Ductal carcinoma in situ diagnosed with stereotactic core needle biopsy: can invasion be predicted?

PURPOSE: To determine whether mammographic or histologic features can be used to predict which cases diagnosed as ductal carcinoma in situ (DCIS) without invasion by means of stereotactic core needle biopsy (SCNB) will have invasive disease at surgery. MATERIALS AND METHODS: From July 1992 to March 1999, DCIS without invasion was diagnosed by means of SCNB in 59 patients. Seventeen (29%) were found to have invasive disease after surgery. The underestimation rate for SCNB was compared with that obtained by means of open surgical biopsy. Mammographic and histologic features of cases with and those without invasion were compared. RESULTS: All patients had calcifications on mammograms. There was no significant difference (P: =.26) between the underestimation rate for SCNB with the 11-gauge vacuum-assisted device and that for open surgical biopsy. No statistically significant differences between cases with and those without invasion were seen in patient age, mean number of core specimens, level of suspicion, size of lesion, distribution and morphology of the calcifications, presence of an associated mass or density, subtype of DCIS, nuclear grade, or presence of necrosis or desmoplasia. CONCLUSION: Mammographic and histologic features cannot be used reliably to predict cases that are underestimated with SCNB. However, SCNB with the 11-gauge vacuum-assisted device was as reliable as open surgical biopsy for diagnosing DCIS without invasion.

Underestimation of breast cancer with II-gauge vacuum suction biopsy.

OBJECTIVE: The purpose of this study was to determine the mammographic and histologic features of cancerous lesions underestimated using 11-gauge vacuum suction biopsy. MATERIALS AND METHODS: Retrospective review of 11-gauge vacuum suction biopsy was performed to identify lesions diagnosed as atypical ductal hyperplasia or carcinoma. The histology of the core and surgical specimens was compared. Of 158 cases of cancer, underestimation occurred in 15 (9.5%). The mammographic and histologic features were assessed. RESULTS: Of 15 underestimated cases, six were atypical ductal hyperplasia that proved to be cancer (5 ductal carcinoma in situ and 1 invasive) and nine were ductal carcinoma in situ that proved to have invasion. The underestimation rate for calcifications was 16.3% (14/86) and for masses was 1.6% (1/64) (p = 0.007). Most (5/6) underestimated atypical ductal hyperplasia cases were reported as "markedly atypical," and four of nine underestimated ductal carcinoma in situ cases were reported as "possible invasion." No significant difference was seen in the number of core specimens obtained or the sizes of the lesions for underestimated cases versus accurately diagnosed cases. The percentage of calcifications retrieved was significantly different (p = 0.017). No underestimations were found among cases in which the entire mammographic lesion was removed at vacuum suction biopsy. CONCLUSION: The cancer underestimation rate with vacuum suction biopsy was 9.5%. The underestimation rate for calcifications (16.3%) was significantly higher than that for masses (1.6%) (p = 0.007). The percentage of the lesion removed was an important factor in reducing underestimation, as reflected by the percentage of calcifications retrieved and the instances of complete resolution of the lesion seen on mammography.

Uncommon high-risk lesions of the breast diagnosed at stereotactic core-needle biopsy: clinical importance.

PURPOSE: To assess the outcome of papillary lesions, radial scars, or lobular carcinoma in situ (LCIS) diagnosed at stereotactic core-needle biopsy (SCNB). MATERIALS AND METHODS: Retrospective review of 1,236 lesions sampled with SCNB yielded 22 papillary lesions, nine radial scars, and five LCIS lesions. Diffuse lesions such as papillomatosis, papillary ductal hyperplasia, papillary ductal carcinoma in situ (DCIS), and atypical lobular hyperplasia were not included. The mammographic findings, associated histologic features, and outcome were assessed for each case. RESULTS: Sixteen papillary lesions were diagnosed as benign at SCNB. Of these, five were benign at excision, and 10 were unremarkable at mammographic follow-up. At excision of an unusual lesion containing a microscopic papillary lesion, DCIS was found. Three of four papillary lesions suspicious at SCNB proved to be papillary carcinomas; the fourth had no residual carcinoma at excision. Eight of nine radial scars were excised, which revealed atypical hyperplasia in four scars but no malignancies. One LCIS lesion was found at excision to contain DCIS. CONCLUSION: Benign or malignant papillary lesions were accurately diagnosed with SCNB in the majority of cases. Cases diagnosed as suspicious for malignancy or with atypia or unusual associated histologic findings should be excised. No malignancies were found at excision of radial scars diagnosed at SCNB. Surgical removal of these lesions following SCNB may not be routinely necessary. DCIS was found in one lesion diagnosed as LCIS at SCNB, which suggests that removal of these lesions may be prudent.

Follow-up of breast lesions diagnosed as benign with stereotactic core-needle biopsy: frequency of mammographic change and false-negative rate.

PURPOSE: To determine how often lesions diagnosed as benign with stereotactic core-needle biopsy (SCNB) change at follow-up mammography and to determine the optimal follow-up strategy and the delayed false-negative rate. MATERIALS AND METHODS: From July 1992 through December 1995, 355 of 540 cases (66%) in which SCNB yielded benign results were managed with follow-up mammography. Mammographic follow-up was available for 298 of these cases (84%). Follow-up mammography reports were reviewed. When a change was reported, pre- and postbiopsy mammograms, pathology reports, and results of subsequent mammographic follow-up were reviewed. RESULTS: Mammographic change occurred in 21 of 298 cases (7%) at intervals of 6-55 months (mean, 20 months). Change occurred after initial mammographic stability in 10 of 21 cases. Repeat biopsy was performed in 18 of 21 cases. Malignancy was diagnosed in two cases: one mass that changed at 6 months and one case of microcalcifications that changed at 24 months. This represented a delayed false-negative rate of 2% (two of 105 malignancies among 540 biopsies). CONCLUSION: A small percentage of cases diagnosed as benign with SCNB will change on follow-up mammograms, which may necessitate repeat biopsy. These results suggest that 6-month follow-up for cases that yield nonspecific benign results at SCNB and yearly screening mammography for cases with specific benign results is a reasonable management strategy.

Comparison of rebiopsy rates after stereotactic core needle biopsy of the breast with 11-gauge vacuum suction probe versus 14-gauge needle and automatic gun.

OBJECTIVE: The 11-gauge vacuum suction probe is an alternative to the 14-gauge needle and automatic gun for performing stereotactic core needle biopsies. This study compares rebiopsy rates after stereotactic core needle biopsies that were performed with the two methods. The study also assesses the outcomes of those repeat biopsies. MATERIALS AND METHODS: Five hundred ninety-two stereotactic core needle biopsies using a 14-gauge needle and automatic gun and 354 using an 11-gauge vacuum suction probe were performed consecutively. Excluding malignancies, the number of cases requiring rebiopsy and the reasons for rebiopsy were determined for each group. The histologic diagnoses of the repeat biopsies were assessed. RESULTS: The rebiopsy rate was significantly lower with the 11-gauge vacuum suction probe (9.0%) than with the 14-gauge needle and automatic gun (14.9%) (p = .013). Significant reductions were found in cases of insufficient sampling (probe, 1.7%; needle, 4.4%; p = .042) and mammographic-pathologic discrepancy (probe, 0.8%; needle, 3.4%; p = .026). The rebiopsy rate for masses was 6.1% with the vacuum probe versus 10.7% with the 14-gauge needle (p = .12) and for calcifications was 11.6% with the vacuum probe versus 23.7% with the 14-gauge needle (p = .003). After rebiopsy, the percentage of cases in which malignancy was found was 18.5% with the vacuum probe versus 13.7% with the 14-gauge needle. On rebiopsy, the percentage of malignancies found in each category were atypical hyperplasia: probe 26.7%, needle 20.0%; insufficient sample: probe 0%, needle 9.5%; pathologist recommendation: probe 50.0%, needle 12.5%; and lobular carcinoma in situ: probe 0%, needle 100%. CONCLUSION: Use of the 11-gauge vacuum-assisted device significantly decreases but does not eliminate the need for rebiopsy after stereotactic core needle biopsy. The rebiopsy rate for calcifications was significantly reduced by using the vacuum suction probe rather than the 14-gauge needle; however, the rate for masses was reduced only slightly. On rebiopsy, malignancies were found in both groups.

Prognostic significance of mammographic detection in a cohort of conservatively treated breast cancer patients.

PURPOSE: This study aimed to evaluate the prognostic significance of nonpalpable mammographically detected breast cancer in a cohort of conservatively treated breast cancer patients. METHODS AND MATERIALS: The records of 953 patients with invasive stage I and II breast cancer treated with conservative surgery and radiation therapy prior to January 1990 were reviewed. Mode of presentation with reference to clinical and mammographic findings was recorded. For statistical analysis, patients were divided into two groups: 748 patients presented with clinically palpable masses with or without mammographic abnormalities (PALP), and 205 presented with nonpalpable mammographically detected tumors (MGDET). RESULTS: Patients in the MGDET group presented with cancers at earlier stages of disease, had tumors of smaller pathological size, were more often hormone-receptor positive, and less frequently required adjuvant systemic therapy. As of December 1995, with a median follow-up of 11.6 years, the MGDET group had a higher 10-year overall survival rate (82% vs 68%) and a superior 10-year distant-metastasis-free rate (87% vs 75%). The ipsilateral breast tumor relapse rate was similar between the PALP and MGDET groups. When broken down by age (< 50 years vs > or = 50 years), the benefits of early detection remained apparent with a statistically significant superior distant-metastasis-free rate in women under age 50 in the MGDET group compared with women under age 50 in the PALP group. In a multivariate analysis, mammographic detection remained an independent prognostic factor for distant-metastasis-free survival. CONCLUSION: Patients presenting with nonpalpable mammographically detected invasive breast cancer have a favorable prognosis compared with their counterparts presenting with clinically palpable masses. Although the issue of lead-time bias cannot be addressed adequately in this retrospective review, the favorable prognosis with respect to disease-free survival and breast conservation is quite evident. The high probability of disease-free survival and breast preservation in these patients should further encourage the widespread using of screening mammography and the increased use of breast-conserving surgery with radiation therapy.

Canceled stereotactic core-needle biopsy of the breast: analysis of 89 cases.

PURPOSE: To determine reasons for cancellation of stereotactic core-needle breast biopsy and outcome in canceled cases. MATERIALS AND METHODS: Among 572 scheduled stereotactic core-needle biopsies, 89 cases (16%) in 88 patients were canceled. In canceled cases, mammogram origin, mammographic abnormality, reason for cancellation, and outcome were determined. RESULTS: In canceled cases, 50 (57%) of 88 patients were referred from another facility. Mammographic abnormality in most cases (72 [81%] of 89 canceled biopsies) was a mass(es); calcifications occurred in 14 cases (16%). Reasons for cancellation included (a) lesion was not recognized (26 cases [29%]), (b) lesion was reassessed as benign (17 cases [19%]), (c) cysts were diagnosed with ultrasound (US) (12 cases [13%]) or aspiration (11 cases [12%]), (d) lesion location was suboptimal (12 cases [13%]), (e) patient was intolerant of procedure (seven cases [8%]), and (f) other (four cases [4%]). Numbers of canceled biopsies from another facility and those from the authors' institution differed in cases in which lesions were reassessed as benign (12 and five cases, respectively) or cysts were diagnosed with US (10 and two cases, respectively). Lesions that could not be targeted included many pseudolesions and three cancers. CONCLUSION: Complete work-up, including US examination, of breast lesions is necessary before stereotactic core-needle biopsy is scheduled. Inability to recognize a suspected lesion on stereotactic images should not preclude biopsy with another method.

Pancreatic schwannoma: report of two cases and review of the literature.

Solitary intrapancreatic schwannoma is a rare tumor. We present two patients with this tumor and review 13 previously reported cases from the English-language literature. While the final diagnosis was made based on pathological examination of the tumors, both computed tomography scan and magnetic resonance imaging helped establish the benign nature of the lesion, narrow the differential diagnosis, and define the anatomical locations of the small tumors. Both tumors were treated by enucleation from the surrounding pancreatic parenchyma, and both patients, after 2 years of follow-up, are alive and well. It is concluded that multimodality radiologic investigations are useful in the workup of unusual pancreatic masses. In addition, based on the known biologic behavior of schwannomas occurring elsewhere in the body, simple enucleation, rather than more radical resection, is likely to be adequate therapy for these tumors.

Clinical importance of unilaterally enlarging lymph nodes on otherwise normal mammograms.

PURPOSE: To determine the clinical importance of unilateral enlargement of axillary or intramammary lymph nodes on otherwise normal mammograms. MATERIALS AND METHODS: Twenty-four patients (aged 33-76 years) with unilaterally enlarging lymph nodes on otherwise normal mammograms were identified in a review of mammographic reports from 1991 to 1995. Mammograms, medical history, follow-up findings, and biopsy results were reviewed. RESULTS: The initial nodal size was 3-17 mm. The size increased by 20%-312%. Seven patients had a history of malignancy. Six patients had a clinical history suggestive of a benign cause of nodal enlargement. Seven patients underwent biopsy. Two patients had results positive for malignancy (one, melanoma; one, lymphoma). Both patients had a known history of malignancy and a size increase of greater than 100%. In 17 patients, mammographic follow-up findings at 6-58 months (mean, 26 months) showed decreased nodal size in 13 and no change in four patients. CONCLUSION: Enlarging lymph nodes on otherwise normal mammograms are usually benign. Clinical history can reveal possible causes of nodal enlargement. If the patient has no history of malignancy, the amount of nodal size increase is small, and the node maintains a benign appearance, mammographic follow-up is a reasonable alternative to biopsy.

Cost-effectiveness of stereotactic core needle biopsy: analysis by means of mammographic findings.

PURPOSE: To determine the cost savings of stereotactic core needle biopsy over open surgical biopsy in patient subgroups defined according to mammographic findings. MATERIALS AND METHODS: From July 1992 through February 1995, stereotactic core needle biopsy was performed in 356 women with 405 nonpalpable breast lesions (254 were masses and 151 were calcification). Lesions were classified according to mammographic finding, size, and level of suspicion. Two hundred three lesions were classified as indeterminate, 166 as suspicious, and 36 as highly suspicious. Medicare reimbursements for 1995 were used to determine costs and cost savings. RESULTS: Overall cost savings for stereotactic core biopsy over open surgical biopsy was $741 per case. Average cost savings per case was $807 for masses and $630 for calcifications. The greatest savings occurred in the cases of indeterminate masses, with an average of $856 saved per case. The least savings occurred in the cases of highly suspicious calcifications, with $446 saved per case. CONCLUSION: Cost savings of stereotactic core needle biopsy vary in subgroups of patients defined according to mammographic findings. Over-all savings will depend on the distribution of patients among these groups. In this series, cost savings were realized with stereotactic core biopsy over open surgical biopsy for all mammographic subgroups.

Mammographic findings of recurrent breast cancer after lumpectomy and radiation therapy: comparison with the primary tumor.

PURPOSE: To compare the mammographic findings of recurrent breast cancer with those of the primary tumor in patients who underwent lumpectomy and radiation therapy. MATERIALS AND METHODS: Mammograms were reviewed of primary and recurrent tumors in 25 patients (26 lesions). Mammographic appearance, location, and histopathologic characteristics were retrospectively compared between primary and recurrent tumors. RESULTS: Primary and recurrent tumors were mammographically similar in 21 (81%) of the 26 lesions. Of 14 primary tumors with calcifications, 12 (86%) recurred with calcifications, and of the 12 masses, nine (75%) recurred as masses. Recurrent tumors that occurred in the lumpectomy quadrant were more often similar in mammographic appearance to the primary tumor (20 of 22 tumors) than those in other quadrants (one of four tumors) (P < .02). CONCLUSION: After conservative treatment of breast cancer, the majority of recurrent tumors appear to be mammographically similar to primary tumors. It is prudent to review preoperative mammograms during follow-up of patients after lumpectomy and radiation therapy.

Optical breast lesion localization fiber: preclinical testing of a new device.

Preclinical testing was performed of an optical breast lesion localization fiber to guide surgical excision. The prototype device comprised dual 0.010- inch (0.254-mm)-diameter hooks attached to the tip of a 1,000-microns (0.03937-inch)-diameter optical fiber, which allowed retention in soft tissue after passage through a 17-gauge extra-thin-wall needle. The proximal end of the optical fiber was attached to a 15-mW, 635-nm diode laser, with a thumbscrew connector. The tip of the optical fiber was visible through several centimeters of breast tissue in two human mastectomy specimens, which facilitated determination of the location of the hooks. The optical localization fiber may allow lesions to be approached at surgery by many different paths. Clinical tests are indicated to further evaluate this device.

Stereotaxic core needle biopsy of breast microcalcifications: correlation of target accuracy and diagnosis with lesion size.

PURPOSE: To determine if lesion size or number of calcifications affects the ability to obtain microcalcifications or a specific histologic diagnosis at stereotaxic core needle biopsy (SCNB). MATERIALS AND METHODS: Mammographic findings and histopathologic reports of 138 lesions in 124 patients (aged 30-87 years; mean age, 56.2 years) who underwent SCNB of calcifications were reviewed. Calcifications in the specimen and attainment of a specific diagnosis were correlated with lesion size and number of calcifications. RESULTS: Calcifications were obtained in 118 cases (86%). A specific diagnosis was reported in 72 cases (52%). Differences in retrieval of calcifications or ability to establish a specific diagnosis with decreasing lesion size or decreasing number of calcifications were not statistically significant. Attainment of a specific diagnosis was significantly related to retrieval of calcifications (P<.005). CONCLUSION: SCNB was successful in obtaining calcifications in a high percentage of cases regardless of lesion size or number of calcifications. When calcifications were retrieved, a specific diagnosis was attained in most cases (72 of 118).

Colitis: use of CT findings in differential diagnosis.

PURPOSE: To determine whether colitides can be differentiated based on computed tomographic (CT) features. MATERIALS AND METHODS: The CT scans of 117 patients with documented colitis and colon wall thickening were reviewed. Features evaluated included mural thickness and homogeneity, distribution of bowel involvement, and associated mesenteric and small bowel disease. RESULTS: The mean colon wall thickness in Crohn colitis (11.0 mm +/- 5.1) was significantly greater than in ulcerative colitis (7.8 mm +/- 1.9) (P < .002). Submucosal fat deposition, not observed in the acute colitides, was present significantly more often in ulcerative (61%) than in Crohn colitis (8%) (P = .0001). Exclusive involvement of the right colon and small bowel was most frequent with Crohn and infectious colitis. Abscess was associated almost exclusively with Crohn colitis (35%) but was seen in one patient with radiation colitis. CONCLUSION: Although many CT findings in patients with colitis are nonspecific, some features are helpful in suggesting a specific diagnosis.