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Letters to the Editor |
Hill Breast Center, 50 Alessandro Place, Suite A-30, Pasadena, CA 91105
Editor:
I read with interest the discussion of the case of an elderly woman with papillary carcinoma in the September 1998 of RadioGraphics (1). I must take issue with the interpretation of the original studies performed 2 years before the diagnosis was made.
On a clinical basis, a malignant diagnosis would be strongly suspected based on this patient's age, her strong family history of breast cancer, and the appearance of a mass detected during a 1-year interval. The appearance of a cyst in an 85-year-old woman who was not taking replacement hormones would be extremely unusual.
On a mammographic basis, a malignant diagnosis would also be strongly suspected based on the appearance of the mass in Figure 1 of the article (1). The mass does not have a smooth border but rather has a finely spiculated margin. The mass is also much denser than the glandular tissue in the breast. It would be graded as at least a BIRADS 4, if not a BIRADS 5, lesion.
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In a teaching journal such as RadioGraphics, it should have been pointed out that the original interpretation and evaluation were substandard, and how to avoid making similar mistakes should have been discussed. Sonography, when performed and interpreted correctly, has been shown to be an extremely useful tool in diagnostic evaluation of breast disease, but poorly done sonography is worse than no sonography at all.
References
Department of Radiology, Division of Ultrasound, Thomas Jefferson University Hospital, 1100 Walnut Street, Philadelphia, PA 19107-5563
Dr Kelly's careful scrutiny of the original studies performed 2 years before the diagnosis was made is the type of exercise that should increase the educational benefit of this case for all readers.
The details of the interpretation of the original images were not discussed in the text of this purposefully concise Case of the Day article, nor were all of the mammograms and sonograms provided. The features of the mass demonstrated 2 years later were described and were considered to be more specific and relevant to the discussion of the diagnosis.
We do not believe that the original studies were misinterpreted or substandard. Careful mammographic and sonographic evaluations of the mass were performed.
In the practice of mammographic interpretation, a diagnosis of malignancy is not made from a single view of a mass, regardless of the patient's age, the patient's family history, or the level of clinical suspicion. Dr Kelly noted spiculation of the mass on the one mammographic view provided, when in fact other views not shown demonstrated well-circumscribed margins without spiculation (Fig 1). The fact that the mass is denser than the glandular tissue in the breast is of limited value as a solitary feature in the evaluation of breast masses (1).
It cannot be emphasized enough how much sonographic interpretation of breast masses should be based on a composite of real-time evaluation and hard-copy images in different planes and projections. All sonographic examinations in our department are performed real time on state-of-the-art equipment by experienced radiologists who specialize in breast imaging. There have been significant advances in the diagnostic capabilities of breast sonography over the past 10 years, and even in 1994 (when the original study was performed) our evaluation included proper adjustment of technical parameters, analysis of the internal echotexture and margins, and appreciation of posterior acoustic properties. I have provided another sonogram of the same mass from the same examination, which shows a thin capsule (Fig 2). The radiologist's report from that study described this mass as anechoic with smooth margins and expressed concern about the lack of posterior enhancement in some planes and the presence of posterior shadowing in others. The report mentioned that these variable findings may have been technically related to how the mass projected deep against the chest wall within a large breast. This is a known technical difficulty in breast sonography. If the original study had demonstrated a solid mural nodule or projection or focal wall thickening within the cyst, use of color Doppler imaging would have been helpful and may have demonstrated a fibrovascular stalk within the solid component, a finding that is present in papillary malignancies and not in benign papillary lesions.
Our assessment of the original studies was that the features of this mass were most consistent with those of a benign-appearing complex cyst. This assessment was based not only on mammographic and sonographic interpretation but on our knowledge that intracystic malignancies are rare and that a benign cyst would be more likely, even in an 85-year-old woman. The images in the article were selected to illustrate why some of the features of this mass raised enough concern to warrant a fine-needle aspiration biopsy. We apologize if these figures were misleading.
Sonography-guided fine-needle aspiration of nonpalpable, complex cysts of low suspicion is one of our most useful diagnostic tools in breast imaging in that it serves to decrease the high rate of negative results from excisional biopsy, to decrease medical costs, and to alleviate patient anxiety. After the original radiologic studies, the cyst was aspirated to completion, and the aspirate was not bloody. The cytologic results were consistent with findings of fibrocystic change. The false-negative rate for fine-needle aspiration biopsy of probably benign breast masses varies among institutions. The rate at our institution is less than 1% when the biopsy sample is considered sufficient. Similar data have been reported in recent studies in the world literature (2,3).
We agree with the integrative approach to breast imaging described by Dr Kelly, which involves making appropriate use of the growing number of diagnostic tools at hand, including imaging-guided needle aspiration and biopsy for making a tissue diagnosis. In the case of the 85-year-old woman, we believe that our acceptance of the negative result from fine-needle aspiration biopsy was appropriate based on careful evaluation of the original mammographic and sonographic studies. When the patient presented 2 years later with a recurring mass with suspicious mammographic and sonographic features, excisional biopsy was recommended.
References
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