Mammographic Findings Research Articles

Utility of Diagnostic Mammography as the Primary Imaging Modality for Palpable Lumps in Women With Almost Entirely Fatty Breasts.

OBJECTIVE. The purpose of this study was to assess the performance of diagnostic mammography alone for evaluation of palpable symptoms in women with almost entirely fatty breast composition. MATERIALS AND METHODS. All diagnostic mammograms performed for palpable symptoms in women who had been assigned a breast density of "almost entirely fatty" over an 8-year period (2009-2017) at an academic breast center were retrospectively identified. Each symptomatic breast was considered a separate case and analyses were performed at the case level. Clinical, imaging, and pathologic results were reviewed. Descriptive statistics and 2 × 2 contingency table analyses were performed. RESULTS. The study cohort included 323 cases evaluated with mammography. Of these, 294 (91%) had undergone targeted ultrasound. At mammography, 240 (74%) had no correlate to the palpable lump; 38 (12%), a benign correlate; and 45 (14%), a suspicious correlate. Three cases had incidental suspicious mammographic findings, for a total of 48 positive mammography cases. Twenty-seven (8%) cases were malignant. Mammography alone detected all but one cancer, which was detected by ultrasound. In retrospect, the woman from whom this single false-negative mammogram was obtained did not have almost entirely fatty breast density. Mammography alone yielded a negative predictive value of 99.6%, percentage of diagnostic examinations recommended for biopsy that resulted in a tissue diagnosis of malignancy within 1 year of 54%, sensitivity of 96%, and specificity of 93%. Adjunct ultrasound contributed to 11 false-positives but also identified benign correlates in eight cases with no mammographic finding. CONCLUSION. In patients with almost entirely fatty breast tissue presenting with palpable symptoms, mammography alone had a high sensitivity and specificity. Our results support that mammography alone may be sufficient for evaluation of palpable symptoms in these women as long as density criteria are strictly applied.

Primary Neuroendocrine Carcinoma of the Breast: Mammographic, Ultrasound, and Magnetic Resonance Imaging Findings

Objective: The purpose of this study was to investigate the mammography, ultrasound (US), magnetic resonance imaging (MRI) features that characterise primary neuroendocrine breast carcinomas (NEBC) to improve the awareness of the disease. Materials and Methods: The mammography, sonography, MRI and pathologic features in a total of 54 pathologically proven NEBC cases at Fudan University Cancer Hospital from January 2003 to January 2013 were retrospectively analysed. All 54 patients were women with a mean age of 65 years old (ranging from 35 to 80 years). Results: The 54 NEBC patients had a total of 63 lesions. Pathological diagnosis included endocrine ductal carcinoma in situ (E-DCIS) in 20 lesions, E-DCIS with microinvasion in 17 and invasive solid neuroendocrine carcinoma in 26 lesions. The imaging characteristics of NEBC is a high-density round mass (64.1%) with obscured or indistinct margins on mammograms. All masses without malignant calcifications are the most frequent appearances. A hypoechoic mass (78.4%) with irregular shape and circumscribed margins on sonograms; and lobular or irregular shaped mass with spiculated margins, associated with homogeneous or heterogeneous enhancement on MR images. The highest positive predictive value (PPV) for BI-RADS (Breast Imaging Reporting and Data System) 4, and 5 categories was seen by MRI (0.67 [4/6]). In total, 5 patients (9.2%) had axillary lymph node metastasis. 52 (82.5%) lesions were estrogen receptor-positive and 52 (82.5%) progesterone receptor-positive. 45 (71.4%) lesions were negative for HER2/neu. Thirty patients bearing NEBC received hormone therapy; 5 of these patients underwent radiotherapy and/or chemotherapy. Compared with pure NEBC, NEBC with invasive showed larger size of the lesion (t = –2.41, P = 0.024). Conclusion: MRI may have a role in early detection of NEBC. No calcification is a notable mammographic feature that differ from invasive mammary carcinoma. Positive estrogen and progesterone receptor results and negative Her2/neu results have been linked more frequently to NEBC especially in elderly woman with a palpable lump or nipple discharge.

HIV and breast cancer - a mammographic analysis: An observational study to identify the mammographic pattern of breast cancer in HIV-positive patients.

Data on the association between HIV and breast cancer mammographic patterns and histological subtypes are limited. To determine whether specific mammographic findings, histological features and patient profiles were unique to a cohort of HIV-positive patients who developed breast cancer, by comparing them with a HIV-negative cohort. This was a descriptive study in which we conducted a retrospective chart review and mammographic and pathology analysis of newly diagnosed breast cancer patients referred to the Addington Hospital breast clinic between August 2008 and June 2012 and entered into a prospective database. Thirty-eight HIV-positive and 38 HIV-negative patients were included in the study. HIV-positive patients were more likely to have multifocal breast cancer (p=0.007), but not multicentric disease (p=0.05). The presence of grouped and fine pleomorphic microcalcifications and positive HIV status demonstrated statistical significance (p=0.000). A statistically significant relationship between grouped and fine pleomorphic microcalcifications with biopsies confirming high-grade ductal carcinoma in situ (HGDCIS) and HIV status was demonstrated (p=0.001). The mean age of the HIV-positive patients was 42.5 years (p=0.000). We demonstrated a statistically significant relationship between HIV status, the presence of multifocal breast cancer, and mammographically detected grouped and fine pleomorphic microcalcifications. A statistically significant relationship between HGDCIS and HIV status, and the presence of grouped and fine pleomorphic microcalcifications in HIV-positive patients with biopsies confirming HGDCIS, was demonstrated. Our study also showed that there is a relationship between age of presentation and HIV status.

Fat necrosis in level I oncoplastic breast-conserving surgery focusing on a modified round block technique.

The modified round block technique (MRBT) is a level I oncoplastic breast-conserving surgery (OBCS), which contains a very wide glandular flap created by extensive dual-plane undermining that is achieved by entire subcutaneous dissection and approximately 50% dissection of the breast parenchyma from the pectoralis muscle. A retrospective analysis was performed for 100 patients who underwent OBCS using MRBT from February 2009 to October 2017. The incidence of positive margin was 7.0% (seven cases), and there has been no local recurrence during a median follow-up period of 68months. Short- and long-term complications included fat necrosis (11.0%), infection (4.0%), and hematoma formation (4.0%). When patients were divided into two groups based upon the preoperative mammography findings, fat necrosis occurred in 5.2% of the patients with extremely dense or heterogeneously dense mammography, and in 19.0% of patients with scattered fibroglandular or entire fat mammography, which showed a statistically significant difference. Therefore, in level I OBCS, the extent of dual-plane undermining should be minimized to less than 50% of the total parenchyma in fatty breasts.

Clinical and imaging presentation of molecular types of breast cancer

Introduction: Breast cancer is the second most common malignant neoplasm among women in Brazil and worldwide. Its incidence increases with age, especially in individuals older than 50 years. Mammography is the main screening test, has high sensitivity, and is the only method that has made an impact on mortality rate. Breast cancer is classified into molecular subtypes, based on immunohistochemical markers. The luminal A subtype (LA) presents estrogen receptor (ER) and progesterone receptor (PR) positive, HER2 negative, and low Ki-67 index. Luminal B (LB) shows ER and/or PR positive, HER2 negative, high Ki-67 index, or HER2 positive (luminal HER2). HER2 has HER2 overexpression and ER and PR negative. Triple-negative (TN) has ER, PR, and HER2 negative and high histological grade. Objective: To evaluate patient characteristics according to the molecular subtypes of breast carcinoma among individuals treated at the Hospital São Paulo – Universidade Federal de São Paulo. Method: This is a retrospective study based on the analysis of medical records of breast cancer cases from the Hospital São Paulo between 2013 and 2016. During this period, 235 patients were treated. Among them, 40% were classified as LA, 34% as LB, 8% as luminal HER2, 15% as TN, and 3% as HER2. The mean age was 57.6 years. The incidence of breast carcinoma was higher in women over 50 years of age in all subtypes: 75.2% for LA, 65% for LB, 58% for luminal HER2, 100% for HER2 overexpression, and 75.1% for TN. Regarding ethnicity, most women were white in all subtypes, accounting for 66.5% of cases. In all subtypes, the most common clinical complaint was nodule: 86% for LA, 86% for LB, 100% for HER2 overexpression, and 96% for TN. Among the mammographic findings, nodule was the most frequent in all subtypes. Luminal subtypes presented other findings, such as suspicious calcifications (14% for LA and 21% for LB), focal asymmetries (14% for LA and 5% for LB), and distortions (2% for LA and 3% for LB). Conclusion: Breast cancer has a higher incidence among Caucasian individuals and those aged 50 to 60 years. The clinical and imaging presentation of tumors is influenced by their molecular subtype: luminal subtypes have a greater diversity of findings and non-palpable lesions, while TN tumors usually manifest as palpable nodules.

Диагностика заболеваний молочной железы в программе вспомогательных репродуктивных технологий

Objective. To study the state of the breasts in women who undergo assisted reproductive technologies treatment, using modern methods of radiation imaging. Patients and methods. Pre- and prospective examination and analysis of the data of radiation imaging of the breasts of 220 women, having tubal factor infertility in combination with benign mammary dysplasia, who have successful or unsuccessful experience of participation in assisted reproductive technology programmes. The average age of patients was 42.5 years. Assessment points were: breast tissue density according to the findings of ultrasound, mammography and tomosynthesis, presence of clustered microcalcifications, presence of benign dysplastic processes and fibroadenomas of the breasts. Results. In the group of 35–39-year old patients, the most common pathological processes were fibrocystic mastopathy and fibroadenomas. The main diagnostic methods were ultrasound visualization and US-controlled core-needle vacuum-assisted biopsy. In the group of 40–44-year old women, the predominant pathological process was microcalcification clusters alongside high mammographic density. The main diagnostic methods were digital x-ray tomosynthesis and X-ray-guided core-needle vacuum-assisted biopsy. In the group of 45–49-year old women, cases of breast cancer were diagnosed. 12 women in this group had breast implants. Conclusion. Hormonal medication used in assisted reproductive technologies under the protocols of in-vitro fertilization and intracytoplasmatic sperm injection influence the state of the breasts, increasing a risk of developing diffuse benign mammary dysplasias and, quite possible, a risk of developing breast cancer later in life. Key words: breast diseases, assisted reproductive technologies, tomosynthesis, mammotome, clustered microcalcifications

Utility and Diagnostic Performance of Automated Breast Ultrasound System in Evaluating Pure Non-Mass Enhancement on Breast Magnetic Resonance Imaging.

ObjectiveTo compare the utility and diagnostic performance of automated breast ultrasound system (ABUS) with that of hand-held ultrasound (HHUS) in evaluating pure non-mass enhancement (NME) lesions on breast magnetic resonance imaging (MRI).Materials and MethodsOne hundred twenty-six consecutive MRI-visible pure NME lesions of 122 patients with breast cancer were assessed from April 2016 to March 2017. Two radiologists reviewed the preoperative breast MRI, ABUS, and HHUS images along with mammography (MG) findings. The NME correlation rate and diagnostic performance of ABUS were compared with that of HHUS, and the imaging features associated with ABUS visibility were analyzed.ResultsAmong 126 pure NME lesions, 100 (79.4%) were malignant and 26 (20.6%) were benign. The overall correlation rate was 87.3% (110/126) in ABUS and 92.9% (117/126) in HHUS. The sensitivity and specificity were 87% and 50% for ABUS and 92% and 42.3% for HHUS, respectively, with no significant differences (p = 0.180 and 0.727, respectively). Malignant NME was more frequently visualized than benign NME lesions on ABUS (93% vs. 65.4%, p = 0.001). Significant factors associated with the visibility of ABUS were the size of NME lesions on MRI (p < 0.001), their distribution pattern (p < 0.001), and microcalcifications on MG (p = 0.027).ConclusionABUS evaluation of pure NME lesions on MRI in patients with breast cancer is a useful technique with high visibility, especially in malignant lesions. The diagnostic performance of ABUS was comparable with that of conventional HHUS in evaluating NME lesions.

Metastatic Carcinoma to Breast from Renal Cell Carcinoma- A Rare Case Report with Unusual Cytology

Metastatic carcinoma to breast is an uncommon entity compared to the primary breast malignancies. Renal Cell Carcinoma (RCC) metastasising to breast is very rare as it commonly metastasises to lung, liver or bone. An accurate diagnosis of Secondary Tumour is must, since the prognosis and treatment differs between primary and secondary tumours. Here, the authors present the case of a 55-year-old female patient who presented with lump in right breast measuring 5×4 cm. Mammographic findings showed relatively well-defined round irregular marginated heterogenous radioopaque mass in outer lower quadrant, Breast Imaging Reporting and Data System (BIRADS- IV B). Fine Needle Aspiration Cytology (FNAC) showed atypical cells arranged in cohesive clusters with focal papillary architecture, entangled in eosinophilic stroma and cellular stromal fragments. The cells were small with ill-defined cell borders, granular to focal vacuolated cytoplasm, mild anisocytosis and indistinct nucleoli. Stain for mucin was negative. The differential diagnosis offered were primary breast carcinoma with possibility of metaplastic carcinoma and metastatic carcinoma. A trucut biopsy showed fibrocellular stroma, islands of cells with clear cytoplasm separated by thin fibrous septa. Immunohistochemical (IHC) for pancytokeratin (panCK), CD10 and vimentin were positive and Estrogen Receptor (ER), Progesterone Receptors (PR), Human epidermal growth factor receptor 2 (HER2) were negative and the diagnosis of metastatic RCC was made. The cytology case reports in the literature have shown characteristic cytomorphological features composed of cells with abundant, finely vacuolated cytoplasm, moderate pleomorphism and prominent nucleoli. This case is unusual as it was predominated by small cells with granular cytoplasm. Therefore, it was concluded that trucut biopsy is mandatory for breast lump in patient with RCC since the cytological features on FNAC might not always be characteristic.

Study of mammography reports made between 2015 and 2019

Introduction: Screening and early diagnosis are crucial strategies for the detection of breast cancer. In Brazil, the Ministry of Health recommends annual clinical screening in women over 40 years of age, with the addition of biennial mammography for those aged between 50 and 69 years. However, high-risk patients should have mammography annually after the age of 35 years. Objectives: To study the reasons for mammography screening in the age group 50 to 69 years. Method: This is an ecological study of the number of patients per mammography report according to age group, from 2015 to 2019. Data from the Cancer Information System (Sistema de Informação do Câncer – SISCAN) were obtained from the Technology Department of the public health system (Departamento de Informática do Sistema Único de Saúde – DATASUS). Results: When comparing data from the Breast Cancer Information System (Sistema de Informação do Câncer de Mama – SISMAMA) from 2015 to 2019, we found 8,569,457 mammographies, of which 5,216,473 were performed in women aged 50 years to 69 years, which corresponds to 60.87% of the procedures. In addition, 4.90% of these women were high-risk individuals, and 1.24% had been treated for breast cancer. Mammography reports showed that 12.01% of the results were inconclusive, 38.28% were normal, 46.12% had a benign radiological finding, 2.58% had a probably benign finding, 0.78% had a suspicious finding, 0.14% had a highly suspicious finding, and 0.04% had malignant confirmation. The proportion of BI-RADS categories 4, 5, and 6 totaled 83,852 screenings, the equivalent to 0.97% of reports. In addition, 59.49% (49,891) of women who presented mammographic findings with malignant characteristics belonged to the age group 50–69 years. Conclusion: This study concluded that the strategy of biennial breast cancer screening shows scientific evidence of mortality reduction, given that 59.49% of the reports with malignant characteristics corresponded to the age group 50 to 69 years. However, the data presented did not allow calculating the number of women outside this age group who do not receive care and develop breast cancer.

Mammographic abnormalities after conservative breast surgery with immediate lipofilling: case control study

Introduction: Conservative breast surgery with immediate autologous fat grafting reconstruction (lipofilling) is emerging as a new technique for breast reconstruction. Concerns have been raised about mammographic abnormalities caused by immediate lipofilling. Lipofilling can lead to mammographic abnormalities, with diffuse microcalcifications as the most frequent, followed by oil cysts. The incidence of radiological abnormalities resulting from fat grafting varies significantly in the literature, ranging from 0 to 86%. However, until now, no study has addressed the mammographic abnormalities found after conservative breast surgery with immediate lipofilling. Methods: This case-control study involved patients submitted to conservative breast surgery with or without immediate lipofilling in our facility between 2010 and 2013. Pathological and clinical characteristics of both groups were compared. The patients included underwent breast imaging tests with digital mammography every six months for two years. In each period, image changes were compared between the two groups. Results: Patients submitted to conservative breast surgery with immediate lipofilling were compared to those without immediate lipofilling. The mean volume grafted was 125±39 cc. Patients who underwent immediate lipofilling were younger than control patients (52.5 vs. 58.9 years, p=0.001). Other pathological and clinical characteristics were not statistically different between the two groups. Mammographic findings revealed no significant differences in the frequency of nodules (0 vs. 8, p=0.2) and calcifications (30 vs. 92, p=0.2) between patients with and without lipofilling. However, patients submitted to immediate lipofilling presented a higher frequency of oil cysts (6 vs. 5, p=0.01) and fat necrosis (3 vs. 1, p=0.03) after 24 months of radiotherapy. No patient was submitted to biopsy during the follow-up. Conclusions: This was the first study to show that lipofilling concomitantly with conservative breast surgery does not seem to induce significant radiological changes. These findings indicate that, from a radiological point of view, immediate lipofilling is safe and can be a new tool in breast oncoplasty.

Predicting Patients Found to Have Malignancy at Nipple Duct Surgery

Introduction: The unexpected diagnosis of breast cancer following total duct excision is distressing for patients. Despite advances in radiology and the description of suspicious nipple discharge, pre-operative diagnosis of malignancy still evades us. The aim of this study was to review the pathological findings of total duct excision and microdochectomy with reference to pre-operative symptoms, ultrasound, or mammographic findings and identify features associated with increased likelihood of malignant disease. Methods: Data were collected retrospectively of all patients who underwent total duct excision surgery in a single centre (2011–2017). Pre-operative demographics, symptoms, and imaging findings were recorded and correlated with subsequent pathology. Results: 214 patients underwent total duct excision; data were available for 211. Median age was 53 years. 175/211 (82.9%) patients had benign pathology (duct ectasia, papilloma without atypia, fibrocystic change) on final histological examination, 21/211 (10%) had “risk” lesions (papilloma with atypia, atypical ductal hyperplasia), and 15/211 (7.1%) had malignancy (ductal carcinoma in situ). Of the 15 patients with malignant lesions, 6/15 (40%) had normal imaging (M1, U1). 71/211 (33.6%) had normal imaging (M1, U1): 60/71 (84.5%) had benign disease, 5/71 (7%) had “risk” lesions, and 6/71 (8.5%) had malignant lesions. 83/211 (39.3%) patients presented with bloody discharge: 64/83 (77.1%) had benign pathology, 9/83 (10.8%) risk, and 10/83 (12%) malignancy. 38/211 (18%) patients presented with non-bloody discharge: 32/38 (84.2%) had benign disease, 4/38 (10.5%) risk, and 2/38 (5.3%) malignant lesions. ­Conclusion: Neither imaging nor presenting symptoms correlate with the likelihood of malignant disease being present at final pathology. Even with advances in pre-operative diagnosis, total duct excision remains an essential diagnostic and therapeutic procedure.

Imaging of Pregnancy Associated Breast Cancer

AbstractBackground: Pregnancy-Associated Breast Cancer (PABC) is breast cancer presenting either during pregnancy or in the first postpartum year.Aim of Study: The purpose of this study was to calculate the incidence of pregnancy associated breast cancer in patients presenting with clinically palpable masses during pregnancy or first postpartum year and to evaluate the role of sonomam-mography in the diagnosis of pregnancy associated breast cancer.Patients and Methods: The study included 100 female patients with clinically palpable breast masses discovered during pregnancy and first year of lactation. All patients were evaluated by Ultrasound. Mammography was only performed on 23 patients. Mammographic and sonographic findings were evaluated retrospectively. No further diagnostic evaluation was done in case of benign radiological findings, yet biopsy was the next step performed if findings were suspicious.Results: In total, 100 women were enrolled in this study; the mean age of this study population was 29 years. Among the studied cases only 15 cases (n=15/100, 15%) were malig-nant, their age ranged from 26 years to 40 years with average 34.6, four of them (n=4/15) were presented by right breast palpable lumps and 11 (n=11/15) by left breast palpable lumps. Ultrasound helped to classify 2 cases (n=2/15) as BIRADS 4 and the rest (n=13/15) as BIRADS 5. Ultrasound guided biopsy was then performed for the 15 patients confirming their malignant nature.Conclusion: Even though the majority of the pregnancy-associated breast masses are benign; a strict evaluation of any lesion is still required to exclude malignancy.

Eficácia da campanha “Outubro Rosa” no rastreamento do câncer de mama baseada no BIRADS®

Introdução: O câncer de mama é a segunda neoplasia mais comum entre as mulheres do mundo e a causamais frequente de óbitos. A mamografia é o principal método de imagem para o rastreio e diagnóstico precoce. Objetivo: Analisar o impacto da política de saúde da campanha “Outubro Rosa” sobre o diagnóstico precocedo câncer de mama e os resultados de suas estratégias de marketing social. Métodos: Estudo observacional, descritivo, transversal e retrospectivo, a partir da coleta e análise deregistros de mamografias no SISMAMA, padronizados no Breast Imaging Reporting and Data System(BIRADS®) realizado em um hospital quaternário no ano de 2016. Resultados: Foram realizadas 1.844 mamografias no serviço de diagnóstico por imagem. A análise do número de exames realizados nos meses anteriores (janeiro a setembro) e posteriores (outubro a dezembro)à campanha evidenciou um aumento estatisticamente significativo no número médio de exames após o“Outubro Rosa” (125,8 exames/mês vs 237,3 exames/mês; p = 0,003). Observou-se que a categoriaBIRADS® 2 (achados mamográficos benignos) representou a maioria dos resultados (40,9%). Não houve diferença estatisticamente significativa entre a categorização BIRADS® para o mês de outubro emcomparação com os demais meses do ano. Conclusão: Foi possível demonstrar que a campanha do “Outubro Rosa” cumpriu seu objetivo, como políticade saúde pública, de estimular o rastreamento do câncer de mama pelas mulheres brasileiras.

Postoperative Cancer Surveillance Following Oncoplastic Surgery with Latissimus Dorsi Flap: a Matched Case-Control Study.

The latissimus dorsi (LD) myocutaneous flap is a widely used local option in oncoplastic surgery for avoiding breast deformities; however, concerns exist regarding its influence in monitoring recurrence. In this study, we evaluated the impact of this flap on postoperative cancer surveillance. Each patient receiving oncoplastic surgery with LD flap after partial mastectomy were matched in age, cancer stage, and body mass index with patients receiving partial mastectomy alone. Twenty-nine patients with the oncoplastic LD flap received 99 mammograms and 139 ultrasonograms, while 29 patients with partial mastectomy alone underwent 92 mammograms and 129 ultrasonograms. Mammographic and ultrasonographic findings were classified by Breast Imaging Reporting and Data System (BI-RADS) category and reviewed. Any recommendations for additional evaluation and recurrence were documented. During an average follow-up period of 44months, although the oncoplastic group demonstrated more newly developed benign calcifications (control 14% vs. oncoplastic 41%; p = 0.019) on mammography, the percentage of recall for additional imaging in category 0, and the short-interval follow-up in category 3, was not different between the control and oncoplastic group. Regarding ultrasonography, BI-RADS category was also not different between the two groups; however, the control group showed more fluid collections than the oncoplastic group (control 21% vs. oncoplastic 0%; p = 0.023). One case of local recurrence was observed in the control group. Although there was an increase in benign calcifications in the oncoplastic group, there were no additional abnormal findings requiring further intervention. We concluded that the LD flap for oncoplastic surgery does not interfere with cancer surveillance, and even decreases the rate of fluid collection.

Adding the merits of contrast to the ease of mammography; can we highlight what\u2019s behind breast asymmetries?

BackgroundBreast symmetry is one of the major things that radiologists assess when looking at mammograms and is one of the most challenging mammographic findings to evaluate. Contrast-enhanced spectral mammography (CESM) is an emerging mammography technique that has shown comparable sensitivity and specificity to MRI. The purpose of this study is to assess the value of CESM in characterization of breast asymmetries (BAs) and if it should be incorporated in its diagnostic work-up.ResultsThree hundred sixty-five patients with mean age of 47 years were included in the study. CESM was performed aiming for characterization of 380 suspicious or indeterminate breast asymmetries. Assessment of subtracted high-energy images (HEI) markedly improves the overall accuracy reaching 88.4%. Further improvement of the overall accuracy was achieved on combined assessment of the low-energy images (LEI), subtracted high-energy images (HEI), and ultrasound reaching 91.3%.ConclusionCESM is considered as a valuable complementary imaging tool considering the evaluation of breast asymmetries and should be incorporated in its diagnostic work-up in cases not resolved on an initial combined mammography and targeted ultrasound study especially in the presence of a heterogeneous dense breast parenchyma. Yet, this may be hindered in the presence of inflammatory signs because of the overlapping imaging criteria.

Idiopathic granulomatous mastitis: a diagnostic challenge

Introduction: Idiopathic granulomatous mastitis is an uncommon and benign inflammatory breast disease that usually occurs in young women of childbearing age. Most common presentation is a slowly growing breast mass that is hard in consistency and can greatly mimic breast cancer. Mammographic and ultra-sonographic findings are non- specific and usually mimic malignant masses leading to higher BIRADS grading in reports. The only way to reach a definitive diagnosis is by histopathological diagnosis. Material & Methods: In the present study eight patients were presented to The Integrated Breast Care Centre (IBCC) department of AIIMS Rishikesh with breast lump or nipple discharge during January 2019 to June 2019. All the patients underwent mammography and ultrasonography followed by FNAC or Biopsy of the lesion as findings were mimicking malignant etiology. Results: On HPE all the patients showed features of granulomatous inflammation and diagnosis of idiopathic granulomatous mastitis was made. TB was excluded by CBNATT (Cartridge Based Nucleic Acid Amplification Test) examination of the aspiration cytology samples. To our knowledge, such a report is the first of its kind to address this topic in this region. Conclusion: In a young child-bearing age group female presenting with breast mass a differential of idiopathic granulomatous mastitis should also be considered. The clinicians as well as radiologists should be aware of this entity so that appropriate management may be done.

Flat epithelial atypia on core needle biopsy does not always mandate excisional biopsy

Flat Epithelia Atypia (FEA) is a proliferative lesion of the breast where cells demonstrate columnar change and cytologic atypia. This lesion has been identified as distinct from the classic atypical hyperplasias (AH). While many patients undergo excisional biopsy, management of FEA identified on core needle biopsy (CNB) is controversial, and the rate of associated ductal carcinoma in situ (DCIS) or invasive cancer is not well defined. The aim of this study was to determine the upstage rate of FEA diagnosed by CNB. We identified patients from a prospectively maintained data base who had FEA diagnosed by CNB from 01/2010 to 07/2015. Patient variables collected included age at presentation, imaging findings, pathologic findings following surgical excision, and subsequent development of breast cancer. Of 132 patients, 62 (n=62/132, 47.0%) patients had FEA associated with DCIS and invasive ductal carcinoma (IDC) on CNB and were excluded from analysis. Of the remaining 70 patients, median age was 52 (range 31-84) years. Thirty-two (45.7%) patients had FEA plus AH, 4 (5.7%) patients had FEA plus lobular carcinoma in situ (LCIS), and 34 (48.6%) patients had FEA alone or with another non-pathologic finding (pure FEA). Two (6.3%) patients with FEA plus AH had DCIS or IDC on subsequent excisional biopsy. Of the 34 patients with pure FEA who underwent excisional biopsy, only one (2.9%) was found to have IDC. Twenty-two (64.7%) patients with pure FEA who underwent excisional biopsy presented with calcifications on mammography. None of these patients had cancer on excisional biopsy, and 10 (45.5%) patients had AH (3 ADH, 3 ALH, and 4 both ALH and ADH). Twelve (n=12/34, 35.3%) patients with pure FEA underwent CNB for a mass or asymmetry noted on imaging. Of these 12 patients, 9 (75.0%) had benign findings on excisional biopsy, two (16.7%) patients had AH, and one (8.3%) patient had IDC. Median follow-up was 4.6years (IQR 3.1-6.5years). Three (4.3%) patients subsequently developed IDC, two of which were in the contralateral breast. FEA is often found in combination with ADH and ALH as well as carcinoma on CNB. In our study, pure FEA was upstaged to cancer in only 2.9% of patients. Mammographic findings unlikely predict upstaging to malignancy. These findings suggest that excisional biopsy may not be warranted in patients with pure FEA and could be managed with close imaging surveillance.

Tuberculous mastitis: A review of 32 cases

BackgroundBreast tuberculosis (TB) is a rare disease, still present in endemic areas. The significance of breast TB is due to its rare occurrence and its resemblance to malignant breast lesions. The objective of this study was to study various clinical presentations and imaging features of different forms of tuberculous mastitis. MethodsA retrospective study was conducted over a 10-year period. Thirty-two consecutive patients diagnosed with tuberculous mastitis were included. ResultsThere was only one male patient in this series. The patients ranged in age from 25 to 60 years (mean age was 33.69 years). A solitary breast mass was the most common clinical presentation, which was associated with inflammatory findings in the majority of cases. The most common mammographic finding was diffusely increased density and the most common pathological finding was solitary mass. The most common appearance on ultrasound was of multiple intercommunicating breast masses with axillary lymphadenopathy. ConclusionsBreast TB should be considered in the differential diagnosis in the presence of a painful breast mass, discharging sinuses, mastitis, or a breast abscess that does not respond to conventional medical treatment. A multidisciplinary approach is required to aid timely diagnosis and to provide appropriate management and treatment in order to avoid complications.

Detection of TP53 and PIK3CA Mutations in Circulating Tumor DNA Using Next-Generation Sequencing in the Screening Process for Early Breast Cancer Diagnosis.

Circulating tumor DNA (ctDNA) has emerged as a non-invasive “liquid biopsy” for early breast cancer diagnosis. We evaluated the suitability of ctDNA analysis in the diagnosis of early breast cancer after mammography findings, comparing PIK3CA and TP53 mutations between tumor biopsies and pre-biopsy circulating DNA. Matched plasma and frozen fresh tissue biopsies from patients with Breast Imaging-Reporting and Data System (BIRADS) 4c/5 mammography findings and subsequent diagnosis of primary breast cancer were analyzed using NGS TruSeq Custom Amplicon Low Input Panel (Illumina) and plasma SafeSEQ (Sysmex Inostics). The same plasma and tumor mutations were observed in eight of 29 patients (27.6%) with four in TP53 and five in PIK3CA mutations. Sequencing analysis also revealed four additional ctDNA mutations (three in TP53 and one in PIK3CA) previously not identified in three patients tissue biopsy. One of these patients had mutations in both genes. Age, tumor grade and size, immunohistochemical (IHC) subtype, BIRADS category, and lymph node positivity were significantly associated with the detectability of these blood tumor-derived mutations. In conclusion, ctDNA analysis could be used in early breast cancer diagnosis, providing critical clinical information to improve patient diagnosis.

Ultrasound Findings of MammographicallyDense Breasts in a Sample of Iraqi Female PatientsDOI:https

Background: Breast problems including breast cancer have been increasing in Iraq during the recent years. Yet, early detection and screening programs using mammography mainly with complementary ultrasound had dramatically decreased the mortality rates from this emerging disease.&#x0D; Objective: To assess the dense breast detected by mammography for the presence of any hidden&#x0D; suspicious lesion by using ultrasound.&#x0D; Patients and methods: this is a cross - sectional study on 53 female patients who came for breast cancer&#x0D; screening or attended the Breast Clinic in the Oncology Teaching Hospital of the Medical City Complex in Baghdad –Iraq. The study was conducted from January to October 2018. Two -view mammography was done for each breast, and those with dense breasts underwent further ultrasound assessment done by a board-&#x0D; certified radiologist.&#x0D; Results: The mean age for the 53 patients included in the study was 48 years. Mammographic findings&#x0D; showed that heterogeneous fibroglandular tissue density was present in (89%) of the study population.&#x0D; Suspicious or clearly defined mass(es) by mammograph were seen in 16 (30%) of the patients, while no&#x0D; mass was identified in (22%). Ultrasound findings we re as follows: Suspicious mass in (75%) of the cases&#x0D; and benign lesions such as simple cysts or fibroadenoma in (9%). The results showed that ultrasound has&#x0D; upgraded 12 cases that were diagnosed as BI -RADS I/II to BI-RADS IV/V and this represented (23%) of&#x0D; the cases. On the other hand, the mammogram and the ultrasound were in concordance for BI RADS&#x0D; IV/V in 28 cases (54%). The positive predictive value of the ultrasound and the mammogram for BI -&#x0D; RADS IV and V breast lesions is 72% for BI - RADS IV and 95% for BI - RADS V for ultrasound and that of mammograph is 83% for BI - RADS IV 80% for BI- RADS V, while the negative predictive value of mammograph is 55% for BI - RADS I/II 25% for BI - RADS III.&#x0D; Conclusion: Dense breast is still an important problematic issue in mammographic screening as it may&#x0D; obscure small lesions, for which, ultrasound is proved to be a complementary and essential targeting tool&#x0D; in the assessment process.