Low-Grade Adenosquamous Carcinoma of the Breast Developing Around a Localization Wire Fragment.

We present the case of a 67-year-old white woman with a history of benign biopsy results in the previous 10 years before she developed low-grade adenosquamous carcinoma around a residual localization wire fragment. A possible theory of carcinogenesis may be related to reparative epithelium in a healing biopsy site that underwent squamous metaplasia; alternately, there may have been carcinogenesis related to long-term metal exposure at the wire placement site. In vitro and in vivo studies have demonstrated a link between carcinogenesis and long-term exposure to various metals. This case report raises important questions regarding carcinogenesis in the setting of long-term metal exposure and the reparative response of the body at the site of injury or biopsy.

Breast arterial calcifications on mammograms do not predict coronary heart disease at coronary angiography.

PURPOSE: To examine, in women who underwent cardiac catheterization, whether breast arterial calcifications (BACs) seen at screening mammography correlate with coronary heart disease (CHD) seen at coronary angiography. MATERIALS AND METHODS: In an institutional review board-approved, HIPAA-compliant study, 172 women (mean age, 64.29 years +/- 11.97 [standard deviation]) who underwent coronary angiography were recruited, interviewed, and assigned to two groups: those with (CHD+) and those without (CHD-) CHD. The severity and location of the CHD were considered. Their mammograms were reviewed by a breast imaging specialist who was blinded to the CHD status. Student t test, chi(2), and multiple logistic regression tests were performed as appropriate. Presence of BAC was noted and correlated with presence of CHD and presence of cardiac risk factors. RESULTS: There were 104 women with and 68 women without CHD. Thirty-seven (36%) women in the CHD+ group versus 20 (29%) in the CHD-group (P = .40) had BAC. The mean age of the patients with BAC, 72 years +/- 9.8, was significantly older than the mean age of the patients without BAC, 60.4 years +/- 11.1 (P < .001). Therefore, subjects were divided into those younger than 65 years and those 65 years and older. No correlation existed, despite the fact that BAC was associated with some cardiac risk factors. CONCLUSION: The authors did not observe a correlation between BAC and coronary angiography-detected CHD, even when CHD severity was considered. On the basis of these results, caution should be exercised when using screening mammography-detected BAC to identify patients with CHD.

Improving access to breast health services with an interdisciplinary model of care.

This article reports a hospital's experience confronting a community crisis, stemming from local and national breast health access issues, and evaluates the subsequent effectiveness of the initiative to improve breast care service. An interdisciplinary Breast Care Facility was developed adjacent to a Community Hospital. Patients receiving breast cancer screening during the year prior to the Breast Center opening (2002) were compared with patients in subsequent years (2003-2005). Program effectiveness was evaluated by examining screening mammography volume, wait times and cancer detection rates. Screening volume increased by 29.6%. Wait times declined from 30 weeks to 3.5 weeks. Initially, patients with a suspicious screening mammography had a 2-3 week delay for diagnostic mammography and the subsequent evaluation took another 3-4 weeks. Both times improved to an average of 2-5 days. Screening cancer detection rates increased from 3.2 per 1,000, to 6.3 per 1,000. In addition, the number of cancers identified by screening increased from 40% to 58%, p = 0.002. Patient satisfaction measured by survey was over 95%, in areas of courtesy, counseling, and overall care. Our study demonstrates that a comprehensive breast center model can increase access to breast care services, improve patient satisfaction and address focal areas of shortage. Furthermore, in the years after the opening of the breast center the cancer detection rate during screening increased, an important observation that needs to be investigated with future studies.

Breast cancer screening in women with chronic kidney disease: the unrecognized effects of metastatic soft-tissue calcification.

Patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD) are known to develop metastatic soft-tissue calcification, secondary to hyperparathyroidism, in tissues including the breast. Such calcifications in women could pose a problem for interpretation of mammograms, since they are thought to mimic malignant lesions and interfere with differentiation of benign from malignant disease. Investigation of this issue is important to provide high-quality, accurate breast care to women with CKD or ESRD, but little evidence is so far available. In a systematic review of the literature on the types and patterns of breast calcifications, we found only three studies that examined metastatic soft-tissue calcifications of the breast. The studies did, however, confirm that women with CKD or ESRD have a higher frequency of breast calcification than women with normal kidney function. The two older studies reported that these breast calcifications are not associated with malignancy, but the later study reported a raised rate of suspicious breast calcification among women with ESRD receiving hemodialysis, leading to an increased biopsy referral rate. In this Review we discuss the strengths and limitations of the available data and whether mammography is recommended in women with CKD or ESRD.

Increased breast calcifications in women with ESRD on dialysis: implications for breast cancer screening.

BACKGROUND: Different appearances of breast calcification on mammography can differentiate benign from malignant disease. An increased incidence of breast calcifications in dialysis patients is established, but data for morphological characteristics in renal patients, incidence of benign and malignant calcifications, and clinical consequences are limited. In this study, we compare mammograms and the workup of abnormal calcifications of women on hemodialysis with that of women with normal renal function. METHODS: This is a retrospective case-control study; 45 women on hemodialysis had their screening mammograms reviewed. A control group of 86 age-matched women with normal renal function was randomly obtained for comparison. Mammograms were examined and the recommended workup was traced. Breast calcification morphological characteristics, incidence of benign versus malignant calcifications, callback rate, and biopsy recommendation rates were compared to determine whether breast calcifications in renal patients led to excessive workups. RESULTS: Overall, breast calcifications in the renal group were statistically significantly increased compared with controls, mostly because of several benign-appearing morphological characteristics. No statistically significant difference was present between the 2 groups with respect to callback rates. However, incidences of malignancy-associated calcification and hence biopsy recommendation rate were slightly greater for the renal group. CONCLUSION: Renal patients have an increase in breast calcification, mostly caused by several benign calcifications. The callback rate is no greater than that in the general population. However, there is a slightly greater incidence of malignancy-associated calcifications; hence, once called back, they have a greater probability of being recommended for biopsy.

Pseudoangiomatous stromal hyperplasia of the breast: sonographic features with histopathologic correlation.

The objective of this study was to evaluate the spectrum of sonographic findings in pseudoangiomatous stromal hyperplasia (PASH) of the breast when it presents as a tumoral mass with pathologic correlation. Breast sonogram studies of 13 patients with 13 pathologically proven PASH lesions were retrospectively reviewed. The morphologic characteristics of the lesions as seen on ultrasound were evaluated and correlated with histopathologic findings. Sonography demonstrated most lesions, 11 of 13, to be hypoechoic in echotexture. One lesion was isoechoic in echotexture, also demonstrating small internal cysts, and one was predominantly hyperechoic. Two of the 11 hypoechoic lesions also demonstrated a complex heterogeneous pattern with a central hypoechoic area and a peripheral echogenic rim. All lesions were oval in shape with the long axis of the lesion parallel to the chest wall. None of the lesions demonstrated posterior acoustic shadowing. PASH lesions of the breast have a varied sonographic appearance. Knowledge of the spectrum of morphologic features shown on sonography can be helpful in the diagnosis of this entity.

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.

Stratification of mammographic computerized analysis by BI-RADS categories.

The Breast Imaging Reporting and Data System (BI-RADS) was implemented to standardize characterization of mammographic findings. The purpose of the present study was to evaluate in which BI-RADS categories the changes recommended by computerized mammographic analysis are most beneficial. Archival cases including, 170 masses (101 malignant, 69 benign) and 63 clusters of microcalcifications (MCs; 36 malignant, 27 benign), were evaluated retrospectively, using the BI-RADS categories, by several radiologists, blinded to the pathology results. A computerized system then automatically extracted from the digitized mammogram features characterizing mammographic lesions, which were used to classify the lesions. The results of the computerized classification scheme were compared, by receiver operating characteristics (ROC) analysis, to the conventional interpretation. In the "low probability of malignancy group" (excluding BI-RADS categories 4 and 5), computerized analysis improved the A(z )of the ROC curve significantly, from 0.57 to 0.89. In the "high probability of malignancy group" (mostly category 5) the computerized analysis yielded an ROC curve with an A(z )of 0.99. In the "intermediate probability of malignancy group" computerized analysis improved the A(z )significantly, from 0.66 for to 0.83. Pair-wise analysis showed that in the latter group the modifications resulting from computerized analysis were correct in 83% of cases. Computerized analysis has the ability to improve the performance of the radiologists exactly in the BI-RADS categories with the greatest difficulties in arriving at a correct diagnosis. It increased the performance significantly in the problematic group of "intermediate probability of malignancy" and pinpointed all the cases with missed cancers in the "low probability" group.

Can the size of microcalcifications predict malignancy of clusters at mammography?

RATIONALE AND OBJECTIVES: The purpose of this study was to determine whether the size of mammographically detected microcalcifications is predictive of malignancy. MATERIALS AND METHODS: Two hundred sixty mammograms showing clustered microcalcifications with proven diagnoses (160 malignant, 100 benign) were respectively reviewed by experienced mammographers. Lesions that were obviously benign in appearance were excluded from the study. A computer-aided diagnosis system digitized the lesions at 600 dpi, and the microcalcifications on the digital image were interactively defined by mammographers. Subsequently, three quantitative features that reflected the size of the microcalcifications-length, area, and brightness-were automatically extracted by the system. For each feature, the standard average of values obtained for individual calcifications within the cluster and the average with emphasis on extreme values (E) obtained in a single cluster were analyzed and matched with pathologic results. RESULTS: In the malignant group of cases, the mean values of the standard average length and area were significantly higher (P < .0001) than the mean values in the benign group. Distribution analysis demonstrated that an average length of more than 0.41 mm was associated with malignant lesions 77% of the time, while an average length of less than 0.41 mm was associated with benign lesions 71% of the time. The mean of the average length (E) and area (E) of microcalcifications within the cluster demonstrated an even higher discriminative power when compared with the standard average length and area. The average brightness, on the other hand, showed only a low discriminative power. CONCLUSION: Digital computerized analysis of mammographically detected calcifications demonstrated that the average length and area of the calcifications in benign clusters were significantly smaller than those in malignant clusters.