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Demonstration of Ductal Carcinoma in situ with Microcalcifications in a Patient with Augmentation Mammoplasty by Free Silicone Injection
C A S R E P O R
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Demonstration of Ductal Carcinoma in situ with Microcalcifications in a Patient with Augmentation Mammoplasty by Free Silicone Injection Wei-Hsin Tung, Yi-Hong Chou1, Chui-Mei Tiu1*, Siew-Peng Chen1, Huay-Ru Chiang1, Ling-Ming Tseng1, Hong-Jen Chiou1, See-Ying Chiou1, Hsin-Kai Wang1, Chao-Hsuan Yen1 Free liquid silicone injections were used for breast augmentation in the 1950s and 1960s. Patients who received these breast silicone injections are now at the age of high breast cancer risk, but breast masses in such patients are difficult to detect by clinical examination and imaging studies. Ultrasonography may be affected by silicones, but lesions superficial to the silicones can still be detected. Here, we report one patient who received silicone injection 35 years ago when she was 18 years old. Ductal carcinoma in situ with clustered multiple microcalcifications was noted on ultrasound and confirmed by histopathologic examination. Surgery was performed and there was no evidence of recurrence 20 months after operation.
KEY WORDS — breast silicone injection, ductal carcinoma in situ, microcalcification ■ J Med Ultrasound 2005;13(3):135–139 ■
Introduction Free liquid silicone injections were used for breast augmentation in the 1950s, 1960s, and beyond [1]. Initially developed in 1962 for the purpose of breast enlargement, the silicone gel breast implant evolved to become a principal method of reconstruction after mastectomy with improvement in reconstructive surgical techniques in the 1970s. Although autogenous reconstructive techniques such as myocutaneous flaps have steadily improved during the 1980s and 1990s, a variety of breast implants have remained
the basic method of postmastectomy reconstruction [2]. Since then, free silicone injections have rarely been used as a method of breast augmentation. Ultrasonography (US) is occasionally used to evaluate the breasts of patients who have undergone liquid silicone injections for augmentation, but it is not a primary imaging modality because of the strong acoustic shadows resulting from the silicone droplets or granulomas [1,3]. Although free silicone injections into the breast can significantly affect the ability of US to detect breast masses, lesions that have developed superficial to the silicone can be
Department of Family Medicine, Mackay Memorial Hospital, and 1Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, R.O.C. *Address correspondence to: Dr. Chui-Mei Tiu, Department of Radiology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei, Taiwan, R.O.C. E-mail: [email protected]
©Elsevier & CTSUM. All rights reserved.
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W.H. Tung, Y.H. Chou, C.M. Tiu, et al detected by US. We herein report a patient who underwent free silicone injection of the breasts 35 years ago, and in whom a small focus of ductal carcinoma in situ (DCIS) with microcalcifications was incidentally detected on US.
Case Report A 53-year-old woman presented with diffuse palpable nodules in both breasts, ranging from about 1.0 cm to 3.5 cm in greatest dimensions. The nodules had been present for 15 years. On palpation of the breasts, they were painless and not mobile. Clinical examination was negative for enlarged axillary lymph nodes. Trace of her past history revealed free liquid silicone injections when she was 18 years old (i.e. 35 years before this presentation to the breast clinic). Because of the diffuse nodularity in both breasts and as no particularly suspicious focal tumor could be felt, breast US and mammography were requested. Breast US showed diffuse amorphous hyperechoic structures with reverberation artifacts in the breast stroma, presenting as a “snowstorm” pattern. There were also some cystic structures of various sizes (0.4–0.8 cm) in the superficial portion of the breast, while the posterior parenchyma had lost its definition due to strong attenuation of the sound beam. All the US findings were attributed to the overwhelming silicone-induced fibrosis and silicone granulomas. In addition, a small hypoechoic
A
area containing clustered microcalcifications was incidentally found in the left breast in the 2 o’clock direction, 4 cm away from the nipple, and measuring 1.3 × 0.4 cm. The US features were highly suggestive of a DCIS (Fig. 1A). Color Doppler study showed no evidence of color flow signals in the nodule (Fig. 1B). US of the axillary region showed no remarkable enlargement of the lymph node. US-guided fine needle aspiration was done to sample the region with clustered microcalcifications, and the cytologic results showed some malignant cells. Mammography was done, but only diffuse silicone granulomas were noted in both breasts on the mediolateral oblique view. No definite tumor was seen, but clustered microcalcifications were demonstrated on the craniocaudal view (Fig. 2). Available A management options were discussed with the patient. Wide local excision of the mass was performed. The tumor inside the resected specimen measured 1.1 × 0.4 cm and consisted of a circumscribed firm nodule. The perimeter of the lesion was well demarcated and appeared to be encapsulated. Histopathologic examination revealed a DCIS pattern. At the 20-month postoperative followup, the patient was healthy, with no evidence of disease recurrence [2].
Discussion Although liquid silicone injections are no longer an accepted method of breast augmentation, the
B
Fig. i 1. (A) Grayscale ultrasound of the right breast demonstrates a small hypoechoic zone (arrow) in which microcalcifications are depicted. (B) Color Doppler ultrasound shows no significant color flow signals in the territory of the hypoechoic zone (arrows).
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Breast DCIS with Microcalcifications
Fig. i 2. Mammography (craniocaudal view, right side) depicts microcalcifications (arrows) located superficially to the diffuselyy distributed silicone granulomas (close-up view).
cohort of patients who received silicone injections is now at the age associated with a high incidence of breast cancer. However, any breast masses that develop in these patients are more difficult to detect, whether by clinical physical examination or by imaging studies. US is one of the major imaging modalities used to diagnose breast pathologies. Although US is not recommended for screening, it can yield a diagnostic accuracy of 90% for breast carcinomas, even higher than that yielded by mammography [4]. When US is applied in the evaluation of breasts with remote free silicone injections, the US beams are hampered by the various acoustic properties of silicone and related tissue reactions in the breast. Strong reflection, refraction, reverberation, and attenuation of the sound beam by overwhelming silicone-induced fibrosis and silicone granulomas lead to diffuse acoustic shadowing, which substantially hinders the capability of US evaluation of the breasts. Loss of definition of the posterior parenchyma is a common sonographic feature of liquid silicone augmented breasts [1,3,4]. Silicone leakage into surrounding tissues can cause three primary physical interactions with an US beam: (1) distortions due to changes in the speed of sound; (2) refraction, causing a “lens” effect; and (3) multiple scattering, producing the “snowstorm” effect
described previously as a signature pattern for detection of silicone migration in breast tissue [3]. Although free silicone spread can be identified by US, the extent of migration cannot always be depicted clearly [2]. Silicone gel breast implants may cause local symptoms, rupture over time, or be associated with an immunologic reaction such as local granulomatous reaction, silicone-induced mastitis, foreign body reaction, fibrosis, silicone migration, and autoimmune reaction [1,2]. Comprehensive epidemiologic studies have concluded that there is no definite connection between breast implants and the known connective tissue diseases, or between implants and breast carcinoma [2,5]. There is no increase in the risk of recurrence in mastectomy patients reconstructed with implants and no delay in the detection of recurrences [2]. US screening of high familial risk women has better specificity than magnetic resonance imaging (MRI), albeit with a decrease in sensitivity but at a fraction of the cost of MRI [6,7]. US has the advantage of providing convenient imaging guidance for biopsy [4]. Additional MRI can be restricted to problematic cases in women who have dense breast parenchyma [8]. In women younger than 40 years, in whom normal glandular nodularity may be mistaken for a dominant mass, US has a role in providing strong negative reassurance that there is no real mass but only gland [4,9]. Employing US after mammography would match MRI in sensitivity, specificity, positive predictive value, negative predictive value, and accuracy, and should be used in these women [8–13]. Combined US and mammographic assessment has been shown to be very helpful in identifying benign as well as malignant lesions causing palpable abnormalities of the breast, although the sensitivity and specificity may be related to breast density and age [8–10]. The sensitivity and specificity of combining US with mammography are reported to be 100% and 80.1%, respectively, and the positive and negative predictive values are 23.3% and 100%, respectively [8,11–14]. Breast biopsy and MRI may be avoided in women with palpable abnormalities when both US and J Med Ultrasound 2005 • Vol 13 • No 3
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W.H. Tung, Y.H. Chou, C.M. Tiu, et al mammography depict normal tissue at the lump site, but the patient should be followed-up at shortterm intervals with clinical examination and imaging [7,11,14]. Combined US and mammography are therefore commonly used in the assessment of breast lumps and are now used in some institutions as a possible screening method in women aged 40–50 years [4,9]. The clinical manifestations of silicone mastopathy are nonspecific. It is difficult to differentiate silicone granulomas from carcinoma clinically because both may manifest themselves as a palpable mass [1,3,15]. Identification of focal tumor or carcinoma of the breast can be hindered by silicone granulomas and associated calcifications. Neither US nor mammographic studies can reliably exclude superimposed carcinoma [1]. Contrast-enhanced fat-suppressed MRI is a useful imaging modality for the evaluation of siliconeinjected breasts and associated liquid silicone migration, enabling granulomatous disease to be differentiated from tumor development and metastasis [6,16]. Silicone particles exhibit high signal intensity on T2-weighted images and inversion recovery images, but demonstrate intermediate signal intensity on non-fat-suppressed T1-weighted images, hypointensity on fat-suppressed T1-weighted images, and do not exhibit definite enhancement. In patients who have had liquid silicone injections, lesions exhibit low signal on T2-weighted images and fatsuppressed T1-weighted images. This difference may be the result of two factors. First, the liquid silicone may have contained adulterated materials, such as some kind of oil, leading to the unusual signal characteristics on MRI. Second, the breasts may have sustained a long period of chronic granulomatous reaction resulting in fibrosis and formation of multiple silicone granulomas with or without calcifications, potentially causing the low signal seen on the T2-weighted images [15,17]. Free silicone injection of the breast may make US detection of breast mass difficult, but any mass superficial to the silicone granulomas can be depicted by US without being hampered by the silicone.
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In our patient, the presence of clustered microcalcifications in a small area of hypoechogenicity was highly suggestive of DCIS on US, and the histologic diagnosis was conclusive after US-guided biopsy.
References 1. Cheung YC, Lee KF, Ng SH, et al. Sonographic features with histologic correlation in two cases of palpable breast cancer after breast augmentation by liquid silicone injection. J Clin Ultrasound 2002;30:548–51. 2. Noone RB. A review of the possible health implications of silicone breast implants. Cancer 1997;79:1747–56. 3. Lopez H, Harris KM. Ultrasound interactions with free silicone in a tissue-mimicking phantom. J Ultrasound Med 1998:17:163–70. 4. Chou YH, Tiu CM, Lee SS, et al. Imaging of breasts in symptomatic patients: comparison of ultrasonic and x-ray mammography. J Ultrasound Med ROC 1992; 9:1–10. 5. Gabriel SE, O’Fallon WM, Kurland LT. Risk of connective-tissue diseases and other disorders after breast implantation. N Engl J Med 1994;330:1697–702. 6. Komatsu S, Lee CJ, Hosokowa Y, et al. Comparison of intraductal spread on dynamic contrast-enhanced MRI with clinicopathologic features in breast cancer. Jpn J Clin Oncol 2004;34:515–8. 7. Hlawatsch A, Teifke A, Thelen M. Preoperative assessment of breast cancer: sonography versus MR imaging. AJR Am J Roentgenol 2002;179:1493–501. 8. Soo MS, Rosen EL, Baker JA, et al. Negative predictive value of sonography with mammography in patients with palpable breast lesions. AJR Am J Roentgenol 2001;177:1167–70. 9. Kolb TM, Lichy J, Newhouse JH. Comparison of the performance of screening mammography, physical examination, and breast US and evaluation of factors that influence them: an analysis of 27825 patient evaluations. Radiology 2002;225:165–75. 10. Moy L, Slanetz PJ, Moore R, et al. Specificity of mammography and US in the evaluation of a palpable abnormality: retrospective review. Radiology 2002; 225:176–81. 11. Dennis MA, Parker SH, Klaus AJ, et al. Breast biopsy avoidance: the value of normal mammograms and normal sonograms in the setting of palpable lump. Radiology 2001;219:186–91.
Breast DCIS with Microcalcifications 12. Shetty MK, Shah YP, Sharman RS. Prospective evaluation of the value of combined mammographic and sonographic assessment in patients with palpable abnormalities of the breast. J Ultrasound Med 2003:22:263–68. 13. Shetty MK, Shah YP. Prospective evaluation of the value of negative sonographic and mammographic findings in patients with palpable abnormalities of the breast. J Ultrasound Med 2002;21:1211–6. 14. Kaiser JS, Helvie MA, Blacklaw RL. Palpable breast thickening: role of mammography and US in cancer detection. Radiology 2002;223:839–44.
15. Peng HL, Wu CC, Choi WM, et al. Breast cancer detection using magnetic resonance imaging in breasts injected with liquid silicone. Plastic Reconstr Surg 1999;104:2116–20. 16. Wang J, Shih TF, Chang KJ, et al. Silicone migration from silicone-injected breasts: magnetic resonance images. Ann Plast Surg 2002;48:617–21. 17. Caskey CI, Berg WA, Hamper UM, et al. Imaging spectrum of extracapsular silicone: correlation of US, MR imaging, mammographic, and histopathologic findings. Radiographics 1999;19:39–51.
J Med Ultrasound 2005 • Vol 13 • No 3
139
E T
Demonstration of Ductal Carcinoma in situ with Microcalcifications in a Patient with Augmentation Mammoplasty by Free Silicone Injection Wei-Hsin Tung, Yi-Hong Chou1, Chui-Mei Tiu1*, Siew-Peng Chen1, Huay-Ru Chiang1, Ling-Ming Tseng1, Hong-Jen Chiou1, See-Ying Chiou1, Hsin-Kai Wang1, Chao-Hsuan Yen1 Free liquid silicone injections were used for breast augmentation in the 1950s and 1960s. Patients who received these breast silicone injections are now at the age of high breast cancer risk, but breast masses in such patients are difficult to detect by clinical examination and imaging studies. Ultrasonography may be affected by silicones, but lesions superficial to the silicones can still be detected. Here, we report one patient who received silicone injection 35 years ago when she was 18 years old. Ductal carcinoma in situ with clustered multiple microcalcifications was noted on ultrasound and confirmed by histopathologic examination. Surgery was performed and there was no evidence of recurrence 20 months after operation.
KEY WORDS — breast silicone injection, ductal carcinoma in situ, microcalcification ■ J Med Ultrasound 2005;13(3):135–139 ■
Introduction Free liquid silicone injections were used for breast augmentation in the 1950s, 1960s, and beyond [1]. Initially developed in 1962 for the purpose of breast enlargement, the silicone gel breast implant evolved to become a principal method of reconstruction after mastectomy with improvement in reconstructive surgical techniques in the 1970s. Although autogenous reconstructive techniques such as myocutaneous flaps have steadily improved during the 1980s and 1990s, a variety of breast implants have remained
the basic method of postmastectomy reconstruction [2]. Since then, free silicone injections have rarely been used as a method of breast augmentation. Ultrasonography (US) is occasionally used to evaluate the breasts of patients who have undergone liquid silicone injections for augmentation, but it is not a primary imaging modality because of the strong acoustic shadows resulting from the silicone droplets or granulomas [1,3]. Although free silicone injections into the breast can significantly affect the ability of US to detect breast masses, lesions that have developed superficial to the silicone can be
Department of Family Medicine, Mackay Memorial Hospital, and 1Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, R.O.C. *Address correspondence to: Dr. Chui-Mei Tiu, Department of Radiology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei, Taiwan, R.O.C. E-mail: [email protected]
©Elsevier & CTSUM. All rights reserved.
J Med Ultrasound 2005 • Vol 13 • No 3
135
W.H. Tung, Y.H. Chou, C.M. Tiu, et al detected by US. We herein report a patient who underwent free silicone injection of the breasts 35 years ago, and in whom a small focus of ductal carcinoma in situ (DCIS) with microcalcifications was incidentally detected on US.
Case Report A 53-year-old woman presented with diffuse palpable nodules in both breasts, ranging from about 1.0 cm to 3.5 cm in greatest dimensions. The nodules had been present for 15 years. On palpation of the breasts, they were painless and not mobile. Clinical examination was negative for enlarged axillary lymph nodes. Trace of her past history revealed free liquid silicone injections when she was 18 years old (i.e. 35 years before this presentation to the breast clinic). Because of the diffuse nodularity in both breasts and as no particularly suspicious focal tumor could be felt, breast US and mammography were requested. Breast US showed diffuse amorphous hyperechoic structures with reverberation artifacts in the breast stroma, presenting as a “snowstorm” pattern. There were also some cystic structures of various sizes (0.4–0.8 cm) in the superficial portion of the breast, while the posterior parenchyma had lost its definition due to strong attenuation of the sound beam. All the US findings were attributed to the overwhelming silicone-induced fibrosis and silicone granulomas. In addition, a small hypoechoic
A
area containing clustered microcalcifications was incidentally found in the left breast in the 2 o’clock direction, 4 cm away from the nipple, and measuring 1.3 × 0.4 cm. The US features were highly suggestive of a DCIS (Fig. 1A). Color Doppler study showed no evidence of color flow signals in the nodule (Fig. 1B). US of the axillary region showed no remarkable enlargement of the lymph node. US-guided fine needle aspiration was done to sample the region with clustered microcalcifications, and the cytologic results showed some malignant cells. Mammography was done, but only diffuse silicone granulomas were noted in both breasts on the mediolateral oblique view. No definite tumor was seen, but clustered microcalcifications were demonstrated on the craniocaudal view (Fig. 2). Available A management options were discussed with the patient. Wide local excision of the mass was performed. The tumor inside the resected specimen measured 1.1 × 0.4 cm and consisted of a circumscribed firm nodule. The perimeter of the lesion was well demarcated and appeared to be encapsulated. Histopathologic examination revealed a DCIS pattern. At the 20-month postoperative followup, the patient was healthy, with no evidence of disease recurrence [2].
Discussion Although liquid silicone injections are no longer an accepted method of breast augmentation, the
B
Fig. i 1. (A) Grayscale ultrasound of the right breast demonstrates a small hypoechoic zone (arrow) in which microcalcifications are depicted. (B) Color Doppler ultrasound shows no significant color flow signals in the territory of the hypoechoic zone (arrows).
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J Med Ultrasound 2005 • Vol 13 • No 3
Breast DCIS with Microcalcifications
Fig. i 2. Mammography (craniocaudal view, right side) depicts microcalcifications (arrows) located superficially to the diffuselyy distributed silicone granulomas (close-up view).
cohort of patients who received silicone injections is now at the age associated with a high incidence of breast cancer. However, any breast masses that develop in these patients are more difficult to detect, whether by clinical physical examination or by imaging studies. US is one of the major imaging modalities used to diagnose breast pathologies. Although US is not recommended for screening, it can yield a diagnostic accuracy of 90% for breast carcinomas, even higher than that yielded by mammography [4]. When US is applied in the evaluation of breasts with remote free silicone injections, the US beams are hampered by the various acoustic properties of silicone and related tissue reactions in the breast. Strong reflection, refraction, reverberation, and attenuation of the sound beam by overwhelming silicone-induced fibrosis and silicone granulomas lead to diffuse acoustic shadowing, which substantially hinders the capability of US evaluation of the breasts. Loss of definition of the posterior parenchyma is a common sonographic feature of liquid silicone augmented breasts [1,3,4]. Silicone leakage into surrounding tissues can cause three primary physical interactions with an US beam: (1) distortions due to changes in the speed of sound; (2) refraction, causing a “lens” effect; and (3) multiple scattering, producing the “snowstorm” effect
described previously as a signature pattern for detection of silicone migration in breast tissue [3]. Although free silicone spread can be identified by US, the extent of migration cannot always be depicted clearly [2]. Silicone gel breast implants may cause local symptoms, rupture over time, or be associated with an immunologic reaction such as local granulomatous reaction, silicone-induced mastitis, foreign body reaction, fibrosis, silicone migration, and autoimmune reaction [1,2]. Comprehensive epidemiologic studies have concluded that there is no definite connection between breast implants and the known connective tissue diseases, or between implants and breast carcinoma [2,5]. There is no increase in the risk of recurrence in mastectomy patients reconstructed with implants and no delay in the detection of recurrences [2]. US screening of high familial risk women has better specificity than magnetic resonance imaging (MRI), albeit with a decrease in sensitivity but at a fraction of the cost of MRI [6,7]. US has the advantage of providing convenient imaging guidance for biopsy [4]. Additional MRI can be restricted to problematic cases in women who have dense breast parenchyma [8]. In women younger than 40 years, in whom normal glandular nodularity may be mistaken for a dominant mass, US has a role in providing strong negative reassurance that there is no real mass but only gland [4,9]. Employing US after mammography would match MRI in sensitivity, specificity, positive predictive value, negative predictive value, and accuracy, and should be used in these women [8–13]. Combined US and mammographic assessment has been shown to be very helpful in identifying benign as well as malignant lesions causing palpable abnormalities of the breast, although the sensitivity and specificity may be related to breast density and age [8–10]. The sensitivity and specificity of combining US with mammography are reported to be 100% and 80.1%, respectively, and the positive and negative predictive values are 23.3% and 100%, respectively [8,11–14]. Breast biopsy and MRI may be avoided in women with palpable abnormalities when both US and J Med Ultrasound 2005 • Vol 13 • No 3
137
W.H. Tung, Y.H. Chou, C.M. Tiu, et al mammography depict normal tissue at the lump site, but the patient should be followed-up at shortterm intervals with clinical examination and imaging [7,11,14]. Combined US and mammography are therefore commonly used in the assessment of breast lumps and are now used in some institutions as a possible screening method in women aged 40–50 years [4,9]. The clinical manifestations of silicone mastopathy are nonspecific. It is difficult to differentiate silicone granulomas from carcinoma clinically because both may manifest themselves as a palpable mass [1,3,15]. Identification of focal tumor or carcinoma of the breast can be hindered by silicone granulomas and associated calcifications. Neither US nor mammographic studies can reliably exclude superimposed carcinoma [1]. Contrast-enhanced fat-suppressed MRI is a useful imaging modality for the evaluation of siliconeinjected breasts and associated liquid silicone migration, enabling granulomatous disease to be differentiated from tumor development and metastasis [6,16]. Silicone particles exhibit high signal intensity on T2-weighted images and inversion recovery images, but demonstrate intermediate signal intensity on non-fat-suppressed T1-weighted images, hypointensity on fat-suppressed T1-weighted images, and do not exhibit definite enhancement. In patients who have had liquid silicone injections, lesions exhibit low signal on T2-weighted images and fatsuppressed T1-weighted images. This difference may be the result of two factors. First, the liquid silicone may have contained adulterated materials, such as some kind of oil, leading to the unusual signal characteristics on MRI. Second, the breasts may have sustained a long period of chronic granulomatous reaction resulting in fibrosis and formation of multiple silicone granulomas with or without calcifications, potentially causing the low signal seen on the T2-weighted images [15,17]. Free silicone injection of the breast may make US detection of breast mass difficult, but any mass superficial to the silicone granulomas can be depicted by US without being hampered by the silicone.
138
J Med Ultrasound 2005 • Vol 13 • No 3
In our patient, the presence of clustered microcalcifications in a small area of hypoechogenicity was highly suggestive of DCIS on US, and the histologic diagnosis was conclusive after US-guided biopsy.
References 1. Cheung YC, Lee KF, Ng SH, et al. Sonographic features with histologic correlation in two cases of palpable breast cancer after breast augmentation by liquid silicone injection. J Clin Ultrasound 2002;30:548–51. 2. Noone RB. A review of the possible health implications of silicone breast implants. Cancer 1997;79:1747–56. 3. Lopez H, Harris KM. Ultrasound interactions with free silicone in a tissue-mimicking phantom. J Ultrasound Med 1998:17:163–70. 4. Chou YH, Tiu CM, Lee SS, et al. Imaging of breasts in symptomatic patients: comparison of ultrasonic and x-ray mammography. J Ultrasound Med ROC 1992; 9:1–10. 5. Gabriel SE, O’Fallon WM, Kurland LT. Risk of connective-tissue diseases and other disorders after breast implantation. N Engl J Med 1994;330:1697–702. 6. Komatsu S, Lee CJ, Hosokowa Y, et al. Comparison of intraductal spread on dynamic contrast-enhanced MRI with clinicopathologic features in breast cancer. Jpn J Clin Oncol 2004;34:515–8. 7. Hlawatsch A, Teifke A, Thelen M. Preoperative assessment of breast cancer: sonography versus MR imaging. AJR Am J Roentgenol 2002;179:1493–501. 8. Soo MS, Rosen EL, Baker JA, et al. Negative predictive value of sonography with mammography in patients with palpable breast lesions. AJR Am J Roentgenol 2001;177:1167–70. 9. Kolb TM, Lichy J, Newhouse JH. Comparison of the performance of screening mammography, physical examination, and breast US and evaluation of factors that influence them: an analysis of 27825 patient evaluations. Radiology 2002;225:165–75. 10. Moy L, Slanetz PJ, Moore R, et al. Specificity of mammography and US in the evaluation of a palpable abnormality: retrospective review. Radiology 2002; 225:176–81. 11. Dennis MA, Parker SH, Klaus AJ, et al. Breast biopsy avoidance: the value of normal mammograms and normal sonograms in the setting of palpable lump. Radiology 2001;219:186–91.
Breast DCIS with Microcalcifications 12. Shetty MK, Shah YP, Sharman RS. Prospective evaluation of the value of combined mammographic and sonographic assessment in patients with palpable abnormalities of the breast. J Ultrasound Med 2003:22:263–68. 13. Shetty MK, Shah YP. Prospective evaluation of the value of negative sonographic and mammographic findings in patients with palpable abnormalities of the breast. J Ultrasound Med 2002;21:1211–6. 14. Kaiser JS, Helvie MA, Blacklaw RL. Palpable breast thickening: role of mammography and US in cancer detection. Radiology 2002;223:839–44.
15. Peng HL, Wu CC, Choi WM, et al. Breast cancer detection using magnetic resonance imaging in breasts injected with liquid silicone. Plastic Reconstr Surg 1999;104:2116–20. 16. Wang J, Shih TF, Chang KJ, et al. Silicone migration from silicone-injected breasts: magnetic resonance images. Ann Plast Surg 2002;48:617–21. 17. Caskey CI, Berg WA, Hamper UM, et al. Imaging spectrum of extracapsular silicone: correlation of US, MR imaging, mammographic, and histopathologic findings. Radiographics 1999;19:39–51.
J Med Ultrasound 2005 • Vol 13 • No 3
139