Med. Oncol. & Tumor Pharmacother, Vol. 8. No. 3, pp. 169-174, 1991
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BREAST CANCER: EARLY DIAGNOSIS OF PRECURSOR LESIONS AND CLINICALLY INAPPARENT CARCINOMA BY FINE NEEDLE ASPIRATION
J O S E P H A. LINSK Atlantic City Medical Center, 4021 Atlantic Avenue, Atlantic City, NJ 08401, U.S.A. (Received 5 May t99 t; accepted 12 May t 991) Breast cancer death rate has remained stable at 26 per 100,000 for over 50 years. This control failure is due in large part to difficulty in early diagnosis. Combined clinical evaluation, mammography and fine needle aspiration (FNA) offer the best opportunity for early diagnosis. Non-directed FNA is a useful adjunctive technique and three illustrative cases are presented. Cancer evolves from proliferative epithelial disease of ducts and Iobules. Atypical duct hyperplasia in association with family history is a pertinent marker for development of cancer. Identification of hyperplastie lesions traditionally occurs after surgical biopsy and histopathologic review~ FNA demonstrates patterns of both duct hyperplasia and atypical duct hyperplasia. Ploidy studies of such smears offer the possibility of selecting precancerous lesions for extirpation. A combination of directed and undirected punctures and ploidy studies may yield early diagnosis of precancerous lesions.
Key words: Breast cancer, Precursor lesions, FNA, Duct hyperplasia, Occult malignancy.
aspiration) "4 Failure of one technique to yield a diagnosis will be compensated by findings in one or both remaining techniques leading to an overall accuracy of over 90%. Where all three techniques agreed, diagnostic error was less than 1%. -~
INTRODUCTION Breast cancer death rate has remained stable at approximately 26 per 100,000 female population for over 50 years in spite of singular advances in diagnosis and treatment, j It is now generally estimated that one in nine Western women will develop breast cancer in her lifetime. This massive control failure has been attributed to public and medical ignorance of the disease leading to absent, infrequent or inadequate medical examinations. More important, however, is the insidious nature of the tumor which allows initiation and progression well beyond the point of cellular dishesion and metastasis before it is detected. This results immediately in a sharp reduction in five-year survival rate from 85 to 90% for local disease with negative nodes to 53% for node-positive patients and an incurable state for metastatic disease. 2 Detection and extirpation of carcinoma before dishesion of cells is curative. Detection and management of precursor alterations may be preventive.
CLINICAL EVALUATION The assessment of palpable breast alterations beyond the welt-defined mass has been a difficult problem for clinicians. Patients are referred for evaluation and/or fine needle aspiration because of perceived palpatory abnormalities which are not always confirmed even when the site is indicated by the patient or marked by the referring physician. There is an inescapable conclusion that some lesions are evanescent. Changes with the menstrual cycle are well-known and palpation at mid-cycle is recommended. It is precisely the lumpy, fibronodular breasts with vaguely outlined and transient masses which require support from mammography and fine needle aspiration in assessing risk and formulating a recommendation for surgical biopsy. More importantly, in seeking early disease, the decision whether to biopsy or follow is based on the experience and self-assurance of the clinician, tech-
EARLY DIAGNOSIS OF BREAST CANCER Early diagnosis of breast cancer is best achieved by the integration of three techniques - - clinical evaluation, mammography and fine needle 169
170 Joseph A. Linsk niques of examination and, at least in the United States, medical-legal considerations. Some patients may be seen with multiple bilateral incisions and others with advanced cancer having fallen through the surveillance net. Clinical assessment includes consideration of risk factors - - family history, s prior mastectomy or biopsy, 5-7 age and weight, s Clearly, with equivalent physical findings, risk factors will help direct the decision to pursue or withhold surgical biopsy. Palpation of the breast is a highly individualized craft. For the interested physician with experience, so-called non-palpable disease may, in fact, be palpable. Lesions 2-3 mm in diameter are detectable) ) Finger pad palpation particularly after soaping the breast provides the best opportunity for detecting early disease, m
MAMMOGRAPHY The survival benefit of screening mammography has been established by several large series.l~'~2 In the Health Insurance Plan of New York study, there was a one-third reduction in mortality in the study group compared to the control group at 18 years. 14 While the overall benefits are inescapable, therewas a large number of variables in the studies. These include frequency of screening, one view vs two views, the addition of physical examination, the quality of the physical examination and varying levels of technical skill in performing mammography. It is important to note that most tumors detected in screening are relatively easy to detect and therefore are not early. ~3 Non-palpable abnormalities are reported radiographically as benign, varying levels of suspicion, and malignant. Surgery is withheld for benign and mandated for malignant diagnosis. Discriminating radiographic diagnosis, which includes physical and historic factors as adjuvant data, has yielded a diagnosis of cancer in only 6-27% of surgically biopsied cases. ~4 In contrast, utilizing fine needle aspiration data from stereotactic mammographic sampling techniques, 75% of surgically biopsied cases had cancer. 15 Of perhaps broader importance is the fact that mammography may reveal alterations not suspicious for cancer but consistent with epithelial proliferation and therefore suggestive of a precursor lesion. ~
073(~-0!18/9t $3.(X)+ .00 Pergamon Prcss plc
Printed in Great Britain
BREAST CANCER: EARLY DIAGNOSIS OF PRECURSOR LESIONS AND CLINICALLY INAPPARENT CARCINOMA BY FINE NEEDLE ASPIRATION
J O S E P H A. LINSK Atlantic City Medical Center, 4021 Atlantic Avenue, Atlantic City, NJ 08401, U.S.A. (Received 5 May t99 t; accepted 12 May t 991) Breast cancer death rate has remained stable at 26 per 100,000 for over 50 years. This control failure is due in large part to difficulty in early diagnosis. Combined clinical evaluation, mammography and fine needle aspiration (FNA) offer the best opportunity for early diagnosis. Non-directed FNA is a useful adjunctive technique and three illustrative cases are presented. Cancer evolves from proliferative epithelial disease of ducts and Iobules. Atypical duct hyperplasia in association with family history is a pertinent marker for development of cancer. Identification of hyperplastie lesions traditionally occurs after surgical biopsy and histopathologic review~ FNA demonstrates patterns of both duct hyperplasia and atypical duct hyperplasia. Ploidy studies of such smears offer the possibility of selecting precancerous lesions for extirpation. A combination of directed and undirected punctures and ploidy studies may yield early diagnosis of precancerous lesions.
Key words: Breast cancer, Precursor lesions, FNA, Duct hyperplasia, Occult malignancy.
aspiration) "4 Failure of one technique to yield a diagnosis will be compensated by findings in one or both remaining techniques leading to an overall accuracy of over 90%. Where all three techniques agreed, diagnostic error was less than 1%. -~
INTRODUCTION Breast cancer death rate has remained stable at approximately 26 per 100,000 female population for over 50 years in spite of singular advances in diagnosis and treatment, j It is now generally estimated that one in nine Western women will develop breast cancer in her lifetime. This massive control failure has been attributed to public and medical ignorance of the disease leading to absent, infrequent or inadequate medical examinations. More important, however, is the insidious nature of the tumor which allows initiation and progression well beyond the point of cellular dishesion and metastasis before it is detected. This results immediately in a sharp reduction in five-year survival rate from 85 to 90% for local disease with negative nodes to 53% for node-positive patients and an incurable state for metastatic disease. 2 Detection and extirpation of carcinoma before dishesion of cells is curative. Detection and management of precursor alterations may be preventive.
CLINICAL EVALUATION The assessment of palpable breast alterations beyond the welt-defined mass has been a difficult problem for clinicians. Patients are referred for evaluation and/or fine needle aspiration because of perceived palpatory abnormalities which are not always confirmed even when the site is indicated by the patient or marked by the referring physician. There is an inescapable conclusion that some lesions are evanescent. Changes with the menstrual cycle are well-known and palpation at mid-cycle is recommended. It is precisely the lumpy, fibronodular breasts with vaguely outlined and transient masses which require support from mammography and fine needle aspiration in assessing risk and formulating a recommendation for surgical biopsy. More importantly, in seeking early disease, the decision whether to biopsy or follow is based on the experience and self-assurance of the clinician, tech-
EARLY DIAGNOSIS OF BREAST CANCER Early diagnosis of breast cancer is best achieved by the integration of three techniques - - clinical evaluation, mammography and fine needle 169
170 Joseph A. Linsk niques of examination and, at least in the United States, medical-legal considerations. Some patients may be seen with multiple bilateral incisions and others with advanced cancer having fallen through the surveillance net. Clinical assessment includes consideration of risk factors - - family history, s prior mastectomy or biopsy, 5-7 age and weight, s Clearly, with equivalent physical findings, risk factors will help direct the decision to pursue or withhold surgical biopsy. Palpation of the breast is a highly individualized craft. For the interested physician with experience, so-called non-palpable disease may, in fact, be palpable. Lesions 2-3 mm in diameter are detectable) ) Finger pad palpation particularly after soaping the breast provides the best opportunity for detecting early disease, m
MAMMOGRAPHY The survival benefit of screening mammography has been established by several large series.l~'~2 In the Health Insurance Plan of New York study, there was a one-third reduction in mortality in the study group compared to the control group at 18 years. 14 While the overall benefits are inescapable, therewas a large number of variables in the studies. These include frequency of screening, one view vs two views, the addition of physical examination, the quality of the physical examination and varying levels of technical skill in performing mammography. It is important to note that most tumors detected in screening are relatively easy to detect and therefore are not early. ~3 Non-palpable abnormalities are reported radiographically as benign, varying levels of suspicion, and malignant. Surgery is withheld for benign and mandated for malignant diagnosis. Discriminating radiographic diagnosis, which includes physical and historic factors as adjuvant data, has yielded a diagnosis of cancer in only 6-27% of surgically biopsied cases. ~4 In contrast, utilizing fine needle aspiration data from stereotactic mammographic sampling techniques, 75% of surgically biopsied cases had cancer. 15 Of perhaps broader importance is the fact that mammography may reveal alterations not suspicious for cancer but consistent with epithelial proliferation and therefore suggestive of a precursor lesion. ~
