Breast cancer. Making the diagnosis

Should all breast cancers be diagnosed by needle biopsy?

BACKGROUND

Although much data support the National Quality Forum recommendation that breast cancers should be diagnosed by needle biopsy before surgical resection, the exclusion criteria for those that may not be suitable have yet to be defined.

METHODS

We reviewed all patients treated over the past 3 years at the Yale Breast Center to determine the percentage of patients not diagnosed by needle biopsy, and why.

RESULTS

Reasons for the 17% of 630 patients who were not diagnosed by needle biopsy were as follows: inability to cooperate (1%); small or superficial lesion less than 1 cm that technically was easier to excise in the office (4%); bloody discharge without clinical or mammographic mass (1%); lesion adjacent to implant (.5%); a mammographic lesion that was too posterior, too superficial, or too faint to be performed stereotactically (5%); or patient preference (5%).

CONCLUSIONS

Needle biopsy is the preferred method of diagnosis in most cases, but there are valid reasons why all breast cancers will not be diagnosed in this fashion.

Lebensqualität und Zufriedenheit nach Brustrekonstruktion

BACKGROUND

Nowadays, the array of methods for reconstruction of the female breast following mastectomy is vast. In this study, we investigate and compare quality of life after breast reconstruction and satisfaction with the results of two commonly used techniques (autologous tissue vs. expander/implant).

METHODS

Ninety-one consecutive patients who underwent breast reconstruction at a German clinic between 1996 and 2001 were included in the study. Patient satisfaction and quality of life were assessed retrospectively using self-evaluation questionnaires.

RESULTS

Patients were generally more satisfied with the outcome of the operation when autologous tissue was used. This was significant in the following areas: breast size, form, definition of the lower breast fold, softness of the breast, and symmetry of the breasts. In both groups the quality of life following breast reconstruction at least 2 years after the operation was equal to that of healthy women of the same age group.

CONCLUSION

Although patients were more satisfied with the results of autologous breast reconstruction, procedure choice did not affect quality of life.

Comparing the cost-effectiveness of the triple test score to traditional methods for evaluating palpable breast masses

BACKGROUND

Physical examination, mammography, ultrasonography, and fine needle aspiration are traditionally used to guide further management of palpable breast masses, often leading to open biopsy of benign masses. The triple test score (TTS) integrates physical examination, mammography, and fine needle aspiration in the initial evaluation, limiting open biopsy.

OBJECTIVE

To compare cost-effectiveness of TTS and traditional methods.

METHODS

The primary measure of clinical effectiveness, frequency of missed malignancy, was determined for each strategy using probabilities and outcomes from a systematic literature review. Costs were calculated using the Medicare resource-based relative-value scale. A decision-analytic model compared costs of initial work-up, costs per mass evaluated, and costs per malignancy diagnosed. Sensitivity analyses assessed the influence of variations in model assumptions.

RESULTS

In the base case, neither strategy led to undiagnosed breast cancer. However, open biopsy was required in 13% of benign masses using TTS versus 88% using the traditional strategy. The cost of the initial work-up using traditional management was less than TTS (377 US dollars vs. 627 US dollars), but cost per mass evaluated and cost per malignancy diagnosed (1793 US dollars vs. 925 US dollars and 5670 US dollars vs. 2925 US dollars) favored TTS, due to substantially reduced open biopsy.In sensitivity analyses, TTS cost varied most with changes in cost of initial evaluation, whereas the traditional strategy cost varied most with changes in open biopsy cost.

CONCLUSIONS

The TTS provides equivalent diagnostic effectiveness but substantially lower cost than traditional management. Cost savings are based on decreased open biopsy, a major contributor to the cost of traditional evaluation in this model.

Nonsurgical evaluation of pathologic nipple discharge

BACKGROUND

Nipple discharge is a common breast complaint. Because most nipple discharge is a result of benign processes, less-invasive, nonsurgical diagnostic modalities have been explored to reduce the need for surgical intervention.

METHODS

Between September 1994 and December 2000, 108 female patients aged 25 to 77 years underwent duct excision for bloody or clear nipple discharge. Results of various preoperative studies were compared with surgical pathology to determine the sensitivity, specificity, positive predictive value, and negative predictive value of these tests in detecting malignant ductal pathology.

RESULTS

Of the 108 surgical histopathology specimens, 90 of 108 patients were benign, 5 of 108 patients were atypical, and 13 of 108 patients were malignant. The sensitivity of mammography was 57.1%, specificity was 61.5%, positive predictive value was 16.7%, and negative predictive value was 91.4%. Hemoccult sensitivity was 50%, specificity was 0%, positive predictive value was 20%, and negative predictive value was 0%. The sensitivity of ductography was 0%, specificity was 90%, positive predictive value was 0%, and negative predictive value was 81.8%. The sensitivity of cytology was 11.1%, specificity was 96.3%, positive predictive value was 50%, and negative predictive value was 76.5%.

CONCLUSIONS

Preoperative evaluations by mammography, Hemoccult, ductography, and cytology are poor predictors of histological diagnosis. These data suggest that patients with pathologic nipple discharge should undergo surgical biopsy for accurate diagnosis.

Contribution of 99mTc-anti-carcinoembryonic antigen antibody and 99mTc-sestamibi scintimammography in the evaluation of high risk palpable breast lesions

Mammography is the screening test of choice for breast cancer. Its low specificity leads to a large number of unnecessary biopsies. Scintimammography, with either Tc-sestamibi (MIBI) or Tc-anti-carcinoembryonic antigen (CEA) Fab', has been proposed as a non-invasive test to lower the high false positive rate of mammography in certain patients. The two agents have not been compared, nor has their combined application been evaluated. We performed a prospective, non-randomized, open-label, single-centre study of 32 women with clinically and mammographically suspected breast cancer [Breast Imaging Reporting and Data System (BI-RADS, American College of Radiology) 4 or 5]. All patients underwent Tc-MIBI and Tc-anti-CEA Fab' scintimammography, and the results were correlated with histopathology. Overall, the accuracies for MIBI and CEA scans were 90.3% (28/31) and 77.4% (24/31), respectively. The probability of disease after mammography was 0.939+/-0.081 (95% confidence interval, CI). The post-mammography probabilities after positive MIBI or CEA scan were 0.965 and 0.960, respectively, and after negative MIBI or CEA scan 0.750 and 0.875, respectively. None of the above differences is significant. The post-test probability when both scans were positive (irrespective of which was performed first) was 0.977. It can be concluded that there are indications that scintimammography with Tc-MIBI is superior to that with Tc-anti-CEA Fab' when these tests are used as screening tests for breast cancer. However, mammography remains the screening test of choice for highly suspicious clinically palpable breast lesions. In this group of patients, the application of scintimammography with either Tc-MIBI or Tc-anti-CEA Fab' (alone or in combination) offers no additional advantage.

Mammography and computerized decision systems: a review

Computer-aided diagnosis (CAD) systems in mammography have been developed and investigated for several years and recently they have left the research stage to enter the clinical stage. The purpose of this article is to review the present situation of mammography for breast cancer detection and the role played by CAD systems. Results from the recent literature show that CAD systems have the potential to improve the sensitivities of radiologists in the detection of malignant clustered microcalcifications and masses, while keeping specificities at acceptable levels. This leads to the conclusion that CAD systems can be incorporated into clinical practice as a double reading option to radiologists. However, some issues have yet to be tackled for CAD systems to gain better acceptance and more widespread use worldwide.