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A new score for the evaluation of palpable breast masses in women under age 40
The American Journal of Surgery 184 (2002) 346 –347
Scientific paper
A new score for the evaluation of palpable breast masses in women under age 40 Katherine T. Morris, M.D.a, John T. Vetto, M.D.a, J. K. Petty, M.D.a, Sharon S. Lum, M.D.a, Waldemar A. Schmidt, M.D., Ph.D.a, SuEllen Toth-Fejel, Ph.D.a, Rodney F. Pommier, M.D.a,b,* a
Department of Surgery, Oregon Health and Science University, Portland, OR, USA b 3181 S.W. Sam Jackson Park Rd, L223A, Portland, OR 97201, USA Manuscript received May 6, 2002; revised manuscript May 27, 2002
Presented at the Third Annual Meeting of the American Society of Breast Surgeons, Boston, Massachusetts, April 24 –28, 2002.
Abstract Background: The purpose of this study was to develop a rapid and accurate diagnostic test for palpable breast masses in women under age 40. Methods: Masses were evaluated utilitzing a modified triple test score (MTTS), which assigned scores of 1 point for benign, 2 points for suspicious, or 3 points for malignant findings from physical examination, ultrasonography, and fine needle aspiration. The MTTS was the sum of the three scores and was correlated with biopsy or follow-up. Results: Among 113 masses, 100 scored 3 points, 8 scored 4 points; all were benign. Three scored 5 points; 1 was malignant. Two scored ⱖ6 points: both were malignant. Conclusions: The MTTS has 100% diagnostic accuracy when other than 5 points. Masses scoring ⱕ4 points are benign. Masses scoring ⱖ6 points may proceed to definitive therapy. Masses scoring 5 points (3%) require biopsy. This approach avoids open biopsy in the majority of cases, while capturing all malignancies. © 2002 Excerpta Medica, Inc. All rights reserved. Keywords: Breast cancer; Fine needle aspiration; Ultrasonography
We have previously reported [1] and verified [2] the triple test score (TTS) as a rapid and accurate means for evaluating palpable breast masses in women 40 years of age and older. The three components of the TTS are a physical examination, a diagnostic mammogram, and a fine needle aspiration (FNA) biopsy, all performed concurrently on the breast mass. The examiners independently rate each component of the TTS as benign, suspicious for malignancy, or malignant. One point is given for each benign finding, 2 points for each suspicious finding, and 3 points for each malignant finding. The three scores are then added to arrive at the final TTS.
* Corresponding author. Tel.: ⫹1-503-494-5501; fax: ⫹1-503-4948884
After evaluating 484 masses, 315 masses with a TTS ⱕ4 points were benign. One hundred thirty masses with a TTS ⱖ6 were all malignant. Thirty-nine masses (8%) with a TTS of 5 points required open biopsy, and 49% of those were malignant. Thus, the TTS has 100% sensitivity and specificity when the score does not equal 5 points, and masses that score 5 points have comprised only 8% of masses encountered. The purpose of the present study was to determine if a modification of the TTS, in which ultrasonography is substituted for mammography, could be developed to rapidly and accurately assess breast masses in women under age 40, a population in which the incidence of breast cancer is low [3]. However, it is also within this population that most cases of a missed diagnosis of breast cancer occur [4].
0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 2 ) 0 0 9 4 7 - 9
K.T. Morris et al. / The American Journal of Surgery 184 (2002) 346 –347
Methods Women younger than age 40 seen between July 1997 and February 2000 with a palpable breast mass had their breast masses evaluated utilizing a modified TTS (MTTS). Surgical oncologists performed physical examinations, a radiologist performed ultrasonograms, and a cytopathologist performed FNA biopsies. Each component of the MTTS was independently scored by the examiner as benign, suspicious for malignancy, or malignant. The finding of each examination were scored, giving 1 point for each benign finding, 2 points for each suspicious finding, or 3 points for each malignant finding. The final MTTS was the sum of the three independent scores.
Results A total of 113 breast masses were evaluated in 108 women (mean age 27 years, range 14 to 39). One hundred masses (89%) had an MTTS of 3 points (concordant benign). All masses were benign on clinical follow-up or on open biopsy done at the patient’s request (n ⫽ 9). Eight masses (7%) had an MTTS of 4 points. All eight masses were benign on follow-up (n ⫽ 7 by biopsy, n ⫽ 1 by clinical follow-up). Three masses (3%) had an MTTS of 5 points. All underwent biopsy analysis, and one was malignant. Two masses (2%) had an MTTS ⱖ6 points and both were malignant on biopsy. The overall malignancy rate for this series was 3%, consistent with national averages for this age group [3].
Comments The MTTS scoring system, which substitutes ultrasonography for mammography in women younger than age 40, yields the same diagnostic accuracy as the TTS. It has 100% diagnostic accuracy when the MTTS is other than 5 points. In addition, the scoring system derived in this series for diagnosing breast masses using the MTTS is identical to that derived for the TTS. Masses with an MTTS of ⱕ4 points are benign and may be safely followed. Masses with an MTTS ⱖ6 points are all malignant and may proceed to definitive therapy with a confirmatory frozen section. Only masses with an MTTS of 5 points cannot be definitively
347
diagnosed and will require open biopsy. Such masses, however, constituted only 3% of breast masses in this series. Thus, 97% of women less than age 40 with palpable breast masses may be spared an open biopsy, while still capturing all malignancies. Breast biopsies for benign breast masses result in scarring and disfigurement. However, it is the 3% malignancy rate for breast masses in this age group that prompts the excessive number of breast procedures that are done, all in order to avoid missing the rare case of breast cancer. Furthermore, Kern [3,4] has documented a “triad of error:” women aged 45 or younger with a self-discovered breast mass and a false negative mammogram. In young women, the false-negative rate of mammography approaches 80% [3]. This clinical “triad of error” is associated with the majority of breast cancer malpractice litigation cases [5]. The errors involved include assuming that the patient is too young to have breast cancer, that a negative mammogram in this age group assures a low probability of malignancy, and failure to obtain either cells or tissue from the mass for diagnostic evaluation. The MTTS provides a multidisciplinary approach that addresses each of these errors specifically. Firstly, all young women with a breast mass are evaluated with the attitude that the mass is malignant until proven otherwise. Secondly, rather than relying on mammography, ultrasonography is utilized, which has a much lower false negative rate in this age group. Lastly, cells or tissue are obtained for analysis in every case, either by FNA or by open biopsy in instances of a nondiagnostic MTTS of 5 points. Importantly the MTTS avoids these pitfalls of the “triad of error” while producing no scarring or disfigurement for the vast majority of women with benign breast masses.
References [1] Vetto JT, Pommier RF, Schmidt WA, et al. Use of the “triple test” for palpable breast lesion yields high diagnostic accuracy and cost savings. Am J Surg 1995;169:519 –22. [2] Morris KT, Pommier RF, Morris A, et al. usefulness of the triple test score for palpable breast masses. Arch Surg 2001;136:1008 –13. [3] Cancer statistics. Cancer 1989;39:3–39. [4] Kern KA. Causes of breast cancer malpractice litigation: a 20-year civil court review. Arch Surg 1992;127:542–7. [5] Kern KA. Medicolegal analysis of the delayed diagnosis of cancer in 338 cases in the United States. Arch Surg 1994;129
Scientific paper
A new score for the evaluation of palpable breast masses in women under age 40 Katherine T. Morris, M.D.a, John T. Vetto, M.D.a, J. K. Petty, M.D.a, Sharon S. Lum, M.D.a, Waldemar A. Schmidt, M.D., Ph.D.a, SuEllen Toth-Fejel, Ph.D.a, Rodney F. Pommier, M.D.a,b,* a
Department of Surgery, Oregon Health and Science University, Portland, OR, USA b 3181 S.W. Sam Jackson Park Rd, L223A, Portland, OR 97201, USA Manuscript received May 6, 2002; revised manuscript May 27, 2002
Presented at the Third Annual Meeting of the American Society of Breast Surgeons, Boston, Massachusetts, April 24 –28, 2002.
Abstract Background: The purpose of this study was to develop a rapid and accurate diagnostic test for palpable breast masses in women under age 40. Methods: Masses were evaluated utilitzing a modified triple test score (MTTS), which assigned scores of 1 point for benign, 2 points for suspicious, or 3 points for malignant findings from physical examination, ultrasonography, and fine needle aspiration. The MTTS was the sum of the three scores and was correlated with biopsy or follow-up. Results: Among 113 masses, 100 scored 3 points, 8 scored 4 points; all were benign. Three scored 5 points; 1 was malignant. Two scored ⱖ6 points: both were malignant. Conclusions: The MTTS has 100% diagnostic accuracy when other than 5 points. Masses scoring ⱕ4 points are benign. Masses scoring ⱖ6 points may proceed to definitive therapy. Masses scoring 5 points (3%) require biopsy. This approach avoids open biopsy in the majority of cases, while capturing all malignancies. © 2002 Excerpta Medica, Inc. All rights reserved. Keywords: Breast cancer; Fine needle aspiration; Ultrasonography
We have previously reported [1] and verified [2] the triple test score (TTS) as a rapid and accurate means for evaluating palpable breast masses in women 40 years of age and older. The three components of the TTS are a physical examination, a diagnostic mammogram, and a fine needle aspiration (FNA) biopsy, all performed concurrently on the breast mass. The examiners independently rate each component of the TTS as benign, suspicious for malignancy, or malignant. One point is given for each benign finding, 2 points for each suspicious finding, and 3 points for each malignant finding. The three scores are then added to arrive at the final TTS.
* Corresponding author. Tel.: ⫹1-503-494-5501; fax: ⫹1-503-4948884
After evaluating 484 masses, 315 masses with a TTS ⱕ4 points were benign. One hundred thirty masses with a TTS ⱖ6 were all malignant. Thirty-nine masses (8%) with a TTS of 5 points required open biopsy, and 49% of those were malignant. Thus, the TTS has 100% sensitivity and specificity when the score does not equal 5 points, and masses that score 5 points have comprised only 8% of masses encountered. The purpose of the present study was to determine if a modification of the TTS, in which ultrasonography is substituted for mammography, could be developed to rapidly and accurately assess breast masses in women under age 40, a population in which the incidence of breast cancer is low [3]. However, it is also within this population that most cases of a missed diagnosis of breast cancer occur [4].
0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 2 ) 0 0 9 4 7 - 9
K.T. Morris et al. / The American Journal of Surgery 184 (2002) 346 –347
Methods Women younger than age 40 seen between July 1997 and February 2000 with a palpable breast mass had their breast masses evaluated utilizing a modified TTS (MTTS). Surgical oncologists performed physical examinations, a radiologist performed ultrasonograms, and a cytopathologist performed FNA biopsies. Each component of the MTTS was independently scored by the examiner as benign, suspicious for malignancy, or malignant. The finding of each examination were scored, giving 1 point for each benign finding, 2 points for each suspicious finding, or 3 points for each malignant finding. The final MTTS was the sum of the three independent scores.
Results A total of 113 breast masses were evaluated in 108 women (mean age 27 years, range 14 to 39). One hundred masses (89%) had an MTTS of 3 points (concordant benign). All masses were benign on clinical follow-up or on open biopsy done at the patient’s request (n ⫽ 9). Eight masses (7%) had an MTTS of 4 points. All eight masses were benign on follow-up (n ⫽ 7 by biopsy, n ⫽ 1 by clinical follow-up). Three masses (3%) had an MTTS of 5 points. All underwent biopsy analysis, and one was malignant. Two masses (2%) had an MTTS ⱖ6 points and both were malignant on biopsy. The overall malignancy rate for this series was 3%, consistent with national averages for this age group [3].
Comments The MTTS scoring system, which substitutes ultrasonography for mammography in women younger than age 40, yields the same diagnostic accuracy as the TTS. It has 100% diagnostic accuracy when the MTTS is other than 5 points. In addition, the scoring system derived in this series for diagnosing breast masses using the MTTS is identical to that derived for the TTS. Masses with an MTTS of ⱕ4 points are benign and may be safely followed. Masses with an MTTS ⱖ6 points are all malignant and may proceed to definitive therapy with a confirmatory frozen section. Only masses with an MTTS of 5 points cannot be definitively
347
diagnosed and will require open biopsy. Such masses, however, constituted only 3% of breast masses in this series. Thus, 97% of women less than age 40 with palpable breast masses may be spared an open biopsy, while still capturing all malignancies. Breast biopsies for benign breast masses result in scarring and disfigurement. However, it is the 3% malignancy rate for breast masses in this age group that prompts the excessive number of breast procedures that are done, all in order to avoid missing the rare case of breast cancer. Furthermore, Kern [3,4] has documented a “triad of error:” women aged 45 or younger with a self-discovered breast mass and a false negative mammogram. In young women, the false-negative rate of mammography approaches 80% [3]. This clinical “triad of error” is associated with the majority of breast cancer malpractice litigation cases [5]. The errors involved include assuming that the patient is too young to have breast cancer, that a negative mammogram in this age group assures a low probability of malignancy, and failure to obtain either cells or tissue from the mass for diagnostic evaluation. The MTTS provides a multidisciplinary approach that addresses each of these errors specifically. Firstly, all young women with a breast mass are evaluated with the attitude that the mass is malignant until proven otherwise. Secondly, rather than relying on mammography, ultrasonography is utilized, which has a much lower false negative rate in this age group. Lastly, cells or tissue are obtained for analysis in every case, either by FNA or by open biopsy in instances of a nondiagnostic MTTS of 5 points. Importantly the MTTS avoids these pitfalls of the “triad of error” while producing no scarring or disfigurement for the vast majority of women with benign breast masses.
References [1] Vetto JT, Pommier RF, Schmidt WA, et al. Use of the “triple test” for palpable breast lesion yields high diagnostic accuracy and cost savings. Am J Surg 1995;169:519 –22. [2] Morris KT, Pommier RF, Morris A, et al. usefulness of the triple test score for palpable breast masses. Arch Surg 2001;136:1008 –13. [3] Cancer statistics. Cancer 1989;39:3–39. [4] Kern KA. Causes of breast cancer malpractice litigation: a 20-year civil court review. Arch Surg 1992;127:542–7. [5] Kern KA. Medicolegal analysis of the delayed diagnosis of cancer in 338 cases in the United States. Arch Surg 1994;129