ARTICLE IN PRESS

The Breast (2006) 15, 744753

THE BREAST

www.elsevier.com/locate/breast

ORIGINAL ARTICLE

Radiological features and pathologicalbiological

correlations in 348 women with breast cancer
under 35 years old
Brunella Di Nubilaa, Enrico Cassanoa, Linei A.B.D. Urbana,b,,
Palmina Fedelea, Francesca Abbatea, Patrick Maisonneuvec,
Paolo Veronesid, Giuseppe Rennee, Massimo Bellomif,g

a
Breast Imaging Unit, European Institute of Oncology, 435, Ripamonti Street, 20141 Milan, Italy
b
Division of Radiology, DAPI Clinic, 913 Padre Agostinho Street, 80430-050 Curitiba, Brazil
c
Division of Epidemiology and Biostatistics, European Institute of Oncology, 435 Ripamonti Street,
20141 Milan, Italy
d
Division of Senology, European Institute of Oncology, 435 Ripamonti Street, 20141 Milan, Italy
e
Division of Pathology and Laboratory Medicine, European Institute of Oncology, 435, Ripamonti Street,
20141 Milan, Italy
f
Division of Radiology, European Institute of Oncology, 435 Ripamonti Street, 20141 Milan, Italy
g
Istituto di Scienze Radiologiche, Universita
` degli Studi di Milano, 435 Ripamonti Street, 20141 Milan, Italy

Received 12 July 2005; received in revised form 14 February 2006; accepted 17 February 2006

KEYWORDS Summary The aim of this study was to present mammography and ultrasound
Breast cancer; features, and accuracy, in 348 young women (under 35 years old) with breast cancer,
Young women; and to determine whether such features could be correlated with pathological and
Diagnosis; biological factors. We performed a retrospective review of the radiological,
Radiology; pathological and biological features of women under 35 years old with breast
Tumour markers cancer who were seen in our institute between January 2000 and December 2002. A
total of 348 women were analysed. The sensitivity of mammography was 84.9% and
that of ultrasound was 88%. There is a statistically signicant positive correlation
between the high sensitivity of ultrasound and the histology type (P 0:004) as well
as the expression of PgR (P 0:01). Also, there is a correlation between the
sensitivity of mammography and the histology type (P 0:004). Microcalcications
are associated with age (P 0:05) and overexpression of HER2/neu (P 0:007).
Ultrasound may be the appropriate initial imaging test for symptomatic young
women, and mammography may be useful in conrming the features, although there

Corresponding author. Division of Radiology, DAPI Clinic, 913 Padre Agostinho Street, 80430-050 Curitiba, Brazil.
Tel.: +55 41 32341469; fax: +55 41 32503010.
E-mail address: lineiurban@hotmail.com (L.A.B.D. Urban).

0960-9776/$ - see front matter & 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.breast.2006.02.006
 ARTICLE IN PRESS
Radiological features and pathologicalbiological correlations in women with breast cancer
was no signicant difference in the accuracy of the two tests. Histological and
biological proles may be correlated with imaging sensitivity.
& 2006 Elsevier Ltd. All rights reserved.
Introduction
Breast cancer is a disease found mainly in older
women, with 75% of the cases occurring in women
over 50 years old.1,2 Although only 2.5% of the cases
occur in women under 35 years old and 0.6% in
those under 30 years old, breast cancer is the
leading cause of cancer mortality in women aged
1534.1,35 Breast imaging may be less reliable, and
radiologists may have limited experience or a lower
index of suspicion, in this age group, all of which
may contribute to a delay in diagnosis.610 It is also
known that breast tumours in younger women are
associated with a higher prevalence of poor
histological and biological factors (such as high
proliferative rate, negative steroid receptors and
vascular invasion).69 In addition, since screening
mammography is not recommended for young
women most breast cancers are diagnosed by
detection of a palpable mass. All these reasons
may contribute to patients under 35 years old
having larger and more advanced tumours relative
to older women.1,5
The aim of this study was to present mammo-
graphy and ultrasound features in young women
with breast cancer, and to determine whether such
features may be correlated with pathological and
biological factors. To our knowledge, there are no
reports correlating radiological features with
pathological and biological proles.
Materials and methods
Of the 6516 consecutive women treated for breast
cancer in our institute between January 2000 and
December 2002, 397 were under 35 years old. We
subsequently excluded patients who presented
with recurrent tumours (49 cases). A total of 348
patients (5.3%) were included in this analysis, and
for these patients clinical, radiological, pathologi-
cal and biological reports were retrospectively
reviewed.
Clinical evaluated data were age, presence of
symptoms (asymptomatic, palpable mass and other
symptoms) and family history of breast cancer (rst
relatives or no relatives).
The mammograms were performed in our insti-
tute in almost all cases (84%), with the use of
745
digital techniques in 33% of the cases (Senograph
2000D, General Electric, Germany) and analogical
in 67% (Senograph DMR, General Electric). In 16% of
the cases, the mammograms came from other
institutes. Breast Imaging Reporting and Data
System (BI-RADS) classication was taken from the
original report, and followed the standards of the
American College of Radiology BI-RADS.11 Breast
density grades were also taken from the original
report and were determined according to BI-RADS.
The ultrasound analysis was conducted in our
institute in 89% of the cases. A high-resolution
unit was used (Technos MPX; Esaote, Genoa, Italy
and AU5 Harmonic; Esaote), with a linear array
probe between 7.5 and 13 MHz. A radiologist with
prior knowledge of clinical and mammographic
features performed examination procedures in our
institute. In 11% of the cases, US procedures were
performed in other institutes. The report was
reviewed and it was classied by the authors as
normal (category 1), benign (category 2), probably
benign (category 3), and suspected malignancy
(category 4).
The histopathology was reported according to
the WHO classication.12 The tumour grade (G) was
evaluated according to Elston and Ellis13 and the
peritumoral vascular invasion (VI) was assessed
according to Rosen and Oberman.14 The oestrogen
receptor (ER) and the progesterone receptor (PgR)
status, and the expression of Ki-67 were deter-
mined by MIB1 monoclonal antibody. HER2/neu was
evaluated immunocytochemically, as previously
reported.15
The aim of the statistical analysis was to compare
the radiological features with the pathological
ndings and the biological markers. This analysis
was performed with the use of Fishers exact test.
Variables were divided into groups, and included:
1. Age: 2030 years old and 3135 years old.
2. Family history: rst degree (mother, daughter
and son) and no relative.
3. Mammography density: scale 1/2 and scale
3/4.
4. Mammography reports: lesion with clustered
calcications and lesion with no clustered
calcications.
5. Mammography BI-RADS: categories 0/1/2/3
and categories 4/5.
 ARTICLE IN PRESS
746 B. Di Nubila et al.

6. Ultrasound features: categories 1/2/3 and
category 4.
7. Histology: inltrating ductal, other tu-
mours and DCIS.
8. G: grades 1/2 and grade 3.
9. VI: absent and present.
10. ER: o10% and X10%.
11. PgR: o10% and X10%.
12. Ki-67: p25% and 425%.
13. HER2/neu: p10%/410% (incomplete and
complete moderate expression) and 410%
(complete intense expression).
Results
Of the 348 patients under 35 years old with primary
breast cancer, data on clinical features were
available in 256 cases, mammographic features in
233, ultrasound features in 239, pathological

Figure 1 A 30-year-old woman with a recently discovered palpable mass in the left breast. An oblique mammograms (a)
demonstrated a mass with extremely dense breast tissue and obscured margins at the site of clinical suspicion. The
ultrasound examination (b) revealed irregular, heterogeneous, microlobulated contours, 30-mm in diameter, and a
hypoechoic mass in the upper quadrants. The pathological diagnosis was inltrating ductal carcinoma.
 ARTICLE IN PRESS
Radiological features and pathologicalbiological correlations in women with breast cancer 747

features in 348 and biological features in 336. A

total of 233 patients had a complete set of data
available.
The women were between 22 and 35 years old
(the mean age was 32 years old). At diagnosis,
97.2% (238 out of 256) were symptomatic. Of this
group, 92.9% (238 out of 256) had a palpable mass
(average diameter 29.3 mm) and 4.3% (11 out of
256) had other breast symptoms (haematic nipple
discharge, breast pain and skin thickness). Only
2.7% (7 out of 256) of the patients were asympto-
matic, and the mammography was performed due
to positive family history. All women in this study
were pre-menopausal prior to diagnosis. The rst-
degree family history was positive in 12.2% of the
cases (31 out of 256).
The sensitivity of mammography was 84.9% (198
out of 233). False-negative results occured in 15.1%
(35 out of 233). Mammographic abnormalities were
reported as a mass in 53.2% (116 out of 218; Fig. 1),
as a mass with calcication in 21.5% (47 out of 218;
Fig. 2), as architectural distortion in 3.6% (8 out of
218), as architectural distortion with calcication
in 3.2% (7 out of 218), as a single cluster of
microcalcications in 5.5% (12 out of 218), as
multiple clusters of microcalcications in 11.0% (24
out of 218), as diffuse microcalcications in 0.9% (2
out of 218) and as others in 0.9% (2 out of 218).
In 80.8% of the cases (188 out of 233), the lesions Figure 2 A 34-year-old woman with a palpable mass in
were classied as suspect (category 4) and in 4.2% the right breast. An oblique mammograms showed an
(10 out of 233) as highly suspect (category 5). In irregular, ill-dened, highly dense mass with heteroge-
5.1% (12 out of 233) the ndings were probably neous dense breast tissue associated with pleomorphic
benign (category 3) and in 1.7% (4 out of 233) they calcication in the upper quadrants of the right breast.
were benign (category 2). Mammography was The pathological diagnosis was inltrating ductal carci-
normal (category 1) in 5.1% (12 out of 233) and noma.
was not sufcient for diagnosis (category 0) in 3% of
the cases (7 out of 233). Density of breast 3). In 80% of the cases (n 16), both methods
parenchyma on the mammogram was grade 1 in showed a mass that was classied as benign/
3.3% of the cases (5 out of 148), grade 2 in 9.4% (14 probably benign, although biopsy showed malig-
out of 148), grade 3 in 68.2% (101 out of 148) and nancy. In 20% of the cases (n 4), the mammo-
grade 4 in 18.9% (28 out of 148). graphy and the ultrasound did not show lesions, but
Breast ultrasound had a sensitivity of 88.7% (212 a biopsy was performed because there were
out of 239) and was falsely positive in 11.3% (27 out suspected palpable lesions, and the histology was
of 239). There was no statistically signicant ductal carcinoma. In seven patients, mammography
difference between the sensitivity of ultrasound was positive and the ultrasound was negative
and of mammography. According to the ultrasound, because only microcalcications were seen on the
lesions were classied as suspected malignancy mammography. In 15 patients, the mammography
(category 4) in 88.7% of the cases (212 out of 239), was negative and the ultrasound was positive. This
probably benign (category 3) in 5.0% (12 out of 239; occurred mainly because mammography was not
Fig. 3), and benign (category 2) in 3.3% (8 out of able to show the nodule due to breast density,
239). Ultrasound was normal (category 1) in 2.8% of while ultrasound showed the lesions and was able
the cases (7 out of 239). The average diameter of to point to the suspected malignancy (category 4).
the lesions on ultrasound was 25 mm. The histopathological features (size, type, G, VI),
Concerning false-negative cases, we observed ER/PgR status, and Ki-67 and HER2/neu expression
that 20 patients were negative with both methods are shown in Table 1. The macroscopic average
(mammography and ultrasound; categories 1, 2 and tumour size was 23 mm.
 ARTICLE IN PRESS
748 B. Di Nubila et al.

Figure 3 A 31-year-old woman with a palpable mass in the left breast. The examination showed a well-dened
hypoechoic mass with an increase in its diameter (initial ultrasound performed at another institution showed a probably
benign mass 6 months before). The pathological diagnosis was mucinous carcinoma.

The statistical analysis of the association be-
tween radiological features, age and family history
is shown in Table 2. There was a signicant
statistical correlation (P 0:05) between age and
presence of microcalcications. There was also
some correlation between age and the capacity of
ultrasound to classify the lesion as suspicious, but
this was not signicant (P 0:09).
The association between the radiological and the
histological features is also shown in Table 2. There
was a signicant statistical correlation between the
histological type of the tumour and the capacity
of mammography (Po0:0001) or ultrasound (P
0:004) to correctly classify the lesions as suspicious.
The association between biological proles and
radiological features is shown in Table 3. There was
a signicant statistical correlation (P 0:01) be-
tween the expression of PgR and an ultrasound
result of suspected malignancy. The expression of
HER2/neu had a signicant correlation (P 0:0007)
with the presence of microcalcications. There was
borderline correlation between the expression of
PgR and the presence of microcalcications
(P 0:09), between the expression of HER2/neu
and mammographic density (P 0:09), and be-
tween tumour grade and ultrasound classication
of suspected malignancy (P 0:07).
Discussion
The incidence of breast cancer in women under 35
years old in our institute was 5.3%. This gure is
slightly higher than that reported in the literature,
which varies from 1% to 3%.1,3,4,16 Such discordance
may be explained based on the fact that our
institute is an oncological referral centre, and as
such our series is prone to selection bias.
The usefulness of mammography in women under
35 years old is controversial, mainly because of the
great density of the glandular parenchyma and
radiosensitivity.1,4,17,18,19,20,21 In a study of 577
breast cancer cases, Saarenma et al. reported that
sensitivity of mammography decreases in young
patients.22 Initial reports described how approxi-
mately 60% of breast cancer cases in younger
women were not detected through mammo-
grams.23,24 However, recent studies reported that
mammography was able to detect as many as 90% of
the breast cancer cases in women under 35 years
old, despite 4070% with dense parenchyma. This
increase in sensitivity may be due to technical
improvements in the mammographic equip-
ment.4,16,19,25
In our study, mammograms were dense in 87% of
the cases (grade 3/4 BI-RADS) and the sensitivity
was 85%. Several hypotheses might account for the
high percentage of mammographic ndings suggest-
ing malignancy, despite the high density of gland-
ular parenchyma. Firstly, the radiologist might be
inuenced by clinical information (97% were symp-
tomatic) and by ultrasound (88% had suspected
malignancy) features at the moment of reporting
the mammography. In our institute, when patients
are symptomatic, mammography and ultrasound
are usually requested together, and it is frequently
the same doctor who performs both examinations.
 ARTICLE IN PRESS
Radiological features and pathologicalbiological correlations in women with breast cancer 749

Table 1 Histological and biological characteris- number of lesions with microcalcications than
tics of the breast cancer in young women. older women (3135 years).
Ultrasound has been considered the method of
N (%)
choice for symptomatic young women. The higher
Tumor size percentage of glandular tissue and the presence of
o1 cm 42 (16.1) a palpable mass favour the sensitivity of this
12 cm 96 (36.9) method.2628 Recently, Houssami et al. published
25 cm 98 (37.6) a study comparing the sensitivity of mammography
45 cm 24 (9.2) and ultrasound in young symptomatic women, using
Tumor type independent prospective interpretation of the two
Inltrating ductal 275 (79.0) imaging tests. The authors demonstrated that
Inltrating lobular 7 (2.0) ultrasound has a signicantly greater sensitivity
Inltrating ductal+lobular 8 (2.3) than mammography (84 and 76% respectively) in
Mucinous 6 (1.7) women who are 35 years old or younger.29 In our
Medullary 5 (0.1) study, the sensitivity of US was slightly higher than
Papillary 2 (0.5) that of mammography (88.7% versus 84.9%, respec-
Others 15 (4.2)
tively), but this difference was not statistically
DCIS 26 (7.4)
signicant. However, we recognise that our design
LCIS 4 (1.1)
may be prone to some bias, and the accuracy of the
Tumor grade (G) two imaging tests presented by Houssami and
G1 21 (8.5) colleagues may be the more valid estimate based
G2 102 (41.63) on the study design.29
G3 122 (49.8)
The false-negative rate found in the literature
Vascular invasion has been reported in up to 30% of ultrasound
Absent 181 (59.74) procedures.16,19,25,30 This occurs because the dif-
Present 122 (40.26) ferential diagnosis between well-differentiated
ER (%) carcinomas and benign tumours is very difcult to
o10 103 (30.9) obtain, mainly because broadenoma is the most
X10 230 (69.1) common lesion in young women.4,17,31 In our study,
we found a low proportion of benign and probably
PgR (%)
benign reports (8.3%). This may be due to the way
o10 168 (50.3)
X10 166 (49.7) in which our institute is structured. Our radiologists
are dedicated only to breast diagnosis. Another
Ki-67 (%) important factor is the use of high-quality ultra-
p25 159 (49.3) sound equipment.
425 163 (50.7)
The histopathological examination in our study
HER2/neu (%) revealed that almost all tumours in young women
p10 163 (48.5) were invasive, as approximately 70% of the cases
o10 (incomplete moderate) 28 (8.3) were inltrating ductal carcinomas. These ndings
410 (complete moderate) 39 (11.6) are similar to others reported in the litera-
410 (complete intense) 106 (31.5) ture.3,32,33,34 Some series reported an increasing
incidence of medullary carcinomas in younger
women, but this was not present in our study.1,3,31
Carcinomas in situ have a low incidence in this
Secondly, around 42% of the patients had suspect group of patients, being reported in approximately
calcications that were easily visible in the dense 710% of the cases, similar to what was reported in
breast. Finally, in patients with a mass (74%), the our series. This is typical of a non-screened
lesions were very large (average 3 cm), thereby population.2,3,32
facilitating diagnosis. When we compared pathological and radiological
When we analysed the association between features, we observed that the capacity of mam-
mammographic features and age, it came as no mography and ultrasound to indicate suspected
surprise that breasts were denser in the group of malignancy is related to histological types. For
very young women (p30 years old). However, the ductal carcinoma, the mammography and the
mammography showed similar sensitivity in the two ultrasound were able to indicate suspected malig-
groups. This may result from the fact that very nancy in almost all cases. However, it did not occur
young patients had a statistically signicant higher in the group of other tumours (lobular, medullary,
 ARTICLE IN PRESS
750 B. Di Nubila et al.

Table 2 Association between radiological features, age, family history and histological types.

Age Family history Histological types

n (%) n (%) n (%)

2030 years 3135 years No. 11 Inltrating ductal Other (4) DCIS

Mammographic density (1)

Scale 1+2 1 (3.3) 18 (15.2) 13 (10.9) 5 (3.5) 17 (13.7) 1 (6.2) 1 (12.5)
Scale 3+4 29 (96.6) 100 (84.7) 106 (89.0) 17 (77.2) 107 (86.2) 15 (93.7) 7 (87.5)
P 0:12 P 0:40 P 1:00
Mammographic feature
Without calcication 24 (46.1) 102 (61.4) 100 (55.5) 19 (70.3) 112 (58.0) 10 (66.6) 4 (40.0)
With calcication 28 (53.8) 64 (38.5) 80 (44.4) 8 (29.6) 81 (41.9) 5 (33.3) 6 (60.0)
P 0.05 P 1:00 P 0:50
BI-RADS category (2)
Category 03 7 (13.2) 28 (15.5) 29 (14.9) 6 (21.4) 24 (11.8) 8 (42.1) 5 (41.6)
Category 45 46 (86.7) 152 (84.4) 165 (85.0) 22 (78.5) 180 (89.1) 11 (57.8) 7 (58.3)
P 0:82 P 0:16 Po0.0001
Ultrasound category (3)
Category 1-3 10 (17.5) 17 (9.2) 23 (11.4) 3 (10.3) 19 (9.2) 3 (13.0) 5 (45.4)
Category 4 47 (82.4) 166 (90.7) 178 (88.5) 26 (89.6) 187 (90.7) 20 (86.9) 6 (54.5)
P 0.09 P 0:20 P 0.004

(1) Scale 1 fat breast; scale 2 scattered broglandular densities; scale 3 heterogeneous breast; and scale 4 dense
breast.
(2) Category 0 need additional imaging evaluation; category 1 negative; category 2 benign nding; category
3 probably benign nding; category 4 suspected abnormality; and category 5 highly suggestive of malignancy.
(3) Category 1 normal; category 2 benign; category 3 probably benign; and category 4 suspected malignancy.
(4) Others tumours inltrating lobular, mucinous, medullary, papillary and other tumours.

mucinous, papillary, and tubular), in which the
sensitivity of mammography was low (57%), but
that of the ultrasound was high (86%). Carcinoma in
situ has a low sensitivity on mammography and on
ultrasound.
Several reports in which young women with
breast cancer have a higher prevalence of adverse
prognostic factors have been published.7,9,18 The
tumours often have a higher grade of vascular
invasion (4050%), poorer histological grade
(5075%), more lymph node involvement, more
frequent involvement of the margins, and a more
extensive intraductal component.5,6 Furthermore,
it has been reported that this group presents with
worse biological proles, such as overexpression of
HER-2/neu (3040%), high levels of Ki-67 (6070%),
and decreased expression of ER (4050% negative)
and PgR (5060% negative) compared with groups of
older women.2,5,6,32,34,35,36 Our study showed simi-
lar results in this group of patients.
The correlation between radiological features
and biological factors showed some interesting
points. The rst point is that the ability of
ultrasound to classify the lesion as suspicious
correctly is correlated with biological proles. If
the lesions had poor prognostic factors the ultra-
sound had more sensitivity to enable malignancy to
be suspected. Although this nding was statistically
signicant in terms of the PgR and grade of tumours
only, it could have resulted from the fact that less
differentiated tumours show more echographic
features of malignancy. The second point is that
the capacity of mammography to indicate sus-
pected malignancy is not inuenced by the biolo-
gical proles of the tumours. Only overexpression
of HER2/neu was associated with the mammary
density, but it did not inuence the sensitivity of
mammography. The nal point is that the micro-
calcications are associated with less differen-
tiated (negative PgR) and highly proliferative
(overexpression of HER2/neu) tumours, which
shows that this group of patients may have more
aggressive tumours. However, it is relevant to
mention that there is always a risk of association
between the described factors, which can inuence
results, in spite of sample size.
The main limitation of this study was the fact
that we did not have access to all radiological and
biological data of the patients, due to the retro-
spective nature of this type of work. In only a total
of 233 patients were all sets of data available.
However, all patients in the sample were included
Table 3 Association between radiological features and biological prole.

ER PgR Ki-67 Her 2 Grade Vascular invasion

n (%) n (%) n (%) n (%) n (%) n (%)

o10% X10% o10% X10% p25% 425% 02 3 12 3 Present Absent

Mammographic density (1)

Scale 1+2 3 (7) 16 (15) 9 (15) 10 (12) 10 (14) 9 (12) 17 (16) 2 (5) 7 (13) 6 (11) 11 (13) 7 (12)
Scale 3+4 38 (93) 88 (85) 53 (85) 73 (87) 59 (86) 66 (88) 90 (84) 39 (95) 46 (87) 47 (89) 71 (87) 53 (88)
P 0:28 P 0:80 P 0
81 P 0.09 P 1:00 P 0:80
Mammographic feature
Without calcication 32 (58) 92 (58) 52 (52) 73 (64) 67 (62) 57 (54) 102 (65) 23 (38) 51 (60) 41 (52) 74 (62) 49 (54)
With calcication 23 (42) 66 (42) 48 (48) 41 (36) 41 (38) 48 (46) 55 (35) 37 (62) 35 (40) 38 (48) 45 (38) 42 (46)
P 1:00 P 0.09 P 0:27 P 0.0007 P 0:35 P 0:26
BI-RADS category (2)
Category 03 9 (16) 26 (15) 14 (13) 21 (17) 20 (18) 14 (13) 27 (16) 8 (12) 14 (15) 12 (15) 19 (15) 11 (12)
Category 45 49 (85) 144 (85) 91 (87) 103 (83) 97 (82) 97 (87) 141 (84) 56 (87) 77 (85) 70 (85) 108 (85) 83 (88)
P 1:00 P 0:47 P 0:47 P 0:55 P 1:00 P 0:55
Ultrasound category (3)
ARTICLE IN PRESS

Category 13 5 (8) 21 (12) 6 (5) 20 (16) 14 (12) 11 (9) 23 (13) 4 (6) 16 (18) 7 (8) 17 (12) 9 (10)
Category 4 59 (92) 149 (88) 105 (95) 104 (84) 99 (88) 109 (91) 149 (87) 62 (94) 74 (82) 82 (92) 119 (87) 82 (90)
P 0:48 P 0.01 P 0:53 P 0:17 P 0.07 P 0:67

(1) scale 1 fat breast; scale 2 scattered broglandular densities; scale 3 heterogeneous breast; and scale 4 dense breast.
(2) category 0 need additional imaging evaluation; category 1 negative; category 2 benign nding; category 3 probably benign nding; category 4 suspected abnormality;
and category 5 highly suggestive of malignancy.
(3) category 1 normal; category 2 benign; category 3 probably benign; and category 4 suspected malignancy.
Radiological features and pathologicalbiological correlations in women with breast cancer
751
 ARTICLE IN PRESS
752
so that selection bias could be avoided. Another
limitation was the BI-RADS classications, which
were taken from the original radiological report.
Nevertheless, the original report is more reliable
for us to show the difculty of the initial diagnosis
of breast cancer in young patients. If we classied
BI-RADS retrospectively, it would be a bias because
we already knew that all cases were cancer. Breast
density classication was also taken from the
original report, but almost all cases (84%) were
from our institute, where only ve dedicated breast
radiologists carried out the radiological report.
Another problem is the reproducibility of ultra-
sound classications. We used an authors classi-
cation in four categories. This was done because at
that time there was no BI-RADS classication for
ultrasound. The suspected cases (category 4)
included BI-RADS categories 4 and 5.
In conclusion, although breast cancer in women
under 35 years old is rare, it is important to bear in
mind the possibility of malignancy in women with
clinical ndings or symptoms. Ultrasound has better
sensitivity than mammography and it may repre-
sent the appropriate initial imaging test for
symptomatic young women. Mammography may
be useful to visualise associated microcalcications
and to ascertain the true extent of disease. Dense
parenchyma was not a problem for the visualisation
of palpable lesions in this group, although the high
sensitivity of mammography in the present study
may result from knowledge of clinical and ultra-
sonographic data at the time of mammography
reporting. The histological and biological proles
are correlated with the appearance of the tumours
on imaging.
Acknowledgements
We thank the data managers Stefania Andrighetto
and Simona Menna for their invaluable work in
organising patients data.
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