A mass on breast imaging predicts coexisting invasive carcinoma in patients with a core biopsy diagnosis of ductal carcinoma in situ.

An image-guided core-needle breast biopsy (IGCNBB) diagnosis of ductal carcinoma in situ (DCIS) is often upgraded to invasive carcinoma (IC) after complete excision. When IC is identified after excision patients must be returned to the operating room for evaluation of their axillary nodes. We performed this study to identify histologic or mammographic features that would predict the presence of invasion when DCIS is documented by IGCNBB. Patients with an IGCNBB diagnosis of DCIS were identified from a prospective database. Imaging abnormalities were classified as either calcification only or mass with or without calcifications. IGCNBB specimens were reviewed to document nuclear grade and the presence of comedo-type necrosis, periductal fibrosis, and periductal inflammation. Patients were divided into two groups, DCIS and IC, on the basis of the final diagnosis after complete excision. From July 1993 through May 2000, 148 of 2995 (4.9%) IGCNBBs demonstrated DCIS; eight were excluded after pathologic review. Of the remaining 140 patients 36 (26%) demonstrated IC after complete excision. The presence of a mass on breast imaging was the only significant predictor of IC (P = 0.04). On the basis of the results of this study we now perform sentinel lymph node mapping and biopsy at the initial surgical procedure for patients with an IGCNBB diagnosis of DCIS and an associated mass on breast imaging.

Biopsy technique has no impact on local recurrence after breast-conserving therapy.

Image-guided core needle breast biopsy (IGCNBB) is an incisional biopsy technique that has been associated with tumor cell displacement. Theoretically tumor cell displacement may affect local recurrence rates in patients treated with breast-conserving therapy (BCT). We performed a study to determine if the biopsy method impacted local control rates following BCT. Patients with nonpalpable breast cancer (invasive and intraductal) diagnosed at our institution and treated with BCT between July 1993 and July 1996 were selected to provide a follow-up period in which the majority of local recurrences should be detected. Patients were divided into two groups based on their method of diagnosis. Group I patients were diagnosed by IGCNBB and group II patients were diagnosed by wire localized excisional breast biopsy (WLEBB). Factors potentially affecting local recurrence rates were retrospectively reviewed. Two hundred eleven patients were treated with BCT, 132 were diagnosed by IGCNBB and 79 by WLEBB. The two patient groups were similar when compared for prognostic factors and treatment. All patients' BCT included histologically negative margins. There were 4 (3.0%) local recurrences in Group I at a median follow-up of 44.4 months and 2 (2.5%) local recurrences in group II at a median follow-up of 50.1 months. This difference was not significant. Breast cancer patients diagnosed by IGCNBB can be treated by BCT with acceptable local control rates. Additional surveillance of our institutional experience and others' is mandatory to validate IGCNBB as the preferred biopsy method for nonpalpable mammographic abnormalities.

Power Doppler imaging: initial evaluation as a screening examination for carotid artery stenosis.

PURPOSE: To evaluate power Doppler imaging as a possible screening examination for carotid artery stenosis. MATERIALS AND METHODS: In the principal pilot study, a prospective, blinded comparison of power Doppler imaging with duplex Doppler imaging, the reference-standard method, was conducted in 100 consecutive patients routinely referred for carotid artery imaging at a large, private multispecialty clinic. In the validation pilot study, a prospective, blinded comparison of power Doppler imaging with digital subtraction angiography, the reference-standard method, was conducted in 20 consecutive patients routinely referred at a teaching hospital. Using conservative assumptions, the authors performed cost-effectiveness analysis. RESULTS: Power Doppler imaging produced diagnostic-quality images in 89% of patients. When the images of the patients with nondiagnostic examinations were regarded as positive, power Doppler imaging had an area under the receiver operating characteristic curve, A(z), of 0.87, sensitivity of 70%, and specificity of 91%. The validation study results were very similar. The cost-effectiveness of screening and, as indicated, duplex Doppler imaging as the definitive diagnostic examination and endarterectomy was $47,000 per quality-adjusted life-year. CONCLUSION: The A(z) value for power Doppler imaging compares well with that for mammography, a generally accepted screening examination, and with most other imaging examinations. Power Doppler imaging is likely to be a reasonably accurate and cost-effective screening examination for carotid artery stenosis in asymptomatic populations.

Benign diagnosis by image-guided core-needle breast biopsy.

Image-guided core-needle breast biopsy (IGCNBB) is widely used to evaluate patients with abnormal mammograms; however, information is limited regarding the reliability of a benign diagnosis. The goal of this study was to demonstrate that a benign diagnosis obtained by IGCNBB is accurate and amenable to mammographic surveillance. Records of all patients evaluated by IGCNBB from July 1993 through July 1996 were reviewed. Biopsies were classified as malignant, atypical, or benign. All benign cases were followed by surveillance mammography beginning 6 months after IGCNBB. Of the 1110 patients evaluated by IGCNBB during the study period, 855 revealed benign pathology. A total of 728 of the 855 patients (85%) complied with the recommendation for surveillance mammography. A total of 196 IGCNBBs were classified as malignant; 59 cases were classified as atypical. The atypical cases were excluded from the statistical analysis. Only two patients have demonstrated carcinoma after a benign IGCNBB during the 2-year minimum follow-up period. The sensitivity and specificity of a benign result were 100.0 and 98.9 per cent, respectively. A benign diagnosis obtained by IGCNBB is accurate and therefore amenable to mammographic surveillance. The results of this study support IGCNBB as the preferred method of evaluating women with abnormal mammograms.

A better understanding of the term radial scar.

BACKGROUND: Radial scar is a breast lesion with mammographic and histologic features similar to carcinoma. We reviewed the characteristics of patients with radial scars to better understand these lesions and to determine the incidence of associated carcinoma. METHODS: Records for all patients undergoing diagnostic wire localized excisional breast biopsy from January 1993 to September 1999 were reviewed to identify those with histologic or mammographic evidence of radial scar. Clinical records, mammograms, and pathologic slides of these patients were reviewed. RESULTS: We identified 45 cases of radial scar: 10 patients had mammographic and histologic evidence of radial scar (group I), 29 only mammographic evidence (group II), and 6 only histologic evidence (group III). Breast cancer risk was similar in the three patient groups. Carcinoma was identified in 18 patients with mammographic radial scars. CONCLUSION: Mammographically detected radial scars were associated with carcinoma in 18 of 39 (46%) cases. Histologically identified radial scars are not associated with malignancy and should not be confused with mammographically identified lesions.

Radial scar of the breast: radiologic-pathologic correlation in 22 cases.

Twenty-two cases were reviewed in which the diagnosis of radial scar (complex sclerosing lesion) of the breast was suspected preoperatively. At mammography, the lesions had a "black star" appearance with long, thin spicules radiating from a radiolucent central area. Excisional rather than core needle biopsy was recommended in all cases. In 13 of 22 cases, including one case of atypical ductal hyperplasia, the lesions proved benign at pathologic analysis. The remaining nine cases were malignant and included one case with a low-nuclear-grade cribriform and micropapillary ductal carcinoma in situ adjacent to the lesion. Results of this study confirm the previously reported association of atypical ductal hyperplasia and carcinoma with radial scar. Furthermore, they demonstrate that a mammographic finding suggestive of radial scar may represent a malignancy that mimics the typical imaging findings in these entities. In cases of mammographically suspected radial scar, all members of the management team as well as the patient should be made aware preoperatively of the potential for benign as well as malignant pathologic findings.

Image-guided core-needle breast biopsy is an accurate technique to evaluate patients with nonpalpable imaging abnormalities.

OBJECTIVE: The goal was to evaluate one institution's experience with image-guided core-needle breast biopsy (IGCNBB) and compare the pathologic results with wire-localized excisional breast biopsy (WLEBB) for patients with positive cores and the mammographic surveillance results for patients with negative cores. SUMMARY BACKGROUND DATA: IGCNBB is becoming a popular, minimally invasive alternative to WLEBB in the evaluation of patients with nonpalpable abnormalities. METHODS: This study includes all patients with nonpalpable breast imaging abnormalities evaluated by IGCNBB from July 1993 to February 1997. Patients with positive cores (atypical hyperplasia, carcinoma in situ, or invasive carcinoma) were evaluated by WLEBB. Patients with negative cores (benign histology) were followed with a standard mammographic protocol. IGCNBB results were compared with WLEBB results to determine the sensitivity and specificity for each IGCNBB pathologic diagnosis. RESULTS: Of 1440 IGCNBBs performed during the study period, 1106 were classified as benign, and during surveillance follow-up only a single patient was demonstrated to have a carcinoma in the index part of the breast evaluated by IGCNBB (97.3% sensitivity, 99.7% specificity). IGCNBB demonstrated atypical hyperplasia in 72 patients, 5 of whom refused WLEBB. The remaining 67 patients were evaluated by WLEBB: nonmalignant findings were found in 31, carcinoma in situ was found in 25, and invasive carcinoma was found in 11 (100% sensitivity, 88.8% specificity). IGCNBB demonstrated carcinoma in situ in 84 patients; WLEBB confirmed carcinoma in situ in 54 and invasive carcinoma in 30 (65.4% sensitivity, 97.7% specificity). IGCNBB demonstrated invasive carcinoma in 178 patients. Three were lost to follow-up. On WLEBB, 173 of the remaining 175 had invasive carcinoma; the other 2 patients had carcinoma in situ (80.8% sensitivity, 99.8% specificity). CONCLUSIONS: An IGCNBB that demonstrates atypical hyperplasia or carcinoma in situ requires WLEBB to define the extent of breast pathology. Mammographic surveillance for a patient with a benign IGCNBB is supported by nearly 100% specificity. An IGCNBB diagnosis of invasive carcinoma is also associated with nearly 100% specificity; therefore, these patients can have definitive surgical therapy, including axillary dissection or mastectomy, without waiting for the pathologic results of a WLEBB. Based on the authors' findings, IGCNBB can safely replace WLEBB in evaluating patients with nonpalpable breast abnormalities.

A core breast biopsy diagnosis of invasive carcinoma allows for definitive surgical treatment planning.

BACKGROUND: We reviewed our image-guided core needle breast biopsy (IGCNBB) experience with patients diagnosed with invasive carcinoma (IC) to determine the accuracy of a core biopsy diagnosis of invasion and our ability to perform a single definitive cancer operation. METHODS: All IGCNBBs between July 1993 and July 1997 were reviewed to identify patients diagnosed with IC. Data included initial surgical treatment, surgical pathology, and subsequent surgical treatment. RESULTS: Of the 1,676 biopsies, invasive carcinoma was diagnosed in 208 with follow-up in 204 cases. Invasive carcinoma diagnosis was confirmed in 202 of 204 cases (99%). One hundred ninety-two patients had surgical treatment. Of these 192 patients, 173 (90%) could have achieved definitive surgical treatment with a single operation. CONCLUSIONS: An IGCNBB diagnosis of IC is accurate and allows for definitive breast cancer therapy. The potential impact on patient management is that a single operation can usually accomplish what traditionally has required at least two surgical procedures.