Nipple fluid carcinoembryonic antigen and prostate-specific antigen in cancer-bearing and tumor-free breasts.

PURPOSE: Mammograms and breast examinations are established methods for early breast cancer detection. Routine mammography screening reduces breast cancer mortality among women ages > or = 50 years, but additional screening methods are needed. We and others have found high levels of carcinoembryonic antigen (CEA) and prostate-specific antigen (PSA) in nipple aspirate fluids (NAFs), but the usefulness for these bio-markers for early breast cancer detection is unknown. PATIENTS AND METHODS: NAFs from one or both breasts of 388 women were analyzed for CEA, PSA, and albumin levels. The study included 44 women with newly diagnosed invasive breast cancers, 67 women with proliferative breast lesions (ductal and lobular carcinoma in situ and atypical ductal hyperplasia), and 277 controls without these breast lesions. Analyses were conducted using the log(10)-transformed CEA and PSA levels to normalize the distributions of these tumor markers. RESULTS: Nipple fluid CEAs are significantly higher for cancerous breasts than tumor-free breasts (median 1,830 and 1,400 ng/mL, respectively; P <.01). However, at 90% specificity of the assay (CEA = 11,750 ng/mL), the corresponding sensitivity for cancer detection is 32%. CEA levels are not significantly different for breasts with proliferative lesions compared with tumor-free breasts. Nipple fluid PSAs do not differ by tumor status. Analyses of NAF albumin-standardized CEAs and PSAs yield similar results. Nipple fluid CEA and PSA titers are correlated in the affected and unaffected breast of women with unilateral lesions. CONCLUSION: Nipple fluid CEAs are higher for breasts with untreated invasive cancers, but the test sensitivity is low. Nipple fluid PSA titers do not seem to be useful for breast cancer detection.

Is mammography painful? A multicenter patient survey.

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.

Carcinoembryonic antigen in breast nipple aspirate fluid.

New diagnostic tools are needed to complement mammography and physical examinations for early detection of breast cancer, particularly among younger women. We evaluated the tumor biomarker, carcinoembryonic antigen (CEA), in 215 nipple aspirate fluid (NAF) samples collected from one or both breasts of 147 women, ages 27-87 years. Most subjects were recruited at the time of mammography examination. The 215 nipple fluid CEAs range from undetectable levels to 8400 ng/ml (median, 1100 ng/ml). Normal serum CEA levels are less than 6 ng/ml. There are no significant differences between the CEAs in fluid from normal breasts (112 samples) and breasts with various histories of tumors (total, 103 samples). Analyses for determinants of CEAs in fluids from normal breasts show higher levels among current smokers (P = 0.03) and marginal elevations among nulliparous women (P = 0.07). CEAs in these samples are not correlated with age, menopausal status, current hormone use, prior breastfeeding, or family history of breast cancer. Follow-up studies of these women and comparisons of CEAs in fluids from normal and cancer-containing breasts will help clarify whether this biomarker is useful for risk assessment or early cancer detection.

Mammography of women with suspicious breast lumps.

We analyzed 342 women who had suspicious breast lumps to determine if preoperative mammography could improve the malignancy yield of biopsy procedures. The number of women with cancer of the breast and false-negative mammogram reports ranged from 11% to 25%, depending on how equivocal mammogram reports were interpreted. Therefore, women with clinically suspicious breast lumps should undergo biopsy regardless of mammographic findings. A significant difference in the mean (+/- SD) predictive value of a positive mammogram existed between women above and below the age of 50 years (80 +/- 8 vs 43 +/- 14) because of the age-specific relative prevalence of benign and malignant disease, and because mammography had difficulty distinguishing between benign and malignant lumps (specificity, 70). Preoperative mammography of women with suspicious breast lumps is indicated to screen for occult carcinoma, to prevent biopsy sampling errors, and to judge the adequacy of lumpectomy if the lesion is malignant.

An improved system for surgical excision of needle-localized nonpalpable breast lesions.

A technique for improved localization and surgical excision of nonpalpable breast lesions is described. The method employs an atraumatic outer stiffening cannula which is available in a variety of lengths and eliminates several of the technical difficulties encountered during these procedures. Successful initial excision of over 50 consecutive nonpalpable breast lesions has been obtained with this technique.

Clinical problems in follow-up of patients after conservative surgery and radiotherapy.

Patients treated with conservative surgery and radiotherapy for early-stage breast carcinoma are at risk of developing an ipsilateral breast recurrence for a long period. Fortunately, few such patients present with an inoperable recurrence or simultaneous distant metastases. Salvage rates are high and may be improved by early detection. Although usually unambiguous, physical examination of the treated breast may reveal changes attributable to surgery and radiotherapy that can mimic a recurrent cancer. There also is substantial overlap in radiologic appearance between benign and malignant lesions. It may be necessary to perform a biopsy when there is a question of recurrence. Careful life-long follow-up of patients thus is a critical part of their care.

Ultrasonographic guidance for needle biopsy of breast lesions.

The use of imaging-guided needle biopsies of the breast to establish the histology of lesions has become an important tool in the clinical management of breast pathology. Avoiding excision of benign lesions and allowing definitive surgery of malignant lesions to be planned from the outset are to the benefit of the patient and also decrease the cost of breast health care. The use of ultrasonographic guidance for such procedures provides a safe and effective real time technique to sample tissue while the patient lies in a comfortable supine position. The operator who has a good understanding of the procedure will be able to obtain reliable specimens efficiently and consistently.

Xeroradiography in the diagnosis of facial fractures.

Xeroradiography, because of its unique phenomenon of "edge enhancement," has some advantages for assessing facial fractures. In 17 of the 19 patients in our pilot study group, this technique was as valuable as, or more so than, plain films. The xerogram done prior to laminagraphy is a useful "map" for the radiologist to use in planning laminagraphic cuts. For the surgeon this technique offers a relatively accurate diagnostic tool, useful early after the facial injury.

Reconstruction of the radiated partial mastectomy defect with autogenous tissues.

As conservative surgery and radiation therapy have become accepted treatments for early-stage breast cancer, increasing attention has focused on the cosmetic results of this technique. When partial mastectomy--a term which encompasses a diversity of excisional techniques--is followed by radiation therapy, breast defects characterized by parenchymal loss, nipple-areola complex distortion, and cutaneous abnormalities can occur. From 1981 to 1990, eight patients sought reconstructive correction of a radiated partial mastectomy deformity. Patients were from 42 to 70 years of age (mean 49 years). All had breast cancer, except for one patient with diffuse and chronic breast abscesses. Six patients were reconstructed with latissimus dorsi flaps and two with rectus flaps. No patient underwent reconstruction sooner than 1 year after completion of radiation therapy; for the entire group, a mean of 2.6 years elapsed from completion of radiation therapy to flap reconstruction of the breast. Mammograms were obtained on all the breast cancer patients before and after the myocutaneous flap procedure. Follow-up extended from 1 to 9 years after reconstruction (mean 3.6 years) and included both physical examination and serial mammographic evaluations. Myocutaneous flap reconstruction with either latissimus or rectus flaps achieved an aesthetic improvement of the partial mastectomy deformity in all eight patients. Complications consisted only of seroma formation in two patients following latissimus flap reconstruction. Mammographic evaluation revealed fibrofatty degeneration of the soft tissues of both types of flaps, a change that occurs as early as 6 months after operation and appears as a radiolucent area. The feasibility of mammography as a screening adjunct for recurrent cancer in this group of patients is demonstrated. Advantages of this technique of autogenous tissue reconstruction are improvement of contour deformities associated with conservative surgery and radiation therapy, preservation of normal, sensate breast skin, enhancement of symmetry with the contralateral breast, and avoidance of a prosthesis.

Microwave thermography: principles, methods and clinical applications.

We review the physical principles, method of operation, measurement limitations, and potential medical applications of microwave thermography. We present detailed results of a study of breast cancer detection at 1.3 and 3.3 GHz, including the dependence of detection rates on microwave frequency, time, tumor depth, and tumor size. At 1.3 GHz, microwave thermography detects breast cancer as well as infrared thermography (true-positive rate = 0.76 when true-negative rate = 0.63). When the two methods are combined, the true-positive rate increases by about 0.1 over that of either method alone.

Microwave thermography in the detection of breast cancer.

Microwave thermography, a method of sensing subcutaneous temperatures, was used in a breast cancer detection study of about 5,000 female patients. The data were taken at wavelengths of 9.1 and 23 cm. Microwave thermography at 23 cm has true-positive and true-negative detection rates of 0.8 and 0.6, respectively, comparable to those of infrared thermography (0.7) and inferior to those of xeromammography (0.9). However, a potential advantage results if microwave and infrared thermography are used together for screening, and if mammography is used only for follow-up on those patients who were positive on either the microwave or the infrared thermograms. It is then possible to obtain true-positive and true-negative detection rates of 0.9 and 0.9, respectively, while only half the number of patients need be subjected to x-rays.

Breast imaging. A critical aspect of breast conserving treatment.

Breast imaging provides essential information for the selection and management of patients with early breast cancer who are treated by lumpectomy, irradiation, or both. In addition to its role in the detection and localization of early breast cancer, imaging is also important in the postoperative evaluation and in the long-term monitoring of these patients for the early detection of recurrence. The need for tailoring the examination at each stage and the significance of the findings for clinical and surgical management are discussed.

Radiologic detection of breast cancer. Review and recommendations.

In response to recent public demand for mammographic examination after the discovery of breast cancer in two women of national prominence, the Ad Hoc Committee on Mammography of the Massachusetts Radiological Society reviewed the present indications, benefits, and risks of radiologic technics used in the detection of neoplastic breast disease. Either low-dose film mammography or xeromammography can provide diagnostic information with minimal radiation hazard, and thermography is a sensitive though nonspecific technic for interim follow-up observations and for screening of large groups of well patients. Mammographic examination should be performed before contemplated breast operations and in women at high risk for the development of breast cancer, especially those who have had previous neoplastic breast disease. Routine mammographic studies on well women may be initiated after the age of 35 years, the frequency of periodic re-examination being determined by clinical and mammographic findings.

Mammographic features of the breast and breast cancer risk.

The authors conducted a case-control study at two Boston, Massachusetts, are hospitals to evaluate the relation of anatomic features of the breast, visible on the xeromammogram, to the risk of breast cancer. The cases were 408 women with newly diagnosed breast cancer and the controls were 1021 women without signs or symptoms of breast disease. The features of the breast assessed were the "parenchymal pattern" as defined by Wolfe (Am J Roentgenol 1976; 126:1132-9), and specific radiologic characteristics which are components of the parenchymal pattern classification. Women whose mammogram showed the P2 or DY parenchymal patterns were at elevated risk compared to women with the N1 pattern. Further, risk increased regularly with increases in the percentage of the breast that showed nodular densities and with increases in the average size and concentration of these densities. Women with extensive homogeneous density were also at elevated risk. These findings were observed only among women aged 20-59 years. In this group, women with nodular densities in 60% or more of the breast appeared to have a five-fold increase in risk compared to women without nodular densities in the breast.

The relation of mammographic features of the breast to breast cancer risk factors.

The authors evaluated the relation of breast cancer risk factors to the appearance of the breast on xeromammograms. Subjects were 1021 women without breast cancer whose first xeromammographic examination at one of two Boston, Massachusetts, area hospitals was done for a reason described as "baseline" or "routine." The principal mammographic features assessed were the percentage of the breast showing nodular densities and the percentage showing homogeneous density. The extent of nodular and homogeneous densities decreased as age increased. The amount of both types of density decreased with increase in the number of full-term pregnancies. The percentages of the breast showing nodular and homogeneous densities were slightly higher for premenopausal compared to postmenopausal women, and for women with a history of breast biopsy or aspiration compared to women without. Certain characteristics of observed relations between risk factors and mammographic features differed for the two types of densities.

Computer-assisted analysis of mammographic clustered calcifications.

A total of 127 biopsy-proven clustered mammographic calcifications were diagnosed and evaluated using multiple parameters. The results were subjected to computer analysis. The number of calcifications/cm2 was the most important parameter. Less than 10 calcifications/cm2 resulted in an 82% chance of being benign while 10 or more calcifications/cm2 had a 44% chance of being malignant. The average distance between the calcifications in the cluster was also significant, with a 92% chance of being benign if greater than 1 mm and a 52% chance of being malignant if less than 1 mm. The remaining parameters did not yield statistically significant results, but there were trends which suggest that less than 10 clustered calcifications that are regular in size and shape and orderly in appearance tend to be benign while disorderly clusters tend to be malignant. In order to decrease the number of false positive biopsies and improve the cost-effectiveness of screening mammography, radiologists should consider 6-month follow-up mammography as a reasonable alternative for clustered calcifications that appear benign.

Speech-controlled generation of radiology reports.

Voice entry has been successfully employed to generate radiology reports with a word recognizer with a 1,000-word lexicon capacity. About 50% of reports were able to be dictated with a single 900-word lexicon. This was split into five sections by anatomic or subspecialty application. Each was augmented to 900 words. By switching from one lexicon to another, it was possible to dictate more than 70% of reports. With exclusive use of three lexicons in subspecialty areas (gastrointestinal radiology, neuroradiology, and mammography), and with further modification of the respective vocabulary, it has been possible to employ the system 88% of the time. Twelve percent of cases included wording that was beyond the scope of the lexicon. Computer subsets that allow different translations of some words when used in different contexts have been used. Some of these are used as triggers that will print whole lines, sentences, or even complete reports. Dictation times with voice entry take about 20% longer. Recognition reliability has been greater than 95%.

Histologic and mammographic specificity of risk factors for benign breast disease.

This study evaluates the effects of potential risk factors for benign breast disease (BBD) with special attention to the histologic and mammographic specificity of the effects. Cases were 172 women with BBD that underwent biopsy; controls were 134 women free of breast signs or symptoms. All cases and controls had undergone mammography. For all types of BBD combined, parity, use of oral contraceptives, and use of exogenous estrogen after menopause were strongly protective, whereas obesity and early menarche were weakly protective. Family history of breast cancer was virtually unrelated to BBD. The protective effect of parity was stronger for BBD with intralobular or extralobular fibrosis, and with mammographic homogeneous density or large nodular densities, than it was for BBD without these characteristics. Similar relations with the histologic and mammographic features were observed for obesity. These findings suggest that some risk factors for BBD have effects that are related to specific features of its morphology.

Height and weight, mammographic features of breast tissue, and breast cancer risk.

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.