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1
Division of Diagnostic Imaging, The University of Texas M. D. Anderson Cancer
Center, Box 57, 1515 Holcombe Blvd. Houston, TX 77030.
2
Department of Radiology, The University of Texas Health Science Center, 6411
Fannin St., Houston, TX 77030.
3
Division of Pathology, The University of Texas M. D. Anderson Cancer Center,
Houston, TX 77030.
Received July 2, 1998;
accepted after revision June 29, 1999.
Address correspondence to G. J. Whitman.
Abstract
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MATERIALS AND METHODS. Seventeen pathologically confirmed cases of tubular carcinoma were characterized retrospectively by two radiologists. Mammograms and sonograms were available for all patients.
RESULTS. Fifteen of the 17 tubular carcinomas appeared as irregularly shaped masses with spiculated margins on mammography. Sixteen of the 17 masses had central densities. Spicules longer than the diameter of the central lesion were noted in eight (53%) of 15 tubular carcinomas. Eight tubular carcinomas had associated calcifications, with calcifications suspected of being malignant in four cases. On sonography, 15 hypoechoic masses were seen. The margins of the masses on sonography were described as ill-defined in 14 (93%) of the 15 cases. Posterior acoustic shadowing was present in 14 of the 15 cases.
CONCLUSION. Tubular carcinomas are usually seen on mammography as irregularly shaped masses with central densities and spiculated margins, and most tubular carcinomas can be identified on sonography as hypoechoic masses with ill-defined margins and posterior acoustic shadowing. Although the mammographic and sonographic features of tubular carcinoma are not sufficiently specific to differentiate tubular carcinomas from radial scars, sonography can be useful for guiding biopsies and evaluating for multifocal and multicentric disease.
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Previous studies have concentrated on the mammographic and pathologic findings associated with tubular carcinoma; few reports have described the sonographic findings. We aimed to describe in detail the mammographic and sonographic features of tubular carcinoma, using modern equipment and imaging techniques, and to determine whether specific mammographic or sonographic features of tubular carcinoma can be seen.
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The mean patient age was 56 years (range, 42-75 years). Mammograms and sonograms of the 17 pathologically confirmed cases of tubular carcinoma were retrospectively evaluated by two radiologists. Mammographic and sonographic features assessed are listed in Tables 1 and 2, respectively. The collected data were then reviewed by one radiologist, who compared the mammographic and sonographic findings. In cases of discrepant interpretations, additional observers adjudicated.
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The mammographic findings are summarized in Table 1. On mammography, all 17 tubular carcinomas were described as irregularly shaped masses. An area of central density was described in 16 (94%) of 17 cases (Fig. 1A, Fig. 1B, Fig. 1C, Fig. 1D, Fig. 1E); the remaining case was described as having an area of central lucency. Fifteen tubular carcinomas (88%) were described as having spiculated margins (Fig. 1A, Fig. 1B, Fig. 1C, Fig. 1D, Fig. 1E); the remaining two tubular carcinomas had ill-defined margins (Fig. 2). The spicules were longer than the central density diameter in eight (53%) of 15 cases (Fig. 3A, Fig. 3B) and were equal to or shorter than the central density diameter in seven cases (47%) (Fig. 1A, Fig. 1B, Fig. 1C, Fig. 1D, Fig. 1E). The mean diameter of the central mass was 0.7 cm (range, 0.5-1.2 cm). The mean maximum diameter, comprising the central lesion and the surrounding spicules, was 1.7 cm (range, 0.8-2.5 cm). Calcifications were identified in eight of 17 tubular carcinomas, with four clusters of calcifications described as suggestive of malignancy. Magnification views were available for all the cases in which calcifications were present. In all eight cases with calcifications, the calcifications were within 0.1-0.2 cm of the center of the primary lesion.
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At our center, sonography was used to confirm the presence of a mass, to guide biopsies (fine-needle aspirations in most cases), and to evaluate for possible multifocal or multicentric disease. The sonographic findings are summarized in Table 2. In 15 (88%) of 17 cases, masses were seen on sonography that corresponded to the tubular carcinomas. In the two cases in which no mass was seen on sonography, the tubular carcinomas were identified on mammography. The average tumor size on sonography was 0.9 cm (range, 0.3-1.2 cm). All 15 lesions detected on sonography were described as hypoechoic masses (Fig. 1A, Fig. 1B, Fig. 1C, Fig. 1D, Fig. 1E and 3). The margins of the masses were ill-defined on sonography in 14 (93%) of 15 cases (Figs. 1 and 3). The lesion height-to-width ratio was greater than 1:1 (taller than wide lesion) in eight (53%) of 15 cases (Fig. 3A, Fig. 3B) and less than or equal to 1:1 (oval lesion) in seven (47%) of 15 cases. Posterior acoustic shadowing was present in 14 (93%) of 15 cases (Fig. 1A, Fig. 1B, Fig. 1C, Fig. 1D, Fig. 1E). Hyperechoic foci representing calcifications were noted in two cases. The sonograms of the two cases with false-negative findings on sonography were reviewed and no abnormalities could be identified. The lesions with false-negative sonographic findings measured 0.5 and 0.7 cm on mammography and 0.6 and 0.8 cm on histopathologic evaluation.
All cases of tubular carcinoma were confirmed by pathologists experienced in breast pathology. To facilitate surgical planning, preoperative sonographically guided fine-needle aspirations were performed in all 15 cases having positive findings on sonography. In 10 cases, the fine-needle aspirates were interpreted as suggestive of carcinoma. In the remaining five cases, the aspirates were read as showing cellular atypia, and excisional biopsy was recommended. In one of the cases with cellular atypia, a core biopsy was performed under sonographic guidance, and histopathologic evaluation of the cores showed tubular carcinoma. In two cases with positive findings on mammography and negative findings on sonography, the diagnosis of tubular carcinoma was established at surgery. The mean gross tumor size at pathology was 1.0 cm (range, 0.4-1.7 cm). As seen in Table 3, imaging, especially mammography, tended to underestimate lesion size compared with histopathologic measurements.
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Tubular carcinoma (defined as a lesion with at least 80% tubular elements) was diagnosed in all 17 cases. Four additional histologic subtypes were present in 12 of 17 cases. The other histologic subtypes included ductal carcinoma in situ (n = 6) (Figs. 2 and 3), invasive ductal carcinoma not otherwise specified (n = 6), and lobular carcinoma in situ (n = 2). In three cases (18%), an additional ipsilateral primary breast carcinoma was confirmed pathologically. Two of the ipsilateral carcinomas, an invasive ductal carcinoma and a mixed tubular carcinoma (40% tubular carcinoma and 60% invasive ductal carcinoma), were identified in the same quadrants as the tubular carcinomas. The invasive ductal carcinoma was detected on mammography alone. In the case of the mixed tubular carcinoma, sonography detected both lesions, and the initial mammographic interpretation detected the mixed tubular carcinoma only. Subsequent review of the mammograms confirmed the presence of an additional mass corresponding to the sonographic and pathologic findings. The third ipsilateral carcinoma was an invasive ductal carcinoma. This ipsilateral lesion was detected on both mammography and sonography in a different quadrant from that of the tubular carcinoma. Two contralateral breast cancers were identified, and both were invasive ductal carcinomas.
Axillary lymph node dissections were performed in 10 of 17 patients. The average number of lymph nodes removed was 16.8 (range, 10-25). Four patients had metastatic axillary lymph nodes at surgery. Two of these four patients had ipsilateral invasive ductal carcinomas, and lymph node dissections were positive for malignancy in three of 15 and two of 10 axillary lymph nodes. One patient with a contralateral invasive ductal carcinoma had metastatic axillary lymph nodes on the contralateral side. One patient with a solitary tubular carcinoma had metastatic disease in one of 17 axillary lymph nodes. In that case, the primary tubular carcinoma measured 0.8 cm, and associated invasive ductal carcinoma was identified at pathology. The metastatic focus in the lymph node measured approximately 0.2 cm. Fourteen patients underwent segmental mastectomies, and three patients had total mastectomies. Thirteen patients received radiation therapy, including 12 patients who had undergone segmental mastectomies. All four patients with metastatic axillary lymph nodes received adjuvant chemotherapy. All 17 patients are alive and disease-free at the time of this report. The mean disease-free survival is 30 months (range, 13-61 months).
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Most reports have failed to show any unique mammographic features of tubular carcinoma [5, 6]. A prior report suggests that no specific mammographic features can be used to differentiate tubular carcinomas from radial scars [14]. To our knowledge, only one report has suggested that tubular carcinoma can be differentiated from other conditions on the basis of its small size and lack of physical findings [3]. Our study concurs with previously published reports that tubular carcinoma is usually identified on mammography as a small irregularly shaped mass with spiculated margins [3, 6, 11, 12]. In our series, long spicules, a feature that might be more typically associated with radial scars [15], were seen in 53% of the tubular carcinomas.
Suspicious microcalcifications on mammography have been described in 8-19% of cases of tubular carcinoma [3, 6, 12]. In our population, the percentage of cases with suspicious calcifications was higher (24%). The higher rate of detection of calcifications in our series may be the result of the availability of magnification views rather than a higher prevalence of calcifications. The availability of additional views is not commented on in most studies. Although one report suggested that the presence of calcifications is useful for differentiating invasive carcinomas from radial scars [16], another noted that the calcifications may be unrelated to the adjacent mass [6]. After excluding cases with typical malignant-appearing calcifications, Frouge et al. [17] were unable to distinguish malignant spiculated lesions from radial scars on the basis of the presence or the type of microcalcifications.
Sonography of the breast in benign and malignant disease is well established [18, 19, 20]. Sonography can detect lesions that are nonpalpable and mammographically occult [18, 21, 22]. In many breast imaging practices, sonography has assumed a major role in guiding percutaneous biopsies. In a study of 750 nonpalpable solid breast lesions, a 99.5% negative predictive value for cancer was reported in masses with a benign sonographic appearance [18]. In that study, the authors reported a sensitivity of 98.4% and a specificity of 67.8% for malignant lesions defined as either indeterminate or malignant on sonography [18]. Previously, sonography was not thought to be useful in the identification of tubular carcinomas because of their small size [3]. In this study, we successfully identified 15 of 17 tubular carcinomas sonographically. Nearly all the tubular carcinomas were hypoechoic masses with ill-defined margins and posterior acoustic shadowing, and the smallest tubular carcinoma detected on sonography in our series measured 0.3 cm. A lesion height-to-width ratio greater than or equal to 1:1 is suggestive of carcinoma [18]. However, a ratio of less than 1:1, which is generally thought to be associated with benign lesions, occurred in 47% of the tubular carcinomas in our study. These findings may be a result of the small size of the tumors identified on sonography in this series (average size, 0.9 cm). Posterior acoustic shadowing, which occurred in 93% of the tubular carcinomas in our series, is not unique to breast carcinoma, and benign conditions with fibrous elements can attenuate the ultrasound beam and cause shadowing [23]. It has been reported that no characteristic sonographic features will reliably identify radial scars [24] or differentiate them from tubular carcinomas [14]. Hypoechogenicity, which was noted in 15 of 15 tubular carcinomas, is not specific for carcinoma. Also, negative findings on sonography do not exclude a tubular carcinoma.
We have shown that the mammographic and sonographic features of tubular carcinoma are not specific, and those features overlap with the classic mammographic description of radial scars. On mammography, tubular carcinomas are usually identified as irregularly shaped masses with central densities and spiculated margins. On sonography, tubular carcinomas are usually seen as hypoechoic masses with ill-defined margins and posterior acoustic shadowing. We believe that sonography can play a significant role in the evaluation of suspicious irregularly shaped masses with spiculated margins identified on mammography. In addition to verifying that a real mass is present, sonography can be used to guide percutaneous biopsies (fine-needle aspirations and core needle biopsies) and to evaluate for multifocal and multicentric disease.
A high incidence of additional histologic subtypes is associated with tubular carcinomas. The identification of tubular carcinoma by fine-needle aspiration will not differentiate a pure tubular carcinoma, which has a good prognosis, from one of mixed pathologic features, the behavior of which will likely depend on the most aggressive histologic component. In the future, perhaps core needle biopsy (with an automated biopsy gun or a directional vacuum-assisted biopsy device) will allow a more accurate preoperative differentiation of pure tubular carcinoma from mixed tubular carcinoma containing other histologic components. With more accurate preoperative histopathologic information, the patient, her family, and her doctors can make informed management decisions, including the selection of the appropriate one-step surgical procedure (segmental mastectomy, total mastectomy, or total mastectomy with immediate reconstruction) to be performed in conjunction with an assessment of the axillary lymph nodes (by sentinel lymph node mapping or lymph node dissection).
Acknowledgments
We thank Deanna Sanchez, Mary Ann Waggoner, and Mary Carr for secretarial
assistance and Stephanie Deming for editorial assistance.
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