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Results of breast biopsies for mammographic findings
Results of Breast Biopsies for Mammographic Findings J. Harold Cheek, MD, FACS,’ Dallas Texas A. D. Sears, MD,* Dallas, Texas
It is doubtful that the predicted epidemic of breast cancer will ever occur, but there is little doubt that the controversy relating to mammography has caused a sharp decrease in the number of mammographic studies being done. The strident criticism of the value of mammography because of a theoretical risk will, we believe, prove to be detrimental to good patient care. The material to be presented herein is from a referral type of private practice and covers the seven and a half years in which senography and xerography have been utilized for mammographic studies. Of the 4,203 patients with new breast examinations in this interval, biopsy was required in 1,389 (33 per cent): 963 (69 per cent) proved to be benign, and the remaining 426 (31 per cent) were malignant. The correlation between the physical and mammographic findings, as well as our indications for biopsies, have been reported elsewhere [I]. Basically the indications for biopsies are those recognized by all who are familiar with diseases of the breast, and now must include suspicious mammographic findings. Of the mammographic indications for biopsy that have been suggested [2-41, this experience has been limited to those biopsies needed for calcifications, masses (stellate or otherwise), and localized asymmetrical fibrotic areas within the breast. From the present study we have found that when both the physical and mammographic findings were suspicious, cancer was nearly always diagnosed at the time of biopsy. Cancer was found at hiopsies done for clinical reasons in a number of instances when the mammograms had been reported as benign or negative, when both clinically and mammographically the lesion was considered benign, or when no mammograms had been done preoperatively. There have now been 314 biopsies necessary in 274 women for mammographic findings only in whom there was no palpable lesion. Frcm the Departments of Sugery’ acd FIadiologyT.Baylor UniversityMedical Center, Dallas, Texas. Reprint requests should be addressed to J. Harold Cheek. MD. 3600 Gaston Avenue, Dallas. Texas 75246. Presented at the Thirtieth Annual Meeting of the Southwestern Surgical Congress, Palm Springs, California, April 17-20. 1978.
726
Results and Comments
Of the 314 biopsies done for mammographic findings, specimen radiography was required to identify the lesion in 268 (85 per cent) (42 cancerous, 227 benign) and unnecessary in the remaining 46 (15 cancerous, 30 benign). Therefore, from these biopsies, 57 cancers were diagnosed, 42 found only with the use of specimen radiography. It is important to emphasize that 47 of the 57 cancers were diagnosed at the time of surgery by frozen section examination after specimen radiography had revealed the lesion. The remaining 10 cancers were diagnosed from the permanent sections. (Table I.) As expected, a majority of the biopsies yielded a diagnosis of some benign process. The most common lesion histologically was some form of fibrocystic disease, and many with some proliferative change such as intraductal hyperplasia, apocrine metaplasia, sclerosing adenosis, and/or papillomatosis being identified. The most common cancer diagnosed was infiltrating duct cell carcinoma. Pure intraductal carcinoma was the next most frequent. Other forms of cancer were few in number, as was in situ carcinoma, which was surprisingly infrequent. (Table II.) In this nonscreening private practice setting, 314 biopsies were necessary because of nonpalpable lesions discovered only by mammographic studies. This number of biopsies resulted in 57 cancers being discovered. They make up 13 per cent of the total number of cancers found in this period of study. Most of the carcinomas were diagnosed in breasts biopsied for calcifications. These calcifications were usually of a fine variety and arranged in a clustered or linear fashion or, occasionally, in a branching pattern. In many instances they were so characteristic that the diagnosis of carcinoma could be readily made by the radiologist. The nonpalpable mass lesions occurred only in large breasts which were difficult to examine because of size. The role of specimen radiography in the pathology laboratory has been well established and is now recognized as an essential study after blind biopsy of the
The American Journal of Surgery
Mammography
TABLE I
Success of Frozen Section Diagnosis (mammographic group) _.__~ No. of Patients
Specimen X-Ray
Frozen Section Diagnosis
42
40
34
8
15 57
2 42
13 47
2 10
Biopsied for calcifications Biopsied for mass Total -
TABLE II
Infiltrating duct cell carcinoma lntraductal carcinoma lntraductal carcinoma in situ lntraductal papillary carcinoma Infiltrating lobular carcinoma Tubular carcinoma
Delayed Diagnosis
for mammographic findings. It is particularly important for the pathologist and surgeon to be convinced that the findings on the mammogram which led to biopsy are those seen on the specimen radiograph. We believe that it is contraindicated to undertake biopsies for mammographic findings in si.tuations in which specimen radiography is not available. Ideally, it is best accomplished with the use of a Faxitron unit within the frozen section area of the pathology laboratory. The age distribution of the 274 patients operated on for mammographic findings is shown in Figure 1. A majority of these (70 per cent) were between the ages of forty and sixty years. One hundred and twenty-two of the women (45 per cent) biopsied solely for suspicious mammographic findings were less t,han fifty years old. Twenty-two of the 57 cancers (39 per cent) found in this study were in these patients. (Figure 2.) This finding casts serious doubt on recommendations that mammography not be performed on women aged less than fifty years. We believe there are certain clinical indications for mambreast
Variety of Cancers in Mammographic Group __32
ia 3 2 1 1
mography which, when present, dictate its use even in the earlier age groups. In this study, an interesting observation was the marked increase in the number of biopsies done for mammographic reasons beginning in late 1974. This was a natural result of the increased awareness of breast cancer with the vast publicity following the operations of Mrs. Ford and Mrs. Rockefeller. (Figure 3.) This increased number of biopsies was, of course, directly related to the increased number of mammograms ordered by the physicians or demanded by the patient. An equally interesting observation was the significant increase in t.he number of cancers found annually following those events. The increased number of cancers diagnosed parallels the increased number of biopsies done for mammographic reasons subsequent to 1974. (Figure 4.) Most of the biopsies done for mammographic findings result in a benign pathologic report,. However, since 18 per cent of the biopsies resulted in the diagnosis of carcinoma, it is believed that this approach to the management of the patient with positive mammographic findings should continue. It is our experience, as it has been of others [4-71, that study of the axil-
r-
22 20 18
80
16 14
10
20
30
40
50
60
70
80
90
100
L
Figure 1. Ages of patients operated on for mammographic reasons.
Volume138,December1978
z
12
"E 3
10
I
a
!
Figure 2. Ages of patients in the mammographic group in whom breast cancer was found.
727
Cheek and Sears
‘70
‘71
‘72
‘73 -YEAR
‘74
‘75
‘76
‘77
-
Figure 4. Number of cancers diagnosed per year in the present study.
‘70
‘71
‘72
‘73 -
‘74
‘75
‘76
‘77
YEAR -
Figure 3. Number of biopsies for mammographic findings per year.
lary lymph nodes after surgery reveals metastases to them to be much less frequent than one would expect with palpable carcinoma of the breast. (Table III.) The presence of lymph node metastasis in only 11 per cent of these patients indicates that the survival rate of these particular women should certainly be better than that of patients with obvious clinical carcinomas. Conclusions
In this study, there was a close correlation between the mammographic and clinical findings in the majority of cases. At the same time, we must emphasize that where there is clinical evidence for biopsy, biopsy should be done despite a negative or benign mammographic report. Conversely, where there are suspicious mammographic findings, biopsy should be done despite benign clinical findings. When biopsy
TABLE III
Lymph Node Metastases in Mammographic Group No. of
Biopsied for calcifications Biopsied for mass Total
728
Patients 42 15 57
Positive Nodes 4 2 6
is performed for a nonpalpable lesion, specimen radiography is essential to the pathologist if the region in question is to be conclusively identified. This has been necessary in a majority of the patients in this report. Although occult, since the majority of these carcinomas were of the infiltrating duct cell variety, these may not be particularly minimal lesions. Long-term follow-up will supply that information. The number of carcinomas seen in patients younger than fifty years indicates that if there is reason for mammography to be done, it certainly should be done with no reluctance whatsoever. We are concerned that the adverse publicity, so prevalent in the news media, may cause many women to be denied the benefit of mammography in situations in which it is obviously indicated. One must hope that the physicians and the news media will take a sensible approach to the usefulness of mammography. Summary
The results of breast biopsies for mammographic findings have been presented, in which 314 biopsies were done on 274 patients. From this number of biopsies, the diagnosis of cancer was established in fifty-seven cases (18 per cent of the biopsies). More than 50 per cent of the lesions were infiltrating duct cell carcinomas. The number of breast biopsies required increased markedly after the national publicity in 1974. As more biopsies were done, the incidence of carcinoma increased, and a significant number of these were found in women less than fifty years old. We believe this justifies the continued judicious use of mammography, even in the younger patient, if clinically indicated.
The American Journal of Surgery
Mammography
References 1. Cheek JH: Experience with breast biopsies for mammographic findings. Breast 4: 4, 1978. 2. Duncan S, Soder P, Cooper D, Eaton B, Godwin JT: Mammography: an aid in the treatment of carcinoma of the breast. Ann Surg 179: 749, 1974. 3. ICheek JH, Sears AD: Management of the breast lump. Tex Med 71: 39, 1975. 4. Malone LJ, Frank1 G, Dorazio RA, Winkley JH: Occult breast carcinomas detected by xeroradiography: clinical considerations. Ann Surg 181: 133, 1975. 5. Frank1 G, Rosenfeld DD: Breast xeroradiography: an analysis of our first 17 months. Ann Surg 178: 676, 1973. 6. Sayler C, Egan JF, Raines JR, Goodman MJ: Mammographic screening-value in diagnosis of early breast cancer. JAMA 238: 872, 1977. 7. Kalisher, L, Schaffer D: Indications and guidelines for mammographic examinations. Am J Surg 133: 326, 1977.
Discussion Shields 0. Livingston (Dallas, TX): The authors certainly add ammunition to the continuing use of mammography as a diagnostic tool. These fifty-seven patients with carcinoma who were operated on for mammographic findings only fall into a very special category. These fortunate women certainly have a better prognosis than the patients we operated on after clinical findings. The number of positive results in people who would not otherwise have been operated on at all leads me to wonder if I am using mammography as much as I should and leads me also to ask what indications would lead you to perform mammography on the patient in whom on physical examination there is no evidence of breast disease. Charles Kruse (Santa Monica, CA): In 1972, we introduced xerography, and the incidence of bilateral carcinoma increased from 1.9 to 10.8 per cent. The overall incidence
Volume 136, December 1976
of bilaterality in 1,189 patients in a twenty-one year period in the same institution was only 2.9 per cent. Usually in the literature bilaterality occurs in 1 to 9 or 14 per cent. But this proves that increased use of xerography correlates with the increased pickup of bilateral breast cancer. J. Harold Cheek (Dallas, TX): If we suspect cancer in one breast in an individual patient, we certainly are going to biopsy that breast. We are confirming what our suspicion may be, but actually we are more concerned about what is in the opposite breast, because it has been our experience also, Dr. Kruse, that we have found an increased number of bilateral carcinomas with the help of mammography. Certainly, survey of the remaining breast after radical mastectomy is a direct indication for mammography. In one group, the large breasted women, mammography is particularly important, because in these women one cannot always tell what one is feeling. Screening mammograms in patients between forty and fifty years of age is important. There is a great “roar” going on about no screening before the age of fifty. We believe high risk women should be screened at forty to forty-five years. We are talking about those women with a strong family history of breast cancer or women who have had multiple biopsies for gross fibrocystic change with hyperplastic changes within the breast. Then there is that group of women with evidence of metastatic disease without a known primary. We have found an occasional cancer by this means. Finally, there are those women whose suspicions were aroused after the operations of Mrs. Ford and Mrs. Rockefeller, and many demanded mammograms from their physician or radiologist. One must discuss mammography at length with these patients because of what they read in the magazines and newspapers.
729
It is doubtful that the predicted epidemic of breast cancer will ever occur, but there is little doubt that the controversy relating to mammography has caused a sharp decrease in the number of mammographic studies being done. The strident criticism of the value of mammography because of a theoretical risk will, we believe, prove to be detrimental to good patient care. The material to be presented herein is from a referral type of private practice and covers the seven and a half years in which senography and xerography have been utilized for mammographic studies. Of the 4,203 patients with new breast examinations in this interval, biopsy was required in 1,389 (33 per cent): 963 (69 per cent) proved to be benign, and the remaining 426 (31 per cent) were malignant. The correlation between the physical and mammographic findings, as well as our indications for biopsies, have been reported elsewhere [I]. Basically the indications for biopsies are those recognized by all who are familiar with diseases of the breast, and now must include suspicious mammographic findings. Of the mammographic indications for biopsy that have been suggested [2-41, this experience has been limited to those biopsies needed for calcifications, masses (stellate or otherwise), and localized asymmetrical fibrotic areas within the breast. From the present study we have found that when both the physical and mammographic findings were suspicious, cancer was nearly always diagnosed at the time of biopsy. Cancer was found at hiopsies done for clinical reasons in a number of instances when the mammograms had been reported as benign or negative, when both clinically and mammographically the lesion was considered benign, or when no mammograms had been done preoperatively. There have now been 314 biopsies necessary in 274 women for mammographic findings only in whom there was no palpable lesion. Frcm the Departments of Sugery’ acd FIadiologyT.Baylor UniversityMedical Center, Dallas, Texas. Reprint requests should be addressed to J. Harold Cheek. MD. 3600 Gaston Avenue, Dallas. Texas 75246. Presented at the Thirtieth Annual Meeting of the Southwestern Surgical Congress, Palm Springs, California, April 17-20. 1978.
726
Results and Comments
Of the 314 biopsies done for mammographic findings, specimen radiography was required to identify the lesion in 268 (85 per cent) (42 cancerous, 227 benign) and unnecessary in the remaining 46 (15 cancerous, 30 benign). Therefore, from these biopsies, 57 cancers were diagnosed, 42 found only with the use of specimen radiography. It is important to emphasize that 47 of the 57 cancers were diagnosed at the time of surgery by frozen section examination after specimen radiography had revealed the lesion. The remaining 10 cancers were diagnosed from the permanent sections. (Table I.) As expected, a majority of the biopsies yielded a diagnosis of some benign process. The most common lesion histologically was some form of fibrocystic disease, and many with some proliferative change such as intraductal hyperplasia, apocrine metaplasia, sclerosing adenosis, and/or papillomatosis being identified. The most common cancer diagnosed was infiltrating duct cell carcinoma. Pure intraductal carcinoma was the next most frequent. Other forms of cancer were few in number, as was in situ carcinoma, which was surprisingly infrequent. (Table II.) In this nonscreening private practice setting, 314 biopsies were necessary because of nonpalpable lesions discovered only by mammographic studies. This number of biopsies resulted in 57 cancers being discovered. They make up 13 per cent of the total number of cancers found in this period of study. Most of the carcinomas were diagnosed in breasts biopsied for calcifications. These calcifications were usually of a fine variety and arranged in a clustered or linear fashion or, occasionally, in a branching pattern. In many instances they were so characteristic that the diagnosis of carcinoma could be readily made by the radiologist. The nonpalpable mass lesions occurred only in large breasts which were difficult to examine because of size. The role of specimen radiography in the pathology laboratory has been well established and is now recognized as an essential study after blind biopsy of the
The American Journal of Surgery
Mammography
TABLE I
Success of Frozen Section Diagnosis (mammographic group) _.__~ No. of Patients
Specimen X-Ray
Frozen Section Diagnosis
42
40
34
8
15 57
2 42
13 47
2 10
Biopsied for calcifications Biopsied for mass Total -
TABLE II
Infiltrating duct cell carcinoma lntraductal carcinoma lntraductal carcinoma in situ lntraductal papillary carcinoma Infiltrating lobular carcinoma Tubular carcinoma
Delayed Diagnosis
for mammographic findings. It is particularly important for the pathologist and surgeon to be convinced that the findings on the mammogram which led to biopsy are those seen on the specimen radiograph. We believe that it is contraindicated to undertake biopsies for mammographic findings in si.tuations in which specimen radiography is not available. Ideally, it is best accomplished with the use of a Faxitron unit within the frozen section area of the pathology laboratory. The age distribution of the 274 patients operated on for mammographic findings is shown in Figure 1. A majority of these (70 per cent) were between the ages of forty and sixty years. One hundred and twenty-two of the women (45 per cent) biopsied solely for suspicious mammographic findings were less t,han fifty years old. Twenty-two of the 57 cancers (39 per cent) found in this study were in these patients. (Figure 2.) This finding casts serious doubt on recommendations that mammography not be performed on women aged less than fifty years. We believe there are certain clinical indications for mambreast
Variety of Cancers in Mammographic Group __32
ia 3 2 1 1
mography which, when present, dictate its use even in the earlier age groups. In this study, an interesting observation was the marked increase in the number of biopsies done for mammographic reasons beginning in late 1974. This was a natural result of the increased awareness of breast cancer with the vast publicity following the operations of Mrs. Ford and Mrs. Rockefeller. (Figure 3.) This increased number of biopsies was, of course, directly related to the increased number of mammograms ordered by the physicians or demanded by the patient. An equally interesting observation was the significant increase in t.he number of cancers found annually following those events. The increased number of cancers diagnosed parallels the increased number of biopsies done for mammographic reasons subsequent to 1974. (Figure 4.) Most of the biopsies done for mammographic findings result in a benign pathologic report,. However, since 18 per cent of the biopsies resulted in the diagnosis of carcinoma, it is believed that this approach to the management of the patient with positive mammographic findings should continue. It is our experience, as it has been of others [4-71, that study of the axil-
r-
22 20 18
80
16 14
10
20
30
40
50
60
70
80
90
100
L
Figure 1. Ages of patients operated on for mammographic reasons.
Volume138,December1978
z
12
"E 3
10
I
a
!
Figure 2. Ages of patients in the mammographic group in whom breast cancer was found.
727
Cheek and Sears
‘70
‘71
‘72
‘73 -YEAR
‘74
‘75
‘76
‘77
-
Figure 4. Number of cancers diagnosed per year in the present study.
‘70
‘71
‘72
‘73 -
‘74
‘75
‘76
‘77
YEAR -
Figure 3. Number of biopsies for mammographic findings per year.
lary lymph nodes after surgery reveals metastases to them to be much less frequent than one would expect with palpable carcinoma of the breast. (Table III.) The presence of lymph node metastasis in only 11 per cent of these patients indicates that the survival rate of these particular women should certainly be better than that of patients with obvious clinical carcinomas. Conclusions
In this study, there was a close correlation between the mammographic and clinical findings in the majority of cases. At the same time, we must emphasize that where there is clinical evidence for biopsy, biopsy should be done despite a negative or benign mammographic report. Conversely, where there are suspicious mammographic findings, biopsy should be done despite benign clinical findings. When biopsy
TABLE III
Lymph Node Metastases in Mammographic Group No. of
Biopsied for calcifications Biopsied for mass Total
728
Patients 42 15 57
Positive Nodes 4 2 6
is performed for a nonpalpable lesion, specimen radiography is essential to the pathologist if the region in question is to be conclusively identified. This has been necessary in a majority of the patients in this report. Although occult, since the majority of these carcinomas were of the infiltrating duct cell variety, these may not be particularly minimal lesions. Long-term follow-up will supply that information. The number of carcinomas seen in patients younger than fifty years indicates that if there is reason for mammography to be done, it certainly should be done with no reluctance whatsoever. We are concerned that the adverse publicity, so prevalent in the news media, may cause many women to be denied the benefit of mammography in situations in which it is obviously indicated. One must hope that the physicians and the news media will take a sensible approach to the usefulness of mammography. Summary
The results of breast biopsies for mammographic findings have been presented, in which 314 biopsies were done on 274 patients. From this number of biopsies, the diagnosis of cancer was established in fifty-seven cases (18 per cent of the biopsies). More than 50 per cent of the lesions were infiltrating duct cell carcinomas. The number of breast biopsies required increased markedly after the national publicity in 1974. As more biopsies were done, the incidence of carcinoma increased, and a significant number of these were found in women less than fifty years old. We believe this justifies the continued judicious use of mammography, even in the younger patient, if clinically indicated.
The American Journal of Surgery
Mammography
References 1. Cheek JH: Experience with breast biopsies for mammographic findings. Breast 4: 4, 1978. 2. Duncan S, Soder P, Cooper D, Eaton B, Godwin JT: Mammography: an aid in the treatment of carcinoma of the breast. Ann Surg 179: 749, 1974. 3. ICheek JH, Sears AD: Management of the breast lump. Tex Med 71: 39, 1975. 4. Malone LJ, Frank1 G, Dorazio RA, Winkley JH: Occult breast carcinomas detected by xeroradiography: clinical considerations. Ann Surg 181: 133, 1975. 5. Frank1 G, Rosenfeld DD: Breast xeroradiography: an analysis of our first 17 months. Ann Surg 178: 676, 1973. 6. Sayler C, Egan JF, Raines JR, Goodman MJ: Mammographic screening-value in diagnosis of early breast cancer. JAMA 238: 872, 1977. 7. Kalisher, L, Schaffer D: Indications and guidelines for mammographic examinations. Am J Surg 133: 326, 1977.
Discussion Shields 0. Livingston (Dallas, TX): The authors certainly add ammunition to the continuing use of mammography as a diagnostic tool. These fifty-seven patients with carcinoma who were operated on for mammographic findings only fall into a very special category. These fortunate women certainly have a better prognosis than the patients we operated on after clinical findings. The number of positive results in people who would not otherwise have been operated on at all leads me to wonder if I am using mammography as much as I should and leads me also to ask what indications would lead you to perform mammography on the patient in whom on physical examination there is no evidence of breast disease. Charles Kruse (Santa Monica, CA): In 1972, we introduced xerography, and the incidence of bilateral carcinoma increased from 1.9 to 10.8 per cent. The overall incidence
Volume 136, December 1976
of bilaterality in 1,189 patients in a twenty-one year period in the same institution was only 2.9 per cent. Usually in the literature bilaterality occurs in 1 to 9 or 14 per cent. But this proves that increased use of xerography correlates with the increased pickup of bilateral breast cancer. J. Harold Cheek (Dallas, TX): If we suspect cancer in one breast in an individual patient, we certainly are going to biopsy that breast. We are confirming what our suspicion may be, but actually we are more concerned about what is in the opposite breast, because it has been our experience also, Dr. Kruse, that we have found an increased number of bilateral carcinomas with the help of mammography. Certainly, survey of the remaining breast after radical mastectomy is a direct indication for mammography. In one group, the large breasted women, mammography is particularly important, because in these women one cannot always tell what one is feeling. Screening mammograms in patients between forty and fifty years of age is important. There is a great “roar” going on about no screening before the age of fifty. We believe high risk women should be screened at forty to forty-five years. We are talking about those women with a strong family history of breast cancer or women who have had multiple biopsies for gross fibrocystic change with hyperplastic changes within the breast. Then there is that group of women with evidence of metastatic disease without a known primary. We have found an occasional cancer by this means. Finally, there are those women whose suspicions were aroused after the operations of Mrs. Ford and Mrs. Rockefeller, and many demanded mammograms from their physician or radiologist. One must discuss mammography at length with these patients because of what they read in the magazines and newspapers.
729