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We measured the incident angle of the feeding artery of breast tumors on color Doppler ultrasonography. Ninety-two tumors that had plunging arteries (21 fibroadenomas and 71 breast cancers) were retrospectively evaluated. Breast cancers were divided into three types [accentuating type (ACC), 25; intermediate type (INT), 35; and attenuating type (ATT), 11] by posterior echo. Color Doppler ultrasonography was performed using an HDI 5000 (ATL Ultrasound, USA) with a 7- to 10-MHz linear probe.We measured the incident angle of the feeding artery on color Doppler imaging. If the tumor had many plunging vessels, we measured all of them. The average incident angle of the artery of fibroadenoma was 47.5° and that of breast cancer was 17.6°. Fibroadenoma ranged from 15° to 70° and breast cancer from 0° to 70°. In breast cancer, there were no significant differences among the three types (ACC, INT, and ATT). We concluded that the incident angle of the feeding artery adds valuable information to the color Doppler ultrasonographic diagnosis for breast tumors.

From 1994 until 2002, we performed 6956 ultrasonic screenings of the thyroid for all patients who received breast examination by ultrasonography. We discovered 14 thyroid cancers (0.32%) from 4327 cases with breast complaints. The incidence of thyroid cancer with breast cancer (0.25%) was three times higher than that of thyroid cancer without breast cancer (0.73%). It was concluded that ultrasonic screening of the thyroid was useful in patients with breast complaints.

We have reported the Diagnostic Guidelines for Non-Mass Image-Forming Lesions. These have been discussed in the subcommittee of the Japan Association of Breast and Thyroid Sonology (JABTS) and the Japan Society of Ultrasonics in Medicine.

This report is now the draft. We will discuss it further, and it will become a useful guideline for the ultrasonic diagnosis of breast cancers.

The educational committee of the JABTS (Japanese Association of Breast and Thyroid Sonology) organized a breast ultrasound training course as a method for quality control. The course consisted of pre- and posttests, lectures, and small group learning. To simulate an actual examination, moving images of clinical cases were used in some of the small learning groups and the tests. After the course, although the specificity deteriorated from 75.4% to 68.0%, the sensitivity rose from 62.5% to 75.4%. The training course was considered to be effective in improving the ability to find lesions.

The hormone-sensitive epithelial cells within the lobules are the major source of ductal carcinoma in situ (DCIS) of the breast. The neoplastic cells grow, and fill and increase the volume of the spaces bound by the basement membrane until they disrupt them. Even extensive cases of DCIS are unifocal in three dimensions and are usually confined to a single segment of the mammary duct system. The neoplastic cells can proliferate within the spaces that have been altered by benign proliferative diseases such as adenosis and multiple papilloma. The concept of unfolding is the key to understanding the morphology of DCIS as well as benign breast cysts, both of which have larger and fewer structures although they originated in the small blindending structures within the lobules. Atypical ductal hyperplasia (ADH) can be understood as minimal low-grade DCIS that incompletely fills the spaces bound by the basement membrane. Although ADH, atypical lobular hyperplasia, and lobular carcinoma in situ (LCIS) carry a general risk for later development of invasive mammary carcinoma, DCIS carries a localized risk. The management of the DCIS should be determined based on pathological evidence including grade, size, and surgical margin status.

Ductal carcinoma in situ (DCIS) is mostly diagnosed by mammography. The incidence is between 1% and 5% in countries without widespread use of mammography, but the incidence in mammography screening programs is between 8% and 25%. However, DCIS can also be diagnosed by galactography in patients with nipple discharge, by ultrasound, and sometimes also by MRI. These methods can tell precisely how big the cancer is and exactly where in the breast. However, to morphologically verify a suspicion of malignancy from any of these imaging methods, needle biopsy can be performed. By using needle biopsy, surgery can be planned more accurately as a curative measure instead of as a diagnostic biopsy. Fine-needle biopsy with thin needles for cytological diagnosis can be used successfully, especially in DCIS of the comedo type, but this technique is more operator dependent than core-needle biopsy and vacuum-assisted biopsy techniques where small pieces of tissue are sampled for histopathological analyses and diagnosis. There are no real complications for all these techniques. Patients diagnosed with DCIS have an excellent prognosis to survive without any local recurrences and general metastases.

Ductal carcinoma in situ (DCIS) has been detected primarily by palpation, calcification on mammogram (MMG), and nipple discharge. Ultrasonographic investigation of DCIS has been performed, but has not up to now revealed any form of DCIS that could not be discovered by the above three methods. In the present report, we describe a form of DCIS that has not been detected by earlier methods, and propose to refer to this new DCIS as 3 non-DCIS to distinguish it from conventional DCIS: 3 non-DCIS represents nonpalpable DCIS without calcification on MMG and without nipple discharge. Only the method of ultrasound screening described in this chapter can detect 3 non-DCIS. We diagnosed 23 patients as 3 non-DCIS at this institution between May 1997 and March 2003. There was neither calcification, mass, nor distortion on MMG in these patients. On ultrasonography, a small mass measuring 10mm or less was revealed. Thorough examination by fine-needle aspiration cytology showed 90% of the patients were positive. On analysis of subtype of DCIS, 22 of the 23 cases of DCIS were classified into pure noncomedo type and 1 was mixed type. Lesions in 3 non-DCIS were frequently less extensive than those in conventional DCIS.

We investigated the characteristics of non-mass image-forming breast cancer and the relationship between non-mass image-forming breast cancer and ductal carcinoma in situ (DCIS). We reviewed 47 non-mass image-forming breast cancers and 75 ultrasonic images of DCIS. We classified non-mass image-forming breast cancers into four subtypes: a homogeneous pattern, a ductal pattern, a mottled pattern, and a geographic pattern. The 47 cases were classified into 2, 6, 12, and 27 cases, respectively. Histological findings were 24 DCIS, 19 invasive ductal carcinomas with predominant intraductal components, and 4 invasive carcinomas. The 16 of 27 cases with a geographic pattern included invasive components. The 15 of 24 geographic cases had a comedo type of intraductal component. Of the 75 cases of DCIS, 51 cases were a mass image-forming type and 24 cases were a non-mass imageforming type. The histological findings for non-mass image-forming breast cancer tend to be DCIS and/or invasive ductal carcinoma with a predominant intraductal component. The geographic pattern often contained invasive components. The geographic pattern and/or the lesion with echogenic spots often had a comedo type. These results revealed the close relationship between the progress of breast cancer and ultrasonic imaging.

Some cases of ductal carcinoma in situ (DCIS) of the breast are arising in sclerosing adenosis. Sclerosing adenosis can sometimes resemble invasive carcinoma, especially in mammography (MMG). We attemped to reevaluate images from DCIS arising in sclerosing adenosis in MMG and ultrasonography (US) by comparing pathological reports. Four of the 90 (4.4%) cases of DCIS operated on at the Cancer Institute Hospital in 2001 arose from sclerosing adenosis. Three of the 4 cases showed characteristic images, focal distortion without mass lesion in MMG and indistinct and irregularly shaped hypoechoic area in US. It is usually easy to conclude the presence of malignancies from MMG findings. However, using US findings, it can difficult not only to detect abnormalities but also to determine the presence of malignancy. It is important to be able to detect this type of DCIS to make the correct diagnosis and to select suitable treatment.

Our aim was to appreciate the value of our newly equipped ultrasonic device in assessing margin status and to evaluate the policy of oncoplastic surgery in breast-conserving treatment (BCT). Of 783 cases of primary breast cancer treated between January 1991 and December 2001, 407 cases undergoing BCT were studied. A GE-YMS Logiq 700 MR was introduced as the new device in January 2000 and its outcome was calculated. In BCT, we intended to take the policy of oncoplastic surgery with the goal of ultimately obtaining a negative margin using both image-guided biopsy and frozen section analysis. Ninety percent (366/407) of patients received radiation therapy. Outcome was calculated using crude rates of first site of failure. After introducing the new device, the rate of BCT increased to 80% (86/108) from 69% and the rate of pathologically negative margins (>5mm; PNM) also increased to 91% (78/86) from 82%. At a mean follow-up time of 49 months, the overall local recurrence rate was 0.5% (2/407). Comparatively high percentages of BCT and PNM were obtained mainly by introducing the Logiq 700 MR. A small local recurrence rate (0.5%) was derived from taking the policy of oncoplastic surgery.