5 mm) septations, intracystic or mixed cystic and solid masses (at least 50% cystic), or predominantly solid masses with eccentric cystic foci.

RESULTS

Of 150 lesions, 16 were simple cysts aspirated for symptomatic relief. Of 38 lesions characterized as complicated cysts and one cyst with thin septations, none proved malignant, nor did any of 16 lesions characterized as clustered microcysts. Of 23 masses with thick indistinct walls or thick septations, seven proved malignant. Of 18 intracystic or mixed cystic and solid masses, four proved malignant. Of 38 predominantly solid masses with eccentric cystic foci, seven proved malignant.

CONCLUSION

Symptomatic complicated cysts generally warrant aspiration. All clustered microcysts were benign, but further study is required. Cystic lesions with thick indistinct walls and/or thick septations (> or =0.5 mm), intracystic masses, and predominantly solid masses with eccentric cystic foci should be examined at biopsy; 18 of 79 of such complex cystic lesions proved malignant in this series.

[Differential diagnosis of benign and malignant mammary lesions with special regard to the BI-RADS((R)) classification system in mammography]

Mammography is the imaging method of choice for the diagnostic workup of breast tumors in screening programs as well as in symptomatic patients. Quality assurance is one of the main prerequisites for a successful performance in both fields. Quality assurance on the technical and film processing level can be easily achieved compared to reporting and outcome monitoring on the level of the physician performing mammography. This is especially due to the lack of standards of the written reports. This article reviews the Breast Imaging Reporting and Data System (BI-RADS((R))) developed and commercialized by the American College of Radiology, contains several examples of lesion classification and discusses the significance of the BI-RADS((R)) approach.

Percutaneous imaging-guided core breast biopsy: 5 years' experience in a community hospital

OBJECTIVE

This study reports the results of a percutaneous imaging-guided core breast biopsy program in a community hospital.

MATERIALS AND METHODS

We reviewed the prospectively collected results of our imaging-guided core biopsy program during its first 5 years (1994-1998). A total of 1333 lesions (94% of which were Breast Imaging Reporting and Data System (BI-RADS) assessment category 4) were sampled in 1183 patients. Patients with BI-RADS assessment category 5 lesions were referred to surgeons. Stereotactic guidance was used for the core biopsy of 506 lesions, and sonography was used to guide the predominantly 16-gauge needle core biopsy of 827 solid masses.

RESULTS

One hundred forty-seven cancers were diagnosed in 1333 biopsies, resulting in a positive yield of 11%. Of 1020 patients with benign, concordant core biopsy results, 981 (96%) had at least one follow-up imaging examination within 36 months of the biopsy. Nineteen (2%) of these 1020 patients had a suspicious change at follow-up; 18 of these patients underwent surgical excision with benign findings. No cancers were found at imaging follow-up or by tumor registry linkage. All malignant core biopsy results were confirmed as malignant at surgical excision (positive predictive value 100%). Twenty-two patients with atypical ductal hyperplasia at core biopsy had subsequent surgery, and 12 (55%) of them were found to have cancer at surgery.

CONCLUSION

An imaging-guided core biopsy program, developed and implemented by a small group of radiologists in a community hospital, can achieve successful results and provide an important service to patients and a cost-effective alternative to surgical biopsy. Our program emphasized sonographic guidance and achieved high follow-up compliance.

Observer variability and applicability of BI-RADS terminology for breast MR imaging: invasive carcinomas as focal masses

OBJECTIVE

The purpose of this study was to assess whether the descriptive terminology and final assessment categories of the Breast Imaging Reporting and Data System (BI-RADS) lexicon can be used for breast carcinomas detected on MR imaging and to assess the inter- and intraobserver variabilities in the use of the descriptors and final assessment categories.

MATERIALS AND METHODS

In 82 patients, 101 masses, including 68 infiltrating carcinomas and 33 benign lesions, were interpreted independently by four radiologists and described by BI-RADS terminology with respect to mass shape and margin and BI-RADS final assessment categories. The enhancement pattern of the mass was also reported. In addition, two radiologists interpreted each case twice to evaluate intraobserver variability. The final case set for analysis was the 68 infiltrating carcinomas.

RESULTS

Most of the infiltrating carcinomas were described as irregular, spiculated, and heterogeneously enhancing masses. The final impression of the 68 carcinomas was BI-RADS category 5 (highly suggestive of malignancy) in 41 (61%), category 4 (suspicious abnormality) in 24 (35%), and category 3 (probably benign) in three (4%). Enhancement pattern was heterogeneous in 40 (59%), homogeneous in 14 (21%), and rim in 14 (21%). Interobserver agreement was moderate for mass margin, shape, enhancement, and final assessment category.

CONCLUSION

This study suggests that the mammographic BI-RADS lexicon with some modifications may be applied to describe the features of infiltrating carcinoma seen on breast MR imaging.

Mammographic breast density during hormone replacement therapy: effects of continuous combination, unopposed transdermal and low-potency estrogen regimens

OBJECTIVE

The aim of this study was to evaluate the impact of different hormone replacement therapy (HRT) regimens on mammographic breast density.

STUDY DESIGN

Mammographic density was recorded in women participating in a population-based screening program. At first mammogram, all women were non-users of HRT, and thereafter reported continuous use of the same HRT regimen. The study population comprised 158 women: a total of 52 women were using continuous combined HRT (conjugated equine estrogen 0.625 mg plus medroxyprogesterone acetate 5 mg); 51 women were using low-dose oral estrogen alone (estriol 2 mg daily); and 55 women were using unopposed transdermal estrogen given as a patch (estradiol 50 micrograms/24 h). Films were coded and analyzed for mammographic density by an independent radiologist blinded to treatments. Mammographic density was classified according to Wolfe.

RESULTS

An increase in mammographic density was much more common among women taking continuous combined HRT (40%) than for those using oral low-dose estrogen (6%) and transdermal (2%) treatment. The increase in density was already apparent at the first visit after starting HRT. During long-term follow-up, there was very little change in mammographic status.

CONCLUSION

HRT regimens were shown to have different effects on the normal breast. There is an urgent need to clarify the biological nature and significance of a change in mammographic density during treatment and, in particular, its relation to symptoms and breast cancer risk.

Beyond fibrocystic disease. The evolving concept of pre-malignant breast disease

There is a broad spectrum of benign and pre-malignant breast disease that may be diagnosed on biopsy. Some of these conditions place affected women at significantly increased risk for breast cancer, particularly the atypical hyperplasias. All health care workers should be aware of recent developments in this important aspect of breast disease. The classification, criteria for diagnosis, associated risks for cancer development and various controversies related to these benign and borderline breast diseases are discussed.

Ultrastructural characterization and biochemical profile of human gross cystic breast disease

Human gross cystic breast disease is a benign condition affecting about 7-10% of adult women occurring with the highest incidence in the premenopausal decade. Although breast cysts do not represent a preneoplastic condition per se, several studies indicate an increased breast cancer risk in women affected by this pathology. In this report we study 115 breast cystic fluid samples obtained by needle-aspiration from women with gross cystic breast disease. The samples were analysed biochemically and the cells contained therein were observed at the electron microscope. According to their biochemical profiles, the cysts were subdivided into three types: Type I, showing a Na/K ratio < 0.5 and a typical protein content; Type II, showing a Na/K ratio >10 and a protein content quite similar to plasma; Type III, showing a Na/K ratio between 1 and 7 and an intermediate protein content. The electron microscopic examination demonstrated that Type I cystic fluid cells exhibit morphological features typical of actively synthesising and secreting cells, while the characteristics of Type II cells indicate a low metabolic activity. Type III cells have characteristics typical of both Type I and Type II cells, thereby confirming the intermediate nature of this cyst type. We hypothesise that these cyst types could represent different developmental stages of a structural evolution pathway, during which the biosynthetically active 'apocrine stage' would be the key step to cell neoplastic transformation.

Cohort study of association of risk of breast cancer with cyst type in women with gross cystic disease of the breast

OBJECTIVE

To assess correlation between type of breast cyst and risk of breast cancer in women with gross cystic disease of the breast.

DESIGN

Cohort study of women with breast cysts aspirated between 1983 and 1993 who were followed up until December 1994 for occurrence of breast cancer.

SETTING

Major cancer prevention centre.

SUBJECTS

802 women with aspirated breast cysts.

MAIN OUTCOME MEASURES

Type of breast cyst based on cationic content of cyst fluid: type I (potassium:sodium ratio > 1.5), type II (potassium:sodium ratio < 1.5), or mixed (both types). Subsequent occurrence and type of breast cancer.

RESULTS

After median follow up of six years (range 2-12 years) 15 cases of invasive breast cancer and two ductal carcinomas in situ were diagnosed in the cohort: 12 invasive cancers (and two carcinomas in situ) among the 417 women with type I cysts, two cancers among the 325 women with type II cysts, and one among the 60 women with mixed cysts. The incidence of breast cancer in women with type I cysts was significantly higher than that in women with type II cysts (relative risk 4.62 (95% confidence interval 1.26 to 29.7)). These results were confirmed after adjustment for several risk factors for breast cancer (relative risk 4.24 (1.12 to 27.5)).

CONCLUSIONS

The increased risk of breast cancer of women with breast cysts seems to be concentrated among women with type I breast cysts.

Insulin-like growth factor binding protein-3 in breast cyst fluid: relationships with insulin-like growth factors I and II and transforming growth factor-beta 1 and 2

Women who have palpable breast cysts with intracystic Na/K > 3 may have a lower risk of developing breast cancer than those with intracystic Na/K < 3. In this study significantly higher concentrations of insulin-like growth factor-binding protein-3 (IGFBP-3), insulin-like growth factors I and II (IGF-I, IGF-II) and transforming growth factor-beta 2 (TGF-beta2) were found in the Na/K > 3 sub-group. No difference was found in transforming-growth factor-beta 1 (TGF-beta1) levels between the two sub-groups of breast cysts. A positive correlation was obtained for IGFBP-3 and TGF-beta1 in the Na/ K > 3 sub-group consistent with reports that TGF-beta1 may regulate the production of IGFBP-3. Equimolar amounts of total IGFs and IGFBP-3 in breast cyst fluid imply that most, if not all, of these IGFs are protein-bound. The significantly higher concentrations of TGF-beta2 in the Na/K > 3 sub-group may partly explain the lower risk of breast cancer in this group of women.

[The correlation between morphology, electrolytic content and risk factors in breast cysts]

Many studies on the biochemical composition of the liquid aspirated from breast cysts have identified three types of cysts: type I (apocrine) cysts, with a high concentration of K+ and low levels of Na+ and C1-; type II (transudate) cysts, with an electrolytic content similar to that of plasma and high Na+ levels and, finally, type III cysts, with intermediate characteristics. The literature data appear to indicate that the women with type I cysts are at higher risk for breast cancer. The authors report the results of a study carried out on 143 women from October, 1991, through October, 1994, in the Radiology Department of the University of Bologna, to investigate the correlations between some risk factors for breast cancer, the characteristics of cyst fluid and the morphology of the cysts after pneumocystography. Of 186 cysts, 104 (55.9%) were type I, 49 (26.4%) were type II, and 33 (17.7%) were type III. Among the risk factors we considered, only the premenopausal state (41 to 45 years of age) exhibited a statistically significant correlation with the presence of type I cysts. The morphological study of the cysts after pneumocystography showed a surprisingly high correlation between the honeycomb pattern and type I cysts. The constant correlation between cyst morphology and electrolytic content may allow the easy identification of the subgroups of patients eligible for a closer follow-up.

The biochemistry of breast cyst fluids and duct secretions

The ratio of potassium to sodium concentrations in breast fluids has led other investigators to the subclassification of cysts into two types: 1) apocrine (secretory) cysts with high potassium and low sodium, and 2) attenuated (flattened) cell cysts with low potassium and high sodium content. Apocrine cells are thought by some to actively secrete potassium. Cell typing is considered important as apocrine cysts are more likely to be bilateral, multiple, recurrent, and serve as markers for epithelial cell atypia. A retrospective study of the biochemical analyses of 58 cyst fluids and 28 duct secretions obtained by nipple aspiration was conducted. Potassium and sodium concentrations obtained from 12 cyst fluids were statistically correlated with creatinine concentrations. Evidence is presented indicating that micro cysts are initially apocrine in cell type and are more likely in continuity with the terminal ductal-lobular unit. It is postulated that apocrine cysts undergo cellular desquamation and lysis, becoming attenuated cysts. The ratio of potassium to sodium is altered by cell degradation rather than active secretory processes. Biochemical contents of cysts and nipple aspiration fluids are compared.

Wolfe's mammographic patterns in women with gross cystic disease of the breast

The epidemiologic determinants of the mammographic pattern were studied in 710 patients with aspirated gross (> 1 ml) cysts of the breast. The prevalence of the mammograms classified as P2-DY, that are considered to be associated with an increased breast cancer risk, was 636/710 or 89.6%. No relationship between mammographic patterns and characteristics of breast cyst fluid such as K+/Na+ ratio, apocrine changes and dehydroepiandrosterone sulfate concentration was observed. A significant decrease in the proportion of these patterns with increasing age (p = 0.006), Quetelet Index (p < 0.001), parity (p = 0.001), and in postmenopausal women (p = 0.026) was found. Conversely, P2-DY patterns were significantly associated with a later age at menarche (p = 0.023) and alcohol consumption (p = 0.001). In multivariate analysis, an independent association with age was not observed whereas the associations with age at menarche, parity, and relative weight were confirmed. In conclusion, the epidemiologic determinants of mammographic patterns are the same in Gross Cystic Disease patients as in unaffected women, and the lack of correlation between mammographic pattern and cyst type suggests that the latter may represent an independent predictor of breast cancer risk.

[Studies on the histological classification of proliferative disease of breast and its relation with breast carcinoma]

According to the degree of fibroplastic proliferation, proliferative disease of breast can be divided into three types: lobular hyperplasia type, fibroadenosis type and fibrosclerosis type. Each type could have simple or compound lesions. The latter include: atypical hyperplasia of duct epithelial cells, large sweat gland metaplasia, cyst and fibroadenoma formation. The progress of lesions coincided with the increase of age. The age of fibrosclerosis patients were close to that of patients with breast carcinoma accompanied with proliferative breast disease. The level of PCNA expression in the three types of proliferative breast disease increased progressively and the level of PCNA expression in fibrosclerosis and breast carcinoma being similar. It is emphasized that in the fibrosclerosis type hyperplasia, the presence of twisting, fragmentation or incomplete encirclement of the periductal myoepithelial cells as well as the basement membrane of the tubules may be considered as a warning to call one's attention to follow up patients closely.

Benign tumors of the breast

Most patients who consult their physician for "breast lesions" do not have a malignancy of the breast. The benign lesions of the breast include fibrocystic condition, macrocyst fibroadenomas, and intraductal papillomas. Nipple discharge is a common condition, and the diagnosis and treatment is discussed. Rarer benign tumors such as adenoid tumors, lipomas, neurofibromatosis, benign fibrous histiocytoma, and glandular cell tumors are briefly discussed.

[The histology of mastopathy and cumulative ipsilateral breast cancer sequence]

In a retrolective and follow-up study the ipsilateral cumulative risk of breast carcinoma after histological benign diseases in women under 66 years of age (n = 1397) is investigated. The subtypes are mastopathy I (= changes without proliferative lesions), mastopathy II (= proliferative lesions without atypia), and mastopathy III (id sunt atypical ductal and lobular hyperplasias). The cumulative risk with mastopathy I and II over a 15 year time period corresponds with the ordinary age related risk, the cumulative risk with mastopathy III is four times higher (p = 0.001). There is no difference between atypical ductal and lobular hyperplasia (p = 0.7). Women in reproductive age have a higher risk (p = 0.03), which exists even after a carcinoma-free survival of more than 10 years. The mastopathy is more a stigma for a higher breast cancer risk than a direct precancerous lesion.

Reproducibility and validity of pathologic classifications of benign breast disease and implications for clinical applications

BACKGROUND

Research studies on the relationship between benign breast diseases and cancer risk typically identify certain conditions as risk factors, and others as carrying no prognostic significance. This study addresses several issues concerning the relevance of such research results for advising individual patients in a clinical setting.

METHODS

Data were obtained as part of a "blinded" retrospective pathology review of benign breast biopsies. A random sample of cases was reviewed twice, providing information about reliability. Comparisons with diagnoses that used information from the operative reports and gross pathology descriptions as well as microscopic histology were used to assess validity.

RESULTS

Among cases that were reviewed twice, excellent agreement was achieved for diagnosing carcinoma and lobular neoplasia, good agreement for adenosis and intraductal papilloma, and relatively poor agreement about levels of hyperplasia and atypia, and whether ducts or lobules were involved. Distinctions among levels of hyperplasia also apparently were influenced by the number of slides available for review. The "blinded" review diagnoses frequently differed from the diagnoses that used all information available at the time of surgery in detecting the presence or absence of gross cystic disease, and in distinguishing solitary from multiple papillomas.

CONCLUSIONS

Problems with reliability of precise distinctions among levels and sites of hyperplasia and atypia seem to limit the usefulness of such classifications as guidelines for individual patient care. For conditions with some clinical manifestations, diagnoses based exclusively on histologic review of biopsy specimens often are not accurate.

Lipid-associated sialic acid levels in human breast cyst fluids

Benign mammary gross cystic disease is the most common breast lesion. Women with apocrine changes of epithelium lining the cysts are at higher risk for developing breast cancer than the normal female population. Sialic acid has drawn considerable interest because of carbohydrate aberrations in malignant cells. The current investigation determined the concentrations of lipid-associated sialic acid (LASA) in 62 breast cyst fluids and sera. Data analyses show a significant increase in the mean values of LASA in metabolically active apocrine cysts when compared to the cysts with Na+/K+ > 3 (flattened cysts) (p < 0.001). The greater LASA levels in cyst fluids with lower intracystic Na+/K+ ratios could represent an altered expression of biosynthetic activity of the surrounding apocrine cell surface sialoglycolipid metabolism, providing a possible explanation of why women with apocrine cysts may be at greater cancer risk and being useful in further studies on functional stage changes in the cysts and their relationship to breast cancer.

GCDFP-70 protein in cyst fluid identified as albumin and used to classify cysts in women with breast gross cystic disease

We used sodium dodecyl sulfate-polyacrylamide gel electrophoresis to study cyst fluids from women with breast gross cystic disease. The subjects could be classified into two categories according to the concentrations of protein GCDFP-70 in the cyst fluid: those with Type I cysts had a very low content of this protein; those with Type II cysts had very high concentrations. Analysis of the amino acid sequence of GCDFP-70 from both cyst fluid types confirmed that this protein is human plasma albumin. The average concentration of albumin found in Type I cyst fluids was 0.32 g/L and that corresponding to Type II was 10.16 g/L. Thus, albumin quantification from cyst fluids or analysis by either polyacrylamide or agarose gel electrophoresis provides a simple procedure for classifying these fluids, yielding results that correlate well with previous classifications based on other measurements such as sodium, potassium, and chloride concentrations. This albumin-based quantification method may improve the classification of breast cysts and might be useful in further studies on functional changes in the cysts and their relationship to breast cancer.

Accumulation of active androgens in breast cyst fluids

80 breast cyst fluids (BCF) from 57 patients were divided by K+/Na+ ratio: 56 with ratio over 1 (type I) and 24 with ratio less than 1 (type II). Significantly higher amounts of testosterone, dihydrotestosterone and dehydroepiandrosterone sulphate (DHAS) were found in type I than in type II cysts. A positive relation was found between testosterone and dihydrotestosterone in both types. DHAS was significantly correlated with testosterone and dihydrotestosterone in type I casts only. In 52 patients, blood was sampled after cyst evacuation. Testosterone was significantly higher in blood than in BCF while dihydrotestosterone and androstenedione were significantly higher in BCF. No relation was observed between circulating levels of androgens and their intracystic concentrations. Women bearing type I cysts may be at increased risk of developing cancer. These findings support the hypothesis that androgens play a role in the hormonal aetiology of breast cancer.

Evaluation of human breast cysts according to their biochemical and hormonal composition, and cytologic examination

Breast cyst fluids were aspirated during the mild luteal phase of the menstrual cycle from 88 patients with gross cystic disease. According to intracystic Na+/K+ ratio three categories of cyst were identified: Type I with low Na+/K+ ratio, low levels of chloride, glucose, and pH, and high concentrations of dehydroepiandrosterone-sulphate (DHAS) and apocrine epithelium; Type II with high Na+/K+ ratio presenting levels of chloride, glucose, pH, and DHAS similar to those found in plasma, and flattened epithelium; Type III with intermediate values for the above parameters. The findings suggest that the cysts could correspond to the different functional stages of the epithelium lining the cysts. Cyst classification was evaluated using a discriminant analysis, which allows breast cyst fluids to be assigned within a category defined by the Na+/K+ ratio. The apparent correct rate for each category was more than 87%. The variables that better discriminate among groups of cysts were chloride, glucose, intracystic prolactin, and pH, respectively. These discriminant functions could be used as criteria for an optimal classification of breast cysts, which might help study of the epidemiology of breast cancer and its relationship to gross cystic disease.

Digoxinlike materials in human breast cyst fluids

Digoxinlike materials (DLMs) are compounds found in animals that (1) cross-react with digoxin antibodies in specific radioimmunoassay procedures and (2) bind to Na+, K(+)-ATPase and inhibit its activity. DLMs may play a part in the regulation of electrolyte composition. We have determined DLM concentrations in breast cyst fluids and found that these fluids were a rich source of DLMs. Total DLMs were elevated in fluids with type 1 electrolyte composition (high K+ and low Na+ content) when compared to fluids with type 2 composition (low K+ and high Na+ content). Chromatographic studies showed that the basis for the increase was the presence of an additional DLM in the type 1 cyst fluids rather than an increased concentration of the same DLM present in both types of fluids. We propose that this additional DLM may have a role in the accumulation of K+ ions in type 1 fluids. In addition, 7 of 80 cyst fluid samples subjected to high-performance liquid chromatography had a large UV-absorbing peak at 6.4 minutes. Four of these samples were taken from women who later developed breast cancer; information on the subsequent medical history of the other 3 women was unavailable. We suggest that the presence of this material in cyst fluid may be a marker of risk for development of breast cancer.