Aspiration cytology is superior to Tru-Cut needle biopsy in establishing the diagnosis of clinically suspicious breast masses.

Eighty-one consecutive patients with breast masses clinically suspicious for malignancy were evaluated prospectively. There were 31 benign lesions and 50 malignancies. Clinical diagnosis was correct in 85% (2.5% false negative, 12.5% false positive). Mammography was diagnostic in 52.8% (31.5% false negative, 15.7% false positive). Needle biopsy was accurate in 78.9% (21.1% false negative, 0% false positive). Aspiration cytology was diagnostic in 96.2% (3.8% false negative, 0% false positive). Statistical comparison of all four tests revealed that aspiration cytology was slightly more accurate than physical examination for all lesions (p = 0.07), but significantly more accurate for benign lesions (p = 0.005). Overall, aspiration cytology was significantly more accurate than mammography (p = 0.000001) and needle biopsy (p = 0.008). Only one minor complication, a superficial infection, occurred with aspiration cytology and needle biopsy. Thin-needle aspiration cytology is a benign procedure that appears to be superior to physical examination, mammography, and needle biopsy in establishing the diagnosis of clinically suspicious breast masses.     

Lymphoma of the breast: clinical and radiologic features with pathologic correlation in 28 patients

The objective of this study was to determine the clinical and radiologic findings of lymphoma involving the breast, separately evaluating primary and secondary forms. We retrospectively reviewed the medical reports of 28 patients with lymphoma of the breast: 12 patients with primary lymphoma and 16 with secondary lymphoma. In primary lymphoma, mammography revealed a solitary mass (58.3%), multiple unilateral masses (8.3%), unilateral diffuse involvement (25%), and bilateral diffuse involvement (8.3%). The margins of masses were irregular (50%), partially defined (37.5%), and well defined (12.5%). The mean diameter of the masses was 4.6 cm. In secondary lymphoma, mammography revealed multiple masses (56.2%), solitary masses (12.5%), and diffuse unilateral breast involvement (31.2%). Their margins were irregular (18.1%), partially defined (27.2%), and well-defined (54.5%). The mean diameter of the masses was 2.8 cm. Cytologic examination ( n = 13) was demonstrative of lymphomatous involvement in all cases. We observed an association between high-grade types of malignancy and a diffuse pattern of radiologic breast involvement. Masses in primary disease tended to have less-defined margins and greater diameters than those observed in secondary cases. Cytologic examination proved to be a useful diagnostic procedure in the evaluation of secondary disease. The involvement of the breast in extranodal lymphomas does not seem to affect the prognosis of the disease.     

Solid masses: What are the underlying histopathological lesions?

The ultrasound signs of breast masses are explained by the histopathological data. Ultrasound masses are classified according to their shape and margin. Round or oval masses are benign when their margins are circumscribed (fibroadenoma, intramammary lymph node); on the other hand, with non-circumscribed margins (microlobulated or irregular), masses that are round or oval may be cancers. Seven histological types of round cancers have been identified: grade III invasive ductal carcinoma, colloid or mucinous carcinoma, medullary carcinoma, intramammary metastases, intracystic papillary carcinoma, lymphoma and high-grade phyllodes tumors. Irregularly shaped ultrasound masses with non-circumscribed margins are predominantly cancers but may in some cases be benign lesions such as sclerosing adenosis, a radial scar, fibroadenoma or phyllodes tumor.     

Negative findings on fine-needle aspiration biopsy of solid breast masses: patient management

A series of 245 fine-needle aspirations of solid breast masses has been reviewed. Seven aspirations were reported as unsatisfactory, 178 revealed benign masses, 7 were indeterminate, and 53 revealed malignancy. Fifty-two of 53 masses diagnosed on aspiration as malignant were confirmed by surgical biopsy (98 percent sensitivity). Open biopsy was carried out on 50 of 178 masses reported as negative on needle biopsy and benign masses were revealed in 46 cases (92 percent specificity). The remaining 128 masses with negative findings were observed and follow-up of 101 patients obtained. Cancer did not develop in any of these patients. Careful physical examination and mammography can predict if a breast mass is malignant or benign in 85 to 90 percent of patients. If fine-needle aspiration biopsy is added and performed by physicians and cytopathologists experienced in the technique, additional information is obtained which allows greater diagnostic accuracy and may eliminate many breast biopsies.     

Breast masses in young women

Based on our review we conclude the following concerning breast masses in young women under 30 years of age: (1) Breast masses are nearly always benign. (2) Mammograms are not helpful in most patients. (3) Needle aspiration or needle biopsy is rarely indicated. (4) Excisional biopsy should be performed through a circumareolar or other cosmetic incision. (5) Preparation for frozen section and mastectomy is not indicated. (6) The breast should be reconstructed in layers without drains. (7) Further manifestations of benign disease can be expected in 15 percent of the cases.     

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.     

Clinical Examination, Mammography, and Fine-Needle Aspiration Cytology in the Management of Palpable Breast Masses

Abstract: The combination of examination, mammography, and fine-needle aspiration cytology is increasingly being used to identify palpable breast masses that can be followed rather than excised. Since all three modalities are highly dependent on training and experience, causing the accuracy of the triple test to be highly variable, we examined the results of our own experience, expecting to find at least one triply false-negative cancer.
Consecutive patients (198) with breast masses subjected to clinical examination, mammography, fine-needle aspiration cytology, and confirmatory excisional biopsy were studied. Sensitivity and specificity were calculated for all combinations of the three diagnostic methods and the significance of concordant and discordant findings was evaluated.
The sensitivities of examination, mammography, and cytology were 96%, 82%, and 85% respectively and the specificities were 75%, 90%, and 82%. No cancers were missed when all three diagnostic modalities were used together. Benign concordance of examination, mammography, and cytology was invariably associated with benign pathology.
These results validate the use of the triple test in our hands. However, the accuracy of the triple test will vary from physician to physician and its validity in following benign lesions must be evaluated with confirmatory excisional biopsies.     

Metastatic disease in the breast

Breast cancer is the commonest malignancy in women. However, metastatic involvement of the breast is relatively rare. Metastatic disease of the breast is therefore often an unexpected diagnosis in a female patient presenting with a breast mass. The commonest cause is spread from a contralateral breast carcinoma. Of solid tumors at other sites, the most common cancers to metastasize to the breast are, in declining order of frequency, malignant melanoma, lymphoma, lung cancer, ovarian carcinoma, soft tissue sarcoma, and gastrointestinal and genitourinary tumors. Besides these, metastases from osteosarcoma, thyroid neoplasms, and cervical, vaginal and endometrial carcinomas to the breast have been sporadically reported in the literature. A clinical presentation with pain, tenderness and discharge is distinctly unusual. A solitary lesion is the most common clinical presentation. Lesions that metastasize to the breast may produce changes that look similar to those of primary breast cancer on mammography, but they are more likely to be multiple, are frequently bilateral, and form a nidus of tumor cells that are usually round with fairly well-defined margins. Microcalcifications are not a distinguishing feature, and although their margins may be ill defined, spiculations are not commonly found. Diagnosis is generally achieved by means of fine-needle aspiration cytology or open biopsy of the breast masses. In recent reports, particular importance has been attached to the performance of fine-needle aspiration cytology diagnosis, to differentiate a metastasis from a second primary tumor, thus making it possible to avoid unnecessary mastectomy and ensure that appropriate chemotherapy and radiotherapy are implemented.     

Wire-guided biopsies of nonpalpable breast lesions

The purpose of this study was to review the results of mammographic wire-guided biopsies of nonpalpable breast lesions and the features of the lesions in the preoperative examinations. Sixty women, mean age 50.2 years (range 31 to 74), underwent a wire-guided biopsy of the lesion. Twenty-nine patients had preoperative fine needle aspiration of the lesion. The radiographic diagnosis was correct in 33 patients (55%); 25 had breast cancer and 8 patients had a benign lesion. In 9 of the 14 patients with clustered microcalcifications in mammography and in 13 of the 15 patients with a mass noted in mammography, the cytological examination was correct. Nonpalpable mammographic masses with regular borders and normal fine needle aspiration examination do not require biopsy. In malignant mammographic appearances associated with a normal fine needle aspiration examination, biopsy of the lesion should always be done.     

Image-guided aspiration of solitary occult breast 'cysts'.

During the 30-month period from March 1, 1988, through August 31, 1990, image-guided aspirations of 183 solitary occult breast masses, which were considered possible cysts, were performed. Indications for aspiration included (1) mass on mammography, either invisible on ultrasonography or with features atypical of a cyst, in 111 patients; (2) enlarging solitary mass on mammography with ultrasonic features suggesting a cyst in 45 patients; and (3) mammographic mass with features typical of a cyst in 27 patients, with confirmation requested by the referring physician. Of the group, 151 (83%) lesions were fluid-filled and 32 (17%) were solid. All aspirates had normal cytologic features. Of the 32 aspirates found to be solid, 19 were subsequently removed after wire localization and 13 were unchanged on mammography for a minimum of 6 months after aspiration. This is a simple and safe procedure, confirming the innocuous nature of an occult solitary breast cyst, and obviates the need for surgical biopsy.     

Fine‐Needle Aspiration Cytology for Diagnosis and Management of Palpable Breast Mass

Background : The present study aims to clarify the use, in a developing country, of fine‐needle aspiration cytology (FNA) instead of open biopsy as a cost‐saving, reliable initial diagnostic and management tool for patients with breast mass. Methods : A prospective study of 60 patients (71 breast masses) was carried out. The accuracy of physical diagnosis of the mass was compared with that obtained by FNA. The cytological results were analysed with the clinical profile s and pathological result s . Results : Physical examination was unreliable for the diagnosis of breast cyst (61.1% positive predictive value, 73.6% negative predictive value), which accounted for 35% of breast masses studied. Aspiration alone determined the diagnosis and management in 39% of masses. For solid breast masses benign cytological results (class I, II) were proved to be reliable (100% positive predictive value), as were malignant cytological results (class V; 100% positive predictive value). Inadequate cytology was reported for five masses (11.9%). Conclusions : Fine‐needle aspiration should be routinely performed in all patients with breast masses. This would facilitate prompt diagnosis and treatment in one‐third of patients with breast cyst, and the benign cytological result could facilitate definite management in the majority of patients with a low risk of malignancy. This could save cost, time and patient anxiety. For the patients with a high clinical suspicion of breast cancer, the positive cytological result could reliably confirm the diagnosis, while the equivocal result could be combined with mammography or open biopsy. Considering the ease, simplicity and low cost, FNA may be suitable for developing countries where other non‐invasive procedures are unavailable or difficult to obtain, and it could replace open biopsy, which is still commonly done.     

Fine-needle aspiration cytology for diagnosis and management of palpable breast mass

BACKGROUND: The present study aims to clarify the use, in a developing country, of fine-needle aspiration cytology (FNA) instead of open biopsy as a cost-saving, reliable initial diagnostic and management tool for patients with breast mass. METHODS: A prospective study of 60 patients (71 breast masses) was carried out. The accuracy of physical diagnosis of the mass was compared with that obtained by FNA. The cytological results were analysed with the clinical profiles and pathological results. RESULTS: Physical examination was unreliable for the diagnosis of breast cyst (61.1% positive predictive value, 73.6% negative predictive value), which accounted for 35% of breast masses studied. Aspiration alone determined the diagnosis and management in 39% of masses. For solid breast masses benign cytological results (class I, II) were proved to be reliable (100% positive predictive value), as were malignant cytological results (class V; 100% positive predictive value). Inadequate cytology was reported for five masses (11.9%). CONCLUSIONS: Fine-needle aspiration should be routinely performed in all patients with breast masses. This would facilitate prompt diagnosis and treatment in one-third of patients with breast cyst, and the benign cytological result could facilitate definite management in the majority of patients with a low risk of malignancy. This could save cost, time and patient anxiety. For the patients with a high clinical suspicion of breast cancer, the positive cytological result could reliably confirm the diagnosis, while the equivocal result could be combined with mammography or open biopsy. Considering the ease, simplicity and low cost, FNA may be suitable for developing countries where other non-invasive procedures are unavailable or difficult to obtain, and it could replace open biopsy, which is still commonly done.     

Tc-99m Sestamibi Scintimammography for the Evaluation of Breast Masses in Patients with Radiographically Dense Breasts

Abstract: The objective of this study was to evaluate the usefulness of technetium-99m sestamibi (MIBI) scintimammography for the diagnosis of breast cancer in patients with palpable breast masses that cannot be adequately evaluated by mammography due to the presence of radiographically dense breasts. At 5 minutes after intravenous injection of MIBI, scintimammograms were obtained in 80 patients who had grade 3 or 4 glandular density on mammograms and a palpable breast mass. Excisional biopsy or FNA biopsy was obtained in 68 lesions in 67 patients. Scintimammography (22 true positive, 4 false positive, 41 true negative, 1 false negative) resulted in a sensitivity of 95.6%, specificity 91.1%, positive predictive value 84.6%, and negative predictive value 97.6%. Mammography (19 true positive, 21 false positive, 24 true negative, 4 false negative) resulted in a sensitivity of 73.9%, specificity 53.3%, positive predictive value 44.7%, and negative predictive value 80%. MIBI scintimammography has a higher sensitivity and specificity than mammography in patients with radiographically dense breasts. It is useful as an adjunct to mammography in those patients with radiographically dense breasts for the characterization of palpable masses. Although sensitivity of mammography in this cohort was high, its specificity was significantly lower than scintimammography. If validated in prospective studies it could provide a safe way of avoiding a breast biopsy in patients with benign findings on clinical exam, mammography, and needle aspiration cytology.     

Usefulness of the triple test score for palpable breast masses; discussion 1012-3

HYPOTHESIS: The triple test score (TTS) is useful and accurate for evaluating palpable breast masses. DESIGN: Diagnostic test study. SETTING: University hospital multidisciplinary breast clinic. PATIENTS: Four hundred seventy-nine women with 484 palpable breast lesions evaluated by TTS from 1991 through July 2000. MAIN OUTCOME MEASURES: Physical examination, mammography, and fine-needle aspiration were each assigned a score of 1, 2, or 3 for benign, suspicious, or malignant results; the TTS is the sum of these scores. The TTS has a minimum score of 3 (concordant benign) and a maximum score of 9 (concordant malignant). The TTS was correlated with subsequent histopathologic analysis or follow-up. INTERVENTIONS: The TTS was prospectively calculated for each mass. Lesions with a TTS greater than or equal to 5 were excised for histologic confirmation, whereas lesions with scores less than or equal to 4 were either excised (n = 60) or followed clinically (n = 255). RESULTS: All lesions with TTS less than or equal to 4 were benign on clinical follow-up, including 8 for which the fine-needle aspiration was the suspicious component. Of the 60 biopsied lesions, 51 were normal breast tissue, 4 showed fibrocystic change, 1 was a papilloma, and 4 were atypical hyperplasia. All lesions with a TTS greater than or equal to 6 (n = 130) were confirmed to be malignant on biopsy. Thus, a TTS less than or equal to 4 has a specificity of 100% and a TTS greater than or equal to 6 has a sensitivity of 100%. Of the 39 lesions (8%) with scores of 5, 19 (49%) were malignant, and 20 (51%) were benign. CONCLUSIONS: The TTS reliably guides evaluation and treatment of palpable breast masses. Masses scoring 3 or 4 are always benign. Masses with scores greater than or equal to 6 are malignant and should be treated accordingly. Confirmatory biopsy is required only for the 8% of the masses that receive a TTS of 5.     

Primary breast lymphoma: case report and review of literature

Primary non-Hodgkin's lymphoma of the breast is a rare entity representing 0.04-0.5% of all malignant female breast tumors, less than 1% of all patients with non-Hodgkin lymphoma and approximately 1.7-2.2% of all patients with extranodal non-Hodgkin lymphomas. A 75 years old patient presented with masses in the lateral part of the left breast for 6 weeks. Ultrasound detected 3 masses suggesting fibroadenomas while mammography set the suspicion of breast multicentric carcinoma. Fine needle aspiration cytology of one mass showed low grade lymphoma subsequently confirmed with histopathology which diagnosed extranodal non-Hodgkin lymphoma MALT type CD 20+/CD 79a+/CD 3-/Bcl 2- and index of proliferation Ki 67=30% (stage IE). Primary non-Hodgkin lymphomas of the breast, though rare, should be considered in the differential diagnosis of breast malignancies. At present, a standard treatment doesn't exist yet; low grade lymphomas should be managed with excision biopsy and/or local radiation therapy, while high grade lymphomas should be managed with chemotherapy in association with radiation therapy.     

The role of magnetic resonance imaging mammography in the surgical management of the index breast cancer

HYPOTHESIS: Preoperative magnetic resonance imaging (MRI) mammography, after positive fine-needle aspiration (FNA) or stereotactic biopsy, may alter surgical management of the index breast cancer. DESIGN: Review of MRI mammograms compared with conventional mammograms and clinical examination. SETTING: Rural community hospital. PATIENTS: Consecutive cohort of 27 patients with breast cancer who underwent prebiopsy or preoperative MRI mammography. INTERVENTION: Surgical management of breast cancer. MAIN OUTCOME MEASURE: Change in surgical management prompted by findings on MRI mammography. RESULTS: Prebiopsy or preoperative MRI mammography changed surgical management in 13 (48%) of 27 patients with breast cancer by discovering multicentric cancers or more extensive cancer. Of the 27 patients, 9 with positive FNA biopsy results of palpable masses underwent preoperative MRI; in 6 of the 9, ipsilateral multicentric cancers or more extensive cancer was discovered that necessitated mastectomy rather than breast conservation. Eighteen of the 27 patients had category 4/5 mammograms. Ten of these patients had stereotactic biopsies followed by MRI; 4 of the 10 had changes on the MRIs that required mastectomy rather than breast conservation. Eight of the 27 patients had MRI before stereotactic biopsy; 3 of the 8 had MRI abnormalities that required mastectomy. One patient had contralateral, multicentric cancers not seen on conventional mammography, necessitating bilateral mastectomies. CONCLUSIONS: We recommend that patients who desire breast conservation undergo MRI mammography before biopsy of a category 4/5 mammogram or immediately after a positive FNA biopsy result of a palpable mass.     

Comparison between sonography and mammography for breast cancer diagnosis in oriental women after augmentation mammaplasty

Augmentation mammaplasty has become more popular in Taiwan. Therefore, clinical imaging is necessary to evaluate those patients who develop breast cancers. The purpose of this study was to evaluate the detection of breast diseases after augmentation mammaplasty by means of mammography and sonography. A retrospective follow-up study and analysis of diagnostic methods including mammography, sonography, physical examination, and aspiration cytology was conducted on 105 patients who underwent augmentation mammaplasty at Kaohsiung Medical University Hospital between 1989 and 2001. A total of 105 patients were identified in this study, and mean follow-up was 4 years. Two tumors from 8 cancer patients were visible on standard mammograms, and seven tumors were diagnosed as cancer by sonography. One of 15 benign breast tumors was interpreted as a suspected cancer, and 7 tumors were interpreted as normal findings on mammograms. Fourteen of 15 benign breast tumors were diagnosed correctly except for one suspicious case examined by sonography. Sonography showed the highest rate of diagnostic accuracy (91.3%) and mammograms had the lowest rate (73.9%). The accuracy rate of physical examination was 73.9%, and aspiration cytology was 90.0% accurate. This study affirms that sonography is a more useful diagnostic tool than mammography in Taiwanese women who have undergone augmentation mammaplasty.     

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.     

Pre-operative evaluation of palpable breast tumours

The diagnostic accuracy of clinical examination, mammography and fine-needle aspiration cytology in identifying malignancy was retrospectively assessed in 207 women with palpable breast masses undergoing breast biopsy for histological examination. Clinical examination was more sensitive (96%) than mammography (81%) or cytology (69%). Cytological examination was totally specific for malignancy. The combined evaluation of clinical examination, mammography and cytological examination revealed a 100% diagnostic accuracy for concordant triplet results. Where discordant triplet results were recorded, 75% of tumours were malignant. Biopsy and frozen section are thus recommended if the 'triplet' provides conflicting results. Preliminary biopsy and frozen section may be unnecessary when the diagnostic triplet unequivocally demonstrates malignancy, or when cytological examination reliably reveals the presence of malignancy. Where the components of the triplet all point to benignity, the patient may be confidently followed up without the necessity of biopsy. The adoption of these guidelines may safely reduce the number of open breast biopsies by about 50-60%.     

Needle aspiration cytology of breast masses

Needle aspiration cytology has been reported to be a highly sensitive and specific method of evaluation of solid breast masses when used by a single individual or closely knit group of clinicians and cytopathologists. This report summarizes the experience in 86 patients in whom needle aspiration cytology and excisional biopsy of solid breast masses were performed. All clinical evaluations, including needle aspirations and excisional biopsies, were performed by surgical residents in the Breast Clinic of Grady Memorial Hospital. The cytologic and histologic interpretations were performed by members of the Department of Pathology without direct interaction with the patients. Of the entire group of 86 patients, 27 had cancer and 59 had benign breast disease. There were no false-positive findings and five (11.9%) false-negative findings. The sensitivity of fine-needle aspiration was 73.7 per cent and specificity 100 per cent. The results are compatible with previously reported studies and it is believed that needle aspiration cytology is an integral part of evaluation of breast masses.