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Fine needle aspiration biopsy of the breast using ultrasound techniques - superficial localization and direct visualization
Ultrasound in M e d . & Biol. Vol. 14, Sup. i, pp. 5-11, 1988 Printed in the U.S.A.
0301-5629/88 ~3.00 + .00 (e) 1988 Pergamon Press plc
FINE NEEDLE ASPIRATION BIOPSY OF THE BREAST USING ULTRASOUND TECHNIQUES - SUPERFICIAL LOCALIZATION AND DIRECT VISUALIZATION
A. P. Harper
Indianapolis Breast Center Indianapolis, IN 4626@
Abstract-From July 1982 to December 1987, 519 fine needle aspiration biopsies were performed at the Indianapolis Breast Center. Both the superficial localization and the direct visualization methods were used. The fine needle aspiration biopsy technique (FNAB) was definitive in 92% of malignant masses, with minimum of 6 month follow up to date. The technique significantly alters the traditional approach to the management o£ breast cancer in that it allows preoperative discussions of options for treatment and eliminates the cost of excisional biopsies before definitive therapy. Key Words: Breast ultrasound, breast neoplasms, breast biopsy, breast disease diagnosls, ultrasound guided biopsy.
INTRODUCTION The methods of treating breast cancer have changed dramatically during the last few years. The decision process for choosing between the modified radical mastectomy and the lumpectomy with radiation, is aided considerably when an accurate diagnosis is made before surgery. X-ray mammography is the accepted method for evaluating the asymptomatic breast, while ultrasound scanning is used as an adjunct for diagnosis in patients with dense breasts and for further evaluation of masses visualized on x-ray mammograms. (Van Dam, et al. 1988; Harper and Kelly-Fry, 1984; Harper et al. 1983; Eagan, R. and Eagan K., 1984; Harper and Kelly-Fry, 1980). The fine needle aspiration biopsy (FNAB), plays an integral role in the diagnosis and surgical management of breast cancer. (Zajadela et al. 1975; Grlffith et al. (1986). We have found that aspiratlon biopsies performed with ultrasound guidance, facilitates a more precise evaluation and sampling of the abnormal tissue. The ultrasound imaging characteristics of the tumor serve as a determining factor for the use of the procedure. In our study, when a dlscrete mass was found in two or more image planes, there was a hlgher yield of abnormal tissue for cytologic evaluation, thus increasing the ability to make a definitive diagnosis in nonpalpable carcinomas seen on ultrasound imaging. Other authors have reported success in the use of FNAB using ultrasound guidance and also conclude %hat routine use of this technique is cost effective ~Id can lead to earlier diagnosis. (Fornage et al. 1987; Vlaisaveljevic', 1986; Livarghi, 1984; Harper, 1985. }~THODS AND INSTRUI~NTATION ['rom previous experience in the evaluation ot symptomatic breast patients, protocols were developed for the use of interventional procedures such as needle aspiration biopsles and cyst aspirations. (Harper, 1985). Needle aspiration biopsies are performed in the following circumstances: I. 2. 3. 4.
Sy~iptomatic mass ~ith malignant c~aracterlstlcs on ultrasound scans. S?~ptomatic mass wlth indeterminate ultrasound imaging characteristics, Discretely palpable mass :hat is not vlsualized on ultrasound imaging. Asym~ptoma%ic mass, which on ultrasound, demonstrates mallgnant characteristics.
Automated breast scannlng is primarily performed uslng the LaDsonics Ultrasound instrument. The design features of :hls instrument ~ave previously been described. (Ezo et al. 1985). The patient is examin©d Ln the supine ~>osltlon, u~ich is best sulted for performlng aspiration prcce~/res.
6
5th International
C o n g r e s s on t h e U l t r a s o n i c
Examination of the Breast
In the breast, unlike other superficial organs, tumors may move significantly with different patient positions, and therefore, needle aspiration biopsies are performed after ultrasound visualization of the mass, without changing patient position. Superficial localization is used with the Labsonics Instrument while the direct visualization approach is taken with hand-held instruments. Transducers of 7.5 HHz are typically used, but higher or lower frequency transducers have been substituted, when needed, for better visualization of the tumor mass. There are inherent problems with both of the above methods, but these can be offset if the limitations of each procedure are appreciated. Superficial localization is performed by scanning the breast with a metallic marker placed over the area of the tumor for confirmation of the exact location of the tumor. (Harper, 1985). Without moving the patient, the waterbag is removed from the breast, the skin is anethesized, and the needle biopsy is performed. Multiple passes are made throughout the tumor using negative suctioning. The primary limitation of this method is that the depth of the tumor has to be estimated. With experience, this depth measurement can be calculated and the textural difference between the tumor and surrounding tissue appreciated. The commercially hand-held transducers available in the USA have not, until recently, had the needed resolution to image a significant number of small solid tumors. The primary limitation of the direct visualization method, is that, for small tumors, two people are usually needed. One person holds the transducer in a fixed position, while another performs the biopsy. If a needle biopsy holder is attached to the transducer, one operator may suffice. With this method however, there is an increase in the amount of tissue traversed for the biopsy because of the oblique approach of the needle resulting in more trauma to the breast tissue. For FNAB's, a 20cc syringe with a 22 gauge cutting needle is used. The syringe is rinsed with a heparinized balanced salt solution. When performing biopsies using direct visualization, it is helpful to have a small amount of air in the needle and the syringe, as this facilitates visualization of the needle as it enters the breast mass. Hultiple samples of the tumor and adjacent tissues are taken by applying negative suction to the syringe. The aspirated material is then applied to frosted slides, fixed in alcohol, and sent for cytopathological analysis. Cytologic diagnoses fall into two basic categories, diagnostic and non-diagnostic. It is important to strive to achieve a high level of diagnostic results, equal in predictive value to a surgical biopsy with frozen section (99% or higher). The certainty of a diagnosis is communicated by the following terminology. A diagnostic case for malignancy might be signed out as "malignant cells are present from adenocarcinoma, infiltrating ductal type". If a malignancy has features which make a cell typing difficult, the diagnosis would be "adenocarcinoma, small celled ductal or lobular type". A definitive benign fine needle aspiration biopsy diagnosis would be "Negative for malignancy - fibrocystic change predominantly sclerosing adenosis", or "Negative for malignancy - fibroadenoma". At times the pattern of the benign lesions are definitive and require a diagnosis, such as, "negative for malignancy" - ductal hyperplasia and dense fibrosis are present, consistent with fibrocystic change; however, a fibroadenoma cannot be excluded." This often occurs in bland, low grade, ductal carcinomas (frequent in women over 65) or small carcinomas which are poorly sampled. A diagnosis in this instance mlght read "markedly atypical ductal cells are present, consistent with, but not diagnostic of, an adenocarcinoma - recommmend excisional biopsy with frozen section". Definitive diagnoses of malignant lesions allow treatment without frozen section, but currently all masses with a diagnosis of malignancy have a frozen section diagnosis before definitive treatment is performed. In definitive benign diagnoses, correlation with imaging and clinical features may preclude the need for excision in the majority of cases. In nondefinitive diagnoses, follow up or treatment is dictated by any suspicious findings on the clinical evaluation or imaging results. RESULTS At the Indianapolis Breast Center, there were approximately 2 6 , ~ 0 patient visits over the five year period, 1982 - 1987. Two hundred and forty five breast cancers were diagnosed and of these, 186 breast cancers were found with needle aspiration biopsies. This represents 76% of the cancers. (Table I) This study minimum of aspiration tables 2 &
reflects the 4 i/2 year period from July 1982 to December 1986, which allows a a 6 month follow up of the benign masses. Five hundred and nineteen needle biopsies were performed. The number of benign and malignant masses is shown in 3.
5th International
C o n g r e s s on t h e U l t r a s o n i c
Examination of the Breast
7
Table i Total number of needle biopsies in 5 year period.
INDIANAPOLIS BREAST CENTER
FIVE YEAR PERIOD
7/82 - 7/87
TOTAL NUMBER OF MALIGNANT BREAST MASSES
2~5
TOTAL NUMBER OF NEEDLE BIOPSIES IN THIS GROUP
-
186
Table 2
TOTAL NUMBER NEEDLE ASPIRATION BIOPSIES
-
519
Results of 4 1/2 year study period 7/82-12/86
TOTAL NUMBER OF BENIGN MASSES
-
383
TOTAL NUMBER OF MALIGNANT MASSES
-
133
( 76% )
( 3 ) inadequate needle b i o p s i e s lost to follow up
MAL IGNANT
MASSES
MALIGNANT
ON N E E D L E
133
Table 3
ASPIRATION
BIOPSY
-
123
-
5
-
I
Cytologic
diagnoses of
ATYPIA
malignant
INADEQUATE
breast masses.
BENIGN
RECOMMEND
BIOPSY
SPECIMEN
DIAGNOSIS
-
4
The patient population has been predominantly symptomatic, but the percentage of symptomatic to asymptomatic patients is changing. The current ratio is 7:3 symptomatic to asymptomatic. Physical findings and symptoms, as determined both by the referring physician and the patient, are recorded. The majority of our breast patients practice breast self-examination, and many breast cancers are detected by the patients. X-ray mammograms are usually performed on all patients except in patients who are either less than 25 years of age or pregnant. Ultrasound scans are used to evaluate the radiographically dense areas of the breast, the young and pregnant patients and to localize masses for needle aspiration biopsy procedures. Typical examples of palpable and nonpalpable masses on which FNAB's were performed are demonstrated in figures 1 & 2 respectlvely. Figure 1 is an ultrasound image of a degenerating fibroadenoma in a 37 year old. In this case, the direct visualization approach is the method of choice because &t enables retrieval of tissue from the abnormal area of attenuation, which is the most susplcious for malignancy. The remainder of the mass demonstrates the benign characteristics of smooth walls and uniform internal echoes.
8
5th International
C o n g r e s s on t h e U l t r a s o n i c
Examination of the Breast
]:igu/e I begenerating fibroadenoma (arrow heads). Large arrow indicates the area of degeneratlor~.
Figure 2 demonstrates a nonpalpable malignant mass which could be easily aspirated because it was easily visualized on ultrasound imaging in more than one plane. Although this mass was less than Icm in diameter and nonpalpable, using ultrasound, the mass was localized and FNAB performed. It was not difficult to detect the difference in texture between thiE small mass and the surrounding tissue. Five masses described by the pathologist as having sufficient atypia to warm,ant biopsy, were malignant at excisional biopsy. Figure 2a X-ray mamm~grams - comparison cranio-caudal views of left and right breasts demonstrate a nonpalpable mass. arrowhead)
Figure 2b Cone down magnification mammogram of the mass demonstrates malignant characteristics.
x-ray
Figure 2c Biplane ultrasound scans demonstrate a solid mass (large arrowhead) with jagged walls. Some architectural distortlon of the breast tissue is present superior to the mass. (small arrowhead).
Sth International
Congress on the Ultrasonic
RTAmtnatton of the Breast
9
Figure 3 demonstrates such an example. FNAB of this mass revealed fibrocystic changes with atypical ductal hyperplasia. The ultrasound image did not demonstrate a discrete mass but architectural disruption of the normal pattern of the breast. There was no obvious textural difference between the malignant mass and the surrounding tissue, even though an obvious mass was present on x-ray mammography. At excision, hematoma from the FNAB was present within the tumor. Figure 3a Cranio-caudal x-ray marm~ogram demonstrates a mass in the medial aspect of the breast (arrowhead).
Figure 3b Cone d o ~ x-ray mammogram demonstates some irregularity of the margins o£ this tumor.
Figures 3c & 3d Two adjacent ultrasound scans 2mm apart demonstrate some abnormal echogenic tissue (arrowheads) but no discrete mass. Minimal attenuation of the ultrasound beam is present. (large arrow head).
I0
5th International Congress on the Ultrasonic Examination of the Breast
These five masses all demonstrated imaging characteristics which were suspicious for malignancy, and therefore, the cytopathological report, as stated previously, is not the only determinant in the decision for excisional biopsy. There were four malignant breast masses which were diagnosed as benign on cytology. In one instance, a bloody tap was obtained, which often results in an inadequate specimen for diagnosis. In two cases, the size of the mass was greater than 4cm and inadequate specimens could have been obtained because of poor sampling. In the fourth case, a prlor attempt at cyst aspiration was performed by the primary care physician, with resultant hematoma formation, resulting in an inadequate specimen. DISCUSSION Aspiration cytology of the breast has been used extensively in certain centers as a method of diagnosing breast cancer. Zajadela et al found this method to be useful only when positive for malignancy and advocated that the diagnosis should be ignored if no malignant cells are observed. In our study, with a minimum of 6 month follow up, we found that ultrasound assisted needle aspiration biopsies allowed us to make a definitive diagnosis in 123 of 133 malignant breast masses. Biopsy was recommended in all cases because of either atypia or imaging abnormalities. Using the direct visualization approach for the sampling of the tissue, it is easy to document that sample was taken from the tumor itself. Fornage et al recently reported a sensitivity of 92% and specificity of 93% for the cytologic diagnosis of breast masses. The percentages of misdiagnoses for cancer is as low as .5% (Zajadela) and as high as 12% (Griffith) have been reported. With the use of ultrasound guidance, our missed rate for carcinomas, including nondefinitive diagnoses was 8% and is similar to the recently reported study of Fornage. The ability to accurately perform needle aspiration biopsies on palpable and non palpable breast cancers visualized on ultrasound imaging will have a significant impact on the management of breast cancer. S ~ Y We have found the method of performing needle aspiration biopsies with ultrasound using either the superficial localization technique or direct visualization technique to be an accurate effective method for diagnosis of the majority of breast cancer patients at our institution. With the improvement in the resolution of the commercially available hand held transducers, the potential to visualize small breast masses has increased significantly. An increase in the use of FNAB's of these masses will result and we anticipate a changing role in the use of ultrasound for both the detection and subsequent management of early breast cancer. ACKNOWLEDGEMENTS The expertise of M. Glant, M.D., in the interpretation of the cytology specimens is gratefully acknowledged. REFERENCES Eagan, R., Eagan, K., Detection of breast carcinoma: comparison of automated water path whole sonography, mammography, and physical examination, AJR. 143:493-497. Ezo, M., Fair, G., Hagen-Ansert, S., Hensley, L. (1985) Practical Techniques as an aid to Diagnosis: in Harper, P. (ed) Ultrasound Mammography. University Park Press. Fornage, B.D., Faroux, M.J., Simatos, A., (1987) Breast Masses: Ultrasound guided fine needle aspiration biopsy. Radiology 409-414. Griffith, C.N., Kern, W.H., Mikkensen, W.P. (1986) Needle aspiration cytologic examination in the management of suspicious lesions of the breast. Surgery, Gynecology and Obstetrics. Vol. 162: 142-144. Harper, P., Kelly-Fry, E. (1980) Ultrasound visualization of the breast in symptomatic patients. Radiology 137: 465-469. Harper, P., Kelly-Fry, E., Noe, J.S. et al. (1983) Ultrasound in the evaluation of solid breast masses. Radiology 146: 731-736. Harper, P., Kelly-Fry, E., (1984) Breast Ultrasound; Report of a five year clinical and research program. Le Journal Francals d'Echographie. 133-139. Harper, P., (1985) The benefit of needle aspiration biopsies using ultrasound localization techniques in the diagnosis and management of breast carcinomas. Proceedings of the Fourth International Congress on the Ultrasonic Examination of the Breast: Eds Jellins, J., Kosoff, G., Cro!l, J. 83-90. Witton Press, Sydney, Australia. Harper, A.P., (1985) The correlation of ultrasound imaging characteristics and cytopathology of cystic breast masses. Proceedings of the fourth meeting of the World Federation for Ultrasound in Medicine and Biology. Eds Gill, R. W., Dodd, M. J., 349. Pergamon Press. Livarghi, T. (1984) A simple no-cost technique for real-time biopsy. J. Clin. Ultrasound, 12: 60-62.
5th International
Congress on the Ultrasonic
Examination of the Breast
Van Dam, P., Van Goethem, M., Kersschol, E., Vervliet, J., Van den Veyver, I., Deschepper, A., Buytaert, P. (1988) Palpable solid breast masses: Retrospectlve single and multimodality evaluation of 2@1 lesions. Radiology. 166: 435-439. Vlaisaveljevic', V., (1986) Interventional Ultrasound in breast diseases. Excerpta Medica. ICS. 85-93. Za~adela, A., Ghossein, N.A., Pilleron, J.P., Ennuyer, A. (1975) The value o£ aspiration cytology in the diagnosis of breast cancer: Experience at the Foundation Curie. Cancer. 499-506.
11
0301-5629/88 ~3.00 + .00 (e) 1988 Pergamon Press plc
FINE NEEDLE ASPIRATION BIOPSY OF THE BREAST USING ULTRASOUND TECHNIQUES - SUPERFICIAL LOCALIZATION AND DIRECT VISUALIZATION
A. P. Harper
Indianapolis Breast Center Indianapolis, IN 4626@
Abstract-From July 1982 to December 1987, 519 fine needle aspiration biopsies were performed at the Indianapolis Breast Center. Both the superficial localization and the direct visualization methods were used. The fine needle aspiration biopsy technique (FNAB) was definitive in 92% of malignant masses, with minimum of 6 month follow up to date. The technique significantly alters the traditional approach to the management o£ breast cancer in that it allows preoperative discussions of options for treatment and eliminates the cost of excisional biopsies before definitive therapy. Key Words: Breast ultrasound, breast neoplasms, breast biopsy, breast disease diagnosls, ultrasound guided biopsy.
INTRODUCTION The methods of treating breast cancer have changed dramatically during the last few years. The decision process for choosing between the modified radical mastectomy and the lumpectomy with radiation, is aided considerably when an accurate diagnosis is made before surgery. X-ray mammography is the accepted method for evaluating the asymptomatic breast, while ultrasound scanning is used as an adjunct for diagnosis in patients with dense breasts and for further evaluation of masses visualized on x-ray mammograms. (Van Dam, et al. 1988; Harper and Kelly-Fry, 1984; Harper et al. 1983; Eagan, R. and Eagan K., 1984; Harper and Kelly-Fry, 1980). The fine needle aspiration biopsy (FNAB), plays an integral role in the diagnosis and surgical management of breast cancer. (Zajadela et al. 1975; Grlffith et al. (1986). We have found that aspiratlon biopsies performed with ultrasound guidance, facilitates a more precise evaluation and sampling of the abnormal tissue. The ultrasound imaging characteristics of the tumor serve as a determining factor for the use of the procedure. In our study, when a dlscrete mass was found in two or more image planes, there was a hlgher yield of abnormal tissue for cytologic evaluation, thus increasing the ability to make a definitive diagnosis in nonpalpable carcinomas seen on ultrasound imaging. Other authors have reported success in the use of FNAB using ultrasound guidance and also conclude %hat routine use of this technique is cost effective ~Id can lead to earlier diagnosis. (Fornage et al. 1987; Vlaisaveljevic', 1986; Livarghi, 1984; Harper, 1985. }~THODS AND INSTRUI~NTATION ['rom previous experience in the evaluation ot symptomatic breast patients, protocols were developed for the use of interventional procedures such as needle aspiration biopsles and cyst aspirations. (Harper, 1985). Needle aspiration biopsies are performed in the following circumstances: I. 2. 3. 4.
Sy~iptomatic mass ~ith malignant c~aracterlstlcs on ultrasound scans. S?~ptomatic mass wlth indeterminate ultrasound imaging characteristics, Discretely palpable mass :hat is not vlsualized on ultrasound imaging. Asym~ptoma%ic mass, which on ultrasound, demonstrates mallgnant characteristics.
Automated breast scannlng is primarily performed uslng the LaDsonics Ultrasound instrument. The design features of :hls instrument ~ave previously been described. (Ezo et al. 1985). The patient is examin©d Ln the supine ~>osltlon, u~ich is best sulted for performlng aspiration prcce~/res.
6
5th International
C o n g r e s s on t h e U l t r a s o n i c
Examination of the Breast
In the breast, unlike other superficial organs, tumors may move significantly with different patient positions, and therefore, needle aspiration biopsies are performed after ultrasound visualization of the mass, without changing patient position. Superficial localization is used with the Labsonics Instrument while the direct visualization approach is taken with hand-held instruments. Transducers of 7.5 HHz are typically used, but higher or lower frequency transducers have been substituted, when needed, for better visualization of the tumor mass. There are inherent problems with both of the above methods, but these can be offset if the limitations of each procedure are appreciated. Superficial localization is performed by scanning the breast with a metallic marker placed over the area of the tumor for confirmation of the exact location of the tumor. (Harper, 1985). Without moving the patient, the waterbag is removed from the breast, the skin is anethesized, and the needle biopsy is performed. Multiple passes are made throughout the tumor using negative suctioning. The primary limitation of this method is that the depth of the tumor has to be estimated. With experience, this depth measurement can be calculated and the textural difference between the tumor and surrounding tissue appreciated. The commercially hand-held transducers available in the USA have not, until recently, had the needed resolution to image a significant number of small solid tumors. The primary limitation of the direct visualization method, is that, for small tumors, two people are usually needed. One person holds the transducer in a fixed position, while another performs the biopsy. If a needle biopsy holder is attached to the transducer, one operator may suffice. With this method however, there is an increase in the amount of tissue traversed for the biopsy because of the oblique approach of the needle resulting in more trauma to the breast tissue. For FNAB's, a 20cc syringe with a 22 gauge cutting needle is used. The syringe is rinsed with a heparinized balanced salt solution. When performing biopsies using direct visualization, it is helpful to have a small amount of air in the needle and the syringe, as this facilitates visualization of the needle as it enters the breast mass. Hultiple samples of the tumor and adjacent tissues are taken by applying negative suction to the syringe. The aspirated material is then applied to frosted slides, fixed in alcohol, and sent for cytopathological analysis. Cytologic diagnoses fall into two basic categories, diagnostic and non-diagnostic. It is important to strive to achieve a high level of diagnostic results, equal in predictive value to a surgical biopsy with frozen section (99% or higher). The certainty of a diagnosis is communicated by the following terminology. A diagnostic case for malignancy might be signed out as "malignant cells are present from adenocarcinoma, infiltrating ductal type". If a malignancy has features which make a cell typing difficult, the diagnosis would be "adenocarcinoma, small celled ductal or lobular type". A definitive benign fine needle aspiration biopsy diagnosis would be "Negative for malignancy - fibrocystic change predominantly sclerosing adenosis", or "Negative for malignancy - fibroadenoma". At times the pattern of the benign lesions are definitive and require a diagnosis, such as, "negative for malignancy" - ductal hyperplasia and dense fibrosis are present, consistent with fibrocystic change; however, a fibroadenoma cannot be excluded." This often occurs in bland, low grade, ductal carcinomas (frequent in women over 65) or small carcinomas which are poorly sampled. A diagnosis in this instance mlght read "markedly atypical ductal cells are present, consistent with, but not diagnostic of, an adenocarcinoma - recommmend excisional biopsy with frozen section". Definitive diagnoses of malignant lesions allow treatment without frozen section, but currently all masses with a diagnosis of malignancy have a frozen section diagnosis before definitive treatment is performed. In definitive benign diagnoses, correlation with imaging and clinical features may preclude the need for excision in the majority of cases. In nondefinitive diagnoses, follow up or treatment is dictated by any suspicious findings on the clinical evaluation or imaging results. RESULTS At the Indianapolis Breast Center, there were approximately 2 6 , ~ 0 patient visits over the five year period, 1982 - 1987. Two hundred and forty five breast cancers were diagnosed and of these, 186 breast cancers were found with needle aspiration biopsies. This represents 76% of the cancers. (Table I) This study minimum of aspiration tables 2 &
reflects the 4 i/2 year period from July 1982 to December 1986, which allows a a 6 month follow up of the benign masses. Five hundred and nineteen needle biopsies were performed. The number of benign and malignant masses is shown in 3.
5th International
C o n g r e s s on t h e U l t r a s o n i c
Examination of the Breast
7
Table i Total number of needle biopsies in 5 year period.
INDIANAPOLIS BREAST CENTER
FIVE YEAR PERIOD
7/82 - 7/87
TOTAL NUMBER OF MALIGNANT BREAST MASSES
2~5
TOTAL NUMBER OF NEEDLE BIOPSIES IN THIS GROUP
-
186
Table 2
TOTAL NUMBER NEEDLE ASPIRATION BIOPSIES
-
519
Results of 4 1/2 year study period 7/82-12/86
TOTAL NUMBER OF BENIGN MASSES
-
383
TOTAL NUMBER OF MALIGNANT MASSES
-
133
( 76% )
( 3 ) inadequate needle b i o p s i e s lost to follow up
MAL IGNANT
MASSES
MALIGNANT
ON N E E D L E
133
Table 3
ASPIRATION
BIOPSY
-
123
-
5
-
I
Cytologic
diagnoses of
ATYPIA
malignant
INADEQUATE
breast masses.
BENIGN
RECOMMEND
BIOPSY
SPECIMEN
DIAGNOSIS
-
4
The patient population has been predominantly symptomatic, but the percentage of symptomatic to asymptomatic patients is changing. The current ratio is 7:3 symptomatic to asymptomatic. Physical findings and symptoms, as determined both by the referring physician and the patient, are recorded. The majority of our breast patients practice breast self-examination, and many breast cancers are detected by the patients. X-ray mammograms are usually performed on all patients except in patients who are either less than 25 years of age or pregnant. Ultrasound scans are used to evaluate the radiographically dense areas of the breast, the young and pregnant patients and to localize masses for needle aspiration biopsy procedures. Typical examples of palpable and nonpalpable masses on which FNAB's were performed are demonstrated in figures 1 & 2 respectlvely. Figure 1 is an ultrasound image of a degenerating fibroadenoma in a 37 year old. In this case, the direct visualization approach is the method of choice because &t enables retrieval of tissue from the abnormal area of attenuation, which is the most susplcious for malignancy. The remainder of the mass demonstrates the benign characteristics of smooth walls and uniform internal echoes.
8
5th International
C o n g r e s s on t h e U l t r a s o n i c
Examination of the Breast
]:igu/e I begenerating fibroadenoma (arrow heads). Large arrow indicates the area of degeneratlor~.
Figure 2 demonstrates a nonpalpable malignant mass which could be easily aspirated because it was easily visualized on ultrasound imaging in more than one plane. Although this mass was less than Icm in diameter and nonpalpable, using ultrasound, the mass was localized and FNAB performed. It was not difficult to detect the difference in texture between thiE small mass and the surrounding tissue. Five masses described by the pathologist as having sufficient atypia to warm,ant biopsy, were malignant at excisional biopsy. Figure 2a X-ray mamm~grams - comparison cranio-caudal views of left and right breasts demonstrate a nonpalpable mass. arrowhead)
Figure 2b Cone down magnification mammogram of the mass demonstrates malignant characteristics.
x-ray
Figure 2c Biplane ultrasound scans demonstrate a solid mass (large arrowhead) with jagged walls. Some architectural distortlon of the breast tissue is present superior to the mass. (small arrowhead).
Sth International
Congress on the Ultrasonic
RTAmtnatton of the Breast
9
Figure 3 demonstrates such an example. FNAB of this mass revealed fibrocystic changes with atypical ductal hyperplasia. The ultrasound image did not demonstrate a discrete mass but architectural disruption of the normal pattern of the breast. There was no obvious textural difference between the malignant mass and the surrounding tissue, even though an obvious mass was present on x-ray mammography. At excision, hematoma from the FNAB was present within the tumor. Figure 3a Cranio-caudal x-ray marm~ogram demonstrates a mass in the medial aspect of the breast (arrowhead).
Figure 3b Cone d o ~ x-ray mammogram demonstates some irregularity of the margins o£ this tumor.
Figures 3c & 3d Two adjacent ultrasound scans 2mm apart demonstrate some abnormal echogenic tissue (arrowheads) but no discrete mass. Minimal attenuation of the ultrasound beam is present. (large arrow head).
I0
5th International Congress on the Ultrasonic Examination of the Breast
These five masses all demonstrated imaging characteristics which were suspicious for malignancy, and therefore, the cytopathological report, as stated previously, is not the only determinant in the decision for excisional biopsy. There were four malignant breast masses which were diagnosed as benign on cytology. In one instance, a bloody tap was obtained, which often results in an inadequate specimen for diagnosis. In two cases, the size of the mass was greater than 4cm and inadequate specimens could have been obtained because of poor sampling. In the fourth case, a prlor attempt at cyst aspiration was performed by the primary care physician, with resultant hematoma formation, resulting in an inadequate specimen. DISCUSSION Aspiration cytology of the breast has been used extensively in certain centers as a method of diagnosing breast cancer. Zajadela et al found this method to be useful only when positive for malignancy and advocated that the diagnosis should be ignored if no malignant cells are observed. In our study, with a minimum of 6 month follow up, we found that ultrasound assisted needle aspiration biopsies allowed us to make a definitive diagnosis in 123 of 133 malignant breast masses. Biopsy was recommended in all cases because of either atypia or imaging abnormalities. Using the direct visualization approach for the sampling of the tissue, it is easy to document that sample was taken from the tumor itself. Fornage et al recently reported a sensitivity of 92% and specificity of 93% for the cytologic diagnosis of breast masses. The percentages of misdiagnoses for cancer is as low as .5% (Zajadela) and as high as 12% (Griffith) have been reported. With the use of ultrasound guidance, our missed rate for carcinomas, including nondefinitive diagnoses was 8% and is similar to the recently reported study of Fornage. The ability to accurately perform needle aspiration biopsies on palpable and non palpable breast cancers visualized on ultrasound imaging will have a significant impact on the management of breast cancer. S ~ Y We have found the method of performing needle aspiration biopsies with ultrasound using either the superficial localization technique or direct visualization technique to be an accurate effective method for diagnosis of the majority of breast cancer patients at our institution. With the improvement in the resolution of the commercially available hand held transducers, the potential to visualize small breast masses has increased significantly. An increase in the use of FNAB's of these masses will result and we anticipate a changing role in the use of ultrasound for both the detection and subsequent management of early breast cancer. ACKNOWLEDGEMENTS The expertise of M. Glant, M.D., in the interpretation of the cytology specimens is gratefully acknowledged. REFERENCES Eagan, R., Eagan, K., Detection of breast carcinoma: comparison of automated water path whole sonography, mammography, and physical examination, AJR. 143:493-497. Ezo, M., Fair, G., Hagen-Ansert, S., Hensley, L. (1985) Practical Techniques as an aid to Diagnosis: in Harper, P. (ed) Ultrasound Mammography. University Park Press. Fornage, B.D., Faroux, M.J., Simatos, A., (1987) Breast Masses: Ultrasound guided fine needle aspiration biopsy. Radiology 409-414. Griffith, C.N., Kern, W.H., Mikkensen, W.P. (1986) Needle aspiration cytologic examination in the management of suspicious lesions of the breast. Surgery, Gynecology and Obstetrics. Vol. 162: 142-144. Harper, P., Kelly-Fry, E. (1980) Ultrasound visualization of the breast in symptomatic patients. Radiology 137: 465-469. Harper, P., Kelly-Fry, E., Noe, J.S. et al. (1983) Ultrasound in the evaluation of solid breast masses. Radiology 146: 731-736. Harper, P., Kelly-Fry, E., (1984) Breast Ultrasound; Report of a five year clinical and research program. Le Journal Francals d'Echographie. 133-139. Harper, P., (1985) The benefit of needle aspiration biopsies using ultrasound localization techniques in the diagnosis and management of breast carcinomas. Proceedings of the Fourth International Congress on the Ultrasonic Examination of the Breast: Eds Jellins, J., Kosoff, G., Cro!l, J. 83-90. Witton Press, Sydney, Australia. Harper, A.P., (1985) The correlation of ultrasound imaging characteristics and cytopathology of cystic breast masses. Proceedings of the fourth meeting of the World Federation for Ultrasound in Medicine and Biology. Eds Gill, R. W., Dodd, M. J., 349. Pergamon Press. Livarghi, T. (1984) A simple no-cost technique for real-time biopsy. J. Clin. Ultrasound, 12: 60-62.
5th International
Congress on the Ultrasonic
Examination of the Breast
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