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Roentgenography of breast specimens
Roentgenography An Aid in the Management HIDEYO
of Breast Specimens of Nonpalpable
MINAGI, M.D. AND JAMES E. YOUKER,
From the Departvnent of Radiology, University of California School of Medicine, San Francisco, California. This work was supported in pal’ by U.S.P.H.S. Grant DHEW 0517.
N RECENT YEARS the possibility of detecting
I nonpalpable
cancerous lesions of the breast by roentgenographic means has been demonstrated repeatedly. That the yield of positive results on survey mammography in asymptomatic women is rather low is becoming apparent. Conversely, the yield in certain high risk groups is sufliciently great that the discovery of substantial numbers of nonpalpable carcinomas is to be expected [l]. Missakian, Witten, and Harrison [Z], for example, found cancer in the opposite breast in 25 of 397 women who had undergone mastectomy for breast carcinoma. Of these twenty-five tumors, ten were not evident clinically and were diagnosed only by mammography. The lesions detected by mammography were smaller and axillary node metastasis developed in fewer of these patients than in those with clinically palpable lesions. The roentgenographic diagnosis of nonpalpable breast lesions presents a unique set of problems to surgeon and pathologist. No palpable mass is present to guide the surgeon to the proper site and extent of biopsy. On receiving the biopsy specimen, the pathologist is often faced with the problem of where best to cut sections. In some instances, neither the surgeon nor the pathologist can be certain that the tissue actually represents the area roentgenographically suspected of being cancerous. These difficulties may be overcome by obtaining roentgenograms of the excised specimens, particularly when the abnormalities on the original mammograms appeared as fine calcium deposits. For example, in a forty-six Vol.115,March 1968
Breast Carcinoma
M.D.,Sun Francisco, California
year old woman, adenocarcinoma was found in an excised right axillary node. Although the right breast gave negative results clinically, mammograms showed a cluster of fine calcific deposits deep in the right breast adjacent to the chest wall. Because of these combined findings, right radical mastectomy was performed. In sixty-four sections of various areas of the breast, no histologic evidence of malignancy was discernible. A roentgenogram of the specimen demonstrated the cluster of calcifications at one end. (Fig. 1 and 2.) Guided by this roentgenogram, a sixty-fifth section was made in the area of the calcifications and this revealed a small infiltrating ductal carcinoma. Figure 3 is the roentgenogram of a specimen from another patient in whom biopsy was performed because of suspicious calcifications seen on mammography. The fine calcifications apparent on the roentgenogram of the specimen assured the surgeon that the suspicious area had been excised. By referring to this roentgenogram the pathologist obtained representative sections of the precise area of suspicion. The histologic diagnosis in this instance was ductal hyperplasia with interlobular and intralobular proliferation of connective tissue. The calcifications were both stromal and intraductal. TECHNIC
To avoid unnecessary delay, the specimen is brought to the radiology department immediately after excision. Several exposures of the specimen are obtained, using 28 kv., 300 ma., a distance of 30 inches, and Kodak Type M film. The time of exposure varies between one half to two seconds, depending on the thickness of the specimen. Because the exact exposure necessary 435
Minagi and Youker
small infiltrating ductal carcinoma.
for optimal viewing is often uncertain, a range of exposure times is recommended. Immediately after three or four such exposures the specimen is sent to the pathologist who may then prepare frozen sections of any grossly suspicious areas that may be present. Meanwhile,
FIG. 3. Roentgenogram of biopsy specimen. The fine calcifications noted on mammography and suspected as signs of malignancy are demonstrated, assuring surgeon and pathologist that the correct area has been excised. The histologic diagnosis was ductal hyperplasia with interlobular and intralobular proliferation of connective tissue.
the film is developed by hand processing and the wet roentgenogram is available for viewing within fifteen minutes. The presence or absence of fine calcifications may then be ascertained. If the calcifications are seen on the roentgenogram, the surgeon is assured that the area in question has been excised. If the calcifications are not present, additional biopsy material is obtained until subsequent specimen-roentgenograms demonstrate the calcifications. By referring to the roentgenogram of the specimen, the pathologist may now select the precise area of suspicion for frozen or permanent sections. Patton, Poznanski, and Zylak [3] recommend obtaining roentgenograms of the paraffin blocks for further assurance that the calcified area is examined histologically. The delay in terms of the anesthesia time of the patient is approximately five minutes. This interval represents the time required to transfer the specimen to and from the radiology department and to obtain the roentgenogram. Having received the specimen from the radiology department, the pathologist may take the sections with the understanding that additional sections may be required, depending on what is seen on the roentgenogram of the specimen. We have concluded that specimen-roentgenograms are essential in those instances in which nonpalpable carcinomas are suspected by mammography. By referring to these roentgenograms the surgeon, pathologist, and radiologist are assured that a potentially curable lesion American
Journal
of
Surgery
Roentgenography has not been overlooked and that proper treatment has been instituted. SUMMARY
In cases of nonpalpable cancer of the breast detected by mammography, specimen-roentgenograms are an extremely useful tool whereby surgeon and pathologist can be assured that the suspicious area of the breast has been excised. A technic for obtaining roentgenograms of the specimen is outlined.
Vol. 115. March 1968
of Breast Specimens
437
REFERENCES
1. EGAN, R. L. Fifty-three breast, occult until
cases of carcinoma of the mammography. Am. _T Roentgenol., 88: 1095, 1962.
2.
MISSAKIAN, M. M., WITTEN, D. M., and HARRISON,
E. G., JR. Mammography after mastectomy. Usefulness in search for recurrent carcinoma of breast. J.A.M.A., 191: 1045, 1965.
3.
PATTON, R.
B.,
POZNANSKI, A.
K.,
and
ZYLAK,
C. J. Pathologic examination of specimens containing nonpalpable breast cancers discovered by radiography. Am. J. Clin. Path., 46: 330, 1966.
of Breast Specimens of Nonpalpable
MINAGI, M.D. AND JAMES E. YOUKER,
From the Departvnent of Radiology, University of California School of Medicine, San Francisco, California. This work was supported in pal’ by U.S.P.H.S. Grant DHEW 0517.
N RECENT YEARS the possibility of detecting
I nonpalpable
cancerous lesions of the breast by roentgenographic means has been demonstrated repeatedly. That the yield of positive results on survey mammography in asymptomatic women is rather low is becoming apparent. Conversely, the yield in certain high risk groups is sufliciently great that the discovery of substantial numbers of nonpalpable carcinomas is to be expected [l]. Missakian, Witten, and Harrison [Z], for example, found cancer in the opposite breast in 25 of 397 women who had undergone mastectomy for breast carcinoma. Of these twenty-five tumors, ten were not evident clinically and were diagnosed only by mammography. The lesions detected by mammography were smaller and axillary node metastasis developed in fewer of these patients than in those with clinically palpable lesions. The roentgenographic diagnosis of nonpalpable breast lesions presents a unique set of problems to surgeon and pathologist. No palpable mass is present to guide the surgeon to the proper site and extent of biopsy. On receiving the biopsy specimen, the pathologist is often faced with the problem of where best to cut sections. In some instances, neither the surgeon nor the pathologist can be certain that the tissue actually represents the area roentgenographically suspected of being cancerous. These difficulties may be overcome by obtaining roentgenograms of the excised specimens, particularly when the abnormalities on the original mammograms appeared as fine calcium deposits. For example, in a forty-six Vol.115,March 1968
Breast Carcinoma
M.D.,Sun Francisco, California
year old woman, adenocarcinoma was found in an excised right axillary node. Although the right breast gave negative results clinically, mammograms showed a cluster of fine calcific deposits deep in the right breast adjacent to the chest wall. Because of these combined findings, right radical mastectomy was performed. In sixty-four sections of various areas of the breast, no histologic evidence of malignancy was discernible. A roentgenogram of the specimen demonstrated the cluster of calcifications at one end. (Fig. 1 and 2.) Guided by this roentgenogram, a sixty-fifth section was made in the area of the calcifications and this revealed a small infiltrating ductal carcinoma. Figure 3 is the roentgenogram of a specimen from another patient in whom biopsy was performed because of suspicious calcifications seen on mammography. The fine calcifications apparent on the roentgenogram of the specimen assured the surgeon that the suspicious area had been excised. By referring to this roentgenogram the pathologist obtained representative sections of the precise area of suspicion. The histologic diagnosis in this instance was ductal hyperplasia with interlobular and intralobular proliferation of connective tissue. The calcifications were both stromal and intraductal. TECHNIC
To avoid unnecessary delay, the specimen is brought to the radiology department immediately after excision. Several exposures of the specimen are obtained, using 28 kv., 300 ma., a distance of 30 inches, and Kodak Type M film. The time of exposure varies between one half to two seconds, depending on the thickness of the specimen. Because the exact exposure necessary 435
Minagi and Youker
small infiltrating ductal carcinoma.
for optimal viewing is often uncertain, a range of exposure times is recommended. Immediately after three or four such exposures the specimen is sent to the pathologist who may then prepare frozen sections of any grossly suspicious areas that may be present. Meanwhile,
FIG. 3. Roentgenogram of biopsy specimen. The fine calcifications noted on mammography and suspected as signs of malignancy are demonstrated, assuring surgeon and pathologist that the correct area has been excised. The histologic diagnosis was ductal hyperplasia with interlobular and intralobular proliferation of connective tissue.
the film is developed by hand processing and the wet roentgenogram is available for viewing within fifteen minutes. The presence or absence of fine calcifications may then be ascertained. If the calcifications are seen on the roentgenogram, the surgeon is assured that the area in question has been excised. If the calcifications are not present, additional biopsy material is obtained until subsequent specimen-roentgenograms demonstrate the calcifications. By referring to the roentgenogram of the specimen, the pathologist may now select the precise area of suspicion for frozen or permanent sections. Patton, Poznanski, and Zylak [3] recommend obtaining roentgenograms of the paraffin blocks for further assurance that the calcified area is examined histologically. The delay in terms of the anesthesia time of the patient is approximately five minutes. This interval represents the time required to transfer the specimen to and from the radiology department and to obtain the roentgenogram. Having received the specimen from the radiology department, the pathologist may take the sections with the understanding that additional sections may be required, depending on what is seen on the roentgenogram of the specimen. We have concluded that specimen-roentgenograms are essential in those instances in which nonpalpable carcinomas are suspected by mammography. By referring to these roentgenograms the surgeon, pathologist, and radiologist are assured that a potentially curable lesion American
Journal
of
Surgery
Roentgenography has not been overlooked and that proper treatment has been instituted. SUMMARY
In cases of nonpalpable cancer of the breast detected by mammography, specimen-roentgenograms are an extremely useful tool whereby surgeon and pathologist can be assured that the suspicious area of the breast has been excised. A technic for obtaining roentgenograms of the specimen is outlined.
Vol. 115. March 1968
of Breast Specimens
437
REFERENCES
1. EGAN, R. L. Fifty-three breast, occult until
cases of carcinoma of the mammography. Am. _T Roentgenol., 88: 1095, 1962.
2.
MISSAKIAN, M. M., WITTEN, D. M., and HARRISON,
E. G., JR. Mammography after mastectomy. Usefulness in search for recurrent carcinoma of breast. J.A.M.A., 191: 1045, 1965.
3.
PATTON, R.
B.,
POZNANSKI, A.
K.,
and
ZYLAK,
C. J. Pathologic examination of specimens containing nonpalpable breast cancers discovered by radiography. Am. J. Clin. Path., 46: 330, 1966.