Ann O'Doherty

Radial scars/complex sclerosing lesions and malignancy in a screening programme : incidence and histological features revisited

Aims:  Radial scars (RS) are benign entities, frequently identified on screening mammography, which may be associated with malignancy. Much debate has been generated with regard to the optimum management of RS. We present our experience of RS in the first 5 years of a screening programme. The aim was to evaluate (i) the incidence of atypia and malignancy and (ii) the value of the preoperative core biopsy. We also further characterize the histological features.

Correlation of needle core biopsy with excision histology in screen-detected B3 lesions: the Merrion Breast Screening Unit experience

Aims: Needle core biopsy (NCB) is a widely-used technique for non-operative evaluation of screen-detected breast lesions. Although most NCBs are B2 (benign) or B5 (malignant), some fall into the B3 category of “uncertain malignant potential”. This study aims to categorise the lesions prompting a B3 NCB in the Merrion Breast Screening Unit, and establish the incidence of malignancy on subsequent excision biopsy. Methods: Patients attending the Merrion Breast Screening Unit in Dublin between 2000 and 2008 who had a B3 NCB were identified. The NCB pathology reports were reviewed and the diagnosis correlated with excision histology; the latter was classified as benign, atypical or malignant. Lesion-specific positive predictive values (PPVs) for malignancy were derived. Results: 141 patients with a B3 NCB were identified. The most frequent lesions on NCB were radial scar (RS; n = 57), atypical intraductal epithelial proliferation (AIDEP; n = 25) and papillary lesion (n = 24). The final diagnosis was malignant in 22 patients (16%), atypical in 40 (28%) and benign in 79 (56%). Two of the patients with a malignant diagnosis had invasive carcinoma. The lesion-specific PPVs were: lobular neoplasia 50%, AIDEP 32%, columnar cell lesion with atypia 12.5%, RS 12.3%, papillary lesion 8.3%, suspected phyllodes tumour 7.7%, and spindle cell lesion 0%. Atypia on RS NCB predicted an atypical or malignant excision diagnosis, but atypia on papillary lesion NCB did not. Conclusions: One-sixth of B3 NCBs in this series proved to be malignant on excision. The PPV for malignancy varied according to lesion type.

Sentinel lymph node biopsy in patients with a needle core biopsy diagnosis of ductal carcinoma in situ: is it justified?

Background: The incidence of ductal carcinoma in situ (DCIS) has increased markedly with the introduction of population-based mammographic screening. DCIS is usually diagnosed non-operatively. Although sentinel lymph node biopsy (SNB) has become the standard of care for patients with invasive breast carcinoma, its use in patients with DCIS is controversial. Aim: To examine the justification for offering SNB at the time of primary surgery to patients with a needle core biopsy (NCB) diagnosis of DCIS. Methods: A retrospective analysis was performed of 145 patients with an NCB diagnosis of DCIS who had SNB performed at the time of primary surgery. The study focused on rates of SNB positivity and underestimation of invasive carcinoma by NCB, and sought to identify factors that might predict the presence of invasive carcinoma in the excision specimen. Results: 7/145 patients (4.8%) had a positive sentinel lymph node, four macrometastases and three micrometastases. 6/7 patients had invasive carcinoma in the final excision specimen. 55/145 patients (37.9%) with an NCB diagnosis of DCIS had invasive carcinoma in the excision specimen. The median invasive tumour size was 6 mm. A radiological mass and areas of invasion <1 mm, amounting to “at least microinvasion” on NCB were predictive of invasive carcinoma in the excision specimen. Conclusions: SNB positivity in pure DCIS is rare. In view of the high rate of underestimation of invasive carcinoma in patients with an NCB diagnosis of DCIS in this study, SNB appears justified in this group of patients.

Needle core biopsy characteristics identify patients at risk of compromised margins in breast conservation surgery.

Selection of patients for breast-conserving surgery relies on inexact parameters such as the preoperative estimation of lesion size. This study investigates the value of needle core biopsy findings, in particular, the relative quantity of DCIS, in improving patient selection for breast conservation. Patients undergoing breast-conserving surgery for invasive ductal carcinoma from 1999 to 2004 were identified. Only patients who had a preoperative diagnosis of carcinoma (DCIS and invasive) on core biopsy were included. All core biopsies were reviewed by a breast histopathologist to document the quantity and characteristics of the DCIS component. Of a total of 281 patients, 46% (n=129) had invasive disease on core biopsy (group 1) and 54% (n=152) had either invasive disease with an accompanying DCIS component or DCIS only on core biopsy (group 2). The compromised margin rate for group 1 was 23% compared to 39% for group 2 (P=0.004). The rate of compromised margins increased progressively as the core biopsy DCIS component increased until a rate of 75% (n=18/24) was reached in patients with DCIS only on core biopsy. In patients with a DCIS component on core biopsy, the presence of necrosis (P=0.002), solid type architecture (P=0.008), high grade DCIS (P=0.007), calcification (P=0.003), and the relative proportion of DCIS present (P<0.001) were associated with compromised margins on univariate analysis. On multivariate analysis of this subgroup, the proportion of DCIS in this subgroup (P=0.048) was an independent predictor of compromised margins. The presence and relative proportion of DCIS on core biopsy provides important information as to whether patients are at risk of compromised margins. Documentation of these parameters may assist patient selection for breast-conserving surgery or identify patients who may benefit from wider margins at the time of initial operation.

Axillary nodal burden in primary breast cancer patients with positive pre-operative ultrasound guided fine needle aspiration cytology: management in the era of ACOSOG Z011.

INTRODUCTION Recent years have seen a dramatic shift to more conservative management of the axilla in patients with a positive sentinel lymph node biopsy (SLNB). Identification of nodal disease with positive pre-operative ultrasound guided axillary fine needle aspiration cytology (AUS/FNAC) may represent a higher axillary disease burden mandating an axillary clearance and thus an upfront SLNB may be avoided. The aims of this study were to quantify nodal burden in patients with positive pre-operative AUS/FNAC and identify patients who may have been able to avoid an axillary clearance (ALND) based on ACOSOG Z011 criteria. METHODS A retrospective review of a prospectively maintained database identified patients with positive pre-operative AUS/FNAC between 2007 and 2012. Core biopsies were excluded. Demographic and tumour characteristics were analysed. Eligibility for ACOSOG Z011 criteria was assessed and patients who may have avoided ALND were identified. RESULTS 432 patients were identified with positive AUS/FNAC. 85 patients were excluded leaving 347 for analysis. Median age was 56 years (22-87), median tumour size was 25 mm (1.5 mm-150 mm) and median tumour pathology was grade 3 (50%) and invasive ductal carcinoma (82%). Median number of nodes removed at ALND was 23 (1-55) with a median number of positive nodes being 4 (1-47). 134 (39%) patients had ≤2 positive nodes identified on ALND making them eligible for the ACOSOG Z011 study. When other ACOSOG Z011 exclusion factors were applied only 27 (7.8%) patients may have avoided ALND. CONCLUSIONS Nodal positivity on AUS/FNAC is associated with higher axillary disease burden. Few patients would satisfy ACOSOG/Z011 criteria and avoid ALND making an upfront SLNB unnecessary.

Epithelial displacement during breast needle core biopsy causes diagnostic difficulties in subsequent surgical excision specimens

Background: The use of needle core biopsy (NCB) as part of triple assessment for non-operative evaluation and diagnosis of breast lesions is now routine practice. Trauma to breast tissue during NCB may result in displacement of breast epithelium and may lead to diagnostic difficulty in subsequent excision specimens. Methods: The cases of seven mammographically detected breast lesions in which epithelial displacement due to NCB was identified and caused problems in confirmation of tumour size, assessment of surgical margins, and interpretation of possible invasive carcinoma and lymphovascular invasion are reported here. Conclusion: Previous observations that epithelial displacement is more likely to occur when the interval between NCB and surgical excision is short are supported.

Diagnostic accuracy of core biopsy for ductal carcinoma in situ and its implications for surgical practice

Background: Core biopsy is considered to be a highly accurate method of gaining a preoperative histological diagnosis of breast cancer. Ductal carcinoma in situ (DCIS) is often impalpable and is a more subtle form of breast cancer. Aim: To investigate the accuracy of core biopsy in the diagnosis of cancer in patients with DCIS. Methods: All patients who had invasive cancer (n = 959) or DCIS (n = 92) that was confirmed by excision between 1999 and 2004 were identified. The diagnostic methods, histology of the core biopsy specimen and excision histology were reviewed in detail. Results: Core biopsy was attempted in 88% (81/92) of patients with DCIS and in 91% (874/959) of those with invasive disease. Of those patients who underwent core biopsy, a diagnosis of carcinoma on the initial core was made in 65% (53/81) of patients with DCIS compared with 92% (800/874) of patients with invasive disease (p<0.0001). Smaller lesion size (p = 0.005) and lower grade (p = 0.03) were associated with increased risk for a negative or non-diagnostic core in patients with DCIS. The nature of the mammographic lesion or the method of biopsy did not affect the probability of an accurate core biopsy. Patients who had a preoperative diagnosis of DCIS by core biopsy had a reoperation rate of 36% compared with 65% of those that did not have a preoperative diagnosis (p = 0.007). Conclusion: Although core biopsies are highly accurate forms of obtaining a preoperative diagnosis in patients with invasive breast cancer, this is not the case in DCIS. As the number of surgical procedures can be reduced by core biopsy, it is still of considerable value in the management of DCIS.

Surgical intervention in screen-detected patients versus symptomatic patients with breast cancer

Objectives: The impact of population-based screening for breast cancer on the rate of breast-conserving surgery has not been established. We sought to evaluate whether surgical intervention in patients with screen-detected breast cancer differed from those with clinically detected tumours. Settings: St Vincents University Hospital and the BreastCheck Merrion Unit, part of the Irish National Breast Screening Programme, were the setting for the study. Methods: A total of 902 patients referred for surgery to St Vincents University Hospital over a four-year period (2000–2003) were studied. Patients with breast cancers detected during the prevalent round of screening (n=325) were compared with patients presenting with symptomatic disease (n=577). The operative procedure, nature of axillary surgery and histopathological findings were recorded in each case. Results: There was an increase in breast-conserving therapy in the screened population compared with symptomatic cases (68% screened versus 53% symptomatic; p<0.0001), with a corresponding reduction in axillary clearance rates (65% screened versus 81% symptomatic; p<0.0001). Nodal positivity was similar following correction for size in all tumours >1 cm, regardless of method of detection. Sentinel node biopsy was successfully undertaken in 39% of tumours <2 cm (T1 tumours) in the screening population. Conclusions: The screened population was statistically more likely to have breast-conserving therapy than the symptomatic group. Sentinel node biopsy has evolved into an acceptable alternative to axillary clearance in T1 cancers, particularly in screen-detected cases.

Magnetic resonance imaging appearances in primary and secondary angiosarcoma of the breast

Angiosarcomas are malignant tumours of endovascular origin. They are rare tumours accounting for 0.04-1% of all breast malignancies. Two different forms are described: primary, occurring in young women, and secondary angiosarcoma, which occurs in older women with a history of breast-conserving surgery and radiation therapy. Imaging findings on mammography and ultrasound are non-specific, but magnetic resonance imaging with dynamic contrast enhancement is more informative. We present two cases - one of primary and one of secondary angiosarcoma - and review the imaging findings.

Fourteen‐gauge needle core biopsy of mammographically evident radial scars

We read with interest the article by Cawson et al. regarding the use of image-guided 14-gauge needle core biopsy (14G NCB) in the evaluation of mammographically detected radial scars. We would like to report our experience with this technique in the nonoperative assessment of 30 screen-detected radial scars (RSs). Between November 2000 and April 2003, 40,944 women were screened at the Merrion Unit and 1474 women with possible abnormalities were recalled to a dedicated multidisciplinary assessment clinic. All patients provided consent for the exchange of data prior to screening. The cancer detection rate for the period was 7.1/1000. RSs were diagnosed histologically in 30 women (0.73/1000) after imageguided 14G NCB using ultrasound (21 patients) or stereotaxis (9 patients). The radiologic abnormality was architectural distortion in 23 patients, spiculate lesion in 6 patients, and a calcified nodule in one patient. The average number of biopsies submitted for examination was four (range, three to nine biopsies). All 30 NCB specimens demonstrated histologic features typical of RS. In 16 patients no additional abnormality was evident on NCB. Six patients had accompanying ductal carcinoma in situ (DCIS), one patient had invasive carcinoma (IC), six patients had atypical ductal hyperplasia (ADH), and one patient had lobular neoplasia (LN). Twenty-nine patients proceeded to undergo surgical excision, with 1 patient having declined surgery. Histology of the final excision specimens revealed malignancy in 10 patients, DCIS in 8 patients, IC in 2 patients, ADH in 3 patients, LN in 2 patients, and RS only in 15 patients. We agree with Cawson et al. that NCB has good predictive value in the identification of RS-associated malignancy. In our series of 29 excised RS lesions, 10 patients were found to have an associated malignancy on final histology, 8 of whom were found to have either malignancy (7 patients) or ADH (1 patient) on NCB. However, the finding of DCIS in the excision specimens from two patients without atypical features on NCB suggests that this technique carries a small but significant sampling error rate, leading to underestimation of malignancy. At the present time it is our view that 14G NCB does not have sufficient sensitivity to exclude RS-associated malignancies. In our experience, we observed a 34% incidence of RS-associated malignancy, in contrast to the 7% reported by Cawson et al. This discrepancy is reflected in the literature, with reported incidences of RS-associated malignancy ranging from 0 – 43%. As highlighted by Cawson et al., these differences may be explained in part by interobserver variation in the diagnosis of ADH versus DCIS. In this regard, Cawson et al. observed a 57% incidence of RS-associated ADH on final histology compared with 11% in our series. Although the qualitative 652