Application of the breast imaging reporting and data system final assessment system in sonography of palpable breast lesions and reconsideration of the modified triple test Jin Young Kwak , MD, Eun-Kyung Kim, MD, Hai-Lin Park, MD, Ji-Young Kim, MD, Ki Keun Oh, MD Department of Diagnostic Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea;Departments of Diagnostic Radiology,General Surgery, and Pathology Pochon Cha University College of Medicine, Seoul, Korea Journal of ultrasound in Medicine ,October,2006 Intern李明吉

Introduction For evaluating palpable breast lesions 1975 triple test: physical examination, mammography, FNA 1996 Modified triple test :replaced mammography with sonography in younger women

Recently, American College of Radiology introduced application of BI-RADS(breast imaging reporting and data system) to sonography. little evidence This studyto evaluate the effectiveness of BI-RADS sonographic final assessment system

Materials and Methods Review data (May, 2002~October ,2004) -408 palpable lesions of breast -Palpation-guided FNA :188 cases included 160 lesions(151 p’t) that underwent modified triple test (PE, echo, FNA) and pathologic conformation

Mean age:34 y/o(range:14~73 y/o) Palpable lesions size:23.3mm(range:6~65mm) Exclude simple cysts on sonography

Mammography:performed on 132 --28 not donevery young age and loss of outside mammography services Sonography:performed with full knowledge of clinical and mammographic findings. - performed by the same radiologist who interpreted mammogram)

Sonography: classified according to BI-RADS category -1:normal -2:benign finding(eg:a cyst or a nodule with intense homogeneous hyperechogenicity) -3:a mass orther than 2,4,5 -4:suspicious findings -5:suspicious ≧ 3 Suspicious findings:irregular shape, complex echogenicity, posterior shadowing, spiculated margins, microlobulated margins, nonparallel orientation,microclacifications, and duct extension.

Fine-Needle Aspiration:with palpation guidance,done after imaging studies (mammography, sonography, or both) not disturbing interpretation of the images.

Histopathologic confirmation: -sonographyically guide:37/160 -vacuum-assisted:37/160 -excision:86/160 74 needle biopsy: scheduled screening follow up(duration :12~32 months, mean 26 months)

Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of malignancy were calculated for sonography and palpation-guided FNA.

Results Histopathologic confirmation 33 malignant, 127 benign younger than 30 y/o :38.8% The percentage of malignancy increased according to age.

Mammography and sonography 160 lesions, mammography :132(99 benign, 33 malignant) 4 cases, mammo(-) , sono (-)excision -3 :heterogeneously dense breast -1 : breast extremely dense patho:2 fibrocystic change,1 fibroadenoma, 1 periductal chronic inflammation 5/33 (15.2%) malignancies had negative mammographic findings

Analysis of cytologic examination and sonography Result of FNA:benign,atypical cells, suspicious for malignancy, and insufficiency. Sonography: BI-RADS sonographic final assessment system. (category 1~5)

7/18 :benign condition -5/7 :category 1 or 3 11/18(61.1%) :cancers -10/11 (90.9%) :category 4 -1/11:category 3

2/17(11.8%) cancers : category 4 15/17(88.2%) benign condition -13/15(86.7%) : category 1,2,3

No statistical significant difference for sensitivity and NPV between sonography and FNA.

Discussion Many palpable lesions are benign(79.38%) , in concordance with previous report. No significant difference for sensitivity and NPV between sonography and FNA. In the objective of not missing malignancy, sensitivity and NPV are most important.

When cytologic results revealed insufficiency, atypical cells, and suspicion of malignancy, sonography provide good guidance -atypical or suspicion(18 cases): -11/18 cancers -10/11 category 4

--7 benign -5/7 :category 1 or 3 false-positive cytologic result. Insufficient on FNA :2/2(100%) cancers : category 4

Mammography:132(99 benign,33 malignant) -5/33(15%): mammographically occult, similar to other reports. 4 negative results on mammo and sonoall 4 were confirmed by excision: benign support other studies in which NPV of negative mammographic and sonographic findings was 100%.

Limitation: -Period of imaging follow-up(12~32 months was insufficient in some cases. -based on examination of data by breast specialists (an expert surgeon and an expert radiologist)may not be reproducible -Data group was small

The application of FNA results can be difficult, especially when the result is insufficiency and atypical cells. Conclusion: sonography can replace palpation-guided FNA for diagnosis of palpable lesions of the breast when sonographic examinations are done meticulously.

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