Renal Leiomyoma: A Case Report and Review of the Literature.

Leiomyoma is an uncommon tumor of the kidney. The authors report a rare case of renal leiomyoma in a 39-year-old male patient who presented with a right flank mass. Laparoscopic nephrectomy was performed. The histopathology and immunohistochemistry confirm the diagnosis of renal leiomyoma. The review of literature in the clinicoradiopathological correlation was illustrated.

Bilateral pseudoangiomatous stromal hyperplasia in a human immunodeficiency viral-infected patient.

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon mesenchymal neoplasm of the breast demonstrating stromal myofibroblastic proliferation and having the appearance of anastomosing slit-like pseudovascular spaces lined by spindle-shaped cells. A case of nodular PASH of the bilateral breasts in a 40-year-old woman with clinically presenting with a progressive enlarged breast lump is reported. Mammographic and ultrasonographic features of the right and left breasts showed a large solid lump with well-circumscribed border measuring 4 cm × 1.7 cm × 3.4 cm and 13.8 cm × 10.9 cm × 12.1 cm, respectively. Wide excision of the right breast and quadrantectomy of the left breast were performed. The histopathological examination of the lesion showed anastomosing slit-like pseudovascular spaces. The stromal cells were immunoreactive for muscle actin (HHF35), smooth muscle actin, and progesterone receptor. Clinical and pathological findings with briefly reviewed relevant literatures are discussed. This is the first clinicopathological and radiological report of bilateral mammary nodular PASH in a human immunodeficiency viral-infected patient.

Esthesioneuroblastoma metastasis to the breast: A case report and review of the literature.

Metastasis to the breast from an extramammary malignant neoplasm, including esthesioneuroblastoma, is uncommon. The present study describes a rare case of sinonasal esthesioneuroblastoma, Hyams' histologic grade 2, Kadish's stage C, T4N0M0, in a 30-year-old female. The patient underwent a radical ethmoidectomy with external beam radiotherapy, followed by chemotherapy including five cycles of cisplatin and etoposide. One year after the initial diagnosis, the patient presented to the hospital with the chief complaint of a rapidly enlarging lump in the right breast. A fine needle aspiration was performed and immunocytochemistry revealed a metastatic esthesioneuroblastoma. The patient received palliative chemotherapy and radiotherapy; however, the patient developed a local recurrence with systemic metastasis and succumbed to the disease seven months later.

Development and validation of a breast cancer risk prediction model for Thai women: a cross-sectional study.

BACKGROUND: Breast cancer risk prediction models are widely used in clinical practice. They should be useful in identifying high risk women for screening in limited-resource countries. However, previous models showed poor performance in derived and validated settings. Therefore, we aimed to develop and validate a breast cancer risk prediction model for Thai women. MATERIALS AND METHODS: This cross-sectional study consisted of derived and validation phases. Data collected at Ramathibodi and other two hospitals were used for deriving and externally validating models, respectively. Multiple logistic regression was applied to construct the model. Calibration and discrimination performances were assessed using the observed/expected ratio and concordance statistic (C-statistic), respectively. A bootstrap with 200 repetitions was applied for internal validation. RESULTS: Age, menopausal status, body mass index, and use of oral contraceptives were significantly associated with breast cancer and were included in the model. Observed/expected ratio and C-statistic were 1.00 (95% CI: 0.82, 1.21) and 0.651 (95% CI: 0.595, 0.707), respectively. Internal validation showed good performance with a bias of 0.010 (95% CI: 0.002, 0.018) and C-statistic of 0.646(95% CI: 0.642, 0.650). The observed/expected ratio and C-statistic from external validation were 0.97 (95% CI: 0.68, 1.35) and 0.609 (95% CI: 0.511, 0.706), respectively. Risk scores were created and was stratified as low (0-0.86), low-intermediate (0.87-1.14), intermediate-high (1.15-1.52), and high-risk (1.53-3.40) groups. CONCLUSIONS: A Thai breast cancer risk prediction model was created with good calibration and fair discrimination performance. Risk stratification should aid to prioritize high risk women to receive an organized breast cancer screening program in Thailand and other limited-resource countries.

Fibroadenoma versus phyllodes tumor: distinguishing factors in patients diagnosed with fibroepithelial lesions after a core needle biopsy.

PURPOSE: We aimed to identify factors that might help differentiate phyllodes tumors from fibroadenomas among cases in which a fibroepithelial breast lesion was diagnosed from core needle biopsy (CNB) under imaging guidance. MATERIALS AND METHODS: A retrospective review was performed on 213 lesions in 200 patients who had undergone both CNB and excisional biopsy during a four-year period between 2008 and 2011. The final pathology revealed 173 fibroadenomas and 40 phyllodes tumors. The data, including patient characteristics, clinical presentation, and mammography, ultrasonography (US), and pathology findings were analyzed. RESULTS: Upon univariable analysis, the factors that significantly helped to identify phyllodes tumors consisted of the presenting symptoms (palpable mass or breast pain), increased size on clinical examination, hyperdense mass on mammogram, and the following three US features: heterogeneous echo, presence of round cysts within the mass, and presence of clefts within the mass. The pathologist's suggestion of a phyllodes tumor was also helpful. The factors that remained statistically significant upon multivariable analysis consisted of symptoms of breast pain, the presence of clefts on US, the presence of round cysts on US and the pathologist's favoring of phyllodes tumors from a CNB specimen. CONCLUSION: A multidisciplinary approach was needed to distinguish phyllodes tumors from fibroadenomas in patients who had undergone CNB. US findings (clefts and round cysts), suggestive pathological diagnoses, and clinical symptoms were all useful for the decision to surgically remove the fibroepithelial lesions diagnosed from CNB.

Ultrasound predictors of thyroid cancer.

OBJECTIVE: To identify ultrasound (US) features associated with cancer in thyroid nodules. MATERIAL AND METHOD: During a two and a half-year period, medical charts, US images, and pathological findings in 629 consecutive patients with thyroid nodules who underwent US examination as well as fine needle aspiration biopsy (FNAB) or surgical excision or both were retrospectively reviewed. Clinical and US findings associated with thyroid cancer were identified using statistical models. RESULTS: Unequivocal cytological or pathological findings were available for 578 patients. Forty-eight patients (8%) had thyroid cancer. Independent clinical and US features associated with thyroid cancer included younger age, symptoms other than palpable mass, solid nodules, fewer number of nodules, presence of calcifications, and enlarged cervical lymph nodes. The combination of all these features was most specific for the diagnosis of thyroid cancer. The absence of all these features could rule out all thyroid cancers. CONCLUSION: The risk of the thyroid cancer in patients with thyroid nodules could be estimated by using relevant clinical and US features.

Upgrading rate of papillary breast lesions diagnosed by core-needle biopsy.

PURPOSE: We aimed to estimate the upgrading rate of core-needle biopsy (CNB)-diagnosed papillary breast lesions to atypical or malignant papillary lesions on subsequent surgery. MATERIALS AND METHODS: We performed a retrospective review of medical records and imaging findings of patients diagnosed by CNB as having papillary lesions from January 1, 2005 to May 31, 2011. Outcomes were determined by pathology findings from surgical excision or by imaging findings at 12 months follow-up. RESULTS: Of 130 papillary lesions in 127 patients, the upgrading rates were 0% for benign papillary lesion to malignancy, 19% for benign papillary lesion to atypical papillary lesion, and 31% for atypical lesion to malignancy. Most of the malignancies were ductal carcinoma in situ. The presence of malignant lesions was related to specific symptoms (palpable mass or nipple discharge; P = 0.020) and to a higher Breast Imaging Reporting and Data System (BIRADS) category (P = 0.017). CONCLUSION: CNB is accurate in the diagnosis of benign papillary lesions. If no atypical cells are present, no malignancy is found. The presence of atypia on CNB strongly indicates a need for surgical excision.

Risk factors of breast cancer: a systematic review and meta-analysis.

The etiology of breast cancer might be explained by 2 mechanisms, namely, differentiation and proliferation of breast epithelial cells mediated by hormonal factors. We performed a systematic review and meta-analysis to update effects of risk factors for both mechanisms. MEDLINE and EMBASE were searched up to January 2011. Studies that assessed association between oral contraceptives (OC), hormonal replacement therapy (HRT), diabetes mellitus (DM), or breastfeeding and breast cancer were eligible. Relative risks with their confidence intervals (CIs) were extracted. A random-effects method was applied for pooling the effect size. The pooled odds ratios of OC, HRT, and DM were 1.10 (95% CI = 1.03-1.18), 1.23 (95% CI = 1.21-1.25), and 1.14 (95% CI = 1.09-1.19), respectively, whereas the pooled odds ratio of ever-breastfeeding was 0.72 (95% CI = 0.58-0.89). Our study suggests that OC, HRT, and DM might increase risks, whereas breastfeeding might lower risks of breast cancer.

Focal fibrosis of the breast diagnosed by core needle biopsy under imaging guidance.

BACKGROUND: Focal fibrosis of the breast is an uncommon pathology, recognition of this lesion is important because it could mimic malignant lesions on both mammogram and ultrasonography (US). Concordance with the pathology result from core needle biopsy (CNB) and follow-up are essential to avoid false negative. OBJECTIVE: To characterize the mammographic and US features of focal fibrosis of the breast and to estimate the false negative rate for breast cancer when focal fibrosis was diagnosed by CNB. MATERIAL AND METHOD: The subjects were 82 patients diagnosed fibrosis of the breast by CNB during 7-year period. RESULTS: Of 38 mammographic visible lesions there were mass lesions in 12 (32%), calcifications in 14 (37%), mass with calcifications in four (11%), architectural distortion in one (3%) and asymmetrical density in seven (18%). Most of the lesions seen on the US were hypoechoic mass (81%). The suspicious features, which warrant CNB, included irregular shape in 37 (55%), indistinct margin in 38 (57%), and posterior shadowing in 28 (42%). Most of the lesions were categorized as Breast Imaging Reporting and Data System (BI-RADS) 4A (59%). Thirteen cases underwent surgical biopsy and all showed benign pathologic results. No false-negative cases were detected. CONCLUSION: Focal fibrosis had some features similar to malignant lesion. CNB showed reliable pathological result. No false negative result was found in the present study.

A clinicopathologic study of tuberculous epididymo-orchitis in Thailand.

Tuberculous epididymo-orchitis is an uncommon disease caused by Mycobacterium tuberculosis of the testis and epididymis. We reviewed 25 cases of tuberculous epididymo-orchitis, diagnosed at the Faculty of Medicine Ramathibodi Hospital, Mahidol University between July 2000 and June 2010. The mean age at diagnosis was 54.5 years (range: 30 to 91 years). Cultures from testicular and epididymal tissues were positive for Mycobacterium tuberculosis in 6 cases. The clinical presentations of tuberculous epididymo-orchitis included scrotal mass (80%), scrotal pain (44%), micturition syndrome (8%), urethral discharge (4%), and scrotal fistula (4%). One third of the patients had pulmonary tuberculosis. Four patients (16%) had underlying human immunodeficiency virus infection. Tuberculous epididymo-orchitis should be considered in the patients who present with a scrotal mass. The preoperative differentiation of tuberculous epididymoorchitis from non-tuberculous epididymo-orchitis and testicular tumor is difficult. In patients who have epididymal and testicular lesions, surgical excision provides the diagnosis. Exact histopathologic categorization is important to select appropriate medical therapy.

Impact and appropriateness of the emergency ultrasonography in a tertiary care hospital.

OBJECTIVE: To quantify the notion of the impact of ultrasonography (US) on and the appropriateness of its use in, the diagnosis and treatment of emergency conditions. MATERIAL AND METHOD: A prospective study was conducted between September 2006 andApri 2007 at a tertiary care hospital. US was performed or supervised by experienced staff radiologists during the working hours and by final year radiology residents during the off-hours. Data collection forms were filled by radiology residents. The final discharge diagnoses were obtained from medical charts and computerized records. Data collected included age, gender provisional diagnosis, ultrasound findings, the discharge diagnosis, time of ultrasound examination, other radiologic investigations and therapeutic interventions. Outcomes included the impact, appropriateness, and diagnostic accuracy of US. RESULTS: Six hundred eighteen patients underwent 702 emergency ultrasound examinations. The median age was 51 years. Approximately 50% were male. The anatomical region most commonly examined was the abdomen (80%). US had an impact on clinical management in 85% of all examinations. Appropriate use of US was seen in 64% of all examinations. The overall accuracy of US was 90%. Factors associated with higher impact included suspected urological, vascular and musculoskeletal conditions, while vague abdominal conditions were associated with less impact. CONCLUSION: The impact of US on the management of emergency conditions was high and most requests for US were appropriate. However a more efficient use of emergency US is still possible, especially for abdominal conditions.

Factors associated with upstaging of ductal carcinoma in situ diagnosed by core needle biopsy using imaging guidance.

PURPOSE: The aim of this study was to estimate the upstaging rate of ductal carcinoma in situ (DCIS) diagnosed by core needle biopsy (CNB) under imaging guidance and to identify factors related to upstaging. MATERIALS AND METHODS: During an 8-year period, pure DCIS was diagnosed by imaging-guided CNB followed by definitive surgery in 128 patients. Data on pathological, clinical, and radiological findings were obtained. RESULTS: DCIS upstaging in the present study was 24% (31 of 128 patients had invasive cancer in the final surgical specimen), and the rate was 41% if the cases with microinvasion were included. Factors significantly associated with any type of upstaging included radiological factors (BI-RADS category), factors related to CNB technique (modality of image guidance, size of the core needle, number of cores), and pathological factors (histological grading and presence of comedonecrosis). Multivariable analysis revealed that higher histological grade [odds ratio (OR) and 95% confidence interval (CI) were 2.50 (1.10-5.67)], smaller needle size (no. 14 vs. no. 11) [OR 3.57 (1.11-11.4)], and the presence of comedonecrosis [OR 3.78 (1.32-10.8)] were significantly and independently related to upstaging. CONCLUSION: High-grade DCIS, using a smaller needle, and the presence of comedonecrosis in the CNB specimen were associated with a higher risk for invasive carcinoma.

Diagnostic accuracy of vacuum-assisted stereotactic core needle biopsy for breast lesions.

OBJECTIVE: To evaluate the diagnostic accuracy of the vacuum-assisted stereotactic core needle biopsy (CNB) for breast lesions. MATERIAL AND METHOD: Sixty-four lesions that had undergone vacuum-assisted stereotactic CNB between January 2003 and December 2005 in Ramathibodi Breast diagnostic center were included in this study. Pathologic results of CNB were reviewed and correlated with pathologic results of subsequent open surgery. For benign lesions without surgery, the authors correlated the result of CNB with stability of the lesion at or more than 2-year interval follow-up. Agreement rate, high-risk under estimate rate, Ductal carcinoma in situ (DCIS) underestimate rate, false negative rate, and sensitivity were accessed RESULTS: The pathologic results for the CNB were malignancy in 20%, high-risk in 13%, and benign in 67%. The agreement rate was 93.8% (60 of 64). The under estimate rate for atypical ductal hyperplasia (ADH) was 50% (3 of 6). There was no underestimate for DCIS in the present study. Of 43 benign lesions, malignancy was found at subsequent open surgery in one lesion and false negative rate was 6%. Calculated sensitivity was 96%. CONCLUSION: Vacuum-assisted CNB is an accurate method for evaluating breast lesions. This procedure is an alternative to surgical excision for lesion assessments.

Biopsy rate and positive predictive value for breast cancer in BI-RADS category 4 breast lesions.

OBJECTIVE: To examine the biopsy rate and positive predictive value (PPV) for breast cancer in lesions categorized as BI-RADS (Breast Imaging reporting and Data System) category 4. MATERIAL AND METHOD: The medical records of patients with BIRADS 4 breast lesion diagnosed at the breast diagnostic center Ramathibodi Hospital between December 1, 2004 and December 31, 2005 were retrospectively reviewed. PPV was calculated for patients who had biopsy performed or had clinical follow-up for at least two years. The radiographic and pathological findings were compared. RESULTS: The biopsy rate of 536 lesions categorized as BI-RADS 4 was 75% (403 of 536). Malignancy was found in 95 of 460 patients; or a PPV of 21%, PPVs for subcategories 4A, 4B and 4C, were 9%, 21% and 57%, respectively. The most common malignancy was invasive ductal carcinoma (67%). Patients with advanced age, having a clinically palpable breast mass of large size, with mammographic findings of architectural distortion and asymmetrical density were significantly associated with a higher risk of breast cancer. CONCLUSION: PPV for malignancy in the present study was comparable to previous studies. In subcategories 4B and 4C, the malignancy rate was higher than that in subcategory 4A.

Indeterminate or suspicious breast lesions detected initially with MR imaging: value of MRI-directed breast ultrasound.

RATIONALE AND OBJECTIVES: To retrospectively determine the value of magnetic resonance imaging (MRI)-directed breast ultrasonography (US) in the evaluation of indeterminate or suspicious lesions identified on contrast-enhanced, breast MRI. MATERIALS AND METHODS: A total of 395 patients presenting for breast MRI during a 4-year period was retrospectively reviewed. Seventy-one patients were recommended for MRI-directed US for further characterization of indeterminate or suspicious breast lesions detected on MRI. Fifty-five patients (all female; age 31-80 years) had US. Their MRI and US were reviewed and tested for correlations with histologic results or long term follow-up. Logistic regression analyses were used to test for associations between MRI lesion characteristics and US detection rate. RESULTS: US identified 46 of 97 (47%) lesions depicted at MRI from 55 patients (47 [85%] of these patients had histories of breast malignancies). Twelve cancers were found from the 97 lesions (12%). Biopsy was avoidable in 10 lesions (10%). The detection rate with US was slightly higher with "mass" (55% [23/42]) lesions described in MRI than "non-mass" lesions or lymph nodes (42% [23/55]). There was a significant positive association (odd ratio = 1.23: 95% CI = 1.05-1.43, P = .01) between US detection rate and MRI mass lesion size. There was no statistical significance between US detection rate and the presence of malignancies; 42% (5/12) of MRI malignant lesions were not visualized with US. CONCLUSIONS: MRI-directed US reduced the number of biopsies required for indeterminate or suspicious MRI lesions. Nevertheless, the lesions which were biopsied had a low rate of malignancy.

Positive predictive value of breast cancer in the lesions categorized as BI-RADS category 5.

OBJECTIVE: To determine positive predictive value (PPV) of the breast imaging reporting and data systems (BI-RADS) category 5 mammogram and ultrasound (US) in the diagnosis of breast cancer in the study center and correlation between clinical, mammographic and US findings, and breast cancer. MATERIAL AND METHOD: Four hundred and ninety seven patients with BI-RADS category 5 who underwent mammograms and US at the Breast diagnostic center, Ramathibodi Hospital from January, 1, 2002 to December 31, 2004 were enrolled into the present study. Selected clinical information, mammographic and US findings, and histopathological diagnosis were retrospectively reviewed. RESULTS: Breast cancer was found in 467 of 497 patients, giving a PPV of 94%. Invasive ductal carcinoma was the most common malignancy (89.5%). Fibrocystic change was the most common benign pathology found in the remaining patients. Discrete mass was the most frequently encountered lesion detected on mammography and US, followed by mass containing calcifications. Patients with advanced age, having a clinically palpable breast mass, with mammographic and US evidence of mass containing calcifications showed significant statistical association with breast cancer. CONCLUSION: PPV of BI-RADS category 5 lesions in the present study was comparable to other published studies. Although the probability of malignancy was very high, a small number of patients had benign pathologies. Preoperative histopathologic diagnosis is necessary before definitive treatment.

Breast cancer in patients initially assigned as BI-RADS category 3.

OBJECTIVES: To determine the Positive Predictive Value (PPV) for malignancy and characteristics of breast cancer found in patients who were initially categorized as having Breast Imaging Reporting and Data System (BI-RADS) 3. MATERIAL AND METHOD: Medical records of patients assigned to BI-RADS 3 from January, 1st to December; 31st 2002 at the Breast diagnostic center, Ramathibodi Hospital who had imaging follow-up for at least 2 years or had biopsy performed were retrospectively reviewed RESULTS: Of 949 patients, 23 were found to have malignancy, i.e., 2.4% PPV. The most common imaging findings of breast cancer were calcifications on mammogram and mass on sonogram. Mean interval from first imaging to biopsy was 13.1 months. Only 78% of malignancies were diagnosed within 2 years. Less than 50% of these were ductal carcinoma in situ or stage I invasive ductal carcinoma. CONCLUSION: PPV for malignancy in the present study was comparable to the previous studies. However, longer time to diagnosis and more advanced stage of breast cancer at diagnosis were found Periodically short-interval mammogram and sonogram, at not less than 2 year-intervals, were recommended

Breast pain and service satisfaction during digital mammography.

OBJECTIVES: To determine the frequency and predisposing factors of breast pain felt during digital mammography, and factors associated with service satisfaction. MATERIAL AND METHOD: A questionnaire was distributed to 1250 women immediately after their mammography. The outcomes assessed were a five-point scale of breast pain and rating of the satisfaction with the mammography service. Several factors potentially associated with breast pain and satisfaction were obtained from the questionnaire and analyzed. Multiple cumulative logit regression was used to identify independent, significant factors. RESULTS: Breast pain was found to be absent in 22% of patients, slight in 50%, moderate in 23% and substantial or severe in only 4%. Significant factors associated with breast pain during mammography included higher educational level, having no children, having had prior mammography, impolite and rough radiographer and poorly performed mammography. Factors associated with satisfaction with the mammography service included older age, polite and gentle radiographer and well-performed mammography. CONCLUSION: Radiographer delivery of the mammography service seemed to be the most important, modifiable reason for breast pain during mammography and dissatisfaction with the mammography service.

Breast cancer underestimation rate of atypical ductal hyperplasia diagnosed by core-needle biopsy under imaging guidance.

OBJECTIVE: To evaluate breast cancer underestimation rate of atypical ductal hyperplasia (ADH) diagnosed by core-needle biopsy (CNB) under imaging guidance in Ramathibodi Hospital and to determine the difference between the malignant and benign groups in terms of clinical and imaging characteristics. MATERIAL AND METHOD: The pathological records of 1521 patients who underwent CNB under imaging guidance were reviewed. Thirty-nine patients diagnosed with ADH were enrolled into the present study. Clinical data, imaging features, biopsy technique and result of excisional biopsy as well as follow-up data were retrospectively reviewed. RESULTS: Of 39 ADH cases, eight (20.5%) were found to have malignancy on subsequent excisional biopsy. The majority of these were ductal carcinoma in situ (DCIS) (62.5%). Lesion categorized as category 5 according to BI-RADS (Breast imaging reporting and data system) was the only feature which was statistically different between the benign and malignant groups. No statistically significant difference was found between the benign and malignant groups in terms of age, personal and family history of breast cancer, clinical finding, mammographic lesion type, size of lesion, image-guided technique and percentage of lesion removal. CONCLUSION: The underestimation rate of ADH in the present study was comparable to other studies. The finding of Bl-RADS category 5 in patients with ADH diagnosed from CNB is a strong indication for subsequent excisional biopsy.