How significant is detection of ductal carcinoma in situ in a breast screening programme?

PURPOSE: To compare the histological grades of screen detected and non-screen detected ductal carcinoma in situ (DCIS) and to identify any differences that might support the contention that DCIS found by breast screening represents an over-diagnosis. The aim was also to establish whether any particular mammographic features of DCIS can be used to predict tumour grade reliably. MATERIALS AND METHODS: Biopsy proven cases of DCIS (n=153) were reviewed with respect to grade and subdivided into high, intermediate and low grades using the Van Nuys classification. A more aggressive subset of DCIS (microinvasive and interval cancers) were similarly analysed. Mammograms were reviewed with regard to abnormal features and distribution, and the appearances correlated with grade. RESULTS: Fifty-four percent (53/98) of screen detected and 62% (34/52) of non-screen detected DCIS were high grade. The rest were equally intermediate and low grade, with no statistical difference between the two groups. Eighty-four percent of the aggressive subset of tumours were high grade. Micro-calcification was present in 90% and in 10% there were soft tissue changes alone. Seventy-six percent of linear branching calcification was associated with high grade DCIS. Only 13% of high grade DCIS demonstrated punctate micro-calcification; however, 38% of cases of punctate micro-calfication were associated with high grade tumours and there was a great deal of overlap between the groups. CONCLUSION: Most cases of DCIS in both screen and non-screen detected groups were high grade. Only one in five was low grade. Analysis of the aggressive subgroup underlines the significance of high grade DCIS. Mammographic patterns are not always reliable in the prediction of tumour grade. The detection of DCIS in screening programmes is important and should not be regarded as over-diagnosis.

Imaging-guided core biopsy for the diagnosis of malignant tumors in pediatric patients.

OBJECTIVE: We evaluated the ability of imaging-guided core biopsy to obtain sufficient tissue from pediatric tumors for a definitive diagnosis of malignancy on which treatment could be based. MATERIALS AND METHODS: Thirty-four biopsies (biopsies of the abdomen, 32; of the chest, 2) were performed on 34 children at presentation under CT or sonographic guidance using 14-, 18-, or both 14- and 18-gauge needles. A minimum of two tissue cores was obtained. Most biopsies were performed under general anesthesia, permitting other procedures to be performed. The biopsy results were confirmed by subsequent surgical pathology, bone marrow biopsy, biochemical or clinical features, and follow-up examination. RESULTS: The needle biopsy diagnoses were nephroblastoma (n = 11), neuroblastoma (n = 7), renal cell carcinoma (n = 2), synovial sarcoma (n = 1), non-Hodgkin's lymphoma (n = 2), clear cell sarcoma (n = 1), rhabdoid tumor (n = 1), pulmonary blastoma (n = 2), embryonal rhabdomyosarcoma (n 1), germ cell tumor (n = 1), adrenal carcinoma (n = 1), inflammatory tissue (n = 2), desmoplastic tumor of the mesentery (n = 1), and primitive neuroectodermal tumor (n = 1). In 28 patients, the results were confirmed as correct (22 with surgery and 6 with follow-up examination). Four patients required additional biopsy. In two of these patients, the core biopsy showed inflammatory tissue only, and an open biopsy of a different site was performed; the other two patients did not respond to therapy on the basis of needle biopsy results, and an open biopsy altered the diagnosis. Two patients with widespread disease were excluded because they did not respond to treatment and were too ill to undergo an open biopsy. Only one significant complication was recorded. CONCLUSION: Imaging-guided core biopsy is a safe and reliable means of obtaining sufficient tissue to make a confident histologic diagnosis of malignant pediatric tumors in a high percentage of patients.

The significance of new densities and microcalcification in the second round of breast screening.

AIM: To assess the nature of new densities and microcalcifications in the second round of breast screening. MATERIALS AND METHODS: A total of 34 634 women were screened at our unit in the second round of the United Kingdom National Health Service Breast Screening Programme. Of those attending for the second time, 302 were recalled for further work-up of 311 new lesions. The lesions were divided into masses, microcalcifications, asymmetric densities and architectural distortions. Masses were classified according to margin and density, and microcalcifications according to morphology and distribution. RESULTS: Among women attending for the second time, the cancer detection rate was 0.45% (89 cancers). One hundred and eighty-eight new masses were identified: 53 well-defined (two malignant), 67 partially defined (six malignant), 54 ill-defined (18 malignant), and 14 spiculate (14 malignant). Well-defined masses were usually cysts, especially in women on hormone replacement therapy. Of 97 new microcalcifications, 71 were pleomorphic (28 malignant), 12 linear (one malignant), and 14 punctate (none malignant). Twenty-five new asymmetric densities were identified (five malignant). One of two architectural distortions was malignant. Malignancy was found in 21% of new masses, 30% of new microcalcification and 20% of asymmetric densities. CONCLUSION: Carcinoma was found in 24% of all new mammographic abnormalities appearing in a 3-year screening period. Spiculate and ill-defined masses, clustered pleomorphic microcalcification, and new asymmetric densities should be regarded with particular suspicion. The use of fine needle aspiration cytology in combination with imaging assessment may help to reduce the number of benign excisional biopsies for new mammographic lesions.

Power Doppler US of the normal prepubertal testis: does it live up to its promises?

PURPOSE: To assess whether power Doppler ultrasound (US) improves the detection of flow in normal prepubertal testes. MATERIALS AND METHODS: Seventy-two normal testes of 38 prepubertal boys (age range, 2 weeks to 12.5 years) were scanned with color and power Doppler US (7-MHz transducer). The two modalities were compared subjectively to determine which one was more sensitive for detection of flow. Only reproducible intratesticular flow signals were considered positive; capsular flow was disregarded. RESULTS: Power Doppler US depicted flow in 50 testes (69%), while color Doppler US depicted flow in 47 testes (65%, not statistically significant). Power and color Doppler US combined depicted flow in 57 testes (79%), which was significant when compared with color Doppler US alone (P = .002). Detection of flow was subjectively easier with power Doppler US in 10 of 72 testes, while it was easier with color Doppler US in 14 of 72 testes. Motion artifacts were greater with power Doppler US. CONCLUSION: Power Doppler US was equally sensitive as conventional color Doppler US in the detection of flow in normal prepubertal testes. Combining both modalities improved detection of flow in 14% of cases and may be useful in excluding torsion in children. For a positive preoperative diagnosis of torsion in children, radionuclide scintigraphy remains the imaging modality of choice.

Role of image-guided core-needle biopsy in the management of patients with lymphoma.

PURPOSE: The results of 106 radiologically guided core needle biopsies in 96 patients were analyzed retrospectively to evaluate the accuracy, safety, and role of this technique in the management of patients with lymphoma and to determine factors predictive of success. PATIENTS AND METHODS: Biopsies were performed in 51 patients with low-grade non-Hodgkin's lymphoma (NHL), 24 with high-grade NHL, 16 with previously diagnosed Hodgkin's disease (HD), and 15 with no previous history of lymphoma. Disease was infradiaphragmatic in 92 patients and supradiaphragmatic in 14. Computed tomography (CT) guidance was used in 98 biopsies and ultrasonography (US) in eight. RESULTS: The biopsy was diagnostic and yielded information on the basis of which treatment was started in 88 of 106 patients. The procedure was well tolerated and there were no major complications. Small size of the sample or inappropriate tissue sampled were the main causes of failure. The technique was equally successful in the diagnosis of HD and both high-grade and low-grade NHL as in nonlymphoproliferative disorders. The procedure was equally successful at diagnosis as at suspected recurrence or progression. In 33 of 80 cases in which the biopsy was performed at the time of recurrence or progression, the histology had changed; in 31 of 33, this influenced treatment. The technique was efficient at diagnosing transformation of follicular NHL in 16 of 18 patients, which allowed early adjustment of treatment at recurrence. CONCLUSION: At St Bartholomew's Hospital (SBH), image-guided core-needle biopsy has proven to be a quick, safe, and efficient alternative to excisional biopsy in the evaluation of lymphoproliferative disorders at presentation, recurrence, or progression. It should become the procedure of choice for histologic sampling in the absence of peripheral lymphadenopathy.