William H. Hindle

Clinical value of mammography for symptomatic women 35 years of age and younger

OBJECTIVE This retrospective observational study was designed to answer the following question: Is mammography clinically effective in the evaluation of women </=35 years old with breast symptoms or findings. STUDY DESIGN A retrospective review was undertaken of 1908 consecutive initial mammogram reports of symptomatic women </=35 years old who came to a referral breast clinic. The clinic records were analyzed for the working diagnoses and management plans before and after the input of the initial mammogram reports. RESULTS Of the 4160 initial mammograms of women who came (1992-1995) to the Breast Diagnostic Center at Womens and Children Hospital, Los Angeles, Calif, 1908 were of women </=35 years old. The mammogram reports were reviewed and tabulated by age group for mammography recommendations. The working diagnoses and management plans in the centers charts were retrospectively evaluated before and after the mammogram reports to ascertain whether the mammogram reports altered clinical management in this patient population and age group. No clinically unsuspected cancers were perceived by mammography performed at the center in women </=35 years old. (All of the 23 invasive cancers were palpable and had prior diagnoses after fine-needle aspiration biopsy.) The initial mammogram reports did not change the working diagnosis or clinical management of these cases in this patient population and clinic setting. Ultrasonography was recommended by the radiologists in 37% of the study cases. CONCLUSIONS Routine initial mammography was not cost-effective or clinically beneficial in the evaluation of breast symptoms or findings and management of the cases of women </=35 years old who came to our center.

The use of fine-needle aspiration in the evaluation of persistent palpable dominant breast masses.

OBJECTIVE Our purpose was to determine if fine-needle aspiration can decrease the necessity for open surgical biopsy in the diagnosis of a persistent palpable dominant breast mass. STUDY DESIGN In a university obstetrics-gynecology resident physician training program, persistent palpable dominant breast masses seen in the Breast Diagnostic Center at Womens Hospital, Los Angeles County-University of Southern California Medical Center, were evaluated by fine-needle aspiration. When a cytologic diagnosis was obtained, the patients were treated, followed, or referred for treatment. Open surgical biopsy was reserved for those lesions that were not cytologically diagnosed or for which there was no concordance of the diagnostic triad of palpation, fine-needle aspiration, and mammography. RESULTS Resident physicians rotating through the Breast Diagnostic Center performed 568 fine-needle aspirations under staff supervision. The technique was readily learned by most of the resident physicians with equipment already available in most outpatient settings. Fine-needle aspiration was performed on the initial clinic visit, and the preliminary cytologic diagnosis was given to the patient on the same day. Forty-two cancers were cytologically diagnosed (7% of the fine-needle aspirations). Seventy-five (13%) other patients were referred for open surgical biopsy as the definitive diagnostic procedure. Twenty-four (4%) patients elected open surgical excision biopsy of fine-needle aspiration-diagnosed masses. CONCLUSION Fine-needle aspiration of persistent palpable dominant breast masses allows expeditious and potentially cost-effective management of most cases and decreases the necessity of open surgical biopsy for definitive diagnosis.

Conservative management of breast fibroadenomas

Is it conservative or radical management to excise all fibroadenomas of the breast, especially in women less than 30 years old? Once a definite diagnosis is established by physical examination, fine-needle aspiration cytologic testing, and mammography, is it prudent to monitor women with small fibroadenomas (less than 4 cm in diameter)? We reviewed 498 cases of biopsy-proved fibroadenomas and 17 cases of phyllodes tumors (by biopsy) seen at Los Angeles County/University of Southern California Medical Center from 1986 to 1989. Analysis of patient age and measured tumor size in 203 fibroadenomas and 10 phyllodes tumor specimens revealed similar ranges for both tumors. The mean values were 28.5 years and 2.3 cm for fibroadenomas and 44 years and 3.8 cm for phyllodes tumors. No cases of coincident carcinoma within a fibroadenoma or of metastatic malignant phyllodes tumors were present in this review. As an alternative to excising all breast tumors, cytologically diagnosed fibroadenomas can be monitored, because they have no intrinsic premalignant potential and tend to regress with time. All breast tumors that rapidly increase in size should probably be excised at any age.

Breast aspiration cytology: A neglected gynecologic procedure

Presented is a retrospective review of 1,196 breast aspiration cytologic procedures done during 1973 through 1981, at the Straub Clinic and Hospital, Inc., Honolulu, Hawaii. Aspirations which yielded clear fluid are not included. Of all the patients who had breast aspirations, 204 subsequently underwent open biopsy, and a definitive histologic diagnosis was made. Of the 204 open biopsies, 23% proved the existence of malignancy. Thus, 4% of the 1,196 breast aspirations proved the presence of carcinoma. Office aspiration cytologic examination of breast lesions is an efficient and cost-effective technique which is available to every gynecologist, and for which there are no medical contraindications. Complications are rare and usually not significant. If clear fluid is obtained, a clinical diagnosis of benign cystic disease can be made with a high degree of reliability. If the findings of breast aspiration cytologic examination are reported to be suspicious or to disclose malignancy, the patient should be referred as soon as possible for a definitive open biopsy and appropriate surgical treatment.

Fine needle aspiration (FNA) biopsy of palpable breast masses

One of the limitations preventing the widespread use of fine‐needle aspiration (FNA) is that it requires skill to obtain an adequate sample and well prepared smears. In this study, a new monolayer technique, the Cyto‐Tek MonoPrep (MP) system, which obviates the need for smear preparation, was evaluated against conventional smear (CS) preparation for palpable breast lesions.

Breast mass evaluation.

A breast lump is the most common presenting symptom/complaint in most breast clinics and centers. In the Breast Diagnostic Center (Women’s and Children’s Hospital, LAC+USC Medical Center, Los Angeles, CA), statistical review of 2,458 consecutive patients seen in 1999 revealed that 51% of the patients presented with a palpable breast mass. The other presenting complaints were pain 24%, abnormal mammogram 7%, follow-up 7%, pain and mass 6%, nipple discharge 4%, and other 2% (the sum is >100% due to rounding). Thus, 57% of patients actually presented with a possible mass (total number with mass and pain plus mass). It is of interest that clinical breast examination revealed a palpable dominant breast mass in about half of the possible breast mass cases. These percentages are essentially the same as a previous review covering 1995 to 1997. A persistent dominant palpable breast mass must be definitively diagnosed. This can be achieved with cytology of an adequate cellular sample obtained by fineneedle aspiration (FNA) or with histology obtained by tissue core-needle biopsy or open surgical biopsy. If technically feasible and with expectation of a satisfactory cosmetic result, the open surgical biopsy should be the equivalent of a lumpectomy, with excision of the entire intact mass and with clear surgical margins. All of these techniques can be performed in an ambulatory setting. FNA can be done in the office, tissue coreneedle in the office or radiology suite, and surgery in an outpatient facility. No anesthesia is required for an FNA, and usually only minimal local anesthesia is needed for a tissue core-needle biopsy. Sedation and generous local anesthesia is most commonly used for open surgical biopsy. The residual for FNA is a needle puncture site (the same as for a venipuncture), usually a 0.5-cm scar for tissue core-needle biopsy, and about a 2-cm scar for open surgical biopsy. A logical sequence of procedures to follow would seem to be FNA first, then tissue core-needle biopsy, and then open surgical biopsy, the progression proceeding step by step until a definitive diagnosis is obtained. A palpable dominant breast mass is a three-dimensional distinct mass with borders that are separate from, and texture that is different from, the surrounding breast tissue. If such a mass persists, it is imperative to obtain a definitive diagnosis in a timely manner (eg, within 2–4 weeks). However, if the mass is clinically suspicious of maligCorrespondence: William H. Hindle, MD 2389-3E Via Mariposa West, Laguna Woods, CA 92653. E-mail: whindle@goldstate.net PROD. # GRF20312

Breast cancer: introduction.

There were an estimated 203,500 new cases of invasive breast cancer in the United States in the year 2002, 39,600 estimated breast cancer deaths, and 54,300 new cases of breast carcinoma in situ. During the past 10 years the breast cancer incidence rates (new cases per 100,000 women) have been about level, with no apparent trends except for possibly decreasing rates for younger women. The death rates for women with breast cancer, however (1990–1998), have been decreasing about 1.8% per year. The highest absolute number of female breast cancer deaths was 43,844 in 1995. These overall data from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Cancer Statistics Review are general population-based, are profoundly multifactorial, and do not provide direct evidence of correlation with possible clinical causes. From 1979 to 1982, incidence rates for breast cancer increased 1% per year, but then from 1982 to 1987, the rates increased 4% per year. During 1987 to 1996 the incidence rates were stable. Did the increased use of screening mammography during the period from 1982 to 1987 affect the incidence rates and produce what appears to be a marked annual increase in new cases of breast cancer? Has the mammographic identification of nonpalpable cancers, which respond so favorably to and may even be truly cured by surgical excision, correlate with the l.8% per year decreases (1990–1996) in the breast cancer death rates? Could the recent improved adjuvant therapy create a temporary decrease in the death rates by extending survival? We can only speculate and hope that the decreases continue in the coming years.

Diagnosis and treatment of invasive breast cancer during pregnancy and lactation.

The diagnosis and treatment of invasive breast cancer in women who are pregnant or lactating are essentially unchanged from women who are not pregnant or lactating. However, because screening mammography is not used during these times, nonpalpable lesions are rarely detected in pregnant and lactating women. Pregnancy-associated invasive breast cancer tends to be diagnosed at a more advanced stage, with an attendant adverse prognosis, than in women who are not pregnant or lactating. This is particularly unfortunate because pregnant and lactating women tend to be younger than most women diagnosed with invasive breast cancer. Any woman near age 40 or older who is planning pregnancy should have a screening mammogram before attempting to conceive. Pregnancy-associated breast cancer is defined as that occurring during pregnancy or within 1 year after delivery. Tenderness, engorgement, increased size, and increased prominence of the glandular tissue during pregnancy and lactation make mammography and clinical breast examination uncomfortable for the patient and less accurate for the detection of an abnormal breast mass. Not only is compression for mammography compromised, but also the increased vascularity and density within the breast inhibit mammographic perception of suspicious lesions. In these situations, ultrasound breast imaging can be useful. Nevertheless, obstetrician-gynecologists should perform a complete bilateral clinical breast examination on the initial visit of a pregnant or lactating patient and record the findings in her medical record. It is urgent to diagnose a breast mass definitely during pregnancy because the diagnostic and therapeutic procedures become more difficult and complex, with an increasCorrespondence: William H. Hindle, MD, 2389–3E Via Mariposa West, Laguna Woods, CA 92653. E-mail: whindle@goldstate.net PROD. # GRF20301

Mammography: screening and diagnostic.

About 30 years ago, mammography began to radically change the diagnostic approach to breast cancer; since then, its efficacy has continuously improved, both technically and in clinical application. Now, the arrival of digital mammography signals a major breakthrough in the efficiency of the equipment, particularly for radiologists, although this innovation is not expected to have a marked impact on the clinical outcome, particularly the disease-free survival. Digital mammography has the potential to allow manipulation of the image, such as magnification and increased contrast; eliminate film storage problems; facilitate availability of previous digital mammograms; allow telecommunication of mammograms for consultations and referrals; streamline tissue core-needle biopsies (no waiting for films to be developed); and eliminate waiting time during screening mammography for films to be developed to ensure that appropriate, high-quality views were obtained. Screening Mammography Screening mammography has been proven over time, and in multiple clinical trials, to markedly lower the death rates and the absolute number of disease-specific deaths from breast cancer. Further, mammography is the only effective method of detecting breast carcinoma in situ, which now accounts for as much as 30% of the malignant lesions detected by mammography. Obstetrician-gynecologists, particularly those involved in primary care practice, are obligated to order annual screening mammography on all their patients age 40 or older, to document in the medical record if the patient refuses screening or does not have it performed, to obtain the results if the patient has the mammography, and to follow the breast imaging reporting and data system (BI-RADS) recommendations in the report or to refer the patient to a breast specialist. In the case of a referral, the obstetriciangynecologist should follow up to be certain that the patient keeps her appointment with the breast specialist and that the recommendations and follow-up by the specialist are appropriate and carried out in a timely manner. Legally, obstetrician-gynecologists are Correspondence: William H. Hindle, MD, 2389–3E Via Mariposa West, Laguna Woods, CA 92653. E-mail: whindle@goldstate.net PROD. # GRF20311

Breast cancer prevention and surveillance.

True prevention of breast cancer is the ultimate goal. Future advances in cancer microbiology and genetic cellular manipulations potentially can provide the tools to achieve such a lofty aim. Current clinical research demonstrates that at many as 50% of diagnosable breast cancers can be suppressed, at least, with up to 5 years of tamoxifen therapy. Why did the remainder of the cancers continue to grow? Why does the effectiveness of tamoxifen therapy seem to cease after 5 years? Will the undiagnosed cancers grow to a clinically detectable size in the future, perhaps in 10 years? Are the seemingly suppressed cancers still viable in the breast? Further research, we hope in the not-too-distant future, should provide the answers.