Ann O’Doherty

The accuracy of ultrasound, stereotactic, and clinical core biopsies in the diagnosis of breast cancer, with an analysis of false-negative cases.

Objective:Preoperative core biopsy in breast cancer is becoming the standard of care. The aim of this study was to analyze the various methods of core biopsy with respect to diagnostic accuracy and to examine the management and outcome of those patients with false-negative biopsies. Methods:All patients undergoing core biopsy for breast abnormalities over a 5-year period (1999–2003) were reviewed. The accuracy rates for each method of core biopsy, the histologic agreement between the core pathology and subsequent excision pathology, and the length of follow-up for cases of benign disease were studied. Patients whose biopsies were benign but who were subsequently diagnosed with cancer underwent detailed review. Results:There were 2427 core biopsies performed over the 5-year period, resulting in a final diagnosis of cancer in 1384 patients, benign disease in 954 patients, and atypical disease in 89 patients. Biopsy type consisted of 1279 ultrasound-guided cores, 739 clinically guided cores, and 409 stereotactic-guided cores. The overall false-negative rate was 6.1%, with specific rates for ultrasound-, clinical-, and stereotactic-guided cores of 1.7%, 13%, and 8.9%, respectively. False-negative biopsies occurred in 85 patients, and in 8 of these patients the diagnosis was delayed by greater than 2 months. In all other false-negative cases, “triple assessment” review allowed prompt recognition of discordant biopsy results and further evaluation. Conclusion:Ultrasound guidance should be used to perform core biopsies in evaluating all breast abnormalities visible on ultrasound. Adherence to principles of triple assessment following biopsy allows for early recognition of the majority of false-negative cases.

The significance of immunohistochemistry positivity in sentinel nodes which are negative on haematoxylin and eosin in breast cancer

INTRODUCTION Sentinel lymph node (SLN) biopsy allows a more detailed examination of a smaller number of lymph nodes in patients with clinically node negative breast cancer. Immunohistochemistry detects small tumour burden not routinely seen on haematoxylin and eosin (H&E). The significance of such findings remains to be fully elucidated. AIM To assess the axillary disease burden of patients in whom the sentinel lymph node biopsy was positive on immunohistochemistry and negative on H and E. METHODS An analysis of patients who underwent SLN mapping for breast cancer at St Vincents University Hospital from January 1st, 2000 to December 31st, 2006 was conducted. All SLNs were assessed by serial H&E and IHC sections. Patients with micrometastases (0.2-2mm) underwent a completion axillary lymph node dissections (CLND). Patients with ITC (<0.2mm) were individually discussed and a CLND was performed selectively based on additional clinicopathological criteria and patient preference. Analysis of the additional nodes from CLND was performed. Patients were followed for a median of 27 months (range 12-72 months). RESULTS 1076 patients who underwent SLN were included for analysis. 211 (20%) had a positive SLN biopsy using H&E. Forty-nine patients (5%) had a negative SLN on H&E which was positive on IHC. Of these, 15 had micrometastases and underwent a CLND. Two had further axillary nodal disease. ITC were found in the remaining 34 patients. Sixteen of these patients underwent a CLND. Five of this group had further nodal disease. CONCLUSION Micrometastases and isolated tumour cells, detected only by immunohistochemical analysis of sentinel lymph nodes, are associated with further positive nodes in the axilla in up to 15% of patients. This upstaging of disease may impact upon patient outcome.

With the Advent of Tomosynthesis in the Workup of Mammographic Abnormality, is Spot Compression Mammography Now Obsolete? An Initial Clinical Experience

To determine if the routine use of spot compression mammography is now obsolete in the assessment of screen detected masses, asymmetries and architectural distortion since the availability of digital breast tomosynthesis. We introduced breast tomosynthesis in the workup of screen detected abnormalities in our screening center in January 2015. During an initial learning period with tomosynthesis standard spot compression views were also performed. Three consultant breast radiologists retrospectively reviewed all screening mammograms recalled for assessment over the first 6‐month period. We assessed retrospectively whether there was any additional diagnostic information obtained from spot compression views not already apparent on tomography. All cases were also reviewed for any additional lesions detected by tomosynthesis, not detected on routine 2‐view screening mammography. 548 women screened with standard 2‐view digital screening mammography were recalled for assessment in the selected period and a total of 565 lesions were assessed. 341 lesions were assessed by both tomosynthesis and routine spot compression mammography. The spot compression view was considered more helpful than tomosynthesis in only one patient. This was because the breast was inadequately positioned for tomosynthesis and the area in question was not adequately imaged. Apart from this technical error there was no asymmetry, distortion or mass where spot compression provided more diagnostic information than tomosynthesis alone. We detected three additional cancers on tomosynthesis, not detected by routine screening mammography. From our initial experience with tomosynthesis we conclude that spot compression mammography is now obsolete in the assessment of screen detected masses, asymmetries and distortions where tomosynthesis is available.

Isolated calcification on needle core breast biopsy: A potential pitfall for under diagnosis of ductal carcinoma in situ of the breast

To the Editor: Mammographically detected breast calcifications are a common indication for further assessment of breast tissue and biopsy. The role of the histopathologist in such cases is to identify and categorize the corresponding calcification histologically. Isolated deposits of calcification detected on NCB with no associated epithelial lining may represent “burnt out” ductal carcinoma in situ (DCIS) and are a potential pitfall for under diagnosis. In our institution, we encountered two cases which highlight this entity and discuss features that should prompt suspicion for its presence. A 57-year-old woman had 23 mm of calcifications in the left breast on routine screening mammography. A biopsy was performed. This demonstrated glandular breast tissue containing multiple discrete, circumscribed deposits of coarse calcium phosphate (Figure 1). There was no associated epithelial lining in any of multiple levels examined. No features to account for the presence of calcification were identified. The histologic findings were considered to be nondiagnostic and further investigation was advised. An excisional biopsy was performed that showed multiple foci of high-grade DCIS, some with associated calcification (Figure 2). There was prominent periductal inflammation and fibrosis and the adjacent breast tissue contained foci of coarse calcification surrounded by concentric hyalinized stroma as seen on the initial biopsy. DCIS extended over 16 mm. The patient proceeded to wide local excision that contained further foci of high-grade DCIS. A 62-year-old woman had calcifications extending across 45 mm in the right breast, detected on mammography. A biopsy showed small deposits of calcium phosphate and no associated epithelial cell lining or features to account for calcification. Repeat needle core biopsy was performed. This revealed large deposits of calcium phosphate bordered by a rim of hyalinized breast tissue with focal chronic inflammation and vascular proliferation. The appearances were considered to be nondiagnostic and excision was recommended. The excision specimen showed coarse deposits of calcium phosphate bordered by hyalinized connective tissue similar to that seen in the biopsy specimen. Calcification was also identified in association with high-grade DCIS with periductal inflammation and fibrosis. There was an accompanying 4 mm focus of invasive ductal carcinoma. Although the natural history of DCIS is uncertain due to surgical intervention and the administration of adjuvant radiotherapy, the standardized incidence ratio for the development of subsequent invasive breast carcinoma after primary DCIS is estimated to be 4.5 (95% CI: 3.7-5.5). The early detection and treatment of DCIS remains a primary aim and marker of efficacy of population-based breast screening. DCIS accounts for approximately 20% of screen-

Removal of Multiple Sentinel Lymph Nodes in Patients With Breast Cancer: Defining the “Correct” Node

Abstract Purpose: Sentinel node biopsy is routinely used for axillary staging in patients with clinical and radiological node negative breast cancer. The number of nodes removed at surgery is highly variable. A mean of 2.4 nodes is frequently seen in the larger series. Removal of multiple (3 or more) nodes does not improve the accuracy but increases both operative time and pathological analysis. The aim of the current study was to define the correct sentinel node based on uptake of blue dye and radioactive counts. Methods: The sentinel node was identified in 121 consecutive patients using isosulfan blue dye and radioisotope. Nodes were labelled sequentially as (i) Hot (ii) Blue or (iii) Hot and Blue and submitted for pathological analysis. Data pertaining to blue dye uptake and radioisotope counts were recorded prospectively. This was correlated with pathological and scintigraphy findings. Results: Thirty eight (32%) patients had a positive sentinel node. “Hot and Blue” nodes were found in 105 cases. The number of hot and blue nodes correlated exactly with the number seen on scintigraphy. “Blue” nodes were found in one case. “Hot” nodes were found in 15 cases. In cases where a “hot and blue” node was positive there were no further “hot” or “blue” nodes found to be positive. Conclusion: Removal of multiple sentinel nodes can be avoided by removing all hot and blue nodes and correlating with findings on lymphoscintigraphy. When present (87% of cases), the “hot and blue” node accurately predicts the pathological burden of the axilla.

Is there an optimal route for injecting radioisotope for sentinel lymph node biopsy injection in patients with breast cancer

ConclusionID injection of radioisotope was associated with a 95% rate of identification of the SLN on lymphoscintigraphy and a 100% identification rate at surgery. We recommend the intradermal route for injecting radioisotope for sentinel lymph node biopsy.

The role of intraoperative pathology margin assessment in breast conserving surgery

ConclusionMeticulous assessment of margin status is associated with a high re-excision rate. Intraoperative assessment is valuable in reducing the number of second operative procedures.