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Objective To compare cancer detection rate (CDR), patient recall, and interpretation time of a full protocol MRI (fpMRI) to an abbreviated MRI protocol (abMRI) in high-risk women. Methods This retrospective study was approved by the IRB. All sequential high-risk screening MRI examinations performed between January 1, 2013, and December 31, 2016, were included. Breast radiologists reviewed patient history, prior images, and abMRI images and recorded their interpretation. Time for interpretation reflected review of the MRI study but not dictation or report generation. Following a minimum 30-day washout period, radiologists interpreted the fpMRI, with interpretation and timing recorded. Data collected included CDR, interpretation time, and patient recall rate. Statistical analyses utilized were Cohen’s kappa coefficient, Student’s t-test, and McNemar’s test. Results Included were 334 MRI examinations of 286 women. Interpretation time was 60.7 seconds for the abMRI compared to 99.4 seconds for the fpMRI, with an average difference of 38.7 ± 5.4 seconds per patient (P < 0.0001). Recall rates were comparable: the abMRI recall rate was 82/334 (24.6%) and the fpMRI 81/334 (24.3%). All five cancers included were detected by both protocols with equal recall rate. However, there were more recommendations for biopsy with the fpMRI, although this difference was not statistically significant. Conclusion The abMRI demonstrated comparable CDR to fpMRI, with shortened interpretation time and similar recall rates. Implementing an abMRI to screen high-risk women reduces imaging and interpretation time, thereby improving cost-effectiveness and the patient experience without reduction in cancer detection.

The purpose of this study was to evaluate our initial experience with gamma imaging-guided vacuum-assisted breast biopsy in women with abnormal findings.A retrospective review of patients undergoing breast-specific gamma imaging (BSGI), also known as molecular breast imaging (MBI), between April 2011 and October 2015 found 117 nonpalpable mammographically and sonographically occult lesions for which gamma imaging-guided biopsies were recommended. Biopsy was performed with a 9-gauge vacuum-assisted device with subsequent placement of a titanium biopsy site marker. Medical records and pathologic findings were evaluated.Of the 117 biopsies recommended, 104 were successful and 13 were canceled. Of the 104 performed biopsies, 32 (30.8%) had abnormal pathologic findings. Of those 32 biopsies, nine (28.1%) found invasive cancers, six (18.8%) found ductal carcinoma in situ (DCIS), and 17 (53.1%) found high-risk lesions. Of the 17 high-risk lesions, there were three (17.6%) lobular carcinomas in situ, five (29.4%) atypical ductal hyperplasias, two (11.8%) atypical lobular hyperplasias, one (5.9%) flat epithelial atypia, and six (35.3%) papillomas. Two cases of atypical ductal hyperplasia were upgraded to DCIS at surgery. The overall cancer detection rate for gamma imaging-guided biopsy was 16.3%. In this study, gamma imaging-guided biopsy had a positive predictive value of total successful biopsies of 16.3% for cancer and 30.8% for cancer and high-risk lesions.Gamma imaging-guided biopsy is a viable approach to sampling BSGI-MBI-detected lesions without sonographic or mammographic correlate. Our results compare favorably to those reported for MRI-guided biopsy.

Purpose The aim of this study was to assess variability in radiologist-patient communication practices and barriers to communication among members of the Society of Breast Imaging (SBI). Methods A 36-item questionnaire developed by the SBI Patient Care and Delivery Task Force was distributed electronically to SBI members to evaluate patient communication, education, and screening practices. Data from 14 items investigating patient communication (eg, practices, comfort, barriers to communication) were analyzed and compared with demographic variables using χ2 or independent t tests as appropriate. Results Ninety-three percent of radiologists reported that they directly communicate abnormal results of diagnostic mammographic examinations that require biopsy and malignant or high-risk biopsy results that require surgery. Radiologists (66%) and technologists (57%) often provide normal or negative diagnostic mammographic results. Most respondents were completely comfortable discussing the need for additional imaging, recommending biopsy, and discussing biopsy results directly with patients, and 71% rated their communication skills as excellent. Radiologists who spend less time in breast imaging reported only average communication skills. The most frequent barriers to communication were that practices were not set up for direct communication (loss of revenue) and discomfort with angry patients. Conclusions Although variation in breast imaging communication practices exists among radiologists and practice types, the majority of radiologists directly communicate the most distressing results to patients, such as those regarding abnormal diagnostic mammographic findings requiring biopsies and abnormal biopsy results leading to cancer diagnoses and surgery. The majority of radiologists are completely comfortable with these conversations, but all feel that enhancing communication with patients will lead to greater patient satisfaction.

Breast-specific γ-imaging (BSGI) is a physiologic imaging modality that can detect subcentimeter and mammographically occult breast cancer, with a sensitivity and specificity comparable to MRI. The purpose of this study was to determine the incremental increase in breast cancer detection when BSGI is used as an adjunct to mammography in women at increased risk for breast cancer. Methods All patients undergoing BSGI from April 2010 through January 2014 were retrospectively reviewed. Eligible patients were identified as women at increased risk for breast cancer and whose most recent mammogram was benign. Examinations exhibiting focally increased radiotracer uptake were considered positive. Incremental increase in cancer detection was calculated as the percentage of mammographically occult BSGI-detected breast cancer and the number of mammographically occult breast cancers detected per 1,000 women screened. Results Included in this study were 849 patients in whom 14 BSGI examinations detected mammographically occult breast cancer. Patients ranged in age from 26 to 83 y, with a mean age of 57 y. Eleven of 14 cancers were detected in women with dense breasts. The addition of BSGI to the annual breast screen of asymptomatic women at increased risk for breast cancer yields 16.5 cancers per 1,000 women screened. When high-risk lesions and cancers were combined, BSGI detected 33.0 high-risk lesions and cancers per 1,000 women screened. Conclusion BSGI is a reliable adjunct modality to screening mammography that increases breast cancer detection by 1.7% (14/849) in women at increased risk for breast cancer, comparable to results reported for breast MRI. BSGI is beneficial in breast cancer detection in women at increased risk, particularly in those with dense breasts.

The purpose of this study was to determine the sensitivity of breast-specific gamma imaging (BSGI) in the detection of invasive breast cancers and to characterise the sensitivity of BSGI based on tumour size and pathological grade.139 females with invasive carcinoma who underwent BSGI were retrospectively reviewed. Patients were injected in the antecubital vein with 20-30 mCi (925-1110 MBq) of (99m)Tc-sestamibi. Images were obtained with a high-resolution, breast-specific gamma camera (Dilon 6800; Dilon Technologies, Newport News, VA) and were categorised based on radiotracer uptake as normal, normal with heterogeneous uptake, probably abnormal and abnormal. For a positive examination, the region of the area of increased uptake had to correlate with the laterality and location of the biopsy-proven cancer.149 invasive cancers in 139 patients with a mean size of 1.8 cm (0.2-8.5 cm) were included. 146 were identified with BSGI (98.0%). All cancers which measured ≥ 0.7 cm (n = 123) as well as all cancers grade 2 or higher (n = 102), regardless of tumour size, were identified with BSGI (100%). There were 6 cancers that were pathological grade 1 and measured7 mm, of which 50% (3/6) were identified with BSGI. The overall sensitivity of BSGI for the detection of invasive breast cancer is 98.0%. The sensitivity for subcentimetre cancers is 88.5% (23/26).BSGI has a high sensitivity for the detection of invasive breast cancer. Our results demonstrate that BSGI detected all invasive breast cancers pathological grade 2 and higher regardless of size and all cancers which measured ≥ 7 mm regardless of grade. BSGI can reliably detect invasive breast cancers and is a useful adjunct imaging modality for the diagnosis of breast cancer.

One of the risks of breast conservation surgery is local recurrence, which predominantly occurs as a result of inadequate surgical margins. The purpose of this study was to identify factors associated with close or positive surgical margins leading to reexcision (RE). The charts of 532 consecutive breast cancer patients treated at our center between September 2001 and June 2007 were reviewed to evaluate patients who opted for breast conservation surgery and needed reexcision. A total of 351 patients were treated with breast conservation, of which 118 (34%) had positive or close surgical margins and went on to RE. On univariate analysis, factors that significantly correlated with RE ( P < 0.05) were preoperative diagnosis, final pathology, size of tumor, and presentation with nipple discharge. RE was necessary in 53 per cent of patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS), 57 per cent of patients diagnosed by surgical excision, 86 per cent of patients presenting with nipple discharge, and 87 per cent of patients with DCIS or invasive carcinoma with extensive intraductal component in the final pathology. Additionally, 53 per cent of patients with T3 tumors required RE. Age, race, and grade of tumor had no effect on RE rates. Most (75%) patients were able to ultimately have breast conservation.

To develop a means of quantifying axillary radio-tracer uptake in patients undergoing breast specific gamma imaging. This may help differentiate uptake secondary to extravasation of the radio-tracer at the injection from increased uptake as a result of breast cancer metastatic to lymph nodes. A retrospective analysis of patients who had undergone breast specific gamma imaging was performed. Scans from 26 patients showing increased axillary uptake of radio-tracer were identified from 939 patients reviewed. Eighteen of these patients had increased axillary uptake ipsilateral to the side of tracer injection in the absence of breast cancer on that side. Of these 18 cases, eight patients had pathologic proven axillary metastatic disease with increased axillary uptake contralateral to the side of tracer injection. The maximum signal intensity for each region of increased radio-tracer uptake was measured using the net maximum uptake per region of interest and the two groups of patients were compared. Statistical significance was determined using a two-tailed p-value and 95% confidence intervals were considered statistically significant. The calculated means of the “net maximum uptake per region of interest” in the subjects with increased radio-tracer uptake secondary to radio-tracer extravasation and metastatic breast cancer were 177.89 and 117.25, respectively. Comparison of the means yielded a two-tailed p-value of 0.0498, which is statistically significant. There is a statistically significant greater intensity of axillary radio-tracer uptake when the uptake occurs secondary to extravasation when compared with metastases to axillary lymph nodes.

The objective of our study was to compare the sensitivity of mammography, sonography, MRI, and breast-specific gamma imaging (BSGI) in the detection of invasive lobular carcinoma.This is a retrospective multicenter study of women with biopsy-proven invasive lobular carcinoma. All patients had undergone mammography and BSGI, and the imaging findings were classified as positive or negative for invasive lobular carcinoma by experienced breast imagers. The results of MRI and sonography, if either was performed, were included. Final surgical pathology results were used as the reference standard and the lesion sensitivities of BSGI, mammography, sonography, and MRI were then statistically compared using CIs.Twenty-six women ranging in age from 46 to 82 years (mean age, 62.8 years) with a total of 28 biopsy-proven invasive lobular carcinomas were included in the study group. Mammograms were negative in six of 28 (21%), yielding a sensitivity of 79%. In the 25 patients who underwent sonography, 17 had focal hypoechoic areas, yielding a sensitivity of 68%. In the 12 patients who underwent MRI, the sensitivity was 83%. BSGI had a sensitivity of 93%. There was no statistically significant difference in the sensitivity of BSGI, MRI, sonography, or mammography, although there was a nonsignificant trend toward improved detection with BSGI.BSGI has the highest sensitivity for the detection of invasive lobular carcinoma with a sensitivity of 93%, whereas mammography, sonography, and MRI showed sensitivities of 79%, 68%, and 83%, respectively. BSGI is an effective technique that should be used to evaluate patients with suspected cancer and has a promising role in the diagnosis of invasive lobular carcinoma.

Objective: The purpose of this study was to determine the accuracy of the pathologic diagnosis of papillary breast lesions when evaluated by percutaneous biopsy. Materials and Methods: A total of 2307 consecutive breast lesions, diagnosed by percutaneous biopsy, were retrospectively reviewed. Of these, 45 lesions were papillary lesions; 15 of the 45 cases were lost to follow-up or had not had imaging follow-up and were excluded. The remaining 30 papillary lesions constituted the study population. Subsequent surgical excision or imaging follow-up (a minimum of 6 months) was performed and correlated with the initial diagnoses. Results: Of the 30 lesions, 11 intraductal papillomas were diagnosed with stereotactic vacuum assisted biopsy (SVAB). Surgical excision was performed on four lesions (36.4%). Pathologic findings in all four lesions (100%) were benign. Of the 13 papillary lesions diagnosed with ultrasound-guided core needle biopsy, three (23.1%) demonstrated papillomatosis. Subsequent surgical excision was performed on 11 (84.6%) of the 13 papillary lesions, including two of the three papillomatosis. Pathology was benign in all. The two (18.2%) other lesions, initially diagnosed as papillomatosis and benign papilloma, were a fibroadenoma and organizing papillomatosis, respectively, at surgery. The six lesions that were sampled with fine needle aspiration (FNA) demonstrated intraductal papillary lesions, two (33.3%) of which had cytologic atypia. Surgical excision was performed on all six (100%) with benign breast tissue in four (66.7%) including one of the lesions demonstrating atypia. The two (33.3%) other lesions demonstrated high-grade invasive papillary carcinoma with in-situ components. Conclusion: Surgical excision is warranted when a percutaneous breast biopsy demonstrates a papillary lesion with atypia or when there is radiologic-pathologic discordance. Otherwise, these lesions can be followed conservatively. Furthermore, for improved diagnostic accuracy, indeterminate intraductal lesions should undergo biopsy with CNB or stereotactic vacuum assisted biopsy and not fine needle aspiration. The cytologic diagnosis of papillary lesions is considered only preliminary by fine needle aspiration, and should await surgical resection and histologic examination to further classify these lesions.

Our aim was to determine whether breast density affects the performance of a computer-aided detection (CAD) system for the detection of breast cancer.Nine hundred six sequential mammographically detected breast cancers and 147 normal screening mammograms from 18 facilities were classified by mammographic density. BI-RADS 1 and 2 density cases were classified as nondense breasts; BI-RADS 3 and 4 density cases were classified as dense breasts. Cancers were classified as either masses or microcalcifications. All mammograms from the cancer and normal cases were evaluated by the CAD system. The sensitivity and false-positive rates from CAD in dense and nondense breasts were evaluated and compared.Overall, 809 (89%) of 906 cancer cases were detected by CAD; 455/505 (90%) cancers in nondense breasts and 354/401 (88%) cancers in dense breasts were detected. CAD sensitivity was not affected by breast density (p=0.38). Across both breast density categories, 280/296 (95%) microcalcification cases and 529/610 (87%) mass cases were detected. One hundred fourteen (93%) of the 122 microcalcifications in nondense breasts and 166 (95%) of 174 microcalcifications in dense breasts were detected, showing that CAD sensitivity to microcalcifications is not dependent on breast density (p=0.46). Three hundred forty-one (89%) of 383 masses in nondense breasts, and 188 (83%) of 227 masses in dense breasts were detected-that is, CAD sensitivity to masses is affected by breast density (p=0.03). There were more false-positive marks on dense versus nondense mammograms (p=0.04).Breast density does not impact overall CAD detection of breast cancer. There is no statistically significant difference in breast cancer detection in dense and nondense breasts. However, the detection of breast cancer manifesting as masses is impacted by breast density. The false-positive rate is lower in nondense versus dense breasts. CAD may be particularly advantageous in patients with dense breasts, in which mammography is most challenging.

The purpose of our study was to quantitatively compare the time for interpretation of screening full-field digital mammography (FFDM) images using prior analog film mammograms for comparison versus digitized prior analog mammograms.Images from 100 FFDM studies were interpreted by four radiologists. All FFDM images had comparison analog mammograms obtained a minimum of 1 year earlier that were digitized using a 43-μm film digitizer. Initially, the FFDM images were interpreted using the digitized prior mammogram on two, 5-megapixel monitors and PACS. All available PACS tools could be used. Four weeks later, the same 100 screening FFDMs were interpreted using the original analog mammograms on an alternator at 90° to the monitors used to interpret the screening FFDMs. The interpretation times were recorded and compared. The results were compared and evaluated for statistical significance using statistical software, with statistical significance set at p0.05.For each radiologist, the mean reading time for FFDM with digitized priors was significantly shorter in length in comparison with the mean reading time calculated for interpreting FFDM using analog film priors. The differences in times recorded between digitized analog versus analog ranged from 11.31 to 74.18 seconds. The reading times for the four readers ranged from 17.32 to 185.94 seconds, with a mean of 58.56 seconds when using analog film prior mammograms. When using digitized analog prior mammograms, the reading times for the four readers ranged from 11.32 to 109.11 seconds with a mean of 39.76 seconds. The average difference in reading time was calculated to be 18.80 seconds, showing that there is a 32% increase in interpretation speed when using a digitized prior analog for comparison studies as opposed to an analog prior.There is a statistically significant 32.1% average improvement in interpretation time when FFDM screening mammograms use digitized analog comparison mammograms than if FFDM is interpreted with the original analog film mammograms. This should allow more FFDMs to be interpreted in the same amount of time if digitized prior analog mammograms are used.

To determine improvement in breast cancer detection by using supplemental three-dimensional (3D) automated breast (AB) ultrasonography (US) with screening mammography versus screening mammography alone in asymptomatic women with dense breasts.Institutional review board approval and written informed consent were obtained for this HIPAA-compliant study. The SomoInsight Study was an observational, multicenter study conducted between 2009 and 2011. A total of 15 318 women (mean age, 53.3 years ± 10 [standard deviation]; range, 25-94 years) presenting for screening mammography alone with heterogeneously (50%-75%) or extremely (75%) dense breasts were included, regardless of further risk characterization, and were followed up for 1 year. Participants underwent screening mammography alone followed by an AB US examination; results were interpreted sequentially. McNemar test was used to assess differences in cancer detection.Breast cancer was diagnosed at screening in 112 women: 82 with screening mammography and an additional 30 with AB US. Addition of AB US to screening mammography yielded an additional 1.9 detected cancers per 1000 women screened (95% confidence interval [CI]: 1.2, 2.7; P.001). Of cancers detected with screening mammography, 62.2% (51 of 82) were invasive versus 93.3% (28 of 30) of additional cancers detected with AB US (P = .001). Of the 82 cancers detected with either screening mammography alone or the combined read, 17 were detected with screening mammography alone. Of these, 64.7% (11 of 17) were ductal carcinoma in situ versus 6.7% (two of 30) of cancers detected with AB US alone. Sensitivity for the combined read increased by 26.7% (95% CI: 18.3%, 35.1%); the increase in the recall rate per 1000 women screened was 284.9 (95% CI: 278.0, 292.2; P.001).Addition of AB US to screening mammography in a generalizable cohort of women with dense breasts increased the cancer detection yield of clinically important cancers, but it also increased the number of false-positive results.

The purpose of this study was to evaluate the sensitivity of breast-specific gamma imaging (BSGI) for the detection of breast cancer in dense versus nondense breasts.This was a retrospective study of 341 women with biopsy-proven breast cancer diagnosed from January 2004 to August 2009 who underwent BSGI before surgical excision. Patients with predominantly fatty replaced (BI-RADS density 1) or scattered fibroglandular tissue (BI-RADS density 2) breasts were classified as nondense, and those with heterogeneously dense (BI-RADS density 3) or extremely dense tissue (BIRADS density 4) were classified as dense. BSGI examinations exhibiting focal increased radiotracer uptake in the area of biopsy-proven cancer were classified as positive according to BSGI reports in the medical record. The sensitivity of BSGI was calculated using Microsoft Excel 2003. Between-group differences were evaluated statistically using the Student t test for continuous variables and the chi-square test for categoric variables, with p0.05 considered statistically significant.The overall sensitivity of BSGI for breast cancer detection was 95.4%. Positive BSGI examinations were present in 136 of 142 nondense breast cancers and 195 of 205 dense breast cancers, for sensitivities of 95.8% and 95.1%, respectively. There was no significant difference in BSGI breast cancer detection and parenchymal breast density (p = 0.459).BSGI has high sensitivities for the detection of breast cancer in women with dense and nondense breasts and is an effective adjunct imaging modality in women with both dense and nondense breasts.

Stein LF, Zisman G, Rapelyea JA, Schwartz AM, Abell B, Brem RF oote and Stewart [1] described lobular carcinoma in situ (LCIS) as a distinct pathologic entity in 1941. Historically, it has been considered an incidental finding in breast tissue, often adjacent to the area of abnormality that prompts biopsy. It was previously thought to lack any corollary signs of mass or calcification on mammogram [2, 3]. Recent studies indicate that LCIS foci may contain specific microcalcifications [3, 4], but to our knowledge, there is no report of LCIS forming a solid mass. We report a case of LCIS that presented as a focal mass.

Breast-specific gamma imaging (BSGI) is a physiologic breast imaging modality that provides more sensitive detection of breast lesions than mammography or ultrasound, and appears to have greater specificity than breast MRI. The purpose of this study was to evaluate how often BSGI changed surgical management in patients with breast cancer. Charts were reviewed from 218 consecutive eligible patients who had preoperative evaluation with BSGI or MRI before surgery for breast cancer from January 2008 to May 2010. Patients who were initially considered eligible for breast-conserving therapy (BCT) were evaluated to determine how many ultimately had mastectomies. Patients who underwent mastectomy because of personal choice or ineligibility for BCT were excluded. Management was changed to mastectomy in 11.9% of those who had BSGI and 28.9% of those who had MRI. Review of pathology demonstrated that all patients who underwent mastectomies were not candidates for breast conservation. 15.4% of patients who underwent BCT based on BSGI findings required a single re-excision due to positive surgical margins. 14.4% required mastectomy. In the MRI group, 18.8% required a single re-excision, and 6.3% required mastectomy. Evaluation with BSGI changed management to mastectomy in a substantial proportion of patients believed to be eligible for BCT following standard imaging. BSGI is effective in evaluation of extent of disease in patients with breast cancer, and is comparable to MRI in terms of its influence on surgical management.

To the Editor I applaud the members of the medical community who have taken the lead in the fight against breast cancer; however, the idea that there is progress toward a consensus on breast cancer screening guidelines from a recent article1 in JAMA Internal Medicine is misconstrued. New recommendations from the American Cancer Society maintain that women should have every opportunity to begin breast cancer screening at the age of 40 years. Yet, the Grade C recommendation put forth by the US Preventive Screening Task Force (USPSTF) for women age 40 to 49 years jeopardizes the benefit of early detection in women for whom the number of years of life lost is the greatest.2 The USPSTF recommendation to begin mammography screening at age 50 years instead of 40 years denies this benefit to the 20.6 million women in their fifth decade of life.

Rationale and Objectives Atypical lesions such as atypical ductal hyperplasia (ADH) and lobular neoplasia are nonmalignant lesions that are associated with significant increased risk of developing breast cancer. Atypical lesions have been reported to present with focal increased radiotracer uptake on breast-specific gamma imaging (BSGI) examination, a novel physiologic tool for the detection of breast cancer. To date the sensitivity of BSGI in the detection of atypical lesions has not been reported. The purpose of this study is to determine the sensitivity of BSGI in detecting ADH and lobular neoplasia. Materials and Methods A total of 1316 patients who received a BSGI exam between January 2006 and July 2009 were retrospectively reviewed. All patients who underwent minimally invasive biopsy and subsequent surgical excision where the highest pathology was solely ADH or lobular neoplasia (reported as ALH, lobular carcinoma in situ or lobular neoplasia), according to the pathology database were included ( n = 15). The sensitivity was determined as the percentage of positive BSGI exams out of all patients diagnosed with ADH or lobular neoplasia who received a BSGI. Results Patient ages ranged from 39 to 67 (mean, 52). Eight of 15 patients had ADH, 6/15 lobular neoplasia, and 1/15 ADH and lobular neoplasia in one lesion. Fifteen of the 15 (100%) patients with surgically confirmed ADH or lobular neoplasia had a positive BSGI, with focally increased radiotracer uptake at the site of the verified high-risk lesion. Conclusion BSGI has a high sensitivity for the detection of atypical, high-risk breast lesions. A diagnosis of an atypical lesion is concordant with focal increased radiotracer uptake with BSGI and can identify women at increased risk for breast cancer.

One of the risks of breast conservation surgery is local recurrence, which predominantly occurs as a result of inadequate surgical margins. The purpose of this study was to identify factors associated with close or positive surgical margins leading to reexcision (RE). The charts of 532 consecutive breast cancer patients treated at our center between September 2001 and June 2007 were reviewed to evaluate patients who opted for breast conservation surgery and needed reexcision. A total of 351 patients were treated with breast conservation, of which 118 (34%) had positive or close surgical margins and went on to RE. On univariate analysis, factors that significantly correlated with RE (P0.05) were preoperative diagnosis, final pathology, size of tumor, and presentation with nipple discharge. RE was necessary in 53 per cent of patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS), 57 per cent of patients diagnosed by surgical excision, 86 per cent of patients presenting with nipple discharge, and 87 per cent of patients with DCIS or invasive carcinoma with extensive intraductal component in the final pathology. Additionally, 53 per cent of patients with T3 tumors required RE. Age, race, and grade of tumor had no effect on RE rates. Most (75%) patients were able to ultimately have breast conservation.

Purpose: The injection techniques and use of lymphoscintigraphy for sentinel lymph node (SLN) biopsy in breast cancer patients vary. Some do not advocate routine use of lymphoscintigraphy. The purpose of this case report is to illustrate when lymphoscintigraphy should be used. Methods: At our institution, we use periareolar intradermal injections of 0.6 mCi Tc-99m sulfur colloid followed by lymphoscintigraphy with reported identification rates greater than 99%. The only patient in our series who did not have a SLN identified had presented after excisional biopsy of an upper outer quadrant cancer. We report the case of another patient who presented after excision of an upper outer quadrant invasive ductal carcinoma and had no evidence of lymphatic drainage on lymphoscintigraphy after the periareolar injections of radioisotope. Results: Additional injections of 0.4 mCi Tc-99m sulfur colloid were performed lateral to the incision in the upper outer quadrant. On lymphoscintigraphy a SLN was visualized and was subsequently successfully identified intraoperatively. Conclusion: This case report supports the value of lymphoscintigraphy for successful identification of a SLN in a patient with prior surgery. We therefore recommend imaging patients who have had prior breast surgery, particularly excisions in the upper outer quadrant.

To retrospectively determine the sensitivity and specificity of breast-specific gamma imaging (BSGI) for the detection of breast cancer by using pathologic results as the reference standard.This study was Institutional Review Board approved and Health Insurance Portability and Accountability Act compliant. Informed consent was obtained for participants who were not imaged as part of their clinical protocol but were participating in other Institutional Review Board-approved studies that used BSGI. A retrospective review of 146 women (aged 32-98 years) undergoing BSGI and breast biopsy was performed. Patients underwent BSGI with intravenous injection of 30 mCi (1110 MBq) of technetium 99 ((99m)Tc)-sestamibi and were imaged in craniocaudal and mediolateral oblique projections. Study images were assigned scores, and scores were classified as positive (focal increased radiotracer uptake) or negative (no uptake or scattered heterogeneous physiologic uptake) and compared with biopsy results. The sensitivity, specificity, and positive and negative predictive values were determined.In 146 patients, 167 lesions underwent biopsy, of which 83 (16 ductal carcinoma in situ [DCIS] and 67 invasive cancers) were malignant. Of 84 nonmalignant lesions, 82 were benign and two showed atypical histologic results (one atypical lobular hyperplasia and one lobular carcinoma in situ). BSGI helped detect cancer in 80 of 83 malignant lesions with a sensitivity of 96.4% (95% confidence interval [CI]: 92%, 99%) and correctly identified 50 of 84 nonmalignant lesions as negative for cancer with a specificity of 59.5% (95% CI: 49%, 70%). The positive predictive value for 80 of 114 malignant lesions with a BSGI examination with findings positive for cancer was 68.8% (95% CI: 60%, 78%) and the negative predictive value for 50 of 53 nonmalignant lesions was 94.3% (95% CI: 88%, 99%). The smallest invasive cancer and DCIS detected were both 1 mm. BSGI helped detect occult cancer not visualized at mammography or ultrasonography in six patients.BSIG has high sensitivity (96.4%) and moderate specificity (59.5%) helping detect breast cancers.

The purpose of our study was to better define the rate and variables associated with cancer underestimation when lobular neoplasia is found at minimally invasive breast biopsy.The records of 32,420 patients who underwent imaging-guided needle biopsy of the breast for mammographic or sonographic abnormalities from 1988 to 2000 were retrospectively reviewed. The 278 cases in which lobular neoplasia was the highest-risk lesion at biopsy were included. Of the 278 cases, 164 proceeded to surgical excision, allowing calculation of rates of underestimation from minimally invasive biopsy.Of the 32,420 minimally invasive breast biopsies, lobular neoplasia was found in 278 (0.9%). One hundred sixty-four of the 278 (59%) continued to surgical excision, where cancer was pathologically confirmed in 38 (23%). No difference was seen in the underestimation rates for lesions diagnosed as lobular carcinoma in situ (25%, 17 of 67 lesions) versus atypical lobular hyperplasia (22%, 21 of 97 lesions). Statistically significant underestimation of carcinoma was found with biopsy of masses (with or without associated microcalcifications) rather than calcifications only, a higher BI-RADS category (p0.0001), use of a core biopsy device rather than a vacuum device (p0.01), and obtaining fewer specimens (p0.0001).Significant sampling error occurs regardless of the type of core biopsy device, number of specimens obtained, histologic-radiographic concordance, mammographic appearance, and complete excision of the lesion as determined by imaging. For this reason, all patients with lobular neoplasia at core or vacuum-assisted biopsy should undergo surgical excision until further differentiating criteria can be determined.

Rationale and Objectives. To evaluate the sensitivity of high-resolution breast-specific gamma imaging (BSGI) for the detection of ductal carcinoma in situ (DCIS) based on histopathology and to compare the sensitivity of BSGI with mammography and magnetic resonance imaging (MRI) for the detection of DCIS. Materials and Methods. Twenty women, mean 55 years (range 34‐76 years), with 22 biopsy-proven DCIS were retrospectively reviewed. After injection of 25‐30 mCi (925‐1,110 MBq) technetium 99m-sestamibi, patients had BSGI with a high-resolution, small-field-of-view gamma camera in craniocaudal and mediolateral oblique projections. BSGI studies were prospectively classified according to focal radiotracer uptake usin ga1t o 5scale, as normal 1), with no focal or diffuse uptake; benign 2), with minimal patchy uptake; probably benign 3), with scattered patchy uptake; probably abnormal 4), with mild focal radiotracer uptake; and abnormal 5), with marked focal radiotracer uptake. Imaging findings were compared to findings at biopsy or surgical excision. The sensitivity of BSGI, mammography, and when performed, MRI were determined for the detection of DCIS. Breast MRI was performed on seven patients with eight biopsy-proven foci. The sensitivities were compared using a two-tailed t-test and confidence intervals were determined. Results. Pathologic tumor size of the DCIS ranged from 2 to 21 mm (mean 9.9 mm). Of 22 cases of biopsy-proven DCIS in 20 women, 91% were detected with BSGI, 82% were detected with mammography, and 88% were detected with magnetic resonance imaging. BSGI had the highest sensitivity for the detection of DCIS, although this small sample size did not demonstrate a statistically significant difference. Two cases of DCIS (9%) were diagnosed only after BSGI demonstrated an occult focus of radiotracer uptake in the contralateral breast, previously undetected by mammography. There were two false-negative BSGI studies. Conclusions. BSGI has higher sensitivity for the detection of DCIS than mammography or MRI and can reliably detect small, subcentimeter lesions.

To prospectively evaluate a high-resolution breast-specific gamma camera for depicting occult breast cancer in women at high risk for breast cancer but with normal mammographic and physical examination findings.Institutional Review Board approval and informed consent were obtained. The study was HIPAA compliant. Ninety-four high-risk women (age range, 36-78 years; mean, 55 years) with normal mammographic (Breast Imaging Reporting and Data System [BI-RADS] 1 or 2) and physical examination findings were evaluated with scintimammography. After injection with 25-30 mCi (925-1110 MBq) of technetium 99m sestamibi, patients were imaged with a high-resolution small-field-of-view breast-specific gamma camera in craniocaudal and mediolateral oblique projections. Scintimammograms were prospectively classified according to focal radiotracer uptake as normal (score of 1), with no focal or diffuse uptake; benign (score of 2), with minimal patchy uptake; probably benign (score of 3), with scattered patchy uptake; probably abnormal (score of 4), with mild focal radiotracer uptake; and abnormal (score of 5), with marked focal radiotracer uptake. Mammographic breast density was categorized according to BI-RADS criteria. Patients with normal scintimammograms (scores of 1, 2, or 3) were followed up for 1 year with an annual mammogram, physical examination, and repeat scintimammography. Patients with abnormal scintimammograms (scores of 4 or 5) underwent ultrasonography (US), and those with focal hypoechoic lesions underwent biopsy. If no lesion was found during US, patients were followed up with scintimammography. Specific pathologic findings were compared with scintimammographic findings.Of 94 women, 78 (83%) had normal scintimammograms (score of 1, 2, or 3) at initial examination and 16 (17%) had abnormal scintimammograms (score of 4 or 5). Fourteen (88%) of the 16 patients had either benign findings at biopsy or no focal abnormality at US; in two (12%) patients, invasive carcinoma was diagnosed at US-guided biopsy (9 mm each at pathologic examination).High-resolution breast-specific scintimammography can depict small (1-cm), mammographically occult, nonpalpable lesions in women at increased risk for breast cancer not otherwise identified at mammography or physical examination.

BACKGROUND The objective of this study was to evaluate the performance of a computer-aided detection (CAD) system for the detection of breast cancer, based on mammographic appearance and histopathology. METHODS From 1000 consecutive screening mammograms from women with biopsy-proven breast carcinoma, 273 mammograms were selected randomly for retrospective evaluation by CAD. The sensitivity of the CAD system for breast cancer was assessed from the proportion of masses and microcalcifications detected. The corresponding tumor histopathologies also were evaluated. Normal mammograms (n = 155 patients) were used to determine the false-positive rate of the system. RESULTS Of the 273 breast carcinomas, 149 appeared mammographically as masses, and 88 appeared as microcalcifications, including 36 carcinomas that presented as mixed lesions. The CAD system marked 125 of 149 masses correctly (84%), marked 86 of 88 microcalcifications correctly (98%), and marked 32 of 36 of mixed lesions correctly (89%.). The system showed a high sensitivity for the detection of ductal carcinoma in situ (95%; 73 of 77 lesions), invasive lobular carcinoma (95%; 18 of 19 lesions), invasive ductal carcinoma (85%; 125 of 147 lesions), and invasive mammary carcinoma (90%; 27 of 30 lesions). The highest CAD system sensitivity was for all invasive carcinomas that presented as microcalcifications (100%). On normal mammograms, there was an average of 1.3 false-positive CAD marks per image. CONCLUSIONS The CAD system correctly marked a large majority of biopsy-proven breast cancers, with a greater sensitivity for lesions with microcalcifications and without significant impact of performance based on tumor histopathology. CAD was highly effective in detecting invasive lobular carcinoma (sensitivity, 95%) and ductal carcinoma in situ (sensitivity, 95%). CAD represents a useful tool for the detection of breast cancer. Cancer 2005. © 2005 American Cancer Society.

The increased interest in the use of neoadjuvant chemotherapy for patients with locally advanced or large tumors at initial presentation necessitates the recognition of sequelae of this therapy. This article describes the interval appearance of malignant, linear-branching, microcalcifications during neoadjuvant chemotherapy for locally advanced breast cancer. Mammographically the malignant microcalcifications appeared only in the region of the breast where the primary tumor was found. Pathologically only a subpopulation of malignant cells responded to the chemotherapy, demonstrating viability of the majority of the tumor, with cell death only in the subpopulation. With the increased use of neoadjuvant chemotherapy, it is important to recognize previously undescribed mammographic findings secondary to this therapeutic approach.