How to Minimize Patient Anxiety From Screening Mammography.

Anxiety has been portrayed by the media and some organizations and societies as one of the harms of mammography. However, one experiences anxiety in multiple different medical tests that are undertaken, including screening examinations; it is not unique to mammography. Some may argue that because this anxiety is transient, the so-called harm is potentially overstated, but for some women the anxiety is significant. Anxiety can increase or decrease the likelihood of obtaining a screening mammogram. There are multiple ways that anxiety associated with screening mammography can be diminished, including before, during, and after the examination. These include simple measures such as patient education, improved communication, being aware of the patient's potential discomfort and addressing it, validating the patient's anxiety as well as providing the patient with positive factual data that can easily be implemented in every breast center. More complex interventions include altering the breast center environment with multisensory stimulation, reorganization of patient flow to minimize wait times, and relaxation techniques including complementary and alternative medicine. In this article we will review the literature on measures that can be taken to minimize anxiety that would maximize the likelihood of a woman obtaining an annual screening mammogram.

Breast Cancer Screening Recommendations: African American Women Are at a Disadvantage.

Since 1990, breast cancer mortality has decreased by 40% in white women but only 26% in African American women. The age at diagnosis of breast cancer is younger in black women. Breast cancer diagnosed before age 50 represents 23% of all breast cancers in African American women but only 16% of all breast cancers in white women. White women have a higher incidence of breast cancer over the age of 60. Tumor subtypes also vary among racial and ethnic groups. The triple-negative (TN) subtype, which has a poorer outcome and occurs at a younger age, represents 21% of invasive breast cancers in black women but only 10% of invasive breast cancers in white women. The hormone receptor-positive subtype, which is more common in older women and has the best outcome, has a higher incidence in white women (70%) than in black women (61%). The BRCA2 mutation is also more common in black women than in white women (other than those who are of Ashkenazi Jewish ancestry). There are also many barriers to screening. Major ones include the lack of contact with a primary health care provider as well as a decreased perceived risk of having breast cancer in the African American population. Given the younger age of onset and the higher incidence of the TN molecular subtype, following breast cancer screening guidelines that do not support screening before the age of 50 may disadvantage black women.

Does the use of pretreatment MRI change the management of patients with newly diagnosed breast cancer?

Breast MRI plays a critical role in the diagnosis and management of breast cancer. The purpose of this study is to evaluate the effect of preoperative breast MRI on the management of a large cohort of breast cancer patients at our institution. This study is a retrospective chart review of all newly diagnosed breast cancer patients who underwent preoperative breast MRI at our institution between January 1, 2004 and December 31, 2009. 1352 patients comprised the study population. 241 (17.8%) patients underwent a change in surgical management as a result of preoperative MRI. Patients with tumors in the lower inner quadrant and the central breast and those with pathology of invasive lobular carcinoma were significantly more likely to have their management changed by preoperative MRI. There was also a significant trend for larger tumors to be associated with a change in surgical management. No statistically significant association was found between breast density and change in management. This study supports the recommendation for the use of preoperative breast MRI in the majority of newly diagnosed breast cancer patients, especially those with larger tumors, pathology of invasive lobular carcinoma, and tumors in the lower inner quadrant. Preoperative breast MRI is a useful tool for the evaluation of additional disease that led to a change in the surgical management of 17.8% of patients.

Factors associated with repetitive strain, and strategies to reduce injury among breast-imaging radiologists.

PURPOSE: To investigate the prevalence of repetitive strain injury (RSI) among breast-imaging radiologists, the factors associated with such symptoms, and strategies to reduce injury. METHODS: In 2012, an anonymous survey regarding RSI and work habits was administered to 2,618 physician members of the Society of Breast Imaging via e-mail. Analysis of 727 (27.8%) de-identified responses was completed using STATA 12.1. Pain levels before and after implementation of digital imaging were compared with the Wilcoxon signed-rank test. The associations between RSI symptoms and work habits were assessed with logistic regression and test for trend. RESULTS: In the survey 438 of 727 (60.2%) respondents reported RSI symptoms, and 242 of 727 (33.3%) reported prior diagnosis/treatment. Results showed a statistically significant trend for the odds of RSI symptoms to increase with decreasing age (P = .0004) or increasing number of daily hours spent working (P = .0006), especially in an awkward position (P < .0001). Respondents recalled a significant increase in pain level after implementation of PACS, and a decrease in pain after ergonomic training or initiating use of an ergonomic mouse, adjustable chair, or adjustable table (P < .001, all comparisons). Only 17.7% (129 of 727) used an ergonomic mouse and 13.3% (97 of 727) had attended ergonomic training. Those with RSI symptoms or prior diagnosis of a Repetitive Strain Syndrome (RSS) were more likely to desire future ergonomic training compared with those without symptoms or injury (odds ratio 5.36, P < .001; odds ratio 2.63, P = .001, respectively). CONCLUSIONS: RSI is highly prevalent among breast-imaging radiologists nationwide and may worsen after implementation of PACS or with longer work hours. Ergonomic training and ergonomic devices may diminish or prevent painful RSI among radiologists.

A survey of breast imaging fellowship programs: current status of curriculum and training in the United States and Canada.

PURPOSE: The Society of Breast Imaging and the Education Committee of the ACR Breast Commission conducted a survey of breast imaging fellowship programs to determine the status of fellowship curricula, help identify strengths and potential areas for improvement, and assess the current demand for fellowship programs. METHODS: In 2012, a two-part survey was emailed to breast imaging fellowship directors from 72 fellowship programs. RESULTS: Of the 66 respondents, a total of 115 positions were identified. There were 90 positions with 9-12 months of breast imaging, and 25 positions with 6 months focused on breast imaging. Approximately two-thirds of programs reported an increase in the number of fellowship applicants, with three-quarters having 3 or more applicants for each position. All programs offered digital mammography, breast MRI, and diagnostic ultrasound services, and nearly all provided experience with interventional procedures. Approximately one-third provided breast screening ultrasound training. More than two-thirds required at least a 1-day rotation with a breast surgeon. Important nonclinical areas of training were not addressed in many programs. Approximately 40% of programs did not offer training related to the practice audit, and one-third of programs did not provide formal training related to quality control. CONCLUSIONS: Breast imaging fellowships are currently in higher demand than in the past. Most fellowship programs provide training in the key imaging modalities and interventional procedures. Potential gaps in training for many programs include the practice audit, quality control procedures, breast positioning, and mammography technical factors.

The ACR/Society of Breast Imaging Resident and Fellowship Training Curriculum for Breast Imaging, updated.

The education committees of the ACR Commission on Breast Imaging and the Society of Breast Imaging have revised the resident and fellowship training curriculum to reflect the current state of breast imaging in the United States. The original curriculum, created by the Society of Breast Imaging in 2000, had been updated only once before, in 2006. Since that time, a number of significant changes have occurred in the way mammography is acquired, how adjunctive breast imaging methods are used, and how pathology is assessed. This curricular update is meant to reflect these and other changes and to offer guidance to educators and trainees in preparing those interested in providing breast imaging services.

Usefulness of breast arterial calcium detected on mammography for predicting coronary artery disease or cardiovascular events in women with angina pectoris and/or positive stress tests.

Breast arterial calcium (BAC) has been suggested as a marker and predictor of cardiovascular risk and coronary artery disease (CAD). However, an association between BAC and these cardiovascular end points has not been fully elucidated in patients undergoing cardiac catheterization. Consecutive patients undergoing mammography and cardiac catheterization within a 36-month period were retrospectively evaluated through chart review. Cardiac catheterization films and mammograms from 94 patients were independently reviewed for the presence of CAD and BAC, respectively. Cardiovascular risk factors, history of revascularization, and history of myocardial infarction were compared between women with and without BAC. BAC was more prevalent in older women (mean age 69 + or - 10 vs 63 + or - 11 years, p = 0.02). Aside from an inverse correlation with smoking, there was no difference in the presence of CAD or cardiovascular risk factors between patients with and without BAC. Patients with BAC had a lesser history of acute myocardial infarction (21% vs 41%, p <0.05) and were less likely to undergo revascularization (23% vs 43%, p <0.05). In conclusion, BAC was not positively associated with cardiovascular risk factors, documented CAD, or acute cardiovascular events, suggesting that the presence of BAC as determined by mammography is not a useful predictor of CAD in intermediate- to high-risk patients.

Comparison of soft-copy and hard-copy reading for full-field digital mammography.

PURPOSE: To compare radiologists' performance in detecting breast cancer when reading full-field digital mammographic (FFDM) images either displayed on monitors or printed on film. MATERIALS AND METHODS: This study received investigational review board approval and was HIPAA compliant, with waiver of informed consent. A reader study was conducted in which 26 radiologists read screening FFDM images displayed on high-resolution monitors (soft-copy digital) and printed on film (hard-copy digital). Three hundred thirty-three cases were selected from the Digital Mammography Image Screening Trial screening study (n = 49,528). Of these, 117 were from patients who received a diagnosis of breast cancer within 15 months of undergoing screening mammography. The digital mammograms were displayed on mammographic workstations and printed on film according to the manufacturer's specifications. Readers read both hard-copy and soft-copy images 6 weeks apart. Each radiologist read a subset of the total images. Twenty-two readers were assigned to evaluate images from one of three FFDM systems, and four readers were assigned to evaluate images from two mammographic systems. Each radiologist assigned a malignancy score on the basis of overall impression by using a seven-point scale, where 1 = definitely not malignant and 7 = definitely malignant. RESULTS: There were no significant differences in the areas under the receiver operating characteristic curves (AUCs) for the primary comparison. The AUCs for soft-copy and hard-copy were 0.75 and 0.76, respectively (95% confidence interval: -0.04, 0.01; P = .36). Secondary analyses showed no significant differences in AUCs on the basis of manufacturer type, lesion type, or breast density. CONCLUSION: Soft-copy reading does not provide an advantage in the interpretation of digital mammograms. However, the display formats were not optimized and display software remains an evolving process, particularly for soft-copy reading.

Should screening MRI be included in surveillance for patients treated with breast-conserving therapy?

Breast MRI has been shown to provide diagnostic benefit in multiple situations. It has proved useful in the evaluation of ruptured silicone implants and in the evaluation of patients with cancerous axillary lymph nodes, a negative mammogram and unremarkable physical examination. Gorechlad et al. carried out a retrospective study designed to determine whether MRI has a role in screening for cancer recurrence in patients treated with breast-conserving therapy. As the results showed that the recurrence rate and risk of contralateral disease were both very low, the authors concluded that MRI screening would not have been cost-effective and was unlikely to have improved overall survival.

Accuracy of soft-copy digital mammography versus that of screen-film mammography according to digital manufacturer: ACRIN DMIST retrospective multireader study.

PURPOSE: To retrospectively compare the accuracy for cancer diagnosis of digital mammography with soft-copy interpretation with that of screen-film mammography for each digital equipment manufacturer, by using results of biopsy and follow-up as the reference standard. MATERIALS AND METHODS: The primary HIPAA-compliant Digital Mammographic Imaging Screening Trial (DMIST) was approved by the institutional review board of each study site, and informed consent was obtained. The approvals and consent included use of data for future HIPAA-compliant retrospective research. The American College of Radiology Imaging Network DMIST collected screening mammography studies performed by using both digital and screen-film mammography in 49 528 women (mean age, 54.6 years; range, 19-92 years). Digital mammography systems from four manufacturers (Fischer, Fuji, GE, and Hologic) were used. For each digital manufacturer, a cancer-enriched reader set of women screened with both digital and screen-film mammography in DMIST was constructed. Each reader set contained all cancer-containing studies known for each digital manufacturer at the time of reader set selection, together with a subset of negative and benign studies. For each reader set, six or 12 experienced radiologists attended two randomly ordered reading sessions 6 weeks apart. Each radiologist identified suspicious findings and rated suspicion of breast cancer in identified lesions by using a seven-point scale. Results were analyzed according to digital manufacturer by using areas under the receiver operating characteristic curve (AUCs), sensitivity, and specificity for soft-copy digital and screen-film mammography. Results for Hologic digital are not presented owing to the fact that few cancer cases were available. The implemented design provided 80% power to detect average AUC differences of 0.09, 0.08, and 0.06 for Fischer, Fuji, and GE, respectively. RESULTS: No significant difference in AUC, sensitivity, or specificity was found between Fischer, Fuji, and GE soft-copy digital and screen-film mammography. Large reader variations occurred with each modality. CONCLUSION: No statistically significant differences were found between soft-copy digital and screen-film mammography for Fischer, Fuji, and GE digital mammography equipment.

Diagnostic accuracy of digital versus film mammography: exploratory analysis of selected population subgroups in DMIST.

PURPOSE: To retrospectively compare the accuracy of digital versus film mammography in population subgroups of the Digital Mammographic Imaging Screening Trial (DMIST) defined by combinations of age, menopausal status, and breast density, by using either biopsy results or follow-up information as the reference standard. MATERIALS AND METHODS: DMIST included women who underwent both digital and film screening mammography. Institutional review board approval at all participating sites and informed consent from all participating women in compliance with HIPAA was obtained for DMIST and this retrospective analysis. Areas under the receiver operating characteristic curve (AUCs) for each modality were compared within each subgroup evaluated (age < 50 vs 50-64 vs >or= 65 years, dense vs nondense breasts at mammography, and pre- or perimenopausal vs postmenopausal status for the two younger age cohorts [10 new subgroups in toto]) while controlling for multiple comparisons (P < .002 indicated a significant difference). All DMIST cancers were evaluated with respect to mammographic detection method (digital vs film vs both vs neither), mammographic lesion type (mass, calcifications, or other), digital machine type, mammographic and pathologic size and diagnosis, existence of prior mammographic study at time of interpretation, months since prior mammographic study, and compressed breast thickness. RESULTS: Thirty-three centers enrolled 49 528 women. Breast cancer status was determined for 42,760 women, the group included in this study. Pre- or perimenopausal women younger than 50 years who had dense breasts at film mammography comprised the only subgroup for which digital mammography was significantly better than film (AUCs, 0.79 vs 0.54; P = .0015). Breast Imaging Reporting and Data System-based sensitivity in this subgroup was 0.59 for digital and 0.27 for film mammography. AUCs were not significantly different in any of the other subgroups. For women aged 65 years or older with fatty breasts, the AUC showed a nonsignificant tendency toward film being better than digital mammography (AUCs, 0.88 vs 0.70; P = .0025). CONCLUSION: Digital mammography performed significantly better than film for pre- and perimenopausal women younger than 50 years with dense breasts, but film tended nonsignificantly to perform better for women aged 65 years or older with fatty breasts.

Recurrent cancer after breast-conserving surgery with radiation therapy for ductal carcinoma in situ: mammographic features, method of detection, and stage of recurrence.

OBJECTIVE: The purpose of our study was to determine the mammographic appearance, detection method, and stage of ipsilateral breast tumor recurrence in women treated with breast-conserving surgery and whole-breast radiation therapy for ductal carcinoma in situ (DCIS). MATERIALS AND METHODS: Following institutional review board approval, records of women treated with breast-conserving surgery and radiation therapy for DCIS who developed an ipsilateral breast tumor recurrence from 1981 to 2003 were reviewed retrospectively. Multiinstitutional database records showed 513 women were treated, of whom 42 (8.2%) developed local recurrence. Study criteria were fulfilled and complete records were available for 32 women. Mean age at initial diagnosis was 49 years (range, 26-73 years). RESULTS: Of the 32 patients included in our study, 31 (97%) recurrences were mammographically apparent. Twenty-nine (91%) of 32 were diagnosed exclusively by mammography. Mammographic findings at recurrence were calcifications in 24 (75%) of 32, mass in six (19%) of 32, and distortion in one (3%) of 32. The mean time to recurrence was 4.5 years. Twelve (40%) of 30 had the recurrence in a remote quadrant from the original cancer. Recurrences were DCIS in 17 (53%) of 32, DCIS with microinvasion in six (19%) of 32, invasive ductal cancer in three (9%) of 32, invasive lobular cancer in two (6%) of 32, and mixed DCIS and invasive cancer in four (13%) of 32. Six (67%) of nine patients with invasive cancer (excluding microinvasion) had tumors smaller than 1 cm. Ninety-one percent of recurrences were minimal cancers. All recurrences were stage 0 or 1. CONCLUSION: Mammography successfully detected ipsilateral breast tumor recurrence, predominantly as calcifications or masses, after breast-conserving surgery with radiation therapy for DCIS in 97% of cases. The recurrences were located at variable distances from the lumpectomy site. Ninety-one percent of recurrences were minimal cancers and all were early stage, connoting excellent prognosis.

Ductal carcinoma in situ: computer-aided detection in screening mammography.

PURPOSE: To retrospectively evaluate the sensitivity of computer-aided detection (CAD) in depicting ductal carcinoma in situ (DCIS) on screening mammograms by using biopsy proved lesion location as the reference standard. MATERIALS AND METHODS: Institutional review board approval was obtained, with a waiver of patient informed consent for this HIPAA-compliant study. Findings of all image-guided biopsies with a pathologic diagnosis of DCIS during a 1-year period were reviewed. Fifty-eight lesions in 55 women (average age, 61.41 years +/- 12.89 [standard deviation]) were available for review. The screening mammogram of the affected breast and, if available, the prior screening mammogram were digitized by the CAD system. An assessment was then made as to whether the CAD system marked the area of DCIS on the current and prior mammograms. Patient age, location and mammographic size of the lesion, type of lesion, and breast density were recorded and were analyzed by using chi2, Fisher exact, or Cochran-Mantel-Haenzel tests, where applicable. RESULTS: CAD identified DCIS in 53 (91%) of 58 lesions on craniocaudal (CC) and mediolateral oblique (MLO) views of screening mammograms obtained in the year of the diagnosis. On screening mammograms obtained prior to the year of the diagnosis (34 patients), no radiologically or CAD-detected lesion was present on 11 (32%) of 34 mammograms. CAD identified DCIS in 16 (70%) of 23 lesions on one of the two views. Seven (30%) of 23 lesions had mammographic findings at retrospective review that were not identified with CAD. CONCLUSION: CAD had a high sensitivity in the depiction of DCIS.

Diagnostic performance of digital versus film mammography for breast-cancer screening.

BACKGROUND: Film mammography has limited sensitivity for the detection of breast cancer in women with radiographically dense breasts. We assessed whether the use of digital mammography would avoid some of these limitations. METHODS: A total of 49,528 asymptomatic women presenting for screening mammography at 33 sites in the United States and Canada underwent both digital and film mammography. All relevant information was available for 42,760 of these women (86.3 percent). Mammograms were interpreted independently by two radiologists. Breast-cancer status was ascertained on the basis of a breast biopsy done within 15 months after study entry or a follow-up mammogram obtained at least 10 months after study entry. Receiver-operating-characteristic (ROC) analysis was used to evaluate the results. RESULTS: In the entire population, the diagnostic accuracy of digital and film mammography was similar (difference between methods in the area under the ROC curve, 0.03; 95 percent confidence interval, -0.02 to 0.08; P=0.18). However, the accuracy of digital mammography was significantly higher than that of film mammography among women under the age of 50 years (difference in the area under the curve, 0.15; 95 percent confidence interval, 0.05 to 0.25; P=0.002), women with heterogeneously dense or extremely dense breasts on mammography (difference, 0.11; 95 percent confidence interval, 0.04 to 0.18; P=0.003), and premenopausal or perimenopausal women (difference, 0.15; 95 percent confidence interval, 0.05 to 0.24; P=0.002). CONCLUSIONS: The overall diagnostic accuracy of digital and film mammography as a means of screening for breast cancer is similar, but digital mammography is more accurate in women under the age of 50 years, women with radiographically dense breasts, and premenopausal or perimenopausal women. (ClinicalTrials.gov number, NCT00008346.)

American College of Radiology Imaging Network digital mammographic imaging screening trial: objectives and methodology.

This study was approved by the Institutional Review Board (IRB) of the American College of Radiology Imaging Network (ACRIN) and each participating site and by the IRB and the Cancer Therapy Evaluation Program at the National Cancer Institute. The study was monitored by an independent Data Safety and Monitoring Board, which received interim analyses of data to ensure that the study would be terminated early if indicated by trends in the outcomes. The ACRIN, which is funded by the National Cancer Institute, conducted the Digital Mammographic Imaging Screening Trial (DMIST) primarily to compare the diagnostic accuracy of digital and screen-film mammography in asymptomatic women presenting for screening for breast cancer. Over the 25.5 months of enrollment, a total of 49 528 women were included at the 33 participating sites, which used five different types of digital mammography equipment. All participants underwent both screen-film and digital mammography. The digital and screen-film mammograms of each subject were independently interpreted by two radiologists. If findings of either examination were interpreted as abnormal, subsequent work-up occurred according to the recommendations of the interpreting radiologist. Breast cancer status was determined at biopsy or follow-up mammography 11-15 months after study entry. In addition to the measurement of diagnostic accuracy by using the interpretations of mammograms at the study sites, DMIST included evaluations of the relative cost-effectiveness and quality-of-life effects of digital versus screen-film mammography. Six separate reader studies using the de-identified archived DMIST mammograms will also assess the diagnostic accuracy of each of the individual digital mammography machines versus screen-film mammography machines, the effect of breast density on diagnostic accuracy of digital and screen-film mammography, and the effect of different rates of breast cancer on the diagnostic accuracy in a reader study.

Changes in management techniques and patterns of disease recurrence over time in patients with breast carcinoma treated with breast-conserving therapy at a single institution.

BACKGROUND: The authors reviewed changes in the initial clinical presentation, management techniques, and patterns of disease recurrence over time (1981-1996) in patients with breast carcinoma treated with breast-conserving therapy (BCT) at a single institution. The goals of the current study were to determine the frequency and use of optimal local and systemic therapy techniques and to evaluate the impact of these changes on treatment efficacy. METHODS: Six hundred seven patients with American Joint Committee on Cancer Stage I or II invasive breast carcinomas treated with BCT at William Beaumont Hospital (Royal Oak, MI) constituted the study population. All patients received at least an excisional biopsy of the primary tumor, an axillary lymph node staging procedure, and postoperative radiotherapy (RT) (a median tumor bed dose of 61 Gray [Gy] was administered). All sides were reviewed by one pathologist. Numerous clinicopathologic and treatment-related factors were analyzed to monitor changes that occurred over time. Changes in patterns of disease recurrence and treatment efficacy over time also were analyzed. RESULTS: Over the time period analyzed, changes at initial presentation included an increase in the mean age at diagnosis (age 56.1 years vs. 61.4 years; P < 0.001), a decrease in the number of patients with clinically palpable tumors (78% vs. 36%; P < 0.001), a decrease in the mean tumor size (2.2 cm vs. 1.6 cm; P < 0.001), but no change in the percentage of patients with negative lymph nodes (79% vs. 78%; P = 0.83). No differences over time were observed in mean tumor grade (2.0 vs. 1.9; P = 0.2) or the presence of angiolymphatic invasion (27% vs. 26%; P = 0.25). Changes in surgical management and pathologic assessment included the more frequent use of reexcision (46% vs. 81%; P < 0.001), larger mean total volumes of breast tissue specimens excised (115 cm3 vs. 189 cm3; P = 0.001), a larger percentage of patients with final negative surgical margins (74% vs. 97%; P < 0.001), and a small increase in the mean number of lymph nodes excised (13.8 lymph nodes vs. 14.1 lymph nodes; P = 0.01). The only other significant change in the pathologic management of patients over time included a doubling in the mean number of slides examined (10.6 slides vs. 21.1 slides; P < 0.001). Changes in adjuvant local and systemic therapy included an increase in the percentage of patients treated with > 60 Gy to the tumor bed (66% vs. 95%; P < 0.001), a doubling in the mean number of days from the last surgery to the start of RT (24 days vs. 50 days; P < 0.001), and a decrease in the use of regional lymph node RT (24% vs. 8%; P < 0.001). The use of adjuvant tamoxifen increased from 10% to 61% (P < 0.001). Finally, improvements were observed in the 5-year and 12-year actuarial rates of local disease recurrence (8% vs. 1% and 21% vs. 9%, respectively; P = 0.001) and distant metastases (12% vs. 4% and 22% vs. 9%, respectively; P = 0.006). No changes in the mean number of years to ipsilateral (6.5 years vs. 6.4 years; P = 0.59) or distant disease recurrence (4.6 years vs. 3.8 years; P = 0.73) were observed. CONCLUSIONS: The impact of screening mammography and substantial changes in surgical, pathologic, RT, and systemic therapy recommendations were observed over time in the study population. These changes were associated with improvements in 5-year and 12-year local and distant control rates and suggested that improvements in outcome can be realized through adherence to best practice guidelines and continuous monitoring of treatment outcome data.

Lobular carcinoma in situ or atypical lobular hyperplasia at core-needle biopsy: is excisional biopsy necessary?

PURPOSE: To retrospectively determine frequency of invasive cancer or ductal carcinoma in situ (DCIS) at excisional biopsy in women with atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) at percutaneous core-needle biopsy (CNB). MATERIALS AND METHODS: Review of results in 6,081 consecutive patients who underwent CNB at two institutions revealed that in 35 (0.58%), LCIS (n = 15) or ALH (n = 20) was the pathologic finding with highest risk. Patient age range was 41-84 years (mean, 59 years). Of 35 patients, 26 (74%) underwent excisional biopsy and nine (26%) underwent mammographic follow-up for longer than 2 years. Lesions with a pathologic upgrade were noted when invasive cancer or DCIS occurred at the CNB site. CNB results in patients with a diagnosis of atypical ductal hyperplasia (ADH) (75 of 6,081 [1.2%]) were reviewed; these patients underwent subsequent excisional biopsy. Statistical comparison of frequency of upgrading of lesions in patients with a diagnosis of LCIS or ALH at CNB and in those with a diagnosis of ADH at CNB was performed (Pearson chi(2) test). RESULTS: In six (17%) of 35 (95% CI: 4.7%, 29.6%) patients, lesions were upgraded to DCIS (n = 4) or invasive cancer (n = 2). In 15 patients with LCIS diagnosed at CNB, lesions in four (27%) were upgraded to either DCIS or invasive cancer. In 20 patients with ALH diagnosed at CNB, lesions were upgraded to DCIS in two (10%). Lesions in nine patients who underwent mammographic follow-up were stable. No mammographic or technical findings distinguished patients with upgraded lesions from those whose lesions were not upgraded. In 12 (16%) of 75 (95% CI: 7.7%, 24.3%) patients with ADH, lesions were upgraded. Difference between the upgrade rate in patients with LCIS or ALH and that in those with ADH was not significant (P =.88). CONCLUSION: Lesions in 17% of patients with LCIS or ALH at CNB were upgraded to invasive cancer or DCIS; this rate was similar to the upgrade rate in patients with ADH. Excisional biopsy is supported when LCIS, ALH, or ADH is diagnosed at CNB.