Faculty Bibliography

Polyacrylamide gel (PAAG) injection remains an uncommon method of breast augmentation. Providers must recognize the clinical and radiological manifestations to optimize management. The clinical and radiological findings of PAAG injection may mimic malignancy and silicone breast augmentation. We described two patients with prior PAAG breast augmentation with physical exam and imaging findings concerning for malignancy. We reviewed the literature on PAAG breast augmentation and compare PAAG to silicone breast augmentation. The management of such patients is discussed.

OBJECTIVE: Imaging of the male breast is most often performed for the evaluation of a clinical abnormality such as breast enlargement or tenderness, a palpable mass, nipple skin changes, or nipple discharge. Most breast lesions encountered in men are benign. Malignant breast lesions are less frequent; breast cancer accounts for less than 1% of all male cancers in the United States. The initial imaging evaluation of a finding in the male breast is performed with mammography. Sonography is frequently used as an adjunct to mammography but is less often used as the primary imaging modality. The objective of this article is to provide readers with a thorough review of the sonographic appearances of benign and malignant male breast disease. METHODS: We reviewed our institution's case database to identify male patients who underwent mammography, sonography, and subsequent biopsy of a breast lesion. These cases were collected and reviewed to select the best imaging examples. RESULTS: A spectrum of benign and malignant male breast disease is presented with corresponding sonographic, mammographic, and pathologic imaging. For each entity, the salient imaging findings and typical clinical presentation are discussed. CONCLUSIONS: Most studies in the literature have reported on the mammographic and sonographic imaging features of primary breast carcinoma in men. However, very little has been reported on the sonographic appearance of benign and malignant male breast conditions. Recognition and correct identification of pathologic male breast entities on sonography is essential to determine appropriate management recommendations and avoid unnecessary biopsies

PURPOSE: To retrospectively review the imaging and histologic findings in patients in whom a benign papillary lesion was diagnosed at core-needle breast biopsy. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board at each institution; patient consent was not required. The study was HIPAA compliant. The authors reviewed the findings from 42 patients (age range, 26-76 years; mean age, 54.3 years) with 43 benign papillary lesions diagnosed at core-needle biopsy. Thirty-six (84%) of the 43 lesions were surgically excised, and seven (16%) were followed up with long-term imaging. The authors assessed the radiographic findings, the histologic findings at core-needle biopsy, and the findings at subsequent surgical excision or imaging follow-up. Statistical analysis was performed on a per-patient basis and included the Blyth-Still-Casella procedure to construct exact 95% confidence intervals (CIs) and the Fisher exact test. RESULTS: At core-needle biopsy, lesions were diagnosed as papilloma (n = 29), sclerosing papilloma (n = 8), and benign papillary lesions not otherwise specified (n = 6). For the 36 lesions that were surgically excised, histologic follow-up showed no residual lesion in 10, intraductal papilloma in 14, intraductal papillomatosis in two, papilloma with adjacent foci of atypical ductal hyperplasia (ADH) in eight, and well-differentiated papillary ductal carcinoma in situ (DCIS) in two. Mammographic follow-up in the remaining seven lesions revealed stable calcifications in five (at 28-55 months) and no residual lesion in two (at 26-29 months). In nine of the 42 patients (21%), the diagnosis was upgraded to either ADH or DCIS (exact two-sided 95% CI = 11.4%, 36.4%). CONCLUSION: The results strongly suggest that papillary lesions diagnosed as benign at core-needle biopsy should be surgically excised because a substantial number of lesions were upgraded to ADH and DCIS at excision

PURPOSE: To evaluate the use of stereotactic directional vacuum-assisted biopsy (SDVAB) in diagnosing and managing papillary lesions of the breast. MATERIALS AND METHODS: The authors retrospectively reviewed the mammographic and histopathologic findings of 26 cases in which papillary lesions were diagnosed at SDVAB. In all cases, subsequent surgical excision (n = 20) or long-term imaging follow-up (n = 6) was performed and correlated with findings at SDVAB. RESULTS: SDVAB of 26 lesions yielded tissue that was classified as benign in 12, atypical in six, and malignant in eight. Of the 12 lesions that were diagnosed as histologically benign at SDVAB, six were surgically excised. Of these six lesions, five yielded benign correlative results. The sixth lesion was thought to be discordant with the imaging findings, and was surgically excised and determined to be malignant. Of the six benign lesions that were not surgically sampled for biopsy, five decreased in size and one was not seen at radiographic follow-up. Of the six lesions diagnosed as atypical at SDVAB that were surgically excised, one was benign and five were atypical. None proved to be malignant. Of the eight lesions diagnosed as malignant at SDVAB, surgical excision demonstrated ductal carcinoma in situ in all eight; two also had foci of invasive carcinoma. CONCLUSION: Benign and malignant papillary lesions of the breast can be reliably diagnosed at SDVAB when the SDVAB results correlate with the imaging findings. However, the extent of malignant papillary disease may be underestimated at SDVAB; in our study, invasive carcinoma was later discovered in 25% of patients with this diagnosis

OBJECTIVE: We describe the mammographic appearance of axillary lymph node calcification in three patients with metastatic ovarian carcinoma. CONCLUSION: Axillary lymph node calcification may be identified mammographically in patients with metastatic ovarian carcinoma and may be evidence of unsuspected metastatic disease. The pattern of calcification differs from that seen with metastatic breast carcinoma

BACKGROUND AND OBJECTIVES: The ability to achieve clean margins with breast conserving therapy varies greatly even when the diagnosis of carcinoma is known beforehand. Although several reports reveal that the incidence of positive margins decreases after stereotaxic core biopsy of nonpalpable lesions and fine-needle aspiration biopsy of palpable lesions, the data on the results following mammotome biopsy (mmbx) is scanty. METHODS: Two hundred and ninety-eight biopsy specimens for mammographically indeterminate microcalcification from 1/97 through 3/30/98 were reviewed. Biopsies were performed using the biopsys method utilizing an 11-gauge multidirectional, vacuum-directed device. RESULTS: Ten percent (n = 31) of the mammotome biopsies were atypical and 9% (n = 27) were malignant. These 58 cases (19%) were recommended for surgical excision. The incidence of positive margins in this subset was determined. Of patients who underwent lumpectomy as their initial surgical procedure 69% had negative surgical margins. Seventy-seven percent of patients with carcinoma diagnosed by mammotome biopsy had definitive initial surgery with a single surgical procedure. CONCLUSIONS: Mmbx facilitates fewer surgical procedures to achieve negative margins, and thus provides a better cosmetic result.

OBJECTIVE: A method for segmenting MR images of the breast was applied to determine fatty and fibroglandular tissue volumes in breasts of women in different age groups. The results were compared with subjective assessments of breast density from X-ray mammograms in the same patients. MATERIALS AND METHODS: Two experienced mammographers assessed the percentage of fat in the breasts of 40 women who were 20-83 years old. MR images were obtained on a 1.0-T scanner equipped with a bilateral receive-only breast coil. Images were acquired using a three-dimensional T1-weighted gradient-echo sequence with a 1.25 x 1.4 x 2.5 mm resolution. On average, breast parenchyma appeared in 30 images in each breast. Image segmentation was based on a semiautomated, two-compartmental (fatty and fibroglandular tissue) model that accounts for partial volume effects. To validate the accuracy of the MR imaging segmentation technique, we performed a phantom study using an identical imaging sequence. RESULTS: The accuracy of the MR imaging segmentation of the phantom was of the order of 2%. In our subjects, fat content was 42.5% +/- 30.3% (mean +/- SD) on mammography versus 66.5% +/- 18% on MR images. Although we found a significant correlation (r = .63) between the two techniques, mammography poorly differentiated breasts containing less than 45% fat. When our analysis included only dense breasts (i.e., those containing less than 75% fat on MR images), the correlation coefficient decreased to .34. The largest discrepancies between mammography and MR imaging occurred in breasts that had 60-80% fat as measured on MR imaging. CONCLUSION: Fatty and fibroglandular tissue can be differentiated on MR images of the breast with high precision and accuracy, therefore allowing assessment of breast density. The conclusions of researchers who used mammographic density patterns should be reassessed