Very large core needle biopsies of the breast: a review.

The commitment to the goal of diagnosing and treating breast cancer at its earliest point of development remains strong. As a result, biopsy techniques continue to evolve. Freehand needle localizations were supplanted by fenestrated grids and hook wires. In the 1990s, stereotactic and ultrasound guided large core needle biopsy techniques were introduced, and now ultrasound and stereotactic guided vacuum-assisted procedures with 11-gauge needles are commonplace. Most recently, very large core needle biopsy devices were developed with a purpose of percutaneously diagnosing and treating nonpalpable breast lesions. However, bigger may not necessarily be better. This paper reviews the very large core needle biopsy technique and compares it to traditional large core needle biopsy. Factors such as technical success, histologic concordance, surgical margin positivity and cost are discussed.

Mammographically detected ductal carcinoma in situ treated with conservative surgery with or without radiation therapy: patterns of failure and 10-year results.

OBJECTIVE: The authors reviewed their institution's experience treating mammographically detected ductal carcinoma in situ (DCIS) of the breast with breast-conserving therapy (BCT) to determine 10-year rates of local control and survival, patterns of failure, and factors associated with outcome. SUMMARY BACKGROUND DATA: From January 1980 to December 1993, 177 breasts in 172 patients were treated with BCT for mammographically detected DCIS of the breast at William Beaumont Hospital, Royal Oak, Michigan. METHODS: All patients underwent an excisional biopsy, and 65% were reexcised. Thirty-one breasts (18%) were treated with excision alone, whereas 146 breasts (82%) received postoperative radiation therapy (RT). All patients undergoing RT received whole-breast irradiation to a median dose of 50.0 Gy. One hundred thirty-six (93%) received a boost to the tumor bed for a median total dose of 60.4 Gy. Median follow-up was 5.9 years for the lumpectomy alone group and 7.2 years for the lumpectomy + RT group. RESULTS: In the entire population, 15 patients had an ipsilateral breast recurrence. The 5- and 10-year actuarial rates of ipsilateral breast recurrence were 7.8% and 7.8% for lumpectomy alone and 8.0% and 9.2% for lumpectomy + RT, respectively. Eleven of the 15 recurrences developed within or immediately adjacent to the lumpectomy cavity and were designated as true recurrences or marginal misses (TMM). Four recurred elsewhere in the breast. Eleven of the 15 recurrences were invasive, whereas 4 were pure DCIS. Only one patient died of disease, yielding 5- and 10-year actuarial cause-specific survival rates of 100% and 99.2%, respectively. Eleven patients were diagnosed with subsequent contralateral breast cancer, yielding 5- and 10-year actuarial rates of 5.1% and 8.3%, respectively. Clinical, pathologic, and treatment-related factors were analyzed for an association with ipsilateral breast failure or TR/MM. No factors were significantly associated with ipsilateral breast failure. In the entire population, the omission of RT and younger age at diagnosis were significantly associated with TR/MM. Patients younger than 45 years at diagnosis had a significantly higher rate of TR/MM in both the lumpectomy + RT and lumpectomy alone groups. None of the 37 patients who received a postexcisional mammogram had an ipsilateral breast failure versus 15 in the patients who did not receive a postexcisional mammogram. CONCLUSIONS: Patients diagnosed with mammographically detected DCIS of the breast appear to have excellent 100-year rates of local control and overall survival when treated with BCT. These results suggest that the use of RT reduces the risk of local recurrence and that patients diagnosed at a younger age have a higher rate of local recurrence with or without the use of postoperative RT.

Factors associated with local recurrence of mammographically detected ductal carcinoma in situ in patients given breast-conserving therapy.

BACKGROUND: The authors reviewed their institution's experience treating patients with mammographically detected ductal carcinoma in situ (DCIS) of the breast with breast-conserving therapy (BCT) to determine 10-year rates of local control and survival and to identify factors associated with local recurrence. METHODS: From January 1980 to December 1993, 132 breasts in 130 patients were treated with BCT for mammographically detected DCIS at William Beaumont Hospital, Royal Oak, Michigan. All patients underwent an excisional biopsy, and 64% were reexcised. All patients received postoperative whole-breast irradiation to a median dose of 45.0 Gray (Gy) (range: 43.1-56.0 Gy). One hundred twenty-four cases (94%) received a boost to the tumor bed for a median total dose of 60.4 Gy (range: 45.0-71.8 Gy). All cases underwent complete pathologic review by one pathologist. The median follow-up was 7.0 years. RESULTS: Of the entire study group, 13 patients developed recurrence within the ipsilateral breast, for 5- and 10-year actuarial rates of 8.9% and 10.3%, respectively. Nine of the 13 recurrences (69%) occurred within or immediately adjacent to the lumpectomy cavity and were designated as true recurrences or marginal misses (TR/MM). Four patients (31%) had recurrence elsewhere in the breast. Ten of the 13 recurrences (77%) were invasive, whereas 3 (23%) were pure DCIS. Only 1 patient died of disease, corresponding to 5- and 10-year actuarial cause specific survival rates of 100% and 99.0%, respectively. Multiple clinical, pathologic, and treatment-related factors were analyzed for association with ipsilateral breast failure or TR/MM. In multivariate analysis, only the absence of pathologic calcifications was significantly associated with ipsilateral breast failure. When specifically analyzed for TR/MM, younger age at diagnosis, number of slides with DCIS, number of DCIS and cancerization of lobules (COL) foci within 5 mm of the margin, and the absence of pathologic calcifications demonstrated a statistically significant association. Close or positive margin status did not significantly predict for either TR/MM (P = 0.14) or ipsilateral breast failure (P = 0.19). CONCLUSIONS: In patients with mammographically detected DCIS treated with BCT, adequate excision of all DCIS prior to RT can result in improved rates of local control. However, margin status may not adequately predict complete tumor extirpation. The volume of DCIS within 5 mm of the margin appears to be a more reliable surrogate for the adequacy of excision. In addition, young patient age and the absence of pathologic calcifications are independent risk factors for the development of local recurrence.

Impact of the mode of detection on outcome in breast cancer patients treated with breast-conserving therapy.

The impact of the mode of detection on outcome in patients with early stage breast cancer treated with breast-conserving therapy (BCT) was reviewed. Between January 1980 and December 1987, 400 cases of stage I and II breast cancer were treated with BCT. All patients underwent an excisional biopsy, external beam irradiation (RT) to the whole breast (45-50 Gy), and a boost to 60 Gy to the tumor bed. One hundred twenty-four cases (31%) were mammographically detected, whereas 276 (69%) were clinically detected. Median follow-up was 9.2 years. Patients whose cancers were detected by mammography more frequently had smaller tumors (90% T1 vs. 62%, p < 0.0001), lower overall disease stage (78% stage I vs. 47%, p < 0.0001), were older at diagnosis (78% >50 years vs. 54%, p < 0.001), less frequently received chemotherapy (8% vs. 21%, p = 0.001), and had an improved disease-free survival (DFS) (80% vs. 70%, p = 0.014), overall survival (OS) (82% vs. 70%, p = 0.005), and cause-specific survival (CSS) (88% vs. 77%, p = 0.003) at 10 years. However, controlling for tumor size, nodal status, and age, no statistically significant differences in the 5- and 10-year actuarial rates of local recurrence (LR), DFS, CSS, or OS were seen based on the mode of detection. Initial mode of detection was the strongest predictor of outcome after a LR. The 3-year DFS rate after LR was significantly better in initially mammographically detected versus clinically detected cases (100% vs. 61%, p = 0.011). Patients with mammographically detected breast cancer generally have smaller tumors and lower overall disease stage at presentation. However, the mode of detection does not independently appear to affect the success of BCT in these patients.

Initial experience with the advanced breast biopsy instrumentation device.

OBJECTIVE: The Advanced Breast Biopsy Instrumentation (ABBI) device (United States Surgical; Norwalk, CT) is designed to percutaneously excise nonpalpable breast lesions. Because this is a new technique, we report our initial experience with regard to technical success, complications, and histologic margins for malignancies. SUBJECTS AND METHODS: From May 14, 1997, until March 4, 1998, 89 consecutive patients elected to undergo the ABBI procedure. Preprocedure imaging included screening mammography and additional mammographic and sonographic studies when deemed necessary. Lesions were targeted by the surgeons. Specimen radiography was performed for all lesions, and the images were interpreted by radiologists. Pathologic analysis was provided or reviewed by a dedicated breast pathologist. Parameters analyzed included technical success, complications, lesion size, histologic diagnosis, and margin status for malignant lesions. RESULTS: There were 29 patients with 30 noncalcified masses, 53 patients with clustered calcifications, three patients with masses and calcifications, three patients with asymmetric densities, and one patient with architectural distortion. Eighteen ABBI procedures were aborted, converted to core biopsy, or failed to remove the targeted lesion. Fifteen patients experienced a total of 19 complications; 10 of the complications required treatment and follow-up after the biopsy. Of 11 malignant tumors revealed by ABBI, four had negative margins. Seven of these 11 malignant tumors had positive margins. CONCLUSION: The ABBI procedure had a high number of complications and technical failures and did not reliably provide cancer-free margins for malignant tumors. Women with nonpalpable breast lesions that need a tissue diagnosis are better treated by stereotactic or sonographically guided needle biopsy.

Inadequate follow-up of abnormal mammograms.

Routine mammographic screening increases detection of nonpalpable breast cancer. Timely follow-up of abnormalities is essential because delays may lead to postponement of treatment and decreased survival for women who have cancer. The purpose of this study was to determine the percentage of women with an abnormal mammogram who do not have adequate follow-up and to determine factors associated with inadequate follow-up. The study was conducted in a metropolitan health system that includes a large urban teaching hospital in Detroit and 26 ambulatory care centers. From the radiology database, all women with an abnormal screening mammogram performed between January 1, 1992, and July 31, 1992 were identified. We defined adequate follow-up as follow-up within three months of due date. Follow-up status was determined using medical records and telephone interviews. The percentage of women with inadequate follow-up was calculated. Relative risks compared percentages of women with inadequate follow-up according to demographic and screening-related variables. We calculated adjusted relative risks using multivariate binomial regression. We identified 1,249 women with abnormal screening mammograms. Inadequate follow-up occurred for 226 (18.1%) of the women. Among women with follow-up recommended in 4-6 months, 36.8% had inadequate follow-up. Among women with immediate follow-up recommended (obtain additional views or outside films for comparison, ultrasound, biopsy, or surgical referral), 7.2% had inadequate follow-up. Inadequate follow-up was associated with lower estimated household income and no history of previous mammogram. Among women with inadequate follow-up who were interviewed, 87% reported that they had been notified of their results. We found that the percentage of women with inadequate follow-up of abnormal mammograms is high, especially among women who require six-month follow-up. Women with low income and no history of a previous mammogram were at greatest risk for inadequate follow-up. These results document a previously unrecognized problem with mammography screening and suggest that the implementation of tracking systems to ensure timely follow-up of abnormal screening mammograms is essential. Medical Subject Headings (MeSH): mammography, follow-up, screening.

Noninvasive breast cancer.

Noninvasive breast cancer comprises two distinct entities, lobular carcinoma in situ (LCIS) and ductal carcinoma in situ (DCIS). The increased use of screening mammography has caused more cases of noninvasive breast cancer to be discovered. However, the increased detection of LCIS and DCIS has posed problems in patient care for the radiologist, pathologist, surgeon, radiation oncologist, and medical oncologist. The authors review the past history of LCIS and DCIS, as well as the diagnostic challenges and therapeutic considerations for the multidisciplinary breast cancer team.

The role of fine-needle aspiration and pneumocystography in the treatment of impalpable breast cysts.

Prior studies have suggested that the recurrence rate is lower in breast cysts treated by pneumocystography (injection of air into cyst cavities after cyst aspiration) than in cysts treated by fine-needle aspiration alone. To determine if this is the case for impalpable breast cysts, we reviewed the hospital records and mammograms of 38 women with 41 impalpable cysts. Mammograms obtained immediately after aspiration show that pneumocystography was successful in 18 and unsuccessful in 20 of the 41 cysts. Four cysts were excluded from the study: one cyst that recurred after aspiration and was sampled by biopsy and three cysts for which immediate post-aspiration mammograms were unavailable but which had recurred or persisted 3 years after aspiration. Review of follow-up mammograms made 4 months to 3 years after the aspiration showed that three (17%) of 18 cysts in the group with successful pneumocystography recurred and 11 (58%) of 19 cysts in the unsuccessful group recurred (p = .02). No difference was found in the number of recurrent cysts in relation to estrogen therapy or menopausal status. Our results indicate that impalpable breast cysts treated by pneumocystography are less likely to recur than are cysts treated by aspiration alone.

Mammographic follow-up of low-suspicion lesions: compliance rate and diagnostic yield.

All recommendations for mammographic follow-up of low-suspicion lesions seen at mammography during a 6-month period were reviewed to establish compliance rate and eventual outcome. One hundred forty-four of 2,650 mammograms (5%) showed minimal abnormalities that warranted short-term and periodic mammographic follow-up. Rates of compliance at 4 months and at 1, 2, and 3 years were 88%, 71%, 60%, and 47%, respectively. Progressive mammographic change was found in 10 patients, only one of whom had a carcinoma. It was concluded that mammographic follow-up of low-suspicion lesions is a reasonable alternative to surgical biopsy, although patient compliance remains a significant problem.

Fine needle aspiration biopsy of the breast. Influence of the number of passes and the sample size on the diagnostic yield.

The sensitivity of fine needle aspiration (FNA) biopsy of the breast as a function of the number of aspirations performed on any given lesion was investigated. Four separate aspirations each were performed on over 400 lesions of the breast, 93 of which yielded a cytologic diagnosis. The incremental diagnostic yields of each subsequent aspiration were tabulated. The first aspirate of the sequence gave the greatest yield, with smaller incremental yields on the second through the fourth aspirates. Benign and malignant lesions gave similar results, as did palpable and nonpalpable lesions (the latter being usually smaller in size). A mathematical extrapolation of the data indicates that three or four aspirations of any given lesion provide the optimal yield within the limits of practicality. This performance of multiple FNA biopsies is particularly important when the pathologist does not perform the biopsy, or is unable to assist in the immediate interpretation of the specimen to assess its adequacy.

Paraffin tissue block radiography: adjunct to breast specimen radiography.

Radiography of specimens is an essential step in confirming excision of nonpalpable breast lesions. On occasion, however, the pathologist may not identify the lesion histologically. The authors report five cases in which suspicious microcalcifications were included in the excised tissue but were not identified by the pathologist. In all five, paraffin tissue block radiography enabled identification of the specific blocks containing the microcalcifications. The correct tissue blocks were then sectioned again, and the microcalcifications were identified histopathologically. In one case, the initial diagnosis of intraductal hyperplasia was changed to intraductal carcinoma with focal invasion. When the pathologist cannot identify the calcifications on initial histopathologic sections, this technique may assist in identification of the mammographic abnormality.

CT appearance of right gonadal vein.

The CT appearance of the right gonadal vein was studied. It is usually first seen 1 cm below the bifurcation of the inferior vena cava (IVC) and empties into the IVC laterally or anterolaterally 4 cm below the union of the right renal vein and IVC. Occasionally, it empties into an accessory right renal vein rather than the IVC. The right gonadal vein was visualized partially or completely in 80% of patients, and generally measured less than or equal to 4 mm in maximum diameter. It was enlarged in a patient with portal hypertension and in a post-partum woman. Knowledge of its typical CT appearance should prevent confusion with abdominopelvic lymph nodes.

Breast microcalcifications after lumpectomy and radiation therapy.

Ten of 152 (7%) consecutive breast cancer patients who underwent excisional biopsy and radiation therapy developed suspect microcalcifications at the biopsy site. All ten patients underwent reexcision. Seventeen other patients developed scattered, coarse, benign macrocalcifications that have remained stable as determined with mammographic follow-up. Of the ten patients who underwent reexcision, six had clusters of calcifications that were benign, and four had malignant calcifications. The morphologic appearance of the microcalcifications was similar in both malignant and benign disease, although the malignant calcifications tended to appear earlier than the benign ones. Three of the four patients with recurrent carcinoma had had calcifications in the original cancer. The mammographic features of the microcalcifications were not specific enough to distinguish recurrent malignancy from benign disease. Unless calcifications that occur in the breast after lumpectomy and radiation therapy have an unequivocally benign appearance (ie, scattered, round, homogeneous-appearing macrocalcifications), they should be viewed with suspicion and subjected to excisional biopsy.

Breast hamartomas: variable mammographic appearance.

The mammograms of 17 women with pathologically proved breast hamartomas were reviewed. Abnormal masses were detected on 12. Nine women had masses with benign features. Two of these had findings considered classic for hamartoma. In three cases, the appearance of the mass was suggestive of carcinoma. The breasts were very dense in four of five women without detectable mass. The findings suggest that the classic mammographic appearance of breast hamartomas is less common than previously reported, which may be explained by earlier detection of small hamartomas.

CT evaluation of enhancing mediastinal masses.

The CT scans of 132 patients with mediastinal masses and CT scans from our teaching file were retrospectively reviewed to evaluate the role of contrast enhancement in limiting the differential diagnosis of a mediastinal mass. Ten patients with an enhancing mediastinal mass were found. Coupled with mass enhancement, location and hypertension were helpful in limiting the differential diagnosis. Four masses were of thyroid origin, and all were contiguous with neck thyroid. All patients with functioning paragangliomas were hypertensive and all intrapericardial enhancing masses were functioning paragangliomas. A normotensive patient had a nonfunctioning aortic body paraganglioma superiolateral to the aortic arch. An enhancing mass in a similar location in a hypertensive patient was a functioning paraganglioma. Castleman disease occurred posterior to the heart.

Two-view specimen radiography in surgical biopsy of nonpalpable breast masses.

Nonpalpable, low-density, noncalcified lesions sometimes can be difficult to see on an initial specimen radiograph. In 57 consecutive wire localizations, 37 patients had obvious microcalcifications and did not require a second specimen radiograph. Twenty-six patients had nonpalpable, noncalcified lesions, and a second specimen radiograph was obtained in 24 of these. In four of these cases the initial specimen radiograph failed to show the suspected lesion, and a second specimen radiograph orthogonal to the original plane of orientation of the specimen showed the lesion to be contained within the biopsied material. Although it is seldom necessary to use this technique, it may obviate a second biopsy specimen as well as reduce operative time. We found that a second orthogonal specimen radiograph provided important information in 7% of cases.

Accessory breast tissue in the axilla: mammographic appearance.

Mammographic features of normal accessory axillary breast tissue were analyzed in 13 women, 54% of whom had positive findings on physical examination. Radiographically the accessory tissue resembled the remaining normal glandular tissue but was separate from it. The mean radiographic dimension of the accessory tissue, which was best seen on oblique or exaggerated craniocaudal views, was 3.9 cm. In most cases the accessory tissue was either bilateral or confined to the right side. When found on mammography, accessory axillary breast tissue should be recognized as a normal developmental variant rather than considered a pathologic lesion, although carcinoma can develop in the accessory tissue. A specific, radiography-aided diagnosis of accessory axillary breast tissue can eliminate unnecessary biopsy.