Bobrow, L.

Britton, P. D.

McIntosh, S.

Purushotham, A. D.

Ravichandran, D.

Wishart, G. C.

Purpose: To compare the effectiveness of fine needle aspiration cytology (FNAC) with core biopsy (CB) in the pre-operative diagnosis of radial scar (RS) of the breast. Patients and methods: A retrospective analysis was made of all radial scars diagnosed on surgical histology over an 8-year period. Comparison was made between the results of different preoperative needle biopsy techniques and surgical histology findings. Results: Forty of 47 patients with a preoperative radiological diagnosis of radial scar were included in this analysis. Thirty-eight patients had impalpable lesions diagnosed on mammography and two presented with a palpable lump. FNAC (n=17) was inadequate in 47% of patients, missed two co-existing carcinomas found in this group, and gave a false positive or suspicious result for malignancy in 4 patients. CB (n=23) suggested a RS in 15 patients, but only diagnosed 4 out of 7 co-existing carcinomas found in this group. Conclusion: CB is more accurate than FNAC in the diagnosis of RS. However, these data demonstrate that CB may offer little to assist in the management of patients with RS. In summary, this paper advocates the use of CB in any lesion with a radiological suspicion of carcinoma and diagnostic excision of all lesions thought to be typical of RS on mammography

Queen's University Belfast Research Portal

The management of radial scars of the breast - does core biopsyhelp?Britton, P. D., Wishart, G. C., Ravichandran, D., McIntosh, S., Bobrow, L., & Purushotham, A. D. (2002). Themanagement of radial scars of the breast - does core biopsy help? Journal of Balkan Union of Oncology, 7(2),137-40.Published in:Journal of Balkan Union of OncologyDocument Version:Publisher's PDF, also known as Version of recordQueen's University Belfast - Research Portal:Link to publication record in Queen's University Belfast Research PortalPublisher rights© 2002 Zerbinis Medical Publications.General rightsCopyright for the publications made accessible via the Queen's University Belfast Research Portal is retained by the author(s) and / or othercopyright owners and it is a condition of accessing these publications that users recognise and abide by the legal requirements associatedwith these rights.Take down policyThe Research Portal is Queen's institutional repository that provides access to Queen's research output. Every effort has been made toensure that content in the Research Portal does not infringe any person's rights, or applicable UK laws. If you discover content in theResearch Portal that you believe breaches copyright or violates any law, please contact openaccess@qub.ac.uk.Download date:16. Feb. 2017Journal of BUON  7: 137-140, 2002© 2002 Zerbinis Medical Publications. Printed in GreeceORIGINAL  ARTICLEReceived  11-03-2002; Accepted  29-03-2002Author and address for correspondence:Dr. P.D. BrittonConsultant RadiologistCambridge Breast UnitBox 97Addenbrooke’s HospitalCambridge CB2 2QQUnited KingdomTel: +44 01 223 217627Fax:+44 01 223 217886E-mail:  peter.britton@addenbrookes.nhs.ukThe management of radial scars of the breast - does core biopsy help?P.D. Britton, G.C. Wishart, D. Ravichandran, S. McIntosh, L. Bobrow, A.D. PurushothamCambridge Breast Unit, Addenbrooke’s Hospital, Cambridge, United KingdomSummaryPurpose: To compare the effectiveness of fine needleaspiration cytology (FNAC) with core biopsy (CB) in thepre-operative diagnosis of radial scar (RS) of the breast.Patients and methods: A retrospective analysis wasmade of all radial scars diagnosed on surgical histologyover an 8-year period.  Comparison was made between theresults of different preoperative needle biopsy techniquesand surgical histology findings.Results:  Forty of 47 patients with a preoperative ra-diological diagnosis of radial scar were included in thisanalysis. Thirty-eight patients had impalpable lesions di-agnosed on mammography and two presented with a pal-pable lump. FNAC (n=17) was inadequate in 47% of pa-tients, missed two co-existing carcinomas found in this group,and gave a false positive or suspicious result for malignan-cy in 4 patients. CB (n=23) suggested a RS in 15 patients,but only diagnosed 4 out of 7 co-existing carcinomas foundin this group.Conclusion:   CB is more accurate than FNAC in thediagnosis of RS.  However, these data demonstrate that CBmay offer little to assist in the management of patients withRS.  In summary, this paper advocates the use of CB in anylesion with a radiological suspicion of carcinoma and di-agnostic excision of all lesions thought to be typical of RSon mammography.Key words: breast, breast neoplasms, diagnosis, radial scarIntroductionRadial scars or complex sclerosing lesions are be-nign lesions predominantly  detected by screening mam-mography. They are usually surgically excised becauseit is difficult to differentiate RS from small carcinomasradiologically. In addition, a proportion of RS are associ-ated with in situ or invasive carcinoma [1] and in thesepatients further surgery is often necessary to achievecomplete tumour clearance and, in invasive disease, tostage the axilla.In the last 10 years image-guided core biopsy (CB)has become an established part of breast diagnosis.Although FNAC is still undertaken extensively, there isincreasing reliance on CB [2].  Published data showadvantages of sensitivity and specificity of CB overFNAC [3].  CB also gives useful information regardingtumour grade, hormone receptor status, and whetherinvasive or in situ disease is present.  CB, however, isassociated with a small number of false negative andvery occasionally false positive results.Current management advocates surgical excisionof all suspected RS to confirm the diagnosis and to de-tect any associated premalignant or malignant change.This paper evaluates the value of needle biopsy, and inparticular CB, in the diagnosis of RS.Patients and methodsA retrospective review was performed on 47 casesof RS diagnosed in our institution between 1991 and1999.  This material includes 43 patients with mammo-138graphic abnormalities detected within the National HealthService Breast Screening Programme (NHSBSP) and4 patients seen in the symptomatic clinic, 2 with palpablelesions and 2 with incidental mammographic findings.Patients with incidental microscopic RS on histology fol-lowing routine excision biopsy for benign disease wereexcluded from this study.  The results of preoperativeassessment by FNAC or CB were recorded. CB tech-nique, including the method of image guidance, needlegauge and the number of passes were noted.  The needlebiopsy results were compared with the final histologyfollowing excision biopsy.  The contribution made by CBto patient management was evaluated.ResultsAmong the 47 patients reviewed (mean age of 54.5years), 45 had impalpable lesions and two patients pre-sented with a palpable lump. Five patients had no preop-erative FNAC or CB and 2 patients declined surgery,leaving 40 for further study. Seventeen of these patientshad FNAC and 23 patients had CB preoperatively.  Themammographic appearances of the 40 lesions are out-lined in Table 1.  The predominant feature was either aspiculated mass or parenchymal deformity in 31 (77.5%)of 40.  Four had mainly microcalcification and a masswas present in 3 patients.  In two patients who present-ed with a palpable mass, the mammogram was normalbut both lesions were visible on ultrasound (US).The final histology showed a benign RS with noatypia or malignancy in 28/40 (70%) patients. The fol-lowing pathological features were associated in the re-mainder: invasive ductal carcinoma (n=2, 5%), ductalcarcinoma in situ (DCIS) (n=4, 10%), lobular carcinomain situ (LCIS) (n=3, 7.5%) and atypical ductal hyper-plasia (ADH) (n=3, 7.5%). The results are summarisedin Table 2.In the FNAC group (n=17) 8 (47%) were inad-equate (C1, category), 4 were benign (C2, 23%), onewas suspicious probably benign (C3, 6%), 3 were suspi-cious probably malignant (C4, 18%) and one was malig-nant (C5, 6%). On final histology there was one inva-sive carcinoma in this group (FNAC - C1) and one DCIS(FNAC - C2). Among 4 patients in whom the FNACwas reported as C4 or C5, 3 had benign RS withoutatypia and one had associated ADH.In the CB group (n=23) 18 (78%) were reportedas benign with no atypia, one (4%) had ADH, one (4%)had LCIS and 3 (13%) had DCIS. Core biopsy sug-gested RS as the likely diagnosis in 15 out of 23 patients(65%). On final histology 13 of 18 (72%) benign coresproved to be RS without atypia or malignancy; the other5 patients had ADH (n=2, 11%), LCIS (n=1, 5.5%), DCIS(n=1, 5.5%) and invasive cancer (n=1, 5.5%). CB wasaccurate in 2 of 3 patients with DCIS. In one patient thecore suggested DCIS but the final diagnosis was LCIS.The method of biopsy for FNAC is displayed inTable 3a.  A more detailed analysis of the method of CBis shown in Table 3b. Nine (39%) of the lesions could beseen using US and this was the preferred method ofCB.  For lesions that could not be seen on US or whereUS was not performed, stereotactic – n  = 12 (52%) –Table 1. Dominant mammographic appearances of radial scars(n=40)Mammographic appearances Number of patients (%)Spiculated mass 16 (40)Parenchymal deformity 15 (37.5)Microcalcification 4 (10)Mass 3 (7.5)Normal* 2 (5.0)*both presented with breast lumps that were mammographicallyoccult but demonstrated on ultrasoundTable 2. Correlation between needle biopsy and surgical histology resultsFinal histology* FNAC (n=17) Core Biopsy (n=23)C1 C2 C3 C4 C5 Inadequate benign ADH LCIS DCIS ICBenign RS 7 3 1 2 1 – 13 1 – – –RS with ADH – – – 1 – – 2 – – – –RS with LCIS – – – – – – 1 – 1 1 –RS with DCIS – 1 – – – – 1 – – 2 –RS with IC 1 – – – – – 1 – – – –FNAC: fine needle aspiration cytology; RS: radial scar; ADH: atypical ductal hyperplasia; LCIS: lobular carcinoma insitu; DCIS: ductal carcinoma in situ; IC: invasive carcinoma*In the case of several pathological conditions being associated with the RS, only the worst prognosis lesion wasconsidered; e.g., a lesion containing both DCIS and LCIS is presented as DCIS139or alphanumeric plate – n = 2 (9%) – was used.  Themajority (89%) of US-guided biopsies were performedusing 16 gauge needles, with a mean of 2.6 passes perprocedure.  Larger gauge needles with more frequentpasses tended to be used for stereotactic-guided biop-sies.  In 75% of biopsies 14 gauge needles were used,with an overall average of 7.9 passes.  There was com-plete correlation between the CB results and the finalsurgical histology in 9 of 12 (75%) of stereotactic-guidedbiopsies and in 6 of 9 (67%) of US-guided biopsies.DiscussionThese results suggest that FNAC has limited valuein the preoperative assessment of RS in keeping withtwo previous studies [1,4]. The high inadequate rate (C1,47% in this study) confirms an earlier study [5], and ispartly due to the fibrous nature of the lesion [6].  Fur-thermore, FNAC often misses associated carcinoma [1,5]and both cancers in the FNAC group in this study (oneinvasive and one DCIS) scored C1 and C2, respectively.Of potentially greater clinical hazard is the single falsepositive FNAC (C5) with benign RS, which might haveresulted in inappropriate cancer surgery.  Such falsepositive FNAC results have previously been describedin patients with RS [1,6,7].This study clearly demonstrates that CB is supe-rior to FNAC in the diagnosis of RS.  We have thereforeevaluated the extent to which CB affects the manage-ment of patients with RS. In this series there were 2patients who had associated DCIS diagnosed preopera-tively.  These patients were able to undergo adequatewide local excision of their malignancy at a single op-eration rather than undergoing an initial diagnostic surgi-cal excision.  The disadvantages of performing CB in allpatients include the time, effort, expense and patient dis-comfort when attempting to biopsy lesions that are fre-quently challenging to image.   In addition there was onefalse positive CB diagnosis of DCIS in this series thatwas downgraded to LCIS on subsequent surgical exci-sion. There were 2 cases of associated malignancy wherethe CB diagnosed benign RS only.  Both these patientsrequired second operations for definitive cancer treat-ment.An alternative strategy is to consider surgical ex-cision of all RS diagnosed on imaging without a preop-erative needle biopsy.   In our series potentially 23 un-necessary needle biopsies with their attendant discom-fort and expense would have been avoided.  One falsepositive patient diagnosed as having DCIS on needle bi-opsy would have undergone excision biopsy rather thanwide excision. False positive results with CB are exceed-ingly uncommon.  There has been one additional falsepositive case reported under similar circumstances wherea CB diagnosis of tubular carcinoma was found to bedue to benign RS following surgery [8].  Four patients inour series would have required additional therapeuticsurgery (3 DCIS, 1 invasive carcinoma). Two of theseadditional operations would have been avoided by thepreoperative core biopsies diagnosing their associatedDCIS.Therefore, in this series of 23 patients undergoingcore biopsy, if all presumed RS underwent surgical exci-sion without previous biopsy, a total of 27 operationswould be necessary, 4 patients with malignancy havingto undergo subsequent cancer surgery.  This is compa-rable to 25 operations required for all patients if eachhad preoperative core biopsies as is the case in our insti-tution.  These 2 additional operations need to be offsetagainst the expense and time to perform the 23 corebiopsies and the potentially unnecessary surgery that thepatient with an erroneous DCIS diagnosis may haveundergone.Although CB substantially outperforms FNAC indiagnosing RS, it actually contributes little in changingthe management of patients with this condition. The mainproblem relates to distinguishing RS from carcinoma onradiological grounds only.  If carcinoma is thought to bea distinct possibility following mammography, then corebiopsy should be performed, as this will reduce unnec-essary second operations.  As a result, CB will be per-formed in a proportion of patients with RS.Table 3. Methods of biopsy3a.  FNAC (n=17)Method of biopsy n (%)Ultrasound 8 (47.1)Alphanumeric plate 5 (29.5)Stereotactic 3 (17.6)Palpation 1 (5.8)3b.  Core biopsy (n=23)Method of n (%) Gauge Number Completebiopsy of passes histologicalcorrelation*n (%)14G 16G 18G Mean (range)Stereotactic 12 (52) 9 1 2 7.9 (6-10) 9 (75)Ultrasound 9 (39) 1 8 0 2.6 (1-5) 6 (67)Alphanumeric 2  (9) 2 - - 5.0 (4-6) 1 (50)plate*complete correlation between the core biopsy and final histologyresults140Is there any way therefore to maximize the infor-mation obtained from the needle biopsy?  In our seriesthere was a trend to more accurate needle biopsy/surgi-cal histology correlation when a greater volume of tis-sue (larger gauge needles and more passes) was re-moved.  This would concur with the findings of a previ-ous study that demonstrates a closer correlation betweenneedle biopsy and subsequent surgical specimens whenvacuum-assisted biopsies (VAB) are used [9].  This isfurther illustrated by reduced upgrading following a VABdiagnosis of benign conditions, such as atypical ductalhyperplasia, to DCIS when compared with CB [9-11].If all suspected RS underwent VAB, with a presumedincrease in the diagnosis of associated malignancy, thenumber of additional operations may be reduced.  Thiswould, however, have to be offset against the consider-able additional expense of VAB over CB.In summary, we would advocate the use of CB inany lesion with a radiological suspicion of carcinoma.Our data show that CB may offer little to alter the man-agement of patients with RS. It is unreliable at detectingassociated malignancy and so will reduce some, but notall, of the need for additional cancer surgery.  If RS issuspected then the greater the volume of tissue removedthe more reliably should associated malignancy be de-tected.At present therefore we would advocate diagnos-tic excision of all lesions thought to be typical of RS onmammography.  If mammography is suspicious of ma-lignancy CB should be performed.  This strategy maybe more cost-effective whilst we await the accrual ofmore data on the efficacy of VAB in the diagnosis ofRS.References1. Mokbel K, Price RK, Mostafa A et al.  Radial scar and carci-noma of the breast: microscopic findings in 32 cases.  TheBreast 1999; 8: 339-342.2. Britton PD, Flower CDR, Freeman AH et al. Changing to corebiopsy in an NHS breast screening unit. Clin Radiol 1997; 52:764-776.3. Britton PD.  Fine needle aspiration or core biopsy.  The Breast1999; 8: 1-4.4. Greenberg ML, Camaris C, Psarianos T, Ung OA, Lee WB. Isthere a role for fine-needle aspiration in radial scar/complexsclerosing lesions of the breast? Diagn Cytopathol 1997; 16:537-542.5. Douglas-Jones AG, Pace DP. Pathology of R4 spiculated le-sions in the breast screening programme. Histopathology 1997;30: 214-220.6. de la Torre M, Lindholm K, Lindgren A. Fine needle aspira-tion cytology of tubular carcinoma and radial scar. Acta Cytol1994; 38: 884-8907. Lamb J, McGoogan E. Fine needle aspiration cytology ofbreast in invasive carcinoma of tubular type and in radial scar/complex sclerosing lesions. Cytopathology 1994; 5: 17-26.8. Britton PD, McCann J.  Needle biopsy in the NHS BreastScreening Programme 1996/97: how much and how accurate?The Breast 1999; 8: 5-11.9. Darling ML, Smith DN, Lester SC et al.  Atypical ductalhyperplasia and ductal carcinoma in situ as revealed by large-core needle breast biopsy: results of surgical excision. Am JRoentgenol 2000; 175: 1341-1346.10. Burbank F. Stereotactic breast biopsy of atypical ductal hy-perplasia and ductal carcinoma in situ lesions: improved accu-racy with directional, vacuum-assisted biopsy.  Radiology,1997; 202: 843-847.11. Jackman RJ, Burbank F, Parker SH et al. Atypical ductalhyperplasia diagnosed at stereotactic breast biopsy: improvedreliability with 14-gauge, directional, vacuum-assisted biopsy.Radiology 1997; 204: 485-488.

The management of radial scars of the breast - does core biopsy help?

Abstract

Similar works

Full text

Available Versions

Queen's University Belfast Research Portal