Stereotaxic Localization for Fine-Needle
Aspiration Initial
Breast
Biopsy
Experience With 300 Patients
Julie S. Mitnick, MD; Madeline F. Vazquez, MD; Daniel F. Roses, MD; Matthew N. Harris, MD; Rosamond Gianutsos, PhD; Jerry Waisman, MD
efficacy of stereotaxic aspiration biopsy was evaluated in 300 consecutive patients with nonpalpable mammographic lesions. Sixty-eight patients (23%) had suspicious or malignant aspirates; all cases were proved malignant by subsequent examination of operative specimens. Two hundred sixteen patients (72%) had benign aspirates. Of these, 65 were confirmed by operation and 151 had subsequent mammography at 6- and 12-month intervals with no demonstrable mammographic change. In 10 instances (3%), the aspirates were atypical, and in six (2%), nondiagnostic. Biopsy specimens were obtained in all 16 instances, and eight were malignant. The sensitivity of stereotaxic breast aspiration for the diagnosis of cancer was 96%, and the specificity was 100%. Our experience confirms the efficacy of stereotaxic aspiration for the initial evaluation of mammographically detected, nonpalpable lesions. (Arch Surg. 1991;126:1137-1140) \s=b\ The
such
mammographie findings, Nonpalpable turbance the parenchymal pattern in
as a dis¬ or a focal
asymmetric density, are well-recognized subtle roentgenographic indicators of breast cancer.1,2 As the use of mammography has become more widespread and the ability to detect cancer has increased owing to improved film screen technique, such findings have led to a greater number of operative biopsies. This has also led to an in¬ crease
in the detection of lesions that prove to be benign.3-4
Aspiration biopsy has been demonstrated to be a valuable technique for the diagnosis of palpable masses and has more recently been applied to diagnose nonpalpable lesions as well, using a variety of techniques for localization. How¬ ever, there has been a wide variation in the reported accu¬ racy when ultrasound or roentgenography has been used for guiding the needle, most likely due to an inability to Accepted
for
publication
March 23, 1991.
Departments of Radiology (Dr Mitnick) and Pathology (Drs Vazquez and Waisman), and the Division of Oncology, Department of Surgery (Drs Roses and Harris), Kaplan Cancer Center, The Tisch Hospital, New York (NY) University Medical Center. Dr Gianutsos is a private consultant. Reprint requests to New York University Medical Center, 530 First From the
Ave, Suite 6E, New York, NY
10016 (Dr Roses).
verify its location.5,6 Initial reports suggest that stereotaxic localization may allow greater accuracy in the performance of aspiration biopsy for nonpalpable lesions.7"12 To evaluate the reliability of this technique, we prospectively performed stereotaxic aspiration biopsies on 300 patients with clinically occult mammographie find¬ ings. We correlated the cytologie findings with both the mammographie appearance and the histopathologic find¬ ings of subsequent operative biopsies when performed, or the clinical and mammographie follow-up when not performed because of benign cytologie findings. PATIENTS AND METHODS Stereotaxic aspiration biopsies were performed on 300 con¬ secutive patients with nonpalpable mammographie findings. The patients were evaluated initially at the New York (NY) Uni¬ versity Medical Center or referred following mammography elsewhere. The stereotaxic procedures were performed on the GE Stereotix unit (GE Medical Systems, Milwaukee, Wis). Pre¬ liminary roentgenograms of the abnormal findings with two views angled at 15° were obtained. The procedures were performed with the patient seated, using a perforated compres¬ sion plate with an opening to permit introduction of the needle. Using the stereoscopic images, the x, y, and z coordinates of the lesion were calculated with a microprocessor, and the needle was advanced to the calculated position, which was confirmed by another roentgenogram. One initial aspirate was obtained by the cytopathologist while the films were being processed. When the correct position had been verified, two additional aspirates were then obtained. If necessary, the position of the needle was adjusted and reconfirmed by additional roentgenograms. The procedure time from preliminary roentgenograms to prelimi¬ nary cytologie assessment rarely exceeded 20 minutes. Air-dried smears were stained immediately by a modified Wright method (Diff-Quik, Baxter Health Care Corp, Dade Di¬ vision, Miami, Fla). These smears were then examined to verify that an adequate sample had been obtained. The cytologie find¬ ings were divided into the following categories: (1) malignant: a definitive diagnosis of cancer was based on cellular material with large numbers of atypical cells, especially dissociated cells, and no extenuating factors; (2) suspicious: an unqualified diagnosis of cancer could not be made because of some mitigating factor, as, for example, severely atypical cells but in small numbers; (3) atypical: there were minimally or moderately atypical cells, often mixed with benign elements; (4) benign: the cytologie findings were compatible with a benign diagnosis and also compatible
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Table
1.—Mammographie Appearance of 300 Lesion
Stellate
density
No. 78
Nodule
With
Lesions
68
adjacent trabecular distortion
23
Well circumscribed
21
Lobulated
15
or
irregular margins
With microcalcifications Focal asymmetric density Localized trabecular distortion Microcalcifications Total
9 67 44 43 300
Fig 2. —Top,
A 6-mm nodule visualized
(arrow). Bottom, The
on
the craniocaudal view
aspirate contained singly dispersed atypical cells with enlarged nuclei and retained cytoplasm, diagnostic of adenocarcinoma (modified Wright's stain, x 300).
Fig 1. Top, A 3-mm stellate lesion in the lateral aspect of the right breastofa 52-year-oldwoman (arrow). Bottom, The aspirate showed elongated tubules composed of well-differentiated columnar cells. The mastectomy specimen showed a tubular adenocarcinoma con¬ firmed at mastectomy (modified Wright's stain, x 600). —
with the mammographie findings, and there were no atypical cells; and (5) nondiagnostic: the specimen was inadequate for making any diagnosis. In all instances when the aspirate was malignant, subsequent operative specimens were available for histopathologic correla¬ tion. In those instances in which an aspirate was suspicious,
atypical, or nondiagnostic, an operative biopsy was performed. In those instances in which the mammogram had malignant characteristics and the aspirate was benign or nondiagnostic, an operative biopsy with preoperative needle localization was per¬ formed. When the mammographie findings had benign charac¬ teristics and the cytologie finding was also benign, the patient was reassessed mammographically at 6-month intervals. RESULTS
The patients in this study were aged from 29 to 86 years
(mean age, 58 years). There were 162 aspirates for findings
in the right breast and 138 in the left breast. Table 1 summa¬ rizes the mammographie appearance of the 300 lesions. The size of the nonpalpable lesions ranged from 3 to 27 mm (mean size, 15 mm). The smallest malignant stellate lesion was a tubular carcinoma 3 mm in greatest diameter (Fig 1). Other instances of carcinoma, which we include as illustra¬ tive of the range of lesions, were a 6-mm nodule, the stereotaxic aspirate of which was malignant and confirmed histopathologically (Fig 2); a 5-mm area of trabecular distor¬ tion, the stereotaxic aspirate of which was malignant (Fig 3) and confirmed to be infiltrative carcinoma (lobular adenocarcinoma); and a 4-mm area of microcalcifications (Fig 4), the stereotaxic aspirate of which was malignant and which was confirmed to be intraductal comedocarcinoma. The as¬ pirate of the last example contained malignant cells along with calcific and necrotic debris. The correlation of stereotaxic aspiration biopsy results with the mammographie findings of the 300 patients is given in Table 2. Sixty (77%) of the 78 stellate densities had malignant, suspicious, or atypical aspirates. Two nondi¬ agnostic aspirates were proved to be malignant on subse¬ quent excisional biopsy specimens. One was close to the chest wall and the other was in axillary breast tissue. Both of these false-negative procedures related to difficulties in positioning that occurred early in the series. Subse¬ quently, no procedure was terminated until it had been ascertained that an adequate cellular aspirate had been obtained. The 16 benign aspirates included nine instances
of mammary dysplasia, five scars secondary to prior sur¬ geries, and two radial scars. There were 16 stellate lesions, nine of which were classified as benign by stereotaxic as¬ piration. All were resected and all proved to be benign.
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In our evaluation of 300 consecutive stereotaxic aspira¬ tion biopsy specimens, 57 (19%) were malignant, 11 (4%) were suspicious for malignancy, 10 (3%) were atypical, and six (2%) were nondiagnostic. All 84 of the lesions were
excised.
Sixty-five lesions designated as benign by aspira¬
tion were also excised. The correlation of the cytologie di¬ agnoses with the microscopic diagnoses of the operative specimens is seen in Table 3. The sensitivity of stereotaxic breast aspiration biopsy for the detection of cancer was 96%. When suspicious cases were included in the compu¬ tation as malignant, a specificity of 100% was achieved. In
COMMENT stereotaxic aspiration has allowed
our experience, precise localization of nonpalpable lesions forforcyto¬ the logie evaluation and has proved highly reliable identification of lesions that require surgery. In our series, all of the nonpalpable breast lesions that yielded suspi¬ cious or malignant aspirates proved to be malignant by
the
Fig 4. —Top, A 4-mm grouping of microcalcifications with a localiz¬ ing needle in position. Bottom, the cytologie diagnosis was adenocarcinoma, and calcific debris was present in the aspirate (modified Wright's stain,
x
300).
Table
3.—Correspondence of(n Cytologie 149)
With
Histologie Findings
=
Histologie Diagnosis
Cytologie
Fig 3. —Top, Trabecular distortion measuring 5 mm present at the superior aspect of the right breast (arrow). Bottom, The aspirate showed pleomorphic malignant epithelial cells with abundant mitotic figures (modified Wright's stain, x300). Table
Malignant
Diagnosis (n) Malignant (57) Suspicious (11) Atypical (10) Nondiagnostic (6) Benign (65)
Atypical
Benign
57 11
2
5
3
3
65
Total (149)
70
76
2.—Correspondence of Stereotaxic Aspiration With Mammographie Findings
Mammographie Findings Stellate density
Malignant
Suspicious
44
10
Nodule Focal asymmetric density Trabecular distortion Microcalcifications Total (%)
5 1
2 5
57(19)
Cytologie Diagnosis Atypical Nondiagnostic 6
2
...
1 11 (4)
Total
16
63
78 68
66
67
2
3
37
44
2
1
34
43
216 (72)
300 (100)
...
...
Benign
10 (3)
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 06/21/2015
6 (2)
Table
4.—Variability of Specificity and Sensitivity
Based
Interpretation
on
of
Inadequate Samples*
Specificity No.
Source
Evans and Cade15 Gent et al8
%
Nondiagnostic
Sensitivity
M
B
50
27
71
100
100
100
M
80
100 98
187
17
74
95
94
98
98
Ciatto et al11 Bibbo et al12
218
17
76
97
97
85
77
84
114
13
78
92
91
100
93
100
Dowlatshahi et al16 Azavedo et al17
528
10
80
92
91
96
95
96
2573
2
97
98
98
80
74
79
300
2
96
98
97
100
95
100
study *Percentage specificity Present
cluded (E).
and
sensitivity computed
when
nondiagnostic samples
subsequent resection, and no lesion that was benign by aspiration has proved malignant. In 5% of cases, the as¬ pirates yielded atypical or nondiagnostic results, and in six instances the lesions proved to be malignant by oper¬ ative biopsy. Our results have confirmed four major observations previously made in a review of 100 aspirates performed at our medical center for palpable breast lesions13: (1) defin¬ itive benign and malignant results are reliable; (2) suspi¬ cious results are indicative of cancer; (3) atypical results may be indicative of benign or malignant processes; and (4) inadequate results must be followed by repeated aspi¬
excision. of specificity and sensitivity must con¬ sider inconsistencies in the statistical treatment of nondi¬ agnostic samples, especially when there are large num¬ bers of them.1416 In most reported studies, sufficient data were presented to allow us to compute specif¬ icity and sensitivity using different computational approaches.8,111215"17 These results are tabulated in Table 4. The computational artifacts and the distortion of spec¬ ificity and sensitivity are minimized when the incidence of inadequate samples is reduced, as in our study. In our experience, the immediate interpretation by the cytopathologist to determine the adequacy of the sample ob¬ tained by aspiration has been essential in reducing the number of inadequate samples. There have been two advantages of stereotaxic aspira¬ tion in our experience. First, stereotaxic aspiration expe¬ dites a malignant diagnosis and permits rapid treatment planning; second, a benign cytologie diagnosis has per¬ mitted greater security in radiologie follow-up. Had biop¬ sies not been performed on those 65 lesions that were cyration
or
Interpretation
tologically benign, the percentage of malignant neoplasms found by aspiration biopsy would have risen from 51% (76/149) to 90% (76/84), yet no cancer would have gone undetected. The impact of this technique, if reproducible by other centers, may be particularly signif¬ icant as the volume of clinically occult mammographically detected lesions increases through more widespread screening programs. This study was supported in part by the Landesberg-Zale Research Fund in Surgical Oncology, New York, NY.
References 1. Sickles EA. Mammographic features of 300 consecutive nonpalpable breast cancers. AJR Am J Roentgenol.
are
considered
malignant (M), benign (B),
or ex¬
1986;146:661-664.
2. Moskowitz M. Minimal breast cancer redux. Radiol Clin North Am. 1983;21:93-113. 3. Homer MJ. Nonpalpable breast abnormalities: a realistic view of the accuracy of mammography in detecting malignan-
cies. 4.
Radiology. 1984;153:831-832. Landercasper J, Gundersen SB,
Gundersen AL,
Cogbill
TH, Travelli R, Strutt P. Needle localization and biopsy of non-
palpable
lesions of the breast.
Surg Gynecol
1987;164:399-403. 5. Fornage BD, Faroux MJ, Simatos A. Breast
Obstet.
masses:
US
guided fine needle aspiration for the cytologic diagnosis of nonpalpable breast lesions. Cancer. 1988;61:1032-1037. 6. Lofgren M, Andersson I, Bondeson L, Lindholm K. X-ray guided fine needle aspiration for the cytologic diagnosis of nonpalpable breast lesions. Cancer. 1988;61:1032-1037. 7. Nordenstrom B, Zajicek J. Stereotaxic needle biopsy and preoperative indication of nonpalpable mammary lesions. Acta Cytol. 1977;21:350-351. 8. Gent H, Sprenger E, Dowlatshahi K. Stereotaxic needle localization and cytological diagnosis of occult breast lesions.
Ann Surg. 1986;204:580-584. 9. 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. 10. Dent DM, Kirkpatrick AE, McGoogan E, Chetty U, Anderson TJ. Stereotaxic localization and aspiration cytology of impalpable breast lesions. Clin Radiol. 1989;40:380-382. 11. Ciatto S, DelTurco MR, Bravetti P. Nonpalpable breast lesions: stereotaxic fine-needle aspiration cytology.
Radiology.
1989;173:57-59. 12. Bibbo M, Scheiber M, Cajulis R, Keebler CM, Wied GL,
Dowlatshahi K. Stereotaxic fine needle aspiration cytology of clinically occult malignant and premalignant breast lesions. Acta Cytol. 1988;32:193-201. 13. Thomas PA, Vazquez MF, Waisman J. Comparison of fine needle aspiration and frozen section of palpable mammary le-
sions. Mod Pathol. 1990;3:570-574. 14. Hann L, Ducatman BS, Wang HH, Fein V, Mclntire JM. Nonpalpable breast lesions: evaluation by means of fine\x=req-\ needle aspiration cytology. Radiology. 1989;171:373-376. 15. Evans WP, Cade SH. Needle localization and fine needle aspiration biopsy of nonpalpable breast lesions with use of standard and stereotactic equipment. Radiology. 1989;173:53-56. 16. Dowlatshahi K, Gent HJ, Schmidt R, Jokich PM, Bibbo M, Sprenger E. Nonpalpable breast tumors: diagnosis with stereotaxic localization and fine needle aspiration. Radiology.
1989;170:427-433. 17. Azavedo E, Svane G, Auer G. Stereotactic fine-needle biopsy in 2594 mammographically detected Lancet. 1989;1:1033-1036.
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 06/21/2015
nonpalpable lesions.
Aspiration Initial
Breast
Biopsy
Experience With 300 Patients
Julie S. Mitnick, MD; Madeline F. Vazquez, MD; Daniel F. Roses, MD; Matthew N. Harris, MD; Rosamond Gianutsos, PhD; Jerry Waisman, MD
efficacy of stereotaxic aspiration biopsy was evaluated in 300 consecutive patients with nonpalpable mammographic lesions. Sixty-eight patients (23%) had suspicious or malignant aspirates; all cases were proved malignant by subsequent examination of operative specimens. Two hundred sixteen patients (72%) had benign aspirates. Of these, 65 were confirmed by operation and 151 had subsequent mammography at 6- and 12-month intervals with no demonstrable mammographic change. In 10 instances (3%), the aspirates were atypical, and in six (2%), nondiagnostic. Biopsy specimens were obtained in all 16 instances, and eight were malignant. The sensitivity of stereotaxic breast aspiration for the diagnosis of cancer was 96%, and the specificity was 100%. Our experience confirms the efficacy of stereotaxic aspiration for the initial evaluation of mammographically detected, nonpalpable lesions. (Arch Surg. 1991;126:1137-1140) \s=b\ The
such
mammographie findings, Nonpalpable turbance the parenchymal pattern in
as a dis¬ or a focal
asymmetric density, are well-recognized subtle roentgenographic indicators of breast cancer.1,2 As the use of mammography has become more widespread and the ability to detect cancer has increased owing to improved film screen technique, such findings have led to a greater number of operative biopsies. This has also led to an in¬ crease
in the detection of lesions that prove to be benign.3-4
Aspiration biopsy has been demonstrated to be a valuable technique for the diagnosis of palpable masses and has more recently been applied to diagnose nonpalpable lesions as well, using a variety of techniques for localization. How¬ ever, there has been a wide variation in the reported accu¬ racy when ultrasound or roentgenography has been used for guiding the needle, most likely due to an inability to Accepted
for
publication
March 23, 1991.
Departments of Radiology (Dr Mitnick) and Pathology (Drs Vazquez and Waisman), and the Division of Oncology, Department of Surgery (Drs Roses and Harris), Kaplan Cancer Center, The Tisch Hospital, New York (NY) University Medical Center. Dr Gianutsos is a private consultant. Reprint requests to New York University Medical Center, 530 First From the
Ave, Suite 6E, New York, NY
10016 (Dr Roses).
verify its location.5,6 Initial reports suggest that stereotaxic localization may allow greater accuracy in the performance of aspiration biopsy for nonpalpable lesions.7"12 To evaluate the reliability of this technique, we prospectively performed stereotaxic aspiration biopsies on 300 patients with clinically occult mammographie find¬ ings. We correlated the cytologie findings with both the mammographie appearance and the histopathologic find¬ ings of subsequent operative biopsies when performed, or the clinical and mammographie follow-up when not performed because of benign cytologie findings. PATIENTS AND METHODS Stereotaxic aspiration biopsies were performed on 300 con¬ secutive patients with nonpalpable mammographie findings. The patients were evaluated initially at the New York (NY) Uni¬ versity Medical Center or referred following mammography elsewhere. The stereotaxic procedures were performed on the GE Stereotix unit (GE Medical Systems, Milwaukee, Wis). Pre¬ liminary roentgenograms of the abnormal findings with two views angled at 15° were obtained. The procedures were performed with the patient seated, using a perforated compres¬ sion plate with an opening to permit introduction of the needle. Using the stereoscopic images, the x, y, and z coordinates of the lesion were calculated with a microprocessor, and the needle was advanced to the calculated position, which was confirmed by another roentgenogram. One initial aspirate was obtained by the cytopathologist while the films were being processed. When the correct position had been verified, two additional aspirates were then obtained. If necessary, the position of the needle was adjusted and reconfirmed by additional roentgenograms. The procedure time from preliminary roentgenograms to prelimi¬ nary cytologie assessment rarely exceeded 20 minutes. Air-dried smears were stained immediately by a modified Wright method (Diff-Quik, Baxter Health Care Corp, Dade Di¬ vision, Miami, Fla). These smears were then examined to verify that an adequate sample had been obtained. The cytologie find¬ ings were divided into the following categories: (1) malignant: a definitive diagnosis of cancer was based on cellular material with large numbers of atypical cells, especially dissociated cells, and no extenuating factors; (2) suspicious: an unqualified diagnosis of cancer could not be made because of some mitigating factor, as, for example, severely atypical cells but in small numbers; (3) atypical: there were minimally or moderately atypical cells, often mixed with benign elements; (4) benign: the cytologie findings were compatible with a benign diagnosis and also compatible
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 06/21/2015
Table
1.—Mammographie Appearance of 300 Lesion
Stellate
density
No. 78
Nodule
With
Lesions
68
adjacent trabecular distortion
23
Well circumscribed
21
Lobulated
15
or
irregular margins
With microcalcifications Focal asymmetric density Localized trabecular distortion Microcalcifications Total
9 67 44 43 300
Fig 2. —Top,
A 6-mm nodule visualized
(arrow). Bottom, The
on
the craniocaudal view
aspirate contained singly dispersed atypical cells with enlarged nuclei and retained cytoplasm, diagnostic of adenocarcinoma (modified Wright's stain, x 300).
Fig 1. Top, A 3-mm stellate lesion in the lateral aspect of the right breastofa 52-year-oldwoman (arrow). Bottom, The aspirate showed elongated tubules composed of well-differentiated columnar cells. The mastectomy specimen showed a tubular adenocarcinoma con¬ firmed at mastectomy (modified Wright's stain, x 600). —
with the mammographie findings, and there were no atypical cells; and (5) nondiagnostic: the specimen was inadequate for making any diagnosis. In all instances when the aspirate was malignant, subsequent operative specimens were available for histopathologic correla¬ tion. In those instances in which an aspirate was suspicious,
atypical, or nondiagnostic, an operative biopsy was performed. In those instances in which the mammogram had malignant characteristics and the aspirate was benign or nondiagnostic, an operative biopsy with preoperative needle localization was per¬ formed. When the mammographie findings had benign charac¬ teristics and the cytologie finding was also benign, the patient was reassessed mammographically at 6-month intervals. RESULTS
The patients in this study were aged from 29 to 86 years
(mean age, 58 years). There were 162 aspirates for findings
in the right breast and 138 in the left breast. Table 1 summa¬ rizes the mammographie appearance of the 300 lesions. The size of the nonpalpable lesions ranged from 3 to 27 mm (mean size, 15 mm). The smallest malignant stellate lesion was a tubular carcinoma 3 mm in greatest diameter (Fig 1). Other instances of carcinoma, which we include as illustra¬ tive of the range of lesions, were a 6-mm nodule, the stereotaxic aspirate of which was malignant and confirmed histopathologically (Fig 2); a 5-mm area of trabecular distor¬ tion, the stereotaxic aspirate of which was malignant (Fig 3) and confirmed to be infiltrative carcinoma (lobular adenocarcinoma); and a 4-mm area of microcalcifications (Fig 4), the stereotaxic aspirate of which was malignant and which was confirmed to be intraductal comedocarcinoma. The as¬ pirate of the last example contained malignant cells along with calcific and necrotic debris. The correlation of stereotaxic aspiration biopsy results with the mammographie findings of the 300 patients is given in Table 2. Sixty (77%) of the 78 stellate densities had malignant, suspicious, or atypical aspirates. Two nondi¬ agnostic aspirates were proved to be malignant on subse¬ quent excisional biopsy specimens. One was close to the chest wall and the other was in axillary breast tissue. Both of these false-negative procedures related to difficulties in positioning that occurred early in the series. Subse¬ quently, no procedure was terminated until it had been ascertained that an adequate cellular aspirate had been obtained. The 16 benign aspirates included nine instances
of mammary dysplasia, five scars secondary to prior sur¬ geries, and two radial scars. There were 16 stellate lesions, nine of which were classified as benign by stereotaxic as¬ piration. All were resected and all proved to be benign.
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 06/21/2015
In our evaluation of 300 consecutive stereotaxic aspira¬ tion biopsy specimens, 57 (19%) were malignant, 11 (4%) were suspicious for malignancy, 10 (3%) were atypical, and six (2%) were nondiagnostic. All 84 of the lesions were
excised.
Sixty-five lesions designated as benign by aspira¬
tion were also excised. The correlation of the cytologie di¬ agnoses with the microscopic diagnoses of the operative specimens is seen in Table 3. The sensitivity of stereotaxic breast aspiration biopsy for the detection of cancer was 96%. When suspicious cases were included in the compu¬ tation as malignant, a specificity of 100% was achieved. In
COMMENT stereotaxic aspiration has allowed
our experience, precise localization of nonpalpable lesions forforcyto¬ the logie evaluation and has proved highly reliable identification of lesions that require surgery. In our series, all of the nonpalpable breast lesions that yielded suspi¬ cious or malignant aspirates proved to be malignant by
the
Fig 4. —Top, A 4-mm grouping of microcalcifications with a localiz¬ ing needle in position. Bottom, the cytologie diagnosis was adenocarcinoma, and calcific debris was present in the aspirate (modified Wright's stain,
x
300).
Table
3.—Correspondence of(n Cytologie 149)
With
Histologie Findings
=
Histologie Diagnosis
Cytologie
Fig 3. —Top, Trabecular distortion measuring 5 mm present at the superior aspect of the right breast (arrow). Bottom, The aspirate showed pleomorphic malignant epithelial cells with abundant mitotic figures (modified Wright's stain, x300). Table
Malignant
Diagnosis (n) Malignant (57) Suspicious (11) Atypical (10) Nondiagnostic (6) Benign (65)
Atypical
Benign
57 11
2
5
3
3
65
Total (149)
70
76
2.—Correspondence of Stereotaxic Aspiration With Mammographie Findings
Mammographie Findings Stellate density
Malignant
Suspicious
44
10
Nodule Focal asymmetric density Trabecular distortion Microcalcifications Total (%)
5 1
2 5
57(19)
Cytologie Diagnosis Atypical Nondiagnostic 6
2
...
1 11 (4)
Total
16
63
78 68
66
67
2
3
37
44
2
1
34
43
216 (72)
300 (100)
...
...
Benign
10 (3)
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 06/21/2015
6 (2)
Table
4.—Variability of Specificity and Sensitivity
Based
Interpretation
on
of
Inadequate Samples*
Specificity No.
Source
Evans and Cade15 Gent et al8
%
Nondiagnostic
Sensitivity
M
B
50
27
71
100
100
100
M
80
100 98
187
17
74
95
94
98
98
Ciatto et al11 Bibbo et al12
218
17
76
97
97
85
77
84
114
13
78
92
91
100
93
100
Dowlatshahi et al16 Azavedo et al17
528
10
80
92
91
96
95
96
2573
2
97
98
98
80
74
79
300
2
96
98
97
100
95
100
study *Percentage specificity Present
cluded (E).
and
sensitivity computed
when
nondiagnostic samples
subsequent resection, and no lesion that was benign by aspiration has proved malignant. In 5% of cases, the as¬ pirates yielded atypical or nondiagnostic results, and in six instances the lesions proved to be malignant by oper¬ ative biopsy. Our results have confirmed four major observations previously made in a review of 100 aspirates performed at our medical center for palpable breast lesions13: (1) defin¬ itive benign and malignant results are reliable; (2) suspi¬ cious results are indicative of cancer; (3) atypical results may be indicative of benign or malignant processes; and (4) inadequate results must be followed by repeated aspi¬
excision. of specificity and sensitivity must con¬ sider inconsistencies in the statistical treatment of nondi¬ agnostic samples, especially when there are large num¬ bers of them.1416 In most reported studies, sufficient data were presented to allow us to compute specif¬ icity and sensitivity using different computational approaches.8,111215"17 These results are tabulated in Table 4. The computational artifacts and the distortion of spec¬ ificity and sensitivity are minimized when the incidence of inadequate samples is reduced, as in our study. In our experience, the immediate interpretation by the cytopathologist to determine the adequacy of the sample ob¬ tained by aspiration has been essential in reducing the number of inadequate samples. There have been two advantages of stereotaxic aspira¬ tion in our experience. First, stereotaxic aspiration expe¬ dites a malignant diagnosis and permits rapid treatment planning; second, a benign cytologie diagnosis has per¬ mitted greater security in radiologie follow-up. Had biop¬ sies not been performed on those 65 lesions that were cyration
or
Interpretation
tologically benign, the percentage of malignant neoplasms found by aspiration biopsy would have risen from 51% (76/149) to 90% (76/84), yet no cancer would have gone undetected. The impact of this technique, if reproducible by other centers, may be particularly signif¬ icant as the volume of clinically occult mammographically detected lesions increases through more widespread screening programs. This study was supported in part by the Landesberg-Zale Research Fund in Surgical Oncology, New York, NY.
References 1. Sickles EA. Mammographic features of 300 consecutive nonpalpable breast cancers. AJR Am J Roentgenol.
are
considered
malignant (M), benign (B),
or ex¬
1986;146:661-664.
2. Moskowitz M. Minimal breast cancer redux. Radiol Clin North Am. 1983;21:93-113. 3. Homer MJ. Nonpalpable breast abnormalities: a realistic view of the accuracy of mammography in detecting malignan-
cies. 4.
Radiology. 1984;153:831-832. Landercasper J, Gundersen SB,
Gundersen AL,
Cogbill
TH, Travelli R, Strutt P. Needle localization and biopsy of non-
palpable
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