Benign Fibrocystic Changes Research Articles

Efficacy of the minimal-invasive vacuum-assisted biopsy under direct visualization with ultrasound for impalpable breast lesions in Taiwanese female: A retrospective case-control study

Abstract Background Although surgical excisional biopsy provides robust diagnostic results, the ultrasound-assisted vacuum-assisted biopsy (VABB) offers an alternative for Asian candidates with dense breasts and lesions which cannot be approached by stereotactic biopsy. The study aims to investigate the efficacy of the ultrasound-assisted VABB for impalpable mammographic-detected lesions. Methods A retrospective case-control study is conducted in a group of Taiwanese female patients who have impalpable breast lesions such as microcalcifications at screening mammography that are limited to BI-RADS category 4. Specifically, the lesions are categorized into three groups: 4a, 4b, 4c, and the histology from B2 through B5. The cases underwent ultrasound-assisted VABB and the controls had lumpectomies. The diagnostic accuracy, rate of discordance, excited tumor size, and the proportion of cancer cases is evaluated and compared using Fisher’s Exact test, Cohen’s kappa test, Chi-Square test, and the use of IBM SPSS statistical programs. Results The histology of the majorities of the collected specimen are B2 benign fibrocystic changes (60-70%). In cases of patients who are diagnosed with breast cancer, most are ductal carcinoma in situ and early-stage diseases. The cancer risks for lesions categorized under BI-RADS 4a, 4b, 4c respectively are consistent with clinical practice. Meanwhile, the diagnostic accuracy of VABB is similar to lumpectomy, as the histologic discordance rate did not differ significantly. Conclusions Ultrasound-assisted VABB does offer an option for patients who are not candidates for stereotactic biopsy, as it has shown to have non-inferior diagnostic values and cosmetic benefits when compared to surgical excision. The use of sonography monitors the biopsy process and guides the needle insertion thus is capable of obtaining samples from multiple directions, without risking the pectoralis muscles underneath. However, VABB may be intended for biopsies in lower-risk findings such as BI-RADS category 4a because doubts persist as complete excisional rates are operator-dependent.

Nonmass Lesions on Breast US: An International Perspective on Clinical Use and Outcomes.

Nonmass lesions (NMLs) on breast US are defined as discrete areas of altered echotexture compared to surrounding breast tissue and lack the 3-dimensionality of a mass. They are not a component of American College of Radiology BI-RADS, but they are a finding type included in the Japan Association of Breast and Thyroid Sonology lexicon. Use of the NML finding is routine in many Asian practices, including the Samsung Medical Center and Seoul National University Hospital, and their features and outcomes have been investigated in multiple studies. Nonmass lesions are most often observed when US is used to evaluate mammographic asymmetries, suspicious calcifications, and nonmass enhancement on MRI and contrast-enhanced mammography. Nonmass lesions can be described by their echogenicity, distribution, presence or absence of associated calcifications, abnormal duct changes, architectural distortion, posterior shadowing, small cysts, and hypervascularity. Malignant lesions, especially ductal carcinoma in situ, can manifest as NMLs on US. There is considerable overlap between the US features of benign and malignant NMLs, and they also must be distinguished from normal variants. The literature indicates that NMLs with linear or segmental distribution, associated calcifications, abnormal duct changes, posterior shadowing, and hypervascularity are suggestive of malignancy, whereas NMLs with only interspersed small cysts are usually benign fibrocystic changes. In this article, we introduce the concepts of NMLs, illustrate US features suggestive of benign and malignant etiologies, and discuss our institutional approach for evaluating NMLs and an algorithm that we use to guide interpretation in clinical practice.

Imaging of Noncalcified Ductal Carcinoma In Situ.

Ductal carcinoma in situ (DCIS) is a commonly encountered malignancy, accounting for approximately 20% of new breast cancer diagnoses in the United States. DCIS is characterized by a proliferation of tumor cells within the terminal duct lobular unit with preservation of the basement membrane. Typically nonpalpable and asymptomatic, DCIS is most often detected as calcifications on screening mammography. However, DCIS may also be noncalcified. When compared to calcified DCIS, noncalcified DCIS is more likely to be symptomatic, with patients most often presenting with nipple discharge or a palpable mass. Diagnosing noncalcified DCIS is challenging since it may be occult or subtle on mammography, and ultrasound findings can be nonspecific and may be interpreted as benign fibrocystic changes. In cases with a calcified component of DCIS, the extent of DCIS may be underestimated by mammography because not all involved areas may calcify. Breast magnetic resonance imaging (MRI), although less readily available than mammography and ultrasound, is advantageous in detecting noncalcified DCIS, especially high grade DCIS, which may not develop microcalcifications. MRI relies on abnormal contrast uptake due to tumor vascularity and changes in vessel density and permeability. This pictoral review presents the spectrum of imaging findings of noncalcified DCIS to assist radiologists in accurately detecting and describing its key imaging findings. Utilizing different modalities, we review the differential diagnoses for noncalcified DCIS, show illustrative cases of noncalcified DCIS, and discuss the importance of this entity.

Cancer Yield of Incidental Breast Lesions Detected on Chest Computed Tomography.

This study aimed to determine the cancer yield for abnormal breast findings initially identified on chest computed tomography (CT). This institutional review board-approved, Health Insurance Portability and Accountability Act-compliant study retrospectively reviewed reports of 41,217 consecutive chest CT examinations done from January 1, 2006, to December 31, 2011, to identify those with breast findings noted in the impression of the report. Examinations done for staging of newly diagnosed breast cancer were excluded. The electronic medical record was searched for any subsequent breast imaging and any corresponding pathology results. Cancer yield was calculated. A total of 258 chest CT examinations with abnormal breast findings were identified in 218 unique patients. Average patient age was 65.6 years (range, 30-100 years). There were 207 women and 11 men. Of these, 75 patients had follow-up breast imaging in our system. One hundred forty-three patients did not have follow-up in our system and were excluded for purposes of cancer detection rate calculation. Thirteen of 75 patients were found to have lesions that were malignant: infiltrating ductal carcinoma (8), invasive lobular carcinoma (2), lymphoma (2), and intracystic papillary cancer with atypical features (1). Four of 75 patients underwent further workup and were found to have lesions that were benign: fibroadenoma (3) and benign fibrocystic change (1). The remainder of the 58 of 75 patients had dedicated breast imaging that was classified as either Breast Imaging Reporting and Data System score 1 or 2, and no further workup was performed. Cancer yield from CT findings was 17.3%. Abnormal CT findings in the breast warrant additional evaluation with dedicated breast imaging to evaluate for a possible underlying malignancy. Cancer yield from CT findings in this study was 17.3%.

Breast cystic lesions: Not so simple after all? An ultrasonographic tactical approach.

A wide spectrum of breast diseases breast diseases have or exhibit at some point in their natural history a complex cysticaspect. Through the lens of B-mode and Doppler ultrasound with sonoelastographic augmentation, conditions ranging fromthe utterly benign fibrocystic change to the most intricate encysted or cystically degenerated cancerous lesions, are covered indetail in this review. The aim of this paper is to familiarize the practitioner with the ultrasonographic aspects of complex breastcystic masses and to implement a gradual, strategic approach in the diagnostic algorithm.

Mucinous breast lesions: diagnostic challenges

Breast lesions with mucin represent a broad spectrum of entities, ranging from benign fibrocystic changes with luminal mucin to mucocele-like lesions (MLL), which can be associated with banal epithelial alterations,...

Magnetic resonance imaging reveals functional diversity of the vasculature in benign and malignant breast lesions

Tumor perfusion through the microvascular network can be imaged noninvasively by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). The objective of the current study was to quantify the microvascular perfusion parameters in various human breast lesions and to determine whether they varied between benign lesions and malignancy and whether they were altered with increased invasiveness. Perfusion parameters in 22 benign fibrocystic changes, 15 ductal carcinomas in situ (DCIS), 30 infiltrating ductal carcinomas (IDC), and 22 fibroadenomas were measured using high-resolution DCE-MRI. Pixel-by-pixel image analysis yielded parametric images of two perfusion indicators: the influx transcapillary transfer constant (k(trans)) and the efflux transcapillary rate constant (k(ep)). Correlations of lesion type and perfusion parameters were calculated using Spearman correlation. Logistic regression analysis evaluated the best predictors of the kinetic parameters that differentiate between IDC and benign lesions. The perfusion parameters exhibited a progressive increase from benign fibrocystic changes to DCIS and IDC, with a significant correlation between lesion type and the parameters' values (range of correlation coefficients, 0.56-0.76; P < 0.0001). In addition, k(trans) increased from low-grade DCIS to high-grade DCIS. Fibroadenomas were characterized uniquely by high k(trans) but low k(ep). Stepwise logistic regression selected k(trans) as the best predictor for distinguishing benign fibrocystic changes from IDC, yielding 93% sensitivity and 96% specificity. The microvascular perfusion parameters in breast lesions were elevated with invasiveness. Quantification of these parameters using high-resolution DCE-MRI was helpful for differentiating between breast lesions and should improve breast carcinoma diagnosis.

Assessment of 142 Stellate Lesions With Imaging Features Suggestive of Radial Scar Discovered During Population-based Screening for Breast Cancer

Because some lesions diagnosed as radial scars (RS) on core biopsy have been found to be malignant on excision, core biopsy has not had an established role in the assessment of RS. In our breast cancer-screening program, we have avoided core biopsy if RS is suspected on imaging. Recently, two reports have expanded the experience with core biopsy of RS, prompting this review of our assessment protocols for lesions suspected as being RS. Between January 1996 and January 2003, stellate lesions with imaging features of RS in which core biopsy was omitted because of a presumptive radiologic diagnosis of RS are included. Demographic, radiologic, and cytologic data were correlated with the histologic findings in the excised specimen. On imaging, 9% (142) of all stellate lesions were suspected to be RS. Only 66.2% (94) were confirmed as RS on histology; 38 cases (28.6%) were carcinomas (36 invasive, 2 in situ) and 7% showed benign fibrocystic changes; 87.1% of the carcinomas required further surgery for positive margins. Axillary staging was also needed for the invasive cancers. Among the histologically proven RS, 28 of 94 (29.8%) showed areas of atypical ductal hyperplasia, lobular neoplasia, ductal carcinoma in situ, or invasive carcinoma. These proliferations were typically focal and unpredictable and were usually completely excised by the initial diagnostic biopsy. Core biopsy would be valuable in the assessment of lesions with imaging features suggestive of RS since 28.6% of such lesions are indeed carcinomas that mimic RS. Identification of these cancers would permit one stage breast and axillary surgery to be planned. The policy of mammographic surveillance for lesions with nonmalignant core biopsies remains controversial because of the paucity of data. Ongoing evaluation is needed as more experience is reported.

The management of lobular neoplasia identified on percutaneous core breast biopsy.

The management of lobular neoplasia (LN) found on percutaneous core biopsy remains a clinical dilemma. The purpose of this study was to establish guidelines for the management of LN when obtained on percutaneous core needle biopsy. A retrospective review of the Breast Imaging Tissue Sampling Database at New York Presbyterian Hospital-Columbia Comprehensive Breast Center was performed from 1998 to 2000. A total of 1460 percutaneous core breast biopsies were performed using 11- or 14-gauge needles with LN identified in 43 biopsies from 34 patients. Eleven biopsies were ultrasound guided for nonpalpable masses and 32 were stereotactically guided for mammographically detected densities (10) and microcalcifications (22). The 43 LN biopsies were divided into three groups based on additional findings associated with LN on core biopsy: group I (n = 19), LN with invasive cancer or ductal carcinoma in situ (DCIS); group II (n = 11), LN plus a second indication for open surgical biopsy, such as atypical ductal hyperplasia (ADH), radial scar, phyllodes tumor, or intraductal papilloma; and group III (n = 13), LN plus benign fibrocystic changes. In group I, 19 of 19 biopsies (100%) yielded invasive cancer or DCIS on surgical biopsy versus 3 of 11 (27%) for group II, and 1 of 13 (8%) for group III. Outcomes in group III are described as follows: three patients were lost to follow-up, three patients did not undergo surgical biopsy but demonstrated more than 1 year of mammographic stability following core biopsy. Of the remaining seven patients, two had LN and ADH on surgical biopsy (one had a contralateral cancer), one had atypical lobular hyperplasia (with a contralateral cancer), two had LN and benign fibrocystic changes, one had LN and intraductal papilloma, and one had LN and invasive ductal carcinoma (IDC) with DCIS (with a contralateral cancer). These results suggest that surgical biopsy is indicated for patients with LN when found on core biopsy and when the biopsy demonstrates invasive cancer, DCIS, or other indications for surgical biopsy such as ADH, or in the examination of a patient with a synchronous contralateral breast cancer. The diagnosis of LN alone without these indications on percutaneous biopsy may not warrant routine surgical biopsy.

Pathologic quiz case: a 41-year-old woman with bilateral nodular breasts.

A woman with no family history of breast cancer, but with a long history of bilateral nodular breasts, complained of increasing breast size. Three previous breast biopsies (the right breast in 1973 and 1983 and the left in 1992) were all reported as benign fibrocystic changes. Physical examination showed pendulous but symmetrical breasts with no noted skin changes. Palpation revealed multiple, discrete, large, firm, and mobile breast masses bilaterally. No axillary adenopathy was detected. Mammography revealed multiple homogeneously dense well-circumscribed masses present in both breasts (Figure 1), which were compatible with giant fibroadenomata or multiple phyllodes tumors. Ultrasonography showed multiple well-demarcated masses with focal cystic change. Ultrasound-guided 14-gauge needle core biopsy of the right and left breast was performed, and microscopic examination of the biopsied tissue revealed dense stromal fibrosis and a few epithelial ducts. The fibrotic areas showed thick bundles of dense collagen admixed with a complex arrangement of cleftlike spaces resembling lymphovascular structures lined by flattened spindle cells, but without red blood cells in the spaces. No atypical epithelial hyperplasia or carcinoma was identified. A diagnosis was suggested. Two weeks later, resection of the bilateral masses along with reduction mammoplasty of both breasts was performed. On the right side, 13 white-pink well-circumscribed nodules with a total weight of 748 g (range: 4 to 382 g) were resected. The nodules had a smooth external surface and ranged in size from 3 to 17 cm in greatest dimension (Figure 2). On the left side, 10 white-pink wellcircumscribed nodules with a total weight of 214 g (range: 2 to 84 g) were resected. Morphologically, the nodules were similar to those seen in the right breast and ranged in size from 1.5 to 11 cm in greatest dimension. The cut surfaces of the nodules showed a generally homogeneous white fibrous parenchyma with occasional cystic spaces. No hemorrhage or necrosis was noted grossly. Microscopically, the breast nodules showed histopathologic changes similar to those seen in the needle core biopsies, showing large areas of dense stromal fibrosis containing numerous cleftlike spaces, often in a complex arrangement (Figure 3). In some areas, the cleftlike spaces and flattened spindle cells were concentrically arranged around breast lobules. The cleftlike spaces did not contain red blood cells. The adjacent breast parenchyma showed focal fibrocystic changes (sclerosing

Gynecomastia-like changes of the female breast: A clinicopathologic study of 4 cases

c Objectives.—Gynecomastia-like changes of the female breast are only sparsely reported and are not well defined in the literature to our knowledge. Our objectives were to determine the incidence, clinical presentation, mammographic findings, and the medical background of patients with these changes. Design.—Two thousand seven hundred nine female breast surgical cases from 1995 to 1999 were searched by SNOMED. Three observers further reviewed all cases with gynecomastia-like changes. Strict criteria were developed and cases that fulfilled the criteria were analyzed further. Results.—We found the incidence of female gynecomastia-like changes to be 0.15% (4/2709) of all female breast lesions, which represents an underestimation. Patients were usually young and had an average age of 32 years. The usual clinical presentation was a palpable mass with a size ranging from about 3.5 3 2 3 2c m to 53 4 3 2.5 cm. Mammography showed either negative findings or a nonspecific density. Gross examination of these specimens revealed no distinct lesions. Histologically, the lesions consisted of ductal hyperplasia with periductal stromal fibrosis or edema. They were associated with fibrocystic changes in the adjacent breast. The patients had no significant medical history. Conclusion.—We propose that the gynecomastia-like change is a specific benign entity within the spectrum of benign fibrocystic changes and that it usually occurs in young patients. (Arch Pathol Lab Med. 2001;125:506‐509)

Atypical ductal hyperplasia: histologic underestimation of carcinoma in tissue harvested from impalpable breast lesions using 11-gauge stereotactically guided directional vacuum-assisted biopsy.

This review was undertaken to determine the reliability of the histologic diagnosis of atypical ductal hyperplasia (ADH) made from tissue obtained by 11-gauge stereotactically guided directional vacuum-assisted biopsy of impalpable breast lesions. Four hundred twenty-two 11-gauge stereotactically guided vacuum-assisted breast biopsies were performed at our institution between November 5, 1996, and June 30, 1998. Biopsies were performed with the patient prone on a dedicated stereotactic biopsy table. A directional vacuum-assisted biopsy device was used. Eight to 24 cores (mean, 13.4) were harvested from each lesion. Radiography of core specimens was performed in cases in which the target lesion contained microcalcifications. Twenty (4.7%) of the 422 biopsies yielded a histopathologic diagnosis of ADH. Surgical excision of 16 of the 20 lesions was subsequently performed. We compared the histopathologic results of the core extracted and the corresponding surgically excised tissue. Of the 16 surgically excised lesions, four (25.0%) retained the diagnosis of ADH. Four (25%) were upgraded to carcinoma: Two (12.5%) were ductal carcinoma in situ without comedonecrosis, one (6.3%) was invasive carcinoma, and one (6.3%) was tubular carcinoma. Of the remaining eight surgically excised lesions, six (37.5%) were interpreted as benign fibrocystic changes with ductal hyperplasia without atypia, and two (12.5%) were interpreted as lobular carcinoma in situ. Because ADH was underdiagnosed in 25% of the lesions, we recommend that surgical excision be performed whenever ADH is found in tissue obtained from 11-gauge directional vacuum-assisted breast biopsy.

Fine‐needle aspiration cytology of cystic hypersecretory ductal carcinoma in situ of the breast: A case report

Cystic hypersecretory intraductal carcinoma is an unusual, cystic form of intraductal breast carcinoma affecting middle-aged women. Cytopathologists have rarely encountered this lesion, with only 2 other cases having been previously reported (Colandrea et al., Arch Pathol Lab Med 1988;112:560–563; Kim et al., Acta Cytol 1997;41:892–896). In our case, the cytologic findings of both air-dried, Diff-Quik-stained and ethanol-fixed, Papanicolaou-stained smears are presented. The cytologic hallmarks of this entity include the presence of a few scattered epithelial cells with bland nuclear morphology in a background of extensive, amorphous, pink-staining material. Cytomorphologically, the differential diagnosis includes other entities containing pink-staining material such as colloid carcinoma, mucocele-like lesion of the breast, and benign fibrocystic change. Diagn. Cytopathol. 1999;20:160–163. © 1999 Wiley-Liss, Inc.

Allergic etiology of benign fibrocystic changes of the breast

We postulate that fibrocystic changes in the female breast are the end result of a series of biochemical events initiated by the mast cell degranulation products histamine and heparin. Two mechanisms are proposed which could lead to mast cell degranulation in breast tissue. First, low progesterone levels lead to decreased intracellular cAMP levels in mast cells which enhance mast cell degranulation. Second, low progesterone levels lead to increased solubilization of breast collagen during tissue turnover. Susceptible individuals may undergo an allergic reaction to soluble collagen resulting in further mast cell degranulation. The degranulation products histamine and heparin may stimulate increased stromal proliferation and vascularization respectively. We provide evidence for the occurance of histamine release by demonstrating an increased incidence of allergic symptoms in white women with fibrocystic breast changes.

High performance liquid chromatographic determination of serum UV profiles of normal subjects and patients with breast cancer and benign fibrocystic changes

High performance liquid chromatography (HPLC) was used to determine the UV profiles of serum samples taken postoperatively from 22 patients with histologically documented breast cancer, 8 patients with benign breast fibrocystic changes and 10 normal subjects. The analyses were performed on coded serum samples and after they were completed, the code was broken and the results correlated with the clinical data. Only one ml of serum was required for the HPLC analysis and identification. Detection limits for the nucleosides and bases were in the 10–20 pmol range and the injection volume of the deproteinated serum was 75 μl. The UV profiles of the normal subjects were very reproducible and similar to those of the patients with benign fibrocystic changes. The profiles of some of the cancer patients were distinctly different from the two other groups, 1-methylinosine and N 2-methylguanosine, which were not detected in sera from normal subjects and patients with benign fibrocystic changes, were found in 45.5% and 22.7% of the cancer patients, respectively. Patients with the metastatic disease also showed elevated levels of guanosine and uridine. Only one false positive was found in the normal population. At present, it is not clear whether this indicates a subclinical manifestation of the disease and it must await further follow-up.