Surgical diseases of the breast during pregnancy

Physicians caring for women with diseases of the breast are well aware of the time lost before many patients consult their physicians. Nowhere is this more apparent than when a breast mass is associated with gestation or lactation. Enlargement of the breast tends to obscure parenchymal masses. Those that are found are too readily attributed to normal hypertrophy, abscess, or resolving fibrocystic disease. In this review we have attempted to focus on the earlier diagnosis and treatment of breast masses in pregnancy. Prompt needle aspiration will elucidate the solid or cystic nature of a mass. A simple cyst or a galactocele can be diagnosed by the fluid obtained. Solid lesions can be further investigated by fine-needle aspiration for cytologic study. Cytologically equivocal lesions should be subjected to excisional biopsy using local anesthesia. Cancerous lesions occurring during pregnancy should be treated promptly by mastectomy. The outlook for these patients, if treated before metastases occur, is comparable to that for nonpregnant patients. Pregnancy need not be terminated unless disseminated cancer is present and chemotherapy is necessary on an urgent basis.     

The accuracy of malignant diagnoses established by fine needle aspiration cytologic procedures of mammary masses

Fine needle aspiration cytologic studies are being used with increasing frequency to diagnose carcinoma of the breast. To determine whether or not a diagnosis of carcinoma established by cytologic examination is sufficiently accurate to proceed to treatment without tissue confirmation, we have examined our results in a series of 109 patients who had 111 aspiration cytologic procedures followed by open biopsy between January 1985 and June 1987. From this group, 39 specimens were read as malignant and 19 were read as suspicious. Thirty-eight of 39 specimens with positive readings were from lesions that proved to be malignant on subsequent open biopsy. Seventeen of 19 suspicious specimens were also from malignant lesions. Three of 17 specimens that were inadequate and nine of 36 negative specimens were from lesions that were later shown to be malignant. Our single false-positive result occurred on cells that had been air dried during preparation in the early months of experience with this technique at our institution. Re-evaluated later in our series, the same specimen was called suspicious rather than malignant. We conclude that a positive reading on fine needle aspiration is highly accurate. The positive predictive value should be 100 per cent, once experience is gained in preparing and interpreting the material. Open biopsy is necessary for inadequate, negative or suspicious specimens to exclude a malignant lesion if the clinical or mammographic findings are consistent with carcinoma.     

Comparison of needle aspiration cytologic diagnosis with excisional biopsy tissue diagnosis of palpable tumors of the breast in a community hospital.

Fine needle aspiration cytologic examination has not extensively been used in our hospital in the work-up evaluation of solid tumors of the breast and its reliability as a basis on which to perform definitive treatment of carcinoma of the breast was in question. One hundred and five aspiration cytologic specimens were obtained from palpable solid tumors of the breast just prior to excisional biopsy. Specimens were numbered and submitted to three different staff pathologists for diagnosis in a single blind manner. Results were then compared with tissue diagnosis of the same tumors. Of 105 specimens taken at biopsy of the breast, 28 malignant lesions were diagnosed on the final tissue report. Of those, ten were diagnosed as malignant (Class V), two were highly suspicious (Class IV) and six were insufficient specimens (Class O). Of those diagnosed as class IV and V by the results of cytologic examination, all were malignant on permanent section for a specificity of 100 per cent and a sensitivity of 36 per cent. The cytologic diagnoses of Classes I, II and III did not correlate with any histologic report, benign or malignant. Malignant growths were misdiagnosed by cytologic examination in 36 per cent and missed because of inadequate specimens in 28 per cent. We believe that a Class V cytologic finding is sufficient basis on which to perform definitive treatment of carcinoma of the breast provided rigid criteria are used. There is a learning curve associated with this diagnostic modality.     

The role of aspiration cytologic examination in the diagnosis of carcinoma of the breast

A study of 2,000 patients who had undergone fine needle aspiration of a solid lump of the breast was conducted to determine the accuracy of this technique. During the period 1982 to 1989, all patients with a solid mammary mass, presenting to a specialized breast unit were initially investigated by fine needle aspiration cytologic examination (FNAC). To date, we present data on 2,000 consecutive aspirations with matching histologic diagnosis on the excised pathologic specimens. In particular, the relationship between tumor histologic factors and the accuracy of cytologic diagnosis was examined. The sensitivity of FNAC in the diagnosis of a malignant growth was 84 per cent; this represents first aspiration results only. The specificity was more than 99 per cent. The rate of acellular or unsatisfactory aspirations was 12 per cent. We had a positive predictive rate for diagnosis in carcinoma of the breast of almost 95 per cent. The diagnosis of lobular and in situ patterns of disease was questioned, with three of three in situ lesions and ten of 23 lobular lesions missed by FNAC. We do not recommend that FNAC replace excision biopsy and frozen section in the diagnosis of carcinoma of the breast.     

Breast aspiration biopsy with multihole needles for histologic and cytologic examination

Multihole needle biopsy has been performed on 166 patients. Commercially available 22-, 20-, 18-, and 16-gauge hypodermic needles (40 to 75 mm in length) are prepared with three sharp-edged holes around the distal part of the needle, allowing aspiration of 3 to 6 ml or more of tissue, for both histologic and cytologic examination. Of patients with carcinoma, fibrocystic disease, fibroadenoma, intraductal proliferation (papillomatosis), and duct ectasia, multihole needle cytologic examination is significantly more accurate (35% to 83%) than single-hole needle examination (11% to 67%). Multihole needle histologic examination, however, is far more accurate, with diagnostic success ranging from 75% to 94% for the disorders described above. The procedure has several uses. For patients with isolated fibrocystic areas, duct ectasia, or papillomatosis, multihole needle biopsy not only is diagnostic but may also be therapeutic by virtue of removal of abnormal tissue by aspiration. Biopsies of areas of microcalcification can be obtained under x-ray control. In patients at high risk of breast cancer (carcinoma in mother and/or sister), breast aspiration is performed when the slightest suspicion arises. In patients with unilateral breast cancer at high risk of bilateral carcinoma (premenopausal breast cancer, lobular carcinoma, tubular carcinoma, family history of breast cancer), random needle biopsy is performed in the contralateral breast for cancer detection. Furthermore, during follow-up of breast cancer patients, biopsies of locoregional changes or suspicious areas in the contralateral breast are obtained with the multihole needle for diagnostic evaluation. Thus multihole needle biopsy represents an improvement over the single-hole needle currently used, with enough tissue provided for adequate initial diagnosis and follow-up diagnostic evaluations in patients with benign and malignant breast disease.     

Fine-needle aspiration cytology accuracy with palpable gynecologic neoplasms

From 1984 to 1988, 62 fine-needle aspirations (FNA) were performed on palpable lesions in 59 gynecologic oncology patients at the UCLA Medical Center. Sites of aspiration included abdomen, cervix, vagina, superficial lymph nodes, and pelvic masses. Confirmatory open biopsy (41) or adequate clinical follow-up (17) was obtained in 55 patients (58 aspirates). FNA correctly established the diagnosis of malignancy in 19 of 26 (73%) biopsied patients. The predictive value for a positive test was 100%, and the predictive value for a negative test was 82%. Initial surgical biopsy had been incorrectly benign in 4 of these patients who were shown subsequently to have malignant tumors by FNA and clinical findings. In 7 patients, FNA failed to diagnose the malignancy found by open biopsy. Two of the false-negative FNAs were insufficient and five were in masses where palpation was inadequate. In 17 patients who were followed clinically without open biopsy, FNA correctly predicted the subsequent clinical course in 15 (88%). There were no false-positive FNA diagnoses obtained when cytologic results were correlated with both clinical outcome and surgical biopsy. Aspiration cytology has a specificity of 100% and a sensitivity of 65%. A negative FNA obtained from a clinically suspicious lesion should be followed by a repeat aspiration or surgical biopsy.     

Diagnosis of carcinoma of the breast by fine needle aspiration cytology

During a six year period, 1,953 fine needle aspiration cytologies (FNAC) were performed for lumps of the breast. Of these, 355 were diagnosed as carcinoma of the breast. The FNAC was performed on an outpatient basis and the pathologic interpretation was available within 30 to 60 minutes. The treatment strategy was always guided by the clinical impression of the physician. If the results of a suspected mass were negative on FNAC, biopsy was performed and histologic study gave the final diagnosis. There were no false-positive results and only 6 per cent were false-negative findings diagnosed later by open biopsy. The over-all accuracy rate was 90 per cent plus 4 per cent diagnosed on cytologic examination as "suspicious" and which proved to be malignant. Based upon our accumulated results, simplicity of performing the test, its low cost, the extremely low morbidity, the immediate response and, above all, an over-all high accuracy rate, we conclude that FNAC is a highly recommended method for the diagnosis of carcinoma of the breast.     

Fine needle aspiration for evaluation of breast masses

PURPOSE OF REVIEW: Fine needle aspiration has been used for many years as a diagnostic tool for breast lesions, with high sensitivity and specificity. There is controversy as to whether this technique should be replaced by other diagnostic procedures such as core biopsy. This review aims to re-evaluate the usefulness of breast fine needle aspiration. RECENT FINDINGS: During the past 10 years many institutions have replaced fine needle aspiration by core biopsy and related techniques such as vacuum-assisted core biopsy and advanced breast biopsy instrument action. Other institutions continue to use fine needle aspiration as a first line of investigation for breast lesions. This technique is especially useful in radiologically benign lesions and when combined with image guidance. The use of the 'triple test' (combined cytologic, clinical and radiologic findings) decreases false-negative and false-positive results. SUMMARY: Fine needle aspiration continues to be an acceptable and reliable procedure for the preoperative diagnosis of breast lesions, particularly in developing countries, and when used as part of the 'triple test'. Accurate diagnosis requires experience in both aspiration technique and specimen interpretation. Clinicians should be mindful of the limitations of the technique. The choice between fine needle aspiration and core biopsy should be individualized for the patient.     

Breast evaluation and diagnosis by obstetrician-gynecologists. Survey of practice patterns.

Surveys of the obstetrician-gynecologists attending the breast disease postgraduate courses at the 1988 and 1990 American College of Obstetricians and Gynecologists annual clinical meetings report a high level of practice involvement in breast disease evaluation and cancer screening for their patients. A consistently high percentage stated they performed regular clinical breast examinations, documented the examinations with a diagram in the medical record, gave breast self-examination instruction, advised screening mammography following the American College of Obstetricians and Gynecologists guidelines, utilized a patient tracking system for follow-up and referred patients with undiagnosed dominant breast masses. Most stated that they did breast cyst aspiration; those who did not mostly referred their patients for cyst aspiration. The accurate and cost- and time-effective office technique of fine needle aspiration of palpable dominant solid breast mass continues to be underutilized even though the procedure has been proven effective and accurate in the cytologic diagnosis of benign and malignant breast neoplasms. Instruction in the technique of fine needle aspiration of palpable breast cysts and solid masses is available in many clinics, workshops and postgraduate courses.     

Needle aspiration cytologic examination in the management of suspicious lesions of the breast

The experience of one surgeon with needle aspiration cytologic examination used as an office procedure in the management of suspicious solid lesions of the breast over a period of seven years in presented. Three hundred and thirty-five aspirations were performed with the diagnosis of carcinoma subsequently established in 126 or 37 per cent of the patients. In 79 of these patients (63 per cent) carcinoma was diagnosed preoperatively by positive needle aspiration cytologic examination only. There were no false-positive results. Thus, this group of patients was spared time and added expense of open biopsy before definitive surgical treatment was instituted.     

Accuracy of mammographic appearances after breast fine-needle aspiration

OBJECTIVE: The objective of this study was to document the observation that fine-needle aspiration of palpable breast masses by use of a modified technique performed shortly before mammography need not adversely interfere with mammographic interpretation nor produce falsely suspicious mammographic lesions that delay meaningful evaluation and management in this breast clinic.STUDY DESIGN: In a retrospective record review 1007 women who were seen in the Breast Diagnostic Center at Women's and Children's Hospital from January 1992 until April 1995 and who had fine-needle aspiration of a palpable solid breast mass within 2 weeks before mammography were analyzed overall and in 10-year age group subsets. The mammographic reports of “suspicious” lesions were correlated with having had a prior fine-needle aspiration (within 2 weeks).RESULTS: Of the 1007 women undergoing fine-needle aspirations, 91 had a cytologic or tissue biopsy specimen diagnosis of malignancy. Of these, 72 had “suspicious” mammograms and 19 had “nonsuspicious” mammograms. The calculated positive predictive value was 58%. The negative predictive value was 98%. Mammographic sensitivity was 79%. Specificity was 94%. Age stratification did not reveal any meaningful trends. Of the 916 patients with benign cytologic results of fine-needle aspiration specimens, 52 had “suspicious” mammograms and 864 had “nonsuspicious” mammograms.CONCLUSION: For patient convenience and expeditious diagnosis of a palpable breast mass, fine-needle aspiration can be performed on the initial visit and mammograms subsequently taken within 2 weeks without undue clinical confusion or misleading mammographic findings. Concordance of the diagnostic triad consisting of (1) clinical impression (by history and examination), (2) fine-needle aspiration, and (3) mammography gives a reliable conclusion and can appropriately be used as the basis for clinical management of a breast mass. However, when there is doubt or anxiety about the diagnosis either on the part of the patient or the physician, a definitive histologic tissue diagnosis should obtained. (Am J Obstet Gynecol 1997;176:1286-92.)     

Aspiration of the breast and nipple discharge cytology

Between 1 January 1974 and 30 June 1984, 1,003 specimens obtained from the breast were submitted for cytologic evaluation to the Department of Pathology at the Waterbury Hospital Health Center. Eighty-eight per cent were obtained by fine needle aspiration of a palpable mass; the remainder were smears of nipple discharges. Precytologic and postcytologic clinical data were available for 80 per cent of the specimens. In the fine needle aspiration group, there were 219 instances of proved carcinomas; 79 per cent of these had either positive or suspicious cytologic findings. Seventy-five per cent of the patients with positive cytologic results underwent mastectomy without prior histologic confirmation of the needle aspiration and all were confirmed as malignant growths. There were 41 false-negative aspirates which were reviewed in detail. The cytologic slides of 24 of the 41 false-negative aspirates were available for re-evaluation by a second, independent cytopathologist. Only one was thought to have been misread initially; the remainder appeared to have been falsely negative for technical reasons related to aspiration or fixation technique or tumor size less than 1 centimeter. There was one false-positive finding in a patient who was found to have fat necrosis at biopsy. Results of nipple discharge cytology were less accurate. Positive or suspicious cytology was found in only five of 11 proved instances of carcinomas. There was one false-positive and five false-negative results in this group. We conclude that needle aspiration of palpable masses of the breast is an accurate, cost effective procedure which is readily adaptable to a community hospital, provided that a pathologist with an interest in cytology is available.     

Ultrasound-guided biopsy of non-palpable breast lesions: correlation with the results of fine-needle aspiration biopsy

PURPOSE: The purpose of this study was the clinical evaluation of ultrasound-guided biopsy in comparison with ultrasound-guided fine-needle aspiration biopsy of identical, non-palpable breast lesions. MATERIALS AND METHODS: From August 1997 until July 1998, 73 ultrasound-guided biopsies were performed in 66 patients with non-palpable lesions of the breast. In 18 patients (age 33-77 years) with 20 non-palpable lesions, fine-needle aspiration biopsy (20-G needle) and biopsy (18-G biopsy needle) were performed on a single occasion. This was the patient selection of our retrospective study. RESULTS: One malignant neoplasm was found among the 20 biopsied lesions, while the remaining 19 lesions were of a benign nature. In 20% of the cases, the material obtained by fine-needle biopsy was not sufficient for a cytologic diagnosis, while biopsy allowed a diagnosis in 19/20 cases. No complications were observed. CONCLUSIONS: Ultrasound-guided biopsy using an 18-G needle is a suitable method for the evaluation of non-palpable lesions that are only visible on ultrasound. It represents an attractive alternative to fine-needle aspiration in the absence of experienced cytologic diagnosticians.     

Mammographic and histopathologic correlation of nonpalpable lesions of the breast and the reliability of frozen section diagnosis

During a period of ten years, 118 (32.9 per cent) instances of carcinoma were found in 359 specimens taken at biopsy for nonpalpable mammographic lesions. In recent years, the positive predictive value has increased from 68 per cent due to the development of magnification mammography and the use of a mammographic grid. Correlating mammographic and histopathologic data, the rate of malignant disease was 12.7 per cent for instances of a circumscribed or nodular mass, 32.4 per cent for clustered microcalcifications as the only suspect finding, 28.6 per cent when a mass with microcalcifications was present and 66.7 per cent when a stellate-shaped mass was found. Of 188 instances of carcinoma, 40 were noninvasive: 32 instances of ductal carcinoma (27.1 per cent) and eight of lobular carcinoma in situ (6.8 per cent). The possibility of frozen section diagnosis was studied retrospectively by comparison with the paraffin section reports. A correct diagnosis, whether benign or malignant, was achieved in 68 per cent. No frozen section examination was done in 17.3 per cent and the diagnosis was deferred to results of paraffin section in 12.2 per cent. False-negative results were encountered in seven patients (1.9 per cent) and false-positive results in two (0.6 per cent). Both of these patients had florid sclerosing adenosis. Although frozen section diagnosis is feasible in nonpalpable lesions of the breast, it is recommended that this method not be used in instances of pure microcalcifications and tiny solid masses of 5 millimeters or less.     

The initial evaluation of masses of the neck by needle aspiration biopsy

Needle aspiration biopsy for cytologic study is a simple, safe and accurate procedure for evaluation of cervical masses. It is a valuable initial step for evaluation of undiagnosed neck masses and is most efficacious for follow-up evaluation of patients previously treated for cancer. The procedure does not interfere with subsequent treatment. Information obtained from aspiration cytologic findings is used to plan subsequent evaluation and treatment in the simplest and most cost effective manner.     

A prospective study of double diagnosis of nonpalpable lesions of the breast.

Approximately three-fourths of open biopsies of the breast performed for mammographically detected suspicious lesions are shown histologically to be benign. Under the narrow conditions described herein, stereotaxic fine-needle aspiration (FNA) can identify these lesions with an accuracy of more than 90 per cent and a false-negative rate of 5 per cent. In an effort to reduce this failure rate, the mammographic appearance and stereotaxic FNA results of these lesions each were given scores on a scale of zero (benign) to five (malignant), to derive an over-all risk score prospectively applied to 264 suspicious occult lesions of the breast prior to open, biopsy. While all 264 lesions could be assigned a mammographic score, adequate tissue for assignment of a cytologic score could be obtained from 150 lesions. Of the 150 evaluable lesions, 53 were malignant and 97 were benign, historically. With a total score of two as the threshold for open biopsy, 21 of 150 (14 per cent) were proved to be benign, with no false-negative findings. If the total threshold score mandating an open biopsy was raised to four, the comparable figures were 61 of 150 (40 per cent) benign lesions and two false-negative instances of carcinoma in situ. Provided adequate tissue is aspirated for cytologic examination, we conclude that this algorithm has practical value in the management of nonpalpable lesions of the breast in that it can reliably identify a fraction of the benign lesions and spare these patients an operation.     

The predictive value of needle localization mammographically assisted biopsy of the breast

This study was done to review critically the experience at the University of California at San Diego in needle localization mammographic biopsy of the breast with regard to use and accuracy in identifying early carcinoma of the breast. Ninety-seven patients underwent needle localization mammographic biopsy of the breast between 1985 and 1987. Indications for this procedure included the presence of microcalcifications or a mass shown on mammographic examination, or both, in conjunction with physical examination which did not define a discrete abnormality in the area. Mammographic, demographic, pathologic, hormone receptor data and staging information were recorded and processed on the MicroVax II computer (Digital Equipment Corporation). Twenty-four per cent of lesions with needle localization mammographic assisted biopsy proved to be malignant. Sixteen lesions were diagnosed as an infiltrating ductal carcinoma and ten of these had an accompanying intraductal carcinoma. Over-all, intraductal carcinoma was present in 16 of the 23 specimens diagnosed as malignant. At biopsy, the margins were clear in 17 of 23, and vascular invasion was present in only one patient with an infiltrating lobular carcinoma. Five were tumor in situ, 12 were stage 1 and five were stage 2 (staging information was not available in one instance). Hormone receptor data were available in 17 of 23 specimens. Estrogen receptors were positive in 13 and progesterone receptors were positive in six. The smallest preinvasive malignant lesion was 4 millimeters, as seen on the mammogram, and the smallest free-standing invasive lesion was 8 millimeters. Preinvasive lesions (intraductal) presented as microcalcifications in 80 per cent. Invasive lesions presented as either a mass (n = 9) or as a mass and microcalcifications (n = 5) in 81 per cent. All five lesions presenting as both a mass and microcalcifications on mammogram proved to be malignant. Multifocal lesions on mammographic examination which proved to be malignant were multifocal pathologically in only 50 per cent. Needle localization mammographic biopsy is useful in detecting early carcinoma of the breast. Biopsy should be done on lesions presenting on mammogram as both a mass and microcalcifications and not observed. Focality of lesions on mammogram does not correlate with focality on biopsy and may be misleading as criteria for operative planning.     

Palpable abnormalities of the breast not requiring excisional biopsy.

The evaluation of a patient with a palpable abnormality of the breast typically includes physical examination, mammography and fine needle aspiration biopsy (FNAB) with cytologic interpretation of the aspirate. If the findings of these three diagnostic modalities are negative for malignancy, the current standard of care is to proceed to surgical biopsy to confirm the benign nature of the lesion. The current study was done to identify a subset of patients who could be safely observed without surgical (histologic) biopsy. These patients fulfilled specified criteria on physical examination, mammogram and needle sensation when the FNAB needle entered the lesion. Results of the cytologic studies of the FNAB were used as a corroborative rather than as a diagnostic test. Of 305 patients with mammary abnormalities, 106 were identified with "subsuspicious" lesions. Seven of the latter patients underwent surgical biopsy, four because the results of cytologic studies of FNAB revealed cytologic atypia. One of the four patients had infiltrating ductal carcinoma. All other patients have had follow-up evaluation for a mean of 61 months (range of 43 to 74 months). No carcinomas have developed at the subsuspicious site. The current study is the first to clearly define a subset of patients with palpable abnormalities of the breast who do not require surgical biopsy.     

Erosive adenomatosis of the nipple

First rule out galactophoric carcinoma underlying all the erosions of the nipple or a breast tumor. A 52-year-old woman consulted for a right breast tumor that had developing for more than four years due to a serious nipple flow. Physical examination disclosed an ulcer tumor of the nipple and the superior quadrant of the areole. Mammography and mammary ultrasound found a mass texture suspected of malignity. Needle aspiration produced a white fluid. Wide tumor resection was performed. The histological analysis led to the diagnosis of erosive nipple adenomatosis. The patient had recovered at 34 months. Erosive adenomatosis of the nipple is a benign tumor which developing within the lactic nipple. Clinically, the differential diagnosis is breast carcinoma, Paget disease and galactophoric dilatation. Pathology is required for certain diagnosis. The treatment is usually surgical. Erosive adenomatosis of the nipple is very rare and should be suspected in patients with nipple erosions or a nipple tumor. The prognosis is excellent.     

Diagnostic considerations in breast disorders of children and adolescents.

A review of the medical literature on breast disorders in children and adolescents leads to a number of conclusions. Though females may develop breast masses early in life, the risk of malignancy is extremely low. Therefore, most breast masses in the young can be managed conservatively without surgery. Breast masses in young girls may represent thelarche or tumors of adjacent structures, but are unlikely to be malignant. The most common form of bilateral breast enlargement in prepubertal girls is premature thelarche, a benign, transient, and incomplete form of precocious puberty. Fibroadenoma is the most common cause of breast mass in female adolescents. In the rare case in which a breast mass in this population is malignant, it is more likely to be a noncarcinomatous or metastatic cancer. Because of the low risk of malignancy and the relatively different composition of the adolescent as compared to the adult breast, mammography is not recommended for routine screening or routine imaging of breast masses in adolescents. The role of breast self-examination should be further studied.