Preoperative prediction of open breast biopsy results

Axial-shear strain distributions in an elliptical inclusion model: experimental validation and in vivo examples with implications to breast tumor classification

Recently, we reported on the axial-shear strain fill-in of the interior of loosely bonded stiff elliptical inclusions in a soft background at non-normal orientations, and the lack of fill-in in firmly bonded inclusions at any orientation. In this paper, we report on the experimental validation of the simulation studies using tissue-mimicking gelatin-based phantoms. We also show a few confirmatory examples of the existence of these phenomena in benign vs. malignant breast lesions in vivo. Phantom experiments showed that axial-shear strain zones caused by firmly bonded elliptical inclusions occurred only outside of the inclusion, as predicted by the simulation. By contrast, the axial-shear strain zones filled in the interior of loosely bonded elliptical inclusions at non-normal orientations. The axial-shear strain elastograms obtained from the in vivo cases appeared to be in general agreement with our experimental results. The results reported in this paper may have important clinical implications. Specifically, axial-shear strain fill-in inside an inclusion may be a unique signature of stiff, loosely bonded, ellipsoidal or elongated inclusions at non-normal orientations. Thus, it may be useful as a marker of benignity of benign breast lesions (e.g., fibroadenomas) that are generally stiff, elongated and loosely bonded to the host tissues.

Sonography of Palpable Breast Masses

Ultrasound use should be considered in most instances of a palpable breast finding, particularly in young women. A primary advantage is the ability to directly correlate the physical exam finding with imaging. Ultrasound is useful in characterizing palpable masses as well as detecting cancer in women with negative mammograms. The negative-predictive value of imaging for cancer in the evaluation of a palpable lump is very high, which may reassure women with low-suspicion palpable findings. Short-term follow-up of a palpable mass with benign features may be feasible, though further study is needed to establish criteria. A suspicious dominant palpable finding should be further evaluated even if imaging is negative.

Breast Complaints, Biopsies, and Cancer Correlated with Age in 10,000 Consecutive New Surgical Referrals

The incidence of breast cancer in symptomatic women as correlated with the type of complaint and patient age is important for the development of guidelines for patient referral and breast biopsy. The goal of this article is to demonstrate those situations that are most likely to yield a cancer diagnosis and to emphasize the benignity of the majority of breast complaints. It is suggested that the information will be useful to those who develop guidelines for the management of breast complaints. Data on 10,000 consecutive new surgical referrals for breast complaints were reviewed with attention to age, type of complaint, the occurrence of breast biopsy, and the finding of breast cancer. The majority of patients (68%) were less than 50 years old. Only 4% of patients less than 50 years old were found to have breast cancer and 17% of patients >/=50 years old had breast cancer. Only 9% of all of the patients had breast cancer. Nine percent of patients with a chief complaint of discharge >/=50 years old and 8% of patients >/=70 years old with pain as their complaint had breast cancer. Patients with breast symptoms presenting to a surgeon are not usually found to have breast cancer. There is a need for more useful guidelines related to the indications for patient referral and breast biopsies, as well as a need to inform the public that only a minority of complaints result in a cancer diagnosis. Complaints of nipple discharge or pain in older patients require careful evaluation.

BREASTAID: Clinical results from early development of a clinical decision rule for palpable solid breast masses

OBJECTIVE

To develop a clinical decision rule (entitled BREASTAID) that will predict the probability of malignancy in women with palpable solid breast masses.

SUMMARY BACKGROUND DATA

Currently, 80% of open breast biopsies are benign, resulting in excessive economic, psychologic, and physical morbidity.

METHODS

A total of 452 solid breast masses were evaluated in a surgical breast clinic between November 1994 and February 1998. Breast cancer status was defined histologically as ductal carcinoma in situ or invasive cancer. Noncancer status included benign histology, mass resolution, or stability at 12-month follow-up. Data were collected on risk factors, clinical breast examination, mammography, and cytology results. Three multiple logistic regression models were used to generate the probability of cancer at 3 logical steps in the workup; Bayes' theorem was applied in a stepwise fashion to generate a final probability of cancer.

RESULTS

A model incorporating only clinical breast examination and mammography resulted in an excessive number of either missed cases or biopsies compared with one that included cytology. Using a cut-point of 4%, this latter BREASTAID model had 97.6% sensitivity and 85.1% specificity. Compared with triple diagnosis, BREASTAID would have reduced the open biopsy rate from 39.8% (180 of 452) to 22.3% (101 of 452), improving the diagnostic yield from 22.7% to 40.6%.

CONCLUSIONS

This study convincingly demonstrates that at minimum, clinical, radiologic, and cytologic evaluations are required to accurately evaluate a solid breast mass. BREASTAID has the potential to minimize the number of open biopsies performed while allowing safe triage to follow-up. Before widespread application, further validation studies are required.

Benign-appearing mammographic abnormalities in women aged 40-49

The ongoing debate was addressed concerning the appropriateness of mammographic screening for women aged 40-49 years, with particular emphasis on those patients with benign-appearing mammographic abnormalities (BMA), and whether findings differed from those of successive age decades. A review was conducted of 2,482 patients presenting for surgical consultation with a mammographic abnormality as a chief complaint, with particular emphasis on the 1,632 patients with BMA and more specifically those aged 40-49 years. Surgical interventions and risk factors for breast cancer were evaluated. Although 16% of 393 patients with BMAs biopsied were proven to have breast cancer, only 2.7% of all patients with BMAs were found to have breast cancer as a result of biopsy or short-term follow-up. Women aged 40-49 years represented 48% of patients with BMAs, and only 1.5% of these patients had breast cancer. The finding of breast cancer in the BMA population was progressive by decade of age, as would be expected, and in a cut-point analysis of those biopsied, age 60 best divided patients into high- and low-risk groups. Women aged 40-49 years with BMAs should not be excluded from mammographic screening, as they represented part of a continuum when successive decades were compared. Efforts should be directed at minimizing patient and physician anxieties as well as diagnostic interventions related to a BMAs.

Accuracy of frozen section diagnoses of breast lesions after introduction of a national programme in mammographic screening

AIMS

By introducing mammography screening programmes, the size of the detected breast lesions became smaller and the histopathological interpretation problems greater. The study's aim was to analyse the risks and possible limitations of the frozen section method.

METHODS AND RESULTS

Frozen section consultations of breast lesions (n=559) 2 years before and 6 years after launching a national mammographic screening programme in 1992 were evaluated in regard of the benign/malignant ratio, tumour size, preoperative frozen section results and final permanent section diagnoses. The breast frozen section examinations of 1990 compared with those from 1998 declined from 70.7% (299/423) to 62.2% (260/418) (P < 0.01), the benign/malignant ratio from 1.09 to 0.54 (P < 0.0001), the rate of the conclusive, correct frozen section diagnoses from 96.3% to 91.9% (P < 0.03). The sensitivity dropped from 92.3% to 87.6%, the negative predictive value from 95.7% to 88.3%, whereas the negative likelihood ratio rose from 0.08 to 0.12. The 'small' (< or = 10 mm) invasive breast carcinomas increased from 14.2% to 22.3% (P < 0.01) and the 'in situ' carcinomas from 2.1% to 6.6% (P < 0.05).

CONCLUSIONS

The declining sizes of breast tumours (< or = 10 mm), especially from radiologically detected lesions and sometimes without a macroscopic correlate, create new limitations and changing indications in the histopathological interpretation. Considering the performance of new diagnostic methods (i.e. large core needle biopsies), frozen sections of surgical specimens should not be the primary diagnostic procedure for breast lesions and should be performed only after other preoperative methods have failed.

Office-based wire-guided open breast biopsy under local anesthesia is accurate and cost effective

BACKGROUND

Mammographic abnormalities found to be malignant by stereotactic biopsy still require a wire-guided biopsy (WGB) in most cases. We have previously described a simplified method of WGB that allows the procedure to be done with a minimum of dissection and under local anesthesia in the office setting. We hypothesized that this procedure can be used to produce cost-effective, office-based breast preservation therapy (BPT).

METHODS

We reviewed our recent experience with this WGB method to determine applicability and accuracy in the office setting. A cost-effectiveness analysis was also performed to determine potential charge reductions when this method is used to avoid operating room (OR) usage for either lumpectomy or lumpectomy plus sentinel lymph node biopsy (SLNB).

RESULTS

Of the 164 biopsies reviewed, 114 (70%) were performed in the office setting under local anesthesia and 50 (30%) were performed in the OR. The most common reasons for choosing the OR setting included performance of biopsy during an unrelated procedure requiring the OR (16 cases), patient preference (12), deep lesions (6), and the inability of the patient to cooperate with local anesthesia (5). The complication rates were similar between the two settings (7% for office-based and 4% for OR; P = 0.697), and in neither setting were any lesions missed. A cost-effectiveness analysis using our Current Procedure Terminology (CPT)-based charges revealed a potential per-case charge reduction of $4,632 for office-based lumpectomy and $4306 for office-based lumpectomy/SLNB, using our method of WGB and local anesthesia, compared with the OR setting.

CONCLUSIONS

Office-based WGB using our previously described method is accurate and can be applied to at least 70% of patients. Based on the favorable results of our cost analysis and rising support for SLNB, we anticipate increased utilization of the clinic setting and local anesthesia for BPT in the future.

Ultrasound-guided fine-needle aspiration cytology of nonpalpable breast lesions: Institut Curie's experience with 198 histologically correlated cases

BACKGROUND

The value of ultrasound-guided fine-needle aspiration cytology (FNAC) in the diagnosis of nonpalpable breast lesions remains a subject of debate. To determine the accuracy of this procedure in these lesions, a comparative analysis with open surgical biopsy in 188 patients was performed.

METHODS

Six hundred and fifty-four nonpalpable breast lesions detected by ultrasound in 585 patients were subjected to FNAC. Of these, 198 lesions (30.3%) from 188 patients were surgically excised.

RESULTS

Histologically, 105 lesions (53%) were malignant and 93 (47%) were benign. Among carcinomas, 65 cases (61.9%) were concordant, whereas 21 cases (20%) were suspicious, 12 cases (11.4%) were false-negative (benign), and 7 cases (6.7%) were unsatisfactory for diagnosis. Among benign lesions, 80 cases (86%) were concordant, whereas 5 cases (5.4%) were suspicious, and 8 cases (8.6%) were unsatisfactory. No false-positive diagnoses were made. The sensitivity of the FNAC method was 87.8%, the specificity was 94.5%, and the positive predictive value was 94.6%.

CONCLUSIONS

These results indicate that, with the exception of random microcalcified lesions, ultrasound-guided FNAC is a valuable and reliable technique in the diagnosis of nonpalpable breast lesions.