J. Homer,
Marc
MD
Nonpalpable Frequency, of Incisional
Breast Microcalcifications: Management, and Results Biopsy’
In a series of 500 consecutive needle localizations, there were 165 biopsies for benign microcalcifications without a mass. An incisional biopsy was performed in 49 of these cases (30%). Follow-up mammograms were available for review in 39 of the cases. The average length of follow-up was 32 months.
In no
case
did
malignancy
develop at the biopsy site. When an incisional biopsy is performed, careful follow-up mammography is an alternative to a repeated needle localization and biopsy in selected cases. Index terms:
Breast, calcification, 00.811 ization, 00.125, 00.312 lization, 00.125
biopsy, 00.12986 #{149} Breast, Breast neoplasms, local#{149} Breast radiography, uti-
#{149}
T
HE
1992;
185:411-413
by a radiobo-
to perform
a biopsy
operative tion
of a
nonpalpable breast lesion indicates an unequivocal concern that the lesion may be malignant. Complete excision of the mammographic abnormality permits the pathologist to evaluate the entire lesion for any histologic evidence of tumor so that the definitive diagnosis of its benign or malignant nature can be established. Less than complete excision of a nonpalpable breast lesion, or incisional biopsy, however, presents a management dilemma for both the clinician and radiobogist
when
histologic
analysis
proves the specimen to be benign. Since some of the lesion remains in vivo, the possibility exists that the excised
Radiology
recommendation
gist
benign
tissue
was
not
represen-
tative of the entire lesion and that diagnosed malignancy may remain within the breast.
un-
Numerous series have analyzed the experience of localization with needle or dye for the nonpalpabbe breast besion. These reviews address issues such as the positive of mammographic
tion techniques, mammographic the procedure edge, little has localization for graphic lesions
biopsy.
predictive findings,
failure to excise the lesion, and pitfalls of (i-fl). To my know!been written about nonpalpabbe mammoresulting in incisionab
It is the
purpose
tigation to review Tufts University-New cal Center Hospitals biopsy
for
the
of this
From the Department of Radiology, Box 388, New England Medical Center Hospitals, Tufts University School of Medicine, 750 Washington St. Boston, MA 02111. Received April 15, 1992; revision requested May 28; revision received June 16; accepted June 24. Address reprint requests to the author. 0 RSNA, 1992
nonpalpabbe
MATERIALS
mammo-
izations
for
were
reviewed.
nonpa!pable
needle breast
From
these
lesions
that without
In each
of these
the fob-
local-
lesions
cases,
benign
were manifest mass were
cases
the pre-
needle specimen
and pathology Determination
incisional or excisiona! performed. In all cases sional biopsy had been findings
and
an
biopsy had been in which an mciperformed, the
of follow-up
obtained
localiza-
radiographs,
reports were correlated. was made as to whether
mammography
were
correlated.
RESULTS Review boca!izations
of 500 consecutive for nonpalpable
needle breast
lesions identified 213 (43%) lesions that were manifest as microcalcifications without an associated mass. these, 48 were malignant and 165
were benign. Incisionab in 49 of the
biopsies 165 cases
Of
were performed of benign micro-
calcifications (30%). In 18 cases an incisional biopsy was performed purposeby because of the barge volume of the lesion (Figure), while in 31 cases
the original intent complete excisional
was to perform a biopsy. Of these
49 cases, 39 had follow-up grams available for review. cases form the basis of this
the
mammoThese report.
39
The average length of follow-up 39 cases was 32 months (range,
6-71 in the
months).
In one
number
cations findings
case,
an
in
increase
of residual
microcalcifiin a repeated needle biopsy. Histologic
resulted
localization
and again
proved
benignity
and
revealed lobular hyperplasia, intraductal papibbomatosis, and apocrine metaplasia. In none of the other cases did the residual microcabcifications change
in appearance
repeated
to require
a
for a breast
le-
biopsy.
DISCUSSION
METHODS
consecutive
mammographic as microca!cifications
identified.
including and
AND
Five hundred
inves-
experience at England Mediwith incisionab
graphic ca!cifications, frequency, management, low-up results.
I
values bocaliza-
mammogram,
radiographs,
The sion,
goal whether
of biopsy palpable
or nonpalpa-
ble, is total excision to allow complete histologic analysis. Though this goal should be easily achieved for the palpable
breast
lesion,
it is not
always zill
a.
b.
C.
(a) Lateral-view mammogram shows a geographic area of microcalcifications (arrows) measuring d!e localization was performed because nothing was palpable. An incisional biopsy was purposely the specimen confirms excision of many microcalcifications (original magnification, x2). Histologic brocystic follow-up
changes with mammography.
easily
achieved
breast
lesion.
calcifications.
The
calcifications
for the nonpalpable Before
the
current
wide-
spread use of localization techniques, surgeons often removed large volumes of breast tissue, sometimes approaching the size of an entire quandrant, to guarantee excision of the mammographic abnormality. The accuracy of needle localization techniques has resulted in the removal of smaller volumes of breast tissue. While small-volume biopsies should be encouraged because they result in better cosmetic outcome, they can result in failure to excise some or all of the mammographic abnormality. Previous investigations have reported failure to excise a nonpalpable mammographic abnormality after bocalization
with
a frequency
10% (7-10). In our recent (ii) with 200 consecutive cabizations,
we
of i%-
experience needle lo-
completely
missed
the
lesion in 6% of cases. When there has been failure to excise any of the besion, it is clear that the histologic composition of the lesion remains totally unknown. When incomplete excision of the mammographic abnormality shows
ther 412
malignancy,
action
Radiology
#{149}
it is clear
is mandatory.
that
fur-
were
in ducts
and
periductal
stroma.
The
Management becomes bess clear, however, when histologic study of an incisional biopsy specimen shows no evidence of malignancy. Accepting nothing less than total excision for a nonpalpabbe mammographic lesion would mean that every patient must undergo repeated needle localization and surgery. This procedure would guarantee more postoperative deformity and in some cases result in unacceptable cosmesis for what in most cases
would
ultimately
prove
to be a
benign lesion. A repeated localization and biopsy incur added surgical, radiobogic, and pathologic costs and require additional time in the operating room and by the physician. On the other hand, assuming that the incisionab biopsy always reflects the benign nature of the unsampled portion of the lesion may not always be true (12). In our material the performance of an incisionab biopsy for benign microcalcifications without a mass was not infrequent and occurred in 30% of cases.
In 31 of 49 cases
(63%)
mci-
sional biopsy occurred despite the plan for an excisional biopsy. In the other i8 cases (37%) an incisional bi-
more than 3 cm in greatest diameter. (b) Neeperformed. (c) Magnification radiograph of examination revealed nonpro!iferative firesidual calcifications showed no change at
opsy
had
been
planned
because
re-
moval of all the microcalcifications would have resulted in an unacceptable cosmetic appearance. When an incisionab biopsy occurs, a determination must be made as to whether mammographic follow-up or repeated needle localization are options.
This
decision
requires
input
from the radiologist and pathologist to the surgeon. First, the radiologist must
judge
whether
the
site
at which
the biopsy specimen was obtained and whether the amount of the lesion excised are representative of the mammographic lesion. When necessary,
a repeated
postoperative
mogram can be obtained the precise site of biopsy by
the
location
mam-
to confirm as evidenced
of postoperative
edema and hemorrhage. The pathologist must not only be certain that no malignancy is present in the excised tissue, but determine the specific nature of the benign histologic findings. A lesion with little in the way of proliferative changes is viewed much differently from one with severe ductal hyperpbasia with cellular atypia. In the batter case, a repeated localization and biopsy November1992
might be indicated just on the basis of histologic analysis. Finally, the surgeon weighs the radiobogy and pathology information with the specifics of the case. Factors such as patient anxiety, risk factors, and cosmesis all have an impact on the final recommendation. In our experience it is only occasionally that a patient requests a repeated biopsy to achieve complete excision of the lesion when there is an option. Most of our patients prefer the follow-up option rather than repeated surgery. The ultimate choice of the patient is also dependent on the rapport and confidence she has with her surgeon as well
as the
way
in which
the
op-
tions are presented. Review of the radiology reports from needle localization procedures at our institution demonstrates the evolution in our management of the incisionab biopsy. At first, the performance of an incisional biopsy was often not even mentioned in the report. Now, when the occurrence of an incisional biopsy is discovered by the radiologist during review of the specimen radiograph, the surgeon is immediately informed when the findings of the specimen radiograph are telephoned to the operating room. A recommendation is made in the report that, if the incisional biopsy specimen proves to be benign and fobbow-up is chosen, mammography of the breast subjected to biopsy be performed within 6 months to assess stability
of the
residual
lesion.
An incisionab biopsy may occur with both a calcified and noncalcified mammographic abnormality. This study was limited to the experience with calcifications without a mass for several reasons. For the purpose of this analysis it is easier to objectively determine whether an incisional biopsy has occurred with calcifications,
Vnliim#{248}
1R
#{149} Miimhor
since there is a clear mammographic marker of calcium. Often it is more difficult to be certain whether an mcisional biopsy has occurred when the mammographic
lesion
is an
indistinct
mass or an asymmetric area of high opacity. Follow-up of noncalcified lesions is also complicated by the difficulty
in distinguishing
between
findings, management options may include follow-up or repeated needle localization and biopsy. Whenever an incisional biopsy has been performed and a repeated biopsy is not recommended, we perform mammographic follow-up to ensure stability of residual lesion left in vivo. U
the
actual residual lesion and expected postoperative area of high opacity. A more frequent clinical situation is to be faced with the problem of management of a barge geographic vobume of microcalcifications in which total excisionab biopsy is clearly an unacceptable option. Finally, an mcisional biopsy is usually more common in cases of microcalcifications when there is almost never a palpable abnormality to guide the surgeon at the time of dissection. With noncabcified masses, the surgeon can often palpate the abnormality at the site of the localization wire. At our institution management is the same for all incisional biopsies regardless of the mammographic appearance of the lesion. To be specific, the recommendation after incisional biopsy for microcalcifications does not differ from the recommendation after incisional biopsy for an asymmetric area of high opacity or noncalcified mass. The follow-up protocol that we use is the same that we use for lesions with a high probability of benignity. Follow-up begins within 6 months and lasts for a minimum of 21,43 years. In summary, the performance of an incisional biopsy for a mammographic lesion of microcalcifications without a mass is not uncommon. In cases in which complete excision of the volume of calcifications would result in an unacceptable cosmetic outcome, an incisional biopsy can be performed. On the basis of careful correlation between the radio!ogic and pathologic
References 1.
2.
3.
4.
Ciatto pab!e
S, Cataliotti L, Distante V. Nonpa!lesions detected with mammography: review of 512 consecutive cases. Radiology 1987; 165:99-102. Hall FM, Storella JM, Siverstone DZ, Wyshak C. Nonpalpable breast lesions: recommendations for biopsy based on suspicion of cardnoma at mammography. Radiology 1988; 167:353-358. MeyerJE, Kopans DB, Stomper PC, Lindfors KK. Occult breast abnormalities: percutaneous preoperative needle localization. Radiology 1984; 150:335-337. MeyerJE, Sonnenfeld MR, Greenes Stomper PC. Preoperative localization of clinically occult breast lesions: experience at a referral hospital. Radiology 1988; 169:
627-628. 5.
6.
7.
8.
Rosenberg AL, Schwartz GF, Feig SA, Patchefsky AS. Clinically occult breast lesions: localization and significance. Radiology 1987; 162:167-170. Sick!es EA. Mammographic features of 300 consecutive nonpalpable breast cancers. AJR 1986; 146:661-663. Gallagher WJ, Cardenosa C, Rubens JR. McCarthy KA, Kopans DB. Minimal-volume exdsion of nonpa!pable breast lesions. AJR 1989; 153:957-961. Gisvold JJ, Martin JKJr. Prebiopsy localization of nonpa!pab!e breast lesions. AJR 1984;
9.
10.
11.
12.
Hall
143:477-481.
FM, Frank HA. Preoperative localization of nonpalpable breast lesions. AJR 1979; 132:101-105. Homer MJ. Localization of nonpalpab!e breast lesions: technical aspects and analysis of8O cases. AJR 1983; 140:807-811. Homer MJ, Smith TJ, Safaii H. Prebiospy needle !ocalization: methods, problems, and expected results. Radiol Clin North Am 1992; 30:139-153. Homer MJ, Safaii H, Smith TJ, Marchant DJ. The relationship of mammographic microcalcifications to histologic malignancy: radiologic-pathologic correlation. AJR 1989; 153:1187-1189.
Marc
MD
Nonpalpable Frequency, of Incisional
Breast Microcalcifications: Management, and Results Biopsy’
In a series of 500 consecutive needle localizations, there were 165 biopsies for benign microcalcifications without a mass. An incisional biopsy was performed in 49 of these cases (30%). Follow-up mammograms were available for review in 39 of the cases. The average length of follow-up was 32 months.
In no
case
did
malignancy
develop at the biopsy site. When an incisional biopsy is performed, careful follow-up mammography is an alternative to a repeated needle localization and biopsy in selected cases. Index terms:
Breast, calcification, 00.811 ization, 00.125, 00.312 lization, 00.125
biopsy, 00.12986 #{149} Breast, Breast neoplasms, local#{149} Breast radiography, uti-
#{149}
T
HE
1992;
185:411-413
by a radiobo-
to perform
a biopsy
operative tion
of a
nonpalpable breast lesion indicates an unequivocal concern that the lesion may be malignant. Complete excision of the mammographic abnormality permits the pathologist to evaluate the entire lesion for any histologic evidence of tumor so that the definitive diagnosis of its benign or malignant nature can be established. Less than complete excision of a nonpalpable breast lesion, or incisional biopsy, however, presents a management dilemma for both the clinician and radiobogist
when
histologic
analysis
proves the specimen to be benign. Since some of the lesion remains in vivo, the possibility exists that the excised
Radiology
recommendation
gist
benign
tissue
was
not
represen-
tative of the entire lesion and that diagnosed malignancy may remain within the breast.
un-
Numerous series have analyzed the experience of localization with needle or dye for the nonpalpabbe breast besion. These reviews address issues such as the positive of mammographic
tion techniques, mammographic the procedure edge, little has localization for graphic lesions
biopsy.
predictive findings,
failure to excise the lesion, and pitfalls of (i-fl). To my know!been written about nonpalpabbe mammoresulting in incisionab
It is the
purpose
tigation to review Tufts University-New cal Center Hospitals biopsy
for
the
of this
From the Department of Radiology, Box 388, New England Medical Center Hospitals, Tufts University School of Medicine, 750 Washington St. Boston, MA 02111. Received April 15, 1992; revision requested May 28; revision received June 16; accepted June 24. Address reprint requests to the author. 0 RSNA, 1992
nonpalpabbe
MATERIALS
mammo-
izations
for
were
reviewed.
nonpa!pable
needle breast
From
these
lesions
that without
In each
of these
the fob-
local-
lesions
cases,
benign
were manifest mass were
cases
the pre-
needle specimen
and pathology Determination
incisional or excisiona! performed. In all cases sional biopsy had been findings
and
an
biopsy had been in which an mciperformed, the
of follow-up
obtained
localiza-
radiographs,
reports were correlated. was made as to whether
mammography
were
correlated.
RESULTS Review boca!izations
of 500 consecutive for nonpalpable
needle breast
lesions identified 213 (43%) lesions that were manifest as microcalcifications without an associated mass. these, 48 were malignant and 165
were benign. Incisionab in 49 of the
biopsies 165 cases
Of
were performed of benign micro-
calcifications (30%). In 18 cases an incisional biopsy was performed purposeby because of the barge volume of the lesion (Figure), while in 31 cases
the original intent complete excisional
was to perform a biopsy. Of these
49 cases, 39 had follow-up grams available for review. cases form the basis of this
the
mammoThese report.
39
The average length of follow-up 39 cases was 32 months (range,
6-71 in the
months).
In one
number
cations findings
case,
an
in
increase
of residual
microcalcifiin a repeated needle biopsy. Histologic
resulted
localization
and again
proved
benignity
and
revealed lobular hyperplasia, intraductal papibbomatosis, and apocrine metaplasia. In none of the other cases did the residual microcabcifications change
in appearance
repeated
to require
a
for a breast
le-
biopsy.
DISCUSSION
METHODS
consecutive
mammographic as microca!cifications
identified.
including and
AND
Five hundred
inves-
experience at England Mediwith incisionab
graphic ca!cifications, frequency, management, low-up results.
I
values bocaliza-
mammogram,
radiographs,
The sion,
goal whether
of biopsy palpable
or nonpalpa-
ble, is total excision to allow complete histologic analysis. Though this goal should be easily achieved for the palpable
breast
lesion,
it is not
always zill
a.
b.
C.
(a) Lateral-view mammogram shows a geographic area of microcalcifications (arrows) measuring d!e localization was performed because nothing was palpable. An incisional biopsy was purposely the specimen confirms excision of many microcalcifications (original magnification, x2). Histologic brocystic follow-up
changes with mammography.
easily
achieved
breast
lesion.
calcifications.
The
calcifications
for the nonpalpable Before
the
current
wide-
spread use of localization techniques, surgeons often removed large volumes of breast tissue, sometimes approaching the size of an entire quandrant, to guarantee excision of the mammographic abnormality. The accuracy of needle localization techniques has resulted in the removal of smaller volumes of breast tissue. While small-volume biopsies should be encouraged because they result in better cosmetic outcome, they can result in failure to excise some or all of the mammographic abnormality. Previous investigations have reported failure to excise a nonpalpable mammographic abnormality after bocalization
with
a frequency
10% (7-10). In our recent (ii) with 200 consecutive cabizations,
we
of i%-
experience needle lo-
completely
missed
the
lesion in 6% of cases. When there has been failure to excise any of the besion, it is clear that the histologic composition of the lesion remains totally unknown. When incomplete excision of the mammographic abnormality shows
ther 412
malignancy,
action
Radiology
#{149}
it is clear
is mandatory.
that
fur-
were
in ducts
and
periductal
stroma.
The
Management becomes bess clear, however, when histologic study of an incisional biopsy specimen shows no evidence of malignancy. Accepting nothing less than total excision for a nonpalpabbe mammographic lesion would mean that every patient must undergo repeated needle localization and surgery. This procedure would guarantee more postoperative deformity and in some cases result in unacceptable cosmesis for what in most cases
would
ultimately
prove
to be a
benign lesion. A repeated localization and biopsy incur added surgical, radiobogic, and pathologic costs and require additional time in the operating room and by the physician. On the other hand, assuming that the incisionab biopsy always reflects the benign nature of the unsampled portion of the lesion may not always be true (12). In our material the performance of an incisionab biopsy for benign microcalcifications without a mass was not infrequent and occurred in 30% of cases.
In 31 of 49 cases
(63%)
mci-
sional biopsy occurred despite the plan for an excisional biopsy. In the other i8 cases (37%) an incisional bi-
more than 3 cm in greatest diameter. (b) Neeperformed. (c) Magnification radiograph of examination revealed nonpro!iferative firesidual calcifications showed no change at
opsy
had
been
planned
because
re-
moval of all the microcalcifications would have resulted in an unacceptable cosmetic appearance. When an incisionab biopsy occurs, a determination must be made as to whether mammographic follow-up or repeated needle localization are options.
This
decision
requires
input
from the radiologist and pathologist to the surgeon. First, the radiologist must
judge
whether
the
site
at which
the biopsy specimen was obtained and whether the amount of the lesion excised are representative of the mammographic lesion. When necessary,
a repeated
postoperative
mogram can be obtained the precise site of biopsy by
the
location
mam-
to confirm as evidenced
of postoperative
edema and hemorrhage. The pathologist must not only be certain that no malignancy is present in the excised tissue, but determine the specific nature of the benign histologic findings. A lesion with little in the way of proliferative changes is viewed much differently from one with severe ductal hyperpbasia with cellular atypia. In the batter case, a repeated localization and biopsy November1992
might be indicated just on the basis of histologic analysis. Finally, the surgeon weighs the radiobogy and pathology information with the specifics of the case. Factors such as patient anxiety, risk factors, and cosmesis all have an impact on the final recommendation. In our experience it is only occasionally that a patient requests a repeated biopsy to achieve complete excision of the lesion when there is an option. Most of our patients prefer the follow-up option rather than repeated surgery. The ultimate choice of the patient is also dependent on the rapport and confidence she has with her surgeon as well
as the
way
in which
the
op-
tions are presented. Review of the radiology reports from needle localization procedures at our institution demonstrates the evolution in our management of the incisionab biopsy. At first, the performance of an incisional biopsy was often not even mentioned in the report. Now, when the occurrence of an incisional biopsy is discovered by the radiologist during review of the specimen radiograph, the surgeon is immediately informed when the findings of the specimen radiograph are telephoned to the operating room. A recommendation is made in the report that, if the incisional biopsy specimen proves to be benign and fobbow-up is chosen, mammography of the breast subjected to biopsy be performed within 6 months to assess stability
of the
residual
lesion.
An incisionab biopsy may occur with both a calcified and noncalcified mammographic abnormality. This study was limited to the experience with calcifications without a mass for several reasons. For the purpose of this analysis it is easier to objectively determine whether an incisional biopsy has occurred with calcifications,
Vnliim#{248}
1R
#{149} Miimhor
since there is a clear mammographic marker of calcium. Often it is more difficult to be certain whether an mcisional biopsy has occurred when the mammographic
lesion
is an
indistinct
mass or an asymmetric area of high opacity. Follow-up of noncalcified lesions is also complicated by the difficulty
in distinguishing
between
findings, management options may include follow-up or repeated needle localization and biopsy. Whenever an incisional biopsy has been performed and a repeated biopsy is not recommended, we perform mammographic follow-up to ensure stability of residual lesion left in vivo. U
the
actual residual lesion and expected postoperative area of high opacity. A more frequent clinical situation is to be faced with the problem of management of a barge geographic vobume of microcalcifications in which total excisionab biopsy is clearly an unacceptable option. Finally, an mcisional biopsy is usually more common in cases of microcalcifications when there is almost never a palpable abnormality to guide the surgeon at the time of dissection. With noncabcified masses, the surgeon can often palpate the abnormality at the site of the localization wire. At our institution management is the same for all incisional biopsies regardless of the mammographic appearance of the lesion. To be specific, the recommendation after incisional biopsy for microcalcifications does not differ from the recommendation after incisional biopsy for an asymmetric area of high opacity or noncalcified mass. The follow-up protocol that we use is the same that we use for lesions with a high probability of benignity. Follow-up begins within 6 months and lasts for a minimum of 21,43 years. In summary, the performance of an incisional biopsy for a mammographic lesion of microcalcifications without a mass is not uncommon. In cases in which complete excision of the volume of calcifications would result in an unacceptable cosmetic outcome, an incisional biopsy can be performed. On the basis of careful correlation between the radio!ogic and pathologic
References 1.
2.
3.
4.
Ciatto pab!e
S, Cataliotti L, Distante V. Nonpa!lesions detected with mammography: review of 512 consecutive cases. Radiology 1987; 165:99-102. Hall FM, Storella JM, Siverstone DZ, Wyshak C. Nonpalpable breast lesions: recommendations for biopsy based on suspicion of cardnoma at mammography. Radiology 1988; 167:353-358. MeyerJE, Kopans DB, Stomper PC, Lindfors KK. Occult breast abnormalities: percutaneous preoperative needle localization. Radiology 1984; 150:335-337. MeyerJE, Sonnenfeld MR, Greenes Stomper PC. Preoperative localization of clinically occult breast lesions: experience at a referral hospital. Radiology 1988; 169:
627-628. 5.
6.
7.
8.
Rosenberg AL, Schwartz GF, Feig SA, Patchefsky AS. Clinically occult breast lesions: localization and significance. Radiology 1987; 162:167-170. Sick!es EA. Mammographic features of 300 consecutive nonpalpable breast cancers. AJR 1986; 146:661-663. Gallagher WJ, Cardenosa C, Rubens JR. McCarthy KA, Kopans DB. Minimal-volume exdsion of nonpa!pable breast lesions. AJR 1989; 153:957-961. Gisvold JJ, Martin JKJr. Prebiopsy localization of nonpa!pab!e breast lesions. AJR 1984;
9.
10.
11.
12.
Hall
143:477-481.
FM, Frank HA. Preoperative localization of nonpalpable breast lesions. AJR 1979; 132:101-105. Homer MJ. Localization of nonpalpab!e breast lesions: technical aspects and analysis of8O cases. AJR 1983; 140:807-811. Homer MJ, Smith TJ, Safaii H. Prebiospy needle !ocalization: methods, problems, and expected results. Radiol Clin North Am 1992; 30:139-153. Homer MJ, Safaii H, Smith TJ, Marchant DJ. The relationship of mammographic microcalcifications to histologic malignancy: radiologic-pathologic correlation. AJR 1989; 153:1187-1189.
