Microcalcification Lesions Research Articles

Our strategy in complication management of augmentation mammaplasty with polyacrylamide hydrogel injection in 235 patients

Polyacrylamide hydrogel (PAAG) was once widely used in breast augmentation in China. Although it had been banned for augmentation mammaplasty in 2006, a large number of patients whose breasts were augmented with the gel injection have continued to seek medical advice because of its complications. The clinical management of these complications has never been standardised. The data of a total of 235 patients with complications following PAAG-injected breast augmentation have been summarised and the types and causations analysed. Magnetic resonance imaging (MRI) was undertaken in 228 patients with palpable masses, breast pain or tenderness, asymmetry or deformity and functional or psychological problems to eliminate neoplasm, infection and to delineate the diseases. The surgical gel evacuation via periareolar incisions was performed for all patients and immediate silicone breast prostheses were implanted in 108 patients and were delayed in 28 cases by 6 months. Most patients (214/235) of the group were satisfied with the treatment, and symptoms disappeared after removal of the gel. The gel distribution and involved tissue were well defined and neoplasm was ruled out by MRI. Postoperative MRI in 68 patients revealed that no obvious PAAG remaining. In either immediate or delayed reconstructive patients with silicone breast implants, good breast contour presented. A diagnosis and management strategy for these complications is proposed. In conclusion, the breast masses, pain and deformity are major complications after PAAG-injected breast augmentation. Psychological problems should be paid attention to. MRI is a sensitive and accurate method for diagnosis and treatment evaluation. Surgical removal of injected gel is the preferred method for complication management. The implantation of silicone prostheses for breast contour restoration after PAAG evacuation is effective for patients under strict selection. Our strategy for treating PAAG-related complications proved useful.

THE VALUE OF DYNAMIC CONTRAST ENHANCED BREAST MRI IN MAMMOGRAPHICALLY DETECTED BI-RADS 5 MICROCALCIFICATIONS

To evaluate the role of dynamic contrast-enhanced magnetic resonance imaging (MRI) in the diagnosis of BI-RADS-5 type of microcalcifications of the breast, to compare the size of the microcalcification lesions using mammography (MG) and MRI, and to determine the value of MRI in surgery for microcalcifications. The study also determines the morphology of microcalcification lesions, assesses kinetic curves and compare MRI features of ductal carcinoma in situ (DCIS) for different histopathological grades. Our group consisted of 32 patients with mammographically detected BI-RADS 5 microcalcifications. The MRI was done in this group of women which was later followed by stereotactic vaccum-assisted biopsy (SVAB). Surgery was performed on all patients with a biopsy that resulted in a diagnosis of breast cancer or atypical ductal hyperplasia (ADH). Of our group of 32 patients, there were 35 mammograhically detected microcalcification lesions, 32 DCIS, one ADH and two benign findings according to the final histology. The microcalcification lesions were larger using MRI than in MG in 10 women. We diagnosed DCIS multifocality in 6 women and bilateral carcinoma in one woman. As with kinetic curve assessment, we found in 67 % of DCIS a rapid rise, 27 % a moderate and in 6 % a slow initial rise. With the pattern of enhancement in the delayed phase, we found in 30 % of DCIS a washout pattern, 67 % a plateau and in 3 % a persistent pattern. Noted difference between high and low grade DCIS was confirmed. MRI sensitivity in the detection of DCIS was 94 % in our group of patients and was the sole evidence for detection of multifocality and bilateral incidence of carcinoma. In 26 % of women the outcome of MRI was the most important for converting breast conserving surgery to mastectomy.

Usefulness and limitations of the Japan Mammography Guidelines for the categorization of microcalcifications

The Japan Mammography Guidelines, referred to the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS), are intended to standardize the terminology in mammographic reports and the assessment of findings and to recommend action to be taken. The Japan Mammography Guidelines have explicit guidelines for the categorization of microcalcifications. The purpose of this study was to assess the positive predictive value (PPV) of each categorization of microcalcifications according to the decision table proposed by the Japan Mammography Guidelines according to BI-RADS morphology and distribution parameters and the pathologic outcome. A retrospective review was performed of 101 non-palpable screening mammography-detected microcalcification lesions without mass that had stereotactic vacuum-assisted breast biopsy (SVAB). This study was approved by our institutional review board, and informed consent was obtained for all SVAB. We classified microcalcification lesions according to the decision table. Histological findings were reviewed. In calcification morphology, all 32 punctate morphology microcalcifications, regardless of distribution, were benign (100%), whereas 25% (9/36) amorphous morphology microcalcifications, 67% (14/21) pleomorphic morphology microcalcifications and 92% (11/12) linear morphology microcalcifications were malignant. For calcification distribution, 28% (15/55) cluster distribution microcalcifications, 40% (17/43) segmental distribution microcalcifications and 67% (2/3) linear distribution microcalcifications were malignant. Features with high positive PPV showed segmental or linear distribution of linear morphology (100%, respectively), segmental distribution of pleomorphic morphology (100%) and cluster distribution of linear morphology (80%). The PPV for cluster punctate, cluster amorphous, cluster pleomorphic and cluster linear microcalcifications was 0, 21, 50 and 80%, respectively. The PPV for segmental punctate, segmental amorphous, segmental pleomorphic and segmental linear microcalcifications was 0, 27, 100 and 80%, respectively. The PPV for linear amorphous and linear linear microcalcifications was 50 and 100%. The decision table proposed by the Japan Mammography Guidelines according to BI-RADS morphology and distribution parameters is useful, but continued development of the decision table to improve standardization in mammographic interpretation is needed.

Soft-copy reading in digital mammography of microcalcifications: diagnostic performance of a 5-megapixel cathode ray tube monitor versus a 3-megapixel liquid crystal display monitor in a clinical setting

A recent study using dedicated contrast-detail phantoms showed that the image quality of a 3-megapixel (M) monitor can approach that of a 5M monitor in digital mammography. To compare a 5M cathode ray tube (CRT) monitor with a 3M liquid crystal display (LCD) monitor for soft-copy reading of digital mammography of microcalcifications in a clinical setting. 100 screen-detected microcalcification lesions (34 malignant and 66 benign) without mass that had been evaluated with 11-gauge stereotactic vacuum-assisted breast biopsy or definitive surgery were recruited into the study. One radiologist analyzed the soft-copy mammograms on a 5M CRT monitor and a 3M LCD monitor with 5 months between interpretations and scored the likelihood of malignancy and calcification distribution on a five-point scale. Calcification morphology and breast density were scored on a four-point scale. Positive predictive value (PPV) and negative predictive value (NPV) were calculated on the basis of a Breast Imaging Reporting and Data System. The interpretation time was also measured. There was no significant difference in the likelihood of malignancy (P = 0.655), calcification morphology (P = 0.168), calcification distribution (P = 0.11), and breast density (P = 0.0608). The PPV and NPV of soft-copy reading on the 5M CRT monitor was 57% (30/53) and 91% (43/47), respectively, identical to the results using the 3M LCD monitor. The total interpretation time averaged 88 s for the 5M CRT monitor and 67 s for the 3M LCD monitor (P<0.0001). Soft-copy reading of a digital mammography of microcalcifications with a 3M LCD monitor was similar in diagnostic performance to a 5M CRT monitor in this study.

Dynamic contrast-enhanced MR imaging in screening detected microcalcification lesions of the breast: is there any value?

To prospectively evaluate whether dynamic contrast-enhanced magnetic resonance (MR) imaging findings can help predict the presence of malignancy when screening detected microcalcification lesions, and its contribution to patient management of stereotactic vacuum-assisted breast biopsy (SVAB). Dynamic contrast-enhanced breast MR imaging was performed when screening 100 detected microcalcification lesions not visualized by ultrasonography with 11-gauge SVAB. Definitive surgery was performed on all patients with the biopsy resulting in the diagnosis of breast cancer or atypical ductal hyperplasia (ADH). Positive predictive values (PPVs) and negative predictive values (NPVs) were calculated on the basis of a BI-RADS (Breast Imaging Reporting and Data System) category and the absence or presence of contrast uptake in the area of microcalcification. The BI-RADS mammography category correlated with the diagnosis of breast cancer (ADH excluded): category 3 = 7% (4/55); category 4 = 48% (13/27); category 5 = 94% (17/18). After dynamic contrast-enhanced MR imaging, three of four malignancies with BI-RADS mammography category 3 were diagnosed as true positive. Therefore, the PPV of BI-RADS mammography category 3 with MR imaging was 1.8% (1/55). The PPV of contrast uptake of MR imaging was 86% (32/37), significantly higher than the 67% (30/45) PPV of BI-RADS mammography 4 and 5 (P = 0.033). The NPV of BI-RADS mammography 3 was 93% (51/55) versus 97% (61/63) NPV of MR imaging (P = 0.167). In the evaluation of screening detected microcalcification lesions, dynamic contrast-enhanced breast MR imaging provides additional information with high PPV and NPV, and may therefore offer an alternative to SVAB for women who do not want to undergo SVAB with equivocal findings following full diagnostic mammographic assessment, but breast MR imaging with imperfect PPV and NPV cannot replace SVAB. Dynamic contrast-enhanced breast MR imaging can demonstrate malignant microcalcifications detected by screening mammography and can be recommended in the evaluation of equivocal microcalcifications prior to SVAB.

Breast Microcalcifications: Retrieval Failure at Prone Stereotactic Core and Vacuum Breast Biopsy—Frequency, Causes, and Outcome

To retrospectively determine the frequency and causes of failure to retrieve microcalcifications in nonpalpable lesions, as judged on a radiograph of the specimen, and to determine outcome in patients with those lesions. Informed consent was obtained from each patient prior to biopsy. The institutional review board approved this HIPAA-compliant study and granted a waiver of informed consent. Retrospective review was performed of 1701 consecutive nonpalpable microcalcification lesions in 1511 women aged 29-92 years (median age, 54 years) who underwent percutaneous stereotactic biopsy on a prone biopsy table. Biopsy was successively performed with 14-gauge core, 14-gauge vacuum, and 11-gauge vacuum devices, with mild selection bias, and for each lesion, biopsy was performed with one device. Radiographs of the specimen were obtained to see whether microcalcifications were retrieved. Patient, mammographic, and biopsy variables were correlated with negative radiographs of the specimen. At repeat biopsy or mammographic follow-up, outcome was evaluated in patients with benign histologic results and negative radiographs of the specimen by using Fisher exact test P values. Radiographs of the specimen were negative in 16% (30 of 182) of lesions at 14-gauge core biopsy, in 4% (four of 96) of lesions at 14-gauge vacuum biopsy, and in 1% (19 of 1423) of lesions at 11-gauge vacuum biopsy (P < .001). Substantial bleeding was a significant factor (P < .001) in failure to retrieve microcalcifications at only 11-gauge vacuum biopsy. Histologic results in 53 lesions with negative radiographs of the specimen were malignant (n = 6), indicated atypical hyperplasia (n = 6), or were benign (n = 41). Follow-up in patients with 40 benign lesions was performed with repeat biopsy (n = 17, with malignancy in three lesions) or mammography (n = 23) for 15-128 months (median, 70 months); one patient with one lesion was lost to follow-up. Failure to retrieve microcalcifications was least common with 11-gauge directional vacuum-assisted biopsy and occurred in 1% (19 of 1423) of lesions. Cancer was missed in 8% (three of 40) of benign lesions in patients who were followed up.

Stereotactic vacuum-assisted breast biopsies in 500 women with microcalcifications: radiological and pathological correlations

Aim: We compared radiological assessment with pathological diagnoses in 500 consecutive vacuum-assisted breast biopsies performed for microcalcifications. Methods: Lesions were biopsied using a 11-gauge mammotome device. Before biopsy, microcalcifications were classified according to the Breast Imaging Reporting and Data System (BI-RADS). Histopathological and radiological diagnosis were compared. Results: Histopathology revealed 333 (67%) benign lesions. Benign lesions were classified as BI-RADS 3 in 19%, and as suspicious in 35%. 167 lesions (33%) were malignant. Malignant lesions were classified as suspicious or highly suggestive of malignancy in 63%. Frequency of malignancy in BI-RADS categories 4 and 5 was 35% and 100%, respectively. In BI-RADS 3 microcalcifications, the malignancy frequency was 19%. The mammographic features with the highest positive predictive value for malignancies were pleomorphic morphology (42%) and a linear or segmental distribution (51%). The microcalcification morphology was not reliably able to predict malignancy. Conclusion: In this study, BI-RADS 3 microcalcification lesions had a malignancy rate that is higher than previously reported. Vacuumassisted biopsy is useful in any indeterminate and suspicious microcalcifications and provides maximum information before any operative intervention.

Stereotactic vacuum-assisted breast biopsies in 500 women with microcalcifications: radiological and pathological correlations

Aim: We compared radiological assessment with pathological diagnoses in 500 consecutive vacuum-assisted breast biopsies performed for microcalcifications. Methods: Lesions were biopsied using a 11-gauge mammotome device. Before biopsy, microcalcifications were classified according to the Breast Imaging Reporting and Data System (BI-RADS). Histopathological and radiological diagnosis were compared. Results: Histopathology revealed 333 (67%) benign lesions. Benign lesions were classified as BI-RADS 3 in 19%, and as suspicious in 35%. 167 lesions (33%) were malignant. Malignant lesions were classified as suspicious or highly suggestive of malignancy in 63%. Frequency of malignancy in BI-RADS categories 4 and 5 was 35% and 100%, respectively. In BI-RADS 3 microcalcifications, the malignancy frequency was 19%. The mammographic features with the highest positive predictive value for malignancies were pleomorphic morphology (42%) and a linear or segmental distribution (51%). The microcalcification morphology was not reliably able to predict malignancy. Conclusion: In this study, BI-RADS 3 microcalcification lesions had a malignancy rate that is higher than previously reported. Vacuum-assisted biopsy is useful in any indeterminate and suspicious microcalcifications and provides maximum information before any operative intervention.

A Comparative Study of Breast Cancer of Korean Women according to Age in Radiological, Pathological, and Clinical Findings

Purpose: The incidence of breast cancer is continuously increasing in Korea, and the age of the initially detected breast cancer is younger than western people. The purpose of this study was to compare radiological, pathological, and clinical findings of breast cancers according to age and then contribute to the basis of screening program of breast cancer. Methods: Retrospectively, the 325 patients who had pathologically confirmed breast cancer were included in this study. The patients were classified into 6 groups according to age, 20∼29, 30∼39, 40∼49, 50∼59, 60∼69, and more than 70 years. We evaluated the radiological findings of 325 cases of mammography and 144 cases of breast ultrasonography, classified as four types; mass, microcalcification, others, and non-detected lesion, and then analyzed radiological findings according to age. We evaluated pathological and clinical findings according to age and compared with radiological findings. We used Mantel-Haenszel's χ test and trend test for comparison according to age. Results: The incidence of breast cancer was 61 cases (19%) in 30∼39 years, 122 (38%) in 40∼49 years, 92 (28%) in 50∼59 years. Most of breast cancer was invasive ductal carcinoma, 258 (79%) and in situ carcinoma was 32 (10%). Most of in situ carcinoma was detected in 20∼59 years, 31/32 (97%). Mammography showed mass in 237 (73%), microcalcification in 45 (14%), other finding in 13 (4%), and non-detected lesion in 30 (9%). Twenty-one (47%) of 45 cases with microcalcification were in situ carcinoma and most of in situ carcinoma was presented as microcalcification on mammography, 21/32 (66%). In twenty-eight of 30 cases (93%) with non-detected lesion on mammography, breast cancer was detected on ultrasonography. In terms of clinical findings, there was no symptom in 12/32 (38%) with in situ carcinoma and 57/258 (22%) with invasive ductal carcinoma. Conclusion: The incidence of breast cancer is abruptly increasing from 4th decades and there is no significant difference in radiological and clinical findings according to age. But, most of in situ carcinoma was detected in 20∼59 years and presented as microcalcification on mammography. Thus, Screening mammography should be considered from 4th decades. (Journal of Korean Breast Cancer Society 2002;5:91-101)

CORE IMPRINT CYTOLOGY: A USEFUL METHOD FOR SAME‐DAY REPORTING

INTRODUCTION: Core biopsy of the breast has become the method of choice for tissue diagnosis of screen detected microcalcifications and some mass lesions in many breast assessment centres. Biopsy results are not available until the following day. Imprint cytology of fresh breast core samples allows same‐day reporting and patient counselling.AIM: To determine the accuracy of core imprint cytology when compared with core biopsy diagnosis when used in a breast assessment centre setting.METHODS: Core imprints (CI) were prepared and reported on all fresh core biopsies (CB) performed at the Sir Charles Gairdner Hospital Breast Centre from May to December 2000. Fresh core samples were placed on a glass microscope slide. Core radiographs were taken for microcalcification lesions (MC). A laboratory technician gently and quickly rolled the cores on the slide with fine forceps. The cores were fixed in formalin, processed and reported next day. The imprint slide was air dried and stained with DiffQuik. CI were reported using four categories: Insufficient, Benign, Indeterminate and Malignant. Counselling and planning for management were possible on the same day in women with malignant diagnoses. Clinicians were advised not to discuss negative or indeterminate CI results with women and to defer to the final CB report.RESULTS: Cores were performed on 381 lesions. There were 83 carcinomas (38 in MC and 45 in masses) and 56 were called malignant on CI (absolute sensitivity 67.5%; 78.9% for MC and 57.8% for masses). 3 malignancies on CB were negative on CI giving a false negative rate of 3.6%. There were no false positive diagnoses. The predictive value of a benign diagnosis was 95.3%. There were no adverse effects in the histology of CB.CONCLUSION: CI was an accurate method of providing an immediate diagnosis of malignancy in two thirds of malignancies confirmed on CB.