Breast Biopsy after an Abnormal Mammogram: Section 2.d.

CONTENTS:

2.13 The Abnormal Mammogram: What Happens Next?
2.13.1 A Clinical Management Algorithm for Patients with Abnormal Mammograms
2.13.2 Repeat Mammography (Recall)
2.13.3 Making the Tissue Diagnosis
i. Fine Needle Aspiration (FNA) Cytology
ii. Stereotactic Biopsy
iii. Core Needle Biopsy (CNB)
iv. Vacuum-assisted Core Needle Biopsy (VAB)
v. Incisional Breast Biopsy
vi. Excisional Breast Biopsy
vii. Wire Localization Biopsy
viii. Excision Specimen Mammography
2.13.4 Management of Concordant Findings (Imaging & Biopsy)
2.13.5 Discordant Findings: Management of (Imaging & Biopsy)
2.13.6 Management of Atypical Lesions on Breast Biopsy
2.14 Mammographic Assessment of the Extent of Disease
2.14.1 Bilateral Mammography
2.14.2 Multi-Focal, Multi-Centric and Synchronous Disease
2.14.3 Extensive Intra-Ductal Component (EIC)

Forward to 2E Axilla imaging. Back to 2C on mammo and MRI.

If you trip over a bra in the bedroom, is that called a ‘booby trap’?

2.13 The Abnormal Mammogram: What Happens Next?

Receiving a result of an abnormal mammogram or being called for further tests can be very worrying. However, in the majority of cases, a mammographic abnormality does not mean that cancer is present. More likely, an abnormal mammogram is an indicator that further investigations are necessary.

2.13.1 A Clinical Management Algorithm

The use of clinical algorithms or clinical pathways, sometimes called clinical ‘trees’ can be a way of explaining the next stages in the diagnostic process (Esserman et al. 2000).

Whoever thought up the actual word ‘mammogram’?

I know! Whenever I hear the word ‘mammogram’ it I think of putting my breast in an envelope and sending it to someone.

2.13.2 Repeat Mammography (Recall)

An unsure diagnosis happens very rarely. But in cases where there is no definitive diagnosis after assessment, the screening team may invite women for an early recall mammogram in 12 months or sooner. About 92% of screening mammograms do not require additional follow-up imaging.

Between 60% to 70% of women who go through a follow-up diagnostic mammogram or ultrasound and have imaging features abnormal enough to require a biopsy, will turn out to have benign breast conditions only.

2.13.3 Making the Tissue Diagnosis

For the patient with a suspicious mammographic abnormality or a palpable breast lump, the obligatory diagnostic next step is a breast biopsy or cytology sample to make a diagnosis of benign or malignant. So, a pathologist takes a look at sections of the breast tissue sample down the microscope.

Breast cancer specialists recommend tissue sampling by palpation-guided or image-guided needle or ‘core’ biopsy. For diagnostic purposes, ‘surgical’ biopsy is not usually appropriate, only in cases where a breast biopsy is not possible. (Gutwein et al., 2011).

This is, understandably, a very worrying time for most women.

Yes, it’s the waiting for both the procedure and the results that causes anxiety.

Don’t forget ladies, only around 20 % of breast lumps turn out to be cancerous, so do check out any lumps.

Confirmation of a pre-operative tissue diagnosis of invasive carcinoma is important. The diagnosis allows the surgeon to plan the surgical procedure and to include biopsy of the sentinel lymph node (SLN) biopsy or a full axillary lymph node dissection as required.

Following a definitive diagnosis of Ductal Carcinoma in Situ (DCIS) by percutaneous core needle biopsy, surgical excision of an extensive area of breast tissue may ensue.

So, to make a tissue diagnosis there are several techniques:-

i. Fine Needle Aspiration (FNA) Cytology and Breast Biopsy.

Fine needle aspiration (FNA) biopsy, percutaneous, palpation-guided is a well-established technique for assessing palpable breast lumps.

Figure 2.11 Fine Needle Aspiration (FNA) and Cytology.

A. Sampling using a needle and syringe. B.
The appearance of the aspirated cells when stained
and viewed down the microscope, show benign
sheets of cells from a fibroadenoma.

An FNA uses a 10 ml or 20 ml syringe and a 23 gauge to 27 gauge needle. The needle passes through the skin and into a palpable lump or area of breast abnormality. The needle tip then passes back and forth within the mass.

Your physician applies negative pressure while pulling the syringe plunger back and rotating the wrist so that the needle is twisting.

EEeeuehhh! Far too much information.

I’m shaking…. these people know that I’m needle phobic too.

The tissue sampling or biopsy itself does not hurt, because of the use of local anesthesia. So, the biopsy shouldn’t be at all painful.

After the breast biopsy, the surgeon places the cytology specimen in a preservative, such as CytoLyte solution. After, medical staff send the sample to the Pathology laboratory. The aim is to have an adequate sample with enough cells for the Cytopathologist to examine.

The pathologist spins down the cells and smears them onto a glass slide, fixes and stains them with a visual histochemical stain. Finally, the pathologist examines the cells under a microscope.

Advantages of FNA Breast Biopsy Cytology

FNA cytology has certain advantages:

There is no special patient preparation with FNA. In addition, special premises are not necessary, a specialist can perform a FNA anywhere.
Fine Needle Aspiration (FNA) is easy to perform and does not require specialist training.
FNA is quick, takes only minutes to perform.
The results of FNA cytology are quick, within a few hours if required.
FNA cytology is inexpensive.

FNA cytology has some disadvantages:

It is not possible to distinguish between in-situ and invasive cancer.
There is a significant rate of non-diagnostic samples; between 5 % to 10 % for palpable lesions and as high as 30 % for non-palpable abnormalities.
There is a significant rate of ‘false negative’ results in inexperienced hands.
The rate of ‘inadequate‘ or ‘non-diagnostic’ cytologic samples, taken from palpable breast abnormalities averages between 4% to 13%, but maybe as high as 36 % for non-palpable abnormalities.

FNA is also used to diagnose simple breast cyst. The fluid within a simple cyst can be clear, yellow, grey, green, blue, milky, or bloody. However, cytology testing is always necessary for bloody fluid, as this may indicate a lesion other than a simple cyst.

Ultrasound-guided fine-needle aspiration of palpable lesions increases the degree of confidence that the needle has been placed accurately.

ii. Stereotactic Breast Biopsy

Mammographic guidance on the stereotactic table increases the accuracy of a core biopsy. The patient lies in a prone or upright position for a stereotactic breast biopsy. For a prone stereotactic biopsy, the patient lies face-down on the table with her breast through an opening in the table.

Certain conditions are not amenable to stereotactic biopsy, including a small breast, lesions close to the chest wall or nipple and faint calcifications.

iii. Core Needle Biopsy (CNB)

At the present time, in most centers, stereotactic CNB has replaced wire localization and excision as the most common initial biopsy method for non-palpable mammographic abnormalities.

Core needle biopsy (CNB) has the following advantages:

CNB offers a more definitive histologic diagnosis.
Core Needle Biopsy avoids inadequate samples.
CNB may allow a distinction between invasive and in-situ carcinoma.
CNB is safe.
The pathologist can make a diagnosis with fewer samples.

What’s the difference between a Fine Needle Aspiration (FNA) and a Core Needle Biopsy (CNB)?

A core needle biopsy has a slightly larger hollow needle that removes small cylinders called ‘cores’ of breast tissue, whereas a fine needle aspiration uses a very thin needle attached to a syringe.

For non-palpable breast lesions, ultrasound-guided CNB is faster. In addition, patients tend to tolerate CNB with ultrasound better than the stereotactic technique.

The use of ultrasound requires that the lesion is well-visualized and confidence that the ultrasound finding and mammographic finding represent the same thing. If the radiographer visualizes a lesion on mammography, but can not reliably reproduce the image on ultrasound, then stereotactic guidance may be necessary.

Stereotactic-guided CNB is the standard approach for lesions with microcalcifications, because these lesions are not usually visual on ultrasound.

iv. Vacuum-assisted Core Needle Biopsy (VAB)

Vacuum-assisted CNB (VAB) was first described in 1995. It is a stereotactic technique that may remove mammographic abnormalities of up to 1 cm in diameter, by just using an 11-gauge needle. Just four needle cores can obtain up to 1 gm of tissue. The accuracy of VAB has been reported, with a false-negative rate as low as 3% (Kettritz et al., 2004)

Moose, have you ever considered acupuncture for your needle phobia?

No, I don’t see the point. [pun intended]

v. Incisional Breast Biopsy

If a core needle biopsy or skin punch biopsy is non-diagnostic, and the breast mass is too large to remove without a significant cosmetic compromise, incision biopsy can be performed to confirm the diagnosis.

vi. Excisional Breast Biopsy

If the core needle biopsy is non-diagnostic, and it is not concordant with imaging results, or if it yields any high-risk abnormality such as atypical hyperplasia, radial scar, papilloma or lobular carcinoma in-situ, excision of the entire lesion is advised.

I’ve not really understood incision and excision biopsies.

I think that it’s something to do with the teeth, the incisors and excisors.

An incisional biopsy takes a bit of the abnormal lump, or lesion, to analyse what it is, whereas an excisional biopsy takes the whole of the abnormality away.

In some cases, a patient will prefer an excision biopsy as they will prefer to have the mass excised, even if it is benign.

Excision biopsy of simple cysts, of clustered micro-cysts or cysts with thin septa, is not necessary.

Excision biopsies may generate scar tissue inside the breast that may prompt a diagnostic evaluation in the future if prior mammograms are not available for comparison.

The role of Excisional Breast Biopsy

Excisional breast biopsy relates to the following cases:-

Complex cysts referred to as a ‘complex mass’ in the BI-RADS classification, not amenable to core needle biopsy should have a needle-localized excisional biopsy for tissue diagnosis.
Aspirated cysts that do not completely resolve should undergo evaluation using a core biopsy or a surgical excision.
The increase in size or suspicious changes is seen on follow-up imaging after a previous core biopsy showed benign results.
If pathology results from a core biopsy are discordant with imaging, or are atypical, indeterminate or reveal a malignancy.

A metallic marker placed at the time of the diagnostic core biopsy will aid in needle localization of the biopsy area at the time of surgery. An intraoperative specimen radiograph will confirm the removal of the entire wire and the metallic marker. Indeed, this can also assure the surgeon that he/she has an adequate sample.

vii. Wire Localization Breast Biopsy

The use of metal clips to identify CNB sites is commonly used and can assist the radiologist and the surgeon. Placement of a clip following ultrasound-guided CNB is important for providing mammographic and sonographic correlation of lesion location.

This is getting worse, first the needles and now wires?

Will you stop, you’re scaring the readers!.

Using mammogram or ultrasound, a small wire is threaded through a needle and the tip of the needle is left in or near the abnormal tissue. That’s all there is to it.

When non-palpable micro-calcifications are found on mammography, wire localization and excision may be used. Wires may be placed mammographically to guide the surgeon to include the mammographic abnormality in the surgical excision. These wires are left in the excised specimen so that pathologist may sample the abnormal breast tissue and correlate the histology with the mammographic findings.

Goals of Wire Localization Breast Biopsy

The goal of wire localization is to obtain a histologic diagnosis, or to perform complete excision of a highly suspicious lesion, to excise CNB-proven tumors, or to remove residual suspicious calcifications following excision of malignant calcifications.

Wire localization performed using ultrasound guidance is more rapid and is better tolerated than mammographic localization.

US-guided wire localization can be accomplished if there is a residual lesion visualized sonographically, or if there is an accurately placed clip.

For patients found to have DCIS, complete excision of the entire breast lesion with appropriate margins is required for successful breast conservation therapy.

What is an appropriate margin?

Well I believe it might be the margin for error.

No it is not, it refers to the distance between a tumor and the edge of the surrounding tissue that’s removed along with it.

The achievement of excision margins that are negative for tumor involvement is a significant factor in the reduction of local tumor recurrence.

The use of stereotactic CNB prior to planned excision of malignant micro-calcifications has decreased the incidence of finding positive margins at the time of excision. But still, 20 % of cases still have a positive histologic margin of excision (Stomper, 2000).

viii. Excision Specimen Mammography

The use of localization wires can be inserted mammographically into the breast to mark the site of the radiologic abnormality.

When an excision of a non-palpable breast lesion is performed, with or without retention of a localization wire, a specimen mammogram and pathologic assessment of tumor margins are required.

Whole specimen mammography is obligatory for clinically occult lesions excised under mammographic localization and is recommended for palpable lesions that are associated with micro-calcifications.

All specimens should be oriented by the surgeon. Specimen radiography is done to confirm the accurate removal of the mammographic abnormality and to guide the pathologist to sample the most appropriate area for histology. Visualization of the clip and/or foreign body material accompanying the clip helps the pathologist and the surgeon identify the prior biopsy site.

Figure 2.12 Wire Localization Excision Specimen.

An excised breast specimen contains a wire, placed
with its tip at the site of the mammographic
breast abnormality. The surgeon removed the breast
tissue with the wire in place. The specimen X-ray
can be compared with the mammogram before
the Pathologist samples the tissue for histopathology.

Specimen radiography can also show whether the lesion has been transected or is in proximity to the edge of the specimen. In such cases, additional tissue may need to be removed to increase the likelihood of negative margins. The best opportunity to achieve clear margins is at the time of the original surgical excision.

Some centers and some breast surgeons use digital imaging in the operating room, such as Faxitrons, to provide an immediate image of the specimen and to improve the ability of the surgeon to see the lesion in relation to the excision margin.

2.13.4 Management of Concordant Findings

All benign histological diagnoses from core needle biopsies (CNB) or cytology following an abnormal mammogram require concordant radiologic-pathologic correlation for lesions.

The National Comprehensive Cancer Network guidelines advise follow-up to include a physical examination and radiographic evaluation (mammogram and/or ultrasound) 6 to 12 months after CNB.

If it was all good, why would you have to come back again so soon?

It’s to be sure that the lump, or abnormality, hasn’t changed or grown into something more suspicious looking.

So ladies, do not be putting off those follow-up appointments, even if you’ve had the all clear.

2.13.5 Management of Discordant Findings

Discordant findings of a histologically benign lesion that does not correlate with the mammographic abnormality require further evaluation. Further investigations may involve another biopsy or MRI and will often require excisional biopsy.

Discordant findings…I have no idea.

I think that chocolate rain might cause some discord!

Discordant findings simply means that the imaging does not agree with the histology (tissue sampling) findings and further tests are necessary.

2.13.6 Management of Atypical Lesions from Core Breast Biopsy Results

If the core biopsy shows any abnormality, your physician will advise a wire localization breast biopsy to confirm the diagnosis.

In cases of benign breast lumps, some are sadly associated with malignancy. Indeed, excisional biopsy leads to a diagnosis of malignancy in 50% of cases. Benign conditions that warrant follow up with further investigations are:-

Sclerosing adenosis
Radial Scar (complex sclerosing lesion)
Atypical Ductal Hyperplasia (ADH)
Atypical Lobular Hyperplasia (ALH)
Lobular Carcinoma in-situ (LCIS)

2.14 Mammographic Assessment of the Extent of Disease

Mammography can assess the extent of in-situ ductal carcinoma (DCIS) and early invasive carcinoma beginning with diagnostic mammography through to the biopsy, specimen management, and the post-excision mammogram.

2.14.1 Bilateral Mammography

Mammography of both breasts is done for the patient with in-situ ductal carcinoma (DCIS) or invasive cancer who is considering breast conservation.

Diagnostic mammography is useful in defining the extent of the disease. Importantly, a pre-operative mammogram may identify multi-focal or multi-centric cancer. If this is the case achieving clear surgical margins or breast conservation surgery may be difficult.

2.14.2 Multi-Focal, Multi-Centric and Synchronous Disease

Multi-focal breast disease involves several areas within the breast quadrant, and probably representing disease along an entire breast duct.

Multi-focal breast tumors are present in 10% to 12% of patients. These represent multiple tumor nodules or masses within the same breast. The sensitivity for detecting these tumors with mammography is between 15% to 45%. Furthermore, whole-breast sonography may improve the sensitivity rate.

In women with dense breast tissue, the sensitivity of mammography in detecting multi-focal breast tumors drops by about 10%.

Magnetic resonance imaging (MRI) is the most sensitive screening tool for multi-focal breast cancer, with a detection rate of around 81%.

Figure 2.13 Magnetic resonance imaging
(MRI) of the breast

Shows multi-focal breast tumors with
extension into breast ducts.

So multi-focal means more than one lump but in the same quadrant of the breast.

You’ve got it, and multi-centric is more than one lump, but not confined to the same quadrant of the breast.

In contrast, ‘multi-centric disease’ involves multiple areas within different breast quadrants and probably represents the malignant involvement of multiple ducts and lobules.

The extent of mammographic non-linear branching micro-calcifications often underestimates the tissue extent of the malignancy in the breast.

In a study in 1990, Holland and colleagues, suggest that the discrepancy is less than 2 cm in 80% to 85% of cases (Holland et al., 1990). A minimum of 2 cm surgical excision margin, beyond the mammographic area of abnormality, is optimal.

The girls are really paying attention, but what is a quadrant?

A quadrant is a quarter of a circle, in the above case, a breast.

Oh no, the only thing a quadrant should be applied to is a quarter of an apple pie!

Studies on Multi Focal Breast Disease

These studies support the observation that several clusters of micro-calcifications separated by normal-appearing breast tissue should not be interpreted as a multi-focal or multi-centric disease. So, these ‘clusters’ may represent areas of a contiguous tumor that may be only partially calcified within a duct or lobule.

A ‘synchronous’ contralateral breast tumor refers to a lump in the opposite breast that occurs within 3 to 12 months of the first tumor. A contralateral tumor often shows on physical examination or mammogram and occurs in around 2% of breast cancer cases.

For women who present with unilateral breast cancer, a subsequent ‘metachronous’ contralateral cancer tends to develop at a rate of 0.5-1% per year, which represents a cumulative risk of 15%.

Contralateral mammography is a mandatory follow-up for all patients with breast cancer.

WTF?

MOOSE!! You can’t say that on here.

What? What? Just asking Where’s The Food.

2.14.3 Extensive Intra-Duct Component (EIC)

The combination of a breast mass with micro-calcification often indicates the presence of an ‘extensive intra-ductal component’ (EIC).

The histological definition of EIC is a DCIS which is adjacent to invasive carcinoma (IDC) and which accounts for more than 25 % of the total volume of disease in the breast.

EIC can be a predictor for more widespread residual tumor (usually DCIS) following excision of the main breast lesion.

References:

Esserman, L.J., Wolverton, D., Hylton, N. (2000). Integration of breast imaging into cancer management. Curr Oncol Rep 2(6), 572-81. (Retrieved October 28^th 2014): https://www.ncbi.nlm.nih.gov/pubmed/11122895

Gutwein, L.G., Ang, D.N., Liu, H., Marshall, J.K., Hochwald, S.N., Copeland, E.M., Grobmyer, S.R. (2011). Utilization of minimally invasive breast biopsy for the evaluation of suspicious breast lesions. Am J Surg. 202(2), 127. (Retrieved October 29^th 2014): https://www.ncbi.nlm.nih.gov/pubmed/21295284

More references for this section are on this page.

Patient Information:

American Cancer Society. For Women Facing a Breast Biopsy: Benign breast conditions: Not all lumps are cancer. http://www.cancer.org/treatment/understandingyourdiagnosis/examsandtestdescriptions/forwomenfacingabreastbiopsy/breast-biopsy-benign-breast-conditions

National Cancer Institute. Mammograms (Retrieved January 26^th 2015) http://www.cancer.gov/cancertopics/factsheet/detection/mammograms

More patient information for this section is on this page.