Diagnostic and therapeutic aspects of fine-wire localization biopsy for impalpable breast cancer.

During the first 2 years (July 1989 to July 1991) of the Avon Breast Screening Service, fine-wire localization biopsy was indicated in 213 impalpable breast lesions. A total of 144 lesions were benign and 69 malignant. Only four of 213 lesions (1.9 per cent) were not excised at the first localization. Factors influencing reoperation in the 69 patients with malignant impalpable lesions were examined. There was a significant association (P < 0.001) between parenchymal disturbances on mammography and invasive carcinoma, and between non-invasive carcinoma and microcalcification (P < 0.001). In 31 patients the localization biopsy was the only surgical procedure. Thirty-eight patients required further surgery: 12 underwent further local excision and 26 mastectomy. Reoperation was more frequent in patients with calcification than in those with parenchymal disturbance (P < 0.001). The most frequent indications for mastectomy were inadequate excision of widespread comedo ductal carcinoma in situ or invasive ductal carcinoma combined with extensive ductal carcinoma in situ. Fine-wire localization biopsy was a combined therapeutic and diagnostic procedure in 31 of 69 women with impalpable screen-detected lesions. The majority of patients required further surgery because radiological abnormalities underestimated the extent of disease.     

Effectiveness of Breast-Specific Gamma Imaging (BSGI) for Breast Cancer in Korea: A Comparative Study

Abstract: Despite the fact that mammography has been the golden standard in breast cancer detection for several decades, its sensitivity decreases for women with dense breast tissue, which happens to be common in Korea. As an alternative, breast ultrasonography can be effective diagnostic modalities that complement the defect of mammography. Recently, breast‐specific gamma imaging (BSGI) has been introduced as a new diagnostic modality for breast cancer. This study was designed to analyze the effectiveness of BSGI in particular. In a retrospective study, 471 patients underwent BSGI, breast ultrasonography, and mammography simultaneously during the period between February 2009 and March 2010. The indications of BSGI were as follows: (a) patient who was diagnosed with malignancy prior to surgery, (b) patient who is under follow up after cancer surgery, (c) patient with lesions which cannot be evaluated by breast ultrasonography or mammography, (d) patient with multiple benign lesions, and (e) patient with suspicious lesion who refuses biopsy. Among these patients, 121 patients underwent biopsy, whereas others were followed up with imaging studies. We compared the BSGI results with those of mammography, breast ultrasonography, and pathology. The mean age of the patients was 49.63 ± 10.43 years. There were 107 patients with 110 malignant lesions and 364 patients with benign lesions. Total 474 lesions were evaluated. The sensitivities of BSGI, mammography, and breast ultrasonography were 94.45%, 93.64%, and 98.18%, respectively, whereas the specificities of BSGI, mammography, and breast ultrasonography were 90.93%, 90.66%, and 87.09%, respectively. The sensitivity and specificity of BSGI for axillary lymph node (LN) status were 44.7 4% and 87.88%, respectively. BSGI is a good complementary imaging modality with high sensitivity and high specificity for breast cancer detection. However, it has low efficacy for the evaluation for axillary LN status.     

Experience with fine-wire localization breast biopsies for nonpalpable breast lesions detected mammographically

There is evidence to suggest that the early diagnosis and treatment of breast cancer may be associated with a better prognosis. Technical advances such as mammography can detect nonpalpable breast lesions and changes associated with early carcinoma. With fine-wire localization under mammographic control, the surgeon can reliably remove nonpalpable lesions while sparing normal breast tissue. The authors describe the technique for fine-wire localization and removal of lesions and report their experience over 3 years with 262 women who underwent 269 biopsies for nonpalpable lesions. Four subgroups were identified: screened women who had no indication for mammography other than age, women who were referred for mammography by community physicians, a group referred to the Cancer Control Agency of British Columbia and a group referred to the agency for localization biopsy after mammography performed outside the Vancouver area had suggested a malignant lesion. The yield of cancers from biopsies was 10%, 38%, 43% and 26% respectively. The yield was significantly (p less than 0.05) lower for the screened group. Age over 60 years, previous breast cancer and mammographic technique were identified as possible predictors of a positive biopsy. The authors have found fine-wire localization biopsy a safe and reliable method of removing nonpalpable breast lesions.     

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.     

Clinical experience with 99mTc-MIBI scintimammography in patients with breast microcalcifications

The aim of this study was to evaluate whether 99mTc-MIBI scintimammography can improve the diagnostic value of mammography for the differentiation of benign and malignant breast microcalcifications. In 41 women presenting 45 clusters of microcalcifications, a 99mTc-MIBI scintimammography was performed before open biopsy. There were 24 malignant lesions (53%). The sensitivity (SE) and specificity (SP) of 99mTc-MIBI scintimammography were 58.3% and 81%, and the positive and negative predictive values (PPV, NPV) were 78% and 63%, respectively. SE and PPV increased for lesions over 10 mm and for the younger patients (under 50 years). No correlation was found between true positive uptake and breast cancer invasiveness: 69% (9/13) for invasive lesions and 45% (5/11) for noninvasive lesions (P = 0.48). 99mTc-MIBI scintimammography was more often positive in high grade than in low- or intermediate-grade ductal carcinoma in situ (P = 0.03). The results were analysed according to the morphologic aspect of the microcalcifications. 99mTc-MIBI scintimammography could not be used for routine evaluation of all the microcalcifications detected by mammography.     

Nonpalpable breast cancer: needle-localized biopsy for diagnosis and considerations for treatment

Screening mammography as an adjunct to physical examination led to the discovery of 237 radiographically suspicious but nonpalpable breast lesions. Needle localization of the lesion preoperatively in the mammography suite followed by breast biopsy led to the diagnosis of 64 nonpalpable carcinomas, including 25 invasive, 16 minimally invasive, and 23 noninvasive cancers. Noninvasive and minimally invasive cancers were microscopic. Of the invasive lesions, 7 were 10 mm or less in diameter and 14 were 11 to 20 mm in diameter. Noninvasive and minimally invasive cancers tended to occur in younger women (average age 52 and 51 years, respectively), and almost uniformly appeared as clustered calcifications mammographically. Invasive cancers affected an older population (average age 65 years), and the mammographic appearance was that of a mass in the majority of cases. A variety of surgical procedures were carried out subsequent to biopsy to provide definite treatment of these nonpalpable breast cancers. A review of surgical specimens available from these procedures demonstrated a 27 percent incidence of residual disease at the biopsy site. In patients who underwent mastectomy, 34 percent had an unsuspected focus of cancer in another quadrant of the breast and an additional 14 percent had an unsuspected focus of epithelial atypia. No patient with either noninvasive or minimally invasive cancer was found to have axillary lymph node metastases. Twenty-nine percent of patients with invasive tumors demonstrated lymph node metastases in the axilla. Our results demonstrate the efficacy of preoperative needle localization to assist in the biopsy of nonpalpable breast lesions and the diagnosis of a significant number of early breast cancers. The treatment plan for patients with these cancers must address the high incidence of residual disease at the biopsy site, multicentricity, and the proved capacity for invasive lesions to metastasize to the axillary lymph nodes, regardless of the size of the primary tumor.     

Contribution of hook-guided breast biopsy to the pathological diagnosis of mammographic lesions

This study was carried out to evaluate the reliability of a diagnostic approach with close cooperation between radiologists and surgeons for minimal breast disease. From 1993 to 1995, 152 evaluable patients with non palpable breast lesions were examined by mammography and their lesion was localized with a hook wire before being referred to the surgeon for biopsy. Comparison of mammography findings with pathological diagnosis indicated a good predictive value for benign lesions with only 8% non concordant diagnosis and a rather low predictive value in case of suspect mammograms with only 64% positive diagnosis. With hook-guided breast biopsy, a correct diagnosis was established in 93% of the cases. The remaining breast samples were either non contributory or necessitated a second biopsy. Several recommendations are proposed for improving accuracy of breast sampling such as securing the hook into the gland, orienting the limits of resection, sending specimen for X-ray study and inking the margins for the pathologist. This field experience revealed that some progress are to be made in diagnosis in particular by standardization of mammography and pathological criteria, more precise localization of the lesions with the hook and more refined surgical techniques for breast biopsy.     

A comparison of mammography and ultrasound in women with breast disease: a receiver operating characteristic analysis

The purpose of this study was to compare mammography and sonography, as well as their combination, for detecting breast tumors in symptomatic patients. The effects of age and hormonal status were also examined. From 1999 to 2007, 549 patients underwent 665 examination sessions (mammography and ultrasound). Abnormalities were deemed positive if biopsy findings revealed malignancy and negative if findings from biopsy or all screening examinations were negative. On pathology, 246 lesions were malignant and 419 were benign in the 549 patients. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating characteristic curve (AUC) of mammography and sonography were 81.71% and 95.53%, 85.44% and 80.43%, 76.72% and 74.13%, 88.83% and 96.84%, and 0.886 and 0.948, respectively. The sensitivity and diagnostic accuracy among patients <50 years of age were significantly higher for sonography than for mammography (p < 0.05). The sensitivity and diagnostic accuracy among premenopausal or perimenopausal patients were significantly higher for sonography than for mammography (p < 0.05). The sensitivity among postmenopausal patients was significantly higher for sonography than for mammography (p < 0.05). The results of combined mammography and sonography were classified using American College of Radiology Breast Imaging Reporting and Data System (BI-RADS). There were 244 positive and two negative examinations of malignant lesions, and 106 positive and 313 negative examinations of benign lesions. The diagnostic accuracy of the combination was significantly higher than that of mammography (p < 0.05) and similar to that of sonography (p > 0.05). Sonography had better sensitivity and diagnostic accuracy than mammography for diagnosing breast diseases, while their specificities were similar. The diagnostic accuracy of diagnostic sonography was significantly better than that of mammography among patients <50 years of age and premenopausal or perimenopausal patients. The combination of mammography and sonography increased the sensitivity and diagnostic accuracy.     

Triple assessment of breast lump

Objective: To determine the sensitivity, specificity, positive and negative predictive values of triple test (TT) consisting of physical examination (PE), mammography, fine needle aspiration cytology (FNAC) in the evaluation and characterization of palpable breast lump. Secondly, whether this can be employed as an alternative for tru cut/ excisional biopsy. Study Design: Cross-sectional study. Place and Duration of Study: This study was conducted in the department of diagnostic imaging, Shifa International Hospital (SIH), Islamabad in collaboration with departments of surgery and pathology from January 2004 to June 2005. Patients and Methods: It comprised of 35 consecutive females presenting in the breast clinic with palpable lump. Females below 35 years of age were excluded due to low sensitivity of the mammography in depiction of focal breast lesions resulting from glandular parenchyma. Patients with acute inflammatory signs, fungating masses, pregnant ladies as well as those with cystic lesions, as confirmed by ultrasound, were also excluded from the study. Number, size and recurrent masses did not influence the inclusion criterion. Detailed history and physical examination was carried out as per established protocol. It was followed by mammography and FNAC. All cases underwent excisional biopsy irrespective of the results of the triple test. Results: The patients' age ranged from 35 to 75 years with mean age of 45.97. Amongst these, 19 cases were benign (54.28 %) and 16 cases (45.71 %) were malignant. The triple test (TT) was scored as concordant if the elements had either all malignant or all benign results. The triple test was non-concordant if the elements had neither all malignant nor all benign results. The TT was concordant in 19 cases (54.28 %) i.e all the benign cases detected by the triple test were benign on final biopsy (100 % specificity and NPV), all the malignant lesions detected by TT turned out to be malignant on final biopsy (100 % sensitivity and PPV). Triple test was non-concordant in 16 cases (45.71 %). Triple Test was scored as benign or malignant based upon the combined results of two elements amongst three components. Out of these, 11 cases were malignant and 5 were benign. In 4 cases, the components of the triple test were suspicious i.e. BIRAD IV on mammography and slight atypical cells without frank malignancy on FNAC. In current study, suspicious cases were taken as malignant. These turned out to be malignant at the end signifying 100% PPV. However, among the 12 cases where, at least one of the 3 components of TT was benign, FNAC was most accurate (2 False Negative (FN) and 0 False Positive (FP), followed by mammography (2 FN and 3 FP) and physical examination was least accurate with 3 FN and 4 FP. It is of note that in 2 cases where FNAC gave FN results, the other two components were either suspicious or malignant. In those cases where two variables were malignant, FNAC and mammography were most accurate with no false positive or false negative. It was followed by physical examination and FNAC with 1 false negative and no false positive. Conclusion: The study shows that when TT is concordant, final treatment may be ensued without open biopsy. In non-concordant cases, FNAC stands as single most important investigation. However due to its false negative results, other components of triple test need to be employed to enhance its efficacy and diagnostic yield. TT is cost effective, easy to perform and time saving approach, however, it can be applied only in those institutions where excellent imaging facilities as well as services of a cytopathologist are available. Due to small sample size, the results of this study needs further verification by relatively larger scale studies.     

Stereotactic Vacuum‐Assisted Biopsies on a Digital Breast 3D‐Tomosynthesis System

The purpose of this study was to describe our operating process and to report results of 118 stereotactic vacuum‐assisted biopsies performed on a digital breast 3D‐tomosynthesis system. From October 2009 to December 2010, 118 stereotactic vacuum assisted biopsies have been performed on a digital breast 3D‐tomosynthesis system. Informed consent was obtained for all patients. A total of 106 patients had a lesion, six had two lesions. Sixty‐one lesions were clusters of micro‐calcifications, 54 were masses and three were architectural distortions. Patients were in lateral decubitus position to allow shortest skin‐target approach (or sitting). Specific compression paddle, adapted on the system, performed, and graduated, allowing localization in X‐Y. Tomosynthesis views define the depth of lesion. Graduated Coaxial localization kit determines the beginning of the biopsy window. Biopsies were performed with an ATEC‐Suros, 9 Gauge handpiece. All biopsies, except one, have reached the lesions. Five hemorrhages were incurred in the process, but no interruption was needed. Eight breast hematomas, were all spontaneously resolved. One was an infection. About 40% of patients had a skin ecchymosis. Processing is fast, easy, and requires lower irradiation dose than with classical stereotactic biopsies. Histology analysis reported 45 benign clusters of micro‐calcifications, 16 malignant clusters of micro‐calcifications, 24 benign masses, and 33 malignant masses. Of 13 malignant lesions, digital 2D‐mammography failed to detect eight lesions and underestimated the classification of five lesions. Digital breast 3D‐tomosynthesis depicts malignant lesions not visualized on digital 2D‐mammography. Development of tomosynthesis biopsy unit integrated to stereotactic system will permit histology analysis for suspicious lesions.     

Breast biopsy with needle localization: influence of age and mammographic feature on the rate of malignancy in 350 nonpalpable breast lesions

The purpose of this study was to determine the influence of mammographic feature and patient age on the rate of malignancy in nonpalpable breast lesions. During a 3-year period, 305 patients underwent biopsy after needle localization of 350 nonpalpable breast lesions. A total of 66 malignant breast tumors were found (biopsy yield rate, 19%): 23 carcinoma in situ, 43 infiltrating cancer. The biopsy yield rate in women younger than 50 years was 8% (12 of 153) and in women 50 years or older 27% (54 of 197; p less than 0.001). The biopsy yield rate varied with the mammographic feature in both groups of patients and was highest for spicular masses (61%), followed by strongly suspicious calcifications (29%). No cancers were found among well-defined masses or asymmetric densities. Other factors that were associated with high biopsy yield rate were personal or family history of breast cancer and diagnostic, rather than screening, mammography. The results suggest that the rate of malignancy in nonpalpable breast lesions is influenced by several factors, including age of patient and mammographic feature of the lesion. By taking all these factors into account, biopsies can possibly be performed more selectively thereby increasing the cost effectiveness of biopsy for occult breast cancer.     

Cytologic diagnosis of occult breast lesions using stereotaxic needle aspiration. A preliminary report

In mammographically detected breast lesions, only 10% to 25% of biopsy specimens are malignant. Furthermore, the current method of needle localization of these lesions is cumbersome and inefficient. Stereotaxic needle aspiration was used to examine 84 patients. Successful localization with the needle tip within 1 to 2 mm of the suspected lesion was possible in 80 cases (95.2%). Following aspirate cytology, the lesion was localized with indigo carmine and Kopans' wire and every patient underwent a standard open excisional biopsy. Twelve cases of breast cancer were diagnosed histologically. Eleven of these cases were correctly diagnosed cytologically, while one case yielded a false-negative result. In the remaining 72 histologically benign cases, four lesions were reported cytologically to be atypical. There were no complications. Stereotaxic needle aspiration localizes occult breast lesions precisely and in conjunction with mammography, and it is an acceptable preoperative method of diagnosing nonpalpable breast tumors.     

Breast biopsy and guidance for occult lesions

Biopsy and histological examination is the only way of determining with absolute accuracy whether a lesion is benign or malignant, as well as its exact nature and whether it shows any evidence of precancerous changes. Occult malignant lesions, not clinically detectable, may be found by the study of surrounding tissue in the course of the excision of a benign lesion. However, they are most often found by breast x-rays (mammography or xerography) which are done for: the survey of high-risk asymptomatic women; contralateral breast studies; symptomatic breasts without palpable findings; nipple discharge; large pendulous breasts; and multinodular breasts. Biopsies for occult lesions, based on radiographic findings, are recommended for: suspicious calcifications; stellate-shaped masses; breast masses with ill-defined borders or nodular contours; dominant masses; and areas of increased density or distorted breast architecture. In general, biopsy for these lesions is best done under general anesthesia, as an in-patient and as a two-step type of procedure, i.e., the biopsy should be studied by permanent histologic sections before making a final diagnosis. Preoperative localization can be done by measurements, markers, radio-opaque dye injections or by needle localization which we feel is the preferred technique because it is simple and accurate and allows for removal of only a small amount of tissue with better cosmetic results. The advantages and disadvantages of various types of needle localization are discussed and figures are given for 387 needle localizations in which 148 cancers were found (38.2%). Of these cancers, 54.1% were invasive and 45.9% were noninvasive.(ABSTRACT TRUNCATED AT 250 WORDS)     

Mammography, sonomammography, and diaphanography (lightscanning). A prospective, comparative study with histologic correlation

While mammography has become a routine method both for the screening and preoperative assessment of breast disease, the role of this modality, especially when compared with newer techniques of breast imaging, needs continued assessment. Recent advances using sonographic principles and diaphanography (light transillumination) must be compared with mammography to define specificity, sensitivity, and accuracy in assessing breast lesions. During a 16-month period between November 1982 and February 1984, 467 women with clinically apparent breast disease (symptoms or palpable lesions) were each studied using all three imaging techniques of mammography, sonomammography, and diaphanography. Of 168 women recommended for biopsy on the basis of these techniques, 84 women had histologic confirmation during this study period. Benign breast disease was diagnosed histologically in 38 women, while carcinoma was found in 46 patients. These techniques showed no significant differences in predicting benign or malignant disease when rates of sensitivity, accuracy, and specificity are computed. Diaphanography (lightscanning), allowed for consistently correct interpretation of cases proven to be histologically malignant and showed a false-negative rate comparable with x-ray mammography. We conclude that diaphanography is a sensitive indicator of both benign and malignant breast disease while serving as a reliable predictor of clinically apparent breast lesions without the potential problems of radiation exposure.     

Not all nonpalpable breast cancers are alike.

Clinical and mammographic data of 1009 consecutive patients were correlated with histopathologic data of 1144 biopsy specimens of nonpalpable breast lesions to better define the presentation and biologic behavior of early breast cancer. Patients with malignant neoplasms (269 [24%] of 1144 specimens) were older (mean age, 62.1 years) than patients with benign lesions (mean age, 54.9 years). Furthermore, patients with invasive disease were older (mean age, 63.3 years) than patients with noninvasive disease (mean age, 58.5 years) with an overall increased risk of invasive cancer per year of 1.035. A 58% incidence of invasive cancer was detected for lesions characterized by calcifications, while the incidence of invasive cancer was 84% for isolated mass lesions (relative risk, 4.31 for masses). Isolated mammographic calcifications associated with cancer appeared in a younger population and were significantly associated with noninvasive ductal cancer. Breast cancer presenting as a mammographic mass appeared in an older group and was highly associated with the presence of invasive disease.     

Technique and results of localization biopsy in a breast screening programme

The techniques of ultrasonographic and hookwire localization biopsy of impalpable breast lesions detected by a large breast screening unit during its first year of operation are described. Hookwire localization (HL) was performed using mammography. Ultrasonographic localization (UL) was used for lesions readily detectable by ultrasonography by marking the skin directly over the lesion and calculating its depth below the surface. UL is not appropriate when microcalcification is the sole mammographic abnormality. Localization was required for 150 of the 191 (78.5 per cent) screen-detected lesions. HL was used for 94 (62.7 per cent) and UL for 56 (37.3 per cent). Four lesions were missed by HL, none by UL; 35 per cent of lesions removed by HL and 39 per cent by UL were malignant, giving benign: malignant biopsy ratios of 1.8:1 and 1.5:1 respectively. Only 22 percent of the patients required overnight hospital stay. Localization biopsy plays a major role in the surgery for screen-detected lesions and, where applicable, UL is the technique of choice.     

Mammography of women with suspicious breast lumps

We analyzed 342 women who had suspicious breast lumps to determine if preoperative mammography could improve the malignancy yield of biopsy procedures. The number of women with cancer of the breast and false-negative mammogram reports ranged from 11% to 25%, depending on how equivocal mammogram reports were interpreted. Therefore, women with clinically suspicious breast lumps should undergo biopsy regardless of mammographic findings. A significant difference in the mean (+/- SD) predictive value of a positive mammogram existed between women above and below the age of 50 years (80 +/- 8 vs 43 +/- 14) because of the age-specific relative prevalence of benign and malignant disease, and because mammography had difficulty distinguishing between benign and malignant lumps (specificity, 70). Preoperative mammography of women with suspicious breast lumps is indicated to screen for occult carcinoma, to prevent biopsy sampling errors, and to judge the adequacy of lumpectomy if the lesion is malignant.     

Breast cancer in nonpalpable lesions: can mammographic parenchymal pattern improve the predictive value of biopsy?

The increasing number of women referred for surgical biopsy of nonpalpable breast lesions detected by screening mammography led to a retrospective review of all such cases from October 1, 1986 to September 30, 1990. There were 165 consecutive, wire-localized, excisional biopsies of radiographic lesions performed on 158 patients during this 4-year period. A positive (i.e., malignant) result was found in 16 patients (10%); all but one of these 16 patients had stage I disease at subsequent treatment. Examination of historical factors (age, family history, prior biopsy, breast symptoms) and mammographic factors (mass, microcalcification, irregular borders, new lesion, parenchymal pattern of increased fibroglandular density) revealed that no patient with a diffuse parenchymal pattern of increased fibroglandular density had a malignant diagnosis. This finding was statistically significant (P = 0.002) by chi-square analysis. This negative relationship of radiographic parenchymal pattern to early cancer in nonpalpable lesions is contrary to what one would expect, based on several reports in the radiology literature. Over one-third (36%) of the author's patients had the increased fibroglandular x-ray pattern, making this finding potentially important for surgeons evaluating the patient with a nonpalpable lesion detected by mammography.     

Diagnostic error in breast disease.

Fifty-six breast biopsies, incorrectly assessed by preoperative clinical or mammographic examination, were reviewed to define the characteristics in the tumor or patient that caused the clinician and mammographer to be diagnostically inaccurate. The most important patient characteristic associated with error was the use of hormones. Failure to recognize that oral contraceptive use significantly reduces the incidience of benign breast disease contributed to the frequent misdiagnosis of lesions in those patients. Twelve of 16 masses in oral contraceptive users were malignant. In seven, their resemblance to cysts or fibroadenomas resulted in treatment delay of two weeks or 18 months. Because benign disease is uncommon in women who have used contraceptives two or more years, all new lesions in those women should be studied by biopsy promptly. Neither clinical nor mammographic evaluation of lesions in postmenopausal women who used estrogens was accurate. Twelve postmenopausal patients with carcinoma had used estrogens. Three of these lesions were considered benign clinically and four, by mammogram. In one, treatment was delayed four years. In women over 50 not using hormones, clinical diagnosis of malignancy was accurate. Ten carcinomas in those women were missed by mammogram. Eight had negative nodes; thus a negative mamogram when the clinical diagnosis is correct may be an effective guide in predicting the status of axillary nodes. Paget's disease was not recognized clinically in two of eight patients with that disease, and an additional two were not recognized on mammography. The initial examiner did not identify three of six inflammatory carcinomas. Ten percent of benign lesions were intraductal hyperplasia or papillomatosis with atypia and were the benign lesions most often misdiagnosed clinically and by mammogram. No microscopic lesions were noted on mammography without an associated palpable mass. Twenty-five per cent of the lesions in women aged 40-49 were incorrectly assessed by mammography or clinical examination. Four (15%) of the 27 carcinomas in this age group were not recognized by either modality. Mammography helped delineate the characteristics of masses in premenopausal women. With recognition that any mass that appears in a woman using oral contraceptives must be studied by biopsy, combined clinical and mammographic study in primenopausal women should minimize diagnostic error. Unfortunately, neither clinical nor mammographic evaluation of the women with irregular periods approaching menopause or within three years past menopause is accurate. It is in that age group that new diagnostic modalities are needed and when reported their efficacy in that age group should be stressed.     

Diagnostic Utility of ABBI(R) (Advanced Breast Biopsy Instrumentation) for Nonpalpable Breast Lesions in Korea

Abstract: Introduction of mammography along with particular attention for the diagnosis and treatment of nonpalpable breast lesions has led to the development of nonresectional biopsies such as mammography-guided core needle biopsy, ultrasound-guided fine needle aspiration cytology, and localization and excisional biopsy. The Advanced Breast Biopsy Instrumentation (ABBI®) system, a recently developed device, has made it possible to remove a lesion completely under local anesthesia, thus providing a more reliable and rapid evaluation on an outpatient basis. We studied 159 patients with nonpalpable breast lesions from December 1996 to August 1998. Fifty-nine patients received core needle biopsies and 100 patients received excision with the ABBI system. The ABBI system patients had postexcisional mammography and specimen radiographs to confirm complete excision of the lesions. Pathologists examined permanent section specimens. In cases of malignancy, total mastectomy or reexcision was performed to secure a tumor-free margin. We collected malignant lesions in 23 of 159 patients, of whom 17 had ductal carcinoma in situ (DCIS). Postoperative histopathologic reports showed DCIS in 11 and infiltrating ductal carcinoma (IDC) in 2 among the 13 malignancies proven by stereotactic core biopsy. Among 10 malignancies proven by the ABBI system, there were 6 DCIS, 1 lobular carcinoma in situ (LCIS), and 3 IDC. In seven patients in whom mammography suggested malignancy but core biopsy showed benign lesion, localization and excisional biopsy confirmed DCIS in four of seven patients. The ABBI system is a more reliable and rapid method of evaluating breast lesions compared with stereotactic core biopsy. It is usually done under local anesthesia, minimizing the deformity of the breast. Therefore the ABBI system can be used as a preferred technique over conventional localization and excisional biopsy.