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Screening mammography: A surgeon's strategy for dealing with abnormal mammographic findings
Screening Mammography: A Surgeon’s Strategy for Dealing With Abnormal Mammographic Findings
Alan Musketi, MD and James M. Wreevy,
MD, Salt Lake City, Utah
The mortality rate associated with advanced breast, cancer remains high despite advances in adjuvant therapy. To improve survival in breast cancer, the disease must be detected at a stage where regional nodal and distant metastases have not occurred. Many breast. cancers are not palpable until metastases have occurred, making the detection of nonpalpable lesions a priority in breast cancer surveillance. In recent years, the use of screening mammography has greatly increased in an attempt to detect breast cancers at an early stage. The American Cancer Society currently recommends that every woman have a baseline screening mammogram at age 35, and then routine studies yearly or every 2 years until age 50, with yearly mammograms after the age of 50. The mammogram is a complex study, and the findings often subtle or indeterminate. The terms, cannot. exclude malignancy, equivocal findings, or recommend biopsy to rule out malignancy, frequently appear in the written interpretation of these studies. In his editorial in the New England Journal of Medicine, Hall [1] stated, “I have found that the problem is overwhelmingly one of overinterpretation rather than underinterpretation, aided and abetted by the present medicolegal climate and an understandable phobia about breast cancer.” As a result, the consulting surgeon is often in the position of determining whether a mammographic finding warrants an operative biopsy. We describe a method for dealing with the burgeoning number of patients referred solely for an abnormal mammographic finding. Patients and Methods Of 416 patients referred to a single surgeon over a 4 year period, 88 were referred solely for an abnormal mammographic finding. The mammograms were obtained in a total of 12 radiology offices, reflecting the wide geographic area served by our particular medical center. At least twice as many radiologists were involved in reading the films. Rather than biopsy all patients initially, the patient and the mammogram were reevaluated. From the Department of Surgery, University of Utah, Salt Lake City, Utah. Requests for reprints should be addressed to James M. McCireevy, MD, Department of Surgery, University of Utah, 50 North Medical Drive, Salt Lake City, Utah 84132. Presented at the 39th Annual Meeting of the Southwestern Surgical Congress, Coronado, California, April 26-29, 1987.
Volume 154, December 1987
The patients ranged in age from 25 to 82 years, with a mean age of 49 years. Forty-three women were premenopausal and 45 were postmenopausal. Fourteen had a family history of breast cancer, 9 were taking exogenous estrogens, and 6 had a history of previous breast cancer. Ten patients had prior breast biopsies. A careful history was obtained and physical examination performed. The mammograms were then reviewed with a single consulting radiologist using the following strict criteria: greater than 5 microcalcifications within 1 cm, microcalcifications in an irradiated breast regardless of number, circumscribed and dense masses with indistinct margins, masses that increased in size, masses that returned after cyst aspiration, and architectural distortion compared with the contralateral breast. After this evaluation, patients were placed in the following groups: Group 1, immediate localization and biopsy based on suspicious mammographic findings; Group 2, biopsy based on an obvious mass; Group 3, repeat mammographic evaluation in 4 to 6 months; and Group 4, routine follow-up according to American Cancer Society guidelines because the mammographic finding was considered normal when reviewed. Results
Of the 88 patients referred solely for an abnormal mammographic finding, 12 (13 percent,) were found to have distinct masses on physical examination corresponding to the mammographic abnormality. All 12 patients underwent biopsy with the discovery of two invasive ductal adenocarcinomas, one of which had metastasized to the axillary lymph nodes. After review of the mammograms, 32 patients (37 percent) underwent biopsy for mammographic findings thought to represent a risk for malignancy. Six of the patients (18 percent) were found to have cancers, none of which had metastasized to the axillary nodes as determined by mastectomy and axillary dissection. The pathologic findings in the patients with malignancy are listed in Table I. Thirty-four patients were advised to return to the clinic in 4 to 6 months for reevaluation, as the mammograms being reviewed were believed to have a low probability of representing a malignancy. All of these patients returned and had repeat mammo-
grams. Two patients were thought to have either persistent or new changes warranting biopsy. Biopsy was benign in both cases. Ten patients were as-
589
Musk&t and McGreevy
TABLE I
66 Patients Referred Solely For Abnormal Mammcgram
Histologic Dlagnosls of Mallgnanl Lesions Present on Mammography n
Palpable lesions Invasive ductal adenocarcinoma Nonpalpable lesions Noninvasive tubular carcinoma Noninvasive ductal adenocarcinoma Invasive ductal adenocarcinoma Noninvasive lobular carcinoma
Involved Nodes
2
1
1 1 1 1
0 0 0 0
All Patients &Examined
and
, 12 Patients 6th
32 Siopsied Immediately
Palpable
For Suspicious
Lesions
I Biopsy
Lesions
I 6 Cancers (16%)
34 Pa&s
signed to routine follow-up as their mammograms were thought to reveal nothing abnormal on review. During the follow-up period of from 3 to 48 months, no nonbiopsied patient had development of a malignancy nor did yearly mammographic follow-up meet the criteria for biopsy. The evaluation of these 88 patients is summarized in Figure 1. All patients with malignancy diagnosed by biopsy had clusters of microcalcification in the biopsy specimen. The presence of a discrete mass correlated less frequently, as did dysplasia, asymmetry, and architectural changes. By reevaluating each patient and the mammogram using specific criteria, 42 patients (48 percent) were spared biopsy, and on follow-up, neither mammographic nor physical evidence of malignancy was found. Comments Unquestionably, screening mammography plays an important role in preventing death from breast cancer. Tabar et al [2], in Sweden, reported a 25 percent reduction in stage II or higher advanced lesions in a group of women screened by mammography when compared with a control group of women not screened. They found an overall decrease in the mortality rate from breast cancer of 31 percent in the women screened compared with those who did not have mammography. According to a recent review by Tinnemans and Wobbes [3], the incidence of malignancy in nonpalpable breast masses detected by mammography alone has ranged in different series from 15.4 to 46.7 percent [3-121. The majority of the cancers discovered in the present series were noninvasive. The American Cancer Society National Cancer Institute Breast Cancer Detection Demonstration Project found 6,000 cancers in 280,000 women. In the patients whose lesions were detected by mammogram alone, 75 percent had uninvolved axillary nodes at operation [13]. Based on calculations from the Demonstration Project data, it has been estimated that a mammogram will detect a cancer 2 years before it becomes palpable [14-161. With 115,000 cases of breast cancer discovered each year in the United States, thousands of lives can be potentially saved by earlier detection. There are concerns over screening mammogra-
590
TO Patlents Routine Follow-up
4-6 Months
I 2 alopsled
I
I 0 Cam&s
2 c:ncers
Figure 1. Evaluation months.
with
Repeat Mammogram
of 88 patients
during
a follow-up
of 3 to 48
phy. Mann et al [17] have reported a 57.9 percent incidence of involved axillary nodes in 19 women whose biopsy of a palpable breast mass was delayed on the basis of a normal mammographic finding. Concerns have been expressed over the unclear effect of radiation exposure resulting from mammographic examination [18]. A breast biopsy requiring preoperative mammographic localization costs about a thousand dollars in our institution. If all patients referred for an abnormal mammographic finding were biopsied, an additional 40,000 to 45,000 dollars of health care expenditures would have resulted without demonstrable benefit. Breast biopsies occasionally result in complications such as infection, hematoma, change in breast contour, loss of the localizing guide wire, or anesthetic reactions. They are stressful to the patient and family. Many centers reporting large series of mammographically directed biopsies have experienced mammographic experts who read these studies and can provide consistent interpretations for the surgeon to use in decision making. But as the use of screening mammography increases, what is the community surgeon to do when faced with increasing numbers of biopsy recommendations from different sources with different criteria for interpretation? Based on our experience, we make the following recommendations: (1) Repeat the history and physical examination. In 13 percent of our patients, there was a palpable mass in the area of the mammographic abnormality that did not require mammographic localization. (2) Become knowledgeable in terms of mammographic abnormalities and what they represent. Being able to ask intelligent questions of the radiologist strengthens your ability to make a decision. (3) Establish a good working relationship with one radiologist who you trust, especially a person who is not overly concerned with covering himself. Have all studies referred to you reviewed by your consultant for a second opinion. By comparing a single consistent interpretation with your operative findings, you can get a feel for
The American Journal of Surgery
Screening Mammography
the accuracy of the mammographic findings. (4) Establish with your radiologic consultant a set of specific criteria for what constitutes a suspicious mammographic finding. This eliminates the vague “cannot exclude” statements. Much more desirable language is “this lesion represents a 1 in 20 probability of being malignant.” Determining probabilities is very helpful for the surgeon in decision making and provides valuable information for the patient in terms of dealing with the anxieties of the situation. (5) In the event that the mammographic finding is not worrisome enough to warrant biopsy but is still abnormal, a 4 to 6 month waiting period followed by a repeat mammogram is unlikely to compromise the patient’s chance of survival in the event a cancer is discovered. Mammography will, in many cases, allow surgeons the satisfaction of curing their patients of a vicious disease. However, it will also lead to many perplexing decisions. A consistent, systematic ap: preach to the interpretation of mammograms and their effective use in clinical decision making will benefit both the patient and the physician. Summary Screening mammography is a valuable tool in the detection of breast cancer at an early stage. Large numbers of patients are being referred to surgeons for biopsies on the basis of mammographic abnormalities alone. As mammograms are complex studies and the findings often subtle, variation in terms of interpretation and recommendations for biopsy can leave the surgeon in a difficult position. We have reported a systematic method for evaluating patients and mammograms. Eighty-eight patients were referred to a single surgeon solely for an abnormal mammographic finding. Physical examination was repeated and the mammogram reviewed with a single consulting radiologist using specific criteria to define a mammographic abnormality. Through this evaluation, biopsy was avoided in 42 of 88 patients, with follow-up mammograms and physical examinations finding no suspicion of malignancy. By becoming educated in regard to mammographic abnormalities, establishing specific criteria with a consistent radiologist, and following patients carefully who are not biopsied, the surgeon can deal effectively with screening mammography. References 1. Hail FM. Screening mammography. Potential problems on the horizon. N Engl J Med 1986; 314: 53-5. 2. Tabar L, Fagerberg CJG. Gad A, et al. Reduction in mortality from breast cancer after mass screening with mammography: randomized trial from the breast cancer screening working group of the Swedish National Board of Health and Welfare. Lancet 1965; 1: 829-32. 3. Tinnemans JGM. Wobbes T. The sianificance of microcalcifications without palpable mass in the diagnosis of breast
Volume 154, December 1987
cancer. Surgery 1986; 99: 652-7. 4. Rogers JV, Powell RW. Mammographic indications for biopsy of clinically normal breasts: correlation with pathologic findings in 72 cases. AJR 1972; 115: 794-800. 5. Murphy WA, DeSchryver-Kecakemeti K. Isolated clustered mlcrocalcifications in the breast radiologic pathologic correlation. Radiology 1978; 127: 335-41.6. Roses DF, Harris MN, Gorstein F, Gumport SL. Biopsy for microcalcifications detected by mammography. Surgery 1980; 87: 248-52. 7. Lanyi M. Formanalyse von 153 Mikroverkalkungsgruppen Malinger Genese: Das “Dreieckprinzip.” Fortschr Rontgenstr 1982; 136: 77-84. 8. Colbassani HJ, Feller WF, Cagtay OS, Chun 8. Mammographic and pathologic correlation of microcalcifications in disease of the breast. Surg Gynecol Obstet 1982; 155: 689-96. 9. Hoehn JL, Hardacre JM, Swanson MK, Williams GH. Localization of occult breast lesions. Cancer 1982; 49: 1142-4. 10. Powell RW, f&Sweeney MB, Wilson CL. X-ray calcifications as the only bases for breast biopsy. Ann Surg 1983; 197: 555-9. 11. Chetty U, Kirkpatrick AE, Anderson TL, et al. Localization and excision of occult breast lesions. Br J Surg 1983; 70: 60710. 12. Meyer JE, Kopans DB, Stomper PC, Lindfors KK. Occult breast abnormalities: percutaneous preoperative needle localization. Radiology 1984; 150: 335-7. 13. Nehme AE, Macksood MJ. Nonpalpable breast lesions: diagnosis and management. Breast Diseases of the Breast 10: 19-25. 14. Council on Scientific Affairs. Early detection of breast cancer. JAMA 1984; 252: 3008-l 1. 15. Fox SH, Moskowitz M, Saenger EL, et al. Benefit/risk analysis of aggressive mammographic screening. Radiology 1978; 128: 359-65. 16. Tabar L, Gad A, Akerlund E, et al. Screening for breast cancer in Sweden: results of the first round of screening. In: Feig SA, McClelland R. eds. Breast carcinoma: current diagnosis and treatment. New York: Masson, 1983; 315-26. 17. Mann BD, Giuliano AE, Bassett LW, et al. Delayed diagnosis of breast cancer as a result of normal mammogram. Arch Surg 1983; 118: 23-4. 18. Thier SO. Breast-cancer screening: a view from outside the controversy. N Engl J Med 1977: 297: 1063-5.
Dale L. Larson (Casper, WY): There are two effective ways of reducing the death rate of cancer of the breast. One is by screening asymptomatic women and the other way is by aggressive diagnosis of symptomatic women who have a lump. The breast cancer mortality rate has not changed in 50 years; however, mammography can bring about a significant improvement with detection at an early date. Ferris M. Hall, MD, from Beth Israel Hospital in Boston has emphasized that “malignancy cannot be excluded” in an x-ray report catches the attention of both the physician and the patient. In half of these cases, the chance of malignancy is estimated to be less than 1 in 20. Mammographic follow-up is an alternative to biopsy; however, many surgeons are reluctant to follow such a recommendation. They find themselves in a no-win situation because carcinoma will inevitably be detected in some of these patients. In general, radiologists have a tendency to cover themselves and will give you an inter-
591
Muskett and McGreevy
pretation that will be vague, sometimes confusing, or set you up for a biopsy that may not be indicated. We all have a tendency to pick out a favorite radiologist for questionable radiograph interpretations, and I wholeheartedly agree with your recommendation, Dr. Muskett, for a second opinion. I would assume that the majority of patients concerned were agreeable to your recommendations. What was your response to those patients who wanted something done immediately or were skeptical of a prolonged follow-up with the fear of the unknown being a constant problem? Your criteria for or against biopsy is very acceptable and I would like your comments on the following questions. Is a mammogram indicated on a palpable breast mass? What is your follow-up standard after 4 to 6 months when the mammographic findings are questionable, knowing that doubling time is so variable? Joseph J. Hyrley (St. Louis, MO): Dr. Muskett, 42 or almost half of the patients did not undergo a breast biopsy. After 12 or more months of follow-up, these lesions are presumed to be benign. There are some notoriously slowgrowing breast malignancies, such as medullary carcinoma, which might easily be mistaken for benign tumors when applying such a short follow-up. Thus, without long-term follow-up or histologic confirmation of benign disease, your conclusions are not valid. Also, Dr. Muskett, do you have any experience with ultrasound-aided aspiration of nonpalpable breast cysts? Have you used this technique to obviate the need for biopsies of lesions that don’t contain calcifications?
592
Russell G. Postier (Oklahoma City, OK): Dr. Muskett, I think that we need very firm data before we can accept the recommendation that a nonpalpable, mammographitally seen lesion should not be biopsied. Half of the patients that you picked up who had cancer bad noninvasive lesions, and again their longest follow-up was 48 months. If all 42 patients who were spared biopsy had noninvasive lesions, you could still have missed them. Claude I-L Organ, Jr. (Oklahoma City, OK): How many of you in the audience are using needle localization for breast masses today? By the show of hands, it seems that the majority does. How many of you feel this technique is currently being overused? Again, by the show of hands, it seems the majority believes it is. Alan Muskett (closing): Dr. Larson, I think a patient who is anxious about potential breast cancer is a dangerous patient to watch. Most patients are grateful to be spared a biopsy. If a patient is really concerned, they probably ought to have a biopsy. What about a patient with a palpable lesion who wants a mammogram? We generally don’t utilize mammography because of the high false-negative rate. Dr. Hurley and Dr. Postier, in regard to your concerns about lesions that were not biopsied, in general, in these patients, we look for regression of the lesion on follow-up. If the lesion hasn’t regressed, we believe biopsy should be the next step. Dr. Hurley, in regard to ultrasonography, we are concerned about the false-negative rate of ultrasonographically guided aspiration biopsy, so we don’t generally employ that technique.
The American Journal of Surgery
Alan Musketi, MD and James M. Wreevy,
MD, Salt Lake City, Utah
The mortality rate associated with advanced breast, cancer remains high despite advances in adjuvant therapy. To improve survival in breast cancer, the disease must be detected at a stage where regional nodal and distant metastases have not occurred. Many breast. cancers are not palpable until metastases have occurred, making the detection of nonpalpable lesions a priority in breast cancer surveillance. In recent years, the use of screening mammography has greatly increased in an attempt to detect breast cancers at an early stage. The American Cancer Society currently recommends that every woman have a baseline screening mammogram at age 35, and then routine studies yearly or every 2 years until age 50, with yearly mammograms after the age of 50. The mammogram is a complex study, and the findings often subtle or indeterminate. The terms, cannot. exclude malignancy, equivocal findings, or recommend biopsy to rule out malignancy, frequently appear in the written interpretation of these studies. In his editorial in the New England Journal of Medicine, Hall [1] stated, “I have found that the problem is overwhelmingly one of overinterpretation rather than underinterpretation, aided and abetted by the present medicolegal climate and an understandable phobia about breast cancer.” As a result, the consulting surgeon is often in the position of determining whether a mammographic finding warrants an operative biopsy. We describe a method for dealing with the burgeoning number of patients referred solely for an abnormal mammographic finding. Patients and Methods Of 416 patients referred to a single surgeon over a 4 year period, 88 were referred solely for an abnormal mammographic finding. The mammograms were obtained in a total of 12 radiology offices, reflecting the wide geographic area served by our particular medical center. At least twice as many radiologists were involved in reading the films. Rather than biopsy all patients initially, the patient and the mammogram were reevaluated. From the Department of Surgery, University of Utah, Salt Lake City, Utah. Requests for reprints should be addressed to James M. McCireevy, MD, Department of Surgery, University of Utah, 50 North Medical Drive, Salt Lake City, Utah 84132. Presented at the 39th Annual Meeting of the Southwestern Surgical Congress, Coronado, California, April 26-29, 1987.
Volume 154, December 1987
The patients ranged in age from 25 to 82 years, with a mean age of 49 years. Forty-three women were premenopausal and 45 were postmenopausal. Fourteen had a family history of breast cancer, 9 were taking exogenous estrogens, and 6 had a history of previous breast cancer. Ten patients had prior breast biopsies. A careful history was obtained and physical examination performed. The mammograms were then reviewed with a single consulting radiologist using the following strict criteria: greater than 5 microcalcifications within 1 cm, microcalcifications in an irradiated breast regardless of number, circumscribed and dense masses with indistinct margins, masses that increased in size, masses that returned after cyst aspiration, and architectural distortion compared with the contralateral breast. After this evaluation, patients were placed in the following groups: Group 1, immediate localization and biopsy based on suspicious mammographic findings; Group 2, biopsy based on an obvious mass; Group 3, repeat mammographic evaluation in 4 to 6 months; and Group 4, routine follow-up according to American Cancer Society guidelines because the mammographic finding was considered normal when reviewed. Results
Of the 88 patients referred solely for an abnormal mammographic finding, 12 (13 percent,) were found to have distinct masses on physical examination corresponding to the mammographic abnormality. All 12 patients underwent biopsy with the discovery of two invasive ductal adenocarcinomas, one of which had metastasized to the axillary lymph nodes. After review of the mammograms, 32 patients (37 percent) underwent biopsy for mammographic findings thought to represent a risk for malignancy. Six of the patients (18 percent) were found to have cancers, none of which had metastasized to the axillary nodes as determined by mastectomy and axillary dissection. The pathologic findings in the patients with malignancy are listed in Table I. Thirty-four patients were advised to return to the clinic in 4 to 6 months for reevaluation, as the mammograms being reviewed were believed to have a low probability of representing a malignancy. All of these patients returned and had repeat mammo-
grams. Two patients were thought to have either persistent or new changes warranting biopsy. Biopsy was benign in both cases. Ten patients were as-
589
Musk&t and McGreevy
TABLE I
66 Patients Referred Solely For Abnormal Mammcgram
Histologic Dlagnosls of Mallgnanl Lesions Present on Mammography n
Palpable lesions Invasive ductal adenocarcinoma Nonpalpable lesions Noninvasive tubular carcinoma Noninvasive ductal adenocarcinoma Invasive ductal adenocarcinoma Noninvasive lobular carcinoma
Involved Nodes
2
1
1 1 1 1
0 0 0 0
All Patients &Examined
and
, 12 Patients 6th
32 Siopsied Immediately
Palpable
For Suspicious
Lesions
I Biopsy
Lesions
I 6 Cancers (16%)
34 Pa&s
signed to routine follow-up as their mammograms were thought to reveal nothing abnormal on review. During the follow-up period of from 3 to 48 months, no nonbiopsied patient had development of a malignancy nor did yearly mammographic follow-up meet the criteria for biopsy. The evaluation of these 88 patients is summarized in Figure 1. All patients with malignancy diagnosed by biopsy had clusters of microcalcification in the biopsy specimen. The presence of a discrete mass correlated less frequently, as did dysplasia, asymmetry, and architectural changes. By reevaluating each patient and the mammogram using specific criteria, 42 patients (48 percent) were spared biopsy, and on follow-up, neither mammographic nor physical evidence of malignancy was found. Comments Unquestionably, screening mammography plays an important role in preventing death from breast cancer. Tabar et al [2], in Sweden, reported a 25 percent reduction in stage II or higher advanced lesions in a group of women screened by mammography when compared with a control group of women not screened. They found an overall decrease in the mortality rate from breast cancer of 31 percent in the women screened compared with those who did not have mammography. According to a recent review by Tinnemans and Wobbes [3], the incidence of malignancy in nonpalpable breast masses detected by mammography alone has ranged in different series from 15.4 to 46.7 percent [3-121. The majority of the cancers discovered in the present series were noninvasive. The American Cancer Society National Cancer Institute Breast Cancer Detection Demonstration Project found 6,000 cancers in 280,000 women. In the patients whose lesions were detected by mammogram alone, 75 percent had uninvolved axillary nodes at operation [13]. Based on calculations from the Demonstration Project data, it has been estimated that a mammogram will detect a cancer 2 years before it becomes palpable [14-161. With 115,000 cases of breast cancer discovered each year in the United States, thousands of lives can be potentially saved by earlier detection. There are concerns over screening mammogra-
590
TO Patlents Routine Follow-up
4-6 Months
I 2 alopsled
I
I 0 Cam&s
2 c:ncers
Figure 1. Evaluation months.
with
Repeat Mammogram
of 88 patients
during
a follow-up
of 3 to 48
phy. Mann et al [17] have reported a 57.9 percent incidence of involved axillary nodes in 19 women whose biopsy of a palpable breast mass was delayed on the basis of a normal mammographic finding. Concerns have been expressed over the unclear effect of radiation exposure resulting from mammographic examination [18]. A breast biopsy requiring preoperative mammographic localization costs about a thousand dollars in our institution. If all patients referred for an abnormal mammographic finding were biopsied, an additional 40,000 to 45,000 dollars of health care expenditures would have resulted without demonstrable benefit. Breast biopsies occasionally result in complications such as infection, hematoma, change in breast contour, loss of the localizing guide wire, or anesthetic reactions. They are stressful to the patient and family. Many centers reporting large series of mammographically directed biopsies have experienced mammographic experts who read these studies and can provide consistent interpretations for the surgeon to use in decision making. But as the use of screening mammography increases, what is the community surgeon to do when faced with increasing numbers of biopsy recommendations from different sources with different criteria for interpretation? Based on our experience, we make the following recommendations: (1) Repeat the history and physical examination. In 13 percent of our patients, there was a palpable mass in the area of the mammographic abnormality that did not require mammographic localization. (2) Become knowledgeable in terms of mammographic abnormalities and what they represent. Being able to ask intelligent questions of the radiologist strengthens your ability to make a decision. (3) Establish a good working relationship with one radiologist who you trust, especially a person who is not overly concerned with covering himself. Have all studies referred to you reviewed by your consultant for a second opinion. By comparing a single consistent interpretation with your operative findings, you can get a feel for
The American Journal of Surgery
Screening Mammography
the accuracy of the mammographic findings. (4) Establish with your radiologic consultant a set of specific criteria for what constitutes a suspicious mammographic finding. This eliminates the vague “cannot exclude” statements. Much more desirable language is “this lesion represents a 1 in 20 probability of being malignant.” Determining probabilities is very helpful for the surgeon in decision making and provides valuable information for the patient in terms of dealing with the anxieties of the situation. (5) In the event that the mammographic finding is not worrisome enough to warrant biopsy but is still abnormal, a 4 to 6 month waiting period followed by a repeat mammogram is unlikely to compromise the patient’s chance of survival in the event a cancer is discovered. Mammography will, in many cases, allow surgeons the satisfaction of curing their patients of a vicious disease. However, it will also lead to many perplexing decisions. A consistent, systematic ap: preach to the interpretation of mammograms and their effective use in clinical decision making will benefit both the patient and the physician. Summary Screening mammography is a valuable tool in the detection of breast cancer at an early stage. Large numbers of patients are being referred to surgeons for biopsies on the basis of mammographic abnormalities alone. As mammograms are complex studies and the findings often subtle, variation in terms of interpretation and recommendations for biopsy can leave the surgeon in a difficult position. We have reported a systematic method for evaluating patients and mammograms. Eighty-eight patients were referred to a single surgeon solely for an abnormal mammographic finding. Physical examination was repeated and the mammogram reviewed with a single consulting radiologist using specific criteria to define a mammographic abnormality. Through this evaluation, biopsy was avoided in 42 of 88 patients, with follow-up mammograms and physical examinations finding no suspicion of malignancy. By becoming educated in regard to mammographic abnormalities, establishing specific criteria with a consistent radiologist, and following patients carefully who are not biopsied, the surgeon can deal effectively with screening mammography. References 1. Hail FM. Screening mammography. Potential problems on the horizon. N Engl J Med 1986; 314: 53-5. 2. Tabar L, Fagerberg CJG. Gad A, et al. Reduction in mortality from breast cancer after mass screening with mammography: randomized trial from the breast cancer screening working group of the Swedish National Board of Health and Welfare. Lancet 1965; 1: 829-32. 3. Tinnemans JGM. Wobbes T. The sianificance of microcalcifications without palpable mass in the diagnosis of breast
Volume 154, December 1987
cancer. Surgery 1986; 99: 652-7. 4. Rogers JV, Powell RW. Mammographic indications for biopsy of clinically normal breasts: correlation with pathologic findings in 72 cases. AJR 1972; 115: 794-800. 5. Murphy WA, DeSchryver-Kecakemeti K. Isolated clustered mlcrocalcifications in the breast radiologic pathologic correlation. Radiology 1978; 127: 335-41.6. Roses DF, Harris MN, Gorstein F, Gumport SL. Biopsy for microcalcifications detected by mammography. Surgery 1980; 87: 248-52. 7. Lanyi M. Formanalyse von 153 Mikroverkalkungsgruppen Malinger Genese: Das “Dreieckprinzip.” Fortschr Rontgenstr 1982; 136: 77-84. 8. Colbassani HJ, Feller WF, Cagtay OS, Chun 8. Mammographic and pathologic correlation of microcalcifications in disease of the breast. Surg Gynecol Obstet 1982; 155: 689-96. 9. Hoehn JL, Hardacre JM, Swanson MK, Williams GH. Localization of occult breast lesions. Cancer 1982; 49: 1142-4. 10. Powell RW, f&Sweeney MB, Wilson CL. X-ray calcifications as the only bases for breast biopsy. Ann Surg 1983; 197: 555-9. 11. Chetty U, Kirkpatrick AE, Anderson TL, et al. Localization and excision of occult breast lesions. Br J Surg 1983; 70: 60710. 12. Meyer JE, Kopans DB, Stomper PC, Lindfors KK. Occult breast abnormalities: percutaneous preoperative needle localization. Radiology 1984; 150: 335-7. 13. Nehme AE, Macksood MJ. Nonpalpable breast lesions: diagnosis and management. Breast Diseases of the Breast 10: 19-25. 14. Council on Scientific Affairs. Early detection of breast cancer. JAMA 1984; 252: 3008-l 1. 15. Fox SH, Moskowitz M, Saenger EL, et al. Benefit/risk analysis of aggressive mammographic screening. Radiology 1978; 128: 359-65. 16. Tabar L, Gad A, Akerlund E, et al. Screening for breast cancer in Sweden: results of the first round of screening. In: Feig SA, McClelland R. eds. Breast carcinoma: current diagnosis and treatment. New York: Masson, 1983; 315-26. 17. Mann BD, Giuliano AE, Bassett LW, et al. Delayed diagnosis of breast cancer as a result of normal mammogram. Arch Surg 1983; 118: 23-4. 18. Thier SO. Breast-cancer screening: a view from outside the controversy. N Engl J Med 1977: 297: 1063-5.
Dale L. Larson (Casper, WY): There are two effective ways of reducing the death rate of cancer of the breast. One is by screening asymptomatic women and the other way is by aggressive diagnosis of symptomatic women who have a lump. The breast cancer mortality rate has not changed in 50 years; however, mammography can bring about a significant improvement with detection at an early date. Ferris M. Hall, MD, from Beth Israel Hospital in Boston has emphasized that “malignancy cannot be excluded” in an x-ray report catches the attention of both the physician and the patient. In half of these cases, the chance of malignancy is estimated to be less than 1 in 20. Mammographic follow-up is an alternative to biopsy; however, many surgeons are reluctant to follow such a recommendation. They find themselves in a no-win situation because carcinoma will inevitably be detected in some of these patients. In general, radiologists have a tendency to cover themselves and will give you an inter-
591
Muskett and McGreevy
pretation that will be vague, sometimes confusing, or set you up for a biopsy that may not be indicated. We all have a tendency to pick out a favorite radiologist for questionable radiograph interpretations, and I wholeheartedly agree with your recommendation, Dr. Muskett, for a second opinion. I would assume that the majority of patients concerned were agreeable to your recommendations. What was your response to those patients who wanted something done immediately or were skeptical of a prolonged follow-up with the fear of the unknown being a constant problem? Your criteria for or against biopsy is very acceptable and I would like your comments on the following questions. Is a mammogram indicated on a palpable breast mass? What is your follow-up standard after 4 to 6 months when the mammographic findings are questionable, knowing that doubling time is so variable? Joseph J. Hyrley (St. Louis, MO): Dr. Muskett, 42 or almost half of the patients did not undergo a breast biopsy. After 12 or more months of follow-up, these lesions are presumed to be benign. There are some notoriously slowgrowing breast malignancies, such as medullary carcinoma, which might easily be mistaken for benign tumors when applying such a short follow-up. Thus, without long-term follow-up or histologic confirmation of benign disease, your conclusions are not valid. Also, Dr. Muskett, do you have any experience with ultrasound-aided aspiration of nonpalpable breast cysts? Have you used this technique to obviate the need for biopsies of lesions that don’t contain calcifications?
592
Russell G. Postier (Oklahoma City, OK): Dr. Muskett, I think that we need very firm data before we can accept the recommendation that a nonpalpable, mammographitally seen lesion should not be biopsied. Half of the patients that you picked up who had cancer bad noninvasive lesions, and again their longest follow-up was 48 months. If all 42 patients who were spared biopsy had noninvasive lesions, you could still have missed them. Claude I-L Organ, Jr. (Oklahoma City, OK): How many of you in the audience are using needle localization for breast masses today? By the show of hands, it seems that the majority does. How many of you feel this technique is currently being overused? Again, by the show of hands, it seems the majority believes it is. Alan Muskett (closing): Dr. Larson, I think a patient who is anxious about potential breast cancer is a dangerous patient to watch. Most patients are grateful to be spared a biopsy. If a patient is really concerned, they probably ought to have a biopsy. What about a patient with a palpable lesion who wants a mammogram? We generally don’t utilize mammography because of the high false-negative rate. Dr. Hurley and Dr. Postier, in regard to your concerns about lesions that were not biopsied, in general, in these patients, we look for regression of the lesion on follow-up. If the lesion hasn’t regressed, we believe biopsy should be the next step. Dr. Hurley, in regard to ultrasonography, we are concerned about the false-negative rate of ultrasonographically guided aspiration biopsy, so we don’t generally employ that technique.
The American Journal of Surgery