Management of Breast Intraductal Papilloma Diagnosed on Core Needle Biopsy: Excision or Follow-up?

Introduction Management of intraductal papillomas (IDPs) diagnosed on core needle biopsy (CNB) remains controversial. We report our experience of IDPs identified on CNB, our institutional rates of upgradation to atypia/malignancy as well as radiologic/pathologic features that may allow selection for surgery as well as those for safe observation. Methods The study is a retrospective review of patient records from 2012 to 2019, at a tertiary care hospital in Pakistan. Data was analyzed using Statistical Package for Social Sciences (SPSS), version 21.0 (IBM Corp., Armonk, NY). Associations between various patient factors were assessed using Pearson's chi-square test. Results This study included a total of 55 female patients with IDPs, with a mean age of 54.67 ± 15.57 years. On CNB, 69.1% (n = 38) of patients had IDP without atypia while 30.9% (n = 17) had IDP with atypia, with single IDPs being the most common lesions on excisional biopsy. Overall, of all CNB-diagnosed IDPs, only 4/55 (7.3%) demonstrated upgradation (3/4 to DCIS, 1/4 showed atypia) on excisional biopsy, and all these upgraded cases had failed to demonstrate atypia on initial CNB. Conclusion CNB-identified cases of IDPs are rarely upgraded on excision and thus routine excision in all cases may be unnecessary. Appropriate patient selection based on radiology-pathology findings should be done. Those with suspicious findings on imaging as well as those that demonstrate atypia on CNB must be excised.

Accuracy of Diffusion Weighted Imaging in Assessment of Pelvic Lymphnode Metastasis in Patients with Endometrial Cancer.

OBJECTIVE: To evaluate the sensitivity and specificity of diffusion-weighted imaging in determining metastatic pelvic lymph nodes in patients of endometrial cancer and comparing its accuracy with contrast-enhanced sequence of MRI, taking histopathology as gold standard. STUDY DESIGN: Retrospective Study. Place and Duration of the Study: Department of Radiology, the Aga Khan University Hospital Karachi, from January to December 2021. METHODOLOGY: Fifty-eight adult females with biopsy proven endometrial carcinoma and complete medical records were included through convenience sampling. Patients who did not have complete medical records were excluded. Studied variables included signal characteristics of lymph nodes and their short axis diameter. The sensitivity and specificity of DWI and contrast-enhanced MRI for evaluation of diseased lymph nodes were calculated using histopathology as the gold standard. RESULTS: Among 58 patients with histopathologically proven endometrial cancer, 14 had metastatic lymphadenopathy. DWI-weighted imaging in the evaluation of metastatic and non-metastatic lymph nodes had sensitivity of 81.1% while specificity, the positive and negative predictive value of 88.8%, 72.2%, and 82.5% and on contrast-enhanced imaging as 66.6%, 58.1%, 35.7%, and 83.3%, respectively. CONCLUSION: The DWI shows better accuracy in evaluation and discrimination between metastatic and non-metastatic lymph nodes as compared to contrast-enhanced MRI examination for the evaluation of diseased lymph nodes in patients with endometrial cancer. KEY WORDS: DWI, Contrast-enhanced MRI, Lymph node, Endometrial cancer.

Role of Multi-Detector Computed Tomography in the Diagnosis of Intestinal Obstruction.

INTRODUCTION: There is a need to identify patients whose small bowel obstruction (SBO) can resolve spontaneously so that unnecessary surgical interventions are avoided. This study aimed to evaluate the diagnostic accuracy of multi-detector computed tomography (MDCT) in intestinal obstruction and find out the presence, level, causes, and degree of intestinal obstruction taking intraoperative findings as gold standard. METHODOLOGY: This cross-sectional study was conducted analyzing 147 patients that were referred from emergency with abdominal pain, abdominal distension, inability to pass flatus, and aged 18-70 years from both genders. Computed tomography (CT) examinations were done and findings like intestinal dilatation, evidence of mesenteric fat stranding, and area of transition between the dilated and collapsed loops were noted. The final report was made by the radiologist while the operative findings were reviewed from the operative notes written by operative surgeons of the same patient. RESULTS: In a total of 147 patients, mean age was 52.38±16.01 years. There were 76 (51.70%) males and 71 (48.30%) females. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of multi-detector computed tomography scan in diagnosing intestinal obstruction, taking operative findings as gold standard, were 98.39%, 65.22%, 93.85%, 88.24%, and 93.20%, respectively. CONCLUSION: The multi-detector CT can be used routinely as a prime modality for detecting intestinal obstruction which will result in proper and timely management for reducing the morbidity and mortality of these particular patients.

Ultrasound-Guided Percutaneous Aspiration for the Treatment of Breast Abscess at a Tertiary Care Center in the Developing World.

PURPOSE: Percutaneous ultrasound (US)-guided aspiration is the first line of management for breast abscess. Our study aimed to look at the success of US-guided percutaneous drainage in managing breast abscesses at a tertiary care center and additionally to look for any correlation between US features and failure rate.  Methods: A retrospective review of the radiology database at a tertiary care hospital in Pakistan was done to identify 54 patients through non-probability convenience sampling who underwent a US-guided percutaneous aspiration with laboratory confirmation of abscess. A treatment course was observed for the development of complications or failure of treatment. A chi-square test was performed to correlate US features and patient characteristics with outcomes of treatment (p<0.05). Fisher's exact test was applied to evaluate the success of aspiration in small versus large abscesses, and in lactating versus non-lactating patients.  Results: 75% of all women were successfully able to avoid surgery. Specifically, 80.6% of all lactating women and 66.7 % of non-lactating women with breast abscesses were successfully managed with US-guided percutaneous aspiration. Across a variety of parameters measured, including pathological and etiological factors, as well as features on imaging, no significant association was established between the variables and the failure of the intervention. CONCLUSION: Low morbidity and high patient satisfaction rates make percutaneous aspiration preferable to surgical intervention as a first-line treatment of breast abscess. Early use of antibiotics is recommended as an adjunct to drainage.

Quadruplet heterotopic pregnancy; ectopic managed successfully with laparotomy with subsequent viable intrauterine pregnancy: A case report.

Heterotopic pregnancy is characterized by a concurrent intrauterine and ectopic pregnancy. It can occur after natural conception, however, it is more common with assisted reproductive techniques , when over one embryo is transferred. Quadruplet heterotopic pregnancy is an exceedingly rare subset. Our case describes a woman who presented to the emergency room with amenorrhea for 9 weeks and lower abdominal pain for 3 days. Transvaginal ultrasound revealed three alive intrauterine fetuses and one left tubal ectopic pregnancy (Quadruplet heterotopic pregnancy). Patient benefited from emergent laparotomy with favorable outcome both in the short term and in the long term. In a patient with a history of assisted reproductive techniques, a high index of suspicion is warranted towards extra-uterine pregnancy. Sonologists should precisely look for adnexal mass. The presence of peritoneal free-fluid requires further investigation. The prognosis of intrauterine fetuses is good, provided the ectopic pregnancy is managed timely and in an effective manner.

Factors associated with mammographic breast density among women in Karachi Pakistan.

BACKGROUND: There are no studies done to evaluate the distribution of mammographic breast density and factors associated with it among Pakistani women. METHODS: Participants included 477 women, who had received either diagnostic or screening mammography at two hospitals in Karachi Pakistan. Mammographic breast density was assessed using the Breast Imaging Reporting and Data System. In person interviews were conducted using a detailed questionnaire, to assess risk factors of interest, and venous blood was collected to measure serum vitamin D level at the end of the interview. To determine the association of potential factors with mammographic breast density, multivariable polytomous logistic regression was used. RESULTS: High-density mammographic breast density (heterogeneously and dense categories) was high and found in 62.4% of women. There was a significant association of both heterogeneously dense and dense breasts with women of a younger age group < 45 years (OR 2.68, 95% CI 1.60-4.49) and (OR 4.83, 95% CI 2.54-9.16) respectively. Women with heterogeneously dense and dense breasts versus fatty and fibroglandular breasts had a higher history of benign breast disease (OR 1.90, 95% CI 1.14-3.17) and (OR 3.61, 95% CI 1.90-6.86) respectively. There was an inverse relationship between breast density and body mass index. Women with dense breasts and heterogeneously dense breasts had lower body mass index (OR 0.94 95% CI 0.90-0.99) and (OR 0.81, 95% CI 0.76-0.87) respectively. There was no association of mammographic breast density with serum vitamin D levels, diet, and breast cancer. CONCLUSIONS: The findings of a positive association of higher mammographic density with younger age and benign breast disease and a negative association between body mass index and breast density are important findings that need to be considered in developing screening guidelines for the Pakistani population.

Feasibility of preoperative tattooing of percutaneously biopsied axillary lymph node: an experimental pilot study.

BACKGROUND: In the last three decades, axillary lymph node dissection (ALND) has been replaced by sentinel lymph node biopsy (SLNB) in all clinically node-negative patients. However, when SLNB alone is performed in clinically node-positive patients who are rendered node-negative by neoadjuvant chemotherapy, the procedure has a high false-negative rate and other complementary procedures have been described to improve its reliability. Preoperative tattooing of the suspicious lymph node with India ink at the time of biopsy, in addition to sentinel lymph node biopsy, is a reasonable alternative. The objective of our study is to determine, in clinically node-positive patients, the feasibility of tattooing suspicious axillary lymph node at the time of percutaneous needle biopsy and its retrieval at the time of surgery. METHODS: A prospective experimental study will be conducted divided into two phases-phases I and II. In phase I, 10 patients committed to undergo upfront surgery (without neoadjuvant chemotherapy) will have a suspicious lymph node tattooed by injecting India ink at the time of core needle biopsy. All patients will undergo a SLNB, during which the axilla will be inspected to determine if the tattooed lymph node can be visualized. Routine microscopic examination will follow, and concordance between the sentinel and tattooed node will also be established. In phase II, the process will be repeated for 30 patients who undergo surgery after neoadjuvant chemotherapy. The analysis will be performed in Stata version 12. DISCUSSION: There is a need to identify and test the techniques for the down-staged axilla in post-neoadjuvant chemotherapy patients, which are not only practical and limit the number of invasive procedures necessary but are representative of the new axillary status and help limit the extent of axillary surgery without negatively impacting outcomes. We propose that, for the patient undergoing neoadjuvant chemotherapy with a biopsy-proven disease in the axilla, this could be achieved by India ink which allows marking, identification, and retrieval of the biopsied lymph node. Retrieval of this previously biopsied lymph node along with sentinel nodes, if found to be representative of the status of the remainder of the axilla, could potentially eliminate the need for routine axillary lymph node dissection and thus limit morbidity. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03939598. Retrospectively registered on 7 May 2019.

Digital Breast Tomosynthesis Versus Additional Diagnostic Mammographic Views for the Evaluation of Asymmetric Mammographic Densities.

Introduction Many young females present with an advanced stage of breast cancer, which has a negative effect on the prognosis. Digital breast tomosynthesis is a new emerging imaging technique that aids in improving the specificity of mammography with subsequent early detection of breast cancer, especially in women with radiographically dense breasts. Tomosynthesis is subjectively preferred to conventional mammography and may offer superior diagnostic accuracy for the evaluation of breast lesions. Method Two breast radiologists retrospectively reviewed asymmetric densities using protocols that were institutional review board-approved in 185 patients aged 18 - 70 years (mean: 48 years) who underwent diagnostic mammography and tomosynthesis. Each asymmetric density was interpreted once with tomosynthesis and once with supplemental mammographic views; both modes included the mediolateral oblique and craniocaudal views in a fully crossed and balanced design by using a five-category Breast Imaging Reporting and Data System (BI-RADS) assessment and a probability-of-malignancy score. If the abnormality persisted and appeared benign or completely disappeared on both modalities, the agreement between additional views and tomosynthesis was determined by calculating Kappa value. If there was a discrepancy between additional views and tomosynthesis, the abnormality was subjected to ultrasound. In our study, 89 asymmetric densities were subjected to ultrasound. Results In a total of 182 cases, 84 (46.15%) were categorized as BIRADS-0; 97 (53.30 %) as BIRADS-I, and one (0.55 %) as BIRADS-II on an additional view. Among the asymmetric densities categorized as BIRADS-0 on additional mammography views, digital breast tomosynthesis categorized 72, six, five, and one patient as BIRADS-0, BIRADS-I, BIRADS-II, and BIRADS-IV, respectively. For densities categorized as BIRADS-I (97) on additional view, digital breast tomosynthesis categorized 10 and 87 densities as BIRADS-0 and BIRADS-I, respectively. No change in the BIRADS category was observed among BIRADS-II and BIRADS-IV. A significant difference was observed with the chi-square test among BIRADS categories assigned by an additional view and digital breast tomosynthesis with a p-value of < 0.001. There was, however, a substantial agreement among additional views and tomosynthesis with a kappa value of 0.767. Conclusion Our study results suggest that tomosynthesis may be equivalent to, if not more equivalent to, additional imaging in the assessment of mammographically-detected asymmetric densities, thus improving BI-RADS classification and patient management.

Outcome of Non-Malignant Papillary Lesions of the Breast on Core Biopsy: An Experience from a Tertiary Care Center in Pakistan.

Background Papillary lesions of the breast constitute a heterogeneous group ranging from non-malignant papillomas to papillary carcinoma. While surgical excision is recommended for atypical papilloma or papillary DCIS/ carcinoma on core biopsy, controversy persists in the management of benign papillomas which are diagnosed with core needle biopsy (CNB) since there are variable reported rates for tumor upgrade. The purpose of this study was to determine the outcome of papillary lesions of the breast diagnosed at image-guided CNB, after surgical excision or follow-up, and to identify potential predictors of high-risk lesions/malignancy on imaging. Materials and methods We retrospectively identified 52 non-malignant papillary lesions on core biopsy between January 2012 and June 2018. The outcome of surgical excision, as well as clinical and imaging features of these lesions, were assessed. The final histologic upgrade was recorded, and variables were compared between benign and atypical lesions on core biopsy as well as between upgraded and non-upgraded lesions after surgical excision.  Results Thirty-six lesions out of 52 lesions were benign papillomas on core biopsy, while 16 were papillary lesions with ADH/DCIS. All of these lesions except four benign papillomas were excised. Of the 32 benign papillomas excised, 7 were upgraded to papilloma with ADH/DCIS and one to DCIS with the focus of invasion. Among the 16 atypical lesions excised, one was upgraded to papillary DCIS with a final upgrade rate of 17.3%. There was no statistically significant clinical or imaging feature among those that were upgraded on excision from those that were not upgraded.  Conclusion Non-malignant papillary lesions have a significant upgrade rate. There are no reliable clinical or imaging features that can pre-surgically predict upgrade. Therefore, surgical excision of all papillary lesions is recommended for definitive diagnosis.

Preoperative Ultrasound-guided Core Biopsy of Axillary Nodes for Staging of Clinically Negative Axilla in Breast Cancer Patients - A Pilot Study.

Objective The aim of the current study is to determine the feasibility and accuracy of ultrasound-guided core biopsy for staging the axilla in clinically node-negative patients with invasive breast cancer. Introduction Historically, in breast cancer patients, axillary lymph node dissection was performed to stage axilla. Because of the high morbidity of axillary lymph node dissection, sentinel lymph node biopsy (SLNB) became the standard of care in patients with clinically node-negative breast cancer. However, SLNB is expensive, time consuming, can cause morbidity and can be complicated by seroma formation, sensory nerve injury, lymphedema, etc. Many centers rely on the availability of frozen section on sentinel lymph nodes to avoid a second procedure with the accuracy of procedure ranging from 73 to 96%, however, the availability of frozen section is limited in our part of the world. Pre-operative identification of axillary node positivity in patients with clinically negative nodes by ultrasound imaging of the axilla would allow one-stage axillary clearance and can decrease the need for SLNB from 21% to 70%. The aim of the present study is to determine the accuracy and feasibility of ultrasound-guided core biopsy to stage the axilla in clinically node-negative breast cancer patients, comparing with final histopathology as gold standard. Material & methods This was a non-randomized, prospective interventional study, done at Radiology Department of Aga Khan University Hospital. All patients diagnosed with breast cancer (histologically proven) with clinically negative axilla and ipsilateral positive axillary ultrasound were included. These patients underwent axillary lymph node core biopsy. If the result was negative they were subjected to SLNB. Histopathology result was taken as gold standard. Results The sensitivity of ultrasound-guided core biopsy was 88%, specificity 100%, positive predictive values (PPV) 100%, negative predictive values (NPV) 89.28%, diagnostic accuracy 94%. Conclusion In conclusion, the present study demonstrated high accuracy of ultrasound-guided axillary lymph node core biopsy in breast cancer patients with clinically node-negative axilla. Positive core biopsy results can thus obviate the need for sentinel lymph node biopsy and allow breast surgeons to directly proceed to axillary lymph node dissection.

Flipped Classroom Model for Teaching Undergraduate Students in Radiology.

OBJECTIVE: To determine the effectiveness of teaching through flipped classroom model on learning and acceptability of undergraduate medical students in their radiology clerkship. STUDY DESIGN: Quasi-experimental design. PLACE AND DURATION OF STUDY: Radiology Department, The Aga Khan University Hospital, Karachi, from July to September 2018. METHODOLOGY: Two groups (A and B) of third year medical students during their two weeks radiology clerkship were included. The topic of "chest X-ray" interpretation was presented in the flip classroom format to group B, while for the group A the same topic of chest X-ray was taught by traditional didactic lecture. The scores of the end of clerkship test of both groups were analysed using independent sample t-test. At the end of the clerkship, the students in group B completed the survey to share their experience and perception of flipped classroom model. RESULTS: A total of 40 third-year students participated in the study, 20 in each group. The mean test scores in the end of rotation test of group A was 7.3 and of group B was 7.2. No significant difference in the post-test scores was observed. Students' feedback on the experience of this pedagogical approach was positive and they also shared a few suggestions. CONCLUSION: Flipped classroom model had no significant impact on the end of clerkship test scores of medical students; however, an increased perceived value and acceptability of this model was noted by the participants.

Antenatal Ultrasound Diagnosis of Congenital High Airway Obstruction Syndrome: A Case Report and Review of Literature.

Congenital high airway obstruction syndrome (CHAOS) is a rare life-threatening fetal condition resulting from obstruction of the upper fetal airway which may be partial or complete. Prenatal diagnosis is crucial as it usually results in stillbirth or death after delivery if unrecognized. We report a case of CHAOS that was diagnosed prenatally due to characteristic ultrasound features. We also briefly review literature in light of current management options.

Polypoid Adenomyoma of the Uterus.

Polypoid adenomyoma is a rare uterine endometrial polypoid tumor of mixed epithelial and mesenchymal origin. Although the clinical and pathologic features of polypoid adenomyomas have been described extensively, imaging findings for these tumors have not been frequently reported in the literature. On imaging, their features may be confused with prolapsed leiomyomas or malignancy. Hemorrhagic cystic spaces in a prolapsed uterine tumor within the vagina should raise consideration of a diagnosis of polypoid adenomyoma. Such blood-containing cystic spaces would be unusual findings in leiomyomas and malignancy. Diagnosing polypoid adenomyoma is vital because it can potentially be managed by hysteroscopic resection, unlike an ordinary form of adenomyosis.

Diagnostic Accuracy of Pelvic MRI for Determination of the Cervical Involvement in Endometrial Cancer.

OBJECTIVE: To determine the diagnostic accuracy of pelvic MRI for assessment of the cervical involvement in endometrial cancer. STUDY DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: Radiology Department of the Aga Khan University Hospital, Karachi from January 2014 to December 2015. METHODOLOGY: Patients with biopsy-proven endometrial cancer were included, who had both their MRI and histopathological diagnosis performed at our institution. Those patients treated with chemo/radiotherapy or had incomplete medical records, were excluded. The extent of cervical involvement by endometrial carcinoma was seen on T2WI images, and findings were correlated after surgery taking histopathology as the gold standard. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were calculated. RESULTS: The mean age of the 56 patients was 60.87 ±8.80 years (range 37-84 years). The most common clinical indication was post-menopausal bleeding (n=37, 66.1%). The most common histological subtype was endometrioid adenocarcinoma (n=50, 89.3%). The sensitivity, specificity, diagnostic accuracy, positive and negative predictive values of MRI in the detection of cervical invasion were 92.85%, 88.09%, 89.28%, 72.22% and 97.36%, respectively. CONCLUSION: MRI is a highly sensitive and specific imaging modality for detection of cervical invasion in endometrial carcinoma.

Cesarean Scar Pregnancy: An Experience of Three Cases with Review of Literature.

Cesarean scar pregnancy (CSP), often considered the rarest form of ectopic pregnancy, is a result of implantation of the gestational sac into the fibrous tissue scar of a previous cesarean section. With an increase in the rate of cesarean sections, along with better awareness and improvement in sonographic diagnosis, the number and detection of scar pregnancies are on the rise. Because of its early invasion of the myometrium, usually in the first trimester, CSP is considered to be potentially lethal, leading to high risks of uterine rupture. We report a series of three cases of scar pregnancy that presented at different gestational ages and were managed by different methods. The aim of this case series is to share our experience with CSP, review previous literature, and emphasize on the radiological criteria to making a confident diagnosis. Diagnosis and management of CSP needs considerable expertise and a multidisciplinary approach to prevent complications.

Accuracy of Specimen Radiography in Assessing Complete Local Excision with Breast-Conservation Surgery

Objective: The aim of this study was to evaluate the accuracy of "X- ray examination of surgically resected specimen'' in assessing complete local excision (CLE). Materials and Methods: In this retrospective cross sectional study, data were collected for all female breast cancer cases who underwent breast-conserving surgery after needle localization of mammographically visible disease. Males, patients with mammographically invisible disease and cases with benign or inconclusive histopathology, those undergoing modified radical mastectomy and individuals with dense breast parenchyma were excluded. We evaluated radiography of resected specimens to assess margin spiculation, distance of mass/microcalcification from the excised margin, presence of a mass, and presence of any adjacent microcalcification, Other features including mass size, nuclear grade and patient's age were also recorded and all were analyzed for any association with CLE. Results: Absence of adjacent microcalcification and the presence of a mass on radiographs showed significant associations with CLE, but no links were evident with other features. Specimen radiography was found to be a sufficient tool to predict CLE with a positive predictive value of 83.3%, a sensitivity of 80.7% and a specificity of 81%. Conclusion: Specimen radiography is an important and sensitive tool to predict CLE.

Transverse Vaginal Septum: Report of Two Patients with MRI Findings.

The transverse vaginal septum is a rare form of Mullerian duct anomaly, and is a disorder of vertical fusion of Mullerian system with the sinovaginal bulb. Magnetic resonance imaging (MRI)is very useful in the detection, classification and management planning of this rare anomaly. We present two cases of transverse vaginal septum in two patients of different age groups and with different clinical presentations. The findings on MRI, related to presence of vaginal septum and the management work-up, are also discussed.

Imaging Guided Breast Interventions.

Breast imaging is a developing field, with new and upcoming innovations, decreasing the morbidity and mortality related to breast pathologies with main emphasis on breast cancer. Breast imaging has an essential role in the detection and management of breast disease. It includes a multimodality approach, i.e. mammography, ultrasound, magnetic resonance imaging, nuclear medicine techniques and interventional procedures, done for the diagnosis and definitive management of breast abnormalities. The range of methods to perform biopsy of a suspicious breast lesion found on imaging has also increased markedly from the 1990s with hi-technological progress in surgical as well as percutaneous breast biopsy methods. The image guided percutaneous breast biopsy procedures cause minimal breast scarring, save time, and relieve the patient of the anxiety of going to the operation theatre. The aim of this review was to describe and discuss the different image guided breast biopsy techniques presently employed along with the indications, contraindication, merits and demerits of each method.

Evaluation of Common Risk Factors for Breast Carcinoma in Females: a Hospital Based Study in Karachi, Pakistan.

BACKGROUND: Breast malignancies are one of the leading causes of deaths in females worldwide. There are a number of risk factors associated with breast cancer but in Karachi Pakistan there are insufficient data available. MATERIALS AND METHODS: A case control study was conducted on females in age group between 30-80 years. This study was accomplished by retrospective data collection in Aga Khan University Hospital Karachi, Pakistan. A total of 108 females with primary malignancy of breast were included along with 108 matched controls. Relationship of various factors with disease was studied using logistic regression to calculate odds ratios with 95 % confidence intervals. RESULTS: A total of 14 variables were analyzed and based on and 7 were found to be risk factors: old age, family history of breast cancer, family history of other carcinomas, personal history of breast carcinoma, early age of menarche, older age of mother at first delivery and lower number of children. Five factors, parity, breast feeding, history of oral contraceptive pills intake, past history of oophorectomy and hysterectomy showed protective associations. One variable, use of hormonal replacement therapy, showed a controversial link and one other, marital status, was not significant in this study. CONCLUSIONS: It is concluded that most of the well-known risk factors for breast cancer are also associated with the disease in the female population of Karachi, Pakistan. High risk patients should be the focus with the help of this study so that screening can be more effective for early diagnosis before clinically evident breast malignancy.

Targeted Ultrasound of an Indeterminate Breast Lesion on Mammography: When Does It Influence Management?

OBJECTIVE: To determine the change over mammographic diagnosis, BI-RADS category and management following targeted ultrasound of an indeterminate lesion seen on mammography and associated factors, if any. STUDY DESIGN: Descriptive, analytical study. PLACE AND DURATION OF STUDY: Radiology Department, The Aga Khan University Hospital and Clifton Medical Services, Karachi, from April 2010 to May 2011. METHODOLOGY: Patients referred for targeted breast ultrasound following X-ray mammography were selected regardless of age. Targeted Ultrasound (TUS) was defined as a limited ultrasound of a specific lesion or breast part as indicated by the referring source. Comparison was made between the post mammography and post TUS lesion characterization, diagnosis and BI-RADS category (0-5) which was taken as a measure of management change. Those were evaluated to determine significance of age, marital status, parity, breast parenchymal pattern ( dense, fatty, heterogeneous), referring source for the TUS (radiology resident, radiologist or surgeon), lesion characteristics (density, echogenecity, shape, location, margins, size, depth-to-width ratio, enhancement or shadowing), presenting symptoms or signs and reason for TUS. Ap-value of 0.05 or less was taken as significant. RESULTS: There were a total of 342 patients with mean age of 49.7 ±13.5 years. It assigned a definite category in 232 patients with an indefinite category (0) on mammography requiring further investigation. It decreased the suspicion for malignancy in 180 (77.58%) by assigning a low BI-RADS category and increased the suspicion in 52 (22.41%). The factors significantly associated with this changes included clinical indication being diagnostic (p < 0.001), lesion characteristics on imaging (p < 0.001), heterogenous breast parenchymal pattern (p < 0.001) and presence of known risk factors (p=0.049). CONCLUSION: TUS served as a problem solving tool in the evaluation and management of an indeterminate breast lesion in a high number of patients, particularly when there was a lump as indication for imaging in the presence of risk factors in a patient with otherwise heterogeneously dense breast parenchyma.