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Clinical and pathologic characteristics of the invasive ductal carcinoma (IDC) presenting as a thick-walled breast cyst are little known. Three female patients were included in this report. A palpable, nontender breast lump was found in all cases. While mammography showed a hyperdense mass, ultrasonography demonstrated a thick-walled cystic mass. Magnetic resonance imaging clearly showed the cystic breast lesions with ring-like or irregular rim enhancement. A grade III IDC was confirmed in all cases. All IDCs but one were estrogen receptor negative, progesterone receptor negative, and human epidermal growth factor receptor 2 negative, with merely weak progesterone receptor positivity (5%) in one case. All cases underwent surgical management first and postoperative chemotherapy. Breast malignancy presenting as a thick-walled cystic mass could be a highly aggressive IDC, even triple-negative breast cancer. It is imperative for breast cancer-related practitioners to identify the potentially malignant cystic lesions timely and adopt appropriate management., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Complex breast cysts (CBC) are characterized by a high (up to 31.0%) oncological potential and the need for a biopsy. In some clinical situations, navigating a biopsy using mammography (MG), ultrasound (US), endoscopy, and magnetic resonance imaging (MRI) may be difficult. The first case of stereotaxic core-needle biopsy (sCNB) under pneumocystography (PCG) guide is presented.

Galactocele of the breast is a benign condition characterised by milk containing cystic lesions, usually present during pregnancy and lactation. The diagnosis of galactocele is difficult due to physiological changes which occur during pregnancy and lactation. Fine needle aspiration cytology proves to be a simple and minimally invasive procedure in diagnosing and treating this condition. Very rarely, long-standing galactoceles can show crystal formation on aspirate smears, termed as crystallising galactocele. Herein, we present this rare case of crystallising galactocele in a 26-year-old lactating woman. We are reporting this case because of its rarity, as less than 10 cases have been reported so far., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Cysts represent the most common cause of a breast mass in women. On the contrary, in men, the presence of a benign apocrine cyst is an exceedingly rare occurrence, with only a few cases reported in the literature. We describe herein a case of benign apocrine breast cyst without concurrent gynecomastia in a 41-year-old male. Diagnostic evaluation and management are discussed, along with a review of the literature. Given the extreme rarity of benign breast cysts in males, a thorough investigation is essential in male patients presenting with cystic breast lesions. Diagnostic breast imaging may be challenging. Surgical resection of the cyst should be considered in the presence of atypical imaging features to exclude underlying malignancy.

Background Clustered microcysts are common, especially in perimenopausal women, and are seen in up to 6% of US examinations. However, there are limited published data on appropriate assessment and management recommendations for clustered microcysts on breast US images. Purpose To determine outcomes of lesions identified as clustered microcysts on breast US images to help guide appropriate management recommendations. Materials and Methods Lesions classified as clustered microcysts at breast US were retrospectively identified in women at two hospitals (a large tertiary care academic hospital and a National Comprehensive Cancer Network-designated comprehensive cancer center) within one metropolitan health system from 2005 through 2015. If US-guided tissue sampling was performed, results were obtained from the pathology or cytology reports. If sampling was not performed, only lesions with at least 24 months of imaging follow-up or any imaging follow-up with interval resolution or decrease in size were included in the study. Data were evaluated using standard statistics, Fisher exact tests, and Wilcoxon rank sum tests. Results A total of 189 women (median age, 52 years [interquartile range, 46-59 years]) with 196 lesions classified as clustered microcysts on US images were included in this study. During the surveillance period of at least 24 months and at tissue diagnosis, malignancy was not found in any of the 196 lesions (0%) (95% confidence interval: 0.0%, 1.9%). A total of 158 of 196 (80%) lesions were followed with imaging, and 38 of 196 (20%) lesions underwent percutaneous sampling. During the follow-up period, 28 of 158 (18%) lesions spontaneously resolved, 13 of 158 (8%) decreased in size, and one of 158 lesions (0.6%) increased at 18-month follow-up but then became stable. One hundred sixteen of 158 lesions (73%) demonstrated no change at follow-up imaging, 38 of 196 (19%) lesions underwent percutaneous sampling, and 38 of 38 (100%) revealed benign results. Conclusion No malignancies were identified in this series. These results further support the existing literature that lesions characterized as clustered microcysts demonstrate a very low risk of malignancy and can be classified as benign. Biopsy may be safely avoided. © RSNA, 2020 See also the editorial by Berg in this issue.

In recent years, there are several cost-effective intelligent sensing systems such as ultrasound imaging systems for visualizing the internal body structures of the body. Further, such intelligent sensing systems such as ultrasound systems have been deployed by medical doctors around the globe for efficient detection of several diseases and disorders in the human body. Even though the ultrasound sensing system is a useful tool for obtaining the imagery of various body parts, there is always a possibility of inconsistencies in these images due to the variation in the settings of the system parameters. Therefore, in order to overcome such issues, this research devises an SVM-enabled intelligent genetic algorithmic model for choosing the universal features with four distinct settings of the parameters. Subsequently, the distinguishing characteristics of these features are assessed utilizing the Sorensen-Dice coefficient, T-test, and Pearson's R measure. It is apparent from the results of the SVM-enabled intelligent genetic algorithmic model that this approach aids in the effectual selection of universal features for the breast cyst images. In addition, this approach also accomplishes superior accuracy in the classification of the ultrasound image for four distinct settings of the parameters., Competing Interests: The authors declare no conflict of interest.

A cholesteroloma or cholesterol granuloma of the breast is an uncommon lesion representing an inflammatory/reactive process with unclear etiology. In this study, we reviewed our 10-year experience with cholesteroloma of the breast with clinical, radiologic, and histopathological correlation. Seventy-nine cases were selected. The mean patient age was 57.7 (range 25-90) years old. Patients had hypercholesterolemia with mean blood cholesterol level of 201 mg/dL (P < 0.001). The mean body mass index (BMI) was 26.7 kg/m 2 (P = 0.1976). The indications for the breast biopsies were mass lesion on radiology (85.5%, n = 65) and microcalcifications (10.5%, n = 8). Of the 65 cases of the mass lesions, 52 presented as solid masses and 13 were cystic. On the diagnostic mammogram or ultrasound, 81.9% were BI-RADS 4% and 6.9% were BI-RADS 5. Macrocysts were the most common pathological finding associated with cholesteroloma suggesting the etiology of cholesteroloma may be the result of repair process from obstruction and rupture of the macrocysts. Six cases (9.2%) of cholesterolomas had persistent masses during follow-up. The recognition of this lesion and radio-pathological correlation can help us better understand this entity and distinguish it from its mimickers., (© 2019 Wiley Periodicals, Inc.)

In ultrasound examinations, mixed mammary gland masses are divided into either intracystic masses that contain a solid component in the cyst or solid masses that contain a fluid component in the mass. The histological types and subtypes of three complex cystic masses that showed different internal compositions in ultrasound were determined using the ultrasound findings of three patients. Case 1: The mass showed a large cystic component (bleeding) inside and a broad-based solid lesion at the margin in the ultrasound finding. The histological type was encapsulated papillary carcinoma and the subtype was luminal A. Case 2: The mass was lobulated with a small cystic component at the margin. The histological type was solid papillary carcinoma and the subtype was luminal A. Case 3: The mass was lobulated with a circumscribed margin. Cystic components suspected of being hemorrhagic necrosis were observed at the margin and within the solid component. The histological type was squamous cell carcinoma and the subtype was triple negative. Case 2 was a solid mass in appearance, but a cystic component noted at the margin was possibly an intracystic mass. For Case 3, findings suggestive of necrosis were observed both at the margin and in the solid component and this suggested a mass with fluid degeneration. Complex cystic masses are usually examined with a focus on the solid component seen on ultrasound images; however, it is also important to observe the cystic composition. This can help determine the subtypes in addition to the histological types.

Rationale and Objectives: The purpose of this work is to determine if the speed of sound value of a breast cyst can aid in the clinical management of breast masses. Breast macrocysts are defined as fluid-filled tissue masses >1 cm in diameter and are thought to be aberrations of normal development and involution, often associated with apocrine metaplasia. The benign natural history of breast cysts is well known, and it is important to obtain high specificity in breast imaging to avoid unnecessary biopsies in women who have benign diseases, particularly those with dense breast tissue. Transmission ultrasound is a tomographic imaging modality that generates high-resolution, 3D speed of sound maps that could be used to identify breast tissue types and act as a biomarker to differentiate lesions. We performed this study to investigate the microanatomy of macrocysts observed using transmission ultrasound, as well as assess the relationship of speed of sound to the physical and biochemical parameters of cyst fluids., Materials and Methods: Cyst fluid samples were obtained from 37 patients as part of a case-collection study for ultrasound imaging of the breast. The speed of sound of each sample was measured using a quantitative transmission ultrasound scanner in vivo. Electrolytes, protein, cholesterol, viscosity, and specific gravity were also measured (in the aspirated cyst fluid) to assess their relationship to the speed of sound values obtained during breast imaging., Results: We found positive correlations between viscosity and cholesterol (r = 0.71) and viscosity and total protein × cholesterol (r = 0.78). Additionally, we performed direct cell counts on cyst fluids and confirmed a positive correlation of number of cells with speed of sound (r = 0.74). The speed of sound of breast macrocysts, as observed using transmission ultrasound, correlated with the cytological features of intracystic cell clumps., Conclusion: On the basis of our work with speed as a classifier, we propose a spectrum of breast macrocysts from fluid-filled to highly cellular. Our results suggest high-speed cysts are mature macrocysts with high cell counts and many cellular clumps that correlate with cyst microanatomy as seen by transmission ultrasound. Further studies are needed to confirm our findings and to assess the clinical value of speed of sound measurements in breast imaging using transmission ultrasound., (Copyright © 2018 Academic Radiology. Published by Elsevier Inc. All rights reserved.)

A 35-year-old lactating woman with pre-existing polyacrylamide gel (PAAG) implants for 10 years presented on numerous occasions following both her pregnancies with bilateral recurrent breast infection, pain and finally massive breast enlargement with a ruptured galactocoele necessitating surgical intervention. As the safety of PAAG for the breastfeeding baby is not known, breastfeeding with PAAG implants is not recommended., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To analyze the feature of breast complex cystic masses and to classify it at ultrasonography (US), which applied to the Breast Imaging Reporting and Data System (BI-RADS) categories 4a to 4c with pathological results as the golden standards. Methods: The ultrasonographic data and clinical features of 78 patients with complex cystic masses confirmed by pathology in Cancer Hospital from July 2014 to June 2017 were retrospectively reviewed. The complex cystic breast masses were divided into four classes on the basis of their US features: type 1 [thick wall and (or) thick septa (> 0.5 mm)], type 2 (one or more intra-cystic masses), type 3 (mixed cystic and solid components with cystic components more than 50%) and type 4 (mixed cystic and solid components with solid components more than 50%). Positive values (PPVs) were calculated for each type. Multiple linear regression analysis was used to analyze the ultrasonographic features of the masses (lesion size, margins, blood flow resistance index, calcification, and axillary lymph nodes, etc.) with malignant correlation. Results: There were 81 lesions in 78 patients. Among the 81 masses based on US appearance, 14 (17.3%) were classified as type Ⅰ, 18 (22.2%) as type Ⅱ, 18 (22.2%) as type Ⅲ, and 31 (38.3%) as type Ⅳ. The positive predictive values of the malignant lesions of type Ⅰ, type Ⅱ, Ⅲ and Ⅳ were 7.1%, 16.7%, 61.1% and 48.3%, respectively ( P =0.040). In all the 81 masses, 14 were BI-RADS categories 4a, 18 were BI-RADS categories 4b and 49 were BI-RADS categories 4c. Masses with maximum diameter equal to or larger than 2.0 cm, unclear margins, RI≥0.7 and presence of abnormal axillary nodes assessment had a high probability of malignancy ( P =0.030, 0.038, <0.001 and 0.025, respectively). Conclusion: Ultrasound typing is helpful for differentiating benign and malignant breast complex cysts and classifying BI-AIDS 4a to 4c, thus providing clearer treatment for clinical practice.

A high F-FDG uptake was found in mammary lesions in a 36-year-old woman who underwent a PET/CT scan for initial staging of diffuse large B-cell lymphoma. The patient has given birth 2 months ago and was breastfeeding. Ultrasound-guided fine-needle aspiration of 1 lesion yielded creamy liquid consistent with milk and confirmed the diagnosis of galactocele.

Autologous fat grafting is quite common for breast augmentations as well as for reconstructive breast surgery. Coleman has described the surgical technique of fat grafting. Fat is harvested, and after centrifugation and refinement, blunt infiltration cannulas are used to place the fat through small incisions. The grafted tissue is placed in small aliquots with each withdrawal of the cannula. In order to achieve an aesthetically pleasing contour of the breast, the fat should be layered into different levels from the chest wall to the skin. However, autogenous lipotransfer if not performed lege artis might lead to complications such as fat necrosis, calcification, formation of encapsulated fatty masses (cystic lesions), lymphadenopathy, disfigurement of breast contouring, hypersensitive breasts, itchy nipples. A 36-year old female patient, presented with multiple palpable cystic lesions, disrupted breast contouring, asymmetry, hypersensation and pain during examination, 6 months after autologous fat grafting for breast augmentation elsewhere. The patient had ultrasound and MRI screening, which revealed the multiple bilateral cysts formation in the breast tissue. Surgical removal of the large lesions was performed, and specimens were sent for pathology and cytology consideration and screening. A few months after surgical removal of these lesions and after symptoms subsided, breast augmentation was performed with silicone implants. An aesthetically pleasing result together with relief of the patient's initial symptomatology was achieved. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

This study was aimed to evaluatethe usefulness of conventional ultrasound (US) and US elastography, including the latest virtual touch tissue imaging and quantification (VTIQ), in malignancy prediction for complex cystic and solid breast lesions. Eighty-nine complex cystic and solid breast lesions were subject to conventional US and US elastography, including strain elastography (SE), virtual touch tissue imaging (VTI) and VTIQ. Among the 89 lesions, thirty-four (38.2%) lesions were malignant and 55 (61.8%) lesions were benign. Sixteen variables were subject to multivariate logistic regression analysis. Pattern 4b in VTI (odds ratio, OR:15.278), not circumscribed margin of lesion (OR:12.346), SWS mean >4.6 m/s in VTIQ (OR:11.896), and age elder than 50 years (OR:6.303) were identified to be independent predictors for malignancy. In receiver operating characteristic (ROC) curve analyses, associated areas under the ROC curve (Az) for conventional US could be significantly elevated, from 0.649 to 0.918, by combining with US elastography (p < 0.0001). The combined diagnostic method was able to improve the specificity (32.7% vs. 87.3%, p < 0.0001) without sacrificing the sensitivity (97.1% vs. 85.3%, p = 0.075). Both conventional US and US elastography contribute substantially to malignancy prediction in complex cystic and solid lesions. The diagnostic efficacy of conventional US in terms of Az and specificity could be significantly improved by combining with US elastography.

Purpose: It is estimated that 7% of women in the western world will develop palpable breast cysts in their lifetime. Even though cysts have been correlated with risk of developing breast cancer, many of them are benign and do not require follow-up. We develop a method to discriminate benign solitary cysts from malignant masses in digital mammography. We think a system like this can have merit in the clinic as a decision aid or complementary to specialized modalities., Methods: We employ a deep convolutional neural network (CNN) to classify cyst and mass patches. Deep CNNs have been shown to be powerful classifiers, but need a large amount of training data for which medical problems are often difficult to come by. The key contribution of this paper is that we show good performance can be obtained on a small dataset by pretraining the network on a large dataset of a related task. We subsequently investigate the following: (a) when a mammographic exam is performed, two different views of the same breast are recorded. We investigate the merit of combining the output of the classifier from these two views. (b) We evaluate the importance of the resolution of the patches fed to the network. (c) A method dubbed tissue augmentation is subsequently employed, where we extract normal tissue from normal patches and superimpose this onto the actual samples aiming for a classifier invariant to occluding tissue. (d) We combine the representation extracted using the deep CNN with our previously developed features., Results: We show that using the proposed deep learning method, an area under the ROC curve (AUC) value of 0.80 can be obtained on a set of benign solitary cysts and malignant mass findings recalled in screening. We find that it works significantly better than our previously developed approach by comparing the AUC of the ROC using bootstrapping. By combining views, the results can be further improved, though this difference was not found to be significant. We find no significant difference between using a resolution of 100 versus 200 micron. The proposed tissue augmentations give a small improvement in performance, but this improvement was also not found to be significant. The final system obtained an AUC of 0.80 with 95% confidence interval [0.78, 0.83], calculated using bootstrapping. The system works best for lesions larger than 27 mm where it obtains an AUC value of 0.87., Conclusion: We have presented a computer-aided diagnosis (CADx) method to discriminate cysts from solid lesion in mammography using features from a deep CNN trained on a large set of mass candidates, obtaining an AUC of 0.80 on a set of diagnostic exams recalled from screening. We believe the system shows great potential and comes close to the performance of recently developed spectral mammography. We think the system can be further improved when more data and computational power becomes available., (© 2017 American Association of Physicists in Medicine.)

Objectives: Round lesions are a common mammographic finding, which can contribute more than 20% of overall recalls at screening. Discrimination of cystic fluid from solid tissue by spectral x-ray imaging has been demonstrated in specimen experiments. This work translates these results into a clinical pilot study to investigate the feasibility of discriminating cystic from solid lesions using spectral mammography., Materials and Methods: Women undergoing mammography as part of their routine diagnostic workup were consented for analysis of spectral information obtained from a photon-counting mammography system. Images were analyzed retrospectively after diagnosis was confirmed with ultrasound and pathology. Well-defined solitary lesions were delineated independently by 3 expert radiologists. A breast lesion model is generated from the spectral mammography data using the energy-dependent x-ray attenuation of cyst fluid, carcinoma, and adipose and glandular tissue. From the breast lesion model, 2 spectral features are computed and combined in a 2-feature discrimination algorithm, which is evaluated in an analysis of the receiver operating characteristic curve for the task of identifying solid lesions ("positive result"). Expected outcomes on a screening population are extrapolated from this pilot study by cross-validation with bootstrapping using a 95% confidence interval (CI)., Results: The 2-feature discrimination algorithm was evaluated on the set of 119 eligible lesions (62 solids, 57 cysts) of diameter greater than 10 mm. The area under the receiver operating characteristic curve (AUC) was 0.88 with a specificity of 61% at the 99% sensitivity level on average over all expert radiologists. Cross-validation with bootstrapping of the clinical data revealed an AUC of 0.89 (95% CI, 0.79-0.96) and a specificity of 56% (95% CI, 33%-78%) when operating the algorithm at the 99% sensitivity level., Conclusions: Discriminating cystic from solid lesions with spectral mammography demonstrates promising results with the potential to reduce mammographic recalls. It is estimated that for each missed cancer at least 625 cystic lesions would have been correctly identified and hence would not have been needed to be recalled. Our results justify undertaking a larger reader study to refine the algorithm and determine clinically relevant thresholds to allow safe classification of cystic lesions by spectral mammography.

Purpose: We aimed to evaluate the effectiveness of single-session ultrasound-guided percutaneous ethanol sclerotherapy in simple breast cysts., Methods: From January 2002 to January 2014, 35 simple breast cysts (mean volume, 8.2 mL; range, 4-33 mL) in 28 females (mean age, 39 years) were evaluated. In a single session, all cysts were aspirated using 20G needles, refilled with 99% ethanol (90% of the volume of the aspirated fluid), and reaspirated completely after 10 minutes of exposure under ultrasound guidance. Follow-up ultrasonography examinations were performed at one week, one month, three months, and six months for all patients and 12 months, 18 months, and 24 months for available patients. Follow- up duration varied between 6 and 24 months (mean, 15 months)., Results: The technical success rate of ultrasound-guided percutaneous etha-nol sclerotherapy was 97%. The needle tip was dislocated and ethanol was given into the breast parenchyma in one patient (3%). One cyst (3%) was reaspirated at the first week follow-up due to intracystic hemorrhage. Of the 34 cysts treated, 25 (74%) completely responded to therapy and were no longer detectable on follow-up examinations. Eight cysts (24%) significantly decreased in size and then completely disappeared at six months. At the end of the follow-up period, the clinical success rate reached 100%, and none of the cysts were visible. Except mild to moderate sensation of burning or pain which disappeared or subsided significantly in a couple of minutes, no other complications were observed in patients., Conclusion: Ultrasound-guided ethanol sclerotherapy is a fast, safe, and highly effective method in the treatment of simple breast cysts.

Objective The objective of this study is to assess whether the largest cyst diameter is useful for BI-RADS ultrasonography classification of predominantly solid breast masses with an oval shape, circumscribed margins, and largest axis parallel to the skin, which, except for the cystic component, would be likely classified as benign. Methods This study received approval from the local institutional review board. From March 2009 to August 2014, we prospectively biopsied 170 breast masses from 164 women. We grouped the largest cyst and mass diameters according to histopathological diagnoses. We used Student's t-test, linear regression, and the area under the receiver operating characteristic curve (AUC) for statistical assessment. Results Histopathological examination revealed 143 (84%) benign and 27 (16%) malignant masses. The mean largest mass diameter was larger among malignant (mean ± standard deviation, 34.1 ± 16.6 mm) than benign masses (24.7 ± 16.7 mm) (P < 0.008). The mean largest cyst diameter was also larger among malignant (9.9 ± 7.1 mm) than benign masses (4.6 ± 3.6 mm) (P < 0.001). Agreement between measurements of the largest mass and cyst diameters was low (R(2) = 0.26). AUC for the largest cyst diameter (0.78) was similar to the AUC for the largest mass diameter (0.69) (p = 0.2). A largest cyst diameter < 3, ≥ 3 to < 11, and ≥ 11 mm had a positive predictive value of 0, 15, and 52%, respectively. Conclusion A largest cystic component < 3 mm identified within breast masses that show favorable characteristics may be considered clinically inconsequential in ultrasonography characterization. Conversely, masses with a largest cystic component ≥ 3 mm should be classified as BI-RADS-US category 4., (Thieme Publicações Ltda Rio de Janeiro, Brazil.)

Objectives: To estimate the impact on recall rate (RR) of digital breast tomosynthesis (DBT) associated with digital mammography (DM+DBT), compared to DM alone, evaluate the impact of double reading (DR) and review the literature., Methods: Ethics committees approved this multicenter study. Patients gave informed consent. Women recalled from population-based screening reading were included. Reference standard was histology and/or ≥ 1 year follow up. Negative multiple assessment was considered for patients lost at follow up. Two blinded readers (R1, R2) evaluated first DM and subsequently DM+DBT. RR, sensitivity, specificity, accuracy, positive and negative predictive values (PPV, NPV), were calculated for R1, R2, and DR. Cohen κ and χ(2) were used for R1-R2 agreement and RR related to breast density., Results: We included 280 cases (41 malignancies, 66 benign lesions, and 173 negative examinations). The RR reduction was 43% (R1), 58% (R2), 43% (DR). Sensitivity, specificity, accuracy, PPV and NPV were: 93%, 67%, 71%, 33%, 98% for R1; 88%, 73%, 75%, 36%, 97% for R2; 98%, 55%, 61%, 27%, 99% for DR. The agreement was higher for DM+DBT (κ=0.459 versus κ=0.234). Reduction in RR was independent from breast density (p=0.992)., Conclusion: DBT was confirmed to reduce RR, as shown by 13 of 15 previous studies (reported reduction 6-82%, median 31%). This reduction is confirmed when using DR. DBT allows an increased inter-reader agreement., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

The study described here sought to identify specific ultrasound (US) automated breast volume scanning (ABVS) features that distinguish benign from malignant lesions. Medical records of 750 patients with 792 breast lesions were retrospectively reviewed. Of the 750 patients, 101 with 122 cystic lesions were included in this study, and the results ABVS results were compared with biopsy pathology results. These lesions were classified into six categories based on ABVS sonographic features: type I = simple cyst; type II = clustered cyst; type III = cystic masses with thin septa; type IV = complex cyst; type V = predominantly cystic masses; and type VI = predominantly solid masses. Comparisons were conducted between the ABVS coronal plane features of the lesions and histopathology results, and the positive predictive value (PPV) was calculated for each feature. Of the 122 lesions, 90 (73.8%) were classified as benign, and 32 (26.2%) were classified as malignant. The sensitivity, specificity and accuracy associated with ABVS features for cystic lesions were 78.1%, 74.4% and 75.4%, respectively. The 11 cases (8.9%) of type I-IV cysts were all benign. Of the 22 (18.0%) type V cysts, 16 (13.1%) were benign and 6 (4.9%) were malignant. Of the 89 (72.9%) type VI cysts, 63 (51.7%) were benign and 26 (21.3%) were malignant. The typical symptoms of malignancy on ABVS include retraction (PPV = 100%, p < 0.05), hyper-echoic halos (PPV = 85.7%, p < 0.05), microcalcification (PPV = 66.7%, p < 0.05), thick walls or thick septa (PPV = 62.5%, p < 0.05), irregular shape (PPV: 51.2%, p < 0.05), indistinct margin (PPV: 48.6%, p < 0.05) and predominantly solid masses with eccentric cystic foci (PPV = 46.8%, p < 0.05). ABVS can reveal sonographic features of the lesions along the coronal plane, which may be of benefit in the detection of malignant, predominantly cystic masses and provide high clinical values., (Copyright © 2016 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Rationale and Objectives: To compare the performance of two shortened breast magnetic resonance imaging (MRI) protocols to a standard MRI protocol for breast cancer screening., Materials and Methods: In this Health Insurance Portability and Accountability Act compliant, institutional review board-approved pilot study, three fellowship-trained breast imagers evaluated 48 breast MRIs (24 normal, 12 benign, and 12 malignant) selected from a high-risk screening population. MRIs were presented in three viewing protocols, and a final Breast Imaging-Reporting and Data System assessment was recorded for each case. The first shortened protocol (abbreviated 1) included only fat-saturated precontrast T2-weighted, precontrast T1-weighted, and first pass T1-weighted postcontrast sequences. The second shortened protocol (abbreviated 2) included the abbreviated 1 protocol plus the second pass T1-weighted postcontrast sequence. The third protocol (full), reviewed after a 1-month waiting period, included a nonfat-saturated T1-weighted sequence, fat-saturated T2-weighted, precontrast T1-weighted, and three or four dynamic postcontrast sequences. Interpretation times were recorded for the abbreviated 1 and full protocols. Sensitivity and specificity were compared via a chi-squared analysis. This pilot study was designed to detect a 10% difference in sensitivity with a power of 0.8., Results: There was no significant difference in sensitivity between the abbreviated 1 (86%; P = .22) or abbreviated 2 (89%; P = .38) protocols and the full protocol (95%). There was no significant difference in specificity between the abbreviated 1 (52%; P = 1) or abbreviated 2 (45%; P = .34) protocols and the full protocol (52%). The abbreviated 1 and full protocol interpretation times were similar (2.98 vs. 3.56 minutes)., Conclusions: In this pilot study, reader performance comparing two shortened breast MRI protocols to a standard protocol in a screening cohort were similar, suggesting that a shortened breast MRI protocol may be clinically useful, warranting further investigation., (Copyright © 2015 AUR. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the change over mammographic diagnosis, BI-RADS category and management following targeted ultrasound of an indeterminate lesion seen on mammography and associated factors, if any., Study Design: Descriptive, analytical study., Place and Duration of Study: Radiology Department, The Aga Khan University Hospital and Clifton Medical Services, Karachi, from April 2010 to May 2011., Methodology: Patients referred for targeted breast ultrasound following X-ray mammography were selected regardless of age. Targeted Ultrasound (TUS) was defined as a limited ultrasound of a specific lesion or breast part as indicated by the referring source. Comparison was made between the post mammography and post TUS lesion characterization, diagnosis and BI-RADS category (0-5) which was taken as a measure of management change. Those were evaluated to determine significance of age, marital status, parity, breast parenchymal pattern ( dense, fatty, heterogeneous), referring source for the TUS (radiology resident, radiologist or surgeon), lesion characteristics (density, echogenecity, shape, location, margins, size, depth-to-width ratio, enhancement or shadowing), presenting symptoms or signs and reason for TUS. Ap-value of 0.05 or less was taken as significant., Results: There were a total of 342 patients with mean age of 49.7 ±13.5 years. It assigned a definite category in 232 patients with an indefinite category (0) on mammography requiring further investigation. It decreased the suspicion for malignancy in 180 (77.58%) by assigning a low BI-RADS category and increased the suspicion in 52 (22.41%). The factors significantly associated with this changes included clinical indication being diagnostic (p < 0.001), lesion characteristics on imaging (p < 0.001), heterogenous breast parenchymal pattern (p < 0.001) and presence of known risk factors (p=0.049)., Conclusion: TUS served as a problem solving tool in the evaluation and management of an indeterminate breast lesion in a high number of patients, particularly when there was a lump as indication for imaging in the presence of risk factors in a patient with otherwise heterogeneously dense breast parenchyma.

Background: Macrolane is a stabilized, hyaluronic acid-based gel that has been available since 2007 as a minimally invasive, nonpermanent option for breast enhancement. However, numerous controversies pertaining to its side effects have highlighted the need for studies involving larger groups of patients., Objectives: The authors sought to determine complications of Macrolane injections for breast enhancement and performed surgical evacuation of cysts comprising collections of hyaluronic acid in patients who previously received Macrolane treatment and presented for augmentation mammaplasty., Methods: The authors reviewed a case series of 20 patients who were treated elsewhere with intramammary injection of Macrolane for cosmetic purposes and who presented at the authors' medical studio with multiple intramammary and intramuscular cysts. All patients underwent surgical evacuation of the hyaluronic acid-based cysts in association with augmentation mammaplasty., Results: Good aesthetic results were achieved in all patients. Three months after surgery, 15 of 20 (75%) patients rated themselves as very much improved; 4 patients (20%) rated themselves as moderately improved, and 1 patient (5%) rated herself as somewhat improved., Conclusions: The authors suggest that Macrolane cannot be considered a valid alternative for breast augmentation at this time., Level of Evidence: 4 Therapeutic., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Cystic breast lesions are caused by a wide spectrum of breast diseases and can range from simple cysts to malignant tumors. Ultrasonography is a good tool for evaluation of the morphology and vascularity of cystic breast lesions. We report three patients in whom contrast-enhanced ultrasonography (CEUS) was used to evaluate intracystic tumors. One of the three patients was diagnosed with intracystic papilloma. Compared with conventional ultrasonography alone, CEUS more clearly demonstrated that the solid component within the mass was lobulated with a narrow base. The other two patients were diagnosed with intracystic papillary carcinoma, and CEUS clearly revealed the presence of widely elevated solid components within both masses, suggesting malignancy. Therefore, CEUS simplified morphological evaluation by enhancing the solid components within the cystic masses.

Purpose: Digital breast tomosynthesis (DBT) offers poor image quality along the depth direction. This paper presents a new method that improves the image quality of DBT considerably through the a priori information from automated ultrasound (AUS) images., Methods: DBT and AUS images of a complex breast-mimicking phantom are acquired by a DBT/AUS dual-modality system. The AUS images are taken in the same geometry as the DBT images and the gradient information of the in-slice AUS images is adopted into the new loss functional during the DBT reconstruction process. The additional data allow for new iterative equations through solving the optimization problem utilizing the gradient descent method. Both visual comparison and quantitative analysis are employed to evaluate the improvement on DBT images. Normalized line profiles of lesions are obtained to compare the edges of the DBT and AUS-corrected DBT images. Additionally, image quality metrics such as signal difference to noise ratio (SDNR) and artifact spread function (ASF) are calculated to quantify the effectiveness of the proposed method., Results: In traditional DBT image reconstructions, serious artifacts can be found along the depth direction (Z direction), resulting in the blurring of lesion edges in the off-focus planes parallel to the detector. However, by applying the proposed method, the quality of the reconstructed DBT images is greatly improved. Visually, the AUS-corrected DBT images have much clearer borders in both in-focus and off-focus planes, fewer Z direction artifacts and reduced overlapping effect compared to the conventional DBT images. Quantitatively, the corrected DBT images have better ASF, indicating a great reduction in Z direction artifacts as well as better Z resolution. The sharper line profiles along the Y direction show enhancement on the edges. Besides, noise is also reduced, evidenced by the obviously improved SDNR values., Conclusions: The proposed method provides great improvement on the quality of DBT images. This improvement makes it easier to locate and to distinguish a lesion, which may help improve the accuracy of the diagnosis using DBT imaging.

Background: Cytology for breast lesions is a safe, rapid and cost-effective with a high specificity and sensitivity., Objective: To determine the cytomorphologic patterns of breast lesions identified among a group of Sudanese patients., Materials and Methods: This study included 759 patients undergoing either a fine needle aspiration FNA, nipple discharge (ND) smears or breast skin scraping (SS) at a cytology clinic in Khartoum. Clinical and demographic data were reviewed. Stained smears were categorized into: inadequate sample, normal breast, benign lesion, suspicious, or malignant neoplasm., Results: of the 759 cases, 734 (96.71%) were FNA, 18 (2.37%) ND and 7 cases (0.92%) SS. For 28 cases, FNA was done under ultrasound guidance. Females were 720 (94.86%). Benign lesions were 423(55.75%) and 248 (32.67%) were malignant and 77 (10.14%) of smears were normal without any detected abnormality. Ten (1.31%) cases were suspicious for malignancy, and only one case (0.13%) was reported as inadequate. Most lesions were observed among the age group 30 years and above., Conclusion: Most patients investigated have benign lesions, one third of cytological smears were malignant. FNAC is a useful tool for investigating breast lesions in limited-resource settings.

There were examined 567 women, in whom inflammatory changes of mammary glands (MG), not connected with a child borning, were revealed. There was established, that "nonlactational mastitis" of various structure: the cyst--in 36.5% of observations, periductal mastitis--in 32.1%, abscess--11.3%, purulent galactophoritis--12.9%, mastitis-like mammary gland cancer--7.2%. In the diagnosis of inflammatory changes of MG the ultrasonographic investigation is the main, which permit to determine the disease, to study the abscesses topography, to control miniinvasive diagnostic-treatment interventions, in cluding, for abscess and cyst. Purulent-inflammatory processes in MG while extralactational period demand individual differentiated treatment-diagnostic approach regarding khowledge of ultrasonographic (echographic) semiotics of pathological process.

A lactating woman in her early 40s with a strong family history of breast cancer presented with a markedly swollen breast days after having a vacuum-assisted core biopsy performed to sample indeterminate microcalcifications in her left breast. Ultrasound showed a large peri-implant fluid collection which yielded milky fluid on aspiration consistent with galactocele formation. Histology of the core specimens revealed a fragment of fibrous capsule suggesting that the core biopsy had created a fistula between the breast tissue and the peri-implant space. Bromocriptine was given and the galactocele slowly resolved.

A 38-year-old woman presented for evaluation of a firm mass (measuring 20 × 20 mm) in the upper outer quadrant of her left breast. On the basis of the clinical and radiologic findings, we diagnosed a benign breast tumor and scheduled removal by a hand-held vacuum-assisted biopsy device (VABD) under ultrasonographic guidance. Because the first specimen removed from the tumor was white, flaky, and waxy material, we strongly suspected that the lesion was an epidermal cyst. We continued VABD treatment until the tumor was invisible on real-time ultrasonography. Histologic examination demonstrated that the tumor was composed of mature stratified squamous epithelium and laminated layers of keratin, findings consistent with a diagnosis of epidermal cyst. These cysts rarely occur in the breast and are sometimes difficult to distinguish from breast cancer. To our knowledge, this is the first report of an epidermal cyst treated by VABD.

Purpose: The vacuum biopsy of the breast under sonographic guidance (VB) was introduced in Germany in the year 2000 and the first consensus recommendations were published by Krainick-Strobel et al. in 2005. Since then, many clinical studies on this technique have been published. The purpose of this publication is to update the consensus recommendations from 2005 regarding the latest literature., Materials and Methods: The consensus statements were the result of two preliminary meetings after the review of the latest literature by members of the Minimally Invasive Breast Intervention Study Group from the German Society of Senology. The final consensus text was review by all members of the working group. The statements listed under results obtained complete acceptance (consensus 100 %)., Results: The consensus recommendations describe the indications, investigator qualifications, technical requirements, documentation, quality assurance and follow-up intervals regarding the latest literature., Conclusion: The VB is a safe method for extracting breast tissue for histological workup. The technique allows the resection of breast tissue up to 8 cm3. Besides the diagnostic indications, the method qualifies for a therapeutic resection of symptomatic benign lesions (e. g. fibroadenomas). The technique should be used in specialized breast centers working in a multidisciplinary setup. This paper is an expert's recommendation for the use of VB under sonographic guidance. It is not formulated as a nationwide guideline., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To study the prevalence of breast cysts in several age groups of the general female population and their association with the MspAI polymorphism of the gene CYP17., Results: In 204 ultrasound tests, cysts were present in 22% of the studied population. The epidemiological-clinical profile of these women was Caucasian, aged 41-50 years, regular menstrual cycles, multiparous and complaining of mastalgia. The genetic distribution of polymorphisms of the gene displayed Hardy-Weinberg equilibrium and the wild homozygous phenotype was observed in 36.4% of the case group and in 37.6% of the control groups; the heterozygous phenotype was observed in 50% of the study group and 46.3% of control group and a mutated homozygous phenotype was seen in 13.6% of the study group and 16.1% of the controls. There was no statistically significant difference between the groups (p = 0.92)., Conclusion: The prevalence and most of the epidemiological profile of breast cysts were in agreement with the literature. There was no statistically significant difference among the genotypic groups (wild homozygous, heterozygous and mutated homozygous), despite a slightly increased frequency of the mutated genotype in the control group. This difference indicates a trend of the MspAI polymorphism of the gene CYP17 to act as a protective factor against the development of breast cysts.

Ultrasonic Nakagami images can complement conventional B-mode images for scatterer characterization. White noise in anechoic areas leads to artifacts that affect the Nakagami image to characterize tissues. Artifact removal requires rejection of the white noise without deforming the backscattered waveform. This study proposes a noise-assisted correlation algorithm (NCA) and carries out simulations, phantom experiments, and clinical measurements to validate its feasibility and practicality. The simulation results show that the NCA can reject white noise in an anechoic area without any deformation of the backscattered waveforms. The results obtained from phantoms and tissues further demonstrate that the proposed NCA can suppress a Nakagami image artifact without changing the texture of the Nakagami image of the scattering background. The NCA is an essential algorithm to construct artifact-free Nakagami image for correctly reflecting scatterer properties of biological tissues.

Recent published results in inverse scattering generally show the difficulty in dealing with moderate to high contrast inhomogeneities when employing linearized or iteratively linearized algorithms (e.g., distorted Born iterative method). This paper presents a fully nonlinear algorithm utilizing full wave field data, that results in ultrasound computed tomographic images from a laboratory breast scanner, and shows several such unique images from volunteer subjects. The forward problem, data collection process and inverse scattering algorithm used are discussed. A functional that represents the "best fit" between predicted and measured data is minimized, and therefore requires a very fast forward problem solver, Jacobian calculation, and gradient estimation, all of which are described. The data collection device is described. The algorithm and device yield quantitative estimates of human breast tissue in vivo. Several high resolution images, measuring ∼150 by 150 wavelengths, obtained from the 2D inverse scattering algorithms, using data collected from a first prototype, are shown and discussed. The quantitative values are compared with previous published work.

Background and Purpose: Simple breast cysts are a common sonographic finding and do not require further diagnostic evaluation. In contrast, atypical breast cysts do harbour a risk of malignancy. The purpose of this study was to evaluate the predictive value of sonographic findings that are considered characteristic of malignant atypical cyst-like lesions., Patients and Methods: Six descriptive sonographic criteria of 202 atypical cysts in 176 women were compared with histopathological findings after surgical excision and their statistical association was evaluated., Results: Of these six criteria thick cyst wall (p < 0.0001), lobulation (p = 0.0001) and hyperechogenicity (p = 0.003) were found to be highly predictive of breast cancer. The presence of two or more sonographic criteria was associated with a 10.3 times greater risk of malignancy (p < 0.0001)., Conclusion: The association between suspicious sonographic criteria and histology after surgery was evaluated. We propose surgical excision when two or more sonographic criteria are diagnosed in a single atypical breast cyst., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Purpose: The purpose of this retrospective study was to calculate the positive predictive value (PPV) of sonographic Breast Imaging Reporting and Data System (BI-RADS) categories 3, 4, and 5 in different age groups to investigate whether age influences the PPV of the BI-RADS category in breast ultrasound., Materials and Methods: From our sonography-guided core biopsy database of breasts between 2006 and 2008, we identified 2817 BI-RADS category 3, 4, and 5 lesions with known pathological diagnosis in 2587 women, all of whom underwent the earlier breast assessment via ultrasound with a sonographic BI-RADS lexicon and later sonography-guided core biopsy. All lesions were classified into three age groups (< 45, 45 - 59, and > 59 years). The age-related PPVs of each BI-RADS category among three age groups were calculated on the basis of pathological diagnoses and were compared using a χ(2)-test., Results: The overall PPV of each BI-RADS category was 2.2 % in category 3, 6.5 % in category 4a, 35.2 % in category 4b, 79.6 % in category 4c, and 99.6 % in category 5. The age-related PPVs of category 3 varied significantly among the three age groups (0.9 % versus 3.9 % versus 2.0 % p = 0.048), and notably, the age-related PPV in group 2 was higher than the others. Additionally, there was a significant positive association between the age-related PPVs and increasing age in categories 4a and 4b (4a, p < 0.0001 and 4b, p = 0.0139), but not in categories 4c and 5 (4c, p = 0.1853 and 5, p = 0.2871)., Conclusion: The incidence of female breast cancer differs not only in different sonographic BI-RADS categories, but also in different age groups. Therefore, more attention should be paid to the special age group that we found for sonographic BI-RADS categories 3, 4a, and 4b., (© Georg Thieme Verlag KG Stuttgart · New York.)

A woman of fertile age who had been suffering from agalactorrhoea since undergoing reductive mastoplasty was referred to us for forensic evaluation. As the impairment rating criteria listed within the main Italian assessment guidelines did not provide us with any helpful clues, we turned our attention to a selection of French, Spanish and Portuguese rating tables either legally binding or merely indicative in nature, to the barème (table) formulated by the CEREDOC (Confédération Européenne d'Experts en Evaluation et Réparation du Dommage Corporel) and to the American Medical Association guidelines, the only ones contemplating rating criteria specific for agalactorrhoea with an impairment score range of 0-5 percentage points. In light of the woman's young age and in subsequent consideration of the implications agalactorrhoea typically has both for nursing mothers and for their newborn babies, we estimated her physical impairment at five percentage points.

Purpose: This prospective study evaluates whether sonoelastography can improve B-mode ultrasonographic sizing of breast tumors. Precise measuring is important for effective therapy planning for breast cancer patients., Materials and Methods: The size of 100 surgically excised breast lesions (92 patients: 77 malignant, 23 benign) was compared to preoperative measurements. Lesions were imaged with both ultrasonographic techniques in identical planes. The largest sizes measured with each modality were compared to the largest histopathological measurements. The interobserver variability was also computed from measurements made by two examiners assessing identical planes., Results: Both ultrasonographic measuring techniques underestimate lesion size. The sonoelastography measurements were within ± 5 mm of the histological size in 70.1 % of malignant lesions, and the B-mode measurements in 57.1 % of cases. Sonoelastography leads to more accurate measurements of 13.0 % of cases (statistically not significant). A total of 22 lesions were also imaged by a second examiner. Sonoelastography had 27.3 % less interobserver variability (examiners agreed in 36.4 % of sonoelastography and in 9.1 % of B-mode results)., Conclusion: In this study there is no significant advantage of sonoelastography, although a tendency is apparent. The low interobserver variability also favors sonoelastography for preoperative diagnostics, since it may be less dependent on the observer than conventional B-mode imaging. The results of this prospective study require validation in a prospective multicenter study with larger case numbers., (© Georg Thieme Verlag KG Stuttgart · New York.)