Biomedical subjects
Publications and source records attributed to D B Kopans.
X-ray mammography is the only breast imaging technique with proven efficacy for screening. Ultrasound is useful for cyst/solid differentiation and to guide the aspiration and localization of selected lesions. All other modalities should be considered experimental with no demonstrated efficacy for detection or diagnosis.
X-ray mammography (film/screen or Xerox) is the only breast imaging technique with proven efficacy for screening. Ultrasound has a limited diagnostic capability for cyst/solid differentiation. All other modalities should be considered experimental or of no proven benefit for breast evaluation.
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Metastatic disease to the intramammary lymph nodes from breast cancer may be seen mammographically. In the four cases reviewed, the affected intramammary lymph nodes were enlarged (1 cm or greater in diameter), homogeneous, and well circumscribed. All lacked the lucent center or hilar notch characteristic of benign intramammary nodes. Differentiation of malignant from benign causes of intramammary lymph node enlargement, such as inflammation or hyperplasia, is impossible by mammography. Biopsy is recommended for all intramammary lymph nodes of 1 cm or greater that are not fat infiltrated unless the patient clearly has an associated dermatitis or mastitis. Metastatic disease to the intramammary lymph nodes may be the first clinical and/or mammographic sign of breast cancer and may significantly affect prognosis.
The pelvic sonograms of 30 postmenopausal women who demonstrated no pathology in 8-18 months of clinical follow-up were reviewed. In 19 cases both ovaries were visualized. Only one ovary was seen in three patients and neither ovary identified in eight patients. Ovarian volumes were all less than or equal to 2.5 cm3. The authors suggest that, contrary to previous experience, a large proportion of normal postmenopausal ovaries can be depicted sonographically. Further data are necessary before definite normal volumes are known but sonography may be useful to screen patients to help detect early ovarian carcinoma.
An endometrial collection in a postmenopausal woman is abnormal. Its potential for heralding pelvic malignancy has been emphasized. Although malignancy must always be excluded, the authors' experience with a large outpatient population indicates that benign causes of uterine fluid collections may be more common than previously reported. During a 14-month period eight postmenopausal women with endometrial fluid collections were identified in the outpatient ultrasound department of the Massachusetts General Hospital. Seventy-five per cent of these were secondary to benign processes.
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The sonographic appearance of the response of the common hepatic duct to physiologic stimulation by a fatty meal was assessed in 131 patients referred because of right upper quadrant symptoms or abnormal liver chemical studies. In the determination of the presence or absence of biliary obstruction, the sensitivity of the examination was 84%, the accuracy of a positive test was 84%, and the accuracy of a negative test was 93%. This test proved helpful in several circumstances: equivocal duct caliber (6-10 mm); abnormal caliber (6-14 mm) with normal laboratory values; normal caliber duct with abnormal laboratory values; persistent question of cholelithiasis or asymptomatic pancreatic duct dilatation. Measurements of bile duct caliber alone may be insufficient to ascertain the presence of bile duct obstruction and fatty meal stimulation significantly improves diagnostic accuracy.
Between March 1980 and April 1981, 1,140 women underwent physical examination, xeromammography, and whole-breast ultrasound (US) using a whole-breast water path system. Results of each study were interpreted independently by separate observers in a blind fashion. Biopsy revealed 125 cancers in 127 breasts. Findings were considered to be suspicious for carcinoma in 199 women based on physical examination, in 201 based on mammograms, and in 255 based on US scans. Physical examinations were able to reveal 91% (115/127) of the cancers, reflecting the referral nature of the population, and failed to detect 12 lesions. Mammograms disclosed 94% (119/127) of the cancers, including 12 clinically occult lesions, but did not show eight palpable cancers. US scans disclosed only 64% (81/127) of the cancers, all of which were palpable. In a 4-year follow-up, no cancers have appeared in the group that had suspicious findings by US only. We conclude that US should not be used routinely to screen women for breast cancer.
Modifications have been made in the spring hookwire system to facilitate accurate three-dimensional placement and to aid surgeons in gauging the location of the hook with respect to a breast lesion. Difficulties in placement of the needle created by rigid compression systems can be overcome by using a combination of a fenestrated compression plate and a spot-compression device.
The accuracy of physical examination is compared with that of computed tomography (CT) of the chest in determining the extent of disease in 42 patients with local and/or regional recurrence of breast cancer. Of the 33 patients with clinical evidence of chest wall recurrence, 16 (49%) had areas of disease visible by CT that were clinically unsuspected. Similarly, in the nine patients who presented with supraclavicular and/or axillary recurrence, five (56%) had additional sites of involvement discovered on CT. Since many of these patients are treated with radiotherapy, the information gained by CT of the chest can be of great value in treatment planning.
The majority of information available today indicates that the most efficient and accurate method of screening women to detect early-stage breast cancer is an aggressive program of patient self-examination, physical examination by well-trained, motivated personnel, and high-quality x-ray mammography. There are two important factors in the implementation of mammographic screening. The first is the availability of facilities to perform high-quality, low-dose mammography, which is directly related to the second factor: the expense to society for support of this large-scale effort. Cost-benefit analysis is beyond the scope of this review. In 1979 Moskowitz and Fox attempted to address this issue, using data from the Breast Cancer Detection Demonstration Project in Cincinnati, but additional analysis is required. The cost for each "curable" cancer that is detected must be compared with the psychological, social, and personal losses that accrue, as well as the numerous medical expenses incurred, in a frequently protracted death from breast cancer. All other imaging techniques that have been reviewed should be regarded as adjuncts to rather than replacements for mammographic screening (Table 1). Ultrasound and computerized tomography are helpful when the physical examination and mammogram are equivocal. Other techniques, such as transillumination, thermography, and magnetic-resonance imaging, should be considered experimental. In patients with clinically evident lesions, x-ray mammography is helpful to evaluate the suspicious area, as well as to "screen" the remaining tissue in both breasts and to search for multicentric or bilateral lesions. Mammography is the only imaging technique that has been proved effective for screening. The low doses required by present-day mammographic technology pose a possible risk that is so small it is not measurable. The image quality has improved considerably over the past decade, and data supporting the benefits of mammography are increasing. As a result, the American Cancer Society has recently modified its recommendations to include mammographic screening of asymptomatic women beginning at the age of 40 years (Table 2). Before any new system can be considered a replacement for mammographic screening, carefully executed trials are necessary to prove efficacy beyond anecdotal claims.
A case-control study was conducted to evaluate the association of body size with morphologic features of breast tissue visible on mammograms, and to analyze the interrelations of these factors with breast cancer risk. The cases were 362 women with newly diagnosed breast cancer identified in 1978-1979 in three large hospital-based xeromammography units in Boston, Massachusetts, and one unit in Livingston, New Jersey. The controls were 686 women referred to these units in the same period for a "routine" mammogram. The parenchymal pattern (N1, P1, P2, DY) and the per cent of the breast showing nodular densities were the principal mammographic features assessed. Among controls, body weight was strongly but inversely associated with the per cent of women who had the high risk P2 or DY patterns and with the mean per cent of the breast showing nodular densities. Body weight and the amount of nodular densities were both directly related to breast cancer risk. The strengths of the relations of body weight and of nodular densities to risk were each increased when the other factor was taken into account.
The results of 500 preoperative radiographically guided localizations for occult breast lesions over a period of more than 5 years are described. Of the total, 117 (23.4%) were found to be malignant. Biopsy was prompted by abnormal calcifications in 41% (203/500) of the cases and by occult masses, areas of architectural distortion, or asymmetry in 59% (297/500). of 74 patients with carcinoma who underwent axillary lymph node sampling, 78% (58/74) were free of metastatic involvement.
X-ray mammography is the only imaging method currently available with any proven efficacy for screening to detect early-stage, clinically occult breast cancer. Sonography has a limited role in the differentiation of cystic from solid masses and as a guide for aspiration and preoperative localization of selected breast lesions. Computed tomography has a more limited role to determine the spatial orientation of a lesion detected only in the lateral mammographic position. All other imaging methods should be considered experimental at this time.
Sonography is unable to replace x-ray mammography in the detection of early-stage clinically occult breast cancer. Despite its inability to differentiate solid benign from malignant masses sufficiently well to avoid biopsy, an important adjunctive role has been defined. Sonography can be used to guide the aspiration of cysts that could not be drained clinically and in so doing obviate surgery to remove these lesions. In addition, in selected patients it can guide the placement of wire guides for the surgical removal of clinically occult lesions. The results of 43 sonographically guided interventional procedures in the breast are discussed. In 35 of 38 sonographically guided cyst aspirations, fluid was obtained, including 11 patients in whom there had been unsuccessful clinical attempts. In five additional patients with indeterminate solid lesions and negative aspirations, sonography was successfully used for preoperative wire placement.
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