Stereotaxic breast biopsy techniques have become the standard of care for mammographically suspicious lesions

An optimal technique for the evaluation of nonpalpable, suspicious mammographic lesions should have a low technical failure rate, no false-negative results and should remove the lesion completely. Since most of these lesions are benign, the procedure should be carried out in an outpatient setting without general anesthesia. Cancer is missed in 2.6% of cases with excisional biopsy following needle localization. Furthermore, 50-83% of these patients undergo a second surgical intervention for definitive surgical treatment. In contrast, the rate of missed cancers is less than 0.7% following stereotaxic core or large-core biopsies. However, using these techniques, discordant results and histologic high-risk lesions need to be recognized and reexcized. The cost-effectiveness of stereotaxic vacuum-assisted core biopsy has been demonstrated. Stereotaxic breast biopsy techniques such as vacuum-assisted core biopsy and large-core biopsy for suspicious mammographic lesions have low false-negative rates and result in few histologic underestimations.     

Mammography in the detection, diagnosis and management of carcinoma of the breast

Mammography is a major advance and essential in the earlier detection, diagnosis and management of carcinoma of the breast and should be more widely applied. Although mammography is at least as important as palpation and the only means of detecting nonpalpable lesions, both examinations are most effective as complementary procedures. A breast operation for suspected carcinoma should never be done without preoperative mammography. Mammographic needle localization and biopsy roentgenography are extremely useful, if not essential, in the surgical management of nonpalpable lesions.     

Open surgical biopsy for nonpalpable breast lesions detected on screening mammography

The aim of this retrospective clinical study was the analysis of histologic findings of nonpalpable breast lesions managed by open surgical biopsy. A series of 630 women underwent 664 preoperative localizations of nonpalpable, mammographically detected breast lesions during the last 10-year period. Indications for biopsy were (1) clustered microcalcifications, (2) solid mass, and (3) radiologic parenchymal distortion. The lesions were localized preoperatively using hook-wire methods, and all biopsies were performed under general anesthesia. Histopathology revealed carcinoma in 172 (25.9%) cases; noninvasive in 114 (66.3%) cases and infiltrating in 58 (33.7%) cases. The highest malignancy rate was found in cases with microcalcifications (112 carcinomas out of 323 cases, 34.7%). Lymph node invasion was present in 25% of patients with invasive cancers. The hook-wire localization of nonpalpable breast lesions is a simple, accurate and safe method for detection of early breast cancers. Frozen section is feasible and accurate in the majority of these lesions, and therefore, diagnostic and therapeutic one-step surgical procedures could be performed.     

Needle localization and biopsy of nonpalpable lesions of the breast

Two hundred and three consecutive needle hookwire guided biopsies for nonpalpable lesions of the breast were performed upon 174 patients over a three year period. Patients ranged in age from 25 to 83 years (a mean of 55.4 years). Malignant growths of the breast were found in 44 of 203 specimens taken for biopsy. Sixty-six per cent of malignant lesions were in situ and 34 per cent were invasive carcinoma. The chance of a biopsy containing a malignant lesion was 17.5 per cent if the biopsy was done because of a discrete density on mammography, 22.1 per cent for microcalcifications and 29.6 per cent if both were present. The incidence of Stage I disease in 24 patients undergoing dissection of the axillary lymph node was 79.2 per cent. Specimen roentgenography was done in 165 biopsies. Anesthesia time was increased an average of 5.8 minutes by specimen roentgenography. In 198 instances, the mammographic lesion was present in the specimen taken for biopsy intended to remove it. Minor complications of needle hookwire insertion occurred in two patients. The mortality rate was nil.     

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.     

Wire localisation biopsy of non-palpable breast lesions: reasons for unsuccessful excision

Surgical excision following needle-wire localization of nonpalpable, mammographically detected breast lesions is a very valuable diagnostic and therapeutic procedure. No further treatment is usually required after establishing an accurate histological benign diagnosis of indeterminate lesions on preoperative assessment. On the other hand, ductal carcinoma in-situ (DCIS) and early invasive cancer, properly excised, may sometimes require further management depending on specific histologic findings. An uncommon problem of this procedure is the failure to identify, localize or excise the breast lesion. In this review article, factors that contribute to the failed needle localization procedure are presented.     

Aktuelle Leitlinien zur interventionellen Mammadiagnostik

Minimally invasive diagnostic procedures for the breast under mammography, ultrasound, and magnetic resonance guidance have led to a higher specificity of imaging techniques and a decrease in open biopsy of the breast. The percutaneous approach is more cost and time effective and reduces morbidity compared with open biopsy. The “Step-3-guideline for early breast cancer detection in Germany” represents the first national guidelines for a nationwide, quality assured, early breast cancer detection program, including recommendations for minimally invasive breast diagnostics. Indications for ultrasound guided vacuum biopsy of the breast are summarized in the “Consensus on the use and technique of vacuum-assisted sonographic breast biopsy” by the Study Group on Minimally Invasive Breast Interventions (AG MiMi) of the German Society of Senology (DGS).     

Localization and management of occult breast lesions

Mammography is an effective method for finding lesions of the breast which are occult at clinical examination. For occult lesions biopsy, including as little surrounding tissue as possible, it is necessary that they be located before surgery in order to improve the pathological process and the cosmetic outcome for the patients. Among the clinically occult lesions shown only by mammography, the frequency of breast cancers ranges from 10% to 47%. There are several different techniques for locating hidden lesions of the breast. We have employed the insertion of a single rigid needle into the breast, with X-ray confirmation of correct positioning. Forty-nine patients underwent this technique in our Institution and in all cases we were able to achieve a correct insertion of the needle at the X-ray check (the tip of the needle was less than 1 cm from the lesion). The target lesion was removed (as confirmed by X-ray of the surgical specimen) in all cases at the first attempt. In our study we found 11 invasive and 7 in situ tumours (36%). No complications delaying the surgical biopsy or the recovery of the patients were observed.     

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.     

Technique and interpretation of breast aspiration cytology

FNA biopsy as a diagnostic modality in breast lesions (palpable and nonpalpable) is a safe, rapid, cost-effective, and accurate method of diagnosis of breast pathology, which is beneficial to the patient, clinician, and cytopathologist. This diagnostic service has become an integral part in the workup of breast lesions in the practice of medicine today.     

The role of mammography in the diagnosis of breast cancer: Survey in a community hospital

Mammography does not replace a good physical examination, and it does not replace clinical indications for a breast biopsy. It may, however, supply important diagnostic information. In order to detect early lesions of the breast, an optimal approach would consist of a routine breast examination every 6 months and a mammography every year. A clinically suspect breast lesion should always be biopsied, regardless of the mammographic interpretation.     

New and old procedures in the diagnosis of dubious breast lesions

In the last years the detection of early breast cancers (lesions less than one centimetre in diameter, with good prognosis) has consistently increased for the wide application of mammary screening programs. At the same time, an increasing number of radiographically detected unexpected lesions (nonpalpable breast lesions) has been evidenced. In those cases, often both mammography and ultrasound evaluation are dubious and a multidisciplinary diagnostic approach is mandatory. Fine-needle aspiration (FNA) and core biopsy (CB) are well established diagnostic methods but, in recent years, new microinvasive bioptic procedures (as the Mammotome and the ABBI systems) have been introduced. In this review the limits and the possibilities of the classical and new cytohistological techniques are evaluated. A possible multistep diagnostic approach is described on a cost-benefit basis and in consideration of the various procedures.     

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.     

Clinical experience with percutaneus large-core needle biopsies of the breast and evaluation of cytopathological and histopathological results

OBJECTIVE: Core needle biopsy (CNB) allows a microinvasive diagnosis of breast lesions. We investigated whether imprint cytology of CNB specimens is a useful method of rapidly obtaining additional diagnostic information. MATERIAL AND METHOD: During five years 46 218 breast examinations for 23 300 patients were performed. 563 patients were examined by CNB. The results of imprint cytology were compared with the histopathological results. Statistical analysis was done for all patients who underwent subsequent surgery. RESULTS: 195 of 563 patients were treated surgically. 155 patients exhibited malign lesions. 40 patients showed benign breast lesions. Four patients with malign findings in imprint cytology and histopathology of CNB were treated conservatively. Imprint cytology had a sensitivity of 0.89, specificity of 0.88, positive predictive value of 0.96 and negative predictive value of 0.67. Histopathology revealed a sensitivity of 0.90, specificity of 0.95, positive predictive value of 0.98 and negative predictive value of 0.70. 364 patients with benign findings in imprint cytology and histopathology were controlled subsequently. One of these patients developed five month later an invasive ductal tumor. CONCLUSION: Imprint cytology of CNB is a reliable method to obtain additional diagnostic information. Inadequate and suspicious cases should be evaluated based on complementary diagnostic procedures for breast lesions.     

Mammary ductoscopy for the evaluation of nipple discharge and comparison with standard diagnostic techniques

STUDY OBJECTIVE: To describe performance of breast duct endoscopy and compare the method with conventional diagnostic techniques. DESIGN: Canadian Task Force classification III. SETTING: Interdisciplinary Breast Unit of a university hospital. PATIENTS: Consecutive and unselected series of 15 female patients including 20 breasts with nipple discharge. INTERVENTIONS: Prospective data assessment on all patients with ductoscopy for nipple discharge between April 2003 to April 2004. All preoperative (mammography, ultrasonography, nipple smear) and minimally invasive (galactography, fine needle aspiration cytologic study) diagnostics were evaluated and compared with ductoscopy. MEASUREMENTS AND MAIN RESULTS: Mammography on 20 breasts showed BI-RADS-I (5%), BI-RADS-II (50%), and BI-RADS-III (45%). Breast ultrasound scanning showed abnormalities, classified as BI-RADS-III equivalent lesions in all cases. Nipple smear showed in 69.2% a normal cytology and in most cases revealed a papilloma later (n=8/9). Unilateral galactography was performed in 46.7% who had spontaneous nipple discharge. Two galactography results were unremarkable, and open biopsy demonstrated 1 atypical ductal hyperplasia and papilloma. On 20 breasts of 15 women, 19 ductoscopies were successfully performed (95%). In 17 cases open biopsy followed ductoscopy, and 1 ductal carcinoma in situ (DCIS), 3 atypical ductal hyperplasia (ADH), 1 ductal hyperplasia without atypias, and 12 ductal papillomas were found. CONCLUSION: Compared to nipple smear, the diagnostic value of ductoscopy in this study is superior but marginally inferior to galactography and highly specialized breast ultrasound scanning. Therefore ductoscopy needs to be evaluated on a larger scale, preferably in multicenter trials to further determine its potential and indications.     

Axillary metastases of an occult primary carcinoma of the breast-discovered only by 99mTc-tetrofosmin scintigraphy

Recent reports consider 99mTc-tetrofosmin scintigraphy to be a powerful new diagnostic tool for discriminating malignant from benign breast disease. We report on a woman suffering from histologically confirmed axillary metastases of a primary unknown, occult carcinoma, whose origin was suspected within the breast. All the diagnostic procedures performed to discover any lesion failed or were inconclusive. The primary cancer was clearly visualized, however, in the right breast by means of 99mTc-tetrofosmin scintigraphy. Conclusion. We suggest that 99mTc-tetrofosmin scintigraphy is a powerful method to detect breast cancer, especially when other diagnostic imaging procedures are inconclusive.     

Surgical management of breast disease in an obstetrics and gynecology group

The surgical management of breast disease from 1978 through 1988 by the Women's Health Center of Logansport is reviewed. Three hundred twelve biopsy procedures resulted in the diagnosis of 59 cancers. Biopsy and mastectomy procedures were performed by the authors (obstetrician-gynecologists). There were no significant complications and all patients had an adequate surgical result. Preoperative needle localization techniques proved to be a safe and effective method to identify and remove nonpalpable mammographic abnormalities. Because women depend on their gynecologist for advice regarding reproductive organs including the breasts, it is logical for the gynecologic surgeon to become involved in the surgical management of breast disease.     

Mastopatía fibroquística. Aspectos controvertidos

ObjectivesTo elucidate the most controversial features of fibrocystic breast disease, which is highly prevalent.MethodsWe reviewed the literature on the topic.ResultsIn fibrocystic breast disease, the diagnostic method of choice is ultrasound, which shows similar characteristics to those in cystic tumors but with differences in number and maximum diameter. With dominant, or separate, nodules, ultrasound can be used to determine whether the lesion is cystic or solid. In cystic lesions, fine-needle aspiration can be used; in solid lesions, core needle biopsy can be employed. No active treatment is required if there is mastalgia and nodularity without a dominant nodule, or if diffusely nodular breasts are painless.Conclusions1. There is no risk of malignancy in simple fibrocystic breast disease but proliferative mastopathy with atypical cells has a relative risk of 4-5. 2. The diagnostic technique of choice for differentiating simple from complex cysts is ultrasound, which can also be used for monitoring and as a guide when aspirating the cyst. 3. When there are clinical and radiologic signs suspicious for malignancy (BI-RADS 3) or suggestive of malignancy (BI-RADS 4 and 5), the first step is fine-needle aspiration or core needle biopsy, or both. 4. Asymptomatic fibrocystic breast disease does not require follow-up, while symptomatic disease can be monitored with ultrasound and/or mammography.     

FNAC: its role, limitations and perspective in the preoperative diagnosis of breast cancer

Fine-needle aspiration cytology (FNAC) was first described and performed in 1930. Thirty years later, it gained acceptance first in Europe and about a decade later in North America. The method is generally considered as a rapid, reliable, safe diagnostic tool to distinguish non-neoplastic from neoplastic breast lesions. In developed countries, in the last 20 years, mammographic screening programmes, which have been used extensively, are designed to detect the earliest possible breast cancer. The FNAC report is extremely important because it gives the necessary information for the management of patients, in order to proceed with more invasive diagnostic methods or surgical treatment, and to decide what kind of operation to perform. In the preoperative phase, FNAC has taken a fundamental role of both palpable and nonpalpable lesions, using ultrasound or stereotactic guidance. New developed techniques, breast biopsy instrumentation (ABBI) and mammotome have the advantage of complete removal of breast lesions, but this is not possible in all the examined cases. In developing countries, economical restrictions, low budget for health care and screening programmes put the patients at a disadvantage because of the high cost of sophisticated diagnostic methods, thus we recommend that FNAC be used as a routine diagnostic method because of its low cost compared with the others and this policy maximizes the availability of health care to women with breast cancer. We conclude that FNAC plays an important and essential role in the management of patients with breast lesions and also offers a great potential for prediction of patient outcome, disease response to therapy and assessment of risk of developing breast cancer. The reliability and efficiency of the method depends on the quality of the samples and the experience of the medical staff that performs the aspiration.