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.     

Stereotaxic localization for fine-needle aspiration breast biopsy. Initial experience with 300 patients.

The efficacy of stereotaxic aspiration biopsy was evaluated in 300 consecutive patients with nonpalpable mammographic lesions. Sixty-eight patients (23%) had suspicious or malignant aspirates; all cases were proved malignant by subsequent examination of operative specimens. Two hundred sixteen patients (72%) had benign aspirates. Of these, 65 were confirmed by operation and 151 had subsequent mammography at 6- and 12-month intervals with no demonstrable mammographic change. In 10 instances (3%), the aspirates were atypical, and in six (2%), nondiagnostic. Biopsy specimens were obtained in all 16 instances, and eight were malignant. The sensitivity of stereotaxic breast aspiration for the diagnosis of cancer was 96%, and the specificity was 100%. Our experience confirms the efficacy of stereotaxic aspiration for the initial evaluation of mammographically detected, nonpalpable lesions.     

A single institution review of new breast malignancies identified solely by sonography

BACKGROUND: The role of sonography as a sole identifier of breast malignancy remains undetermined. Currently, the American College of Radiology Imaging Network (ACRIN) trial, protocol 6666, is accruing high risk patients, with dense breast tissue on mammography, to evaluate the performance of screening sonography. STUDY DESIGN: We conducted a retrospective single institution review to identify the detection rate of nonpalpable, mammographically occult breast malignancies identified solely by sonography. RESULTS: A total of 34,694 breast sonograms were performed at our outpatient radiology affiliate between April 1998 and April 2006. This number includes unilateral and bilateral examinations, and, 6-month followup examinations. Computerized databases and individual charts were retrospectively reviewed. Sonographic and mammographic findings were compared to determine concordance of identified lesions. Four thousand ninety-one ultrasound guided biopsies, (fine needle aspiration biopsy [FNA] and core needle biopsy [CNB]) were performed over the 8-year period, and 452 malignancies were identified. Discarded fluid contents of pure cyst aspirations were not included in this number. Seven percent (32) of the biopsy-proved malignancies were mammographically occult, of which 59% (19) were palpable, and 31% (10) were not palpable. Of all cancers diagnosed, 2.2% were identified solely by sonography. The number of cancers identified solely by sonography relative to the total number of sonograms done was 0.03%. CONCLUSIONS: Given these results, we advocate the selective use of sonography in appropriate populations, namely, in those with palpable findings, mammographic abnormalities, and in women with dense tissue who have personal or family history of breast cancer.     

Comparative Value of Mammography,Fine-Needle Aspiration Biopsy,and Core Biopsy in the Diagnosis of Invasive Lobular Carcinoma

Abstract: Invasive lobular carcinoma of the breast (ILC) is a lesion often cited as being more difficult to diagnose than invasive ductal carcinoma. Our objective was to assess the role of mammography, fine-needle aspiration biopsy (FNAB) and large core needle biopsy (LCNB) in the diagnosis of invasive lobular carcinoma of the breast. We reviewed 1,074 consecutive patients with invasive cancers of the breast, of which 102 (9%) were ILC. All the patients with ILC had mammography, 66 had FNAB, and 15 had LCNB performed. Of the patients with ILC, 95 of 102 (93%) had an abnormal mammogram. Seven patients (7%) had a negative mammogram. The most common radiographic finding in patients with ILC was a spiculated mass (42%). The average size of the cancers detected by mammography was 1.17 cm, with no significant effect of size on the ability to detect cancer based on its mammographic presentation for p > .05. Sixty-six patients had FNAB, with a postive diagnosis of cancer in 27 (41%) and suspicious or atypical aspiration in 20 patients (30%). Nineteen patients (28%) had false-negative aspirates. There was no significant difference in size for patients whose cytology demonstrated malignant, suspicious, atypical, or benign aspirates, F (4,56) = 1.01, p > .05. For the fifteen patients who had LCNB, a definitive diagnosis of ILC was made in 13 cases (87%), with another patient having a diagnosis that was “suspicious” for ILC. One patient had a false-negative LCNB. ILC can be detected by mammography, in most instances. FNAB may fail to diagnose this cancer, particularly if the cancer is of low nuclear grade. The lack of reliability of FNAB for diagnosis of ILC, which may occur in some cases is due to the discontinuous infiltrative pattern and the intrinsic cytologic characteristics of this cancer. LCNB is a complementary diagnostic procedure when the FNAB is nondiagnostic to demonstrate the presence of ILC. In the presence of a dominant mass by palpation and a clinical suspicion of the presence of ILC, a negative mammography or a benign FNA should not preclude a surgical biopsy.     

Clinically occult breast carcinoma: Diagnostic approaches and role of axillary node dissection

Background: Nonpalpable breast lesions are being detected with increasing frequency with the advent of improved mammographic techniques. Although only 20–30% of these lesions are malignant, definitive diagnosis has usually required a needle-localization excisional biopsy, which is costly and increases the psychological stress on the patient. The purpose of this retrospective study was to determine the sensitivity of ultrasound-guided fine-needle aspiration (FNA) biopsy of nonpalpable breast masses and the incidence of axillary nodal metastases in these subclinical lesions. Methods: Seventy-one patients treated for clinically occult malignant breast tumors between 1985 and 1992 were identified. Charts were reviewed to determine the accuracy of breast ultrasonography in detecting occult mass lesions and whether ultrasound guidance improved the accuracy of FNA biopsy. In addition, the incidence of axillary lymph node involvement was noted. Results: Of the 71 malignant tumors, 35 were in situ and 36 were invasive. The median diameter was 0.5 cm for noninvasive lesions and 0.8 cm for invasive tumors. A mass was seen on mammography in 32 (45%) patients, microcalcifications were seen in 36 (51%), and both a mass and microcalcifications were seen in three (4%). Of the 30 patients who underwent an axillary node dissection, 4 (13%) had disease-positive nodes. Ultrasound-guided FNA was performed in 15 patients with a mass lesion, with a sensitivity of 93%. Conclusions: These results indicate that ultrasound-guided FNA cytologic analysis is an accurate diagnostic technique even in small (<1 cm), mammographically detected breast masses. In addition, the incidence of axillary nodal metastases indicates that an axillary lymph node dissection should be performed in invasive lesions, even those <1 cm in diameter.     

Stereotaxic needle localization and cytological diagnosis of occult breast lesions.

A stereotaxic technique for localization of occult breast lesions and fine needle aspiration for cytological diagnosis was used on examination of 543 patients. Successful localization with the needle tip within 1 mm of the suspected lesion was possible in 490 patients (90.2%). Based on a high mammographic index of suspicion for malignancy, 187 of 490 patients were selected to undergo open biopsy, following aspiration cytology and localization with methylene blue injection. The statistical results (cytologic vs. histologic examination) revealed a sensitivity of 97.5% and a specificity of 95.2% for cytologic diagnosis of occult breast lesions. The technique is easy to learn and takes 20-30 minutes to perform. Compliance was 100% and complications were nil. This new technique expedites localization and maximizes the specificity of mammography for occult breast lesions.     

Association of breast cysts and breast cancer

A review of 915 consecutive patients with breast cancer and 812 with breast cysts showed that an association between the two is uncommon--5% of breast cancers were associated with cysts and 4% of cysts were associated with breast cancer. Four types of association were identified: (a) cystic cancers--easily diagnosed because of the characteristic features of the aspirate, failure of the mass to disappear and early recurrence in a patient whose age and menstrual status were not usually associated with cysts; (b) cancers occurring simultaneously with breast cysts--recognized because they did not contain cyst fluid; (c) cysts occurring after breast cancer--diagnosed by aspiration of the mass in premenopausal women; (d) cancers in patients who have had breast cysts--usually occurring many years after the cyst aspiration when menses had ceased. These associations were not sufficiently frequent to justify specific follow-up, but all suspected cysts should be successfully aspirated to confirm the clinical diagnosis.     

Management of nonpalpable ultrasound-indeterminate breast lesions

BACKGROUND: A series of such lesions was studied to determine the validity of applying criteria routinely used to manage palpable breast cysts to the management of mammographically detected, nonpalpable breast lesions characterized as indeterminate on ultrasound (US). METHODS: The clinicopathologic data from a series of 134 patients who underwent US-guided fine needle aspiration biopsy for nonpalpable, mammographically detected breast lesions, categorized as indeterminate on US, were reviewed. RESULTS: Of 139 indeterminate lesions, 78 were consistent with complex cysts, whereas in 61, the cystic-versus-solid nature was indistinguishable. All 71 complex cyst lesions that contained nonbloody fluid and resolved completely were benign. Two of 7 complex cyst lesions that had incomplete resolution, bloody aspirate, or both were malignant. Of 61 cystic-versus-solid lesions, 29 and 32 were primarily solid and cystic, respectively. Three of the 29 solid lesions were malignant. Of the 32 cystic lesions, all 26 that contained nonbloody fluid and resolved completely were benign, whereas 1 of 6 lesions that had incomplete resolution, bloody aspirate, or both was malignant. CONCLUSION: Criteria such as complete resolution and nonbloody aspirate are an effective adjunct to the management of nonpalpable, mammographically detected breast lesions categorized as indeterminate by US.     

Cystic supratentorial gliomas: natural history and evaluation of modes of surgical therapy

The management of cystic supratentorial gliomas is hampered by lack of documentation of the natural history of these lesions and by a lack of evaluation of modes of surgical therapy. We analyzed these factors in 25 patients with solitary cysts operated upon over a 20-year period. Two distinctive patterns of symptoms were seen: short duration (increased pressure and hemiparesis), most often heralding a malignant lesion, and long duration (commonly seizure disorder), associated more often with a benign pathological condition. Large solitary cysts were found in tumors of all histological grades. Surgical procedures included extirpation, biopsy/partial resection, cyst communication to ventricle or marsupialization, burr hole aspiration, aspiration via an indwelling reservoir, and cyst-peritoneal shunting. Radiotherapy, given in all cases, did not prevent cyst recurrence. Of the 25 patients, 76% are alive and remain cyst free at follow-up intervals of 1 to 16 years (mean, 3.2). Five patients died from their tumors, with a mean survival of 33 months after decompression. In 7 of 8 patients with cysts largely or entirely within the basal ganglia or thalamus, successful operative cyst control was achieved. Patients with solitary cystic gliomas seem to have a favorable prognosis, and vigorous efforts to control cyst recurrence and limit disability are warranted. Analysis of our data suggests that craniotomy for tumor resection, cyst decompression, and tissue diagnosis is the initial procedure of choice. Cyst recurrence without major solid tumor should be controlled by computed tomography-guided tap or shunt drainage. Reexploration is indicated when cyst reaccumulation is accompanied by clear regrowth of a solid component.     

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.     

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.     

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.     

Sonographic Evaluation of Clinically Palpable Breast Cancers Invisible on Mammography

Abstract: The purpose of this study was to determine the utility of sonography in the evaluation of palpable breast cancers invisible on mammography. A retrospective review of the pathology department's database was used to identify patients with palpable breast cancers. Consecutive patients that had excision between January 1992 and September 1997 were included. Mammograms and breast ultrasounds were reviewed retrospectively and correlated with pathologic and surgical findings. During the study period 298 women presented with a palpable breast cancer for imaging at our institution. Of these, 38 cancers (12.8%) were not seen on mammography. In 32 patients where no mammographic abnormality was found, ultrasound was able to detect a mass corresponding to the area of clinical concern. Histologic tumor types included 30 invasive ductal carcinomas, 5 ductal carcinomas in situ, and 3 invasive lobular carcinomas. Mammographic density was mild with scattered fibroglandular densities in 2 (5%), heterogeneously dense in 12 (32%), and extremely dense in 24 (63%). Thirty-one masses (97%) were hypoechoic and 1 (3%) was echogenic. Lesion margins were irregular in 23 (72%), lobulated in 5 (16%), and well-circumscribed in 4 (12%). In this group of patients the combination of mammography and ultrasound of the mass demonstrated 99% of the palpable cancers. In patients presenting with a breast mass on physical examination in whom mammography fails to demonstrate an abnormality, supplemental ultrasound is helpful in most instances to further characterize the lesion.     

Which breast to biopsy: an expanding dilemma.

To provide insight into the significance of findings reported from screening asymptomatic women for breast cancer, we reviewed 19,928 mammographic studies with the accompanying physical examination and correlated these findings with 554 breast biopsies. Of 83 breast biopsies with suspicious findings on both physical examination and mammography, 72 demonstrated breast cancer (87%). Of 155 biopsies for suspicious changes on mammography alone, 50 (32%) demonstrated breast cancer. The accuracy of suspicious mammography was independent of findings limited to physical examination, 34 (17%) had breast cancer; 31 were in 152 biopsies of patients with mammography interpreted as normal (20%) and three were in biopsies of 52 patients (6%) in whom a visualized mass was interpreted as benign. One hundred and twelve breast biopsies were performed for changes interpreted as normal or benign. Six malignancies were discovered (5%). No cancer was found in 31 biopsies for nonpalpable benign mammographic abnormalities. Our results emphasize the importance of discriminating between nonvisualization of a mass and mammographic recognition of either a benign or malignant tumor. The reliability of interpretation is considerably greater for a visualized lesion than a nonvisualized one.     

Cytological study of fluid from breast cysts.

A series of 215 patients with breast cysts have provided 348 specimens of cyst fluid for cytological diagnosis. Only one of these specimens was reported positive for malignant cells and this patient had a carcinoma. Nine specimens were reported as suspicious, but none of these patients had or subsequently developed carcinoma. In 338 specimens cytology was negative. A total of 178 patients (294 specimens) was available for follow-up. Of these 2 proved to have carcinomas on immediate follow-up, i.e. a lump presisted after aspiration, and a further 2 patients developed cancers in the same breast, one 4 and the other 7 years after aspiration. We therefore conclude that the routine submission of breast cyst fluid for cytology is wasteful of time and resources.     

超声与钼靶摄片对乳腺癌早期诊断的意义

目的： 评估超声与钼靶摄片检查在乳腺癌早期诊断中的作用,以提高乳腺癌的早期筛查效率。 方法：收集乳腺癌早期诊断的女性患者528例临床资料,其中经B超查出隐匿性乳腺癌132例,经钼靶摄片查出乳癌病灶396例。比较两种检查方式获得初步诊断的乳腺癌患者的临床与影像学特征、手术方式与组织病理学特征、分子生物学标志物与分型的差异。 结果：两者比较显示,绝经前、年青、汉族（相对维吾尔族）女性及致密乳房组织和影像学BI-RADS 4级的乳腺癌超声检查较钼靶摄片更易检出（均P<0.05）;超声检查较钼靶摄片检出的患者更多实行保乳手术,且淋巴结转移阳性率较低,更易发现单发、直径≤1 cm、分化较好的乳腺癌及早期阶段的浸润性乳腺癌（均P<0.05）;超声检查对ER（+）、luminal A乳腺癌检出率高,而钼靶摄片对Her-2（+）、Her-2型乳腺癌检出率高（均P<0.05）。 结论：超声检查较钼钯摄片更容易发现致密乳房组织中的侵袭性与恶性程度较低的早期癌灶,对于检出不同分子分型的早期乳腺癌两者各有优势。故联合应用更利于乳腺癌患者早期筛查。     

Follow-up of patients with aspirated breast cysts is necessary

A review was conducted of 401 women who presented with breast lumps that proved to be cysts by yielding fluid on aspiration. The aim was to determine the proportion of patients with cancers that masqueraded as cysts and to establish whether short-term follow-up was necessary. After the first visit, six patients had biopsies because of a residual mass or a bloodstained aspirate. Of these patients, two were found to have cancer. After the follow-up visit, 20 further biopsies were carried out for presence of a mass, bloodstained fluid, or recurrent fluid, and two more cancers were diagnosed. Of the four patients with malignancy, only one had an intracystic carcinoma, two had necrotic grade 3 ductal carcinomas, and one had a malignant phyllode tumor. These findings underline the value of a single return visit after cyst aspiration.     

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.     

Use and abuse of mammography in the early diagnosis of breast cancer

In the 8 years before 1980, 3958 women were examined in the St. Michael's Hospital breast clinic in Toronto. Of 302 women with breast cancer, 87 (29%) had normal mammograms. Breast cancer was found in 34 after at least one clinical and mammographic examination had given normal results. Of these, 6 (18%) cancers were detected only by mammography while, paradoxically, 23 (68%) were detected only by clinical examination. Normal mammograms are significantly (p less than 0.001) more frequent in young women with breast cancer and in those with small palpable breast cancers. Mammography is most productive when used as a routine study in older women who have clinically normal breasts. All women should start having them around the age of 40 to 45 years. How often they should be repeated is debatable. There is no evidence that they should be repeated annually. Under 35 years of age mammography for any reason is unrewarding. Biopsy of a breast lump that is solid on aspiration should never be delayed because of a normal mammogram. Biopsy of a radiologically suspicious lesion in the breast should never be delayed because the findings on clinical examination are normal.     

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.