Breast cancer in the 21st century: from early detection to new therapies. / El cáncer de mama en el siglo XXI: de la detección precoz a los nuevos tratamientos.

The analysis of the causes that have given rise to a change in tendency in the incidence and mortality rates of breast cancer in the last few decades generates important revelations regarding the role of breast screening, the regular application of adjuvant therapies and the change of risk factors. The benefits of early detection have been accompanied by certain adverse effects, even in terms of an excessive number of prophylactic mastectomies. Recently, several updates have been published on the recommendations in breast cancer screening at an international level. On the other hand, the advances in genomics have made it possible to establish a new molecular classification of breast cancer. Our aim is to present an updated overview of the epidemiological situation of breast cancer, as well as some relevant issues from the point of view of diagnosis, such as molecular classification and different strategies for both population-based and opportunistic screening.

[Analysis of the positive predictive value of the subcategories of BI-RADS(®) 4 lesions: preliminary results in 880 lesions]. / Análisis del valor predictivo positivo de las subcategorías BI-RADS(®)4: resultados preliminares en 880 lesiones.

OBJECTIVES: The positive predictive values (PPV) of the subcategories of BI-RADS(®) 4 lesions (A/B/C) vary widely, and their correlation with specific descriptors has yet to be defined. We aimed to analyze the PPV of the subcategories and of the mammographic and ultrasonographic descriptors assigned to each. MATERIAL AND METHODS: We analyzed 880 histologically confirmed lesions prospectively classified as BI-RADS(®) 4 A/B/C between 2003 and 2010. The statistical analysis included significance tests, contingency tables, and relative risk (RR) ratios, calculated for 545 mammographic lesions and 627 ultrasonographic lesions. RESULTS: The PPV was 8.8% for subcategory 4A, 18.9% for subcategory 4B, and 58.3% for subcategory 4C. The correlation between PPV and lesions was what we expected, with three exceptions: a) the PPV of 4A was greater than that of 4B in nodules that were irregular or had uncircumscribed margins on ultrasonography and in microcalcifications with segmental distribution on mammography, b) BI-RADS(®) 3 lesions classified as BI-RADS(®) 4, and c) identical lesions classified in distinct subcategories. In the contingency table analysis, the mammographic lesions were 4B/C and the ultrasonographic lesions were 4B. On mammography, the RR was significant for nodules with irregular shape (RR=3.205) and for those with spiculated margins (RR=2.469), as well as for microcalcifications that were pleomorphic (RR=2.531) or amorphous (RR=0.334), and for those with segmental (RR=1.895). On ultrasonography, the RR were significant for all the descriptors, with values greater than 1 for irregular shape (RR=1.977) and uncircumscribed margins (RR=2.277). CONCLUSIONS: Our results corroborate previous reports. The exceptions can be explained by aspects related to variability and nonradiological factors that might influence the classification and PPV. Mathematical models should be developed to enable the objective classification and these should include factors not related to imaging.

Percutaneous microductectomy with a directional vacuum-assisted system guided by ultrasonography for the treatment of breast discharge: experience in 63 cases.

BACKGROUND: Vacuum-assisted devices are becoming a useful tool in the diagnosis and treatment of breast pathology. Recent publications show good results in percutaneous removal of benign lesions. PURPOSE: To discuss our experience in percutaneous excision of ductal lesions with a vacuum-assisted, ultrasound-guided directional system. MATERIAL AND METHODS: From January 2003 to July 2006, 63 patients with pathological nipple discharge and intraductal lesion identifiable on imaging were studied at two reference centers. Percutaneous excision with a vacuum-assisted device was offered as an alternative to surgery. RESULTS: A total of 71 lesions were diagnosed in 63 patients with a mean age of 52 years. All the patients presented nipple discharge. Mammography was normal in 65 cases (92%). Galactography showed an intraductal lesion in 67 cases (94%). Mean lesion size on ultrasonography was 7.4 mm (2-26 mm). Percutaneous excision was performed in 45 lesions (63%), while surgical excision was indicated in 26 lesions. The histopathological results in the 45 lesions biopsied demonstrated intraductal papilloma in 30 cases, dilated duct with papillomatous projections in 11, ductal ectasia with no papillary lesion in three, and a nonspecific benign result in one. Excision was considered complete in 41 lesions (91%). Clinical signs of discharge were resolved in 39 patients (95% of cases treated percutaneously). Mild complications occurred in four cases. CONCLUSION: Percutaneous excision of ductal lesions with an ultrasound-guided, vacuum-assisted device is a safe procedure with high diagnostic and therapeutic value for the management of breast discharge.

Impact of a CAD system in a screen-film mammography screening program: a prospective study.

OBJECTIVE: The purpose of our study was to perform a prospective assessment of the impact of a CAD system in a screen-film mammography screening program during a period of 3 years. MATERIALS AND METHODS: Our study was carried out on a population of 21,855 asymptomatic women (45-65 years). Mammograms were processed in a CAD system and independently interpreted by one of six radiologists. We analyzed the following parameters: sensitivity of radiologist's interpretation (without and with CAD), detection increase, recall rate and positive predictive value of biopsy, CAD's marks, radiologist's false negatives and comparative analysis of carcinomas detected and non-detected by CAD. RESULTS: Detection rate was 4.3‰. CAD supposed an increase of 0.1‰ in detection rate and 1% in the total number of cases (p<0.005). The impact on recall rate was not significant (0.4%) and PPV of percutaneous biopsy was unchanged by CAD (20.23%). CAD's marks were 2.7 per case and 0.7 per view. Radiologist's false negatives were 13 lesions which were initially considered as CAD's false positives. CONCLUSIONS: CAD supposed a significant increase in detection, without modifications in recall rates and PPV of biopsy. However, better results could have been achieved if radiologists had considered actionable those cases marked by CAD but initially misinterpreted.

Sonographically guided 11-G directional vacuum-assisted breast biopsy as an alternative to surgical excision: utility and cost study in probably benign lesions.

PURPOSE: To evaluate the utility and economic costs of the 11-G vacuum-assisted biopsy probe under ultrasound (US) guidance as an alternative to surgical excision in patients with probably benign lesions. MATERIAL AND METHODS: US-guided 11-G vacuum-assisted biopsy was performed in 102 probably benign breast lesions in 97 women who refused radiological follow-up. Complete removal of the lesion was intended in all cases. Open biopsy was done if questionable pathologic findings were present. Treatment was indicated if the diagnosis was malignant. Economic costs were estimated taking into consideration monetary expenses generated to the public health system, as well as expenses for the patients receiving percutaneous and open surgical biopsy. RESULTS: Median patient age was 42 years (range 18-77). Median lesion size was 14.7 mm (range 6-30 mm). Complete removal of the lesion seen at imaging was achieved in 72.5% of cases. Adequate tissue samples for histopathological evaluation were obtained in all cases. Surgical biopsy was recommended in nine cases. One patient diagnosed with mucinous carcinoma underwent immediate surgical treatment. The remaining 87 women with 92 lesions were included in a follow-up program. Economic cost of the 11-G vacuum-assisted percutaneous biopsy was 82% lower than the surgical biopsy (total savings in this series: 136,402.84 euros). Time spent for the patient was 71% less in percutaneous biopsy than in surgery. CONCLUSION: Ultrasound-guided 11-G directional vacuum-assisted breast biopsy is an accurate and less expensive procedure that can be used as an alternative to open surgical excision in a selected group of patients.