Breast Julie S. Mitnick, MD #{149}Madeline Matthew N. Harris, MD #{149}Sheldon

Recurrent Localization Aspiration

patients

had

and one amination

malignant

aspirates

had an atypical of the surgical

revealed

all

seven

followed

phy.

The

were

obtained

to be ma-

in seven

remaining

were

ex-

patients underwent the results of which

malignant

in six. The

aspirate; specimens

of these

Thirteen biopsies,

were

up

and

benign

30 patients with

follow-up

mammogra-

mammograms

at 6-month

intervals

and demonstrated no change in appearance. On the basis of this initial experience,

sterotaxic

aspiration

biopsy

to accurately

terms:

tion, 00.811, localization 00.45

Radiology

localization

offers

the

distinguish

malignant Index

#{149} Daniel

Breast Cancer: for Fine-Needle Biopsy

The efficacy of stereotaxic localizalion for fine-needle aspiration biopsy in the detection of recurrent cancer manifested as calcifications on mammograms was evaluated in 43 patients that had been treated with local resection and radiation therapy.

lignant. surgical

MD MD

F. Roses,

MD

Stereotaxic

in Progress’

Work

Six

F. Vazquez, Schechter,

for

potential

benign

from

lesions. Breast, biopsy #{149} Breast, calcifica00.812 #{149} Breast neoplasms, #{149} Breast neoplasms, postoperative,

T

(3,4).

182:103-106

Prompt

recognition

patients

To evaluate

efficacy

technique in the mammographic tection of recurrent cancer, manifested as calcificalions on mammowe

performed

We

in origin,

undergone

lumpectomy criterion

lower

this

1 demonstrates,

cations

were

aspiration

of

(GE Medical ing

the Kaplan Cancer Center, Departments of Radiology (J.S.M.) and Pathology (M.F.V.), and the Division of Oncology, Department of Surgery (D.F.R., M.N.H.), Tisch Hospital, New York University Medical Center, New

York; and the Department Center,

of New

Brooklyn,

York,

of Radiology, Downstate

State

Medical

NY (5.5.). From the 1990

RSNA scientific assembly. Received January 7, 1991; revision requested March 21; final revision received August 2; accepted August 16. Supported in part by a grant from the Landsberg-

Zale Foundation,

New York. Address

requests to J.S.M., Murray Mammography. 30 E 40th 10016. . RSNA, 1992

reprint

Hill Radiology St. New York,

and NY

MATERIALS Stereotaxic aspiration

AND localization

smears

verify

biopsy

was

performed

in 43 pa-

derwent

patients primary institution gery and

mammography

at this

facility.

All

were referred for evaluation after treatment for cancer at another or after follow-up

they underwent mammography

surat this

as

calcifi-

malignancy.

Milwaukee),

outlined

in our

followinitial

cx-

stained

immediately

with

a

Wright method (Diff-Quik; BaxCare, Dade Division, Miami) examined microscopically to

that

fications

an

adequate

had

been

sample

obtained

with and

calci-

to pro-

vide a preliminary diagnosis. When possible, additional samples were fixed in absolute alcohol, and Papanicolaousmears

were

subsequently

evalu-

ated. The aspirates were categorized as malignant, suspicious, atypical, madequate, or benign. Malignant nantly singly hal cells with and

aspirates showed predomidispersed, enlarged epithehyperchromatic eccentric abundant

occasionally features

numbers, abundant

cytoplasm,

vacuolated.

designated

lignant

tients with calcifications at or near the scar after treatment for breast cancer with local excision and irradiation. These 43 patients were selected from a total of 109 patients who underwent lumpectomy and radiation treatment during this study and un-

However, coarse

with

Systems,

were

modified ten Health and were

were

for fine-needle

even

of

included

perience (9). After verification of accurate needle placement, at least three aspirates were obtained in each case. Air-dried

was

METHODS

instances

of patients.

a procedure

nuclei I From

aspiration

were

associated

had

Stereotaxic localizations were performed with the Stereotix unit with a Senographe 500-T mammography system

stained

calcifications at or near the scar in 43 patients treated with local resection and irradiation.

who

suspicion

group

the

calci-

irradiation,

fine-needle

mammographic

Figure

of new demonstrated

and

there

within

the

from

in a patient

for

Certainly,

as

or to be definitely

dystrophic

biopsy.

patient

features

excluded

presence not be

the skin

from 35 of the

Any

such

was

used the that could

to be within

de-

lesion.

mammographic

of a mass,

study. fications

as our

in age None

of malignancy,

presence

of this

ranged 50 years).

a palpable

additional

suggestive

of recur-

the

Patients (mean, had

with

mence and subsequent treatment with mastectomy may offer a 5-year sunvival rate greater than 50% (3). Mammography is the most useful technique to aid in the detection of nonpalpabbe recurrent carcinoma aften local excision, and one of the most common indications of recurrence is the presence of new calcifications. In a previous report, Denshaw et ab (5) attempted to establish mammographic criteria for the differentiation of benign conditions from recurrent cancer, but open surgical biopsy was finally required for the differentiation in their series. Initial reports suggest that stereotaxic localization for fine-needle aspiration biopsy is a reliable technique for the diagnosis of breast cancer (6-8).

1992;

institution. to 64 years

of breast cancer with local excision of the tumor and irradiation has become an accepted alternative to mastectomy when established criteria are fulfilled (1,2). Local recurrence of breast cancer, however, may be the first indication of failure of conservative treatment REATMENT

grams,

University

Imaging

which

Aspirates

as suspicious were

present

when

ma-

in small

or when atypical cells but were predominantly

were in co-

hesive clusters. Aspirates were categorized as atypical, however, when the cytologic findings were not considered entirely nor-

mal yet were lignancy. specimens

not clearly

Nondiagnostic showed

indicative

in the absence of microcalcifications. rates were categorized as benign

they plasia

showed of the

of ma-

or inadequate minimal epithelial

cells Aspi-

when

features

of mammary

proliferative

type

(usually

dys-

Figure 1. (a) Mammogram shows coarse, irregularly shaped calcifications at the scar site of a 60-year-old woman (arrow). The microcalcifications are seen with the localizing needle in place. (b) The aspirate yielded small groups malignant (long arrow) epithelial cells dispersed among calcific and necrotic debris (modified Wright stain; original

monolayered

sheets

of small,

tab cells and abundant dci) or of a nonproliferative fibrous stroma and small

form

ductal

sional

cells,

the

picious,

toning

was

appearance up

and

or inadequate,

was for

(mostly of uni-

malignant,

Table 1 Correlation of Aspiration Results in the 13 Patients Underwent

occa-

any

repeated

carcinoma

(short

arrow)

magnification,

and

x300).

.

and Biopsy Who

Biopsy

Cytologic Findings

sus-

the

interval

Histopathobogic Findings

Diagnosis

aspirate monichange

in

at 6-month

to i’/2 years

Surgical

recurrent

a surgical

performed. When close mammographic

to determine

tervals

cells,

duc-

nu-

nuclei).

aspirate

atypical,

biopsy was was benign,

type clusters

apocrine

myoepithelial

When

uniform

myoepithelial

with

of benign

in-

to date.

Adenocarcinoma Suspicious

N

Diagnosis

N

6 0

Adenocarcinoma Suspicious

6 0

Atypical

I

DCIS

1

Benign

5

Benign Scars

5 (n = 3)

1

.:

Fat necrosis RESULTS

Among the 43 patients who underwent aspiration biopsy, the results were malignant in six, suspicious in none, atypical in one, inadequate in one, and benign in 35. Thirteen of the 43 patients then underwent surgical biopsies, the results of which were malignant in seven and benign in six (Table 1). Five of these 13 patients undenwent surgical biopsy in spite of a benign needle aspirate. In these five instances, preoperative needle localization and radiography of a specimen for verification of the presence of calcifications were performed. In four of these

cases,

either

the

patient

or

referring surgeon requested further assurance that the calcifications were benign and chose surgical biopsy. In the fifth case, insufficient epithelial cells were obtained confirm a benign

cal biopsy

was

At histologic

proved

at aspiration diagnosis, and

therefore evaluation,

to be dense

scar

to surgi-

1114

#{149} Ra1in1nov

Inadequate

1

Note.-DCIS

ductal

=

all 30 cases

(100%),

raphy at 6 months tion demonstrated

peanance.

Scar carcinoma

in situ.

interval

of these

underwent

follow-up

instances 2.5 cm

nal excisional

site;

four

scar

1.0 cm

or within

of 36 cases

of benign

calcifications

Table 2 Distance of Calcifications Original Excision Site

30 mam-

(arrow)

from

the

Diagnosis Distance (cm)

Malignant

Benign

Total 30

Withinl.0 Within 2.0 Within 2.5

4 2 1

26 5 3

Within 3.5 Otherquadrant

0 0

1 1

7

36

of maligof the onigi-

were of the

new

on a 2-year follow-up mammogram obtained in a 42-year-old physician who underwent lumpectomy and radiation therapy. The aspirate showed benign cytologic findings. The histopathologic result was fat necrosis.

mography at 1 year, which demonstrated no interval change, and seven underwent follow-up mammography at 1’/2 years and also had no change. Table 2 shows the distance of the calcifications from the original excision site. All seven nancy were within

Several

mammog-

after the aspirano change in ap-

Twenty-nine

patients

1

2.

Total

7

4

i 1 43

at the scam.

In 26

calcifications,

The

the

earliest

detection

of calcifica-

performed.

calcifications

the

the scar. The one instance in which calcifications occurred in another quadrant of the breast proved to be fat necrosis at subsequent surgical

which aspiration was penformed was at 1 year after local cxcision (five cases). The longest interval was 8 years after treatment (one case). No difference between the time course

biopsy

for

tissue

specimen

with

fibrosis.

The remaining followed up with

Figure

(n=2)

30 patients were mammography.

In

(Fig

were

2).

within

1.0 cm

of

tions

for

benign

and

that

for

malignant Ianiiarv

1l!

tinguish

malignant

from

benign

ease (Fig 5). In all cases, we required ence of microcabcifications smears.

These

were

dis-

the presin the

seen

as dense,

blue, fragmented and laminated cmystabs that were easily identified with the modified Wright stain. The abundance of crystals corresponded to those seen on the histologic sections of the excised tissue. In two cases with coarse calcifications seen on the mammogram, abundant crystals were seen in the cytologic smear, whereas only rare calcifications were noted on a.

b.

Figure

3.

(a) Parenchymal

distortion

at the scar site with

coarse

fications are seen on this craniocaudal magnification view. ized tissue and coarse calcifications (arrow), corresponding (modified Wright stain; original magnification, x 150).

in patients

Table 3 Histologic Features of the Recurrent and Original Carcinomas Carcinoma Patient No.

Original

1

Invasive

ductal

Invasive

ductal

2

Invasive Invasive

ductal ductal

Invasive Invasive

ductal ductal,

Invasive DCIS

ductal,

LCIS Invasive

ductal

3

4

LCIS

6

DCIS

7

microinvasion DCIS

Note.-DCIS LCIS = lobular

with

DCIS

= ductal

carcinoma

Six patients

ries.

nocarcinoma

one

and

underwent

patient

The

original listed

with

recurrent

refused

histologic

se-

in our

features

and recurrent in Table 3.

are

treated

with

local

excision

and

a me-

therapy leaves the breast permanently at risk for recurrent disease. In reported series, mammographic evabuation and surgical biopsy of new calcifications without a palpable mass 1S

#{149} T%Jiimhr

1

to the

scan.

On

the basis

of our

tumor

Three malignant

benign

had

calcifications,

a punctate

due

report

(16),

In a more

all six instances

microcalcifications

rent disease microcalcifications. study, coarse both malignant ditions (Fig cations also tions (Fig 4). calcifications

se-

all of

in recur-

were

described as fine In the present calcifications occurred in as well as benign con1). Fine, punctate calcifioccurred in both condiExcept when the had a linear or branch-

ing configuration, two patients, the

which occurred in configuration of the

calcifications

not

was

helpful

be benign. findings

these

to dis-

after

lumpec-

of malignancy

Five

diag-

proved to be evaluation.

patients

underwent

results

was

with

were

at histologic

lesions

in the or proved to

surgical

of which were

scar

recur-

such biopsies,

confirmed

study; fibrotic

three scars,

of

and

showed fat necrosis. sample from aspira-

a dense

acellubam

30 patients who did not

scam.

The

with benign undergo surgi-

aspirates cab excision have been followed up with interval mammography at 1-1’/2 years after aspiration. With use of this mammognaphic surveillance, there appears to be no evidence for recur-

rence of

with

the

for

Most aspirates of calcifications absence of other mammognaphic physical findings, however,

tion

configuration

to fibrosis.

camcinoma

All cases

remaining

and

case, they were patients in their

benign

were

after

patients in their microcalcifica-

linear

evaluated

the other two One inadequate

recurrence

were

breast

tomy.

as benign et ab

experience

at or near

in patients

rent

the

punc-

larger

Demshaw

to differentiate from

in one Three

had

recent

as fine,

as calcifications

malignant nadia-

tion therapy (10,11). While recurmences in all patients who have undengone mastectomy generally occur within 5 years, as noted by Kurtz et al (12), local excision with radiation

Vnliimp

and

both

all of which

tions,

which

protracted current

rebated

or as coarse, at the

lumpectomy. series had

mies

studies have shown that time course exists for breast cancer in patients

seen

calcifications

irregular; branched.

DISCUSSION Prior

were

calcifications

manifested cxci-

of the

carcinomas

were

calcifica-

43 patients, the use of stereotaxic aspination is efficacious in the initial evaluation of mammognaphically detected

microcalcifications

et al (14) and

series

calcifications

mastectomy wider

vary-

nosed with aspiration malignant at histologic

(5) attempted

ade-

mastectomy,

a second

had

of mabig-

previous surgery or radiation treatment and were secondary to scarring on fat necrosis (Figs 2, 3). These calcifi-

in situ,

in this

underwent

and sion.

detected

has

detection

Smaller

a small number of patients (fewer than 10). The most common benign calcifica-

tate was

local-regional

at biopsy.

tions, which were consistent with malignancy at mammography, were seen more frequently on the histologic sections than in the aspiration smears; in all of these cases, however, surgical excision was performed.

site

cations calcifications

for the

tamed

Stomper et ab (15) reported malignant results in 100% and 67% of cases, mespectively, but both series included

tions

DCIS carcinoma in situ.

with

irradiation

Benenbeng

cases).

LC!S

5

results

microcalci-

only hyalinto scarring

nancy. Sobin et ab (13) evaluated 19 patients and found the biopsy specimens to be positive for recurrent invasive on in situ carcinoma in 58% (11

Type

Recurrent

and

and

showed secondary

treated

excision

ing

calcifications

(b) Aspirate to fibrosis

sections of tissue obtained at biopsy. This is most likely due to the loss of coarse calcifications during the cutting of paraffin-embedded tissue ob-

tients.

of a malignancy Longer

in these

follow-up,

will be required

30 pa-

however,

to ensure

this

contin-

ued

lack of change. Breast-conserving surgery followed by irradiation is becoming a common form of treatment for breast cancer.

The mammognaphic calcifications may

detection be the first

of new indica-

tion of a recurrence. Stereotaxic aspination biopsy of the focus of calcifications may be a promising method to distinguish benign from malignant microcalcifications. #{149}

1ti;ttim.

.

in

a.

b.

4.

Figure

(a) Widely

spaced,

gone resection of carcinoma indicates calcium (modified

punctate 2 years

Wright

microcalcifications previously.

stain;

are present

(b) Aspirate

original

on this magnification

showed

magnification,

malignant

view

epithelial

cells

of the mammogram.

dispersed

singly

The

among

patient

blood

cells.

had

under-

The

arrow

x300).

-

‘..

.#{149}...s.,d,;

,-.:-

‘

-.---:---

‘

,

-

-:-

.-

,-

-.

-

.k-..

...

.%.

-

b ,--

,,‘p#{149}

‘b:

.

#{149} .!.‘

.‘.

‘.1#{149}

. .

.

.

.

-.?

. .

i’

#{149}.

‘

‘

I

i

,

.

.

#{149} #{149} #{149},

.

.

-

.

. .

.

..

.

:

:

#{149} .

#{149}

. ,

,

:

-,-.#{149}

,.

.

.

:

-

.

‘&

,,.

...

.

4

4:

..

.

,

, ,,

“

‘ .

.

#{149}:,I.,#{149}#{149}’.-

,

.,,.‘

,

.

-

;:-“

#{149} #{149}.

l.(

.

,d,

,,

%

‘4.

I

‘#{149}

.

:.

,

‘t

!?-

,

,

(

:i;q#{149}

I

:‘#{149}.#{149}

Ii,

‘

V

,

:

:

‘-.

I

#{149}

#{149}

;;ii#{248}

,

a.

b.

Figure 5. (a) Mammogram shows linear calcifications years previously. (b) Aspirate was malignant, and the (arrow) (hematoxylmn-eosmn stain; original magnification,

References I

.

2.

3.

Baeza MK, Sole J, Leon A, et al. Conservative treatment of early breast cancer. Int J Radiat Oncol Biol Phys 1988; 14:669-676. Harris JR. Connelly JL, Schmitt S. Cohen RB, Hellman S. Clinical-pathological study of early breast cancer treated by primary radiation therapy. J Clin Oncol 1983; 1:184-189. Kurtz 1. Spitalier JM, Amalric R, et al. Mammary recurrences in women younger than forty. Int J Radiat Oncol Biol ‘Phys 1988; 15: 271-276.

4.

Calle R, Vilcoq JR. Zafrani B, Vielh P. Fourquet A. Local control and survival of breast cancer treated by limited surgery followed by irradiation. Int J Radiat Oncol Biol Phys 1986; 12:873-. 878.

5.

6.

Dershaw DD, McCormick B, Cox L, Osborne MP. Differentiation of benign and malignant local tumor recurrence after lumpectomy. AJR 1990; 155:35-38. Lofgren M, Andersson I. Bondeson L, Lindholm K. X-ray guided fine needle aspiration

7.

8.

9.

10.

11.

at the

#{149} Radiology

in a 59-year-old

section

patient

shows

treated

intraductal

for the cytologic diagnosis of nonpalpable breast lesions. CA 1988; 61:1032-1037. Nordenstrom B, Zajicek J. Stereotaxic needle biopsy and preoperative indication of nonpalpable mammary lesions. Acta Cytol 1977; 21: 350-351. Dowlatshahi K,Jokich PM, Schmidt R, Bibbo M. Dawson PJ. Cytologic diagnosis of occult breast lesions using stereotaxic needle aspiration: a preliminary report. Arch Surg 1987; 122: 1343-1346. Mitnick JS, Vazquez MF, Roses DF, Harris MN, Gianutsos R, Waisman J. Stereotactic localization for fine needle aspiration breast biopsy: initial experience with 300 patients. Arch Surg 1991; 126:1137-1140. Stotter AT, McNeese MD, Ames FC, Oswald MJ, Ellerbroek NA. Predicting the rate and extent of locoregional failure after breast conservation therapy for early breast cancer. CA 1989; 64:2217-25. Bedwinek JM, Lee J, Fineberg B, Ocwieza M. Prognostic indicators in patients with isolated local-regional recurrence of breast cancer. CA 1981;

106

scar

histopathologic x200).

with

lumpectomy

comedocarcinoma

12.

13.

14.

and

radiation

therapy

with

central

calcifications

4

Kurtz JM, Amalric R, Brandone H, Ayme Y, Spitalier JM. Results of salvage surgery for mammary recurrence following breast-conserving therapy. Ann Surg 1988; 207:347-351. Solin U, Fowble BL, Troupin RH. Goodman RL. Biopsy results of new calcifications in the post irradiated breast. CA 1989; 63:1956-1961. Berenberg AL, Levene MB, Tonnesen GH. Mammographic evaluation of the post irradiated breast. In: Harris JR. Hellman S. Silen W, eds. Conservative management of breast cancer: new surgical and radiotherapeutic techniques. Philadelphia: Lippincott, 1983; 265272.

15.

Stomper PC, Recht A, Berenberg Harris JR. Mammographic recurrent cancer in the irradiated

MS.

1987; 16.

AL, Jochelson detection of breast. AJR

148:39-43.

Hassell PR, Olivotto IA, Mueller HA, Kingston GW, Basco yE. Early breast cancer: detection of recurrence after conservative surgery and radiation therapy. Radiology 1990; 176:731-735.

412232-2235.

January

1992