Faculty Bibliography

OBJECTIVE: Breast density is increasingly recognized as an independent risk factor for the development of breast cancer, because it has been shown to be associated with a four- to sixfold increase in a woman's risk of malignant breast disease. Increased breast density as identified on mammography is also known to decrease the diagnostic sensitivity of the examination, which is of great concern to women at increased risk for breast cancer. Dense tissue has generally been associated with younger age and premenopausal status, with the assumption that breast density gradually decreases after menopause. However, the actual proportion of older women with dense breasts is unknown. The purpose of this study was to examine the relationship between age and breast density, particularly focusing on postmenopausal women. MATERIALS AND METHODS: All screening mammograms completed at the New York University Langone Medical Center in 2008 were retrospectively reviewed. Analysis of variance and descriptive analyses were used to evaluate the relationship between patient age and breast density. RESULTS: A total of 7007 screening mammograms were performed. The median age of our cohort was 57 years. Within each subgroup categorized by decade of age, there was a normal distribution among the categories of breast density. There was a significant inverse relationship between age and breast density (p < 0.001). Seventy-four percent of patients between 40 and 49 years old had dense breasts. This percentage decreased to 57% of women in their 50s. However, 44% of women in their 60s and 36% of women in their 70s had dense breasts as characterized on their screening mammograms. CONCLUSION: In general, we found an inverse relationship between patient age and mammographic breast density. However, there were outliers at the extremes of age. A meaningful proportion of young women had predominantly fatty breasts and a subset of older women had extremely dense breasts. Increased density renders mammography a less sensitive tool for early detection. Breast density should be considered when evaluating the potential benefit of extended imaging for breast cancer screening, especially for women at increased risk for the disease.

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

OBJECTIVE: The purpose of our study was to describe the clinical features, imaging characteristics, pathologic findings and outcome of microinvasive ductal carcinoma in situ (DCISM). MATERIALS AND METHODS: The records of 21 women diagnosed with microinvasive ductal carcinoma in situ (DCISM) from November 1993 to September 2006 were retrospectively reviewed. The clinical presentation, imaging and histopathologic features, and clinical follow-up were reviewed. RESULTS: The 21 lesions all occurred in women with a mean age of 56 years (range, 27-79 years). Clinical findings were present in ten (48%): 10 with palpable masses, four with associated nipple discharge. Mean lesion size was 21mm (range, 9-65mm). The lesion size in 62% was 15mm or smaller. Mammographic findings were calcifications only in nine (43%) and an associated or other finding in nine (43%) [mass (n=7), asymmetry (n=1), architectural distortion (n=1)]. Three lesions were mammographically occult. Sonographic findings available in 11 lesions showed a solid hypoechoic mass in 10 cases (eight irregular in shape, one round, one oval). One lesion was not seen on sonography. On histopathologic examination, all lesions were diagnosed as DCISM, with a focus of invasive carcinoma less than or equal to 1mm in diameter within an area of DCIS. Sixteen (76%) lesions were high nuclear grade, four (19%) were intermediate and one was low grade (5%). Sixteen (76%) had the presence of necrosis. Positivity for ER and PR was noted in 75% and 38%. Nodal metastasis was present in one case with axillary lymph node dissection. Mean follow-up time for 16 women was 36 months without evidence of local or systemic recurrence. One patient developed a second primary in the contralateral breast 3 years later. CONCLUSION: The clinical presentation and radiologic appearance of a mass are commonly encountered in DCISM lesions (48% and 57%, respectively), irrespective of lesion size, mimicking findings seen in invasive carcinoma. Despite its potential for nodal metastasis (5% in our series), mean follow-up at 36 months was good with no evidence of local or systemic recurrence at follow-up. Knowledge of these clinical and imaging findings in DCISM lesions may alert the clinician to the possibility of microinvasion and guide appropriate management

OBJECTIVE: The purpose of this study was to evaluate the usefulness of MRI of the breast in cases in which mammographic or sonographic findings are inconclusive. MATERIALS AND METHODS: We retrospectively reviewed images from 115 MRI examinations of the breast performed from 1999 to 2005 for the indication of problem-solving for inconclusive findings on a mammogram. Forty-eight of the 115 women (41.8%) were at high risk. We discerned whether sonography or MRI was used as an adjunctive tool and correlated the findings with those in the pathology database. RESULTS: The equivocal findings most frequently leading to MRI were asymmetry and architectural distortion. No suspicious MRI correlate was found in 100 of 115 cases (87%). These cases were found stable at follow-up mammography or MRI after a mean of 34 months. Fifteen enhancing masses (13%) that corresponded to the mammographic abnormality were seen on MR images. All masses identified at MRI were accurately localized for biopsy, and six malignant lesions were identified. Four of six malignant tumors were seen in one mammographic view only; two were seen on second-look ultrasound images. MRI had a sensitivity of 100% and compared with mammography had significantly higher specificity (91.7% vs 80.7%, p = 0.029), positive predictive value (40% vs 8.7%, p = 0.032), and overall accuracy (92.2% vs 78.3%, p = 0.0052). Eighteen incidental lesions (15.7%) were detected at MRI, and all were subsequently found benign. CONCLUSION: We found breast MRI to be a useful adjunctive tool when findings at conventional imaging were equivocal. Strict patient selection criteria should be used because of the high frequency of incidental lesions seen on MR images

OBJECTIVE: We evaluated the benefit of placing a marker under sonographic guidance at the time of localization to aid in identifying mammographically occult lesions within the specimen at the time of surgical excision and to evaluate margin status. MATERIALS AND METHODS: We reviewed 135 sonographically guided needle localizations performed on mammographically occult lesions. Imaging during the localization procedure, marker placement, and specimen radiographs were reviewed, and the findings were correlated with the histopathologic findings. RESULTS: Of the 135 mammographically occult lesions, 77 were localized without marker placement and 58 with marker placement. The 58 localizations with marker placement were for masses with a mean lesion size of 9 mm. Specimen radiography of these lesions showed a marker within the specimen in 56 cases (97%) and visualization of the lesion in only seven cases (12%). Specimen radiography of localizations without marker placement showed visualization of the lesion in 18 cases (23%). Of the 11 malignant lesions (19%) localized with marker placement, none had a positive inked margin, but five (46%) had close margins necessitating reexcision. Of the 26 malignant lesions (34%) localized without marker placement, two (8%) had a positive inked margin, and eight (31%) had close margins necessitating reexcision. CONCLUSION: At needle localization of breast lesions, marker placement under sonographic guidance is beneficial because it enables immediate confirmation of accurate surgical removal of the localized lesion at surgical excision. Use of marker placement, however, does not reduce the percentage of cases with close margins necessitating reexcision

INTRODUCTION: With the adoption of routine screening mammography, breast cancers are being diagnosed at earlier stages, with DCIS now accouting for 22.5% of all newly diagnosed breast cancers. This has been attributed to both increased breast cancer awareness and improvements in breast imaging techniques. How have these changes, including the increased use of image-guided sampling techniques, influenced the clinical practice of breast surgery? METHODS: The institutional pathology database was queried for all breast surgeries, including breast reconstruction, performed in 1995 and 2005. Cosmetic procedures were excluded. The results were analysed utilizing the Chi-square test. RESULTS: Surgical indications changed during 10-year study period, with an increase in preoperatively diagnosed cancers undergoing definitive surgical management. ADH, and to a lesser extent, ALH, became indications for surgical excision. Fewer surgical biopsies were performed for indeterminate abnormalities on breast imaging, due to the introduction of stereotactic large core biopsy. While the rate of benign breast biopsies remained constant, there was a higher percentage of precancerous and DCIS cases in 2005. The overall rate of mastectomy decreased from 36.8% in 1995 to 14.5% in 2005. With the increase in sentinel node procedures, the rate of ALND dropped from 18.3% to 13.7%. Accompanying the increased recognition of early-stage cancers, the rate of positive ALND also decreased, from 43.3% to 25.0%. CONCLUSIONS: While the rate of benign breast biopsies has remained constant over a recent 10-year period, fewer diagnostic surgical image-guided biopsies were performed in 2005. A greater percentage of patients with breast cancer or preinvasive disease have these diagnoses determined before surgery. More preinvasive and Stage 0 cancers are undergoing surgical management. Earlier stage invasive cancers are being detected, reflected by the lower incidence of axillary nodal metastases