Open Breast Biopsy Research Articles

Diagnostik und Therapie des Mammakarzinoms seit Einführung des mammographischen Screenings in der flächendeckenden, ambulanten Versorgung des Großherzogtums Luxemburg*

Fragestellung: Die Effektivität des mammographischen Screenings in spezialisierten Diagnostik-Zentren ist in der Altersgruppe 50 - 65 Jahre gut belegt. Wenige Daten liegen demgegenüber über dem Wert eines solchen Screenings in der dezentralisierten, flächendeckenden Versorgung vor. In Luxemburg wird seit 1992 ein so organisiertes mammographisches Screening (LMSP) für die Altersgruppe 50 - 64 Jahre angeboten.

Infrared Imaging of the Breast: Initial Reappraisal Using High-Resolution Digital Technology in 100 Successive Cases of Stage I and II Breast Cancer

There is a general consensus that earlier detection of breast cancer should result in improved survival. Current breast imaging relies primarily on mammography. Despite better equipement and regulation, variability in interpretation and tissue density still affect accuracy. A number of adjuvant imaging techniques are currently being used, including doppler ultrasound and gadolinium-enhanced MRI, which can detect cancer-induced neovascularity. In order to assess the potential contribution of currently available high-resolution digital infrared technology capable of recognizing minute regional vascular flow related temperature variation, we retrospecitively reviewed the relative ability of our preoperative clinical exam, mammography, and infrared imaging to detect 100 new cases of ductal carcinoma in situ, stage I and II breast cancer. While the false-negative rate of infrared imaging was 17%, at least one abnormal infrared sign was detected in the remaining 83 cases, including 10 of the 15 patients, a slightly younger cohort, who had nonspecific mammograms. The 85% sensitivity rate of mammography alone thus increased to 95% when combining both imaging modalities. Access to infrared information was also pertinent when confronted with the relatively frequent contributory but equivocal clinical exam (34%) and mammography (19%). The average size of those tumors undetected by mammography or infrared imaging was 1.66 cm and 1.28 cm, respectively, while the false-positive rate of infrared imaging in a concurrent series of 100 successive benign open breast biopsies was 19%. Our initial experience would suggest that, when done concomitantly with clinical exam and mammography, high-resolution digital infrared imaging can provide additional safe, practical, and objective information. Further evaluation, preferably in controlled prospective multicenter trials, would provide valuable data.

Clinical management of nonpalpable or small breast masses by fine-needle aspiration biopsy (FNAB) under ultrasound guidance.

Open breast biopsy of palpable breast masses is widely accepted. Now, the use of high-resolution, real-time ultrasound (US) makes it easy to detect nonpalpable or small breast nodules, as well as palpable breast masses. We performed fine-needle aspiration biopsy (FNAB) under US guidance to manage the nonpalpable or small breast masses detected by US examination and to distinguish between benign and malignant tumors. To investigate the usefulness and sensitivity of FNAB under US guidance, we reviewed a total of 137 FNAB records for cases diagnosed between January 1993 and December 1994. Fifty-five cases were classified as benign, 70 as atypical/indeterminate, 1 as suspicious/probably malignant, 6 as malignant, and 5 as unsatisfactory. Of these, five cases were confirmed as malignant, but one case showed no malignancy at surgery. Four cases were nonpalpable breast cancer, two were in stage 0, and two were in stage I. One case in the suspicious/probably malignant group on the initial FNAB was shown to be malignant by re-aspiration on follow-up study. The sensitivity of FNAB under US guidance was 83.3% (5/6) and the specificity was 99.2% (125/126). The diagnostic accuracy was 83.3% (5/6) and the negative predictive value was 99.2% (125/126). FNAB under US guidance is useful for the management of nonpalpable or small breast masses; it is sensitive for distinguishing between benign and malignant tumors and may reduce unnecessary surgical procedures and replace conventional manual aspiration biopsy.

A Comparison of Accuracy Rates Between Open Biopsy, Cutting-Needle Biopsy, and Fine-Needle Aspiration Biopsy of the Breast: A 3-Year Experience

Abstract: The diagnostic accuracy of excisional biopsy is used as the “gold standard” for the diagnosis of breast nodules. In comparison studies involving the diagnostic accuracies of fine-needle aspiration cytology and cutting needle biopsy, the accuracy rate of open biopsy is often assumed to be 100%. While diagnostic accuracy rates are well reported for fine-needle aspiration (FNA) and large-gauge core needle biopsy, little data has been published documenting the accuracy of excisional biopsy. Hence, valid comparisons of relative diagnostic precision between the techniques are difficult to achieve. We report our experience with the sensitivity and specificity of open biopsy, cutting-needle biopsy and fine-needle aspiration biopsy over a three-year period. Between January 1992 and December 1994, histologic specimens from 412 open breast biopsies, and 17 non image guided Tru-cut® biopsies of palpable breast nodules were reviewed. These cases had either histologic follow-up (n= 388) or at least 2 years clinical follow-up (n= 25). Similarly, 450 FNAs were performed of which 215 had histologic study or cytologic follow-up. Within the 388 open biopsies with histologic follow-up, two false-negatives (sensitivity 99%) and one false-positive (specificity 99.5%) were detected based on subsequent biopsies or review of the initial material. No erroneous diagnoses were found in the 25 patients having only clinical follow-up. Among the 17 cutting needle-biopsies, two false-negatives (sensitivity 85%) were detected; no false-positives occurred (specificity 100%). One false-positive and five false-negatives were detected on follow-up of the 215 FNAs. This yielded a sensitivity of 96.2% and a specificity of 99.6%. Fine-needle aspiration compares favorably with both of these techniques, being inferior to open biopsy but of greater accuracy than cutting needle biopsy. These results demonstrate that care must be taken in using the histopathologic findings of open biopsy as the standard with which other methods of diagnosis are compared.

The evaluation of palpable breast masses: common pitfalls and management guidelines

The management of a palpable breast mass starts with identification of the lesion and a suspicion of malignancy. While seemingly simple, the initial evaluation can significantly impact upon treatment options and outcomes. The management of two patients recently referred to this Institution highlights common pitfalls and technical considerations in the diagnosis and treatment of palpable breast masses. The case histories of two patients referred after open breast biopsy were examined. The English language medical literature was searched manually and by Medline for publications related to the evaluation of palpable breast masses. Imaging, diagnostic techniques and technical considerations in the management of palpable lesions were reviewed. The initial use of carefully selected diagnostic and therapeutic measures is critical in optimizing outcomes measured in improved quality of life and survival. Inappropriate choices at this first stage can have extremely negative consequences. The early evaluation of two patients highlighted these considerations. Management pitfalls included serial examination of a suspicious lesion, failure to obtain a mammogram prior to excisional biopsy and unnecessary testing. Technical problems included piecemeal excision of the tumor with positive margins, use of a drain, closure of deep tissues with dimpling of the breast, and incision placement in a location that subsequently necessitated mastectomy. Careful adherence to the clinical and operative principles of breast cancer management optimizes outcomes in the evaluation of palpable breast masses.

General Surgery

The happy cohabitation of surgery with basic science has experienced another productive year. Basic science research is not easily translated into clinical usefulness. The downsizing of federal funding and the increasing participation of the biomedical-industrial complex has affected surgical research. New diagnostic modalities in the panoperative setting have seen increasing application within the last year that affects the volume, type, and extent of future operations. The widespread application of screening mammography has led to an increase (up to sixfold) in the number of open breast biopsies performed for mammographic abnormalities. Most such radiologic findings correspond to benign processes, but the cost to prove benignancy is substantial. Stereotactic automated core breast biopsy is a method of precisely directed tissue sampling that can be performed with the patient under local anesthesia. Comparison of tissue diagnosis using this technique followed by open biopsy in a study of 98 lesions showed a high correlation.

Changing clinical picture of mammary hamartoma

During a 6-year period, we identified 12 patients (age range: 16 to 72 years) with a histologic or mammographic diagnosis of mammary hamartoma. The lesion was found in 9 of 441 open breast biopsy specimens (2%) and was identified radiographically in 5 of 8,122 mammographic examinations (less than 1%). Two groups of patients were identified. Three patients under 30 years of age underwent the excision of small palpable lesions found on pathologic examination to be mammary hamartomas (group I). In nine patients over age 30, masses were identified or confirmed on mammography (group II). Five lesions showed the classic mammographic appearance of a mammary hamartoma (a circumscribed tumor of mixed soft tissue and fatty density), and the other four were indeterminate. Presentation in these older women who had a relatively high incidence of atypical mammographic findings mandates that biopsy be performed.

False negative breast biopsy for palpable mass

Open breast biopsy is considered to be the most reliable method for the diagnosis of breast cancer in patients with palpable masses. Rarely, after a breast biopsy has been reported to be benign, cancer will be identified at the site of the biopsy. Eight patients were reviewed in whom breast cancer was demonstrated at the site of a previously negative biopsy at intervals ranging between 4 months and 3 years after the original, negative biopsy. Several possible explanations exist to account for this occurrence. The surgeon must be aware that the presence of a mass at the site of prior breast biopsy may be an indication for repeat excision.

Techniques for Obtaining the Diagnosis of Malignant Breast Lesions

Although fine needle aspiration is an efficacious method for diagnosing the palpable breast cancer, a negative aspirate does not exclude the presence of a malignancy. Open breast biopsy remains the standard of care in diagnosing a malignant breast lesion. All breast biopsies should be planned as if the scar were to be excised by a definitive surgical procedure (either mastectomy or tylectomy). New lesions in the treated breast require immediate biopsy because of the high likelihood of recurrent disease. Preferably, definitive surgery for malignancy should not be delayed more than 2 weeks after biopsy.

Final diagnosis by fine-needle aspiration biopsy for definitive operation in breast cancer

This work has been based on 15 years experience with more than 10,000 needle aspiration biopsies of the breast. Fine-needle aspiration biopsy was used in place of open breast biopsy for definitive operation in breast cancer. Our experience with 2,623 aspiration biopsies over a 3 year period has been reviewed. There was a total of 323 cancers, of which 257 (80 percent) were unequivocally diagnosed by fine-needle aspiration biopsy. Definitive operation was performed in 244 of these patients (95 percent) without open biopsy. Thirteen had an excisional biopsy before definitive operation at the request of the referring physician. The sensitivity was 80 percent and the specificity was 98 percent. There were no false-positive diagnoses. The positive predictive value was 100 percent. False-negative diagnoses were made in 9 percent of the patients, half of whom had nonpalpable carcinomas. Our experience shows that fine-needle aspiration biopsy is accurate in the diagnosis of breast cancer, and when the finding is positive, it can be used for definitive breast operation, eliminating the need for open biopsy. A management algorithm has also been presented herein.

Histochemical Analysis of Breast Carcinoma Metastatic to the Orbit

A 62-year-old woman was seen for evaluation of an orbital tumor. Recognition of a relatively rare syndrome of pain, ptosis, and a progressively immobilized globe with enophthalmos suggested the diagnosis of metastatic carcinoma to the left orbit. In this case, this was confirmed by open breast and orbital biopsies, revealing infiltrating lobular breast carcinoma. This is the first reported case where estrogen and progesterone receptors were identified in a metastatic orbital tumor using fluorescent histochemical techniques. This technique was of value in confirming the diagnosis and providing direction for subsequent endocrinologic palliative therapy.