OBJECTIVE: To determine the negative predictive value of mammography and sonography in patients with focal/ diffuse breast pain with negative physical examination of the breasts.
METHODS: A descriptive study, conducted at Radiology Department ofAga Khan University Hospital from 2006-2007 for a period of 2 years. A total of 207 women were referred for mammography and sonography because of focal or diffuse breast pain. Complete follow-up was available only in 55 patients. The outcome or gold standard was mammograms or ultrasound after an average follow-up period of 18 months with negative/benign findings or histopathology of the suspicious lesion or imaging which was the gold standard to determine the negative predictive value.
RESULTS: Out of 55 patients, 17 (31%) had negative findings, benign findings were reported in 34 patients (62%), and 4 (7%) patients were subjected to mammographically guided breast biopsy. All the biopsies were done on the basis of abnormal findings on mammograms. All of the 4 patients had no evidence of cancer on subsequent histopathology. The negative predictive value of mammography and ultrasound in women with focal or diffuse breast pain was 100%.
CONCLUSION: Breast imaging using mammography and/or sonography in women who present with local or diffuse breast pain is of significant value, to reassure the patient as well as the clinician. However if imaging findings are suggestive of pathology a biopsy should not be delayed

Afzal, Shaista

Beg, Mirza Amanullah

Kawal, Darakhshan

Khan, Nadir

Masroor, Imrana

Sakhawat, Saima

eCommons@AKU

eCommons@AKUDepartment of Radiology Medical College, PakistanSeptember 2009Negative predictive value of mammography andsonography in mastalgia with negative physicalfindingsImrana MasroorAga Khan UniversityShaista AfzalAga Khan UniversitySaima SakhawatAga Khan UniversityNadir KhanAga Khan UniversityMirza Amanullah BegAga Khan UniversitySee next page for additional authorsFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_radiolPart of the Obstetrics and Gynecology Commons, and the Radiology CommonsRecommended CitationMasroor, I., Afzal, S., Sakhawat, S., Khan, N., Beg, M., Kawal, D. (2009). Negative predictive value of mammography and sonographyin mastalgia with negative physical findings. Journal of the Pakistan Medical Association, 59(9), 598-601.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_radiol/38AuthorsImrana Masroor, Shaista Afzal, Saima Sakhawat, Nadir Khan, Mirza Amanullah Beg, and Darakhshan KawalThis article is available at eCommons@AKU: http://ecommons.aku.edu/pakistan_fhs_mc_radiol/38IntroductionBreast imaging is a valuable tool in the investigationof symptomatic breast disease.  Breast mass and breast painare two common complaints1 responsible for a womanconsulting a health care provider. Established managementof palpable breast lesion is triple assessment which includesphysical examination, mammography, and percutaneousbiopsy.2,3Breast pain, also known as mastodynia or mastalgia,is a common condition.4 Clinically mastalgia is divided intotwo types, cyclical mastalgia and non cyclical mastalgia.5 Inhealthy women self referred to breast screening clinics 69%reported pain severe enough to interfere with their dailyactivities.6 Breast pain is a frequent symptom for whichwomen seek medical attention7 and causes significantpatient anxiety. In women presenting with breast pain, thereported prevalence of breast cancer ranges from 0%-3.2%.8-12A large number of patients with breast symptoms arereferred for mammography and sonography. The utility ofmammography and sonography in the evaluation of apalpable breast lump is well established, with negativepredictive values ranging from 99.8% -100%.13,14598 J Pak Med AssocOriginal ArticleNegative predictive value of mammography and sonography inmastalgia with negative physical findingsImrana Masroor, Shaista Afzal, Saima Sakhawat, Nadir Khan, Mirza Amanullah Beg, Darakhshan KawalDepartment of Radiology, Aga Khan University Hospital, Karachi.AbstractObjective:  To determine the negative predictive value of mammography and sonography in patients with focal/diffuse breast pain with negative physical examination of the breasts.Methods: A descriptive study, conducted at Radiology Department of Aga Khan University Hospital from 2006-2007 fora period of 2 years. A total of 207 women were referred for mammography and sonography because of focal or diffusebreast pain. Complete follow-up was available only in 55 patients. The outcome or gold standard was mammograms orultrasound after an average follow-up period of 18 months with negative/ benign findings or histopathology of thesuspicious lesion or imaging which was the gold standard to determine the negative predictive value.Results: Out of 55 patients, 17 (31%) had negative findings, benign findings were reported in 34 patients (62%),and 4 (7%) patients were subjected to mammographically guided breast biopsy. All the biopsies were done onthe basis of abnormal findings on mammograms. All of the 4 patients had no evidence of cancer on subsequenthistopathology. The negative predictive value of mammography and ultrasound in women with focal or diffusebreast pain was 100%.Conclusion: Breast imaging using mammography and/or sonography in women who present with local ordiffuse breast pain is of significant value, to reassure the patient as well as the clinician. However if imagingfindings are suggestive of pathology a biopsy should not be delayed (JPMA 59:598; 2009).However the value of mammography andsonography in evaluation of focal/ diffuse breast pain is notwell established. This study was conducted to determine thenegative predictive value of mammography and sonographyin evaluation of patients with focal or diffuse breast painwithout a palpable mass.Patients and MethodsIt was a descriptive study conducted at theRadiology department of Aga Khan University Hospital.The duration of study was from January 2006 to December2007. During this period, 207 patients were referred formammography and sonography for focal/diffuse breastpain. Our inclusion criteria were patients with focal/diffusebreast pain without a palpable lump, patients with bothmammograms and whole breast sonograms, those withcomplete medical records and a follow-up of at least 18months with mammograms or sonograms, or withhistopathology of suspicious area seen on imaging.The exclusion criteria was all patients withincomplete records, patient with history of breast cancer orwith family history of breast cancer. All patients underwent mammography onMammomat NOVA 3000 (Siemens). The mammogramswere double read by 2 radiologists. All the patients werethen subjected to whole breast ultrasound. Ultrasound wasdone by a 7.5 MHz probe on either Nemio/ Xario ultrasoundmachines. Both mammograms and breast ultrasound werereported by radiologists with at least 3 years experience inmammography and sonomammography. The gold standardwas taken as final Breast Imaging Reporting and DataSystem (BIRADS) categorization after all workup orhistopathology. Final BIRADS categorization was doneafter an average follow up of 18 months with mammogramsor ultrasound. The patients with suspicious findings onimaging were subjected to imaging guided biopsy ofsuspicious area followed by histopathology.The data was analyzed using SPSS 16.ResultsThe mean age of patients in this study was 44.5 ± 4.6years (range 34-63 years). All the patients presented withunilateral or bilateral breast pain. Only in 5 patients the painwas, focal and the rest had diffuse non-specific pain. Mostof the patient were premenopausal and had no past historyor family history of breast cancer. Out of 207 patientscomplete medical records of only 55 patients wereavailable. Rest of the patients did not have follow up, sowere excluded from the study. The final BIRADS categoryof 55 patients is given in Table-1. The further categorizationof mammographic and sonographic (BIRADS) lexicon isgiven in Table-2.Our of 55 patients 17 had negative findings onmammography and whole breast ultrasound and werecategorized as BIRADS category 1 (Table-1).Thirty four patients were categorized as BIRADScategory 2.Out of these 34 patients 10 were categorized asBIRADS 2 on mammograms. Mammograms had showneither benign type of calcifications or one or two benignappearing 0.5x 0.5 mm nodules in either breast. Ultrasoundshowed benign findings in 26 patients either showing asingle or a few simple cysts or presence of short segmentduct ectasia (Table-2). All these patients had a repeatmammogram or ultrasound after an average follow-upperiod of 18 months, and the finding remained stable orregressed.All patients categorized as BIRADS 1 or 2 weretaken as true negatives.A total of four patients were categorized as category4 on the mammograms due to presence of parenchymalasymmetry or abnormal mammographic density notforming a definite nodule. All these four patients weresubjected to mammographically guided biopsy; one patienthad focal atypical ductal hyperplasia. Atypical ductalhyperplasia and ductal carcinoma in situ are pathologicallysimilar and may coexist, therefore the patient underwentopen surgical biopsy  to obtain a  free margin. This one casewas taken as true positive. One patient had florid ductalhyperplasia, and rest of the two patients had simple ductalhyperplasia, and reactive lymph node hyperplasia. All ofthese findings are suggestive of benign results. All three ofthem were taken as false positive. There were no falseVol. 59, No. 9, September 2009 599Table-1.Total n= 55 BI- RADS (%)17 Category 1 (31%) 34 Category 2 (62%) 4 Category 4 (7%)Table-2.Mammography (n=17) US (n=17) Mammography (n=34) US(n=34) Mammography ( n=4) Birads 1 (17) Birads 1 (17) Birads 2 (10) Birads 1 (8) Birads 4 (4) Birads 0 (24) Birads 2 (26) negative patients. The negative predictive value ofcombined mammography and ultrasonography in patientwith focal/diffuse breast pain in our study was 100%.DiscussionBoth mammography and ultrasound showed normalbreast parenchyma in 31% of patients. Imaging showedbenign findings in 62% of patients, more importantly nocancer was detected, even in those patients in which themammography reported suspicious findings. It is notknown how often breast cancer is manifested as breast painalone, but it appears to be infrequent. Preece et al15reported in their study comprising of 240 women withoperable breast cancer, only 7% had pain alone. However,the discovery of cancer in these patients may have beenincidental and not directly related to the primary symptomof isolated breast pain.One patient underwent biopsy of suspicious lesion asseen on mammogram (True positive), had atypical ductalhyperplasia (ADH), it is known that a histopathologic resultof ADH after an image guided core needle biopsy of a breastlesion may underestimate the presence of ductal carcinomain situ (DCIS) or invasive carcinoma as both ADH andDCIS are pathologically similar and can co exist.. Thesurgeon reexcised the area to obtain a clear margin free ofatypical hyperplasia changes. This was important as inliterature, the reported rates of upgrade  of  atypicalhyperplasia  after 14-guage needle biopsy is 33%.16 Thetissue was removed before the development of overtmalignancy thus reducing morbidity and mortalityassociated with breast cancer. In three patients (Falsepositives) the mammography showed subtle parenchymalasymmetry. In 2 of these patients it persisted on conecompressed view, and in one patients there was a smallcluster of punctuate micro calcifications. All 3 patients hadimaging findings which were not corresponding to area ofpain, but still they were subjected to biopsy to rule outpossibility of malignancy, all three of them had negativehistopathology results. There were no false negative results.In a study conducted by Duijm et al10 which was anobservational follow up study, they compared 987 womenreferred for breast imaging because of pain alone with 987asymptomatic women referred for screeningmammography. Breast imaging consisted of diagnosticmammography and possible sonography in patients olderthan 25 years; they included patients with focal and diffusebreast pain. They found that the prevalence of breast cancerin their study group was 0.8% similar to control group0.7%, suggesting that pain is not associated with increase inbreast cancer risk. However, these results must beinterpreted with caution because of small number of cancersdetected in Duijm study. No cancers were detected in ourstudy. This can be due to the small sample size of 55patients, which is one of the limitations of our study.The negative predictive value of ultrasound infocal/diffuse pain in our study is 100% this is similar to astudy conducted by Tumyan et al,17 who reported a negativepredictive value of 100%. The only difference betweenLusine’s study and our study was that he had included onlypatients with focal breast pain.In a study conducted by Soo et al13 the negativepredictive value of mammography with sonography wasreported as 99.8%. In this study all patients presented withpalpable breast lesions, whereas, in our study all patientshad negative physical examination of breasts and presentedwith either focal or diffuse breast pain. There are a few other limitations of our study that anaverage follow up of only 18 months is available. We are notsure that this is long enough to detect a slow growing cancer. Ifa longer follow up was available  cancers may have beendetected.The other limitation is selection bias, as all thosepatients with palpable masses were excluded from thestudy because it is well established that patients withpalpable findings warrant diagnostic imaging to excludemalignancy. Another limitation was referral bias as generalpractitioners do not always refer patients who present withbreast pain to a radiologist. Several women on the basis ofnegative physical examination must have been reassuredby the general practitioner and had not under gone anyimaging.ConclusionThe combined value of mammography andsonography in focal/diffuse breast pain without a palpablebreast mass is 100%. These imaging modalities can bereassuring to the patients as well as the referring clinician iffollow-up is planned and physical examination is negative.However if the imaging findings are suspicious a biopsyshould not be delayed.References1. Roberts MM, Elton RA, Robinson SE, French K, Consultations for breastdisease in general practice and hospital referral patterns. Br J Surg 1987;74:1020-2.2. Thomas JM, Fitzharris BM, Redding WH, Williams JE, Trott PA, Powles TJ,et al. Clinical examination, xeromammography, and fine needle aspirationcytology in diagnosis of breast tumors. Br Med J 1978; 2: 1139-41.3. Hermansen C, Skovgaard Poulsen H, Jensen J, Langfeldt B, Steenskov V,Frederiksen P, Jensen OM. Diagnostic reliability of combined physicalexamination, mammography and fine needle puncture ("triple test") in breasttumors: A prospective study. Cancer 1987; 60: 1866-71.4. Lamarque JL. The commonest complaints in the radiology clinic. In: An Atlasof the breast: clinical Radiodiagnosis. London, England: Wolfe MedicalPublication Ltd 1984: pp 210.5. Yakut ZI, Kafali H, Karaoglanoglu M, Koktener A, Duvan CI. A newradiological approach to cyclic mastalgia: Venous Doppler ultrasound. The600 J Pak Med AssocBreast 2009; 18: 123-5.6. Be Lieu RM. Mastodynia. Obstet Gynecol Clin North Am 1994; 21: 461-77.7. Marrow M. The evaluation of common breast problems. Am Fam Physician2000; 61: 2371-8.8. Lumachi F, Ermani M, Brandes AA, Boccagni  P, Polistina F, Basso SM, et al.Breast complaints and risk of breast cancer. Population - based study of 2,879self selected women and long -term follow-up. Biomed pharmacotherapy2002; 56: 88-92.9. Stern EE, Age- related breast diagnosis. Can J Surg 1992; 35: 41-5.10. Duijm LE, Guit GL, Hendriks JH, Zaat JO, Mali WP. Value of breast imagingin women with pain full breasts: observational follow-up study. BMJ 1998;317:1492-5.11. Locker AP, Manhire AR, Stickland V, Caseldine J, Blamey RW.Mammography in symptomatic breast disease. Lancet 1989; 1: 887-9.12. Leung JW, Kornguth PJ, Gotway MB. Utility of targeted sonography inevaluation of focal breast pain. J Ultrasound Med 2002; 21: 521-6.13. Soo MS, Rosen EL, Baker JA, Vo TT, Boyd BA. Negative predictive value ofsonography with mammography in patient with palpable breast lesions. AJRAm J Roentgenol 2001; 177: 1167-70.14. Dennis MA, Parker SH, Klaus AJ, Stavros AT, Kaske TI, Clark SB. Breastbiopsy avoidance: the value of normal mammograms and normal sonogramsin the setting of a palpable lump. Radiology 2001; 219: 186-91.15. Preece PE, Baum M, Mansel RE, Webster DJ, Fortt RW, Gravelle IH, et al.Importance of mastalgia in operable breast cancer. Br Med J 1982; 284: 1299-300.16. Mendez I, Andreu FJ, Saez E, Sentis M, Jurado I, Cabezuelo MA, et al. Ductalcarcinoma in situ and atypical ductal hyperplasia of the breast diagnosed atstereotactic core biopsy. Breast J 2001; 7: 14-8.17. Tumyan L, Hoyt AL, Bassett LW. Negative predictive value of sonography andmammography in patients with focal breast pain. Breast J 2005; 11: 333-7.Vol. 59, No. 9, September 2009 601

Negative predictive value of mammography and sonography in mastalgia with negative physical findings

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Negative predictive value of mammography and sonography in mastalgia with negative physical findings

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