Advances in the diagnosis and excision of breast cancer

Until recently little advance in the diagnosis and excision of breast cancer has been made since the inception of needle localization breast biopsy (NLBB). Stereotactic core needle breast biopsy (SCNBB) can avoid most NLBB especially for calcifications. However, when open biopsy is necessary NLBB has been the standard of care. As many as 50 per cent of nonpalpable lesions can be seen by ultrasound (US) to avoid the unpleasantness and complications associated with NLBB. Further SCNBB leaves a blood-filled cavity that can be easily seen by US. Intraoperative US can be used to direct the excision while improving margin negativity. MRI has improved sensitivity in detecting suspicious breast lesions and techniques such as hematoma-directed US-guided breast biopsy can facilitate excision of such masses. Clearly new technologies have improved the ability to diagnosis and excise breast cancer. The onus on the surgeon is to incorporate them into standard practice to improve outcomes.     

Magnetic resonance imaging-guided core needle biopsy and needle localized excision of occult breast lesions.

BACKGROUND: Breast magnetic resonance imaging (MRI) has been reported to be twice as sensitive and three times more specific in detecting breast cancer. We report a series of MRI-guided stereotactic breast biopsies (SCNBB) and needle localized breast biopsies (NLBB) to evaluate MRI as a localization tool. METHODS: Forty-one breast lesions were identified in 39 patients who subsequently had SCNBB or NLBB. Suspicious areas of enhancement were stereotactically biopsied with 16-G core biopsy needles or localized with 22-G wires for excision under laser guidance. RESULTS: Forty-one breast lesions were identified from 1,292 breast MRIs. SCNBB identified three malignancies and two areas of atypia. Two additional cancers were found after NLBB. In patients having NLBB alone, five cancers and two areas of atypia were identified. CONCLUSIONS: In this initial series, breast MRI-guided SCNBB and NLBB were valuable tools in the management of patients with suspicious abnormalities seen only on MRI.     

Needle localization of mammographically detected lesions in perspective

Needle localization of mammographically detected lesions has been shown to detect early breast cancer. One hundred seven patients who underwent needle localized biopsy from June 1977 to September 1985 were reviewed. Eighty percent of the biopsies were benign and 20 percent were cancers (22 patients). In patients undergoing modified radical mastectomy, 80 percent of the axillary specimens were node-negative. During the same 8 year period, 570 breast cancers were diagnosed. Needle localization was responsible for only 4 percent of all cancers found. Though needle localization represents an advance in the detection of early breast cancer, the majority of cancers are found by physical examination. The importance of routine examination by a physician and self-breast examination remains paramount.     

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.     

Interpectoral nodes as the initial site of recurrence in breast cancer

HYPOTHESIS: Interpectoral nodes can be the initial site of recurrent breast cancer. DESIGN: Retrospective review. SETTING: Comprehensive breast center, located in a university-based tertiary care center. PATIENTS: All patients undergoing operations for breast cancer at our breast center from 1995 to 2002 were reviewed. MAIN OUTCOME MEASURES: Patients with interpectoral node recurrence as the initial site of recurrent breast cancer were identified. RESULTS: During the 8-year period, 4097 patients underwent surgical management for breast cancer. During this time, 4 patients (0.1%) had recurrence at the interpectoral nodes. Three of the 4 patients were node-negative at the original operation. All lesions were mammographically occult. Preoperative needle biopsy was effective in the confirmation of malignancy. All 4 underwent excision without complications. CONCLUSIONS: Recurrence at the interpectoral nodes can be the initial site of surgical failure. These nodes may represent the site of primary drainage in a percentage of patients. The sentinel node identification technique, therefore, should diminish the number of patients affected by recurrence at this site. In patients with a palpable mass in the infraclavicular location, however, a high index of suspicion should be maintained. Workup should include additional breast imaging and needle biopsy prior to operation.     

Mammographically detected breast cancer. Benefits of stereotactic core versus wire localization biopsy.

OBJECTIVE: The authors evaluated the differences between stereotactic core needle biopsy (SCNBx) and needle localization surgical biopsy (NLBx) in cost and treatment course for patients with mammographically detected breast cancer. SUMMARY BACKGROUND DATA: Stereotactic core needle breast biopsy is a reproducible and reliable alternative to surgical biopsy for histologic diagnosis of mammographic lesions. METHODS: Records from 52 consecutive patients with invasive breast cancer diagnosed by SCNBx (n = 21) or NLBx (n = 31) over 2 years were reviewed. Episode-of-care costs were extracted from the Barnes Hospital billing system database. RESULTS: At the time of excision, surgical margins were statistically more frequently positive in patients treated with NLBx (55%) than patients treated with SCNBx (0%, p < 0.0001). Furthermore, patients in the NLBx group undergoing breast conservation surgery required re-excision more frequently (74%) than those in the SCNBx group (0%, p = 0.001). There were no complications in either group after the diagnostic procedure. All SCNBx results were correct in the diagnosis of invasive breast cancer. The median cost of SCNBx was approximately $1000 less than the median cost of NLBx. This cost difference was carried through the definitive procedure, whether it was breast conservation or mastectomy. CONCLUSIONS: This study shows the advantage of SCNBx to diagnose breast cancer and definitive operative care at a single procedure. The preoperative diagnosis of breast cancer eliminated positive operative margins and procedures to re-excise breast tissue. The use of SCNBx also saved approximately $1000 per patient compared with the use of NLBx. Our data suggest that SCNBx is the diagnostic procedure of choice for mammographically detected cancers.     

Sentinel node biopsy for nonpalpable breast tumors requires a preoperative diagnosis of invasive breast cancer

A sentinel node biopsy done at the time of initial tumor resection allows for a one-stage surgical procedure. In addition, sentinel node identification may be impaired when done after a previous tumor excision. This study evaluates the sentinel node biopsy in patients with nonpalpable breast cancer and assesses whether a sentinel node biopsy for mammographically suspect breast lesions is justified when preoperative needle biopsy is inconclusive for invasive malignancy. A sentinel node biopsy was done in 67 patients with nonpalpable breast lesions after injection of radioactive tracer (intraparenchymal in 35 and subdermal in 32) and blue dye (para-areolar). A preoperative core needle biopsy was positive for malignancy in 42 patients. Thirteen patients had positive cytology or ductal carcinoma in situ (DCIS). In 12 patients the needle biopsy was nondiagnostic, but the lesions remained highly suggestive of malignancy on mammography. Sentinel node biopsy was successful in 64 patients (96%). In these, the sentinel node was both radioactive and blue in 58 patients (91%). Only 4 of 13 patients with positive cytology or DCIS on preoperative needle biopsy and only 5 of 12 patients without a preoperative diagnosis had an invasive cancer after resection. Sentinel nodes were positive for nodal metastases in 9 of 49 patients (18%) with a successful sentinel node biopsy for invasive malignancy. None of the eight patients with DCIS had nodal metastases. The sentinel node procedure avoids the potential morbidity of an axillary dissection in more than 80% of patients with nonpalpable breast cancer. A sentinel node biopsy for mammographically detected suspect breast lesions is not justified without a preoperative histologic diagnosis of invasive breast cancer.     

Hematoma-Directed Ultrasound-Guided (HUG) Breast Lumpectomy

Background Needle localization breast biopsy (NLBB) is presently the primary means of localizing non-palpable lesions. Disadvantages of NLBB include vasovagal episodes, patient discomfort, and miss rates. Because hematomas naturally fill the cavity after vacuum-assisted breast biopsies (VABB), we hypothesized that ultrasound (US) could be used to find and accurately excise the actual biopsy site of non-palpable breast lesions without a needle. Methods This is a retrospective study from January 2000 to July 2005. Electronic chart review identified patients with non-palpable breast lesions detected by means of mammogram who then underwent lumpectomy via NLBB or the hematoma-directed ultrasound-guided technique (HUG). HUG involved localizing the hematoma with a 7.5-MHz US probe and using the “line of sight” technique straight down toward the chest wall. A block of tissue encompassing the hematoma was then excised. Results Localization procedures were performed in 186 patients—63 (34%) via needle localization and 123 (66%) via HUG. The previous VABB site in 100% of patients was successfully excised using HUG, 65 of 123 (53%) were benign and 58 of 123 (47%) were malignant; margins were positive in 13 of these 58 (22%). NLBB was successful in 100% of patients, 44 of 63 (70%) were benign and 19 of 63 (30%) were malignant; margins were positive in 14 of these 19 (73%). Margin positivity was significantly higher for NLBB than HUG (P = 0.0001, Fisher Exact). Conclusions This study suggests that HUG is more accurate in localizing non-palpable lesions than NLBB. By eliminating the additional procedure needed for NLBB, HUG may also be more time- and cost efficient. HUG makes VABB not only a less invasive diagnostic procedure, but also a localization procedure. Margaret Thompson: Supported by the Virginia Clinton Kelley/Fashion Footwear Association of New York Breast Cancer Research Fellowship Aaron Margulies: Supported by the Susan G. Komen Breast Cancer Clinical Fellowship     

Management of nonpalpable breast abnormalities.

From January 1982 to June 1986, 444 patients had localization of 500 nonpalpable mammographically suspicious lesions using the Kopans hook wire technique. Four hundred ninety-nine biopsies were performed in 443 patients. Cancer was identified in 12% of the biopsies performed for a suspicious mass or density and in 20% of biopsies performed for suspicious calcifications. Carcinoma was identified in a total of 72 biopsies (14%) performed in 65 patients; 82% of the malignant lesions were invasive. All lesions were small; 76% of the cancers were 1.0 cm or less in diameter. Sixty-two axillary dissections were performed of which seven (11%) had positive nodes. Advantages of preoperative needle localization include precise localization of the lesion, a small incision, and removal of a small amount of breast tissue with no cosmetic deformity. Outpatient biopsy of these lesions can be easily performed under local anesthesia. Identification and treatment of these small preclinical cancers should lead to improved survival from breast cancer.     

Local recurrence of breast cancer in the stereotactic core needle biopsy site: case reports and review of the literature

Abstract: Early mammographic detection of nonpalpable breast lesions has led to the increasing use of stereotactic core biopsies for tissue diagnosis. Tumor seeding the needle tract is a theorectical concern; the incidence and clinical significance of this potential complication are unknown. We report three cases of subcutaneous breast cancer recurrence at the stereotactic biopsy site after definitive treatment of the primary breast tumor. Two cases were clinically evident and relevant; the third was detected in the preclinical, microscopic state. All three patients underwent multiple passes during stereotactic large-core biopsies (14 gauge needle) followed by modified radical mastectomy. Two patients developed a subcutaneous recurrence at the site of the previous biopsy 12 and 17 months later; one had excision of the skin and dermis at the time of mastectomy revealing tumor cells locally. In summary, clinically relevant recurrence from tumor cells seeding the needle tract is reported in two patients after definitive surgical therapy (without adjuvant radiation therapy). Often, the biopsy site is outside the boundaries of surgical resection. Since the core needle biopsy exit site represents a potential area of malignant seeding and subsequent tumor recurrence, we recommend excising the stereotactic core biopsy tract at the time of definitive surgical resection of the primary tumor.     

Surgical margins after needle-localization breast biopsy

: The use of needle-localization breast biopsy (NLBB) for the early diagnosis of breast cancer is common. The therapeutic adequacy of tumor-free margins following NLBB is unknown. We hypothesized that the presence of residual tumor after reexcision (mastectomy, tylectomy, or quadrantectomy) does not depend on the margin status following NLBB. : Retrospective cohort analysis was performed on 890 consecutive NLBBs executed between January 1990 and June 1994. Patients with invasive breast neoplasia were divided into two groups based on the tumor margins after NLBB. Group 1 were the women with positive margins, and group 2 had negative margins. Breast specimens after reexcision were reviewed for evidence of residual invasive carcinoma. : Invasive neoplasia was present in 107 patients (12%). Surgical margins and definitive records of care were avaliable for 96 of them (90%). All 45 patients in group 1 and 38 (75%) of 51 patients in group 2 underwent reexcision of the initial biopsy site (P = 0.36). Residual invasive carcinoma was present in 10 patients (22%) in group 1 and 3 (8%) in group 2 (P = 0.13). : Invasive breast neoplasia diagnosed by NLBB requires reexcision regardless of tumor margins to achieve complete local surgical eradication of tumor.     

Vacuum-assisted stereotactic breast biopsy: histologic underestimation of malignant lesions

HYPOTHESIS: The histopathologic correlation between stereotactic core needle biopsy and subsequent surgical excision of mammographically detected nonpalpable breast abnormalities is improved with a larger-core (11-gauge) device. DESIGN: Retrospective medical record and histopathologic review. SETTING: University-based academic practice setting. PATIENTS: Two hundred one patients who underwent surgical excision of mammographic abnormalities that had undergone biopsy with an 11-gauge vacuum-assisted stereotactic core biopsy device. MAIN OUTCOME MEASURE: Correlation between stereotactic biopsy histologic results and the histologic results of subsequent surgical specimens. RESULTS: Results of stereotactic biopsy performed on 851 patients revealed atypical hyperplasia in 46 lesions, ductal carcinoma in situ (DCIS) in 89 lesions, and invasive cancer in 73 mammographic abnormalities. Subsequent surgical excision of the 46 atypical lesions revealed 2 cases of DCIS (4.3%) and 4 cases of invasive carcinoma (8.7%). Lesions diagnosed as DCIS on stereotactic biopsy proved to be invasive carcinoma in 10 (11.2%) of 89 patients on subsequent excision. Stereotactic biopsy completely removed 21 (23.6%) of 89 DCIS lesions and 20 (27.4%) of 73 invasive carcinomas. CONCLUSIONS: In summary, 11-gauge vacuum-assisted core breast biopsy accurately predicts the degree of disease in the majority of malignant lesions; however, understaging still occurs in 11% to 13% of lesions showing atypical hyperplasia or DCIS.     

Impact of core-needle breast biopsy on the surgical management of mammographic abnormalities

OBJECTIVE: To evaluate the accuracy of percutaneous, image-guided core-needle breast biopsy (CNBx) and to compare the surgical management of patients with breast cancer diagnosed by CNBx with patients diagnosed by surgical needle-localization biopsy (SNLBx). SUMMARY BACKGROUND DATA: Percutaneous, image-guided CNBx is a less invasive alternative to SNLBx for the diagnosis of nonpalpable mammographic abnormalities. CNBx potentially spares patients with benign lesions from unnecessary surgery, although false-negative results can occur. For patients with malignant lesions, preoperative diagnosis by CNBx allows definitive treatment decisions to be made before surgery and may affect surgical outcomes. METHODS: Between 1992 and 1999, 939 patients with 1,042 mammographically detected lesions underwent biopsy by stereotactic CNBx or ultrasound-guided CNBx. Results were categorized pathologically as benign or malignant and, further, as invasive or noninvasive malignancies. Only biopsy results confirmed by excision or 1-year-minimum mammographic follow-up were included in the analysis. Patients with breast cancer diagnosed by CNBx were compared with a matched control group of patients with breast cancer diagnosed by SNLBx. RESULTS: Benign results were obtained in 802 lesions (77%), 520 of which were in patients with adequate follow-up. Ninety-five of the 520 evaluable lesions (18%) were subsequently excised because of atypical hyperplasia, mammographic-histologic discordance, or other clinical indications. There were 17 false-negative CNBx results in this group; 15 of these lesions were correctly diagnosed by excisional biopsy within 4 months of CNBx. In two patients (0.9%), delayed diagnoses of ductal carcinoma in situ were made at 15 and 19 months after CNBx. Malignant results were obtained in 240 lesions (23%), 220 of which were surgically excised from 202 patients at our institution. Two lesions diagnosed as ductal carcinoma in situ were reclassified as atypical ductal hyperplasia and considered false-positive results (0.4%). For malignant lesions, the sensitivity and specificity of CNBx for the detection of invasion were 89% and 96%, respectively. During the first surgical procedure, 115 of 199 patients (58%) diagnosed by CNBx underwent local excision; 194 of 199 patients (97%) evaluated by SNLBx underwent local excision. For patients whose initial surgery was local excision, those diagnosed before surgery by CNBx had larger excision specimens and were more likely to have negative surgical margins than were patients initially evaluated by SNLBx. Overall, patients diagnosed by CNBx required fewer surgical procedures for definitive treatment than did patients diagnosed by SNLBx. CONCLUSIONS: Diagnosis by CNBx spares most patients with benign mammographic abnormalities from unnecessary surgery. With the selective use of SNLBx to confirm discordant results, missed diagnoses are rare. When compared with SNLBx, preoperative diagnosis of breast cancer by CNBx facilitates wider initial margins of excision, fewer positive margins, and fewer surgical procedures to accomplish definitive treatment than diagnosis by SNLBx.     

Stereotactic fine needle biopsy of the breast.

The experience of the use of the TRC-Mammotest machine for stereotactic fine needle biopsy (SFNB) of the breast in Perth is presented. During the period 20 October 1988 to 10 January 1990, 404 SFNB were performed on 389 women with impalpable, mammographically detected lesions of the breast. Surgical biopsy was performed in 73 cases, of which 38 were malignant, giving a benign to malignant ratio in less than 1:1. The sensitivity for detecting cancer was 95%, with a positive predictive value of 100%. Using a combination of the mammographic and cytologic rating for the likelihood of cancer, all the cancers were detected and no cancers have developed in those considered mammographically and cytologically benign. The importance of a combined assessment of mammography and cytology in the management of patients with mammographically detected abnormalities is stressed.     

STEREOTACTIC FINE NEEDLE BIOPSY OF THE BREAST

The experience of the use of the TRC-Mammotest machine for stereotactic fine needle biopsy (SFNB) of the breast in Perth is presented. During the period 20 October 1988 to 10 January 1990, 404 SFNB were performed on 389 women with impalpable, mammographically detected lesions of the breast. Surgical biopsy was performed in 73 cases, of which 38 were malignant, giving a benign to malignant ratio in < 1:1. The sensitivity for detecting cancer was 95%, with a positive predictive value of 100%. Using a combination of the mammographic and cytologic rating for the likelihood of cancer, all the cancers were detected and no cancers have developed in those considered mammographically and cytologically benign. The importance of a combined assessment of mammography and cytology in the management of patients with mammographically detected abnormalities is stressed.     

Ultrasound-guided biopsy of nonpalpable breast masses by surgeons

Background: Recently, ultrasound (US)-guided needle biopsy has been proposed as an acceptable alternative to open biopsy in women with nonpalpable breast masses. This study evaluated the accuracy of US-guided needle biopsy of nonpalpable breast masses performed by surgeons at the time of the initial clinical examination. Methods: Ultrasound-guided aspiration and/or core biopsy (US-GAB) was performed on 103 patients presenting with a nonpalpable, new, or increasing-size mass detected on mammography. Study patients included those whose US was classified as: fibroadenoma (FA) (n=26), complex cyst (n=32), indeterminate (complex cyst versus solid; N=24), or suspect (n=21). Results: Of the 32 patients with diagnostic US of complex cyst, US-GAB confirmed 27 to be cysts. Twelve additional cysts were aspirated among the 24 indeterminate lesions. Sixteen FA were diagnosed on US-GAB; 11 of these underwent open biopsy and each was demonstrated to be a FA. Fibrocystic/benign-breast change (FBC) was diagnosed on 26 US-GAB; 15 of these underwent open biopsy, which demonstrated three FA and 12 FBC. Nine atypical lesions were diagnosed on US-GAB; six FBC, one papilloma, one FA, and one cancer were demonstrated on open biopsy. Seven cancers were diagnosed on US-GAB and all were confirmed on open biopsy. There were six insufficient specimens from US-GAB; four of these underwent open biopsy, which demonstrated two FA and two FBC. Conclusion: Ultrasound-guided aspiration and/or core biopsy performed by surgeons in conjunction with the initial clinical examination can accurately diagnose nonpalpable, mammographically detected breast masses. Results of this study were presented at the 48th Annual Cancer Symposium of The Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.     

STEREOTACTIC 14 GAUGE CORE-BIOPSY OF THE BREAST: RESULTS FROM 101 PATIENTS

Background: Along with fine needle aspiration (FNA) cytology, core-biopsy has become an integral part of the assessment of mammographically detected breast lesions. Methods: A series of stereotactic large-core-biopsies of mammographically detected breast lesions was studied to assess the accuracy and limitations of the technique in diagnosing malignancy and in giving specific benign diagnoses, and its use in determining surgical management. Results: Eighty per cent of carcinomas were diagnosed as malignant (absolute sensitivity). In 88.8% of the cancers, the core-biopsy was classified as malignant, suspicious or atypical/indeterminate (complete sensitivity), and in 72% of the invasive carcinomas, invasive tumour was present in the core. The technique was more successful for invasive carcinomas than for ductal carcinoma in situ (DCIS) (absolute sensitivity 86.1 and 55.5, respectively; P= 0.28) and for malignant mass lesions than for a mass with associated microcalcifications or for pure microcalcifications (absolute sensitivity 91, 71 and 66.6%, respectively; P= 0.19). In five of the 45 cancers (11.1%), no tumour tissue was present in the core, but all were excised after mammographic review and no delays in diagnosis have been experienced to date. The benign to malignant ratio for excised lesions was 0.11:1. Of the benign lesions, a specific diagnosis was given in 49% (calcifications in the core in a background of fibrocystic change, or postoperative scarring, or fibro-adenoma); the remainder showed non-specific benign findings. All patients where invasive carcinoma was diagnosed in the core underwent axillary clearance and wide local excision or mastectomy at their first operation. Conclusions: This technique can markedly reduce the number of benign lesions needing open biopsy, and provide information allowing definitive management of most carcinomas at the first operation. The accuracy of core-biopsy was lower in DCIS/ microcalcification lesions; extra core samples or a combination of FNA and core-biopsy may be of value in these cases.     

Mammographically detected ductal carcinoma in situ treated with conservative surgery with or without radiation therapy: patterns of failure and 10-year results

OBJECTIVE: The authors reviewed their institution's experience treating mammographically detected ductal carcinoma in situ (DCIS) of the breast with breast-conserving therapy (BCT) to determine 10-year rates of local control and survival, patterns of failure, and factors associated with outcome. SUMMARY BACKGROUND DATA: From January 1980 to December 1993, 177 breasts in 172 patients were treated with BCT for mammographically detected DCIS of the breast at William Beaumont Hospital, Royal Oak, Michigan. METHODS: All patients underwent an excisional biopsy, and 65% were reexcised. Thirty-one breasts (18%) were treated with excision alone, whereas 146 breasts (82%) received postoperative radiation therapy (RT). All patients undergoing RT received whole-breast irradiation to a median dose of 50.0 Gy. One hundred thirty-six (93%) received a boost to the tumor bed for a median total dose of 60.4 Gy. Median follow-up was 5.9 years for the lumpectomy alone group and 7.2 years for the lumpectomy + RT group. RESULTS: In the entire population, 15 patients had an ipsilateral breast recurrence. The 5- and 10-year actuarial rates of ipsilateral breast recurrence were 7.8% and 7.8% for lumpectomy alone and 8.0% and 9.2% for lumpectomy + RT, respectively. Eleven of the 15 recurrences developed within or immediately adjacent to the lumpectomy cavity and were designated as true recurrences or marginal misses (TMM). Four recurred elsewhere in the breast. Eleven of the 15 recurrences were invasive, whereas 4 were pure DCIS. Only one patient died of disease, yielding 5- and 10-year actuarial cause-specific survival rates of 100% and 99.2%, respectively. Eleven patients were diagnosed with subsequent contralateral breast cancer, yielding 5- and 10-year actuarial rates of 5.1% and 8.3%, respectively. Clinical, pathologic, and treatment-related factors were analyzed for an association with ipsilateral breast failure or TR/MM. No factors were significantly associated with ipsilateral breast failure. In the entire population, the omission of RT and younger age at diagnosis were significantly associated with TR/MM. Patients younger than 45 years at diagnosis had a significantly higher rate of TR/MM in both the lumpectomy + RT and lumpectomy alone groups. None of the 37 patients who received a postexcisional mammogram had an ipsilateral breast failure versus 15 in the patients who did not receive a postexcisional mammogram. CONCLUSIONS: Patients diagnosed with mammographically detected DCIS of the breast appear to have excellent 100-year rates of local control and overall survival when treated with BCT. These results suggest that the use of RT reduces the risk of local recurrence and that patients diagnosed at a younger age have a higher rate of local recurrence with or without the use of postoperative RT.     

Evaluating the impact of preoperative breast magnetic resonance imaging on the surgical management of newly diagnosed breast cancers

HYPOTHESIS: Women with newly diagnosed breast cancers may harbor additional ipsilateral or contralateral breast malignancies that are undetected by mammography and ultrasonography. Magnetic resonance imaging (MRI) has demonstrated excellent sensitivity in the detection of breast cancers. However, the impact of routine MRI on the surgical management of new, biopsy-proven breast cancers remains unclear. DESIGN: Retrospective analysis of a prospective database. SETTING: An academic, tertiary care center in a large metropolitan area. PATIENTS: A total of 155 women with breast cancer newly diagnosed by mammography, ultrasonography, and needle biopsy underwent preoperative bilateral breast MRI in a single-institution, single-surgeon setting during 1 year. MAIN OUTCOME MEASURES: Change in surgical management based on breast MRI findings. RESULTS: The MRI demonstrated 124 additional suspicious lesions in 73 patients. Post-MRI follow-up mammograms or ultrasonograms were required in 65 patients, and 41 patients underwent additional image-guided biopsies. There was a change in surgical management as MRI discovered additional, otherwise undetected malignancies in 36 patients based on radiographic-pathologic correlation. Lumpectomy was converted to mastectomy in 10 patients (8 beneficial), wider excision was performed in 21 patients (10 beneficial), and 5 patients (2 beneficial) underwent contralateral surgery. Larger tumor size was an independent predictor of a beneficial change in surgical management (odds ratio, 1.66; 95% confidence interval, 1.04-2.66). CONCLUSIONS: Breast MRI results in a beneficial change in surgical management in 9.7% of newly diagnosed breast cancers. The detection of additional, otherwise undetected ipsilateral and contralateral breast malignancies with MRI suggests that breast MRI may have a role in the evaluation of new breast cancers.     

Three- to six-year followup for 379 benign image-guided large-core needle biopsies of nonpalpable breast abnormalities

BACKGROUND: Determining the negative predictive value of benign large-core needle biopsy of nonpalpable mammographically detected breast abnormalities has been difficult because benign results generally preclude surgical excision. Longterm followup of these patients is important to ensure timely diagnosis of new abnormalities and to identify false negatives. STUDY DESIGN: This cohort study comprised 379 patients, all with benign diagnoses following imaging-guided large-core needle biopsy of nonpalpable mammographically detected abnormalities. Mammographic, clinical, and laboratory records (when appropriate) were reviewed for all patients followed at our institution. For patients followed elsewhere, these data were provided by each patient's current primary-care physician after obtaining written informed consent from the patient. RESULTS: We obtained followup for 312 patients (82.3% of 379), for whom the mean followup period was 55 months; 67 patients were either lost to followup (44, 11.6%), had no followup by patient choice (18, 4.7%), or died of causes other than breast cancer (5, 1.3%). Of these 312 patients, we found only 1 (0.3%) false negative in which a 4-mm lesion was observed to have grown to approximately 11 mm eight months later, and was found to be an infiltrating ductal cancer at rebiopsy. The negative predictive value was calculated as 0.997 (311/312). Analysis of core histologies indicated the followup group was a representative sample. CONCLUSIONS: These data suggest that benign mammographically detected abnormalities can be diagnosed with a high level of confidence using image-guided large-core needle biopsy, and that mammographic or ultrasonographic screening or both at 6 and 12 months might be sufficient before returning the patient to routine screening mammography.