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Objective: The purposes of this article were to review the mammographic and sonographic features of breast masses yielding atypical ductal hyperplasia (ADH) at sonographically guided biopsy, evaluate the surgical pathology outcome of these lesions, and determine whether clinical or imaging features can be used to predict upgrade to malignancy., Materials and Methods: Among 6325 sonographically guided biopsies (2003- 2010) (14-gauge cores), 56 yielded the diagnosis of ADH (0.9%). Six patients were excluded (lost to follow-up). Fifty lesions were surgically excised in 45 patients. Mammographic and sonographic features were analyzed in consensus by two radiologists using the BI-RADS lexicon., Results: Forty-five patients (mean age, 56 years; 12 < 50 years; six with synchronous breast carcinoma) had 50 ADH lesions (median size, 0.6 cm). Surgical excision yielded malignancy in 28 cases (56% underestimation rate). Among 42 mammograms (47 lesions), 30 lesions were identified (30/47, 64%) as masses (12/30, 40%), asymmetric densities (10/30, 33%), microcalcifications (4/30, 13%), and architectural distortions (4/30, 13%). Sonographically, most lesions appeared as hypoechoic masses (64%, 30/47) with irregular shape (51%, 24/47), microlobulated margins (49%, 23/47), no posterior acoustic feature (25/47, 53%), abrupt interface (70%, 33/47), and parallel orientation (57%, 27/47). No mammographic and sonographic features were associated with malignant outcome, whereas age less than 50 years (p = 0.03) and synchronous malignancy (p = 0.03) were associated with malignant outcome., Conclusion: ADH diagnosed at sonographically guided 14-gauge core needle biopsy shows a high underestimation rate. Synchronous carcinoma or age less than 50 years is associated with malignant outcome.

Objective: The purpose of this article is to evaluate the concordance between tumor grade found on ultrasound-guided core biopsies of invasive ductal carcinomas of the breast and subsequent excision specimens., Materials and Methods: We retrospectively studied 300 consecutive invasive ductal carcinomas (274 women) that were biopsied under sonographic guidance, using 14-gauge core needles exclusively, and that were subsequently excised surgically. A minimum of four cores were taken per lesion. Core biopsy grades were compared with final surgical grades (reference standard). Tumor grade was assigned using the standard modified Scarff-Bloom-Richardson system. The agreement rate was expressed in percentages and in kappa statistics; the rates of overestimation and underestimation were also assessed. The correlation between tumor size (small, ≤ 0.5 cm; medium, 0.6-2.4 cm; and large, ≥ 2.5 cm) and agreement rate was also evaluated., Results: The overall agreement between core biopsy and surgical pathology grade was 69% (simple κ = 0.46; 95% CI, 0.36-0.54). Agreement by biopsy grade was 86% (55/64) for grade 3, 66% (118/180) for grade 2, and 55% (23/42) for grade 1. Core biopsy underestimated 24% (70/286) and overestimated 7% (20/286) of the lesions. When discordant, core biopsy differed from excision by no more than one grade. Large tumors were more likely to show underestimation rather than overestimation when discordant (rate of underestimation, 92% for large, 81% for medium, and 33% for small tumors; p < 0.0031)., Conclusion: Ultrasound-guided core biopsy accurately predicts high-grade breast tumors but is moderately accurate for lower-grade lesions. Large tumor size negatively impacts the accuracy of tumor grade found on biopsy and is associated with underestimation.

Objective: The purpose of this essay is to highlight the clinical features and imaging findings associated with different types of nonthrombotic pulmonary embolism., Conclusion: Nonthrombotic pulmonary embolism is an infrequent condition with various causes that can be life-threatening pathologic conditions. The entity presents a diagnostic challenge because of the low specificity of clinical symptoms and imaging signs. Awareness of the imaging features of nonthrombotic pulmonary embolism facilitates correct diagnosis and leads to appropriate patient care.

Objective: This study was undertaken to determine the prevalence of flat epithelial atypia at ultrasound-guided and stereotactically guided needle biopsies, to describe the mammographic and sonographic features of flat epithelial atypia, and to determine the significance of lesions diagnosed as flat epithelial atypia at imaging-guided needle biopsies., Materials and Methods: Retrospective review of a database of 1369 consecutive sonographically and stereotactically guided needle biopsies performed during a 12-month period yielded 33 lesions with flat epithelial atypia as the most severe pathologic entity (32 patients). Two radiologists retrospectively reviewed the imaging presentation, by combined consensus, according to the BI-RADS lexicon., Results: Twenty-two of 33 flat epithelial atypia diagnoses (67%) were obtained under stereotactic guidance, and 11 (33%) were obtained under sonographic guidance. Six patients had synchronous breast cancer. Flat epithelial atypia lesions presented mammographically most often as microcalcifications (20/33 [61%]) distributed in a cluster (14/20 [70%]) with amorphous morphology (13/20 [65%]). Sonographically, flat epithelial atypia lesions appeared most often as masses (9/11 [82%]), with an irregular shape (6/9 [67%]), microlobulated margins (5/9 [56%]), and hypoechoic or complex echotexture (7/9 [78%]). Twenty-eight of 33 lesions (85%) were surgically excised, confirming the flat epithelial atypia diagnosis in 11 of the 28 lesions (39%), yielding carcinoma in four (14%) and atypical ductal hyperplasia in six (21%). Columnar cell changes without atypia were diagnosed in four lesions (14%), and lobular carcinoma in situ was diagnosed in three lesions (11%)., Conclusion: Mammographic and sonographic presentation of flat epithelial atypia is not specific (clustered amorphous microcalcifications and irregular, hypoechoic or complex masses). Given the underestimation rate of malignancy, surgical excision should be considered when imaging-guided biopsy yields flat epithelial atypia.

Objective: The purpose of our study was to retrospectively evaluate the clinical, imaging, and pathologic findings of breast hemangiomas in 16 patients., Conclusion: A mass displaying an oval or lobular shape with well-circumscribed or microlobulated margins on mammography and sonography, and in a superficial location, should alert the radiologist to the possible diagnosis of hemangioma. Imaging-guided biopsy appears sufficiently reliable to rule out any malignant or premalignant component and to avoid a surgical excision if doing so is clinically appropriate.

Objective: The purpose of this study was to review the sonographic features of breast cancer gene BRCA1- and BRCA2-associated breast carcinomas in comparison with "sporadic" breast carcinomas and benign breast masses., Methods: Sonograms of 233 breast masses, including 33 BRCA-associated malignant masses (BRCA1, 15; BRCA2, 18), 148 sporadic malignant masses, and 52 benign masses, were reviewed by consensus by 2 radiologists according to American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) terminology., Results: Most of the sporadic and BRCA1-and BRCA2-associated cancers displayed an irregular shape (91.2%, 93.3%, and 83.3%, respectively). BRCA1-associated cancers showed microlobulated margins in 53.3% versus 33.8% (sporadic) and 33.3% (BRCA2). A parallel orientation was most frequently encountered in BRCA1-associated lesions (46.7%) versus sporadic (33.8%) and BRCA2 (33.3%), whereas posterior acoustic shadowing was least frequently seen in BRCA1-associated lesions (13.3%) versus BRCA2 (16.7%) and sporadic (31.1%). Most (73.3%) of the BRCA1-associated lesions were classified as BI-RADS category 4, whereas most of the sporadic and BRCA2-associated lesions were classified as BI-RADS category 5 (66.2% and 72.2%)., Conclusions: Sonographic features of BRCA-associated and sporadic breast carcinomas do not differ substantially. BRCA1-associated breast carcinomas trend toward less malignant sonographic characteristics, but strict application of the BI-RADS categorizations demands that they be classified as category 4 or 5.

Objective: The objective of our study was to retrospectively review our experience regarding the value of sonography in identifying a nonpalpable mass within a surgically excised specimen and in assessing the surgical margins in cases of malignancy., Materials and Methods: One hundred four lumpectomies were performed in 99 consecutive patients with 131 nonpalpable breast lesions after sonographically guided needle localization. All 104 surgical specimens were scanned on sonography, and 86 specimen radiographs were obtained. Visualization of the lesion on sonography was compared with specimen radiographs and histologic findings. Sonographic margin status was classified as negative (shortest distance between tumor and specimen margin, > 0.2 cm) or positive (shortest distance between tumor and specimen margin, 0.2 cm) and was compared with pathology results., Results: Specimen sonography showed 95.4% (125/131) of the excised abnormalities; nonfatty background and a lesion size of greater than 0.5 cm contributed significantly to the success of specimen sonography. Four of six lesions missed on sonography were identified on specimen radiography. Among 81 malignant specimens, sonography identified 38 specimens with positive margins and 43 with negative margins. Pathologic examination revealed eight false-positive and 10 false-negative results (21% false-positive rate and 23.2% false-negative rate)., Conclusion: Specimen sonography is an effective procedure for identifying the presence of the lesion within the specimen; however, it is of limited value in cases of small hypoechoic lesions against a fatty background. Assessment of margins is limited by both false-positive and false-negative results.

We report the case of a 78-year-old woman who had been receiving hormone-replacement therapy (HRT) for 6 years and had a 4-month history of a painless nodule in the 9 o'clock position in her right breast. Mammography performed 4 years previously had shown a 4-mm bilobed, ovoid, well-defined nodule in that location; mammography performed 1 year previously had shown that the nodule had increased to 6 mm. We performed mammographic and sonographic examinations, which revealed a 10-mm ovoid nodule in the same 9 o'clock position in the right breast. The imaging findings appeared to indicate benignity, but because of the increasing size of the nodule, we undertook an ultrasound-guided large-core needle biopsy. The histopathologic diagnosis was typical cavernous hemangioma. It was not excised, but HRT was discontinued. Follow-up mammography and sonography 8 months later showed that the nodule had decreased to 6 mm. We believe that the HRT played a contributory role in the increasing size of this patient's cavernous hemangioma. The use of ultrasound-guided large-core needle biopsy is reliable enough to ascertain the benignity of such masses and can thus avoid, if it is clinically appropriate, the need for their surgical removal., (Copyright 2003 Wiley Periodicals, Inc. J Clin Ultrasound 31:430-436, 2003)