The Automation of Breast Ultrasonography and the Medical Time Dedicated to the Method / A automatização da ultrassonografia mamária e o tempo médico dedicado ao método

Abstract In this integrative review, we aimed to describe the records of time devoted by physicians to breast ultrasound in a review of articles in the literature, in order to observe whether the automation of the method enabled a reduction in these values. We selected articles from the Latin American and Caribbean Literature in Health Sciences (LILACS) and MEDLINE databases, through Virtual Health Library (BVS), SciELO (Scientific Electronic Library Online), PubMed, and Scopus. We obtained 561 articles, and, after excluding duplicates and screening procedures, 9 were selected, whose main information related to the guiding question of the research was synthesized and analyzed. It was concluded that the automation of breast ultrasound represents a possible strategy for optimization of the medical time dedicated to the method, but this needs to be better evaluated in comparative studies between both methods (traditional and automated), with methodology directed to the specific investigation of this potentiality.

Resumo Na presente revisão integrativa, objetivamos descrever os registros de tempo dedicado pelos médicos à ultrassonografia mamária em revisão de artigos da literatura, visando observar se a automação do método possibilitou redução destes valores. Selecionamos artigos nas bases de dados Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) e MEDLINE, através da Biblioteca Virtual em Saúde (BVS), Scientific Electronic Library Online (SciELO), PubMed e Scopus. Obtivemos 561 artigos e, após a exclusão de artigos duplicados e procedimentos de triagem, foram selecionados 9 artigos, cujas informações principais relativas à pergunta norteadora da pesquisa foram sintetizadas e analisadas. Foi concluído que a automação da ultrassonografia mamária representa uma possível estratégia de otimização do tempo médico dedicado ao método; porém, essa conclusão necessita ser melhor avaliada em estudos comparativos entre ambos os métodos (tradicional e automatizado), com metodologia direcionada à investigação específica desta potencialidade.

Minimally invasive treatment of gynecomastia by ultrasound-guided vacuum-assisted excision: report of a case series

Introduction: Gynecomastia (GM) is a benign proliferation of glandular breast tissue in men. Some cases need surgical intervention. Traditional open surgery by semicircular inferior periareolar incision is the most common surgical approach. In order to obtain better esthetic results, some alternatives to open surgery have been proposed, such as liposuction, endoscopic mastectomy, and vacuum-assisted excision (VAE). Objective: To describe the technical surgical approach of ultrasound-guided VAE of GM and its results from a case series. Method: This is an evaluation of seven GM cases submitted to ultrasound-guided VAE with a 10G needle using the ENCOR® BD whole circumference automated breast biopsy system in Redimasto ­ Redimama, a Brazilian breast center. The result was considered good or satisfactory when it showed minimal remaining gland, good symmetry, no retraction, necrosis, hypertrophic scar, or displacement of the nipple-areola complex. All patients answered a questionnaire to evaluate their satisfaction and perception of the procedure. Results: Seven (7) patients with Simon grade 1 and 2 bilateral GM underwent ultrasound-guided VAE. No case of displacement, necrosis, or retraction of the nipple-areola complex, post-procedure bleeding, infection, skin necrosis, or asymmetry was detected. No patient reported decrease or change in nipple sensation or erection. All patients had bruises and hematomas that spontaneously resolved within 30 days. All results were considered good or excellent by patients and surgeons. Conclusion: Minimally invasive ultrasound-guided VAE is an excellent alternative for the treatment of GM. It is better indicated for Simon grade 1 and 2 GM, with good and excellent esthetic results, small scar, and low rates of nipple and areolar complications. It allows an outpatient procedure with low morbidity (local anesthesia) and fast recovery.

Elastographic Evaluation of Indeterminate Breast Masses on Ultrasound / Avaliação pela elastografia dos nódulos mamários indeterminados na ultrassonografia

Abstract Objective To evaluate the diagnostic accuracy of elastography for breast cancer identification in patients with indeterminate lesions on ultrasound. Methods This prospective, descriptive study included patients with indeterminate breast lesions in the ultrasound and with indication for percutaneous or surgical biopsy. The elastography was evaluated by qualitative analysis and by two methods for the semi quantitative analysis. Results We evaluated 125 female patients with 159 lesions, with a mean age of 47 years, and a range of 20-85 years. Ultrasound has shown to be a method with good sensitivity (98.1%), but with a lower specificity (40.6%). On the elastography qualitative analysis, the specificity and accuracy were of 80.2% and 81.8% respectively. The mean size of the lesions showed no difference in classification by elastography. For the semiquantitative elastography, the mean values of the malignant lesions were statistically higher when compared with the subcutaneous tissue or the adjacent fibroglandular tissue. The analysis of the receiver operating characteristic (ROC) curves for these two semiquantitativemethods showed that both are considered satisfactory, with an area under the curve above 0.75 and statistical significance (p < 0.0001). The best results were obtained when using the findings of combined conventional ultrasound and qualitative elastography, with 100% sensitivity and 63.2% specificity. Conclusions Elastography can be a useful complementary method, increasing the specificity and diagnostic accuracy of conventional ultrasound for the diagnosis of breast cancer in patients with indeterminate breast lesions.

Resumo Objetivo Avaliar a acurácia diagnóstica da elastografia para identificação do câncer de mama em pacientes com lesões indeterminadas por ultrassom. Métodos Estudo prospectivo, descritivo, com pacientes com lesões mamárias indeterminadas no ultrassom e indicação de biópsia percutânea ou cirúrgica. A elastografia foi avaliada por análise qualitativa e dois métodos de análise semiquantitativa. Resultados Avaliamos 125 pacientes do sexo feminino com 159 lesões, com média de idade de 47 anos, variando de 20 a 85 anos. O ultrassom mostrou ser um método com boa sensibilidade (98,1%), mas com menor especificidade (40,6%). Na elastografia da análise qualitativa, a especificidade e acurácia foram de 80,2% e 81,8%, respectivamente. A dimensão média das lesões não mostrou diferença na classificação por elastografia. Para a elastografia semiquantitativa, os valores médios das lesões malignas foram estatisticamente maiores quando comparados ao tecido subcutâneo ou fibroglandular adjacente. A análise das curvas ROC para estes dois métodos semiquantitativosmostrou que ambos são considerados satisfatórios, com área abaixo da curva acima de 0,75 e significância estatística (p < 0,0001). Osmelhores resultados foram obtidos com os achados de ultrassonografia combinada convencional e elastografia qualitativa, com sensibilidade de 100% e especificidade de 63,2%. Conclusões A elastografia pode ser um método complementar útil, aumentando a especificidade e a precisão diagnósticas do ultrassom convencional para o diagnóstico de câncer de mama em pacientes com lesões mamárias indeterminadas.

Breast cancer diagnosed before the 40 years: imaging findings and correlation with histology and molecular subtype

Background: To evaluate the imaging findings in patients with breast cancer diagnosed before age 40 and their correlation with histological type and molecular subtype. Methods: A descriptive, retrospective, single-center study was conducted by reviewing imaging exams and medical records, after approval of the institution's Ethics Review Board. Among the 120 patients studied, 112 (93.3%) had mammography, 113 (94.2%) underwent ultrasonography and 105 (87.5%) underwent breast magnetic resonance imaging (MRI). Histopathology data was performed in most cases after surgical resection, which was available for 113 patients (94.2%). Results: The mean age at diagnosis of primary breast cancer was 34 years. Most patients had no family history of breast cancer or ovarian cancer (60.7%), and were symptomatic at diagnosis (75.6%). The most common histological type was no-special type (NST) invasive carcinoma (73.8%). Regarding the molecular subtype, luminal B was the most common (42.6%), followed by triple negative (20.2%). The malignant tumor was identified in 92.9% of patients who underwent mammography, 96.5% of patients submitted to ultrasound and 98% of those who performed MRI. MRI was superior to other methods in the evaluation of multifocal and multicentric lesions. There was no statistically significant association between imaging findings and molecular subtypes in the present study. Conclusions: This study demonstrated that imaging methods play a fundamental role in the characterization of cases of breast cancer diagnosed in patients younger than 40 years. Despite the ultrasound has been the most widely used method, we found improved characterization of breast lesions when also used mammography and MRI (AU)

Breast cancer features in women under the age of 40 years / Perfil do câncer de mama em mulheres com idade inferior a 40 anos

Summary Objective: To describe the clinical features, imaging findings and pathological aspects of breast cancer diagnosed in women under the age of 40 years. Method: A retrospective, descriptive study was performed through analysis of medical records between November 2008 and August 2012. One hundred and twenty (120) patients were included, of whom 112 underwent mammography, 113 underwent ultrasonography, and 105 underwent magnetic resonance imaging (MRI). The histopathological data was obtained in most cases from post-surgical analysis, which was available for 113 patients. Results: The mean age at diagnosis of primary breast cancer was 34 years. Only 11 patients (9.0%) had a family history of breast or ovarian cancer in first-degree relative. Ninety-two (92) patients sought medical attention after showing breast symptoms, and the presence of a palpable nodule was the main complaint. One hundred and twenty-two (122) primary tumors were diagnosed, of which 112 were invasive (95%). The most common histological type was invasive ductal carcinoma (73.8%). Luminal B was the predominant molecular subtype (42.6%). Ultrasonography was positive in 94.5% of the cases and the most common finding were nodules (94.8%). At mammography, the malignancy was observed in 92.8% and the presence of suggestive calcifications was the dominant feature. The MRI was positive in 98% of patients, and mass lesions were the most common. Conclusion: Most cases of breast cancer diagnosed in patients under the age of 40 years, in our population, had symptoms at diagnosis and tumor with more aggressive biological behavior. Despite the ultrasound has been the most widely used method, we found improved characterization of breast lesions when also used mammography and MRI.

Resumo Objetivo: descrever o perfil clínico, os achados de imagem e os aspectos anatomopatológicos do câncer de mama em mulheres com idade inferior a 40 anos. Método: estudo retrospectivo, descritivo, com análise de prontuários de novembro de 2008 a agosto de 2012. Foram estudadas 120 pacientes, das quais 112 realizaram mamografia, 113 ultrassonografia e 105 ressonância magnética (RM). A coleta dos dados histopatológicos foi realizada com informações pós-cirúrgicas, disponíveis para 113 pacientes. Resultados: a idade média ao diagnóstico da neoplasia da mama foi 34 anos. Apenas 11 pacientes (9,0%) apresentaram história familiar positiva para câncer de mama/ovário em parente de primeiro grau. Noventa e duas pacientes (92) procuraram atendimento médico após apresentarem sintomas mamários, sendo nódulo palpável a principal queixa referida. Foram diagnosticados 122 tumores primários, dos quais 112 eram invasivos (95%). O tipo histológico mais encontrado foi o carcinoma ductal invasivo (73,8%). Em relação ao subtipo molecular, o luminal B foi predominante (42,6%). A ultrassonografia foi positiva em 94,5% dos casos e o achado mais comum foi nódulo (94,8%). Na mamografia, a lesão maligna foi evidenciada em 92,8% e a presença de calcificações suspeitas foi o padrão dominante. O exame de RM foi positivo em 98% dos pacientes, sendo lesões tipo massa as mais comuns. Conclusão: a maioria dos casos de câncer de mama em pacientes com idade inferior a 40 anos apresentavam sintomas ao diagnóstico e tumores de comportamento biológico mais agressivo. Apesar de a ultrassonografia ter sido o método mais utilizado, observamos uma melhora da caracterização das lesões mamárias quando utilizadas também a mamografia e a RM.

Breast Cancer Detection in a Screening Population: Comparison of Digital Mammography, Computer-Aided Detection Applied to Digital Mammography and Breast Ultrasound / 한국유방암학회지

PURPOSE: We aimed to compare the detection of breast cancer using full-field digital mammography (FFDM), FFDM with computer-aided detection (FFDM+CAD), ultrasound (US), and FFDM+CAD plus US (FFDM+CAD+US), and to investigate the factors affecting cancer detection. METHODS: In this retrospective study conducted from 2008 to 2012, 48,251 women underwent FFDM and US for cancer screening. One hundred seventy-one breast cancers were detected: 115 invasive cancers and 56 carcinomas in situ. Two radiologists evaluated the imaging findings of FFDM, FFDM+CAD, and US, based on the Breast Imaging Reporting and Data System lexicon of the American College of Radiology by consensus. We reviewed the clinical and the pathological data to investigate factors affecting cancer detection. We statistically used generalized estimation equations with a logit link to compare the cancer detectability of different imaging modalities. To compare the various factors affecting detection versus nondetection, we used Wilcoxon rank sum, chi-square, or Fisher exact test. RESULTS: The detectability of breast cancer by US (96.5%) or FFDM+CAD+US (100%) was superior to that of FFDM (87.1%) (p=0.019 or p<0.001, respectively) or FFDM+ CAD (88.3%) (p=0.050 or p<0.001, respectively). However, cancer detectability was not significantly different between FFDM versus FFDM+CAD (p=1.000) and US alone versus FFDM+CAD+US (p=0.126). The tumor size influenced cancer detectability by all imaging modalities (p<0.050). In FFDM and FFDM+CAD, the nondetecting group consisted of younger patients and patients with a denser breast composition (p<0.050). In breast US, carcinoma in situ was more frequent in the nondetecting group (p=0.014). CONCLUSION: For breast cancer screening, breast US alone is satisfactory for all age groups, although FFDM+ CAD+US is the perfect screening method. Patient age, breast composition, and pathological tumor size and type may influence cancer detection during screening.

Doppler and elastography as complementary diagnostic methods for mammary neoplasms in female cats / Doppler e elastografia como métodos diagnósticos complementares de neoplasias mamárias em felinos

Objetivou-se descrever a utilização das técnicas Doppler e elastografia ARFI (acoustic radiation force impulse) na avaliação de neoplasias mamárias de gatas, métodos ainda não utilizados para tal estudo em fêmeas felinas. Após a avaliação física e específica das neoplasias mamárias de duas gatas, foram realizadas as avaliações ultrassonográfica modo-B (ecogenicidade, ecotextura e margeamento), Doppler colorido (característica do fluxo sanguíneo) e espectral (velocidade sistólica/VS; diastólica/VD; e índice de resistência/IR) e a eslatografia ARFI qualitativa (escala de cores) e quantitativa (velocidade de cisalhamento) dos nódulos mamários, avaliando a aplicabilidade destas técnicas para determinar a malignidade dos tumores mamários. Após mastectomia e histopatologia foram diagnosticados: caso 1: carcinoma tubular; e caso 2: carcinoma mamário cribiforme. As características do modo-B foram similares para ambos os casos (heterogeneidade e margens regulares e não invasivas). Ao Doppler verificou-se presença de neovascularização e valores considerados elevados para os índices vasculares (quando comparado com tecidos benignos de outras espécies, como por exemplo caninos) (caso 1 - VS: 23,1cm/s, VD: 8,5cm/s e IR: 0,63; caso 2 - VS: 47,4 e 24,5cm/s; VD: 16,1 e 6,1cm/s e IR: 0,66 e 0,75); assim como os valores da velocidade de cisalhamento dos tecidos (caso 1: 4,07 m/s; caso 2: 4,54 e 6,85 m/s) na elastografia quantitativa; sendo que na avaliação qualitativa observou-se predominante rigidez e não deformidade tecidual, características que podem indicar a malignidade tecidual. Conclui-se que estas técnicas podem auxiliar no estudo de neoplasias mamárias em felinos, sugerindo a implementação destas técnicas de imagem para estudos de tumores mamários em felinos.

Sonographic Findings of Mammary Duct Ectasia: Can Malignancy be Differentiated from Benign Disease / 한국유방암학회지

PURPOSE: This study was designed to investigate differences in ultrasonographic findings between malignant and benign mammary duct ectasia. METHODS: From January 2003 to June 2005, 54 surgically proven mammary duct ectasia lesions depicted on sonograms were included in this study. We evaluated the ultrasonographic (US) findings in terms of involved ductal location, size, margin, intraductal echogenicity, presence of an intraductal nodule, calcification, ductal wall thickening and echo changes of the surrounding breast parenchyma. The US findings were correlated with the pathological features. RESULTS: Of the 54 lesions, 46 lesions were benign and eight lesions were malignant. Benign lesions included an inflammatory change (n=7), ductal epithelial hyperplasia (n=7), fibrocystic change (n=18), intraductal papilloma (n=11), atypical ductal hyperplasia (n=2) and sclerosing adenosis (n=1). Malignant lesions included ductal carcinoma in situ (DCIS) (n=6), infiltrating ductal carcinoma (n=1) and mucinous carcinoma (n=1). On US images, the peripheral ductal location, an ill-defined margin, ductal wall thickening and a hypoechoic change of the surrounding parenchyma were features significantly associated with malignant duct ectasia. CONCLUSION: For ill-defined peripheral duct ectasia with ductal wall thickening and surrounding hypoechogenicity as depicted on US, the possibility of malignancy should be considered and radiologists should not hesitate to recommend a prompt biopsy.

Primary Peripheral T-cell Lymphoma of the Breast: Radiologic and Pathologic Findings / 한국유방암학회지

Primary breast lymphoma is a rare disease entity, particularly the T-cell type. There have been many case reports of primary breast lymphomas; however, these are mostly pathologic reports, with only a few reports in radiology literature. To the best of our knowledge, this is the first report on the radiologic features of primary T-cell type breast lymphoma, including mammography, ultrasonography, MR imaging, and 18 fluorodeoxyglucose positron emission tomography/computed tomography scan. The radiologic findings are rather unique for this T-cell lymphoma compared to B cell type.

Concordância entre o exame ultra-sonográfico e o laudo anatomopatológico no diagnóstico de lesões mamárias sólidas / Breast biopsy histopathologic results and breast ultrasonography findings agreement in solid masses diagnosis

O ultra-som de mama é um exame complementar não-invasivo que vem desempenhando papel importante no diagnóstico das doenças mamárias. Por meio das características de uma imagem ultra-sonográfica, pode-se predizer malignidade ou benegnidade. O objetivo deste trabalho foi identificar, no meio médico, quais são as características ultra-sonográficas que estão mais associadas à malignidade. Pesquisou-se 105 casos de tumores sólidos identificados ao ultra-som de mama no período de janeiro a dezembro de 2005. As variáveis ultra-sonográficas analisadas foram: forma, contorno, limite, ecogenicidade, ecotextura, somra acústica posterior, reforço acústico posterior, relação largura/comprimento da lesão e conclusão do ultra-som. Em seguida, realizou-se a investigação anatomopatológica dos tumores. Entre as características ultra-sonográficas, a irregularidade das margens (p = 0,001) e o contorno mal definido (p = 0,011) foram as que mais se associaram à malignidade. A conclusão do ultra-som, quando presente, também correlacionou-se com o laudo anotomopatológico (p < 0,001). As demais variáveis, por serem pouco descritas, não puderam ser avaliadas quanto à sua malignidade. No meio médico, o estudo das margens e do contorno dos tumores sólidos são as características mais determinantes no diagnóstico ultra-sonográfico de malignidade. Laudos imcompletos e inconclusivos são fatores limitantes no valor do diagnóstico deste método de estudo.

Breast ultrasonography is a non-invasive complementary exam that has been performing an important role in the diagnosis of mammary illness. Through the characteristics of an ultrasonographic image, we can predict malignity or benignity. The object of this research was to identify, in our field, which ultrasonographic characteristics are most commonly associated with malignity. We researched 105 cases of solid turmors identified by mammary ultrasonography in the period of January to December 2005. The various ultrasound characteristics analyzed were: shape, wall contour, margin, echogenicidity, echotexture, posterior acustic shadow, posterior acustic reinforcement, relation width/length of lesion and conclusionof ultrasound. Immediately, we carried out a pathological anatomy investigation of the tumor. Among the ultrasound characteristics, the irregularity of margins (p = 0.001) and badly defined wall contour (9 = 0.011) were the most associated with malignity. The ultrasonography conclusion, when present, also correlated with the pathological anatomy findings (p < 0.001). The other variables, being little descript, could not be evaluated as for their association with malignity. In our field, the study of margin and wall contour of the solid tumors are the most determind characteristics in ultrasound diagnosis of malignity. Incomplete and inconclusive findings are limiting factors in the diagnostic value of this type of study.

Non-Calcified Ductal Carcinoma in Situ: Ultrasound and Mammographic Findings Correlated with Histological Findings

PURPOSE: To evaluate radiological findings of non-calcified ductal carcinoma in situ (DCIS) and to correlate those with histological features. MATERIALS AND METHODS: From July 2002 to March 2006, 22 patients with histologically-proven non-calcified DCIS were included. Mammography was obtained in 19 patients, ultrasound in 18 patients, and both examinations in 15 patients. Radiological findings were evaluated according to the Breast Imaging Reporting and Data System by American College of Radiology. Histological tumor subtype and Van Nuys classification of DCIS were assessed. RESULTS: Histological subtypes consisted of mixed type in 11 patients (50%), comedo in 4 (18%), cribriform in 4 (18%), papillary type in 2 (9%), and solid in one (5%). According to Van Nuys classification, group 3 DCIS was observed in 13 (59%) patients. In the 19 patients who underwent mammography, 13 patients presented with abnormal findings: focal asymmetry in 7 patients (37%), masses in 4 (21%), skin thickening in one (5%), and architectural distortion in one (5%). In the 18 patients who had received breast ultrasound, a mass was present in 15 (83%) patients and ductal changes in 3 patients (17%). Sixty percent of patients with masses on ultrasound had group 3 DCIS and 100% of patients with ductal change had group 1 DCIS (p=0.017). CONCLUSION: Diagnosis of non-calcified DCIS by mammography is not an easy task due to the lack of typical malignant calcifications or masses. High resolution ultrasound can be useful for detecting non-calcified DCIS, and ultrasound findings are correlated with histological features.