Term Paper: Missed Breast Carcinomas Mammography

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[. . .] Margins should not be characterized by screening study only, since the margins of masses are evaluated best with the help of spot compression imaging and while dealing with spot compression imaging, a mass which shows itself to be smooth would be indistinct or microlobulated. Thus while performing screening mammography, the characterization of a lesion should be performed not on the basis of screening findings only, but should include diagnostic mammographic findings.

The breast cancers, which are most wrongly interpreted and would often pose to be a challenge in diagnosing, are those, which exhibit characteristics of indistinct or subtle malignancy. These features are found in those areas of amorphous or punctuate microcalcifications, well-circumscribed masses, architectural distortion, focal asymmetric densities, and in dilated ducks. It is always possible that the spot compression of a circumscribed mass, which shows it to be cancer, would exhibit characteristics of indistinct behavior or microlobulation of the margin. The amount of malignancy that would happen to be present in a circumscribed mass can be understood by way of U.S.. The benign finding can be considered by seeing the simple crysts at U.S.. The lesions that are actually solid and tall, but which appear to be wider, smooth and elliptic, shows signs of malignancy (Stravros, Thickman, Rapp, et al. 1995). At mammography, if a non-palpable circumscribed exhibits solid characteristics, which are somewhat benign at, U.S. can be reevaluated at a very early stage (Sickles, 1994)). But if a lesion is seen as solid, exhibiting characteristics, which show troublesome shapes or margins at U.S., then it indicates to be biopsy.

Mammograghy usually suggests asymmetric densities. With regard to predicting malignancy, they have a low positive value, if being done in isolation. But the issues of malignancy can be increasingly found if these findings are done in conjunction with architectural distortions or microcalcifications. While studying cases of interval cancers by Ikeda et al. (Ikeda, Anderson, Wattsgard, et al. 1992), 21 out of 94 cases, exhibited chances of malignancy, which were subtle, which were mostly asymmetric densities. Asymmetric densities also exhibited characteristics, which were troublesome -- a palpable mass, an asymmetric density that was new, unable to find hormone at mammography and enlargement in intervals.

For understanding important areas of asymmetry, clinical history is essential. Focal densities, which are developing, should provide opportunities for increased assessment, in the event when an infection or tumor is absent. According to Rosen et al. (Hendrick, Basett, Botsco, et al. 1999), 10 out of 12 areas of asymmetry, which were malignant, were new. But even then the radiologist was not able to correctly analyze and deal with it. Hormone replacement therapy can bring about a focal developing density, even though changes in hormones can be bilateral and diffused. If a density is found to develop as a result of hormone replacement therapy, then what is required is that the therapy should be discontinued for three or four weeks time, which should be followed up with repeated forms of mammography.

In the case of Invasive lobular carcinoma, it is found that they account for around 8-10% of breast cancers are easily missed. This is because they have architectural distortion area, mammographic findings which are negative and a focal asymmetric density. U.S. would be helpful in identifying focal shadowing. In the case of a focal asymmetric density, what is required is that of additional mammography, even U.S. would prove to beneficial along with a clinical examination, which is primarily important. Malignancy is not usually found along with dilated ducts, but if dilated ducts suggest denotes malignancy, then it should include a dilated duct, which is unilaterally solitary. It would also include dilated ducts, which are in conjunction with microcalcifications.

The breast cancers would double at a time of 44 to 1809 days (Fournier, Weber, Hoeffken, et al. 1980). With regard to mammography, classifications of malignancy have been found to be stable for a period of 63 months (Lev-Toaff, Feig, Saitas, et al. 1994). However during interval screenings, which take place annually, malignancies, which have low grades, do not undergo changes. So if the findings in the older images were not compared with the new ones, then a radiologist would not detect a cancer, which is slowly changing. A lesion, with strong characteristics of malignancy, which has remained for one or two years would still require biopsy. This is because it would promote chances of a cancer, which is slowly changing. Thus a radiologist should be extremely careful while analyzing masses, which are stable. Again proper attention should be provided in cases where lesions exhibit characteristics of suspect morphology, and would decrease their size in those patients who are taking Tamoxifen. Tamoxifen can be used to control the growth of occult malignancies, along with being used to treat breast cancers and to prevent the development in high-risk women of the occurrence of breast cancers.

It is essential to double read mammograms, since they are helpful in identifying more breast cancers. They increase the rate of detecting breast cancers by 15% (Anderson, Muir, Walsh, et al. 1994) (Thurjell, Lernevall, Taube, 1994). Some new technologies have been introduced recently in double reading. The most important of them is that of Computer Aided Detection (CAD). This new technology has been introduced in some mammograms for the purpose of double reading. It has been found that the use of Computer Aided Detection (CAD) in mammography has led to increased rates of detecting breast cancers-at a rate of 20% (Burhenne, Wood, D'Orsi, et al. 2001) (Brem, Schoonjans, 2001). CAD proves to be of greater use for detecting calcification, than in the place of detecting masses (Lechner, Nelson, Elvecrog. 2002). In a study conducted on 115 cases of breast cancers, it was found that 77% of lesions were diagnosed with the help of CAD. Again with the help of CAD, 73% of 80 missed malignant masses were identified and 86% of 35 missed calcification areas were also identified. (Birdwell, Ikeda, O'Shaugnessey, Sickles, 2001). In future we may see that CAD would be increasingly used in detecting breast cancers.

Even though mammography is the standard of reference for the purpose of diagnosing and detecting breast cancers in its early stages, even as many as 30% of cases would be missed. In order to reduce the chances of reducing the cases of missed breast cancers, it is essential that a radiologist should follow certain methods while interpreting the findings of mammography. For the purpose of understanding abnormality, the radiologist should complete the evaluation with the help of diagnostic mammography, rather than just concentrating in viewing screens alone. Again clinical data should be reviewed. In order to analyze palpable or a mass which is mammograghically obtained, it is always beneficial to use U.S. To help in analyzing them. To optimize the quality of image to be obtained, it is essential that position and technical requirements should be strictly adhered to. The radiologist should be particularly attentive and provide importance to subtle features. For studying the size of the lesion, it is essential that the radiologist compare the present images to the previous images, to understand any subtle changes, if any has occurred. When abnormality is seen in a lesion, other lesions should also be analyzed and a lesion should be judged by its malignant characteristics.

Bibliography

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Elmore JG, Wells C.K, Lee C.H, et al. (1994) Variability in Radiologists' interpretation of mammograms. N Engl J. Med, 331: 1493-1499

Patel MR, Whitman GJ (1998) Negative mammograms in symptomatic patients with breast cancer. Acad Radiol, 5:26-33

Burrel HC, Sibbering DM, Wilson AR, et al. (1996) Screening interval breast cancers: mammographic features and prognosis factors. Radiology, 199: 811-817

Bird RE, Wallace TW, Yankaskas BC. (1992) Analysis of cancers missed at screening mammography. Radiology, 184: 613-617

Ikeda DM, Anderson I, Wattsgard C, et al. (1992) Interval carcinovas in the malmo Mammographic screening trial: radiologioc appearance and prognosis considerations. AJR Am J, Roentegenol, 159: 287-294

Hendrick RE, Basett L, Botsco MA, et al. (1999) Mammography quality control manual. Reston, VA: American College of Radiology

Kinnie, DW (1987) Management of the contralateral breast. In Harris JR, Hellman S, Henderson P, et al., eds. Breast diseases. Philadelphia, PA, Lippincott, 620-621

Khalkhali I, Vargas HI (2001) The role of nuclear medicine in breast cancer detection: functional breast imaging. Radiol Clin North Am, 39: 1053-1068

Orel, SG (2000) MR imaging of the breast. Radiol Clin North Am, 38: 899-913

Stravros AT, Thickman D, Rapp CL, et al. (1995) Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology, 190: 123-124

Sickles, EA. (1994) Nonpalpable circumscribed noncalcified solid breast masses: likelihood of malignancy based on lesion size and age of patient. Radiology, 192: 439-442

Fournier DV, Weber E, Hoeffken W, et al. (1980) Growth rate of 147 mammary carcinomas, Cancer 45: 2198-2207

Lev-Toaff AS, Feig SA, Saitas VL, et al. (1994) Stability… [END OF PREVIEW]

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