Hildegard B Toth, M.D.

Incidence of Pleomorphic and Classic Lobular Carcinoma In Situ in Percutaneous Biopsies of the Breast: An Institutional Review
Lee, J; Mercado, C; Hernandez, O; Moy, L; Toth, H
2010 MAY ;194(5):-, American journal of roentgenology
— id: 111947, year: 2010, vol: 194, page: , stat: Journal Article,

Invasive Micropapillary Carcinoma: Radiographic Features in 18 Patients With This Unusual Variant
Mercado, C; Guth, A; Mercado, C; Moy, L; Lee, J; Toth, H; Cangiarella, J
2010 MAY ;194(5):-, American journal of roentgenology
— id: 111948, year: 2010, vol: 194, page: , stat: Journal Article,

Microinvasive ductal carcinoma in situ: Clinical presentation, imaging features, pathologic findings, and outcome
Vieira, Cristina C; Mercado, Cecilia L; Cangiarella, Joan F; Moy, Linda; Toth, Hildegard K; Guth, Amber A
2010 Jan;73(1):102-107, European journal of radiology
OBJECTIVE: The purpose of our study was to describe the clinical features, imaging characteristics, pathologic findings and outcome of microinvasive ductal carcinoma in situ (DCISM). MATERIALS AND METHODS: The records of 21 women diagnosed with microinvasive ductal carcinoma in situ (DCISM) from November 1993 to September 2006 were retrospectively reviewed. The clinical presentation, imaging and histopathologic features, and clinical follow-up were reviewed. RESULTS: The 21 lesions all occurred in women with a mean age of 56 years (range, 27-79 years). Clinical findings were present in ten (48%): 10 with palpable masses, four with associated nipple discharge. Mean lesion size was 21mm (range, 9-65mm). The lesion size in 62% was 15mm or smaller. Mammographic findings were calcifications only in nine (43%) and an associated or other finding in nine (43%) [mass (n=7), asymmetry (n=1), architectural distortion (n=1)]. Three lesions were mammographically occult. Sonographic findings available in 11 lesions showed a solid hypoechoic mass in 10 cases (eight irregular in shape, one round, one oval). One lesion was not seen on sonography. On histopathologic examination, all lesions were diagnosed as DCISM, with a focus of invasive carcinoma less than or equal to 1mm in diameter within an area of DCIS. Sixteen (76%) lesions were high nuclear grade, four (19%) were intermediate and one was low grade (5%). Sixteen (76%) had the presence of necrosis. Positivity for ER and PR was noted in 75% and 38%. Nodal metastasis was present in one case with axillary lymph node dissection. Mean follow-up time for 16 women was 36 months without evidence of local or systemic recurrence. One patient developed a second primary in the contralateral breast 3 years later. CONCLUSION: The clinical presentation and radiologic appearance of a mass are commonly encountered in DCISM lesions (48% and 57%, respectively), irrespective of lesion size, mimicking findings seen in invasive carcinoma. Despite its potential for nodal metastasis (5% in our series), mean follow-up at 36 months was good with no evidence of local or systemic recurrence at follow-up. Knowledge of these clinical and imaging findings in DCISM lesions may alert the clinician to the possibility of microinvasion and guide appropriate management
— id: 95528, year: 2010, vol: 73, page: 102, stat: Journal Article,

Image presentation. Sonographic appearances of benign and malignant male breast disease with mammographic and pathologic correlation
Yitta, Silaja; Singer, Cory I; Toth, Hildegard B; Mercado, Cecilia L
2010 Jun;29(6):931-947, Journal of ultrasound in medicine
OBJECTIVE: Imaging of the male breast is most often performed for the evaluation of a clinical abnormality such as breast enlargement or tenderness, a palpable mass, nipple skin changes, or nipple discharge. Most breast lesions encountered in men are benign. Malignant breast lesions are less frequent; breast cancer accounts for less than 1% of all male cancers in the United States. The initial imaging evaluation of a finding in the male breast is performed with mammography. Sonography is frequently used as an adjunct to mammography but is less often used as the primary imaging modality. The objective of this article is to provide readers with a thorough review of the sonographic appearances of benign and malignant male breast disease. METHODS: We reviewed our institution's case database to identify male patients who underwent mammography, sonography, and subsequent biopsy of a breast lesion. These cases were collected and reviewed to select the best imaging examples. RESULTS: A spectrum of benign and malignant male breast disease is presented with corresponding sonographic, mammographic, and pathologic imaging. For each entity, the salient imaging findings and typical clinical presentation are discussed. CONCLUSIONS: Most studies in the literature have reported on the mammographic and sonographic imaging features of primary breast carcinoma in men. However, very little has been reported on the sonographic appearance of benign and malignant male breast conditions. Recognition and correct identification of pathologic male breast entities on sonography is essential to determine appropriate management recommendations and avoid unnecessary biopsies
— id: 109807, year: 2010, vol: 29, page: 931, stat: Journal Article,

Cultural Preferences for Chaperone Use during Breast Examinations: A Preliminary Study
Checka, CM; Bright, KL; Toth, HB; Chun, J; Guth, AA
2009 DEC 15 ;69(24):849S-849S, Cancer research
— id: 106459, year: 2009, vol: 69, page: 849S, stat: Journal Article,

Surgical Outcome of High-Risk Lesions at MRI-Guided 9-Gauge Vacuum-Assisted Breast Biopsy
Elias, K; Mercado, C; Toth, H; Moy, L
2009 MAY ;192(5):646-651, American journal of roentgenology
— id: 99180, year: 2009, vol: 192, page: 646, stat: Journal Article,

Is breast MRI helpful in the evaluation of inconclusive mammographic findings?
Moy, Linda; Elias, Kristin; Patel, Vashali; Lee, Jiyon; Babb, James S; Toth, Hildegard K; Mercado, Cecilia L
2009 Oct;193(4):986-993, American journal of roentgenology
OBJECTIVE: The purpose of this study was to evaluate the usefulness of MRI of the breast in cases in which mammographic or sonographic findings are inconclusive. MATERIALS AND METHODS: We retrospectively reviewed images from 115 MRI examinations of the breast performed from 1999 to 2005 for the indication of problem-solving for inconclusive findings on a mammogram. Forty-eight of the 115 women (41.8%) were at high risk. We discerned whether sonography or MRI was used as an adjunctive tool and correlated the findings with those in the pathology database. RESULTS: The equivocal findings most frequently leading to MRI were asymmetry and architectural distortion. No suspicious MRI correlate was found in 100 of 115 cases (87%). These cases were found stable at follow-up mammography or MRI after a mean of 34 months. Fifteen enhancing masses (13%) that corresponded to the mammographic abnormality were seen on MR images. All masses identified at MRI were accurately localized for biopsy, and six malignant lesions were identified. Four of six malignant tumors were seen in one mammographic view only; two were seen on second-look ultrasound images. MRI had a sensitivity of 100% and compared with mammography had significantly higher specificity (91.7% vs 80.7%, p = 0.029), positive predictive value (40% vs 8.7%, p = 0.032), and overall accuracy (92.2% vs 78.3%, p = 0.0052). Eighteen incidental lesions (15.7%) were detected at MRI, and all were subsequently found benign. CONCLUSION: We found breast MRI to be a useful adjunctive tool when findings at conventional imaging were equivocal. Strict patient selection criteria should be used because of the high frequency of incidental lesions seen on MR images
— id: 102506, year: 2009, vol: 193, page: 986, stat: Journal Article,

A decade of change : an institutional experience with breast surgery in 1995 and 2005
Guth AA; Shanker BA; Roses DF; Axelrod D; Singh B; Toth H; Shapiro RL; Hiotis K; Diflo T; Cangiarella JF
2008 ;1:51-55, Breast cancer : basic & clinical research
— id: 93532, year: 2008, vol: 1, page: 51, stat: Journal Article,

A decade of change: an institutional experience with breast surgery in 1995 and 2005
Guth, Amber A; Shanker, Beth Ann; Roses, Daniel F; Axelrod, Deborah; Singh, Baljit; Toth, Hildegard; Shapiro, Richard L; Hiotis, Karen; Diflo, Thomas; Cangiarella, Joan F
2008 ;1:51-55, Breast cancer : basic & clinical research
INTRODUCTION: With the adoption of routine screening mammography, breast cancers are being diagnosed at earlier stages, with DCIS now accouting for 22.5% of all newly diagnosed breast cancers. This has been attributed to both increased breast cancer awareness and improvements in breast imaging techniques. How have these changes, including the increased use of image-guided sampling techniques, influenced the clinical practice of breast surgery? METHODS: The institutional pathology database was queried for all breast surgeries, including breast reconstruction, performed in 1995 and 2005. Cosmetic procedures were excluded. The results were analysed utilizing the Chi-square test. RESULTS: Surgical indications changed during 10-year study period, with an increase in preoperatively diagnosed cancers undergoing definitive surgical management. ADH, and to a lesser extent, ALH, became indications for surgical excision. Fewer surgical biopsies were performed for indeterminate abnormalities on breast imaging, due to the introduction of stereotactic large core biopsy. While the rate of benign breast biopsies remained constant, there was a higher percentage of precancerous and DCIS cases in 2005. The overall rate of mastectomy decreased from 36.8% in 1995 to 14.5% in 2005. With the increase in sentinel node procedures, the rate of ALND dropped from 18.3% to 13.7%. Accompanying the increased recognition of early-stage cancers, the rate of positive ALND also decreased, from 43.3% to 25.0%. CONCLUSIONS: While the rate of benign breast biopsies has remained constant over a recent 10-year period, fewer diagnostic surgical image-guided biopsies were performed in 2005. A greater percentage of patients with breast cancer or preinvasive disease have these diagnoses determined before surgery. More preinvasive and Stage 0 cancers are undergoing surgical management. Earlier stage invasive cancers are being detected, reflected by the lower incidence of axillary nodal metastases
— id: 149787, year: 2008, vol: 1, page: 51, stat: Journal Article,

Sonographically guided marker placement for confirmation of removal of mammographically occult lesions after localization
Mercado, Cecilia L; Guth, Amber A; Toth, Hildegard K; Moy, Linda; Axelrod, Deborah; Cangiarella, Joan
2008 Oct;191(4):1216-1219, American journal of roentgenology
OBJECTIVE: We evaluated the benefit of placing a marker under sonographic guidance at the time of localization to aid in identifying mammographically occult lesions within the specimen at the time of surgical excision and to evaluate margin status. MATERIALS AND METHODS: We reviewed 135 sonographically guided needle localizations performed on mammographically occult lesions. Imaging during the localization procedure, marker placement, and specimen radiographs were reviewed, and the findings were correlated with the histopathologic findings. RESULTS: Of the 135 mammographically occult lesions, 77 were localized without marker placement and 58 with marker placement. The 58 localizations with marker placement were for masses with a mean lesion size of 9 mm. Specimen radiography of these lesions showed a marker within the specimen in 56 cases (97%) and visualization of the lesion in only seven cases (12%). Specimen radiography of localizations without marker placement showed visualization of the lesion in 18 cases (23%). Of the 11 malignant lesions (19%) localized with marker placement, none had a positive inked margin, but five (46%) had close margins necessitating reexcision. Of the 26 malignant lesions (34%) localized without marker placement, two (8%) had a positive inked margin, and eight (31%) had close margins necessitating reexcision. CONCLUSION: At needle localization of breast lesions, marker placement under sonographic guidance is beneficial because it enables immediate confirmation of accurate surgical removal of the localized lesion at surgical excision. Use of marker placement, however, does not reduce the percentage of cases with close margins necessitating reexcision
— id: 93371, year: 2008, vol: 191, page: 1216, stat: Journal Article,

Does Sonographically Guided Clip Placement Facilitate Confirmation of Removal of Mammographically Occult Lesions After Localization?
Mercado CL; Guth AA; Axelrod DM; Moy L; Toth HK; Cangiarella J
2007 ;188:A32-A34 #110, American journal of roentgenology
— id: 97098, year: 2007, vol: 188, page: A32, stat: Journal Article,

Fine-needle aspiration biopsy of benign adenomyoepithelioma of the breast: radiologic and pathologic correlation in four cases
Mercado, Cecilia L; Toth, Hildegard K; Axelrod, Deborah; Cangiarella, Joan
2007 Nov;35(11):690-694, Diagnostic cytopathology
Benign adenomyoepithelioma of the breast is a rare tumor in which the cytologic findings have been described in only a few cases. While benign, the imaging and pathologic features may be mistaken for malignancy. We report the aspiration biopsy findings in four cases of adenomyoepithelioma with radiologic and histologic correlation. Cytopathologists should familiarize themselves with this entity to avoid a misdiagnosis of carcinoma
— id: 75455, year: 2007, vol: 35, page: 690, stat: Journal Article,

Stereotaxic aspiration biopsy in the evaluation of mammographically detected clustered microcalcification
Cangiarella J; Mercado CL; Symmans WF; Newstead GM; Toth HK; Waisman J
1998 Aug 25;84(4):226-230, Cancer
BACKGROUND: Stereotaxic fine-needle aspiration biopsy (SFNA) of mammographically detected nonpalpable lesions of the breast provides accurate diagnosis and may eliminate many unnecessary excisional biopsies of areas of microcalcification. METHODS: SFNA of microcalcification of indeterminate radiologic significance was performed on 125 patients (1991-1994), yielding 130 specimens (2 sites in 2 patients and bilateral aspirations in 3 patients). Stereotaxic localization was performed, and samples from within the area of microcalcification were obtained using 22-gauge needles. Smears stained with a Giemsa-type stain were prepared and studied by a cytopathologist during the procedure to determine the adequacy of each specimen. RESULTS: Of 130 specimens, 104 (80%) were cytologically benign, 13 (10%) were atypical, 6 (4.6%) were suspicious, and 7 (5.3%) were malignant. All malignant diagnoses were confirmed by subsequent operative biopsy. Follow-up was available in 74 of 104 benign cases (71%): surgical excisions (all benign) in 8 cases and follow-up mammograms at 6 months to 5.8 years in 66 cases (no radiologic change in 64 cases and 2 [1.9%] cases with new radiologic findings [SFNAs of the new radiographic abnormality revealed adenocarcinoma in both]). CONCLUSIONS: SFNA is a reliable and cost-effective method of evaluating indeterminate microcalcification; however, mammographic follow-up is indicated because of the possibility of subsequent and independent cancers
— id: 57111, year: 1998, vol: 84, page: 226, stat: Journal Article,

Fatty and fibroglandular tissue volumes in the breasts of women 20-83 years old: comparison of X-ray mammography and computer-assisted MR imaging [see comments]
Lee NA; Rusinek H; Weinreb J; Chandra R; Toth H; Singer C; Newstead G
1997 Feb;168(2):501-506, American journal of roentgenology
OBJECTIVE: A method for segmenting MR images of the breast was applied to determine fatty and fibroglandular tissue volumes in breasts of women in different age groups. The results were compared with subjective assessments of breast density from X-ray mammograms in the same patients. MATERIALS AND METHODS: Two experienced mammographers assessed the percentage of fat in the breasts of 40 women who were 20-83 years old. MR images were obtained on a 1.0-T scanner equipped with a bilateral receive-only breast coil. Images were acquired using a three-dimensional T1-weighted gradient-echo sequence with a 1.25 x 1.4 x 2.5 mm resolution. On average, breast parenchyma appeared in 30 images in each breast. Image segmentation was based on a semiautomated, two-compartmental (fatty and fibroglandular tissue) model that accounts for partial volume effects. To validate the accuracy of the MR imaging segmentation technique, we performed a phantom study using an identical imaging sequence. RESULTS: The accuracy of the MR imaging segmentation of the phantom was of the order of 2%. In our subjects, fat content was 42.5% +/- 30.3% (mean +/- SD) on mammography versus 66.5% +/- 18% on MR images. Although we found a significant correlation (r = .63) between the two techniques, mammography poorly differentiated breasts containing less than 45% fat. When our analysis included only dense breasts (i.e., those containing less than 75% fat on MR images), the correlation coefficient decreased to .34. The largest discrepancies between mammography and MR imaging occurred in breasts that had 60-80% fat as measured on MR imaging. CONCLUSION: Fatty and fibroglandular tissue can be differentiated on MR images of the breast with high precision and accuracy, therefore allowing assessment of breast density. The conclusions of researchers who used mammographic density patterns should be reassessed
— id: 12393, year: 1997, vol: 168, page: 501, stat: Journal Article,

Invasive lobular and ductal carcinoma: mammographic findings and stage at diagnosis [published erratum appears in Radiology 1992 Nov;185(2):616]
Newstead GM; Baute PB; Toth HK
1992 Sep;184(3):623-627, Radiology
The authors reviewed 316 cases of breast carcinoma diagnosed from January 1, 1986, to December 31, 1989. Clinical data and mammograms were available for all patients. Of the 316 carcinomas, 272 (86.1%) were invasive; 37 (13.6%) of these represented pure invasive lobular carcinoma (ILC). Twenty-five (68.5%) of the 37 patients with ILC and 161 (70.3%) of the 229 patients with invasive ductal carcinoma (IDC) presented with clinically palpable masses. Asymmetric opacities and architectural distortion were the predominant mammographic signs in 21 (57%) of the cases of ILC but only 32 (13.6%) of the cases of IDC. Malignant calcifications were not present in any of the patients with ILC but were present in 110 (47%) of those with IDC. Of the ILC lesions, 29 (85%) [corrected] had the same opacity as that of normal fibroglandular tissue, and the mammographic findings were often subtle and seen initially on one view only. There was no substantial difference in the TNM stage at diagnosis between the two study groups
— id: 13472, year: 1992, vol: 184, page: 623, stat: Journal Article,