Difficulties in the pre-operative diagnosis of phyllodes tumours of the breast: a study of 84 cases.

Eighty-four phyllodes tumours (71 benign, eight borderline and five malignant) diagnosed over a 16-year period were studied retrospectively, to assess the diagnostic value of the pre-operative modalities used. Mammography and ultrasound appearances were non-specific. The possibility of phyllodes tumour was raised in only 23% on fine needle aspiration cytology, and in 65% on core biopsy. Accuracy was better in smaller tumours, suggesting that larger tumours need more samples. For phyllodes tumours whose growth was measured, almost all had growth rates greater than for growing fibroadenomas. The pre-operative diagnosis of phyllodes tumours is difficult, and rapid growth and/or large size of apparent fibroadenomas may be the only imaging findings to suggest phyllodes tumour. It is important to review most fibroadenomas with ultrasound, to assess the rate of growth if any. Whole breast ultrasound showed that nearly one third of women with phyllodes tumours had concurrent fibroadenomas.

The diagnosis of breast cancer in women younger than 40.

This study examined how the diagnosis of breast cancer is different in young women. Records were retrieved for 239 women diagnosed with breast cancer before age 40 and compared with 2101 women aged 40 and over with breast cancer. On mammography, lesions in the younger women were more likely to be undetected or interpreted as benign, especially in women with dense breasts. However, there were 10 young women where impalpable cancers with microcalcification under 10 mm would not have been diagnosed without mammography. An abnormality was detected on ultrasound in 92.2% of cancers in young women, but was more likely to be considered benign than in older women. If ultrasound alone had been used in the young women, at least 18 cancers would have been missed. Ultrasound was useful for predicting the ultimate tumour size at pathology, and for detecting multifocality. There were 14 cases where the ultrasound appearance was indistinguishable from fibroadenoma. The importance of fine needle aspiration cytology in the diagnosis of focal lesions in young women (over 20 years) was confirmed. For symptomatic women, the proportion of breast malignancies under 10 mm was similar in the two groups. However, the younger group had significantly more poorly differentiated tumours.

Presentation and diagnosis of adolescent breast disease.

Breast disease in the adolescent female is fortunately uncommon, with most presenting lesions being benign. The type and frequency of breast problems in young women less than 20 years of age are discussed in this paper. There were 634 adolescent females (9-19 years) referred to the Wesley Breast Clinic between January 1990 and December 1999. Of these, 62.6% were aged 18-19 years. The commonest reason for referral was a lump or thickening in the breast (n=554, 87.4%). Six hundred and nineteen females had ultrasound performed, with 59% showing no abnormality. The commonest abnormality in the remainder was probable fibroadenoma (n=162). Twenty-two percent of the females in the study had fine needle aspiration performed; none showed suspicious cytology. Twenty-three females had an excision biopsy following their initial visit. Three of these were found to have benign phyllodes tumour. There were no malignancies detected, although one female had previous DCIS diagnosed elsewhere.

Breast cancers invisible on mammography.

BACKGROUND: A proportion of the cancers 'missed' at mammography are invisible even with the benefit of hindsight. The aim of the present study was to identify a group of women with proven breast cancer whose mammograms did not show a suspicious lesion even in retrospect (i.e. the truly mammographically occult cancers), and to compare them with mammogram-positive cancers. METHODS: A total of 1757 breast cancers was diagnosed at the Wesley Breast Clinic's Screening or Diagnostic Services between July 1987 and August 1997. One hundred and twenty cases were identified where, after independent review by two of the authors, no mammographic abnormality could be found in the region where the cancer was subsequently found. These 120 cases were compared with 1548 cancers considered to have a lesion visible on mammography, whether benign, indeterminate, suspicious or malignant in appearance. RESULTS: In 90% of the mammogram-negative cancers, a clinical abnormality led to further investigation, while the remainder were found incidentally on ultrasound. There were a higher proportion of dense breasts, and of women aged 40-49, in the mammogram-negative cancers than in the mammogram-positive cancers. The mammogram-negative cancers were of smaller size overall, but three of them were surprisingly large (7-11 cm). In both the mammogram-positive and -negative cancers approximately 60% were ductal invasive cancers. CONCLUSIONS: Where factors are present that make mammographically occult malignancy more likely (e.g. age 40-49 and dense breasts), women may be targeted for further investigation by other modalities. This is essential in the presence of a clinical abnormality.