Correspondence
Evaluation of a Breast Mass
N Engl J Med 1993; 328:810-812March 18, 1993
- Article
To the Editor:
The Current Concepts article by Donegan (Sept. 24 issue)1 on the management of palpable breast masses raises several important issues that should be clarified. Although the term “diagnostic mammography” is commonly used, mammography is rarely diagnostic in the sense of “distinguishing one disease from another”2. Mammography is almost exclusively a screening technique. It is rare that the mammogram can characterize a palpable lesion sufficiently that no further evaluation is needed. Even specially targeted mammographic views may fail to image the palpable abnormality. Mammography should be used in a woman who has a mass, but it should be used primarily to screen the clinically normal, ipsilateral breast tissue and the contralateral breast in order to detect occult cancer3.
Although it is unusual, clinically palpable cancers can be missed at open biopsy. If the palpable lesion is visualized on the preoperative mammogram and the mammographic characteristics strongly suggest cancer, then a negative biopsy should not be trusted, and early follow-up mammography should be scheduled to determine whether the lesion has actually been removed4.
The implied suggestion that mammography is valuable for women over 20 with palpable masses is not supported with any but anecdotal information, and this idea has never been established in a prospective, unbiased fashion. Since mammography is inaccurate as a diagnostic test and there are no data with which to establish its efficacy for screening women under 40, it should not be considered a standard mode of evaluation in such women. In the absence of scientific data, however, individual and anecdotal experience must guide clinical practice. Mammography can demonstrate some cancers in women under 405. Individual practitioners may find value in using the technique to evaluate symptomatic women under 40, but it should not be considered the standard of care. The risk associated with radiation, although low, must be balanced against the expected benefit.
The value of having the “physician interpreting the mammogram also” palpate the breast is also unproved. Physical examination and mammography are used to evaluate different characteristics of tissue, and there is little correlation between the mammographic and the clinical assessments of breast-tissue characteristics. The examination that produces the greater concern should usually dictate the next action.
Dr. Donegan is correct in stating that needle aspiration may produce confusing changes on the mammogram, but as the article he cites by Sickles et al. points out,6 these are transient changes and are virtually all resolved within two weeks. Although magnetic resonance imaging (MRI) with contrast enhancement is quite promising, it has not been established that it has a “sensitivity superior to that of mammography,” since MRI has not yet been compared in a prospective fashion with high-quality mammography.
6 ReferencesDaniel B. Kopans, M.D.
Massachusetts General Hospital, Boston, MA 021141
Donegan WL . Evaluation of a palpable breast mass. N Engl J Med 1992;327:937-942
Full Text | Web of Science | Medline2
Dorland's illustrated medical dictionary. 26th ed. Philadelphia: W.B. Saunders, 1981.
3
Kopans DB ,Meyer JE ,Cohen AM ,Wood WC . Palpable breast masses: the importance of preoperative mammography. JAMA 1981;246:2819-2822
CrossRef | Web of Science | Medline4
Meyer JE ,Kopans DB . Analysis of mammographically obvious carcinomas of the breast with benign results upon initial biopsy. Surg Gynecol Obstet 1981;153:570-572
Web of Science | Medline5
Meyer JE ,Kopans DB ,Oot R . Breast cancer visualized by mammography in patients under 35. Radiology 1983;147:93-94
Web of Science | Medline6
Sickles EA ,Klein DL ,Goodson WH III ,Hunt TK . Mammography after needle aspiration of palpable breast masses. Am J Surg 1983;145:395-397
CrossRef | Web of Science | Medline
To the Editor:
Dr. Donegan suggests that fine-needle aspiration be performed before mammography to evaluate palpable breast masses. The diagnostic accuracy of mammography is sacrificed by such an approach. Hematomas or edema created by fine-needle aspiration can appear as masses with ill-defined margins, which are suggestive of cancer. Sickles et al. report an increase of 36 percent in false positive mammograms obtained within one week of aspiration1.
Mammography should be performed before fine-needle aspiration. In rare circumstances, such as that of young patients for whom the risk of cancer is small but for whom the risk associated with radiation may not be negligible, the mammogram may be deferred pending the results of the cytologic evaluation. If at that time mammography is deemed necessary, it should be performed at least two weeks after the fine-needle aspiration2.
Dr. Donegan's scheme of management would require all women to wait two weeks after aspiration for accurate mammography. We do not believe that such a delay would be acceptable either to patients or to their surgeons.
2 ReferencesKaren K. Lindfors, M.D.
Lydia P. Howell, M.D.
University of California, Davis, Sacramento, CA 958171
Sickles EA ,Klein DL ,Goodson WH III ,Hunt TK . Mammography after needle aspiration of palpable breast masses. Am J Surg 1983;145:395-397
CrossRef | Web of Science | Medline2
Klein DL ,Sickles EA . Effects of needle aspiration on the mammographic appearance of the breast: a guide to the proper timing of the mammography examination. Radiology 1982;145:44-44
Web of Science | Medline
To the Editor:
. . . Automated core biopsy performed with a spring-loaded sampling device is as accurate as open biopsy of breast lesions1,2. Although the work of Parker et al.1 was based primarily on patients with nonpalpable lesions, this technique provides a simple, safe, nondisfiguring biopsy equivalent to open biopsy. Donegan's statement that “any diagnostic method short of open biopsy [is] an educated guess” needs to be reevaluated.
The pitfalls of fine-needle aspiration are well known. Automated core biopsy provides better quantity and quality of tissue,3 and it can safely be used to provide multiple samples. Unlike fine-needle aspiration, core biopsy can reliably distinguish invasive from noninvasive carcinoma and lymphoma from poorly differentiated carcinomas. It can also be used to diagnose benign conditions definitively. The study cited3 compares one manual Tru-cut biopsy without image guidance with multiple passes with fine-needle aspiration. Current use of automated core biopsy guided by ultrasonography, stereotactic mammography, or both seems to have reversed this conclusion.
3 ReferencesDavid Thickman, M.D.
Steve Parker, M.D.
David Clark, M.D.
Radiology Imaging Associates, P.C., Denver, CO 801101
Parker SH ,Lovin JD ,Jobe WE ,Burke BJ ,Hopper KD ,Yakes WF . Nonpalpable breast lesions: stereotactic automated large-core biopsies. Radiology 1991;180:403-407
Web of Science | Medline2
Meyer JE . Value of large-core biopsy of occult breast lesions. AJR Am J Roentgenol 1992;158:991-992
Web of Science | Medline3
Hopper KD ,Baird DE ,Reddy VV , et al. Efficacy of automated biopsy guns versus conventional biopsy needles in the pygmy pig. Radiology 1990;176:671-676
Web of Science | Medline
To the Editor:
Dr. Donegan recommends performing a biopsy of every noncystic palpable mass, whether cytologic tests are positive, suggestive, or negative and whether the mammogram is positive or negative. We disagree. We have never examined anyone, male or female, whose breast region did not contain at least one palpable mass. Patients consulting our clinic often have many palpable masses in each breast. Biopsies cannot be performed for all of these. A clinically important palpable mass should be subjected to biopsy, but many marginally suspicious lesions can be followed by fine-needle-aspiration cytology alone.
As our recent article 1 makes clear, in 1988 needle-aspiration cytology detected 8 cancers in 2248 patients with palpable solid masses that we considered not important enough to biopsy. This means that only 1 of every 281 palpable masses proved to be malignant. Thus, fine-needle-aspiration cytology not only helped detect early cancers, but its negative findings spared many patients the ordeal of surgical biopsy for benign conditions.
Although Dr. Donegan believes that sonography has “little place in the evaluation of palpable breast masses,” ultrasound is enormously helpful in assessing multiple cysts or palpably asymmetric areas. Sonography frequently reveals that a palpable mass consists of multiple small cysts. It would be impossible for a surgeon to aspirate them all and dispel the mass. Ultrasound permits us to cancel many unnecessary biopsies in these women with incipient fibrocystic disease who consult our clinic for a second opinion. Moreover, in Rochester, needle aspiration is not less expensive than sonography. . . .
1 ReferencesWende W. Logan-Young, M.D.
Nancy Yanes Hoffman, M.S.
Joyce A. Janus, M.D.
Elizabeth Wende Breast Clinic of Rochester, Rochester, NY 146201
Logan-Young WW ,Hoffman NY ,Janus JA . Fine-needle aspiration cytology in the detection of breast cancer in nonsuspicious lesions. Radiology 1992;184:49-53
Web of Science | Medline
Author/Editor Response
Dr. Donegan replies:
To the Editor: I agree with Dr. Kopans that “diagnostic” is a misnomer when applied to mammography, but it does serve a useful purpose in distinguishing the examination of symptomatic women from that of asymptomatic women. The correlation between image interpretation and histologic assessment remains inexact, and other terms often used in mammographic diagnosis, such as “adenosis,” may be equally misleading.
In my experience, false negative biopsies of palpable cancers occur when surgeons incorrectly assume that a mammographic lesion and a palpable mass are one and the same, when a palpable mass is vague and deeply situated, and when a biopsy is performed under suboptimal conditions. A mammogram soon after a biopsy can show whether or not a lesion was removed, and is also useful in establishing a new base line. Biopsy-related defects often persist and can mimic spiculated cancers, so that the question of cancer is raised again at the next annual mammogram. Comparison with the post-biopsy mammogram can identify the regressing density that is consistent with scar.
Mammography is not currently recommended to screen women less than 40 years of age. When a mass is present, the procedure is performed for the same reason as in older women -- to detect occult lesions in other areas of the breast or in the opposite breast.
Diagnosis of breast masses remains difficult and hazardous. The value of having a breast examined by a radiologist before a mammogram may not be proved, but it is often obvious. Areas of suspicion are not always included in the standard mammographic examination. As with any examination, it helps to know firsthand what one is looking for. When surgeons are familiar with the technique and interpretation of mammograms and review them personally (ideally in conjunction with the radiologist), mistakes and misunderstandings are more likely to be avoided.
Dr. Kopans points out that any changes produced on a mammogram by early aspiration of a palpable mass are transient. I would add that the level of radiologic suspicion generally does not influence the decision to perform a biopsy of a palpable mass. In this circumstance it is not the mass itself, but other areas of the breast that are of principal mammographic interest. To delay aspiration until a mammogram has been scheduled and performed results in diagnostic delay and an extra office visit.
William L. Donegan, M.D.
Sinai Samaritan Medical Center, Milwaukee, WI 53201- Citing Articles (1)
Citing Articles
1
L.S. Wilkinson, C. Charlesworth, J. Crinnian, M. Burke. (1997) Influence of mammography on the management of a palpable breast lesion. The Breast 6:2, 69-71
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