Localisation of impalpable breast masses

352

Use of Clark levels for assessing tumour invasion is not trouble free.8.13 The normal papillary and reticular dermis varies in thickness, and the papillary-reticular interface (level III) was described by Clark as "somewhat ill-defined", especially in certain sites such as the sole of the foot. The main difficulties are encountered with melanomas in levels III and IV; level III tumours may distort the papillary-reticular interface without breaching it. Subdivision of Clark levels has been proposed. 14 Information may be provided by considering the depth of uninvolved dermis.15 Microstaging has been modified in the form of a prognostic index16-tumour thickness measured in millimetres is multiplied by the numbers of mitoses counted in melanoma cells per square millimeter in standard stained sections. In 879 patients with stage I cutaneous melanomas an index of < 19 compared with one of > 19 was found to be a significant and independent prognostic variable when compared with seven other predictive variables, including Breslow thicknessY In patients with melanomas measuring 1-50-3-49 mm in thickness, the prognostic index seemed to be more accurate in predicting five-year survival than did Breslow thickness alone. Breslow thickness and Clark levels provide

different categories of information, and discrepancies between the two systems were apparent almost as soon as they were described. Put very simply, tumour thickness and invasive level are roughly congruent for levels II and V (hypodermal fat) but are discordant in levels IIIand IV. 1-3,18 Numerous analyses have shown consistently significant differences with respect to tumour thickness and outcome within each level of invasion. The prognostic weight of thickness in stage I tumours is not invariable. There is a subgroup of thin (0.6-1.1 mm) level IV melanomas with a poor five-year survival of about 60%, in which the Clark level is the sole,19 or an important,15 independent prognostic factor. A variably small proportion of patients with thick melanomas (> 3 mm,20 > 5 mm21) have unexpectedly long disease-free intervals. Discrepancies between thickness and level in cutaneous melanomas may be more apparent than real. Thin but deeply invasive melanomas19 probably represent early vertical growth phase melanomas. This phase of growth22 is said to represent development within an invasive lesion, previously without metastatic potential, of a cytologically different clone of cells with an expansive growth pattern and the capacity to metastasise. That vascular invasion was found only in melanomas in the vertical growth phase accords with this view. 23 Conversely, the lack of metastasis in some thick but horizontal phase lesions20 may be related to the lack of vascular invasion in the horizontal phase of growth. 23 Some of the difficulties encountered with these systems may be resolved by identification of markers of tumour progression.24 Meanwhile, the Leicester findings remind us of the limitations, as well as the advantages, of microstaging in localised cutaneous melanomas.

Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma. Ann Surg 1970; 172: 902-08. 2. Breslow A. Tumour thickness, level of invasion and node dissection in stage 1 cutaneous melanoma. Ann Surg 1975; 182: 572-75. 1. Breslow A.

3. Breslow A. Problems in the measurement of tumour thickness and level of invasion in cutaneous melanoma. Hum Pathol 1977; 8: 1-2. 4. Clark WH Jr, From L, Bernardino A, Mihm MC. The histogenesis and biologic behaviour of primary human malignant melanomas of the skin. Cancer Res 1969; 29: 705-26. 5. Suffm SC, Waisman J, Clark WH, Morton DL. Comparison of the classification by microscopic level (stage) of malignant melanoma by three independent groups of pathologists. Cancer 1977; 40: 3112-14. 6. EORTC Melanoma Pathologist’s Group. Difficulties encountered in the application of Clark classification and the Breslow thickness measurement in cutaneous malignant melanoma. Int J Cancer 1980; 26: 159-63. 7. Colloby PS, West P, Fletcher A. Observer variation in the measurement of Breslow depth and Clark’s level in thin cutaneous malignant melanoma. J Pathol 1991; 163: 245-50. 8. McGovern VJ. Melanoma: histological diagnosis and prognosis. New York: Raven Press, 1983. 9. Kirkham N, Cotton DWK. Measuring melanomas: the Vernier method. J Clin Pathol 1984; 37: 229-30. 10. Warren BF, Davies JD. Pierre Vernier’s invention: a neglected tool of our trade. Histopathology 1991; 18: 361-62. 11. Jeffrey I, Royston P, Sowter C, et al. Prognostic value of tumour thickness in cutaneous malignant melanoma. J Chn Pathol 1983; 36: 51-56. 12. McGovern VJ, Shaw HM, Milton GW. Prognostic significance of a polypoid configuration in malignant melanoma. Histopathology 1983; 7: 663-72. 13. Huvos AG, Shah JP, Mike V. Prognostic factors in cutaneous malignant melanoma: a comparative study of long term and short term survivors. Hum Pathol 1974; 5: 347-57. 14. Sondergaard K. Depth of invasion and tumour thickness in primary cutaneous malignant melanoma. Acta Path Microbiol Immunol Scand Sect A 1985; 93: 49-55. 15. Blessing K, McLaren KM, McLean A, Davidson P. Thin malignant melanomas (<1·5 mm) with metastasis: a histological study and survival analysis. Histopathology 1990; 17: 389-95. 16. Schmoeckel C, Braun-Falco O. Prognostic index in malignant melanoma. Arch Dermatol 1978; 114: 871-73. 17. Kopf AW, Gross DF, Rogers GS, et al. Prognostic index for malignant melanoma. Cancer 1987; 59: 1236-41. 18. Balch CM, Murad TM, Soong S-J, Ingalls AL, Halpern NB, Maddox WA. A multifactorial analysis of melanoma: prognostic histopathological features comparing Clark’s and Breslow’s staging methods. Ann Surg 1977; 188: 732-42. 19. Kelly JW, Sagebiel RW, Clyman S, Blois MS. Thin level IV malignant melanoma. A subset in which level is the major prognostic indicator. Ann Surg 1985; 202: 98-103. 20. Blessing K, McLaren KM, McLean A, Davidson P. Thick malignant melanomas (>3 mm Breslow) with good clinical outcome: a histological study and survival analysis. Histopathology 1991; 18: 143-48. 21. Rivers JK, McCarthy SW, Shaw HM, et al. Patients with thick melanomas surviving at least 10 years: histological, cytometric and HLA analyses. Histopathology 1991; 18: 339-46. 22. Clark WH Jr, Elder DE, Guerry IV DP, et al. Model predicting survival in stage I melanoma based on tumour progression. J Natl Cancer Inst 1989; 81: 1893-904. 23. Fallowfield ME, Cook MG. Vascular invasion in malignant melanomas. Am J Surg Pathol 1989; 13: 217-20. 24. Albelda SM, Mette SA, Elder DE, et al. Integrin distribution in malignant melanoma: association of the &bgr;3 subunit with tumour progression. Cancer Res 1990; 50: 6757-64.

Localisation of

impalpable breast

masses

Increasing use of mammography both in symptomatic breast disease and especially in screening of symptom-free women has led to the discovery of numerous impalpable breast lesions. Not all of these are malignant and they can be managed either by further mammography, possibly with magnification -at which point most of the abnormalities will either

353

have disappeared or look less suspicious’-or by use of ultrasound plus aspiration.2 The remainder, amounting to about 10%, will appear sufficiently abnormal either initially or on review to warrant removal for histological examination. This figure can be reduced further by regular use of fine-needle aspiration of non-palpable lesions by means of ultrasound or stereotactic mammography.3,4 Many methods have been used for localisation before excision. The simplest approach is "geographic" estimation of the site of abnormality, with measurements taken from the mammogram and transposed to the breast. This technique can be refined with skin marking.5,6 More accuracy can be obtained with injection of a mixture of radiographic contrast media and a coloured dye near the suspicious area, under mammographic control. This method is popular with many surgeons, who locate the coloured dye easily at operation, but the small amount of contrast media makes it less satisfactory for radiologists. Another disadvantage is that dye injection must be followed by surgery within hours because the dye diffuses through the breast, making accurate localisation difficult. This timing of localisation and surgery may not always be easy. The relation of localisation and surgery is not as critical when needles and wires are inserted under radiographic control; this approach enhances the accuracy of localisation. Numerous types of wires and needles are now available, all with their own advocates. Difficulties are encountered with needle misplacement, displacement, and migration,8 although the last mentioned is uncommon. Many ways of preventing displacement have been devised, from hooks and curves to crosses.9-11 Misplacement can be managed by use of a perforated compression plate12 or illuminated cross-wires on the mammographic machine, but the most accurate method of wire placing is probably by use of stereotactic mammography, for which an accuracy to 1-2 mm has been claimed. (Many users have found such claims rather optimistic.) To diminish the possibility of wire migration, surgery should be carried out within a few hours of localisation. Simple methods of securing the wire that protrudes out of the breast-eg, by bending, suturing, or taping-will usually be sufficient. Ultrasoundguided insertion of wires on the operating table has also been advocated.13 The procedure can be unsettling for anxious patients, and even the most experienced operators can take several minutes to do it. Nevertheless, it is important not to use premedication because cooperation is essential and drowsy patients can cause considerable technical difficulties, giving rise to even more distress. Some surgeons, especially those who do only a few biopsies of non-palpable lesions a year, may have trouble in palpating or finding the end of the wire. Moreover, thinner wires and hooks are used with increasing frequency. To overcome this

drawback, methods such

as

leaving

a

stiffening

cannula over the wire have been devised. 14 Whatever method of localisation is used, a radiograph of the excised specimen should be taken with a mammography machine while the patient is still anaesthetised so that the suspicious area is known to have been removed. is However, with cooperation between patients and radiographers, aided by increasing experience of radiologists and surgeons with this technique, almost all impalpable lesions are removed successfully. 1. Brenner RJ, Sickles EA. Acceptability of periodic follow up as an alternative to biopsy for mammographically detected lesions

interpreted as probably benign. Radiology 1989; 171: 645-46. EA, Filly RA, Cullen PW. Benign breast lesions, ultrasound detection and diagnosis. Radiology 1984; 151: 467-70. 3. Kopans DB, Mayer JE, Lindfoss KK, Bucchianeri SS. Breast sonography to guide cyst aspiration and wire localisation of occult solid lesions. AJR 1984; 143: 489-92. 4. Azavedo E, Svane G, Auer G. Stereotactic fine-needle biopsy in 2594 mammographically detected non-palpable lesions. Lancet 1989; i:

2. Sickles

1033-36.

Snyder RE. Specimen radiography and preoperative localisation of non palpable breast cancer. Cancer 1980; 46: 950-60. 6. Stevens MG, Jampus RW. Mammographically directed biopsy of non palpable breast lesions. Arch Surg 1971; 102: 292-95. 7. Wayne RW, Darby RE. Injection mammography. JAMA 1977; 237:

5.

2219-20. 8. Owen AWMC, Kumar EN. Migration of localising wires used in guided biopsy of the breast. Clin Radiol 1991; 43: 251. 9. Frank HA, Hall FM, Steer ML. Pre operative localisation of non palpable breast lesion demonstrated by mammography. N Engl J Med 1976; 295: 259-60. 10. Homer MJ. Non palpable breast lesion localisation using a curved end retractable wire. Radiology 1985; 157: 259-60. 11. Chaudary MA, Reidy JF, Chaudhuri R, Millis RR, Hayward JL, Fentiman IS. Localisation of impalpable breast lesions. A new device.

Br J Surg 1990; 77: 1191-92. 12. Lee MJR, Lee JR, Thompson H, Oates GD. Mammographic identification and biopsy of occult breast cancer. Ann R Coll Surg Engl 1986; 68: 188-90. 13. Schwartz GF, Goldberg BB, Rifkin MD, D’Orazio SE. Ultrasonography: an alternative to X-ray guided needle localisation of non palpable breast masses. Surgery 1988; 104: 870-73. 14. Kwasnik EM, Sadowsky NL, Vollman RW. An improved system for surgical excision of needle localised non palpable breast lesions. Ann J

Surg 1987; 154: 476-77. 15. Boulter PS. The mammographic cancer.

Explaining

Br J Surg 1988; 75:

401.

syncope

for 1-3% of attendances at accident and emergency departments and 3-6% of hospital admissions.1,2 In 30-50% of patients no underlying cause is found despite extensive tests. Subsequent case-fatality in such patients is low but morbidity remains high:l,2 about half will have one or more recurrences, often associated with minor lacerations or bruising, and occasionally syncope results in a serious fracture or even a road traffic accident. Repeated investigations are seldom helpfu1.1 The head-up tilt test reproduces symptoms and also identifies a specific abnormality of the heart rate/blood pressure response to postural stress in patients with syncope,2-13 In susceptible individuals venous pooling and increased sympathetic drive seem to activate ventricular mechanoreceptors (and afferent vagal

Syncope

accounts