Biomedical subjects
Publications and source records attributed to D B Kopans.
Special compression views of the breast were used to detect suspect lesions in eight women who had undergone augmentation mammoplasty. Hook-wire localization with the use of these views proved safe and accurate for preoperative localization in these women, one of whom had a very small cancer.
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To explore the value of accurate preoperative localization of occult breast lesions, we reviewed 100 consecutive needle-directed breast biopsies performed by the same surgeon over a 1-year period. A spring hookwire device for localization was inserted parallel to the chest wall. Two thirds of biopsies were performed under local anesthesia, and all were performed in an outpatient setting. Sixteen lesions were invasive carcinomas, and eight were ductal carcinomas in situ. In 96 lesions, the localizing wire was placed within 2 mm of the lesion, and in the remaining four it was within 5 mm of the abnormality. The mammographic lesion was excised in the first specimen in 96 cases. One patient required a second biopsy because of failure to excise the lesion in question after three specimens were taken. The only surgical complication was one hematoma, which resolved within 3 months. Median specimen volume for the entire series was 6.0 cm3. Median largest specimen diameter was 2.5 cm. Precise preoperative localization with a spring hookwire to within 2 mm of the mammographic lesion allows the surgeon to excise a median volume of 6 cm3 breast tissue with consistent retrieval of the lesion.
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Mammograms and histologic slides of a group of 320 women who had breast symptoms and a biopsy without cancer being found were reviewed. The mammographic features assessed were the parenchymal pattern and extent of nodular and homogeneous densities. In addition to the pathologic diagnosis, the histologic features assessed included epithelial hyperplasia and atypia, intralobular fibrosis, and extralobular fibrosis. Among premenopausal women, those with marked intralobular fibrosis were more likely to have large (3+ mm) nodular densities on the mammogram. Among postmenopausal women, epithelial hyperplasia or atypia was related to having nodular densities in at least 40% of the breast volume. In both groups, marked extralobular fibrosis was related to the presence of homogeneous density on the mammogram. We conclude that mammographic nodular densities may be an expression of lobular characteristics, whereas homogeneous density may reflect extralobular connective tissue changes.
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Between 1978 and 1981, 74 women with nonpalpable breast cancer underwent surgery after localization guides were placed. In 72 patients, guides were introduced parallel to the chest wall; in two the needle was positioned anteroposteriorly under computed tomographic guidance. Fifty-six cases (76%) were infiltrating cancer; 13 (17%), intraductal cancers; two (3%), inflammatory; and three (4%), lobular carcinoma in situ. Surgery was not used to treat the latter five patients. In the remaining 69 women, 42 (61%) were treated by means of modified radical mastectomy; six (9%), total mastectomy; 12 (17%), local excision and radiation therapy; and seven (10%), local excision alone; exact therapy for two women (3%) was unknown. At a minimum follow-up of 5 years, none of the 67 women in whom the parallel approach was used had a local recurrence. The authors conclude that preoperative placement of guides parallel to the chest wall does not appear to increase the risk of local breast cancer recurrence.
A new dual-screen, dual-emulsion-film combination that allows a decrease in radiation dose of approximately 66% was compared with a widely used single-screen, single-emulsion-film system in contact and magnification mammography. Clustered microcalcifications randomly superimposed on a breast phantom were detected, and the location and number of individual calcifications were determined by four observers. The detectability of calcifications, determined with a receiver operating characteristic (ROC) analysis area, was 0.92 for magnification and 0.82 for contact mammography with the single-emulsion-film system, compared with 0.84 and 0.72, respectively, with the dual-emulsion-film system. More clusters were correctly located and more individual calcifications were counted with magnification than with contact mammography. The dual-emulsion-film system with the magnification technique performs as well as the single-emulsion-film system with the contact technique, while retaining a decrease in required dose of approximately 40%.
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Anecdotal reports of pain experienced during mammography have been a source of anxiety and concern for some women considering screening. To determine what asymptomatic women actually experience during mammography, a survey of 1847 women was performed at seven breast-imaging centers. Women recorded their experience on a six-point scale ranging from no discomfort to severe pain. Eighty-eight percent of the women experienced no discomfort (49%) or mild discomfort (39%). Only 9% experienced moderate discomfort; 1%, severe discomfort; and 1%, moderate pain. No woman had pain so severe that it would make her reconsider having a mammogram again. The degree of discomfort was slightly greater in women who complained of breast tenderness within three days prior to the mammogram but was not strongly related to age, menstrual status, or week of the menstrual cycle. We conclude that in a vast majority of women mammography causes no or mild physical discomfort and that actual pain is an uncommon occurrence.
The preoperative triangulation and localization of some occult breast lesions can be complicated if the lesion is located deep in the breast. Based on the authors' experience of 1,400 localization procedures, standard breast positions were modified to help locate lesions that were difficult to see in two projections. Standard compression plates were also modified, allowing placement of fenestrations over deep lesions--especially those in the axillary tail of the breast--to facilitate safe, accurate localization.
Standard film examinations of the chest were compared with low-dose flying spot digital radiographic examinations obtained with a prototype unit in 174 patients. Analysis of pooled data from a double-blind study of 120 patients showed that film was more sensitive than digital images in the detection of pulmonary parenchymal abnormalities, that is, abnormal opacities, atelectasis, scar, and interstitial lung disease (P less than .05). Analysis of pooled data from a side-by-side study of 54 patients showed that the digital images were more sensitive than film in the detection of normal mediastinal and pleural soft-tissue contours, including the azygoesophageal recess, paraspinal line, and vertebral disk spaces (P less than .05). However, film was more sensitive than digital images in the detection of abnormalities of the lung, including scar, interstitial lung disease, septal lines, and the presence of vascular catheters (P less than .05). These findings suggest that low-dose flying spot digital radiography of the chest, as performed with this specific prototype unit, is not adequate to replace film in the detection of abnormalities of the lung parenchyma.
High-frequency, high-resolution sonography was used to detect recurrent thyroid carcinoma in 73 patients with papillary carcinoma, 16 with medullary carcinoma, 10 with follicular carcinoma, and one with small-cell carcinoma. Of the 36 patients with negative sonograms, 35 had no other evidence of recurrence, while one had surgical proof of recurrence. Of 25 patients with positive sonograms, confirmed with surgery or radioactive iodine (I131) scanning (sonographic sensitivity 96%, specificity 83%), palpation was negative in 17 (palpation sensitivity 32%, specificity 100%). Thirty-two patient with positive sonographic findings had no objective clinical proof of recurrence. There were seven false-positive studies. This study suggests that sonography may be the method of choice for earliest detection and localization of recurrent carcinoma of the thyroid.
We studied the relationship between the radiographic density of the breast as measured by parenchymal pattern vs age, breast size, thickness after compression, and compressibility. Two hundred consecutive women were evaluated. None of the three parameters or the patient's age correlated with the degree of radiographic density. Although more older women had lucent parenchyma, 37% of women more than 50 years of age had dense patterns. Thus, these factors cannot be used to predict radiographic density. Phototiming is required to maintain image quality, and only a test exposure can accurately predict breast density.
Occasionally, a breast lesion is visible in only one mammographic projection. A simplified method of using parallax in a dedicated mammographic system has been devised to locate accurately lesions that are not visible in two orthogonal projections. In eight patients, a parallax approach from essentially a single mammographic position was used to place a hookwire preoperatively at nonpalpable suspicious abnormalities detected by mammography. Needles were inserted parallel to the chest wall while the breast was compressed in the mammographic unit. In each case, the tissue containing the lesion was pierced by a needle chosen to be longer than the distance from the skin to the abnormality. Simple geometric ratios were used to determine the position of the lesion along the needle shaft after slightly changing the mammographic projection and viewing the needle obliquely. In all cases, this parallax approach permitted accurate localization of the lesion.
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The halo sign, described as a complete or partial radiolucent ring surrounding the periphery of a breast mass, has long been considered a mammographic sign indicating a benign process. The phenomenon is most frequently seen with cysts and fibroadenomas. Over the past 8 years, 25 malignant breast lesions with a partial or complete halo on mammography have been identified in 19 women. These cases suggest that a halo sign does not guarantee a benign process.