DOI:10.2214/AJR.06.5041.1
AJR 2006; 186:E12-E13
© American Roentgen Ray Society
Reply
Jay A. Baker1,
Andrea Hong2,
Eric L. Rosen3 and
Mary Scott Soo4
1 Duke University Medical Center Durham, NC
2 UIC Advocate Christ Medical Center Oak Lawn, IL
3 University of Washington Seattle, WA
4 Duke University Medical Center Durham, NC
We thank Drs. Rhiem, Flucke, and Schmutzler for their interest in our study
on positive and negative predictive values of sonographic features of breast
masses [1]. Their experience
that masses in patients with a BRCA1 mutation may be dissimilar and
more benign in appearance than masses in other patients is noteworthy. In
fact, this issue has been raised previously
[2].
We would like to make two brief comments regarding the study of 44 patients
with a BRCA1 mutation reported by Drs. Rhiem, Flucke, and Schmutzler
in their letter. First, they report that the cancers in their study that had a
benign appearance had a "round shape" and "enhanced sound
transmission." Although these may at first appear to be benign
characteristics, a round shape (i.e., anteroposterior dimension equal to
radial and antiradial dimension) is not the same as an oval, wider-than-tall
shape and is not generally regarded as a benign sonographic feature. Indeed,
the American College of Radiology's Breast Imaging and Reporting System for
Ultrasound (US BI-RADS) specifically separates round masses from more
benign-appearing oval masses and includes round masses with the "not
parallel" category of mass orientation
[3]. Although only two of the
403 masses in our study scrupulously fit the definition "round,"
they were both malignant. Similarly, "enhanced sound
transmission," although useful in the evaluation of breast cysts, does
not connote a similar level of benignity for solid masses of the breast. The
US BI-RADS lexicon again specifically notes that "Many cancers will
exhibit enhancement or no change in posterior features...."
[3], a fact borne out in our
study in which fully one third of 85 masses demonstrating posterior acoustic
enhancement were malignant.
Second, based on our review of Figures 2A and 2B, the static sonographic
images the authors provide do not necessarily support the reported description
of a "circumscribed margin." Some portion of the mass in each
figure appears indistinct without "an abrupt transition between the
lesion and the surrounding tissue" as required by the US BI-RADS
definition [3]. Although part
of each mass shown does appear circumscribed, it is important in all patients,
regardless of their genetic standing, to describe the margin of a mass by its
most suspicious component. In the examples provided, the indistinct portions
of the margins, though subtle, would render the masses
"indistinct" and therefore, in our opinion, suspicious.
Despite the two issues raised above, we certainly agree with the authors'
main point that any mass that is not definitively benign by agreed-upon
criteria (e.g., oval circumscribed mass with coarse calcification indicative
of a degenerating fibroadenoma) must be treated with suspicion in
very-high-risk patients who carry the BRCA1 mutation. It is also
worth noting that cancers in BRCA1 mutation carriers may not have the
typical appearance of a breast malignancy, and vigilance in such
patients—as with all patients—must be maintained.
References
- Hong AS, Rosen EL, Soo MS, Baker JA. BI-RADS for sonography:
positive and negative predictive values of sonographic features.
AJR 2005; 184:1260
-1265[Abstract/Free Full Text]
- Hamilton LJ, Evans AJ, Wilson ARM, et al. Breast imaging findings
in women with BRCA1- and BRCA2-associated breast carcinoma. Clin
Radiol 2004; 59:895
-902[CrossRef][Medline]
- American College of Radiology. BI-RADS: Ultrasound, 1st ed. In:
American College of Radiology. Breast imaging reporting and data
system: BI-RADS Atlas, 4th ed. Reston, VA: American College of
Radiology, 2003
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