Percutaneous imaging-guided core breast biopsy: 5 years' experience in a community hospital.

OBJECTIVE: This study reports the results of a percutaneous imaging-guided core breast biopsy program in a community hospital. MATERIALS AND METHODS: We reviewed the prospectively collected results of our imaging-guided core biopsy program during its first 5 years (1994-1998). A total of 1333 lesions (94% of which were Breast Imaging Reporting and Data System (BI-RADS) assessment category 4) were sampled in 1183 patients. Patients with BI-RADS assessment category 5 lesions were referred to surgeons. Stereotactic guidance was used for the core biopsy of 506 lesions, and sonography was used to guide the predominantly 16-gauge needle core biopsy of 827 solid masses. RESULTS: One hundred forty-seven cancers were diagnosed in 1333 biopsies, resulting in a positive yield of 11%. Of 1020 patients with benign, concordant core biopsy results, 981 (96%) had at least one follow-up imaging examination within 36 months of the biopsy. Nineteen (2%) of these 1020 patients had a suspicious change at follow-up; 18 of these patients underwent surgical excision with benign findings. No cancers were found at imaging follow-up or by tumor registry linkage. All malignant core biopsy results were confirmed as malignant at surgical excision (positive predictive value 100%). Twenty-two patients with atypical ductal hyperplasia at core biopsy had subsequent surgery, and 12 (55%) of them were found to have cancer at surgery. CONCLUSION: An imaging-guided core biopsy program, developed and implemented by a small group of radiologists in a community hospital, can achieve successful results and provide an important service to patients and a cost-effective alternative to surgical biopsy. Our program emphasized sonographic guidance and achieved high follow-up compliance.

Stereotactic core-needle breast biopsy: a multi-institutional prospective trial.

PURPOSE: To assess the accuracy of stereotactic core-needle biopsy (CNB) of nonpalpable breast lesions within the context of clinically important parameters of anticipated tissue-sampling error and concordance with mammographic findings. MATERIALS AND METHODS: CNB was performed in 1,003 patients, with results validated at surgery or clinical and mammographic follow-up. Mammographic findings were scored according to the American College of Radiology Breast Imaging Reporting and Data System with a similar correlative scale for histopathologic samples obtained at either CNB or surgery. Agreement of CNB findings with surgical findings or evidence of no change during clinical and mammographic follow-up (median, 24 months) for benign lesions was used to determine results. Three forms of diagnostic discrimination measures (strict, working [strict conditioned by tissue sampling error], applied [working conditioned by concordance of imaging and CNB findings) were used to evaluate the correlation of CNB, surgical, and follow-up results. RESULTS: Strict, working, and applied sensitivities were 91% +/- 1.9; 92% +/- 1.8, and 98% +/- 0.9, respectively; strict, working, and applied specificities were 100%, 98% +/- 0.8, and 73% +/- 0.9; strict, working, and applied accuracies were 97%, 96%, and 79%. CONCLUSION: Percutaneous stereotactic CNB is an accurate method to establish a histopathologic diagnosis of nonpalpable breast lesions. Accuracy increases when additional surgery is performed for lesions with anticipated sampling error or when CNB findings are discordant with mammographic findings. An understanding of the interrelationship among these parameters is necessary to properly assess results.

Mammographic changes after hormone replacement therapy in patients who have undergone breast irradiation.

OBJECTIVE: We examined three patients who began hormone replacement therapy after lumpectomy and breast irradiation. In these women increased tissue density appeared on mammography only or disproportionately in the nonirradiated breast. To our knowledge, this observation has not been reported. CONCLUSION: Breast irradiation may induce tissue changes that prevent or diminish the proliferative response that can be induced in breast tissue by postmenopausal hormone replacement therapy. Because this treatment is now recommended for some women after breast conservation therapy, mammographers may recognize this finding with increasing frequency.

Percutaneous core biopsy of the breast: effect of operator experience and number of samples on diagnostic accuracy.

OBJECTIVE: The purpose of our study was to assess the degree of operator experience and the number of core biopsy samples required to achieve an accurate histologic diagnosis for each of five common mammographically defined lesions, using percutaneous core breast biopsy performed on a dedicated prone biopsy table. SUBJECTS AND METHODS: A prospective multisite study was performed that involved nine institutions (academic and private) with experienced breast radiologists and the use of dedicated prone biopsy table units with digital assistance and standardized protocol. Asymptomatic women evaluated during a 2-year study period were assigned a mammographic diagnosis reported in a manner prescribed by the American College of Radiology Breast Imaging Reporting and Data System lexicon. Mammographic lesions evaluated included masses, masses with calcifications, clustered calcifications, focal asymmetries, and architectural distortions. Where histologic diagnosis was indicated, core biopsy was performed with five individual samples obtained and sequentially analyzed. Two hundred thirty patients had immediate excisional biopsy, the results of which provided the basis for a statistical analysis to compare the accuracy of each sequential core biopsy sample with surgical results. Statistical analysis was also done to ascertain the accuracy of core biopsy diagnosis as a function of operator experience. RESULTS: Trends toward increasing accuracy were observed by increasing the number of core biopsies for each of five types of mammographically defined lesions, especially for clustered calcifications. Statistically significant increased accuracy was observed when the number of biopsies was increased beyond one (p = .003). Trends toward increased accuracy with more experience were observed for all lesions, especially for calcifications. Of the 230 lesions studied with immediate surgical validation, more than 80% of all lesions except clustered calcifications (75%) were diagnosed on the basis of two core biopsies; accuracy after five biopsies was 98% for masses, 91% for calcifications, 100% for masses with calcification, 100% for focal asymmetries, and 86% for architectural distortions. CONCLUSIONS: Accuracy of diagnosis based on the results of percutaneous core breast biopsy improved with an increase in the number of core biopsy samples obtained for any given lesion seen on mammograms and with increased experience in performing the procedure. Five samples yielded an overall diagnostic accuracy of 97%. Familiarity with expected accuracy from this procedure for different mammographic lesions and following increased experience may assist physicians in planning patient management.

Ductal carcinoma in situ: the mammographer's perspective.

Ductal carcinoma in situ represents a heterogeneous group of lesions now most commonly discovered by mammography. The biological behavior of ductal carcinoma in situ ranges from indolent, essentially benign lesions to obligate precursors of invasive carcinoma. This article reviews the natural history of this disorder, its mammographic and pathologic features, and current considerations in patient management, including the role of mammography. The results of recent clinical trials are summarized.

Needle localization guided excisional biopsy for mammographically identified nonpalpable breast lesions.

The capability of high-quality mammography to discover early, preclinical breast cancer has demanded the development of a new relationship between radiologists, surgeons, and pathologists. It is only through mutual understanding and appreciation of the technical requirements and interpretive difficulties involved in the successful identification, preoperative localization, and excision of these lesions that the full benefits of this method of early cancer detection can be brought to all of our patients.

Impact of mammographic screening on the size and the relative frequency of invasion in breast cancers seen in a community hospital from 1975-1988.

At CPMC routine mammographic screening was introduced in late 1975. The total volume of breast cancers, other than outside consultations, seen in the department increased from 71 in 1975 to 164 by 1988, an increase of 230%. This expansion in volume was due largely to surgical removal of mammographically detected occult, in situ duct and relatively small invasive duct carcinomas. In 1974, prior to routine mammographic screening, in situ carcinomas represented only 4% of all breast cancers seen in the Department of Pathology at CPMC. However, after the introduction of mammographic screening, the proportion of in situ cancers increased steadily. By 1988, 45% of all breast cancers seen in our hospital were found by mammography. While data on the size distribution of invasive breast cancers are not available at our hospital prior to 1976, an appreciable effect of mammography is still evident when the numbers of relatively small invasive cancers detected in 1976 are compared with those detected in 1988. Invasive breast cancers 10 mm in diameter or less represented only 6% of all cancers in our series in 1976, but 33% in 1988. These findings confirm observations made by Gibbs on the pathology of breast cancers found in mammographically screened and unscreened populations. The detection of increasing numbers of relatively small invasive duct carcinomas produced an overall reduction in the average diameters of invasive cancers seen at CPMC. The average dropped from 30 mm in 1975 to a low of 14.8 mm in 1987. Mammography did not appear to be effective in the early detection of invasive lobular cancers and had no impact on reducing their size. The implications of early discovery of in situ duct and relatively small invasive duct carcinomas are for improved patient survival through: (1) preventing progression of in situ duct to invasive duct cancers, and (2) the removal of invasive duct cancers before reaching a size where there is a high risk of metastasis.

Detecting early breast cancer. Experience in a community hospital.

The successful development and implementation of a mammography program at one community hospital is described. A substantial reduction in the size of breast mammography to change the diagnosis and treatment of breast cancer in one community hospital. As the vast majority of American women receive their medical care in community facilities, the more widespread development and implementation of community hospital-based mammography programs for early breast cancer detection has the potential to significantly improve survival rates for patients in whom these early lesions are found. Substantial improvement in the rate of early breast cancer detection can be achieved by community radiologists whether in private hospital or office-based practices.

Mammographically detected duct carcinoma in situ. Frequency of local recurrence following tylectomy and prognostic effect of nuclear grade on local recurrence.

Seventy-nine patients with mammographically detected foci of duct carcinoma in situ (DCIS) of histologically confirmed extents of 25 mm or less, were treated by tylectomy without irradiation or axillary dissection. Adequacy of excision was confirmed histologically, by radiographic-pathologic correlation and by postoperative mammographic examination. Eight patients (10.1%) have recurred locally in the immediate vicinity of the biopsy site. Four patients developed recurrent in situ disease identified mammographically, and all were initially treated by reexcision. One of these patients subsequently elected to undergo mastectomy; no residual in situ or invasive disease was detected in the breast or in axillary lymph nodes. Four patients developed recurrent invasive disease; 50% of these recurrences were detected mammographically. All patients were treated by mastectomy with node dissection. Three had confirmed minimal invasive carcinomas and were N0, one patient had a 13-mm invasive lobular carcinoma with a single Group I micrometastasis. All patients, including those treated for a recurrence, are presently free of disease but three patients died of heart disease. Nuclear grade would appear to identify subsets of DCIS more likely to produce local failure after tylectomy alone. Duct carcinoma in situ with high-grade nuclear morphology and comedo-type necrosis was associated with a 19% local recurrence rate after an average interval of 26 months; only one of ten patients with intermediate-grade DCIS developed a local recurrence at 87 months; and none of 33 patients with DCIS of micropapillary/nonnecrotic cribriform type and low-grade nuclear morphology developed local recurrence in the follow-up period.

Development of mammography and breast services in a community hospital.

The growth and development of mammography and related breast services in one community hospital are chronicled and described. With mammography providing the initial stimulus, substantial growth, diversification, and sophistication in diagnosis and treatment of breast disease have developed. The achievement of a cooperative and mutually supportive relationship among radiologists, pathologists, and surgeons committed to the goal of early detection of potentially curable breast cancer has succeeded in identifying increasing numbers of such lesions. The more frequent employment of breast-sparing surgical procedures and the encouraging survival rates in patients detected and treated for these early lesions represents an important contribution to the care of these women. Improvement in the detection of early breast cancer can be achieved by community radiologists, whether in private hospitals or office-based practices.

Mammographic detection of early breast cancer. Ten years' experience in a community hospital.

Mammography is currently the most effective method for detecting early breast cancer. In one community hospital during the decade 1974 through 1983, 35% of 415 cases of breast cancer were discovered by xeromammography alone, with a false-positive interpretation rate of 65% and a false-negative rate of 11.1%. Mammography was responsible for detecting an increasing number of smaller cancers with fewer axillary metastases. Such lesions have the most favourable five- and ten-year survival rates. Much lower detection rates of preclinical breast cancer have been reported from other community hospitals.

Computed tomography of posterior lumbar apophyseal ring fractures.

Lumbar apophyseal fracture is an uncommon injury that occurs during adolescence. We described two cases in young adults with back pain. The radiographic findings were distinctive. In both cases CT demonstrated characteristic bony fragments displaced posteriorly into the spinal canal and a corresponding defect in the posteroinferior aspect of the vertebral body rim. Recognition of this entity is important in evaluating back pain in both adolescents and adults.

Duct carcinoma in situ. Relationship of extent of noninvasive disease to the frequency of occult invasion, multicentricity, lymph node metastases, and short-term treatment failures.

Fifty-three breasts resected for a biopsy diagnosis of duct carcinoma in situ were studied with a serial subgross and correlated radiographic method of examination designed to permit quantitation of the extent of the noninvasive lesion in the breast. Overall frequencies of occult invasion and multicentricity were 21 and 32%, respectively. Among 24 lesions 25 mm or larger in extent (average, 63; median, 56 mm) 11 showed occult foci of invasion, 13 had multicentric foci and six had nipple involvement. Among 29 lesions less than 25 mm in extent (average, 10; median, 8 mm) there were no instances of occult invasion, four were multicentric and two had nipple involvement (P = less than 0.05 for multicentricity and occult invasion). Twenty patients with lesions averaging 8 mm in extent are being followed after excision only in an experimental program. There have been three local recurrences at an average follow-up of 44 months. All recurrences occurred ipsilaterally, two were within the prior biopsy site. All patients with recurrence are free of disease following local resection in two and modified radical mastectomy in one. For lesions with associated microcalcifications, the distribution of the mammographic microcalcifications closely approximates the extent of disease as confirmed histologically. These findings suggest that an important predictive factor for the presence of occult invasion and multicentricity in the resected breast is the extent of the noninvasive lesion.

Role of computed tomography in patients with "sciatica".

The computed tomography (CT) findings in 10 patients who presented with lumbosacral radicular symptoms are reported. The CT scans were performed after the more commonly used radiologic studies, including plain films and myelography, had failed to completely define the nature or extent of the underlying disease process. The final diagnoses were metastatic neoplasm to the spine and soft tissue in six cases, primary neoplasm of the sacrum or soft tissue in three cases, and tuberculous osteomyelitis and abscess in one case. The limitations and potential complications of the various radiologic examinations are discussed, and the potential value of CT in selected patients with lumbosacral neuropathy is presented.

Polypoid lipomatosis of the small bowel.

An unusual case of multiple polypoid, benign lipomatous tumors in the ileum of a 53-year-old female with vague gastrointestinal symptoms is described. The pertinent literature is reviewed, and a technique which could have allowed definitive preoperative diagnosis is suggested.

Tubular carcinoma of the breast: association with multicentricity, bilaterality, and family history of mammary carcinoma.

Seventeen tubular carcinomas occurred among 211 consecutive mastectomies (7.6%). The relative frequencies of multicentric involvement in the ipsilateral breast (56%), history of bilateral mammary cancer (38%) (P less than .01), and family history of mammary cancer in a first-degree relative (40%) (P less than .05) were all significantly greater in patients with tubular carcinomas than among patients with other carcinomas studied in a review of serial subgross examined mastectomy specimens. Patients with tubular carcinomas also tended to be somewhat younger (56 vs. 59 years) than those with other forms of mammary cancer. These features suggest that tubular carcinoma may be a histologic marker for a subpopulation of patients with mammary carcinomas strongly associated with multicentricity, bilaterality, and familial history of mammary carcinoma.

Pneumonia of atypical measles.

Infection with rubeola virus after previous immunization with killed measles virus vaccine produced abnormal chest radiographs in 9 patients. Variable pneumonic consolidation occurred in all cases and was mainly lobar or segmental in distribution. Four patients had hilar adenopathy, 3 pleural effusion, and in 1 instance a pulmonary nodule remained 9 months after clearing of the acute pneumonia. Atypical measles pneumonia is a presumed hypersensitivity response in incompletely immunized patients.

Benign, solitary schwannomas of the lesser peritoneal sac.

Two cases of a large schwannoma of the lesser omental sac are described. One arose from the lesser omentum itself. This schwannoma also had roentgenographically visible calcifications, a finding never before reported to have been seen in the abdomen. Emphasis is upon the uniqueness of the site of the tumor.