A practical approach to imaging the axilla.

Imaging of the axilla typically occurs when patients present with axillary symptoms or newly diagnosed breast cancer. An awareness of the axillary anatomy is essential in order to generate an accurate differential diagnosis and guide patient management. The purpose of this article is to review the indications for axillary imaging, discuss the logistics of the scanning technique and percutaneous interventions, and present the imaging findings and management of a variety of breast diseases involving the axilla. Teaching points • Knowledge of normal axillary anatomy aids in determining the aetiology of an axillary mass. • The differential diagnosis of an axillary mass is broad and can be subdivided by the location of the lesion. • Imaging evaluation of the axilla usually entails diagnostic mammography and targeted ultrasound. • FNA or core needle biopsies are safe and accurate methods for diagnosis and guiding management.

Barriers and opportunities for early detection of breast cancer in Gaza women.

A survey of 100 women living inside Gaza (WIG) and 55 Gaza women residing outside Gaza (WOG) was conducted to investigate barriers and opportunities for breast cancer screening, and to better understand possible differences based on residency. The survey found that over 90% of both groups were willing to undergo a diagnostic mammogram for a breast complaint and 86% of WIG and 85% of WOG believed survival was increased with early detection. However, only 27% of WIG and 50% WOG were willing to undergo screening mammography. Religion and culture were not barriers to mammography for over 94% of WIG and 98% of WOG. Limited resources and lack of access to medical facilities were identified as barriers in up to 55% of WIG compared to 15% of WOG. Misconceptions about breast cancer were reported more frequently by WIG, including beliefs that breast cancer is not very common and that breast cancer can be contagious.

Mammographic appearance of ductal carcinoma in situ does not reliably predict histologic subtype.

Histologic subtypes of ductal carcinoma in situ (DCIS) have been correlated with disease prognosis. There are conflicting reports on whether the grade of DCIS can be predicted by the morphology of calcifications seen on mammography. We undertook this study to determine whether the grade of DCIS can be reliably and accurately determined by mammography prior to excisional biopsy. Ninety consecutive cases of DCIS from 1993 to 1996 were identified, of which 75 cases had mammograms available for review. Any lesion with invasion was excluded. The mammogram showed only a mass in 10 of 75 cases, a mass and calcifications in 3 of 75 cases, and calcifications alone in 62 of 75 cases. Three board-certified radiologists with special expertise in mammography reviewed and categorized the mammographic findings as well, intermediate or poorly differentiated DCIS without knowledge of the histologic diagnosis. Histologic grading was performed without knowledge of the mammographic finding. Receiver operating curves (ROCs) were computed for each of the radiologists. For microcalcifications, the ROC comparisons of the radiologists' opinions of tumor grade and random chance were not significantly different. In those cases with available magnification views, the grade assessment did not change significantly. If only a mass was present on mammography, well-differentiated DCIS was the predominant histologic subtype. A histologic grade of DCIS cannot accurately be determined prospectively based on the mammographic appearance of microcalcifications. However, if only a mass is present, this is more likely to represent well-differentiated DCIS.

Mediastinal lymphadenopathy and hazy mediastinal fat: new CT findings of congestive heart failure.

OBJECTIVE: We describe two new CT findings of congestive heart failure (CHF): enlarged mediastinal lymph nodes and hazy heterogeneous mediastinal fat. MATERIALS AND METHODS: Forty-six patients were retrospectively identified who had major and minor clinical signs of congestive heart failure and had undergone chest CT during their symptomatic period. Two radiologists reviewed the CT studies and by consensus documented the presence or absence of imaging findings of CHF, including interstitial abnormalities, vascular redistribution, axial thickening, pleural effusions, cardiac enlargement, and mediastinal abnormalities. RESULTS: Smooth septal thickening, bilateral pleural effusions, vascular redistribution, and cardiac enlargement were the most common CT findings in patients with CHF. Enlarged mediastinal lymph nodes and hazy mediastinal fat were seen in 55% and 33% of cases, respectively. In a cohort of 17 patients with elevated pressures in the pulmonary capillary wedge documented within 24 hr of CT, CT scans revealed lymphadenopathy in 14 patients (82%) and inhomogeneous fat in 10 patients (59%). CONCLUSION: Enlarged mediastinal lymph nodes and hazy mediastinal fat occur in patients with CHF and are revealed by CT. Lymphadenopathy in patients with CHF does not necessarily indicate malignancy or an infectious process.

Previous breast biopsy for benign disease rarely complicates or alters interpretation on screening mammography.

OBJECTIVE: It has been suggested that breast screening leads to too many biopsies for benign disease that permanently scar the breast and confuse the interpretation of subsequent mammograms. We undertook retrospective and prospective studies to determine how often an excisional biopsy for benign breast disease complicates or alters interpretation of screening mammograms. MATERIALS AND METHODS: Retrospective review of our screening center database yielded 31,025 asymptomatic patients who had routine mammographic screening studies between 1993 and 1996. Of the 58,538 examinations of these patients, 53,510 were of patients who had no history of breast biopsy and 5028 were of patients who had a history of breast biopsy for benign disease. Recall rates were compared between the two groups. In the prospective study, radiologists reviewed the mammograms of 1997 consecutive patients presenting to the screening center, 173 of whom reported a prior breast biopsy for benign disease. The radiologist interpreting the images determined how often evidence of the biopsy site was apparent on the mammogram and how often such changes necessitated additional imaging. RESULTS: In the retrospective study, 3296 (6%) of the 53,510 studies done in patients who did not have a biopsy for benign disease and 360 (7%) of the 5028 studies done in women who had a biopsy for benign disease led to additional imaging. Eight recalls for further imaging (0.16%) among the 5028 studies in women with a prior biopsy for benign disease were related to the biopsy site. In the prospective study, 24 (14%) of the 173 women who had a biopsy for benign disease had mammographic evidence of the biopsy site. Nine (5%) of the 173 women who had previously had a biopsy for benign disease and 86 (5%) of the 1824 patients without a prior biopsy were recalled for additional imaging. No women were recalled because a previous breast biopsy for benign disease led to confusion or diagnostic concern. CONCLUSION: Changes in patients' breasts due to previous excisional biopsies for benign breast disease rarely pose a diagnostic dilemma in the interpretation of routine screening mammograms.

Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association.

OBJECTIVE: To deal with public and professional concern regarding possible overprescription of attention-deficit/hyperactivity disorder (ADHD) medications, particularly methylphenidate, by reviewing issues related to the diagnosis, optimal treatment, and actual care of ADHD patients and of evidence of patient misuse of ADHD medications. DATA SOURCES: Literature review using a National Library of Medicine database search for 1975 through March 1997 on the terms attention deficit disorder with hyperactivity, methylphenidate, stimulants, and stimulant abuse and dependence. Relevant documents from the Drug Enforcement Administration were also reviewed. STUDY SELECTION: All English-language studies dealing with children of elementary school through high school age were included. DATA EXTRACTION: All searched articles were selected and were made available to coauthors for review. Additional articles known to coauthors were added to the initial list, and a consensus was developed among the coauthors regarding the articles most pertinent to the issues requested in the resolution calling for this report. Relevant information from these articles was included in the report. DATA SYNTHESIS: Diagnostic criteria for ADHD are based on extensive empirical research and, if applied appropriately, lead to the diagnosis of a syndrome with high interrater reliability, good face validity, and high predictability of course and medication responsiveness. The criteria of what constitutes ADHD in children have broadened, and there is a growing appreciation of the persistence of ADHD into adolescence and adulthood. As a result, more children (especially girls), adolescents, and adults are being diagnosed and treated with stimulant medication, and children are being treated for longer periods of time. Epidemiologic studies using standardized diagnostic criteria suggest that 3% to 6% of the school-aged population (elementary through high school) may suffer from ADHD, although the percentage of US youth being treated for ADHD is at most at the lower end of this prevalence range. Pharmacotherapy, particularly use of stimulants, has been extensively studied and generally provides significant short-term symptomatic and academic improvement. There is little evidence that stimulant abuse or diversion is currently a major problem, particularly among those with ADHD, although recent trends suggest that this could increase with the expanding production and use of stimulants. CONCLUSIONS: Although some children are being diagnosed as having ADHD with insufficient evaluation and in some cases stimulant medication is prescribed when treatment alternatives exist, there is little evidence of widespread overdiagnosis or misdiagnosis of ADHD or of widespread overprescription of methylphenidate by physicians.

Digital tomosynthesis in breast imaging.

PURPOSE: To describe and evaluate a method of tomosynthesis breast imaging with a full-field digital mammographic system. MATERIALS AND METHODS: In this tomosynthesis method, low-radiation-dose images were acquired as the x-ray source was moved in an arc above the stationary breast and digital detector. A step-and-expose method of imaging was used. Breast tomosynthesis and conventional images of two imaging phantoms and four mastectomy specimens were obtained. Three experienced readers scored the relative lesion visibility, lesion margin visibility, and confidence in the classification of six lesions. RESULTS: Tomosynthesis image-reconstruction algorithms allow tomographic imaging of the entire breast from a single arc of the x-ray source and at a radiation dose comparable with that in single-view mammography. Except for images of a large mass in a fatty breast, the tomosynthesis images were superior to the conventional images. CONCLUSION: Digital mammographic systems make breast tomosynthesis possible. Tomosynthesis may improve the specificity of mammography with improved lesion margin visibility and may improve early breast cancer detection, especially in women with radiographically dense breasts.

Imaging of fallopian tube tumors.

OBJECTIVE: The purposes of this study were to investigate the imaging findings in patients with primary fallopian tube neoplasms and to determine whether specific imaging features favor the preoperative diagnosis of fallopian tube tumors (FTT). MATERIALS AND METHODS: Computerized search of medical records from 1984 to 1994 identified 20 patients with a discharge diagnosis of primary fallopian tube carcinoma. Medical records, imaging studies, and pathology findings were reviewed. Eleven patients had available preoperative imaging. RESULTS: Seventeen of 20 patients with primary FTT had unilateral disease. Of these 17, preoperative imaging was available in nine, showing four solid adnexal masses, four complex cystic adnexal masses, and one normal adnexa. The preoperative imaging of these nine patients included six sonographic and five CT studies. Three patients with primary FTT had bilateral tumors, and preoperative imaging was available for two patients: Two sonographic studies and one CT study showed one complex cystic adnexal mass and three normal adnexa. CONCLUSION: Primary FTT commonly presents as an adnexal mass on preoperative imaging and mimics other pelvic malignancies, especially ovarian carcinoma. Making a specific preoperative diagnosis is difficult; however, because primary FTT is unlikely to be confused with a benign process, delay in diagnosis is rare.

Routine addition of an automated biopsy device to fine-needle aspiration of the lung: a prospective assessment.

OBJECTIVE: The purpose of this study was to prospectively assess the usefulness of the routine addition of an automated biopsy device (ABD) to fine-needle aspiration (FNA) of the lung and to examine the complication rate of this procedure. SUBJECTS AND METHODS: Fifty biopsies were performed under CT guidance using a coaxial technique with a 19-gauge introducer needle and a 22-gauge aspirating needle followed by a 20-gauge ABD. An average of 3.5 FNA specimens and 2.5 core specimens were obtained. Cytology and histology specimens were interpreted separately by two experienced pathologists who were unaware of the other's interpretation. Final diagnoses were based on surgery, microbiology, definitive biopsy diagnosis, and clinical follow-up. All complications were recorded. RESULTS: Of 34 malignant lesions, we achieved a diagnostic accuracy of 94% for FNA and 59% for core biopsy (p < .01). Combined accuracy was 94%. Of 16 benign lesions, an accurate definitive diagnosis was made in 31% of cases using FNA and in 69% of cases using core biopsy (p = .08). Combined accuracy was 69%. In the subset of benign lesions that were not acute infections (n = 8), an accurate definitive benign diagnosis was made in 12% of cases using FNA and in 75% of cases using core biopsy (p < .05). No false-positive diagnoses of malignancy occurred. Complications included pneumothorax, nine (18%) of 50 cases; chest tube, one (2%) of 50 cases minor pulmonary hemorrhage, seven (14%) of 50 cases; and minor hemoptysis, two (4%) of 50 cases. CONCLUSION: The complication rates of FNA with the addition of an ABD are similar to those reported in the literature for FNA alone. The addition of an ABD significantly increases the diagnostic accuracy only for the subset of benign lesions that are not acute infections.

Screening mammography: effect of national guidelines on current physician practice.

PURPOSE: To evaluate the effect of national breast cancer screening guidelines on current physician attitudes toward and practice of screening mammography. MATERIALS AND METHODS: Questionnaire responses from 278 physicians were analyzed. The questionnaire had four sections: general information on physician practice and experience, current use of breast cancer screening, perceptions of screening mammography, and physician awareness of and response to the controversy in breast cancer screening. RESULTS: In women aged 40-49 years, 144 (52%) of 278 physicians performed annual clinical breast examination and screening mammography every 2 years; 57 (21%) favored annual mammography and clinical breast examination. In women aged 50 years and older, 232 (83%) physicians screened patients annually with clinical breast examination and mammography. Two hundred seventeen (78%) physicians were aware of the recommended changes in screening guidelines; 54 (19%) were not aware of the changes. Of those aware of the changes, 56 (26%) changed to the new guidelines, 150 (69%) did not change, and six (3%) modified their practice somewhat. CONCLUSION: Physician practice as regards screening mammography is influenced by national guidelines.

Patients' opinion of mammography screening services: immediate results versus delayed results due to interpretation by two observers.

OBJECTIVE: The purpose of this study was to evaluate by random questionnaire mailings the preferences of women who have undergone mammography in our region regarding communication of mammography screening results. MATERIALS AND METHODS: Questionnaires were mailed to 400 randomly selected women who were more than 35 years old and who had been treated at our institution for medical or surgical reasons. Questions regarding use of mammography screening at our institution versus services at other locations were included. The questionnaire described two possible mammography services; either a double reading service that would provide delayed reports (DRDR) with the benefit of extra cancers detected, and a service that provides immediate reports given directly to the patient by an on-site radiologist. The presentation of the services was reversed in half the questionnaires to avoid bias. Patients' choices were collected, as were demographic data. The choice of one system over the other was evaluated using the one-sample lest for binomial probability. The chi-square test was used to determine if the order of questions on the survey or the site of patients' screening mammography affected responses. RESULTS: The response rate was 42% (n = 168). Of these, one response informed us of the death of a patient. Of the remaining 167 respondents, 75% (n = 126) preferred the DRDR system, 13% (n = 22) preferred the system providing immediate results (p < .0001), and the other 19 respondents did not select a preference. Of the 167 respondents, 156 answered the question regarding previous screening mammography experience. Of the 105 patients who had undergone screening mammography at our institution, 78% (n = 82) preferred the DRDR system. Of the 51 patients who had undergone mammography elsewhere or who had never undergone mammography, 75% (n = 38) preferred the DRDR system. We found that ordering of presentation of the systems in the questionnaire had no effect on responses. Likewise, whether a respondent had undergone mammography at our institution had no effect on responses (p = 1.0). CONCLUSION: A statistically significant number of women who responded to our questionnaire preferred the DRDR system of reporting screening mammographic results. Educational material about double reading that we included with each patient's questionnaire could account for these results. If the use of a second interpreter is feasible and is done for batch interpretation of screening mammograms, then education of patients about this process may increase acceptance of a delayed mammographic report.

The frequency and significance of adnexal lesions incidentally revealed by CT.

OBJECTIVE: This paper describes the frequency of incidental adnexal findings revealed by routine CT scanning and determines the significance of these lesions in premenopausal and postmenopausal women, particularly in those with an already known malignancy other than ovarian carcinoma. MATERIALS AND METHODS: A computerized search of all radiology reports from 1992 identified 3448 women who underwent abdominopelvic or pelvic CT scans for an indication other than ovarian carcinoma or a known or suspected pelvic mass. Patients were divided into two subgroups: premenopausal and postmenopausal. CT reports were reviewed to identify patients with incidentally discovered adnexal lesions. Imaging characteristics and lesion size were recorded. To determine the significance of the lesions, we also reviewed clinical, radiologic, and histopathologic data. Lesions were judged to be benign on the basis of 12-month clinical follow-up, additional imaging that revealed stability or resolution, or histopathology. Lesions were judged to be malignant on the basis of progression of the lesion on subsequent imaging or histopathology. Lesions were classified as undetermined in patients with a serious or life-threatening illness who consequently underwent no further evaluation of the lesion. RESULTS: An incidental adnexal lesion was revealed by CT scanning in 168 cases (5%). Seventeen of these patients were lost to follow-up. Of the remaining 151 patients, 104 (69%) had incidental adnexal lesions that represented benign disease, 45 (30%) had undetermined lesions, and two (1%) had malignant lesions. In analyzing the two subgroups of patients, we determined that 56 (81%) of 69 premenopausal patients and 48 (59%) of 82 postmenopausal patients had benign adnexal lesions. On the basis of chart review, 67 patients had a known malignancy. Of these patients, 30 (46%) had benign adnexal disease, and 31 (48%) had undetermined findings. Four (6%) were lost to follow up, and the remaining two patients (3%) who were postmenopausal had metastatic disease of the ovaries. No primary ovarian malignancies were discovered incidentally in our study population. CONCLUSION: Our results indicate that in both premenopausal and postmenopausal women a significant proportion of adnexal lesions incidentally revealed on routine CT scanning are benign, even in women with known malignancies other than ovarian carcinoma.