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Needle localization of mammographically detected lesions in perspective
Needle Localization of Mammographically Detected Lesions in Perspective
Brenda J. Skkk&antanello, MD, Columbus, Ohio, Pakick J. O’Dwyer,MD, London, England, DanielP. McCabe, MD, Everett, Washington, WilliamB. Farrar, MD, JohnP. Mtnton,MD, PhD, and Arthur0. James, MD, Columbus, Ohio
Breast cancer is the most common malignancy in women and the second most common cause of all cancer-related deaths in women. The mortality rate for breast cancer has remained essentially unchanged for over 50 years [I]. In order to improve the survival statistics, the emphasis should be on early detection. Self-breast examination, physical examination by a physician, and mammography are the mainstays of diagnosis. The comparative merits of physical examination and mammography in mass screening to detect breast cancer at an early stage have been evaluated in large studies [2-q. The results have shown that significant numbers of nonpalpable breast cancers were diagnosed by mammography only. Since 1977, mammography with needle localization of nonpalpable lesions has been performed at our institution. This study describes the results obtained and assesses the propo-rtion of needle-localized breast cancers in relation to all breast cancer diagnosed. Mater&l
and h&thods
Five thousand nine hundred forty-one mammograms were performed from June 1977 to September 1985. We retrospectively reviewed patients undergoing needle localization. Suspicious lesions on mammograms were characterized by clusters of microcalcification, architectural asymmetry, or the suggestion of an occult mass. Localization was performed using the hooked guide wire technique in most cases. The pathologic evaluation of all biopsy specimens was reviewed. In patients with confirmed breast cancer, the definitive surgical procedure was reviewed and the stage of disease assessed. The number and stage of needle- localized breast cancers was then From the Divisions of Surgical Oncology. Departments of Surgery, The Dhlo State University College of Medicine and tiant Hospital, Columbus, Ohlo. Dr. Sickle-Santanello was an American Cancer Society Fellow. Requests for reprlnts should be addressed to Brenda J. Slckle-Santanello, MD, Grant Hospital, 300 East Tower Street, Columbus, Ohio 43214.
Volume 154, September 1987
compared to the number and stage of all breast cancers detected in the same period. Results One hundred seven patients underwent needle localization. Eighty-five patients (79.5 percent) had benign disease, such as fibrocystic disease, fibroadenoma, fat necrosis, abscess. Twenty-two breast cancers (20.5 percent) were diagnosed (Figure 1). The average age of the patients with breast cancer was 52 years. The majority of cancers (77.3 percent) were invasive. Only five patients had intraductal or in situ lesions. Nineteen of these patients underwent modified radical mastectomy and 79 percent had node-negative specimens. Two patients underwent simple mastectomy and one patient was treated with primary radiotherapy because of concomitant illness. Two breast cancers were diagnosed by needle localization prior to 1982. Since that time, there has been no increasing trend as measured annually (Figure 2). During the same 8 year period, 570 breast cancers were diagnosed by all other means. Staging of these cancers revealed that 4 percent were intra-
ductal or in situ; 49 percent were local, being confined to breast; 34 percent were regional, with extensive skin involvement or axillary node involvement; and 13 percent were distant, with distant organ or distant lymph node involvement, at the time of presentation compared with 23 percent, 55 percent, 22 percent, and 0, resectively, for needle localized cancers. (Figure 3). The incidence of in situ and local breast cancers detected by needle localization was significantly increased compared with detection of breast cancer by all other means (chi-square 4.1, p <0.05). Overall, needle localization was responsible for 3.8 percent of all breast cancers diagnosed.
279
Sickle-Santanello et al
107 (1.8%) NEEDLE LOCALl2ATIONS / 85 (79.521 BENIQN
1 22 (20.5%) f44LIGNAM / 17 (77.3X) INVASIVE \ 19 WOlFIEO
570 BREAST CMCERS
OR IN-SITU
/ RADICAL UASTECTCHIES
I 15 (791) NWE
22 NEEDLE LOCALIZED BREAST CANCERS
\ 5 (22.72) INTAAOWAL
-
NEGATIVE
3.82
TREATED
Figure 1. Results of needle localized biopsies
----
looI--
N+-SIN
LOCK
_-_-___
1
RECl&L
Figure 3. Stage of breast cancer.
Comments Since the evolution of low-dose, high-resolution mammography and the improvements in localization techniques, new expectations for the prognosis of breast cancer have arisen. Previously, the majority of breast cancers were first noted by the patient, and over 50 percent of those had spread to the lymph nodes at the time of diagnosis [2,8]. Now, the emphasis is on detection of breast cancer at an earlier stage, in some cases before the lesion is palpable. Much of the impetus for this has been generated by two major screening programs, the Health Insurance Program (HIP) of New York and the Breast Cancer Detection Demonstration Projects (BCDDP) sponsored by the American Cancer Society and the National Cancer Institute [2-6]. In the HIP program, begun in 1964, Strax et al [2] divided 60,000 women into control and study groups. The 20,166 women in the study group underwent physical examination and mammography. A total of 132 breast cancers were diagnosed in the study group, 44 of which were detected by mammography alone and 59 of which were diagnosed by
280
Figure 2. lncldence of malignancy diagnosed by needle localked biopsy.
physical examination alone. The percentage of axillary node involvement and breast cancer deaths in the study group was decreased compared with the control group, especially in the patients 50 to 59 years of age. The investigators concluded that physical examination and mammography contributed independently to the detection of breast cancer [4]. Subsequently, the BCDDP program was organized in 1973 by the American Cancer Society and the National Cancer Institute to determine the effects of breast cancer screening in the United States. This study differed from the HIP program in that there was no control group. Also, the patients were self-selected and constituted a high-risk group, which may have biased the results [9]. Forty-five percent of the breast cancers diagnosed were found exclusively by mammography. Physical examination alone accounted for only 6 percent of the cancers detected. It should be noted that most of the physical examinations were performed by paraprofessionals, which may have influenced the low detection rate by physical examination. The BCDDP concluded that the technique of mammography has improved and was capable of detecting both minimal cancers, defined as noninvasive lesions and invasive lesions less than 1 cm in diameter, and those with favorable prognostic factors [S]. The use of mammography has become widespread since the BCDDP experience was reported. In the present study, over 5,000 mammograms were performed during an 8 year period. Both symptomatic and asymptomatic women were included in the study. Mammographically suspicious lesions were found in 107 patients without evidence of a palpable mass. Needle localization of these lesions resulted in detection of cancer in 20.5 percent. This incidence resembles those in other series, which have varied from 10 to 35 percent (10-l 71. Higher
The American Journal of Surgery
Needle Localization of Mammographically Deb&d
detection rates are seen when clusters of microcalcifications are present and are secondary signs that suggest biopsy [16]. The number of patients with in situ and local breast cancers detected by needle localization was significantly increased compared with the number of patients with breast cancer detected by all other means. Almost 80 percent of the women had localized disease with node-negative axillary dissection specimens. Published reports concur that the rate of axillary metastases is low in needle localized cancers, varying from 7 to 32 percent [4,10-12,14,16,18]. It should be mentioned that screening examinations prior to mammography using only physical examination also had a high detection rate of early breast cancer [19,20]. Gilbertsen and Kjelsberg [19] at the University of Minnesota showed improved overall survival rates for the patients whose cancers were detected at their cancer detection center. Also, Holleb et al [20] detected 3.8 cancers per 1,000 patients by physical examination, and 57 percent of these were detected before spread to the axillary lymph nodes. The benefits of mammography have been well publicized, however, there are disadvantages. In our study, 22 of 107 patients with suspicious mammographic findings were proved to have cancer, or stated another way, mammography had a true-positive rate of only 20 percent. Similarly, the HIP study performed over 20 years ago revealed true-positive findings in only 22 percent. This suggests there has not been a trend of improvement in the accuracy of needle-localized biopsy in over 20 years. The other issue of concern is the rate of falsenegative mammographic examinations. Although that data cannot be extrapolated from our study, the HIP study’s false-negative mammography rate was 45 percent (cancers detected by physical examination alone with normal mammograms). Although the BCDDP study reported a much lower rate of only 6 percent, the average false-negative rate probably lies somewhere in between. Lesnick [21], Block and Reynolds [22], and Sokol et al [23] have all shown very high false-negative rates for breast cancer detection using mammography in young women (range 45 to 63 percent). In the study of Lesnick [21], a negative mammographic finding even led to a delay in diagnosis in 15 patients. The reasons suggested for the lower accuracy rata of mammography in the young patient is the prevalence of dense glandular tissue which obscures malignant lesions compared with the large amount of fatty tissue replacement in the older patient. Reliance on mammography alone is ill advised. It was disappointing that needle localization of mammographically detected lesions was responsible for only 4 percent of all breast cancers diagnosed during the 8 year period. This trend may change,
Volume 154, September 1987
Lesions
however, in light of the recent changes in the American Cancer Society guidelines for mammography [24,25]. The guidelines suggest that a baseline mammogram be obtained from women between the ages of 35 and 40, followed by biennial examinations between the ages of 40 and 50, and then yearly thereafter. The Society also recommends that women over 20 years of age have physical examination of the breast periodically and that they perform selfbreast examination monthly, and women 40 to 49 years of age should have physical examination of the breast annually. There appears to be a trend toward reliance on mammography; however, in light of our data, we believe mammography and physical examination contribute independently to the diagnosis of breast cancer. Emphasis should continue to be placed on the technique of self-breast examination and routine physical examination. The percentage of mammographically detected cancers in this series suggests that examination by a physician and routine self-breast examination remain the mainstays of diagnosis of breast cancer. Summary Needle localization of mammographically detected lesions has been shown to detect early breast cancer. One hundred seven patients who underwent needle localized biopsy from June 1977 to September 1985 were reviewed. Eighty percent of the biopsies were benign and 20 percent were cancers (22 patients). In patients undergoing modified radical mastectomy, 80 percent of the axillary specimens were node-negative. During the same 8 year period, 570 breast cancers were diagnosed. Needle localization was responsible for only 4 percent of all cancers found. Though needle localization represents an advance in the detection of early breast cancer, the majority of cancers are found by physical examination. The importance of routine examination by a physician and self-breast examination remains paramount. References 1. Silverberg E, Lubera J. Cancer statistics, 1966. CA 1966; 36: 9-25. 2. Strax P, Venet L, Shapiro S, Gross S. Mammography and clinical examination in mass screening for cancer of the breast. Cancer 1967; 20: 2 164-8. 3. Venet L, Strax P, Venet W, Shapiro S. Adequacies and inadequacies of breast examinations by physicians. Cancer 1969; 24: 1187-91. 4. Venet L, Strax P, Venet W, Shapiro S. Adequacies and inadequacies of breast examlnations by physicians in mass screening. Cancer 1971; 26: 1546-51. 5. Beahrs OH, Shapiro S, Smart CR et al. Report to the working group to review the NCI/ACS breast cancer detection demonstration projects. J Nat1 Cancer lnst 1979; 62: 655709. 6. Beahrs OH, Smart CR. Breast cancer detection demonstration
281
SicklaSantanello et al
7. 8.
9.
10.
11.
12. 13. 14.
15.
282
projects as viewed by the clinician. In: Feig SA, McLelland R, eds. Breast carcinoma current diagnosis and treatment. New York: Masson, 1983: 307-14. Abe R, Kimura M, Sato T, et al. Trial of early detection of breast cancer by mass screening. Cancer 1985; 56: 1479. Bearhs OH. Comparative merits of mammography and physical examination. In: Fieg SA, McLelland R, eds. Breast carcinoma current diagnosis and treatment. New York: Masson, 1983: 303-8. Haagensen CD. Mass screening for breast carcinoma. In: Haagensen CD. Diseases of the breast. Philadelphia: WB Saunders, 1986: 606-12. Bigelow R, Smith R, Goodman PA, Wilson GS. Needle localization of nonpalpable breast masses. Arch Surg 1985; 120: 565-9. Bigongiari LR, Fidler W, Skerker LB, et al. Percutaneous needle localization of breast lesions prior to biopsy: analysis of failures. Clin Radio1 1977; 28: 419-25. Gisvold JJ, Martin JK Jr. Prebiopsy localization of nonpalpable breast lesions. AJR 1984; 143: 477-81. Hall FM, Frank HA. Preoperative localization of nonpalpable breast lesions. AJR 1979; 132: 101-5. Meyer JE, Kopans DB, Stomper PC, Lindfors KK. Occult breast abnormalities: percutaneous preoperative needle localization. Radiology 1984; 150: 335-7. Meyer JE, Kopans DB. Preoperative roentgenographically guided percutaneous localization of occult breast lesions. Arch Surg 1982; 117: 65-8.
16. Murphy WA, DeSchryver-Kecskemeti K. Isolated clustered microcalcifications in the breast: radiologic-pathologic correlation. Radiology 1978; 127: 335-41. 17. Walker HC, Delaney JP, Gedgaudas E. Locating nonpalpable breast lesions for the surgeon. Minn Med 1985; 68: 437-9. 18. Sayler C, Egan JF, Raines JR, Goodman MJ. Mammographic screening value In diagnosis of early breast cancer. JAMA 1977; 238: 872-3. 19. Gilbertsen VA, Kjelsberg M. Detection of breast cancer by periodic utilization of methods of physical dlagnosis. Cancer 1971; 28: 1552-4. 20. Holleb Al, Venet L, Day E, Hoyt S. Breast cancer detected by routine physical examination. NY State J Med 1960; 80: 823-7. 21. Lesnick 61. Detection of breast cancer In young women. JAMA 1977; 237: 967-9. 22. Block MA, Reynolds W. How vital is mammography in the diagnosis and management of breast cancer? Arch Surg 1974; 108: 588-91. 23. Sokol ES, Walker B, Terz V, et al. Role of mammography with palpable breast lesions. Surgery 1970; 87: 748-53. 24. National Task Force on Breast Cancer Control, American Cancer Society. Mammography 1982: a statement of the American Cancer Society. CA 1982; 32: 226-30. 25. Board of Directors. American Cancer Society. Mammography guidelines 1983: background statement and update of cancer-related checkup guidelines for breast cancer detection in asymptomatic women age 40-49. CA 1983; 33: 255.
The American Journal of Surgery
Brenda J. Skkk&antanello, MD, Columbus, Ohio, Pakick J. O’Dwyer,MD, London, England, DanielP. McCabe, MD, Everett, Washington, WilliamB. Farrar, MD, JohnP. Mtnton,MD, PhD, and Arthur0. James, MD, Columbus, Ohio
Breast cancer is the most common malignancy in women and the second most common cause of all cancer-related deaths in women. The mortality rate for breast cancer has remained essentially unchanged for over 50 years [I]. In order to improve the survival statistics, the emphasis should be on early detection. Self-breast examination, physical examination by a physician, and mammography are the mainstays of diagnosis. The comparative merits of physical examination and mammography in mass screening to detect breast cancer at an early stage have been evaluated in large studies [2-q. The results have shown that significant numbers of nonpalpable breast cancers were diagnosed by mammography only. Since 1977, mammography with needle localization of nonpalpable lesions has been performed at our institution. This study describes the results obtained and assesses the propo-rtion of needle-localized breast cancers in relation to all breast cancer diagnosed. Mater&l
and h&thods
Five thousand nine hundred forty-one mammograms were performed from June 1977 to September 1985. We retrospectively reviewed patients undergoing needle localization. Suspicious lesions on mammograms were characterized by clusters of microcalcification, architectural asymmetry, or the suggestion of an occult mass. Localization was performed using the hooked guide wire technique in most cases. The pathologic evaluation of all biopsy specimens was reviewed. In patients with confirmed breast cancer, the definitive surgical procedure was reviewed and the stage of disease assessed. The number and stage of needle- localized breast cancers was then From the Divisions of Surgical Oncology. Departments of Surgery, The Dhlo State University College of Medicine and tiant Hospital, Columbus, Ohlo. Dr. Sickle-Santanello was an American Cancer Society Fellow. Requests for reprlnts should be addressed to Brenda J. Slckle-Santanello, MD, Grant Hospital, 300 East Tower Street, Columbus, Ohio 43214.
Volume 154, September 1987
compared to the number and stage of all breast cancers detected in the same period. Results One hundred seven patients underwent needle localization. Eighty-five patients (79.5 percent) had benign disease, such as fibrocystic disease, fibroadenoma, fat necrosis, abscess. Twenty-two breast cancers (20.5 percent) were diagnosed (Figure 1). The average age of the patients with breast cancer was 52 years. The majority of cancers (77.3 percent) were invasive. Only five patients had intraductal or in situ lesions. Nineteen of these patients underwent modified radical mastectomy and 79 percent had node-negative specimens. Two patients underwent simple mastectomy and one patient was treated with primary radiotherapy because of concomitant illness. Two breast cancers were diagnosed by needle localization prior to 1982. Since that time, there has been no increasing trend as measured annually (Figure 2). During the same 8 year period, 570 breast cancers were diagnosed by all other means. Staging of these cancers revealed that 4 percent were intra-
ductal or in situ; 49 percent were local, being confined to breast; 34 percent were regional, with extensive skin involvement or axillary node involvement; and 13 percent were distant, with distant organ or distant lymph node involvement, at the time of presentation compared with 23 percent, 55 percent, 22 percent, and 0, resectively, for needle localized cancers. (Figure 3). The incidence of in situ and local breast cancers detected by needle localization was significantly increased compared with detection of breast cancer by all other means (chi-square 4.1, p <0.05). Overall, needle localization was responsible for 3.8 percent of all breast cancers diagnosed.
279
Sickle-Santanello et al
107 (1.8%) NEEDLE LOCALl2ATIONS / 85 (79.521 BENIQN
1 22 (20.5%) f44LIGNAM / 17 (77.3X) INVASIVE \ 19 WOlFIEO
570 BREAST CMCERS
OR IN-SITU
/ RADICAL UASTECTCHIES
I 15 (791) NWE
22 NEEDLE LOCALIZED BREAST CANCERS
\ 5 (22.72) INTAAOWAL
-
NEGATIVE
3.82
TREATED
Figure 1. Results of needle localized biopsies
----
looI--
N+-SIN
LOCK
_-_-___
1
RECl&L
Figure 3. Stage of breast cancer.
Comments Since the evolution of low-dose, high-resolution mammography and the improvements in localization techniques, new expectations for the prognosis of breast cancer have arisen. Previously, the majority of breast cancers were first noted by the patient, and over 50 percent of those had spread to the lymph nodes at the time of diagnosis [2,8]. Now, the emphasis is on detection of breast cancer at an earlier stage, in some cases before the lesion is palpable. Much of the impetus for this has been generated by two major screening programs, the Health Insurance Program (HIP) of New York and the Breast Cancer Detection Demonstration Projects (BCDDP) sponsored by the American Cancer Society and the National Cancer Institute [2-6]. In the HIP program, begun in 1964, Strax et al [2] divided 60,000 women into control and study groups. The 20,166 women in the study group underwent physical examination and mammography. A total of 132 breast cancers were diagnosed in the study group, 44 of which were detected by mammography alone and 59 of which were diagnosed by
280
Figure 2. lncldence of malignancy diagnosed by needle localked biopsy.
physical examination alone. The percentage of axillary node involvement and breast cancer deaths in the study group was decreased compared with the control group, especially in the patients 50 to 59 years of age. The investigators concluded that physical examination and mammography contributed independently to the detection of breast cancer [4]. Subsequently, the BCDDP program was organized in 1973 by the American Cancer Society and the National Cancer Institute to determine the effects of breast cancer screening in the United States. This study differed from the HIP program in that there was no control group. Also, the patients were self-selected and constituted a high-risk group, which may have biased the results [9]. Forty-five percent of the breast cancers diagnosed were found exclusively by mammography. Physical examination alone accounted for only 6 percent of the cancers detected. It should be noted that most of the physical examinations were performed by paraprofessionals, which may have influenced the low detection rate by physical examination. The BCDDP concluded that the technique of mammography has improved and was capable of detecting both minimal cancers, defined as noninvasive lesions and invasive lesions less than 1 cm in diameter, and those with favorable prognostic factors [S]. The use of mammography has become widespread since the BCDDP experience was reported. In the present study, over 5,000 mammograms were performed during an 8 year period. Both symptomatic and asymptomatic women were included in the study. Mammographically suspicious lesions were found in 107 patients without evidence of a palpable mass. Needle localization of these lesions resulted in detection of cancer in 20.5 percent. This incidence resembles those in other series, which have varied from 10 to 35 percent (10-l 71. Higher
The American Journal of Surgery
Needle Localization of Mammographically Deb&d
detection rates are seen when clusters of microcalcifications are present and are secondary signs that suggest biopsy [16]. The number of patients with in situ and local breast cancers detected by needle localization was significantly increased compared with the number of patients with breast cancer detected by all other means. Almost 80 percent of the women had localized disease with node-negative axillary dissection specimens. Published reports concur that the rate of axillary metastases is low in needle localized cancers, varying from 7 to 32 percent [4,10-12,14,16,18]. It should be mentioned that screening examinations prior to mammography using only physical examination also had a high detection rate of early breast cancer [19,20]. Gilbertsen and Kjelsberg [19] at the University of Minnesota showed improved overall survival rates for the patients whose cancers were detected at their cancer detection center. Also, Holleb et al [20] detected 3.8 cancers per 1,000 patients by physical examination, and 57 percent of these were detected before spread to the axillary lymph nodes. The benefits of mammography have been well publicized, however, there are disadvantages. In our study, 22 of 107 patients with suspicious mammographic findings were proved to have cancer, or stated another way, mammography had a true-positive rate of only 20 percent. Similarly, the HIP study performed over 20 years ago revealed true-positive findings in only 22 percent. This suggests there has not been a trend of improvement in the accuracy of needle-localized biopsy in over 20 years. The other issue of concern is the rate of falsenegative mammographic examinations. Although that data cannot be extrapolated from our study, the HIP study’s false-negative mammography rate was 45 percent (cancers detected by physical examination alone with normal mammograms). Although the BCDDP study reported a much lower rate of only 6 percent, the average false-negative rate probably lies somewhere in between. Lesnick [21], Block and Reynolds [22], and Sokol et al [23] have all shown very high false-negative rates for breast cancer detection using mammography in young women (range 45 to 63 percent). In the study of Lesnick [21], a negative mammographic finding even led to a delay in diagnosis in 15 patients. The reasons suggested for the lower accuracy rata of mammography in the young patient is the prevalence of dense glandular tissue which obscures malignant lesions compared with the large amount of fatty tissue replacement in the older patient. Reliance on mammography alone is ill advised. It was disappointing that needle localization of mammographically detected lesions was responsible for only 4 percent of all breast cancers diagnosed during the 8 year period. This trend may change,
Volume 154, September 1987
Lesions
however, in light of the recent changes in the American Cancer Society guidelines for mammography [24,25]. The guidelines suggest that a baseline mammogram be obtained from women between the ages of 35 and 40, followed by biennial examinations between the ages of 40 and 50, and then yearly thereafter. The Society also recommends that women over 20 years of age have physical examination of the breast periodically and that they perform selfbreast examination monthly, and women 40 to 49 years of age should have physical examination of the breast annually. There appears to be a trend toward reliance on mammography; however, in light of our data, we believe mammography and physical examination contribute independently to the diagnosis of breast cancer. Emphasis should continue to be placed on the technique of self-breast examination and routine physical examination. The percentage of mammographically detected cancers in this series suggests that examination by a physician and routine self-breast examination remain the mainstays of diagnosis of breast cancer. Summary Needle localization of mammographically detected lesions has been shown to detect early breast cancer. One hundred seven patients who underwent needle localized biopsy from June 1977 to September 1985 were reviewed. Eighty percent of the biopsies were benign and 20 percent were cancers (22 patients). In patients undergoing modified radical mastectomy, 80 percent of the axillary specimens were node-negative. During the same 8 year period, 570 breast cancers were diagnosed. Needle localization was responsible for only 4 percent of all cancers found. Though needle localization represents an advance in the detection of early breast cancer, the majority of cancers are found by physical examination. The importance of routine examination by a physician and self-breast examination remains paramount. References 1. Silverberg E, Lubera J. Cancer statistics, 1966. CA 1966; 36: 9-25. 2. Strax P, Venet L, Shapiro S, Gross S. Mammography and clinical examination in mass screening for cancer of the breast. Cancer 1967; 20: 2 164-8. 3. Venet L, Strax P, Venet W, Shapiro S. Adequacies and inadequacies of breast examinations by physicians. Cancer 1969; 24: 1187-91. 4. Venet L, Strax P, Venet W, Shapiro S. Adequacies and inadequacies of breast examlnations by physicians in mass screening. Cancer 1971; 26: 1546-51. 5. Beahrs OH, Shapiro S, Smart CR et al. Report to the working group to review the NCI/ACS breast cancer detection demonstration projects. J Nat1 Cancer lnst 1979; 62: 655709. 6. Beahrs OH, Smart CR. Breast cancer detection demonstration
281
SicklaSantanello et al
7. 8.
9.
10.
11.
12. 13. 14.
15.
282
projects as viewed by the clinician. In: Feig SA, McLelland R, eds. Breast carcinoma current diagnosis and treatment. New York: Masson, 1983: 307-14. Abe R, Kimura M, Sato T, et al. Trial of early detection of breast cancer by mass screening. Cancer 1985; 56: 1479. Bearhs OH. Comparative merits of mammography and physical examination. In: Fieg SA, McLelland R, eds. Breast carcinoma current diagnosis and treatment. New York: Masson, 1983: 303-8. Haagensen CD. Mass screening for breast carcinoma. In: Haagensen CD. Diseases of the breast. Philadelphia: WB Saunders, 1986: 606-12. Bigelow R, Smith R, Goodman PA, Wilson GS. Needle localization of nonpalpable breast masses. Arch Surg 1985; 120: 565-9. Bigongiari LR, Fidler W, Skerker LB, et al. Percutaneous needle localization of breast lesions prior to biopsy: analysis of failures. Clin Radio1 1977; 28: 419-25. Gisvold JJ, Martin JK Jr. Prebiopsy localization of nonpalpable breast lesions. AJR 1984; 143: 477-81. Hall FM, Frank HA. Preoperative localization of nonpalpable breast lesions. AJR 1979; 132: 101-5. Meyer JE, Kopans DB, Stomper PC, Lindfors KK. Occult breast abnormalities: percutaneous preoperative needle localization. Radiology 1984; 150: 335-7. Meyer JE, Kopans DB. Preoperative roentgenographically guided percutaneous localization of occult breast lesions. Arch Surg 1982; 117: 65-8.
16. Murphy WA, DeSchryver-Kecskemeti K. Isolated clustered microcalcifications in the breast: radiologic-pathologic correlation. Radiology 1978; 127: 335-41. 17. Walker HC, Delaney JP, Gedgaudas E. Locating nonpalpable breast lesions for the surgeon. Minn Med 1985; 68: 437-9. 18. Sayler C, Egan JF, Raines JR, Goodman MJ. Mammographic screening value In diagnosis of early breast cancer. JAMA 1977; 238: 872-3. 19. Gilbertsen VA, Kjelsberg M. Detection of breast cancer by periodic utilization of methods of physical dlagnosis. Cancer 1971; 28: 1552-4. 20. Holleb Al, Venet L, Day E, Hoyt S. Breast cancer detected by routine physical examination. NY State J Med 1960; 80: 823-7. 21. Lesnick 61. Detection of breast cancer In young women. JAMA 1977; 237: 967-9. 22. Block MA, Reynolds W. How vital is mammography in the diagnosis and management of breast cancer? Arch Surg 1974; 108: 588-91. 23. Sokol ES, Walker B, Terz V, et al. Role of mammography with palpable breast lesions. Surgery 1970; 87: 748-53. 24. National Task Force on Breast Cancer Control, American Cancer Society. Mammography 1982: a statement of the American Cancer Society. CA 1982; 32: 226-30. 25. Board of Directors. American Cancer Society. Mammography guidelines 1983: background statement and update of cancer-related checkup guidelines for breast cancer detection in asymptomatic women age 40-49. CA 1983; 33: 255.
The American Journal of Surgery