Papillary lesions of the breast: evaluation with stereotactic directional vacuum-assisted biopsy.

PURPOSE: To evaluate the use of stereotactic directional vacuum-assisted biopsy (SDVAB) in diagnosing and managing papillary lesions of the breast. MATERIALS AND METHODS: The authors retrospectively reviewed the mammographic and histopathologic findings of 26 cases in which papillary lesions were diagnosed at SDVAB. In all cases, subsequent surgical excision (n = 20) or long-term imaging follow-up (n = 6) was performed and correlated with findings at SDVAB. RESULTS: SDVAB of 26 lesions yielded tissue that was classified as benign in 12, atypical in six, and malignant in eight. Of the 12 lesions that were diagnosed as histologically benign at SDVAB, six were surgically excised. Of these six lesions, five yielded benign correlative results. The sixth lesion was thought to be discordant with the imaging findings, and was surgically excised and determined to be malignant. Of the six benign lesions that were not surgically sampled for biopsy, five decreased in size and one was not seen at radiographic follow-up. Of the six lesions diagnosed as atypical at SDVAB that were surgically excised, one was benign and five were atypical. None proved to be malignant. Of the eight lesions diagnosed as malignant at SDVAB, surgical excision demonstrated ductal carcinoma in situ in all eight; two also had foci of invasive carcinoma. CONCLUSION: Benign and malignant papillary lesions of the breast can be reliably diagnosed at SDVAB when the SDVAB results correlate with the imaging findings. However, the extent of malignant papillary disease may be underestimated at SDVAB; in our study, invasive carcinoma was later discovered in 25% of patients with this diagnosis.

Mammographic appearance of axillary lymph node calcification in patients with metastatic ovarian carcinoma.

OBJECTIVE: We describe the mammographic appearance of axillary lymph node calcification in three patients with metastatic ovarian carcinoma. CONCLUSION: Axillary lymph node calcification may be identified mammographically in patients with metastatic ovarian carcinoma and may be evidence of unsuspected metastatic disease. The pattern of calcification differs from that seen with metastatic breast carcinoma.

Mammographically detected breast cancer: location in women under 50 years old.

The mammograms of 86 women under the age of 50 years with mammographically detected cancers were reviewed. Sixty-three of these cancers (73%) were found at the periphery of the breast as defined by a zone 1 cm wide beneath the subcutaneous fat or anterior to the retromammary fat. This finding is likely due to the geometric configuration of the breast. If the breast is hemispheric, then more than 50% of the volume of breast tissue lies within this zone in a large percentage of women. Furthermore, the contrasting adjacent fat likely improves the ability to perceive an abnormality. Interaction of the terminal ducts with chemicals contained within or produced by the fat is a much less likely reason for the high percentage of cancers in this zone. Radiologists should be aware of this phenomenon and pay particular attention to this zone.

Breast cancer survival among women under age 50: is mammography detrimental?

Great uncertainty exists about the benefit of detecting breast cancer by mammography in women under 50 years of age. We have reviewed the survival of patients aged 49 years or less whose cancers were detected by mammography alone. 117 women under the age of 50 years were diagnosed with breast cancer between 1978 and 1991 based only on an abnormal mammogram. Ductal carcinoma in-situ (DCIS) was found in 47 (40%) of these women, whilst 70 (60%) had infiltrating ductal or infiltrating lobular carcinomas. During the same interval, 928 women in this age group presented with palpable breast cancer. DCIS was diagnosed in 82 (9%) of these women, whilst 846 (91%) had infiltrating carcinoma. Among the infiltrating cancers detected by mammography alone, 50% were stage I, whilst only 30% of the women with palpable cancers were stage I. Five-year survival for all mammographically detected cancer patients was 95%, whereas for women with palpable cancers the survival was 74% (p < 0.00005). If DCIS is not included, the corresponding survivals are 91% for mammographically detected infiltrating cancers and 72% for palpable infiltrating cancers. Only 1 woman who died among those with palpable cancer had had a mammogram before diagnosis. Our data contradict the suggestion that women under 50 are put at a survival disadvantage by undergoing mammography. We believe that investigators who have reported negative results in this age group must examine other causes for their results.

Calcified suture material in the breast after radiation therapy.

Of 335 women who underwent lumpectomy and radiation therapy for breast cancer, 42 subsequently developed calcifications. Particles typical of calcified suture material were identified in 21 of the 42 women (50%). No obvious calcified suture material was found in approximately 1,140 women of 38,000 (3%) who had undergone mammography after they had previously undergone breast biopsy for a benign lesion and thus had not undergone radiation therapy. Calcified suture material rarely develops in the nonirradiated breast, but it is common after radiation therapy and should not be confused with recurrent breast cancer. These calcifications are likely the result of delayed resorption of catgut sutures, which provide a matrix on which calcium can precipitate in a suitable local environment.

Interstitial lung disease: impact of postprocessing in digital storage phosphor imaging.

The ability to resolve the fine linear structures of interstitial lung disease is one measure of the limiting performance characteristics of an imaging system. Conventional screen-film radiography was compared with six algorithms of isodose storage phosphor digital radiography (0.2-mm x 10-bit pixel matrix) in the detection of interstitial lung abnormality documented by means of computed tomography in 40 patients with abnormalities and 25 healthy control subjects. Performance was evaluated with an analysis of variance (the Fisher paired comparison test; P less than .05) of the average receiver operating characteristic area of 2,730 observations by six readers. The moderately and the more markedly high-frequency edge-enhanced algorithms of storage phosphor digital radiographs were equivalent in performance to screen-film radiography. The default mode, low- and medium-frequency edge-enhanced algorithms, and gray scale reversed mode of storage phosphor digital radiography were inferior to screen-film radiography. The authors conclude that high-frequency edge-enhanced algorithms can perform as well as screen-film radiography in the detection of interstitial disease.

Mediastinal abnormalities: detection with storage phosphor digital radiography.

Conventional film radiography (FR) and six postprocessing algorithms of isodose storage phosphor digital radiography (SR) (0.2-mm X 10-bit pixel matrix) were compared in the evaluation of 40 mediastinal and 30 pulmonary lesions in 60 patients who underwent computed tomography of the chest. The six SR algorithms varied among each other in only one image parameter. One algorithm approximated conventional image characteristics. The other five algorithms were designed to optimize imaging of the mediastinum and tested the effects of gray-scale reversal, adjustment of optical density, a linear instead of a sigmoid gradation curve, and moderate edge enhancement of high and medium spatial frequencies. Performance was evaluated by calculating the average area under the receiver operating characteristic curve (Az) of 5,040 observations by six readers. Post-processing with high-frequency edge enhancement and density optimization for the mediastinum significantly improved performance of SR over FR in the detection of mediastinal lesions (Az = .80 +/- .02 vs .73 +/- .01, respectively). Gray-scale reversal significantly decreased performance (Az = .64 +/- .03). All SR algorithms that were postprocessed to optimize imaging of the mediastinum were significantly inferior to FR in the detection of pulmonary lesions.

Mixed form, diffusely scattered calcifications in breast cancer with apocrine features.

Diffusely scattered calcifications visible with mammography are almost always benign. Certain patterns, however, should arouse concern. For example, extensive comedocarcinoma is associated with large areas of mammographically visible calcium deposition. The authors identified 10 women in whom calcifications were visible throughout large volumes of breast tissue at mammography. The calcifications did not resemble those typical of extensive comedocarcinoma, yet they were associated with extensive breast cancer. Their mammographic pattern was characterized by a strikingly wild, chaotic appearance with profuse deposition of calcium. As in many cancers, the particles were heterogeneous, but unlike in most carcinomas, many deposits had a typically benign morphology. Histologic examination showed that even these typically benign calcifications were associated with malignant cells. The authors believe that the apocrine features displayed by many of the cancer cells in these 10 patients may explain the unusual profusion of calcium deposits.

Screening for asbestos-related pleural disease with digital storage phosphor radiography.

Digital storage phosphor radiography (SR) has a wide dynamic range and unique postprocessing capabilities that may improve the performance of screening studies for asbestos-related pleural disease compared with conventional film radiography (FR). In a group of 32 asbestos-exposed and nine control subjects with established pleural data, we compared the screening performance of FR and SR obtained with a single isoexposure, dual-energy technique (system resolution 0.2 mm, 10 bits). Performance was evaluated for 7320 observations by eight readers using a paired t test (P less than .02 with Bonferroni correction) of averaged receiver operating characteristic curve (ROC) areas (Az +/- standard error). We found that SR alone and SR supplemented by dual-energy soft-tissue and calcium images (SRde) were superior to FR in the overall detection of pleural abnormalities (Az = 0.90 +/- 0.01, 0.90 +/- 0.01, and 0.88 +/- 0.01, respectively). In the specific detection of pleural calcification, SRde was superior to FR (Az = 0.91 +/- 0.01 and 0.87 +/- 0.01, respectively; P less than 0.01). Analysis of variance indicated that SRde most closely reproduced an established pleural score based on the International Labor Organization (ILO) classification of the pneumoconioses (P less than 0.05, Scheffé's multiple comparison test). We conclude that isodose SR performs at least as well as FR in screening for asbestos-related pleural disease. SR supplemented by dual-energy images might improve the specific detection of pleural calcifications compared with FR.

Digital storage phosphor imaging versus conventional film radiography in CT-documented chest disease.

The advantages of imaging the chest with digital storage phosphor radiography (SR) may be nullified by its spatial resolution, which is lower than that of conventional film radiography (FR). To test the reader detection performance with the two modalities under clinical conditions, the authors compared 140-kVp isoexposure SR (system resolution: 0.2 mm, 10 bits) and FR images of a variety of chest abnormalities proved by computed tomography (CT) (157 patients, 244 abnormalities, 5,652 observations, six readers). In all tests, SR was as good as or better than FR (P less than .05). In overall detection, indicated by the average area of receiver operating characteristics, SR and FR were equivalent. SR was superior for mediastinal lesions and for pulmonary opacities greater than 2 cm in diameter. For all other types of pulmonary lesions and pleural abnormalities, SR and FR were equivalent. Currently available commercial SR systems can replace film radiographic systems in the detection of a wide variety of chest lesions. SR is likely to enable better visualization than FR in the detection of mediastinal and large pulmonary abnormalities.

High frequency edge enhancement in the detection of fine pulmonary lines. Parity between storage phosphor digital images and conventional chest radiography.

Fine linear structures represent a severe test of the minimum spatial resolution that is needed for digital chest imaging. We studied the comparative observer performance of storage phosphor digital imaging (1760 X 2140 pixel matrix, 10 bits deep), and conventional radiography (Lanex medium screen, Ortho C film) in the detection of simulated fine pulmonary lines superimposed on the normal chest when exposure factors were identical (20mR skin entrance dose at 141 kVp). Receiver operating characteristics analysis of 2160 observations by six readers found that high frequency edge-enhanced digital images (ROC area: 0.78 +/- 0.06) performed better than unenhanced digital images (ROC area: 0.70 +/- 0.07) (P less than 0.01 for paired t-test), and that edge enhanced digital images performed on a par with conventional radiography (ROC area: 0.78 +/- 0.09). We conclude that for the detection of fine linear structures, storage phosphor digital images can perform on a par with higher resolution conventional chest radiographs when a high frequency edge-enhancement algorithm is employed.

Subtle gastric abnormalities in a canine model: detection with low-dose imaging with storage phosphors and its equivalence to conventional radiography.

The authors compared low-dose (32% of standard exposure) storage phosphor digital imaging (system resolution: 0.2-mm pixels, 10 bits) with isovoltage 75-kVp conventional radiography (standard exposure) in the detection of subtle simulated gastric abnormalities by using air contrast barium studies. Subtle simulated abnormalities (3-7-mm polyps, 4-15-mm ulcer craters, 4-11-mm-diameter edema, and 11-12-mm linear ulcers) were produced in resected canine stomachs. Receiver operating characteristic analysis of 1,800 observations by six readers indicated that the digital images with and without high-frequency edge enhancement were equivalent to conventional radiographs (mean receiver operating characteristic areas [+/- standard deviation]: 0.76 +/- 0.06, 0.78 +/- 0.04, and 0.77 +/- 0.04, respectively). The accuracy of the diagnosis was equivalent for all three modalities. The following mean accuracies of negative and positive responses, respectively, for unenhanced digital, edge-enhanced digital, and conventional images were determined: 0.71 +/- 0.05 and 0.41 +/- 0.07, 0.71 +/- 0.04 and 0.51 +/- 0.09, and 0.68 +/- 0.04 and 0.43 +/- 0.05. It was concluded that low-dose storage phosphor air-contrast barium studies were equivalent to conventional radiography in the detection of subtle gastric abnormalities.

Residual breast carcinoma after biopsy: role of mammography in evaluation.

The records of 21 consecutive patients referred for breast-conservation treatment of early-stage mammary carcinoma contained insufficient histopathologic documentation of adequate resection margins after tumor excision at other hospitals. All patients underwent postbiopsy mammography before reexcision of the tumor bed. In 12 of the 21 cases, there was pathologic evidence of macroscopic or microscopic residual tumor. In seven of the 12 cases, there was no clinical or mammographic evidence to suggest residual carcinoma. The findings indicate that mammography is insufficient to evaluate the completeness of tumor excision in the absence of histopathologic documentation.

Needle localization of occult breast lesions with a curved-end retractable wire: technique and pitfalls.

A series of 100 consecutive occult mammographic abnormalities were localized with a curved-end retractable wire system. A true-positive rate of 24% and a failure rate of 4% for initial excision were found. The pitfalls and advantages of this new needle-wire breast localizer are presented.