Spindle Cell Metaplastic Breast Carcinoma

INTRODUCTION

Metaplastic breast carcinoma is an uncommon malignancy that constitutes < 5% of all breast cancers. There are 5 subtypes which are spindle cell, squamous cell, carcinosarcoma, matrix-producing and metaplastic with osteoclastic giant cells. Spindle cell carcinoma represents approximately <0.3% of invasive breast carcinomas. It is typically a triple-negative cancer with distinct pathological characteristics, but relatively a non-conclusive imaging findings.

CASE REPORT

An elderly lady presented with an enlarging painful left breast lump for 1 year. Palpable left breast lump noted on clinical examination. Mammography demonstrated a high density, oval lesion with a partially indistinct margin. Corresponding ultrasound showed a large irregular heterogeneous lesion with solid-cystic areas. Histopathology showed atypical spindle-shaped cells which stained positive for cytokeratins and negative for hormone and human epidermal growth factor receptors, which favours spindle cell metaplastic carcinoma. Left mastectomy and axillary dissection were performed, and the final diagnosis was consistent with metaplastic spindle cell carcinoma.

CONCLUSION

Spindle cell carcinoma of the breast is a rare aggressive histological type of carcinoma which may present with benign features on imaging. Tissue diagnosis is essential for prompt diagnosis with multidisciplinary team discussion to guide management and improve patient's outcome.

Is pre-operative axillary ultrasound alone sufficient to determine need for axillary dissection in early breast cancer patients?

Pre-operative status of axillary lymph node (ALN) in early breast cancer is usually initially assessed by pre-operative ultrasound, followed by ultrasound-guided needle biopsy (UNB) confirmation. Patients with positive nodal status will undergo axillary lymph node dissection (ALND), while those with negative nodal status will have sentinel lymph node biopsy. ALND is associated with higher morbidity than Sentinel lymph node biopsy. The objective of this study is to determine if axillary ultrasound alone without UNB is predictive enough to assign patients to ALND and to identify ultrasound features that are significantly associated with pathologically positive ALN.383 newly diagnosed primary breast cancer patients between 2012 and 2014, and who had undergone pre-operative axillary ultrasound in University Malaya Medical Centre with a complete histopathology report of the axillary surgery were retrospectively reviewed. ALN was considered positive if it had any of these features: cortical thickening > 3 mm, loss of fatty hilum, hypoechoic solid node, mass-like appearance, round shape and lymph node size > 5 mm. Post-operative histopathological reports were then analyzed for nodal involvement.The overall sensitivity, specificity, and accuracy of pre-operative axillary ultrasound in detecting diseased nodes were 45.5%, 80.7%, and 60.3% respectively. The positive (PPV) and negative predictive values were 76.5% and 51.8%. Round shape, loss of fatty hilum and mass-like appearance had the highest PPVs of 87%, 83% and 81.6% respectively and significant odds ratios (ORs) of 5.22 (95% confidence interval [CI]: 1.52 - 17.86), ORs of 4.77 (95% CI: 2.62 - 8.70) and ORs of 4.26 (95% CI: 2.37 - 7.67) respectively (P-value < .05). Cortical thickness of > 3 mm was identified to have low PPV at 69.1%, ORs of 1.71 (95% CI: 0.86 - 3.41, P = .126).There are features on axillary ultrasound that confer high PPV for axillary involvement i.e. round shape, loss of fatty hilum, and mass-like appearance. In a low resource setting, these features may benefit from ALND without further pre-operative biopsies. However, pre-operative UNB for features with low PPV that is, cortical thickness > 3 mm should be considered to obviate the unnecessary morbidity associated with ALND.

Spectrum of imaging findings of papillary breast disease: A radiopathological review in a tertiary center

To evaluate the clinical and imaging findings of papillary breast neoplasm and review the pathologic correlation at a tertiary center.Retrospective study of patients diagnosed with benign and malignant papillary lesions between 2008 to 2018. 147 patients were identified with histology diagnosis of papillary lesions. The clinical, imaging, and pathological characteristics were reviewed.Patient cohort included 147 women diagnosed with papillary lesions (mean age at diagnosis 53.8 years) and were divided into 3 histology groups (benign, atypical, and malignant). Common clinical presentations were breast lump (n = 60) and nipple discharge (n = 29), 48 patients were asymptomatic.Only 37 were detected as a mass lesion on mammogram. The presence of mass lesion on mammogram was the most common feature in all 3 papillary lesion groups, and with the presence of asymmetric density, were the 2 mammographic features significantly associated (P < .05) with malignancy.All lesions were detected on ultrasound. The most common sonographic features for all 3 groups were the presence of a mass and irregular shape. Among all the sonographic features assessed, larger size, presence of vascularity and absence of dilated ducts were significantly associated (P < .05) with malignancy.Feature pattern recognition of the variety of benign, atypical and malignant papillary neoplasm on ultrasound and mammogram, with emphasis on size, presence of vascularity and dilated ducts on ultrasound and presence of mass, and architectural distortion on mammogram, is important in the assessment of patients with suspected ductal lesions to facilitate optimal treatment and surgical care.

Epidemiological and ES cell-based functional evaluation of BRCA2 variants identified in families with breast cancer

The discovery of high-risk breast cancer susceptibility genes, such as Breast cancer associated gene 1 (BRCA1) and Breast cancer associated gene 2 (BRCA2) has led to accurate identification of individuals for risk management and targeted therapy. The rapid decline in sequencing costs has tremendously increased the number of individuals who are undergoing genetic testing world-wide. However, given the significant differences in population-specific variants, interpreting the results of these tests can be challenging especially for novel genetic variants in understudied populations. Here we report the characterization of novel variants in the Malaysian and Singaporean population that consist of different ethnic groups (Malays, Chinese, Indian, and other indigenous groups). We have evaluated the functional significance of 14 BRCA2 variants of uncertain clinical significance by using multiple in silico prediction tools and examined their frequency in a cohort of 7840 breast cancer cases and 7928 healthy controls. In addition, we have used a mouse embryonic stem cell (mESC)-based functional assay to assess the impact of these variants on BRCA2 function. We found these variants to be functionally indistinguishable from wild-type BRCA2. These variants could fully rescue the lethality of Brca2-null mESCs and exhibited no sensitivity to six different DNA damaging agents including a poly ADP ribose polymerase inhibitor. Our findings strongly suggest that all 14 evaluated variants are functionally neutral. Our findings should be valuable in risk assessment of individuals carrying these variants.

Diagnostic accuracy of digital breast tomosynthesis in combination with 2D mammography for the characterisation of mammographic abnormalities

This study aims to assess the diagnostic accuracy of digital breast tomosynthesis in combination with full field digital mammography (DBT + FFDM) in the charaterisation of Breast Imaging-reporting and Data System (BI-RADS) category 3, 4 and 5 lesions. Retrospective cross-sectional study of 390 patients with BI-RADS 3, 4 and 5 mammography with available histopathology examination results were recruited from in a single center of a multi-ethnic Asian population. 2 readers independently reported the FFDM and DBT images and classified lesions detected (mass, calcifications, asymmetric density and architectural distortion) based on American College of Radiology-BI-RADS lexicon. Of the 390 patients recruited, 182 malignancies were reported. Positive predictive value (PPV) of cancer was 46.7%. The PPV in BI-RADS 4a, 4b, 4c and 5 were 6.0%, 38.3%, 68.9%, and 93.1%, respectively. Among all the cancers, 76% presented as masses, 4% as calcifications and 20% as asymmetry. An additional of 4% of cancers were detected on ultrasound. The sensitivity, specificity, PPV and NPV of mass lesions detected on DBT + FFDM were 93.8%, 85.1%, 88.8% and 91.5%, respectively. The PPV for calcification is 61.6% and asymmetry is 60.7%. 81.6% of cancer detected were invasive and 13.3% were in-situ type. Our study showed that DBT is proven to be an effective tool in the diagnosis and characterization of breast lesions and supports the current body of literature that states that integrating DBT to FFDM allows good characterization of breast lesions and accurate diagnosis of cancer.

Evaluation of automated volumetric breast density software in comparison with visual assessments in an Asian population: A retrospective observational study

This study aims to compare Quantra, as an automated volumetric breast density (Vbd) tool, with visual assessment according to ACR BI-RADS density categories and to determine its potential usage in clinical practice.Five hundred randomly selected screening and diagnostic mammograms were included in this retrospective study. Three radiologists independently assigned qualitative ACR BI-RADS density categories to the mammograms. Quantra automatically calculates the volumetric density data into the system. The readers were blinded to the Quantra and other readers assessment. Inter-reader agreement and agreement between Quantra and each reader were tested. Region under the curve (ROC) analysis was performed to obtain the cut-off value to separate dense from a non-dense breast. Results with P value <.05 was taken as significant.There were 40.4% Chinese, 27% Malays, 19% Indian and 3.6% represent other ethnicities. The mean age of the patients was 57. 15%, 45.6%, 30.4%, and 9% of patients fall under BI-RADS A, B, C and D density category respectively. Fair agreement with Kappa (κ) value: 0.49, 0.38, and 0.30 were seen for Reader 1, 2 and 3 versus Quantra. Moderate agreement with κ value: 0.63, 0.64, 0.51 was seen when the data were dichotomized (density A and B to "non-dense", C and D to "dense"). The cut-off Vbd value was 13.5% to stratify dense from non-dense breasts with a sensitivity of 86.2% and specificity of 83.1% (AUC 91.4%; confidence interval: 88.8, 94.1).Quantra showed moderate agreement with radiologists visual assessment. Hence, this study adds to the available evidence to support the potential use of Quantra as an adjunct tool for breast density assessment in routine clinical practice in the Asian population. We found 13.5% is the best cut-off value to stratify dense to non-dense breasts in our study population. Its application will provide an objective, consistent and reproducible results as well as aiding clinical decision-making on the need for supplementary breast ultrasound in our screening population.

Diagnostic Efficacy of Synthesized 2D Digital Breast Tomosynthesis in Multi-ethnic Malaysian Population

Synthesized 2D images can be reconstructed from tomosynthesis images in breast imaging. This study aims to investigate the diagnostic efficacy of synthesized 2D images (C-View) in comparison to full field digital mammography (FFDM) when used with digital breast tomosynthesis (DBT) in multi-ethnic Malaysian population. FFDM and C-View images (n = 380) were independently evaluated by three readers through Breast Imaging Reporting and Data System (BI-RADS) categorisation, breast density and lesion characterisation. Statistical analysis was done comparing sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of C-View + DBT with FFDM + DBT as standard of reference. Very good interreader agreement in BI-RADS category and density assessment between C-View + DBT and FFDM + DBT, with high sensitivity, specificity, PPV and NPV of C-View + DBT when compared with FFDM + DBT. There was comparable PPV between C-View + DBT and FFDM + DBT, with histopathology as gold standard. High level of interreader agreement in BI-RADS category and density assessment for FFDM + DBT and C-View + DBT. There was good agreement between FFDM + DBT and C-View + DBT in mass characterization, and almost perfect agreement in calcification and asymmetric density. 52.2% lower radiation dose incurred when using C-View + DBT. Hence, synthesized 2D images are comparable to FFDM with reduction in radiation dose within the limits of Malaysian multi-ethnic population.

Myofibroblastoma of the breast

INTRODUCTION

Myofibroblastoma is a rare benign mesenchymal tumour arising from the stromal elements of the breast tissue. Histopathological variants such as classic, cellular, collagenous / fibrous, lipomatous, infiltrative, myxoid and epithelioid have been identified. Most myofibroblastomas are immunoreactive for CD34, actin, CD10 and desmin, usually express oestrogen receptor (ER), progesterone receptor (PR) and variably express androgen receptor (AR).

CASE REPORT

We report a case of myofibroblastoma in an octogenarian male presenting with painless solitary breast lump. Mammography (digital tomosynthesis) and ultrasound showed a well-circumscribed hyperdense mass and hypoechoic, solid, oval mass with peripheral vascularity respectively. Patient underwent wide local excision.

DISCUSSION

Diverse characteristics of myofibroblastoma on imaging necessitates histopathological analysis for an accurate diagnosis. Myofibroblastoma are often confused with fibroadenomas due to the benign imaging characteristics and with malignant neoplasia due to their wide morphological spectrum. Surgical excision is considered curative.

A case-control study of breast cancer risk factors in 7,663 women in Malaysia

BACKGROUND

Breast cancer risk factors have been examined extensively in Western setting and more developed Asian cities/countries. However, there are limited data on developing Asian countries. The purpose of this study was to examine breast cancer risk factors and the change of selected risk factors across birth cohorts in Malaysian women.

METHODS

An unmatched hospital based case-control study was conducted from October 2002 to December 2016 in Selangor, Malaysia. A total of 3,683 cases and 3,980 controls were included in this study. Unconditional logistic regressions, adjusted for potential confounding factors, were conducted. The breast cancer risk factors were compared across four birth cohorts by ethnicity.

RESULTS

Ever breastfed, longer breastfeeding duration, a higher soymilk and soy product intake, and a higher level of physical activity were associated with lower risk of breast cancer. Chinese had the lowest breastfeeding rate, shortest breastfeeding duration, lowest parity and highest age of first full term pregnancy.

CONCLUSIONS

Our study shows that breastfeeding, soy intake and physical activity are modifiable risk factors for breast cancer. With the increasing incidence of breast cancer there is an urgent need to educate the women about lifestyle intervention they can take to reduce their breast cancer risk.

Radiopathological characteristics and outcomes of phyllodes tumor of the breast in Malaysian women

Phyllodes tumor or cystosarcoma phyllodes is a rare fibroepithelial neoplasm which arises from the periductal stroma of the breast. They are classified as benign, borderline, and malignant based on the histologic features. However, all phyllodes tumor (PT) subtypes are regarded as having malignant potential and correct diagnosis is important for surgical management and optimal care. This study is a retrospective review of 76 women diagnosed as PT with highlights on the imaging characteristics, pathology, and surgical treatment over a 7-year period in a tertiary medical center of urban population in Malaysia. There were 45 benign, 16 borderline, and 15 malignant PT. The median age for benign PT was 43, borderline 48.5, and malignant 42 years. The Malay ethnic group constitute 52.6% of cases, with 27.6% and 18.4% in Chinese and Indian ethnic groups, respectively. On mammograms, most benign (64.3%) and 33.3% of malignant PT showed high-density lesions. Calcifications were only seen in 2 benign PT. On ultrasound, 86% of benign PT was well-circumscribed whilst 50.0% of malignant PT had irregular outline. Cystic spaces were seen in 40.0% of malignant and 9.5% of benign PT. 80% of malignant PT lesions were heterogenous. Malignant PT demonstrates tumor heterogeneity, cystic spaces, and posterior acoustic enhancement on ultrasound. Half of malignant PT showed regular borders on ultrasound and appear well circumscribed on mammogram. A total of 46 patients had wide local excision or excision biopsy whilst 30 underwent mastectomy as primary treatment. The majority of the borderline and malignant PTs in our study (75.0% and 85.7% respectively) and only 5 out of the 43 (11.6%) benign PT underwent mastectomy. There were 2 tumor recurrence in the benign PT group and 1 case in the borderline and malignant group respectively.

Altered body composition, sarcopenia, frailty, and their clinico-biological correlates, in Parkinson's disease

INTRODUCTION

Low body weight in Parkinson's disease (PD) is poorly understood despite the associated risks of malnutrition, fractures, and death. Sarcopenia (loss of muscle bulk and strength) and frailty are geriatric syndromes that are likewise associated with adverse health outcomes, yet have received scant attention in PD. We studied body composition, sarcopenia, frailty, and their clinico-biological correlates in PD.

METHODS

93 patients and 78 spousal/sibling controls underwent comprehensive assessment of diet, clinical status, muscle strength/performance, frailty, body composition (using dual-energy X-ray absorptiometry), and serum levels of neurogastrointestinal hormones and inflammatory markers.

RESULTS

PD patients were older than controls (66.0 ± 8.5 vs. 62.4 ± 8.4years, P = 0.003). Mean body mass index (24.0 ± 0.4 vs. 25.6 ± 0.5kg/m2, P_adjusted = 0.016), fat mass index (7.4 ± 0.3 vs. 9.0 ± 0.3kg/m2, P_adjusted<0.001), and whole-body fat percentage (30.7 ± 0.8 vs. 35.7 ± 0.9%, P_adjusted<0.001) were lower in patients, even after controlling for age and gender. There were no between-group differences in skeletal muscle mass index and whole-body bone mineral density. Body composition parameters did not correlate with disease duration or motor severity. Reduced whole-body fat percentage was associated with higher risk of motor response complications as well as higher levels of insulin-growth factor-1 and inflammatory markers. PD patients had a higher prevalence of sarcopenia (17.2% vs. 10.3%, P_adjusted = 0.340) and frailty (69.4% vs. 24.2%, P_adjusted = 0.010). Older age and worse PD motor severity were predictors of frailty in PD.

CONCLUSIONS

We found reduced body fat with relatively preserved skeletal muscle mass, and a high prevalence of frailty, in PD. Further studies are needed to understand the patho-mechanisms underlying these alterations.

Mammographic density and ageing: A collaborative pooled analysis of cross-sectional data from 22 countries worldwide

BACKGROUND

Mammographic density (MD) is one of the strongest breast cancer risk factors. Its age-related characteristics have been studied in women in western countries, but whether these associations apply to women worldwide is not known.

METHODS AND FINDINGS

We examined cross-sectional differences in MD by age and menopausal status in over 11,000 breast-cancer-free women aged 35-85 years, from 40 ethnicity- and location-specific population groups across 22 countries in the International Consortium on Mammographic Density (ICMD). MD was read centrally using a quantitative method (Cumulus) and its square-root metrics were analysed using meta-analysis of group-level estimates and linear regression models of pooled data, adjusted for body mass index, reproductive factors, mammogram view, image type, and reader. In all, 4,534 women were premenopausal, and 6,481 postmenopausal, at the time of mammography. A large age-adjusted difference in percent MD (PD) between post- and premenopausal women was apparent (-0.46 cm [95% CI: -0.53, -0.39]) and appeared greater in women with lower breast cancer risk profiles; variation across population groups due to heterogeneity (I2) was 16.5%. Among premenopausal women, the √PD difference per 10-year increase in age was -0.24 cm (95% CI: -0.34, -0.14; I2 = 30%), reflecting a compositional change (lower dense area and higher non-dense area, with no difference in breast area). In postmenopausal women, the corresponding difference in √PD (-0.38 cm [95% CI: -0.44, -0.33]; I2 = 30%) was additionally driven by increasing breast area. The study is limited by different mammography systems and its cross-sectional rather than longitudinal nature.

CONCLUSIONS

Declines in MD with increasing age are present premenopausally, continue postmenopausally, and are most pronounced over the menopausal transition. These effects were highly consistent across diverse groups of women worldwide, suggesting that they result from an intrinsic biological, likely hormonal, mechanism common to women. If cumulative breast density is a key determinant of breast cancer risk, younger ages may be the more critical periods for lifestyle modifications aimed at breast density and breast cancer risk reduction.

Evaluation of solid breast lesions with power Doppler: value of penetrating vessels as a predictor of malignancy

INTRODUCTION

This study aimed to evaluate the vascular pattern of solid breast lesions using power Doppler ultrasonography (PDUS) and assess whether the presence of intratumoural penetrating vessels can predict breast cancer malignancy.

METHODS

Greyscale ultrasonography (US) and PDUS were prospectively performed on 91 women in Malaysia with histopathologically proven breast lesions. The diagnostic accuracy of greyscale US, PDUS, and both greyscale US and PDUS was calculated and compared.

RESULTS

The 91 women had 102 breast lesions (55 benign, 47 malignant). Of the 47 malignant lesions, 36 demonstrated intratumoural penetrating vessels. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of greyscale US findings in diagnosing malignancy were 100.0%, 71.4%, 74.1% and 100.0%, respectively. The presence of calcification in the breast lesion and the margin, shape and posterior acoustic features of the lesion were significant parameters in predicting malignancy (p < 0.01). The sensitivity, specificity, PPV and NPV of the presence of intratumoural penetrating vessels in predicting malignancy were 76.5%, 80.0%, 76.5% and 80.0%, respectively. When both greyscale US and PDUS were used, there was a significant correlation in predicting malignancy (p < 0.05). The specificity and PPV values of the combined greyscale US and PDUS method (89.0% and 85.7%, respectively) were higher than those of greyscale US or PDUS alone.

CONCLUSION

Flow patterns revealed by PDUS can be useful for differentiating benign and malignant breast lesions. The visualisation of penetrating vessels in solid breast lesions can be used to complement greyscale US findings in predicting malignancy.

Shearwave Elastography Increases Diagnostic Accuracy in Characterization of Breast Lesions

The purpose of this study was to investigate the diagnostic efficacy of shearwave elastography (SWE) in differentiating between benign and malignant breast lesions.One hundred and fifty-nine lesions were assessed using B-mode ultrasound (US) and SWE parameters were recorded (Emax, Emean, Emin, Eratio, SD). SWE measurements were then correlated with histopathological diagnosis.The final sample contained 85 benign and 74 malignant lesions. The maximum stiffness (Emax) with a cutoff point of ≥ 56.0 kPa (based on ROC curves) provided sensitivity of 100.0%, specificity of 97.6%, positive predictive value (PPV) of 97.4%, and negative predictive value (NPV) of 100% in detecting malignant lesions. A cutoff of ≥80 kPa managed to downgrade 95.5% of the Breast Imaging-Reporting and Data System (BI-RADS) 4a lesions to BI-RADS 3, negating the need for biopsy. Using a combination of BI-RADS and SWE, the authors managed to improve the PPV from 2.3% to 50% in BI-RADS 4a lesions.SWE of the breast provides highly specific and sensitive quantitative values that are beneficial in the characterization of breast lesions. Our results showed that Emax is the most accurate value for differentiating benign from malignant lesions.

Unmasking Heavily O-Glycosylated Serum Proteins Using Perchloric Acid: Identification of Serum Proteoglycan 4 and Protease C1 Inhibitor as Molecular Indicators for Screening of Breast Cancer

Heavily glycosylated mucin glycopeptides such as CA 27.29 and CA 15-3 are currently being used as biomarkers for detection and monitoring of breast cancer. However, they are not well detected at the early stages of the cancer. In the present study, perchloric acid (PCA) was used to enhance detection of mucin-type O-glycosylated proteins in the serum in an attempt to identify new biomarkers for early stage breast cancer. Sensitivity and specificity of an earlier developed sandwich enzyme-linked lectin assay were significantly improved with the use of serum PCA isolates. When a pilot case-control study was performed using the serum PCA isolates of normal participants (n = 105) and patients with stage 0 (n = 31) and stage I (n = 48) breast cancer, higher levels of total O-glycosylated proteins in sera of both groups of early stage breast cancer patients compared to the normal control women were demonstrated. Further analysis by gel-based proteomics detected significant inverse altered abundance of proteoglycan 4 and plasma protease C1 inhibitor in both the early stages of breast cancer patients compared to the controls. Our data suggests that the ratio of serum proteoglycan 4 to protease C1 inhibitor may be used for screening of early breast cancer although this requires further validation in clinically representative populations.

Mild Joint Symptoms Are Associated with Lower Risk of Falls than Asymptomatic Individuals with Radiological Evidence of Osteoarthritis

Osteoarthritis (OA) exacerbates skeletal muscle functioning, leading to postural instability and increased falls risk. However, the link between impaired physical function, OA and falls have not been elucidated. We investigated the role of impaired physical function as a potential mediator in the association between OA and falls. This study included 389 participants [229 fallers (≥2 falls or one injurious fall in the past 12 months), 160 non-fallers (no history of falls)], age (≥65 years) from a randomized controlled trial, the Malaysian Falls Assessment and Intervention Trial (MyFAIT). Physical function was assessed using Timed Up and Go (TUG) and Functional Reach (FR) tests. Knee and hip OA were diagnosed using three methods: Clinical, Radiological and Self-report. OA symptom severity was assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC). The total WOMAC score was categorized to asymptomatic, mild, moderate and severe symptoms. Individuals with radiological OA and ‘mild’ overall symptoms on the WOMAC score had reduced risk of falls compared to asymptomatic OA [OR: 0.402(0.172–0.940), p = 0.042]. Individuals with clinical OA and ‘severe’ overall symptoms had increased risk of falls compared to those with ‘mild’ OA [OR: 4.487(1.883–10.693), p = 0.005]. In individuals with radiological OA, mild symptoms appear protective of falls while those with clinical OA and severe symptoms have increased falls risk compared to those with mild symptoms. Both relationships between OA and falls were not mediated by physical limitations. Larger prospective studies are needed for further evaluation.

Decidualized Ovarian Endometrioma in a Pregnant Woman Mimicking Ovarian Malignancy: Magnetic Resonance Imaging and Ultrasonographic Findings

Decidualized ovarian endometrioma is a rare phenomenon in pregnancy, which can mimic ovarian malignancy in imaging and often poses a diagnostic challenge. We report a case of a large ruptured decidualized ovarian endometrioma in a 15 weeks gestation patient, and we will describe the imaging characteristics (ultrasonography and MR imaging findings) and the histopathological findings (macro- and microscopically).

Opportunistic mammography screening provides effective detection rates in a limited resource healthcare system

Background

Breast cancer is the leading cause of cancer deaths in women world-wide. In low and middle income countries, where there are no population-based mammographic screening programmes, late presentation is common, and because of inadequate access to optimal treatment, survival rates are poor. Mammographic screening is well-studied in high-income countries in western populations, and because it has been shown to reduce breast cancer mortality, it has become part of the healthcare systems in such countries. However the performance of mammographic screening in a developing country is largely unknown.

This study aims to evaluate the performance of mammographic screening in Malaysia, a middle income country, and to compare the stage and surgical treatment of screen-detected and symptomatic breast cancer.

Methods

A retrospective review of 2510 mammograms performed from Jan to Dec 2010 in a tertiary medical centre is carried out. The three groups identified are the routine (opportunistic) screening group, the targeted (high risk) screening group and the diagnostic group. The performance indicators of each group is calculated, and stage at presentation and treatment between the screening and diagnostic group is analyzed.

Results

The cancer detection rate in the opportunistic screening group, targeted screening group, and the symptomatic group is 0.5 %, 1.25 % and 26 % respectively. The proportion of ductal carcinoma in situ is 23.1 % in the two screening groups compared to only 2.5 % in the diagnostic group. Among the opportunistic screening group, the cancer detection rate was 0.2 % in women below 50 years old compared to 0.65 % in women 50 years and above. The performance indicators are within international standards. Early-staged breast cancer (Stage 0–2) were 84.6 % in the screening groups compared to 61.1 % in the diagnostic group.

Conclusion

From the results, in a setting with resource constraints, targeted screening of high risk individuals will give a higher yield, and if more resources are available, population-based screening of women 50 and above is effective.

Opportunistic mammographic screening is feasible and effective in a middle income country with performance indicators within international standards. Waiting until women are symptomatic will lead to more advanced cancers.

MRI of optic tract lesions: review and correlation with visual field defects

Visual field defects are a conglomerate of patterns of visual impairment derived from diseases affecting the optic nerve as it extends from the globe to the visual cortex. They are complex signs requiring perimetry or visual confrontation for delineation and are associated with diverse aetiologies. This review considers the chiasmatic and post-chiasmatic causes of visual disturbances, with an emphasis on magnetic resonance imaging (MRI) techniques. Newer MRI sequences are considered, such as diffusion-tensor imaging. MRI images are correlated with perimetric findings in order to demonstrate localization of lesions in the visual pathway. This may serve as a valuable reference tool to clinicians and radiologists in the early diagnostic process of differentiating causes of various visual field defects in daily practice.

Imaging of an atypical pericardial cyst

Pericardial cysts are uncommon mediastinal lesions that are usually congenital in origin. Patients are usually asymptomatic and the cysts are generally discovered on routine radiography for unrelated purposes. This case illustrates a symptomatic presentation of a haemorrhagic pericardial cyst in which radiographic, echocardiographic and multislice (MRI and CT) imaging were performed. The imaging findings were not typical of pericardial cysts leading to a diagnostic quandary despite the varied imaging techniques. In conclusion, it is important to appreciate that the imaging findings of pericardial cysts can be varied. Radiologists and clinicians alike should be aware of this variability.