Tubular carcinoma of the breast: sensitivity of diagnostic techniques and correlation with histopathology.

OBJECTIVE: Our objective was to assess our experience in diagnosing pure tubular carcinoma of the breast and to correlate the radiologic and histopathologic features. MATERIALS AND METHODS: A retrospective review of 932 consecutive cases of proven breast cancer diagnosed between 1990 and 1997 revealed 78 cases (8.4%) of tubular carcinoma in 69 patients. Clinical, imaging, cytologic, and histologic findings were analyzed. RESULTS: Mammography revealed tubular carcinoma in 68 (87%) of the 78 cases. Sonography showed tubular carcinoma in all 38 cases in which it was used; nine of these lesions were mammographically occult. These nine lesions were slightly, but not significantly (p < .05), smaller than the 29 lesions that had also been detected on mammography. Large core needle biopsy was performed in 22 patients (sensitivity, 91%). At biopsy, diagnoses were malignant (n = 16 [73%]), suspicious (n = 4 [18%]), atypia (n = 1 [4.5%]), and benign (n = 1 [4.5%]). Fine-needle aspiration biopsy was used to evaluate 36 cases of tubular carcinoma (sensitivity, 50%); cytologic diagnoses were malignant (n = 15 [42%]), suspicious (n = 3 [8%]), atypia (n = 10 [28%]), and benign (n = 8 [22%]). Only 15 (19%) of the 78 tubular carcinomas were palpable. Other tumors were detected within the excised tissue in 47 of the patients (68%); of these other types of lesions, ductal carcinoma in situ was found most often. CONCLUSION: Most cases of tubular carcinoma can be revealed by mammography; for mammographically occult tubular carcinoma, sonography can be performed. The rate of accuracy for determining the presence of tubular carcinoma is higher with large core needle biopsy than with fine-needle aspiration biopsy. Finally, when tubular carcinoma is diagnosed, other histologic types of carcinoma often occur in the same breast.

Numerical abnormalities of chromosomes 7, 18, and x in precancerous breast disease defined by fluorescent in situ hybridization.

Nonrandom numerical chromosomal abnormalities (NCA) are frequent in invasive breast cancer, but little is known about such changes in microscopic precursor lesions. Mammographically detected "suspicious" breast lesions were localized by specimen radiology of sliced breast tissue. The slices containing the lesion were imprinted onto coated slides by gentle scraping. The corresponding hematoxylin and eosin stained histologic sections and Diff-Quik stained imprints were used for classification as ductal hyperplasia (DH), atypical ductal hyperplasia (ADH), and ductal carcinoma in situ (DCIS). Additional slide imprints were evaluated for copy number of chromosomes 7, 18, and X by using fluorescent in situ hybridization with alpha satellite probes. NCA were detected in 1 of 9 (11%) cases of DH, in 2 of 8 (25%) cases of ADH, and in 14 of 16 (87%) cases of DCIS. There was selective loss (chromosome 18) in one case of DCIS; all other cases with NCA had a gain of at least one chromosome. There is a progressive increase in incidence of NCA in DH, ADH and DCIS. The majority of NCA are chromosomal gains.

Stereotactic fine-needle aspiration biopsy for the evaluation of nonpalpable breast lesions: report of an experience based on 2,988 cases.

BACKGROUND: The increasing use of mammography has led to a significant increase in the detection of clinically occult lesions, the majority of which prove to be benign. SFNB has been suggested as a means of expediting a diagnosis for lesions that are malignant while limiting surgical biopsies for those that are benign. METHODS: Clinically occult mammographic lesions were assessed by SFNB in 2,988 patients. Definitive histologic diagnoses were made on surgical specimens in all instances in which the cytologic diagnosis was malignant, suspicious, or atypical. Patients with benign cytology were either followed with interval mammograms or underwent surgical biopsy. RESULTS: Two hundred ninety-one of the 295 lesions (99%) diagnosed as cancer via SFNB were confirmed by histopathology. Twenty-two of the 22 lesions (100%) that were diagnosed as suspicious were diagnosed on histopathology as malignant. Forty-three of the 70 lesions (61%) with cytologic atypia were diagnosed on histopathology to be malignant. CONCLUSIONS: SFNB is an accurate means of diagnosing carcinoma, but must be followed by surgical biopsy when the cytology shows atypia. For lesions diagnosed as benign by SFNB, close interval mammography is essential.

Mammographically detected breast lesions: clinical importance of cytologic atypia in stereotaxic fine-needle aspiration biopsy samples.

PURPOSE: To correlate cytologic findings of stereotaxic fine-needle aspiration biopsy samples with histologic findings of excised samples of nonpalpable mammographically detected lesions. MATERIALS AND METHODS: In a retrospective review of 2,988 consecutive stereotaxic fine-needle aspiration biopsy samples of nonpalpable breast lesions obtained within 5 years, 70 samples were categorized as atypical. Excision with needle localization and specimen radiography were performed in all lesions; cytologic findings of aspirates were correlated with histologic findings of excised samples. Histologic findings were the standard of reference. RESULTS: Of the 70 atypical aspirates, 27 were benign (38%) and 43 were malignant (61%). Both the benign and the malignant lesions had an average size at mammography of 1.1 cm. The nuclear grade was low in 21 (49%), moderate in 16 (37%), and high in six (14%) of the malignant lesions. There were axillary lymph node metastases in four samples (9%). CONCLUSION: Although lesions with atypical aspirates usually are benign, to achieve a low prevalence of false-negative diagnoses atypia must be interpreted as potential malignancy.

Malpractice litigation involving patients with carcinoma of the breast.

BACKGROUND: We sought to evaluate recent trends in the United States of America regarding malpractice awards for patients with carcinoma of the breast. STUDY DESIGN: A retrospective review was performed of 118 cases of purported malpractice in the diagnosis and management of patients with carcinoma of the breast and related problems. The information was tabulated from Westlaw Transmission, a computerized database. RESULTS: Gynecologists were the specialists most often sued and accounted for 47 percent of the physicians involved in lawsuits. Radiologists were cited in only 13 percent of the cases. Health maintenance organizations (HMOs) were cited in 5 percent of the cases. The most common complaint was delay in diagnosis, made by a plaintiff who detected her own breast mass (52 percent). In 15 percent of the cases, the plaintiffs complained that a mammogram was not obtained, and 9 percent complained that other diagnostic tests, such as ultrasound or fine-needle aspiration biopsy, were not performed. The average delay in diagnosis was 14 months. The average award to plaintiffs with carcinoma of the breast was $691,449. The average plaintiff's age was 44 years. CONCLUSIONS: Most malpractice complaints related to carcinoma of the breast are instituted by women under the age of 50 years who identified the breast mass by themselves and were assumed by their physicians to have fibrocystic disease of the breast. Complaints can be expected to increase regarding failure to order further diagnostic tests, such as ultrasound or fine-needle aspiration biopsy, despite a negative mammogram. Complaints against HMOs are now also being made, citing failure to properly diagnose or treat patients with carcinoma of the breast.

Stereotactic aspiration biopsy of nonpalpable nodules of the breast.

To evaluate the reliability of stereotactic aspiration biopsy (SAB) in assessing which nonpalpable nodules of the breast should be excised, SAB was performed upon 373 nodules. The nodules were classified as well-circumscribed or irregular and evaluated for the presence of microcalcifications. The cytologic diagnoses were classified as malignant, atypical or benign. Cytologically malignant and atypical nodules were excised. Benign nodules were excised if there was a family or past history of carcinoma of the breast or if they changed mammographically. Twenty-five nodules proved to be malignant. Of these, the diagnoses by stereotactic aspiration biopsy were adenocarcinoma in 20 patients, atypical in three, malignant hemangiopericytoma in one patient and benign in one. The borders of the malignant nodules were well-defined in eight patients and irregular in 17. Three malignant nodules with irregular borders had clustered microcalcifications. One false-positive instance was a sclerosing papilloma with atypical hyperplasia. Twenty-four nodules with benign cytologic diagnoses, which were excised, proved to be benign. An additional 132 nodules with benign cytologic diagnoses had six month interval mammograms for two years; 131 were without interval change and one increased in size and proved to be a carcinoma. SAB is reliable for diagnosing nonpalpable nodules. Nodules with malignant and atypical results must be excised. It is reasonable to have follow-up evaluation of well-defined nodules mammographically when the aspirate is benign.

Breast cancer malpractice litigation in New York State.

PURPOSE: To identify causes of purported malpractice in diagnosis and treatment of breast cancer. MATERIALS AND METHODS: The authors reviewed cases from The New York Jury Verdict Reporter listed between 1985 and 1991 to look for those in which there was alleged delay in diagnosis or treatment of breast cancer. RESULTS: Of 34 cases identified, 32 (94%) were based on presumed delay in diagnosis and only two (6%) on claims of therapeutic malpractice. Delay in diagnosis was commonly claimed in patients younger than 50 years (76%). Palpable masses were present in 94% of these cases. Either mammograms were not obtained (16 cases, 50%) or findings were interpreted as normal or as fibrocystic disease (12 cases, 38%). Specialists most frequently cited were gynecologists (16 of 39,41%). Highest awards (> or = $1 million) were more commonly given to patients younger than 50 years with proved distant or nodal metastasis (six of 34, 18%). CONCLUSION: Emphasis on early diagnosis has led to the perception that purported delay in diagnosis, however short, even in the presence of a palpable mass, changes the chances for survival.

Localization of nonpalpable masses in patients with breast implants.

Nonpalpable nodules in patients with breast implants may represent silicone granulomas, fibrocystic mastopathy, or cancer. We describe a modified technique for needle localization which facilitates the surgical excision of these nodules while minimizing the possibility of rupture.

Fine needle aspiration biopsy in patients with augmentation prostheses and a palpable mass.

Six patients with augmentation prostheses presented with a firm, painless, breast mass that could not be visualized by mammography. One lesion was demonstrated to be solid by ultrasound, and the remaining sonograms were nondiagnostic. The lesions were indistinguishable from carcinoma, by physical examination. All of the patients had fine needle aspiration biopsy despite close proximity to the implant. The patients all had silicone granulomas related to silicone leakage. Our experience suggests that fine needle aspiration biopsy is a useful technique to evaluate palpable breast masses that are not visualized by mammography in patients with augmentation prostheses.

Distinction between postsurgical changes and carcinoma by means of stereotaxic fine-needle aspiration biopsy after reduction mammaplasty.

Stereotaxic fine-needle aspiration biopsy (SFNAB) was performed to evaluate suspicious mammographic findings (31 stellate lesions, 20 regions of grouped calcifications, two nodules, and one area of prominent trabecular markings) in 54 patients who had undergone reduction mammaplasty. SFNAB findings were correlated with findings in histologic specimens whenever possible; the cytologic samples were classified as malignant, atypical, or benign. In 22 lesions, the abnormalities on mammograms were considered highly suspicious for malignancy. In the 32 others, the degree of suspicion was lower, but these lesions had a change in appearance since acquisition of the first postoperative mammogram. SFNAB enabled diagnosis of adenocarcinoma in five women. Patients who have undergone mastectomy with reconstruction of one breast and mammaplasty in the other are at higher risk for development of contralateral breast cancer, as are all patients who have had such cancer. SFNAB is reliable for evaluation of suspicious mammographic abnormalities that develop after mammaplasty and findings that change after acquisition of the first postoperative mammogram.

Stereotactic localization for fine needle aspiration biopsy in patients with augmentation prostheses.

Fifteen patients with augmentation mammoplasties had mammography demonstrating nonpalpable breast lesions. Of the 15 patients, three (20%) had adenocarcinoma confirmed by open biopsy and histopathology. All patients underwent stereotactic localization for fine needle aspiration biopsy. Four of the 15 patients had benign cysts (26%). None of the cysts could be diagnosed by ultrasound. The remaining eight patients had mammary dysplasia of a proliferative or nonproliferative type of fibroadenoma. These benign entities were followed with interval mammography demonstrating no change. The data suggest that fine needle aspiration biopsy is an effective technique to assess nonpalpable breast lesions in patients who have had augmentation mammoplasties.

Recurrent breast cancer: stereotaxic localization for fine-needle aspiration biopsy. Work in progress.

The efficacy of stereotaxic localization for fine-needle aspiration biopsy in the detection of recurrent cancer manifested as calcifications on mammograms was evaluated in 43 patients that had been treated with local resection and radiation therapy. Six patients had malignant aspirates and one had an atypical aspirate; examination of the surgical specimens revealed all seven of these to be malignant. Thirteen patients underwent surgical biopsies, the results of which were malignant in seven and benign in six. The remaining 30 patients were followed up with mammography. The follow-up mammograms were obtained at 6-month intervals and demonstrated no change in appearance. On the basis of this initial experience, stereotaxic localization for aspiration biopsy offers the potential to accurately distinguish benign from malignant lesions.

Stereotaxic localization for fine-needle aspiration breast biopsy. Initial experience with 300 patients.

The efficacy of stereotaxic aspiration biopsy was evaluated in 300 consecutive patients with nonpalpable mammographic lesions. Sixty-eight patients (23%) had suspicious or malignant aspirates; all cases were proved malignant by subsequent examination of operative specimens. Two hundred sixteen patients (72%) had benign aspirates. Of these, 65 were confirmed by operation and 151 had subsequent mammography at 6- and 12-month intervals with no demonstrable mammographic change. In 10 instances (3%), the aspirates were atypical, and in six (2%), nondiagnostic. Biopsy specimens were obtained in all 16 instances, and eight were malignant. The sensitivity of stereotaxic breast aspiration for the diagnosis of cancer was 96%, and the specificity was 100%. Our experience confirms the efficacy of stereotaxic aspiration for the initial evaluation of mammographically detected, nonpalpable lesions.

Invasive papillary carcinoma of the breast: mammographic appearance.

The mammographic findings in 18 patients with invasive papillary carcinoma were studied retrospectively. The mammograms of 10 patients showed a multinodular pattern, and seven patients had solitary nodules. One patient had an irregular, ill-defined mass in the retroareolar region. Two patients were found to have carcinoma in the contralateral breast, and two patients had intraductal carcinoma adjacent to the invasive papillary carcinoma. The varied mammographic features that may occur with this rare breast malignancy are discussed.

Calcifications of the breast after reduction mammoplasty.

Mammograms of 152 patients after mammoplasty were studied and 37 patients were noted to have calcifications. The pattern of these calcifications was studied to determine if specific characteristics could be identified. The calcifications were found to occur within the skin of the breast, mainly at a periareolar location. The ability to identify these benign calcifications further aids in reliably monitoring patients by mammography after reduction mammoplasty.

Differentiation of radial scar from scirrhous carcinoma of the breast: mammographic-pathologic correlation.

Radial scar, a sclerosing ductal breast lesion characterized by an irregular stellate pattern of epithelial proliferation around a central fibroelastic core, may be confused histologically with scirrhous carcinoma of the breast. Mammographic features used to distinguish these two entities were found unreliable in a retrospective review of 255 consecutive stellate lesions. Of 73 nonpalpable carcinomas, fourteen (19%) had radiographic features of radial scar. Only the presence of microcalcifications in 11 of those patients helped the authors distinguish carcinoma from radial scars. Four of nine biopsy-proved radial scars had a dense central region, simulating the appearance of scirrhous carcinoma. Stellate lesions with radiolucent centers should be considered suggestive of carcinoma, particularly if associated with microcalcifications.

Circumscribed intraductal carcinoma of the breast.

In a retrospective evaluation of 350 cases of proved intraductal carcinoma detected over a 3-year period, 13 had mammographic features similar to those of benign tumors. The carcinomas were sharply circumscribed, round or oval lesions that contained microcalcifications. These calcifications were smaller and more likely to be asymmetrically located within the nodule than those of the fibroadenomas that they mimicked. While the carcinomas appeared circumscribed on mammograms, microinvasion of surrounding tissue was proved histologically in five of 13 cases, and in another case biopsy revealed metastasis to an axillary lymph node. Although these carcinomas are relatively rare, mammographic detection is important as none were palpable at the time of diagnosis.