Calcificaciones mamarias: descripción y clasificación según la 5ª edición BI-RADS / Breast calcifications: description and classification according to BI-RADS 5th edition

Abstract. Breast calcifications are frequent findings in mammography. Most of them have a benign origin, such as in the case of the response to inflammatory disease of the ducts or coarse calcifications in benign nodules. Many of these calcifications show a characteristic benign appearance, and they do not need to be magnified or monitored. However, other calcifications can show a grouped pattern, have a suspicious appearance, and transform into an in situ ductal carcinoma or a high risk breast lesion. It is important to know the morphological and distribution patterns of these calcifications in order to make right decisions for each case. In the 5th edition of the BI-RADS atlas, 2013, categories and levels of suspicion for some patterns were modified. The objective of this article is to update descriptors and categories of BI-RADS micro-calcifications, pointing out their most important features and malignancy risk linked to each descriptor.

Resumen. Las calcificaciones mamarias son un hallazgo frecuente en mamografía. La mayoría de ellas tienen un origen benigno, como puede ser la respuesta a patología inflamatoria de los conductos o calcificaciones gruesas en nódulos benignos. Muchas de estas calcificaciones presentan un aspecto benigno característico y no requieren ser magnificadas o controladas. Otras calcificaciones sin embargo pueden presentarse agrupadas, tener un aspecto sospechoso y originarse en un carcinoma ductal in situ o una lesión de alto riesgo. Es relevante conocer los patrones morfológicos y de distribución de estas calcificaciones a fin de tomar la conducta adecuada para cada caso. En la 5.ª edición del atlas BI-RADS, 2013, las categorías y grados de sospecha de algunos patrones fueron modificados. El objetivo del presente artículo es realizar una actualización de los descriptores y las categorías BI-RADS de las microcalcificaciones, señalando sus características más importantes y el riesgo de malignidad asociado a cada descriptor.

The importance of breast elastography added to the BI-RADS® (5th edition) lexicon classification / A importância da elastografia mamária adicionada à classificação, segundo o léxico BI-RADS® (5ª edição)

SummaryObjective:the aim of this study was to investigate the addition of elastography to the BI-RADS® lexicon for the classification of breast lesions.Methods:a total of 955 consecutive patients who were subjected to breast percutaneous biopsy from January 2010 to December 2012 were retrospectively assessed. Overall, 26 patients who did not present with masses on conventional ultrasound were excluded. The patients were classified according to the fifth edition of the breast imaging and reporting data system (BI-RADS®) lexicon, which includes elastographic findings. The BI-RADS®classification is based on the same classification principles that have been suggested by the author, which classify lesions as soft, intermediate, or hard.Results:the addition of elastographic findings to the BI-RADS® lexicon improved the sensitivity (S), specificity (SP), and diagnostic accuracy (DA) of ultrasound in the assessment of breast lesions, which increased from 93.85, 72.07, and 76.64 to 95.90, 80.65, and 91.39%, respectively.Conclusion:these findings suggest that the addition of elastography to the BIRADS ® lexicon will improve the SP and DA of ultrasound in the screening of breast lesions.

ResumoObjetivo:investigar o impacto da adição da descoberta da elastografia das lesões mamárias à classificação segundo o léxico BI-RADS®.Métodos:estudo retrospectivo com 955 pacientes consecutivas, submetidas à biópsia mamária percutânea no período de janeiro de 2010 a dezembro de 2012. Foram excluídas 26 pacientes que apresentaram lesão não nodular ao ultrassom convencional. As lesões foram classificadas conforme proposta da 5ª edição do léxico BI-RADS®, que inclui os achados de elastografia. A classificação BI- -RADS® é baseada nos mesmos critérios propostos pelo autor, que classifica as lesões como macias, intermediárias e rígidas.Resultados:a adição dos achados da elastografia ao léxico BI-RADS® melhorou a sensibilidade (S), a especificidade (E) e a acurácia diagnóstica (AD) do ultrassom na avaliação das lesões mamárias, de 93.85, 72.07 e 76.64% para 95.90, 80.65 e 91.39%, respectivamente.Conclusão:os achados sugerem que a adição dos achados da elastografia ao léxico BI-RADS® pode melhorar a S, a E e a AD do ultrassom no rastreamento de lesões mamárias.

Processos inflamatórios da mama: caracterização e manejo terapêutico / Inflammatory processes of breast: characterization and therapeutic management

Hiperemia, calor e dor na mama podem relacionar-se a um grande número de causas. Processos inflamatórios da mama geralmente estão relacionados ao ciclo grávido-puerperal e suas modificaçöes, principalmente as formas agudas. Este trabalho tem por objetivo a caracterização dos diferentes processos inflamatórios da mama e seu adequado manejo.

Redness, heat, and breast pain may be related to a number of causes. Inflammatory conditions of the breast are usually related to the pregnancy-puerperal cycle and its modifications, mainly acute forms. This work aims to characterize the different inflammatory breast conditions and its adequate management.

Avaliação de microcalcificações mamárias de acordo com as classificações do Breast Imaging Reporting and Data System (BI-RADS TM) e de Le Gal / Evaluation of breast microcalcifications according to Breast Imaging Reporting and Data System (BI-RADS TM) and Le Gal's classifications

OBJETIVO: avaliar a acurácia da mamografia para o diagnóstico de microcalcificações mamárias suspeitas, com as classificações do Breast Imaging Reporting and Data System (BI-RADS TM) e Le Gal em comparação com o resultado histopatológico utilizado como padrão-ouro. MÉTODOS: foram selecionados dos arquivos dos blocos cirúrgicos, 130 casos operados com mamografias contendo somente microcalcificações mamárias, inicialmente classificadas como suspeitas sem lesões detectáveis ao exame clínico. Estas foram reclassificadas por dois examinadores, utilizando as classificações de Le Gal e BI-RADS TM, obtendo-se diagnóstico de consenso. As biópsias foram revistas por dois patologistas e foi obtido diagnóstico de consenso. A leitura das mamografias e a revisão das lâminas foram feitas em duplo-cego. As análises estatísticas utilizadas neste estudo foram o teste do chi2, o modelo Fleiss quadrático para VPP e o programa Epi-Info 6.0. RESULTADOS: a correlação entre a análise histopatológica e mamográfica, usando BI-RADS TM e Le Gal, mostrou a mesma sensibilidade de 96,4 por cento, especificidade de 55,9 e 30,3 por cento, valor preditivo positivo (VPP) de 37,5 por cento e 27,5 por cento e acurácia de 64,6 e 44,6 por cento, respectivamente. Quando discriminamos por categorias de BI-RADS TM, obtivemos VPPs: categoria 2, 0 por cento; categoria 3, 1,8 por cento; categoria 4, 31,6 por cento e categoria 5, 60 por cento. Os VPPs pela classificação de Le Gal foram: categoria 2, 3,1 por cento; categoria 3, 18,1 por cento; categoria 4, 26,4 por cento; categoria 5, 66,7 por cento e não classificável, 5,2 por cento. CONCLUSÕES: observou-se uma maior precisão com a classificação de BI-RADS TM, porém não se conseguiu reduzir a ambigüidade na avaliação das microcalcificações mamárias.

PURPOSE: the aim of this study is to evaluate the accuracy of mammography in the diagnosis of suspicious breast microcalcifications, using BI-RADS TM and Le Gal's classifications. METHODS: one hundred and thirty cases were selected with mammograms contain only microcalcifications of file and initially classified as suspicious (categories 4 and 5) without lesions clinical detectable and reclassified by two examiners, getting a consensus diagnosis. The biopsies were reviewed by two pathologists getting also a consensus diagnosis. Both, mammogram and histopathologic analysis were double blinded reviewed. Qui-square test, Fleiss-square statistic and EPI-INFO 6.0 were used in this study. RESULTS: the correlation between histopathological and mammographic analysis using BI-RADS TM and Le Gal classification showed the same sensitivity of 96.4 percent, specificity of 55.9 and 30.3 percent, positive predictive value (PPV) of 37.5 and 27.5 percent, and accuracy of 64.6 and 44.6 percent respectively. The PPV by BI-RADS TM categories was: category 2, 0 percent; category 3, 1.8 percent; category 4, 30.8 percent; and category 5, 60 percent. The PPV by Le Gal classification was: category 2, 3.1 percent; category 3, 18.1 percent; category 4, 26.4 percent;category 5, 66.7 percent, and non classified 5.2 percent. CONCLUSIONS: the results were better for the classification of BI-RADS™, but it did not get to reduce the ambiguity in assessment of breast microcalcifications.

Value of scoring system in classification of proliferative breast disease on fine needle aspiration cytology.

Fine-needle aspiration (FNA) cytology is successful in identification of benign and malignant breast lesions, but its role in proliferative breast lesions which increase cancer risk is poorly defined. We have analyzed the cytomorphologic features of proliferative breast lesions in conjunction with cytologic scoring system proposed by Masood et al and with histopathology. Sixty two patients (14 cases of fibroadenoma, 15 cases of fibroadenoma with atypia, 11 cases of proliferative breast disease (PBD), 8 cases of PBD with atypia and 14 cases of carcinoma) diagnosed on routine FNA were subjected to scoring following Masood's criteria. All cases with the cytologic diagnosis of fibroadenoma were confirmed on histology. Of 11 cases of PBD on FNA, 10 were PBD without atypia on histology. One case, which showed atypical hyperplasia on histology, was missed by both the scoring system and cytomorphology and one case was over-diagnosed as PBD with atypia by the scoring system. FNA cytology correctly identified all the carcinoma cases, while the scoring system under-diagnosed 2 cases as PBD with atypia. Hence, in cases not suspected to be atypical or confirmed to be cancer on routine cytology, scoring added no information over and above cytomorphology and was not useful. All fourteen cases of fibroadenoma with atypia suspected on routine cytology were fibroadenoma on histology. Scoring system correctly placed 11/14 of these cases as PBD without atypia. Similarly 3/8 cases thought to be PBD with atypia were correctly placed as PBD without atypia by scoring. Only 2/8 cases thought to be PBD with atypia on cytology were confirmed to have atypical hyperplasia on histology. Scoring improved the diagnostic yield to 2/5. Hence, in cases of fibroadenoma or PBD, suspected on FNAC to have cytological atypia, Masood scoring gives additional information by eliminating benign cases and improving diagnostic yield. Application of scoring in a step-wise manner, on atypical aspirates, can help in selection of cases suitable for biopsy.

Correlation of fine needle aspiration cytology and its histopathology in diagnosis of breast lumps.

This study was carried out to evaluate the accuracy of FNAC and the role of FNAC in palpable breast lumps for the early surgical management in out patient and inpatient basis. The study was carried out in Dhaka Medical College during the period of January-December, 2000. FNAC was performed on 310 patients presented with palpable breast lumps. Histopathology was available for 122 cases. Of them, cytologically diagnosed benign cases were 106, histologically 105 cases were proved so. There was false negative diagnosis in one case. All 14 cases diagnosed as malignant cytologically proved as such histologically. Two cases reported as suspicious for malignancy one of which were proved malignant histologically. False positive diagnosis was made in one case. FNAC of breast lump was found to be associated with increased diagnostic yields. It can be carried out safely as a preoperative diagnostic method in-patients with breast lumps mostly in out-patient department.

Galactocele: clasificación / Galactocele: classification

Los galactoceles se hacen semisólidos a medida que evolucionan; por lo tanto; la clínica, la imagenología y la citopatología sufren algunos cambios. Por estas razones los hemos clasificados en tres estadios. Estadio I, o agudo, de contenido líquido y aspecto uniforme. Estadio II, o intermedio, con contenido líquido y semisólido, de aspecto mixto. Estadio III, o crónico, de contenido semisólido y aspecto grumoso. La ecotomografía mamaria revela imagen anecogénica en el estadio I, mixta en el II e hipoecogénica en el III. La mamografía en los estadios I y II ocacionan dudas diagnósticas por lo que requieren complemento ecotomográfico, no así en el estadio III, donde las imagenes son propias: presencia de cápsula, fondo grumoso como copos de nieve y a veces calcificaciones gruesas. La citopatología también muestra variaciones en los diferentes estadios. Los galactoceles estudiados tenían como antecedentes embarazo y lactancia

Malformaciones o anomalías en el desarrollo de la mama / Malformations or abnormalities in breast development

Las malformaciones mamarias se clasifican en congénitas o adquiridas; por defecto o por exceso y en anomalías de número, forma, tamaño y situación. En el capítulo se anlizan los diversos tipos de malformaciones tales como atelia y politelia; amastia, polimastia, macro y micromastia. Se mencionan también algunas alteraciones funcionales como la hipertrofia juvenil y la del embarazo. Se hace hincapié en el pezón invertido o umbilicado por sus repercusiones en la lactancia materna

Enfermedades inflamatorias de la mama / Inflammatory diseases of the breast

Se abordan diversas afecciones inflamatorias agudas y crónicas de la mama tales como: A) Mastitis aguda puerperal ocasionada habitualmente por el staphylococcus aureus que ingresa por vía canalicular durante la succión o a través de grietas del pezón, por vía directa o linfática. De no recibir tratamiento antibiótico mut precoz, la mastitis, favorecida por la retención láctea, va a la abscedación. Porducido el absceso, procede el tratamiento quirúrgico con incisión, vaciamiento y drenaje. En algunos casos pueden intentarse las punciones evacuadoras repetidas. B) Absceso retroalveolar recidivante o fístula mamaria. Es una afección secundaria a metaplasia escamosa originada en el interior de los grandes conductos o a ectasia intraductal, lo que lleva a la formación de una fístula con reactivaciones sucesivas. Debe tratarse con fistulectomía o resección en cono de la zona de los grandes conductos. C) Gangrena de la mama. Sólo se cita un caso aislado. D) Proceso inflamatorio retroalveolar de la adolescente. Es un cuadro poco conocido, que aparece siempre en la adolescencia, entre los 12 y 15 años. Es de iniciación dolorosa, con aparición de una masa retroareolar que va a la regresión espontánea en un plazo de 15 a 30 días. E) Ectasia de conductos o mastitis periductal. La dilatación de los conductos bajo el pezón y la retención y ectasia de escresiones en su interior se acompaña de fenómenos inflamatorios periductales que pueden complicarse con la formación de abscesos que tienden a fistulizarse o de mastitis de células plasmáticas con formación de una masa tumoral, cuya gravedad deriva de su posible confusión con un carcinoma. F) Necrosis grasa y G) mastitis granulomatosa. Son cuadros de evolución tórpida que dan origen a masas de sapecto tumoral, las que plantean el diagnóstico diferencial con las neoplasias. H) Tuberculosis mamaria. Es un cuadro infrecuente pero que debe tenerse presente ante el posible aumento de la enfermedad tuberculosa. I) Micosis. Pueden ser cútaneas o parenquimatosas, las que son muy raras. J) Enfermedad de Mondor. Es una tromboflebitis de las venas superficiales de la pared anterior del tórax. K) Hidatidosis de la mama, sólo se mencionan dos casos clínicos