Downloaded from www.ajronline.org by Dalhousie University on 10/01/13 from IP address 129.173.72.87. Copyright ARRS. For personal use only; all rights reserved
1196
Commentary
Stereotactic Nonpalpable
Fine-Needle Aspiration Breast Lesions
Valerie P. Jackson1
and Lawrence
Dr. Lofgren and associates
W. Bassett2
have reported
their experience
breast lesions by using a stereotactic device to guide needle placement [1 ]. This is an exciting technology that could reduce the number of unnecessary excisional breast biopsies. Good results also have been reported in other studies [2-4], mostly with
fine-needle
aspiration
of 21 9 nonpalpable
biopsy
performed in Europe. Although it is tempting to immediately adapt this technology for widespread clinical practice, we must proceed cautiously because this manuscript originating in Europe may not be applicable to the United States. Satisfactory results with stereotactically guided fine-needle aspiration
biopsy
have
yet
where case selection addition, this method
arena, which, medicine
to
be verified
in the
United
States,
and medical practice are different. In has not been tested in our medicolegal
for better
or worse,
influences
the practice
of
in this country.
Several
of mammography
equipment
are
marketing stereotactic own strengths and $35,000 for systems
devices. Each of these devices has its weaknesses. The costs range from that attach to existing mammography
units,
$1
designed
to
more
than
specifically
20,000
for free-standing
for stereotactic
needle
equipment
placement.
Thus,
a sufficiently large number of nonpalpable breast lesions must be detected mammographically to justify its purchase. Most of the stereotactic devices provide accurate guidance for fineneedle
aspiration
To date, the only proved role for stereotactic mammography devices is for fine-needle aspiration biopsy. They have occasionally been used to guide pneumocystography of non-
palpable cysts (a procedure not widely used in the United States) and to localize suspicious lesions seen in only one mammographic
biopsy
when
properly
installed,
calibrated,
and used. However, stereotactic systems for mammography are in a relatively early stage of development, and mammographers have had significant problems with them.
view.
Use
of a stereotactic
ing of the breast
for biplane
before
of the needle.
removal
the benefit
confirmation
of adjusting
Thus,
June
1990 0361 -803X/90/1
546-1196
for
of needle
im-
placement
the wire was
its depth
placed
on an orthogonal
view. With stereotactic placement from a single plane, the wire and lesion may move apart on the release of breast compression, leaving the hook of the wire too deep (suboptimal) or too superficial (unacceptable). When using a biplane method (fenestrated compression plate or even freehand technique), the relationship of the needle and lesion can be evaluated from two directions before the wire is loaded through the needle. It is difficult to evaluate and compare the data from many
of the reports on stereotactic fine-needle aspiration biopsy because study designs, techniques, and case selection differ significantly. Although LOfgren et al. [1] do elaborate on the mammographic
features
of the lesions
This article is a commentary on the preceding article by Lbfgren et al. This work was supported in part by grant #R01 CA48004-O1A1 of the National Cancer Institute of the National Institutes of Health. Department of Radiology, Indiana University School of Medicine, Wishard Memorial Hospital, 1001 W. 10th St., Indianapolis, IN 46202. to V. P. Jackson. 2 Iris Cantor Center for Breast Imaging, University of California, Los Angeles, School of Medicine, Los Angeles, CA 90024-1721. AJR 154:1196-1197,
system
proving routine preoperative needle localization has been reported once [5]. However, when compared with the use of fenestrated compression plates for preoperative needle localization, the stereotactic devices generally require more time and a larger radiation dose. In addition, stereotactic hookwire placement is sometimes unreliable. This is because, until recently, most stereotactic systems did not allow reposition-
without
manufacturers
Biopsy for
© American Roentgen Ray Society
in their
Address
series,
reprint
other
requests
investigators
do not. Many
reports,
including
that by LOfgren
et al. [1], include many cysts among the nonpalpable The inclusion of cysts, which are readily diagnosed
lesions. by aspi-
Downloaded from www.ajronline.org by Dalhousie University on 10/01/13 from IP address 129.173.72.87. Copyright ARRS. For personal use only; all rights reserved
ration, exaggerates the sensitivity and specificity of fineneedle aspiration biopsy because in the United States most cysts would be diagnosed by sonography alone and thus
would not be selected for fine-needle aspiration biopsy. The categorization of data on fine-needle aspiration biopsy has been inconsistent in published reports. For example, cases with insufficient fine-needle aspiration biopsy specimens have been distributed among normal, negative, and positive categories in different studies. Similar inconsistencies are encountered with “atypical” or “suspicious” lesions, those not clearly
benign
or malignant
by cytology.
However,
only
input from the mammographer, surgeon.
Unfortunately,
managed
in the United
quently
disjointed.
biopsy
provoking
false-negative
rate
is in-
creased. It is imperative that investigators report their data more clearly so that radiologists can make well-informed judgments of the usefulness of fine-needle aspiration biopsy in their practices.
Optimally,
standard
nomenclature
and
methodol-
should be adopted so that data from different sources can be pooled to clarify rather than confuse this issue. Is a stereotactic system essential for fine-needle aspiration biopsy of nonpalpable breast lesions? Two reports showed ogy
good
results
with
a coordinate-grid
fenestrated
compression
plate to guide fine-needle aspiration biopsy [6, 7]. The disadvantage of using a modified compression plate is less precise needle guidance, increasing the possibility of missing the lesion.
Using
a fenestrated
compression
plate,
LOfgren
et al.
reported a 36% insufficient specimen rate, identical to the rate reported by Hann et al. [7] with the same method of [6]
guidance.
reported other
Using
investigators
for this method icant,
the stereotactic
an insufficient
difference
report
[2-4].
system,
specimen
LOfgren
insufficiency
rates of less than 25%
Does this small, yet statistically
in the yield
et al. [1]
rate of only 26%, and most
of diagnostic
specimens
and how an insufficient fine-needle aspiration
aspiration
mammographer,
biopsy
a pathologist
remain skeptical
will improve
is fre-
aspiration
is unlikely
to fulfill its
ing the specificity
our own
image
Another
eliminating
follow-up
workups,
referring
of equivocal
need
the
for
mammograms.
of mammographic
with
potential
of the nature
physicians
only (one benefit
anxiety-
By increas-
we can improve
who
have
come
to
believe that our indecisions outnumber our decisions. Despite the need for further refinements of stereotactic instruments and the paucity of data from the United States, we should not underestimate the impact that this technology could have on mammography. The large number of unnecessary
biopsies
that
mammograms
result
from
false-positive
is a major deterrent
recommending
screening
and
to referring
mammography.
equivocal
physicians
Hopefully,
for mam-
mographically guided fine-needle aspiration biopsy will reduce the number of unnecessary surgical biopsies, and thus we believe that this method will become increasingly important in the management of nonpalpable breast lesions. However, we
caution
readers
to
critically
evaluate
published
studies
in
relation to their own setting, and, as suggested by Kopans [8], perform their own pilot studies before implementing this technology in their clinical practice. Stereotactic fine-needle aspiration biopsy is best suited to high-volume practices many
biopsies
are performed
cytopathologists,
a team approach
to manage
and where and
breast
experienced surgeons
use
each case.
specimen result is handled. A failed biopsy might be followed by another
program
experienced
uses
a compulsive
in breast cytology,
about the role of fine-needle
or lymph node), or there is a possibility that the lesion has been missed, excisional biopsy is still performed. Undoubtresults
4- to 6-month
mammographers,
aspiration biopsy in their practices. They argue that if cytologic findings are positive, they must still remove the lesion, and if cytologic findings are not definitely benign (e.g., fibroadenoma
edly,
the approach fine-needle
lesions
determination findings,
where
and a supportive surgeon who works closely with the radiologist and pathologist. However, many breast surgeons in the
United States
mammographic
signif-
attempt at fine-needle aspiration or by excisional biopsy. For many of us who are not skilled at fine-needle aspiration biopsy with fenestrated compression plates, the improved precision of stereotactic guidance could be a welcome luxury or even an essential ingredient for fine-needle aspiration biopsy of nonpalpable lesions. We cannot overemphasize the benefits of the team approach used by LOfgren et al. Their successful stereotactic fine-needle
breast
and one for treatment).
is the immediate
justify
the purchase of a stereotactic system? The answer to this question depends on the number of procedures performed
where
a setting,
and (2) definite malignant lesions that will necessitate one operation (for treatment), instead of two operations
they
the
States,
In such
for nonpalpable
for diagnosis
as “negative,”
and the are usually
potential. Stereotactic fine-needle aspiration biopsy should not be used as just another step in a costly “multimodality” workup. Optimally, it should make a useful and cost-effective contribution to the management of nonpalpable breast lesions. It can decrease the need for excisional biopsies by identifying (1) definite benign lesions that do not require excisional biopsy
some of these suspicious lesions will turn out to be malignant at excisional biopsy. If such lesions are included in the positive category, the false-positive rate is increased. Conversely, if are listed
the cytopathologist,
this is not the way cases
when
decisions
are based
on joint
REFERENCES 1. LOfgren M, Andersson I, Lindholm K. Stereotactic fine-needle aspiration for cytologic diagnosis of nonpalpable breast lesions. AJR 1990; 154:1191 -1195 2. Ciatto S. Del Turco MA, Bravetti P. Nonpalpable breast lesions: stereotaxic fine-needle aspiration cytology. Radiology 1989;173:57-59 3. Dowlatshahi K, Gent HJ, Schmidt A, Jokich PM, Bibbo M, Sprenger E. Nonpalpable fine-needle
4. Azavedo
breast tumors: diagnosis with stereotaxic aspiration. Radiology 1988;1 70:427-433
E, Svane G, Auer G. Stereotactic
mammographically
detected
non-palpable
localization
fine-needle lesions.
biopsy
Lancet
1989;1
and in 2594 :1033-
1036 CAB, Bergeron RB, Sullivan MA, et al. Stereotactic guidance for breast biopsy localization and aspiration. Radiology 1989;173(P):457 6. LOfgren M, Andersson I, Bondeson L, Lindholm K. X-ray guided fine-needle 5. Merritt
aspiration for the cytologic 1988;61 :1032-1 037
diagnosis
of nonpalpable
breast
lesions.
Cancer
7. Hann L, Ducatman BS, Want HH, Fein V, Mclntire JM. Nonpalpable lesions: evaluation by means of fine-needle aspiration 1989;171 :373-376 8. Kopans DB. Fine-needle aspiration of clinically occult diology 1989;170:313-314
cytology. breast
breast
Radiology lesions.
Re-
1196
Commentary
Stereotactic Nonpalpable
Fine-Needle Aspiration Breast Lesions
Valerie P. Jackson1
and Lawrence
Dr. Lofgren and associates
W. Bassett2
have reported
their experience
breast lesions by using a stereotactic device to guide needle placement [1 ]. This is an exciting technology that could reduce the number of unnecessary excisional breast biopsies. Good results also have been reported in other studies [2-4], mostly with
fine-needle
aspiration
of 21 9 nonpalpable
biopsy
performed in Europe. Although it is tempting to immediately adapt this technology for widespread clinical practice, we must proceed cautiously because this manuscript originating in Europe may not be applicable to the United States. Satisfactory results with stereotactically guided fine-needle aspiration
biopsy
have
yet
where case selection addition, this method
arena, which, medicine
to
be verified
in the
United
States,
and medical practice are different. In has not been tested in our medicolegal
for better
or worse,
influences
the practice
of
in this country.
Several
of mammography
equipment
are
marketing stereotactic own strengths and $35,000 for systems
devices. Each of these devices has its weaknesses. The costs range from that attach to existing mammography
units,
$1
designed
to
more
than
specifically
20,000
for free-standing
for stereotactic
needle
equipment
placement.
Thus,
a sufficiently large number of nonpalpable breast lesions must be detected mammographically to justify its purchase. Most of the stereotactic devices provide accurate guidance for fineneedle
aspiration
To date, the only proved role for stereotactic mammography devices is for fine-needle aspiration biopsy. They have occasionally been used to guide pneumocystography of non-
palpable cysts (a procedure not widely used in the United States) and to localize suspicious lesions seen in only one mammographic
biopsy
when
properly
installed,
calibrated,
and used. However, stereotactic systems for mammography are in a relatively early stage of development, and mammographers have had significant problems with them.
view.
Use
of a stereotactic
ing of the breast
for biplane
before
of the needle.
removal
the benefit
confirmation
of adjusting
Thus,
June
1990 0361 -803X/90/1
546-1196
for
of needle
im-
placement
the wire was
its depth
placed
on an orthogonal
view. With stereotactic placement from a single plane, the wire and lesion may move apart on the release of breast compression, leaving the hook of the wire too deep (suboptimal) or too superficial (unacceptable). When using a biplane method (fenestrated compression plate or even freehand technique), the relationship of the needle and lesion can be evaluated from two directions before the wire is loaded through the needle. It is difficult to evaluate and compare the data from many
of the reports on stereotactic fine-needle aspiration biopsy because study designs, techniques, and case selection differ significantly. Although LOfgren et al. [1] do elaborate on the mammographic
features
of the lesions
This article is a commentary on the preceding article by Lbfgren et al. This work was supported in part by grant #R01 CA48004-O1A1 of the National Cancer Institute of the National Institutes of Health. Department of Radiology, Indiana University School of Medicine, Wishard Memorial Hospital, 1001 W. 10th St., Indianapolis, IN 46202. to V. P. Jackson. 2 Iris Cantor Center for Breast Imaging, University of California, Los Angeles, School of Medicine, Los Angeles, CA 90024-1721. AJR 154:1196-1197,
system
proving routine preoperative needle localization has been reported once [5]. However, when compared with the use of fenestrated compression plates for preoperative needle localization, the stereotactic devices generally require more time and a larger radiation dose. In addition, stereotactic hookwire placement is sometimes unreliable. This is because, until recently, most stereotactic systems did not allow reposition-
without
manufacturers
Biopsy for
© American Roentgen Ray Society
in their
Address
series,
reprint
other
requests
investigators
do not. Many
reports,
including
that by LOfgren
et al. [1], include many cysts among the nonpalpable The inclusion of cysts, which are readily diagnosed
lesions. by aspi-
Downloaded from www.ajronline.org by Dalhousie University on 10/01/13 from IP address 129.173.72.87. Copyright ARRS. For personal use only; all rights reserved
ration, exaggerates the sensitivity and specificity of fineneedle aspiration biopsy because in the United States most cysts would be diagnosed by sonography alone and thus
would not be selected for fine-needle aspiration biopsy. The categorization of data on fine-needle aspiration biopsy has been inconsistent in published reports. For example, cases with insufficient fine-needle aspiration biopsy specimens have been distributed among normal, negative, and positive categories in different studies. Similar inconsistencies are encountered with “atypical” or “suspicious” lesions, those not clearly
benign
or malignant
by cytology.
However,
only
input from the mammographer, surgeon.
Unfortunately,
managed
in the United
quently
disjointed.
biopsy
provoking
false-negative
rate
is in-
creased. It is imperative that investigators report their data more clearly so that radiologists can make well-informed judgments of the usefulness of fine-needle aspiration biopsy in their practices.
Optimally,
standard
nomenclature
and
methodol-
should be adopted so that data from different sources can be pooled to clarify rather than confuse this issue. Is a stereotactic system essential for fine-needle aspiration biopsy of nonpalpable breast lesions? Two reports showed ogy
good
results
with
a coordinate-grid
fenestrated
compression
plate to guide fine-needle aspiration biopsy [6, 7]. The disadvantage of using a modified compression plate is less precise needle guidance, increasing the possibility of missing the lesion.
Using
a fenestrated
compression
plate,
LOfgren
et al.
reported a 36% insufficient specimen rate, identical to the rate reported by Hann et al. [7] with the same method of [6]
guidance.
reported other
Using
investigators
for this method icant,
the stereotactic
an insufficient
difference
report
[2-4].
system,
specimen
LOfgren
insufficiency
rates of less than 25%
Does this small, yet statistically
in the yield
et al. [1]
rate of only 26%, and most
of diagnostic
specimens
and how an insufficient fine-needle aspiration
aspiration
mammographer,
biopsy
a pathologist
remain skeptical
will improve
is fre-
aspiration
is unlikely
to fulfill its
ing the specificity
our own
image
Another
eliminating
follow-up
workups,
referring
of equivocal
need
the
for
mammograms.
of mammographic
with
potential
of the nature
physicians
only (one benefit
anxiety-
By increas-
we can improve
who
have
come
to
believe that our indecisions outnumber our decisions. Despite the need for further refinements of stereotactic instruments and the paucity of data from the United States, we should not underestimate the impact that this technology could have on mammography. The large number of unnecessary
biopsies
that
mammograms
result
from
false-positive
is a major deterrent
recommending
screening
and
to referring
mammography.
equivocal
physicians
Hopefully,
for mam-
mographically guided fine-needle aspiration biopsy will reduce the number of unnecessary surgical biopsies, and thus we believe that this method will become increasingly important in the management of nonpalpable breast lesions. However, we
caution
readers
to
critically
evaluate
published
studies
in
relation to their own setting, and, as suggested by Kopans [8], perform their own pilot studies before implementing this technology in their clinical practice. Stereotactic fine-needle aspiration biopsy is best suited to high-volume practices many
biopsies
are performed
cytopathologists,
a team approach
to manage
and where and
breast
experienced surgeons
use
each case.
specimen result is handled. A failed biopsy might be followed by another
program
experienced
uses
a compulsive
in breast cytology,
about the role of fine-needle
or lymph node), or there is a possibility that the lesion has been missed, excisional biopsy is still performed. Undoubtresults
4- to 6-month
mammographers,
aspiration biopsy in their practices. They argue that if cytologic findings are positive, they must still remove the lesion, and if cytologic findings are not definitely benign (e.g., fibroadenoma
edly,
the approach fine-needle
lesions
determination findings,
where
and a supportive surgeon who works closely with the radiologist and pathologist. However, many breast surgeons in the
United States
mammographic
signif-
attempt at fine-needle aspiration or by excisional biopsy. For many of us who are not skilled at fine-needle aspiration biopsy with fenestrated compression plates, the improved precision of stereotactic guidance could be a welcome luxury or even an essential ingredient for fine-needle aspiration biopsy of nonpalpable lesions. We cannot overemphasize the benefits of the team approach used by LOfgren et al. Their successful stereotactic fine-needle
breast
and one for treatment).
is the immediate
justify
the purchase of a stereotactic system? The answer to this question depends on the number of procedures performed
where
a setting,
and (2) definite malignant lesions that will necessitate one operation (for treatment), instead of two operations
they
the
States,
In such
for nonpalpable
for diagnosis
as “negative,”
and the are usually
potential. Stereotactic fine-needle aspiration biopsy should not be used as just another step in a costly “multimodality” workup. Optimally, it should make a useful and cost-effective contribution to the management of nonpalpable breast lesions. It can decrease the need for excisional biopsies by identifying (1) definite benign lesions that do not require excisional biopsy
some of these suspicious lesions will turn out to be malignant at excisional biopsy. If such lesions are included in the positive category, the false-positive rate is increased. Conversely, if are listed
the cytopathologist,
this is not the way cases
when
decisions
are based
on joint
REFERENCES 1. LOfgren M, Andersson I, Lindholm K. Stereotactic fine-needle aspiration for cytologic diagnosis of nonpalpable breast lesions. AJR 1990; 154:1191 -1195 2. Ciatto S. Del Turco MA, Bravetti P. Nonpalpable breast lesions: stereotaxic fine-needle aspiration cytology. Radiology 1989;173:57-59 3. Dowlatshahi K, Gent HJ, Schmidt A, Jokich PM, Bibbo M, Sprenger E. Nonpalpable fine-needle
4. Azavedo
breast tumors: diagnosis with stereotaxic aspiration. Radiology 1988;1 70:427-433
E, Svane G, Auer G. Stereotactic
mammographically
detected
non-palpable
localization
fine-needle lesions.
biopsy
Lancet
1989;1
and in 2594 :1033-
1036 CAB, Bergeron RB, Sullivan MA, et al. Stereotactic guidance for breast biopsy localization and aspiration. Radiology 1989;173(P):457 6. LOfgren M, Andersson I, Bondeson L, Lindholm K. X-ray guided fine-needle 5. Merritt
aspiration for the cytologic 1988;61 :1032-1 037
diagnosis
of nonpalpable
breast
lesions.
Cancer
7. Hann L, Ducatman BS, Want HH, Fein V, Mclntire JM. Nonpalpable lesions: evaluation by means of fine-needle aspiration 1989;171 :373-376 8. Kopans DB. Fine-needle aspiration of clinically occult diology 1989;170:313-314
cytology. breast
breast
Radiology lesions.
Re-
