Screening and Diagnosis for Breast Cancers

Breast cancer is most common cancer in women in Korea from 2002. Early diagnosis is important to the treatment and the survival of patients. Clinical examination, imaging study, and pathologic examination are essential for diagnosis of breast cancer. Mammography and clinical breast examination have been widely used for screening. However, additional examination like ultrasonography is usually needed due to low sensitivity of mammography to the dense breast as found in many Korean women. The role of ultrasonography and MRI as a screening tool is controversial. Definite diagnosis of breast cancer is confirmed by pathologic review of breast tissue. A palpable lesion can be excised surgically or biopsied with fine-needle aspiration or core needle biopsy. Nonpalpable lesions can be excised surgically with needle localization or biopsied with core needle biopsy or vaccum assisted biopsy under radiologic guidance. For early detection and precise diagnosis of breast cancer, clinical history, physical examination, radiologic imaging and pathologic review should be balanced. The recommendations of screening and diagnostic tools for breast cancer are discussed in this article.

The Value of Ultrasound-Guided Tattooing Localization of Nonpalpable Breast Lesions

OBJECTIVE: To investigate the value of ultrasound-guided tattooing localization (US-tattoo) using a charcoal suspension for breast lesions. MATERIALS AND METHODS: One hundred sixty-four nonpalpable breast lesions in 134 patients (mean age 47 years; range 30-74 years) were marked with a charcoal suspension under US guidance. The medical records associated with the US-tattoo, the pathology results and the follow-up US results were reviewed. RESULTS: The average size of the localized lesions was 1.0 cm. The procedure time was < 5 minutes (range, 2-10 minutes) per lesion. The US-tattoo was well tolerated in all cases. The only technical difficulty encountered was a needle tip blockage caused by a large charcoal particle (4.9%). The surgeon easily identified the tattoo with the exception one case. In addition, surgery could be safely delayed from one to 57 days after the making US-tattoo. The pathology result was benign in 108 cases, borderline in five, and malignant in 51. The excised specimen was < 4 cm in 76.6% (82/107) of the benign cases (mean; 2.7 cm). The pathologist could identify the mass around the tattoo and was able to make a specific diagnosis in 81.3% (87/107) of benign lesions. The only complication encountered was residual charcoal marking along the incision scar (3.6%). All follow-up US documented the removal of the lesions. CONCLUSION: An US-tattoo for nonpalpable breast lesions is a very simple and accurate method that can help surgeons design and schedule an open biopsy.

Male Breast Cancer-10 Cases / 한국유방암학회지

PURPOSE: Male breast cancer is a rare type of neoplasm, account for 1 % of all breast tumors. A retrospective review of the clinical and histological characteristics, types of treatment, pathological staging, and adjuvant treatment was completed. The objective of this study was to make an early diagnosis of male breast cancer and reduce the mortality. METHODS: Over a 5-year period, from Oct. 1994 to July 2000, 10 male breast cancer patients were operated on in the breast cancer clinic of the Samsung Medical Center. Their duration of follow up ranged from 6 to 76 months with a mean of 26 months. The clinical and histological characteristics, associations of the risk factors, type of treatment, and results were studied. RESULTS: Their ages ranged from 40 to 67 years with a mean of 51 years, with 5, 3 and 2 cases in their 5th, 6th, and 7th decades, respectively. A palpable breast lump was the most common presenting symptom. A pathological assessment disclosed 8 infiltrating ductal carcinoma, 1 ductal carcinoma in situ, and 1 invasive adenoid cystic carcinoma. The tumor sizes ranged from 0.5 to 3.7 cm (median, 1.9 cm in diameter). Of the 10 patients, there were 3 T1b, 3 T1c, and 4 T2 in the tumor staging. 4 Patients had axillary node involvement (lymph node positivity, 40%), and of these 4, the metastasis involved 2 lymph nodes and more than 3 lymph nodes in 1 and 3 case, respectively. No distant metastasis was observed in any of the patients. Pathological stages of the patients 0, I, IIIA, and IIIB in 1, 5, 1 and 2 cases, respectively. All the patients underwent surgery, 7 with a modified radical mastectomy and 3 with a radical mastectomy, due to gross invasion of the pectoralis major muscle. CONCLUSION: A subareolar palpable breast mass was the most common presenting symptom of the male breast cancer patients. The optimal treatment for male breast cancer patients is a modified radical mastectomy, combined with radiotherapy, chemotherapy, and hormonal therapy, due to the higher hormone receptors positivity.

Micrometastases in the Sentinel Lymph Nodes of Patients with Ductal Carcinoma In-Situ of the Breast

PURPOSE: Although the axillary lymph node (LN) status is the most important prognostic indicator in breast cancer, due to the very low rae of axillary metastasis, the need for an axillary lymph node dissection in ductal carcinoma in situ (DCIS) and DCIS with a microinvasion (DCIS-M) is still controversial. The sentinel lymph node procedure has emerged as a potential alternative to avoid unnecessary axillary lymph node dissection. This study was performed in order to compare the frequency of metastasis in the sentinel node analyzed by various techniques, and the lymph nodes obtained by a routine axillary dissection in patients with DCIS and DCIS-M. METHODS: A total of 207 patients who underwent surgery for DCIS and DCIS-M at the Samsung Medical Center between 1994 and 2001, including 27 patients who underwent a sentinel node biopsy, were enrolled in this study. The sentinel node was serially cut into 20 slides per paraffin block of which 3 slides were immunostained with anti-cytokeratin antibodies. The medical records for the clinical, radiological, and pathological findings were reviewed. RESULTS: The patients were 205 women and 2 men with a mean age of 47 years. The patients presented with a palpable mass (50.2%), abnormal radiological findings detected in a routine check-up (35.7%), nipple discharge (10.1%), and others (3.9%). The operations applied were a total mastectomy in 120 patients, a lumpectomy in 50, and a lumpectomy with an axillary dissection in 31. The histological types of tumors were DCIS (77.3%) and DCIS with a microinvasion (22.7%). While the conventional pathologic examination showed axillary metastasis in 2 of 151 patients (1.3%) with an axillary dissection, serial sectioning and immunohistochemical staining for cytokeratin on the sentinel node in 27 patients revealed 2 more patients with a micrometastasis that were found to be negative in a conventional pathological examination. CONCLUSION: The serial sectioning and immunohistochemical method for the sentinel LNs of patients with DCIS and DCIS-M are superior to a conventional histological examination for detecting a metastatic carcinoma. The patients with a micrometastasis might be considered as a high risk group and a close long-term follow up would be required to define their prognostic significance.

Comparison of Tc-99m-Tetrofosmin and Tc-99m-MIBI Scintimammography in Differential Diagnosis of Breast Mass / 대한핵의학회잡지

PURPOSE: Tc-99m-MIBI (MIBI) and Tc-99m-Tetrofosmin (TF) are commonly used for scintimammography (SMM). We compared the diagnostic ability of SMM using Tc-99m-MIBI and Tc-99m-TF for the differential diagnosis of breast mass. MATERIALS AND METHODS: The study subjects were comprised of 123 breast lesions and 86 normal breasts of 114 patients who underwent SMM. Bilateral prone images and anterior supine images were obtained at 5 minutes and 1 or 3 hours after intravenous injection of 740 MBq of either MIBI or TF. Sizes of tumors were not significantly different between the MIBI and TF groups. First, two observers independently read the SMM without clinical information (1st interpretation), then read again with information about mass location (2nd interpretation). Sensitivity and specificity of each radiopharmaceutical for the diagnosis of breast cancer were evaluated in terms of image acquisition time, tumor size, and location. RESULTS: The SMM showed a good agreement between two observers for 1st and 2nd interpretation, except for TF SMM at 3 hr. For the first interpretation, the sensitivities at 5 min, 1 hr, and 3 hr were not significantly different between MIBI and TF SMM (81.6%, 80.0%, 60.9% in MIBI vs. 88.9%, 80.6%, 42.9% in TF), although the senstivities of 3 hr images were significantly lower than 5 min images in both MIBI and TF SMM. The specificity of TF at 5 min was superior to that of MIBI (81.5%, 90.0%, 82.9% in MIBI vs. 96.7%, 100%, 90.0% in TF, p<0.01 MIBI vs. TF at 5 min). For the second interpretation with information of mass location, the sensitivities at 3 hr images were significantly lower than 5 min images (86.8%, 86.7%, 78.3% in MIBI vs. 88.9%, 93.5%, 57.1% in TF) between MIBI and TF SMM. However, there was no significant difference in the specificity (60.0%, 53.8%, 75.0% for MIBI vs. 86.7%, 100%, 100% for TF). MIBI and TF SMM showed lower sensitivities for the tumors with less than 1 cm than tumors with more than 1 cm. However, the location of tumors did not influence the sensitivity and specificity between MIBI and TF SMM. CONCLUSION: The ability for the differential diagnosis of breast tumor is similar between MIBI and TF SMM, and delayed image is not necessary. TF may be better than MIBI considering the specificity of SMM without clinical information and labeling convenience.

The Diagnosis and Treatment of Ductal Carcinoma In Situ of the Breast

BACKGROUND: Ductal carcinoma in situ (DCIS) of the breast has been considered a relative rare form of breast cancer because its diagnosis was difficult, but the widespread use of screening mammography makes it easy to detect breast disease and there has been marked increase in the incidence of DCIS. But the exact diagnosis and treatment are controversial. METHODS: We reviewed the clinical records of 55 cases with DCIS treated at the Department of Surgery, Samsung Medical Center, between September 1994 and December 1997. If microinvasion was noted, the case was excluded from this study. RESULTS: The incidence of DCIS was 11.5% of all breast cancer (55 out of 477) with increasing tendency from 1995 to 1997. DCIS was most prevalent in women who were in their fifth decade, and the mean age was 47 years old. Chief complaints were palpable breast masses in 22 (40%) cases, mammographic abnormalities in 21 (38%), abnormal nipple discharge in 7 (13%), and others in 5 (9%). The most common mammographic finding was microcalcifications in 38 (78%) cases, but mass density and architectural distortion were also noted in a small percertage. Diagnostic methods for preoperative pathology were Fine Needle Aspiration (FNA) cytology in 15 (27%) cases, localization and excisional biopsy in 17 (31%), excisional biopsy in 12 (22%), incisional biopsy in 5 (9%), stereotactic core biopsy in 3 (5%), US guided biopsy in 2 (4%), and ABBI (Advanced Breast Biopsy Instrument) biopsy in 1 (2%). If the chief complaint was a palpable mass, FNA was the diagnostic choice. On the other hand, if the problem was mammographic abnormalities, localization and excisional biopsy was preferred. The surgical procedures were modified radical mastectomy in 17 (31%) cases, total mastectomy in 21 (38%), lumpectomy with axillary lymph node dissection in 7 (13%), and lumpectomy only in 10 (18%). If preoperative histology revealed the tumor of comedo type, mastectomy was preferred, but in case ofnon-comedo type, conservative surgery was preferred. Conservative surgery was followed by radiation therapy. Cancers were subclassified according to their histologic subtypes in 51 cases, and comedo type was most common (42%). Prevalent sizes of the masses were less than 2 cm, and the biggest one was 9 cm. There was one case (2%) of lymph node metastasis. It was comedo type and the size of the tumor was 9 cm. CONCLUSIONS: The widespread use of screening mammography and various other diagnostic methods will increase the chance of detecting DCIS, and conservative surgery will be performed more frequently in selected groups of patients.