Letters a

Management Parenchymal

to the of the Tumor

Editor (

Small

1.5 cm)

risk patients (2-4). If we eliminate those who are found to have a cystic mass at ultrasonography, what should we tell our cmical brethren when they ask us to perform mammography in a woman under age 30 years with a “palpable lesion”? It has been my practice to tell them that in such a patient, the yield of

Renal

From:

Morton A. Bosniak, MD Department of Radiology, New York University Center 560 First Avenue, New York, NY 10016

Medical

malignancy

Editor: The omission of the small word “to” from a sentence can, on occasion, have a very big effect on the meaning of that sentence. This unfortunately occurred in the publication process of my recent State of the Art article that appeared in the May 1991 issue of Radiology (1). In the third from the last sentence of the section about management of the very small neoplasm ( 1.5 cm) in younger, healthy individuals, it is written that “if the lesion grows 2.0 cm and the patient can tolerate surgery, partial nephrectomy could be performed.” However, the word “to” was inadvertently omitted so that a very big change in the meaning of that sentence occurred. It was supposed to read “if the lesion grows to 2.0 cm and the patient can tolerate surgery, partial nephrectomy could be performed.” Obviously, that means that a small tumor that measures I .0 cm, for example, that grows to 2.0 cm should be treated surgically at that time-not when it grows 2.0 cm (to 3.0 cm). I hope that this letter will clarify this point so that the readers of Radiology will be informed of my intended meaning concerning the management of these small renal masses.

1.

Bosniak tection,

MA. The small ( 3.0 cm) renal parenchymal diagnosis, and controversies. Radiology 1991;

tumor:

de-

179:307-317.

be

exceedingly

low

and

breast

density

exceed-

References 1.

3.

de Paredes ES, Marsteller LP, Eden BV. Breast cancers 35 years of age and younger: mammographic findings. 1990; 177:117-119. Harris VJ, Jackson VP. Indications for breast imaging under age 35 years. Radiology 1989; 172:445-448. Williams SM, Kaplan PA, Petersen JC, Lieberman RP.

4.

phy in women under age 30: is there clinical benefit? Radiology 1986; 161:49-51. Seltzer MH, Skiles MS. Diseases of the breast in young women.

2.

Surg

Gynecol

a Inconsistencies Used

Reference

will

ingly high, making carcinoma unlikely and, if present, probably not visible. It is expected that many reports of mammograms obtained in women younger than age 30 years will read “indeterminate” or “unable to exclude malignancy,” leading to a low specificity. If a mammographer would attempt to call every case either benign or malignant, the positive and negative predictive values would suffer in the extreme.

for ACR

Obstet

1980;

in women Radiology in women Mammogra-

150:360-362.

in Mammographic Accreditation

Phantoms

From: Robert K. Cacak, PhD Medical Physics Department, 665 Winter Street Southeast,

Salem Salem,

Hospital OR 97309

Editor:

a

Mammography Younger From: Irwin M. Freundlich, Department Anderson

1515

in Women

of Age

and

Imaging,

Cancer Center Boulevard,

University

Houston,

of Texas,

M. D.

TX 77030

Editor: In a retrospective review of 74 proved breast cancers that appeared in the October 1991 issue of Radiology, de Paredes et al (1) found a positive mammogram in 66 of the 74 cases (89%). There is inherent bias in this report, as the authors knew that all the women had cancer. The 89%, therefore, does not represent the sensitivity of mammography in women 35 years of age and younger, nor does it “evaluate the level of accuracy of mammography in detecting or confirming the presence of the lesion.” In addition, the following statement is, in my opinion, quite misleading: “Even in patients in our series with very dense breasts, mammography was able to demonstrate 75% of lesions.” Several previous articles have suggested that mammography should not be carried out in women younger than 35 years and certainly

288

not

younger

than

Part of the mammography can College of Radiology lions submit a radiograph in the phantom should features

MD

of Diagnostic

Holcombe

35 Years

age

30 years

except

for

very

high

frequently

accreditation program of the Ameri(ACR) requires that applicant instituof a “standard” phantom. Contained be a series of small objects simulating

encountered

in clinical

mammography,

in-

cluding calcifications (“specks”), fibrils, and masses. The phantom test objects are graded according to size, and a mammography system must be capable of imaging sufficiently small objects to satisfy ACR criteria. ACR accreditation is awarded after submission of actual clinical mammograms and other operationab information as well as the phantom images, but presumabby the phantom images are the most quantitative of the required tests. As part

of my

institution’s

accreditation

process,

a phantom

(serial no. 156-4294; Radiation Measurements, Middbeton, Wis) was purchased, and the imaging capability of the mammographic system was tested. The mammography unit was a CGR model 500t (Baltimore) with a molybdenum target and a nominab 0.3-mm focal spot, and it operated in the phototimed mode at a nominal 29 kVp. A Kodak Min-R (Regular) screen (Eastman Kodak, Rochester, NY) and Kodak Min-R MRM-1 film were used. A 5:1 grid was in place, and the source-to-image distance was 65 cm. Magnification was not used. The simulated fibrils and masses in the phantom were sufficiently well imaged to pass the ACR’s criteria, but only the larger groups of