Frederick R. Margolin

Seventy-nine patients with mammographically detected foci of duct carcinoma in situ (DCIS) of histologically confirmed extents of 25 mm or less, were treated by tylectomy without irradiation or axillary dissection. Adequacy of excision was confirmed histologically, by radiographic-pathologic correlation and by postoperative mammographic examination. Eight patients (10.1%) have recurred locally in the immediate vicinity of the biopsy site. Four patients developed recurrent in situ disease identified mammographically, and all were initially treated by reexcision. One of these patients subsequently elected to undergo mastectomy; no residual in situ or invasive disease was detected in the breast or in axillary lymph nodes. Four patients developed recurrent invasive disease; 50% of these recurrences were detected mammographically. All patients were treated by mastectomy with node dissection. Three had confirmed minimal invasive carcinomas and were N0, one patient had a 13-mm invasive lobular carcinoma with a single Group I micrometastasis. All patients, including those treated for a recurrence, are presently free of disease but three patients died of heart disease. Nuclear grade would appear to identify subsets of DCIS more likely to produce local failure after tylectomy alone. Duct carcinoma in situ with high-grade nuclear morphology and comedo-type necrosis was associated with a 19% local recurrence rate after an average interval of 26 months; only one of ten patients with intermediate-grade DCIS developed a local recurrence at 87 months; and none of 33 patients with DCIS of micropapillary/nonnecrotic cribriform type and low-grade nuclear morphology developed local recurrence in the follow-up period.

Fifty-three breasts resected for a biopsy diagnosis of duct carcinoma in situ were studied with a serial subgross and correlated radiographic method of examination designed to permit quantitation of the extent of the noninvasive lesion in the breast. Overall frequencies of occult invasion and multicentricity were 21 and 32%, respectively. Among 24 lesions 25 mm or larger in extent (average, 63; median, 56 mm) 11 showed occult foci of invasion, 13 had multicentric foci and six had nipple involvement. Among 29 lesions less than 25 mm in extent (average, 10; median, 8 mm) there were no instances of occult invasion, four were multicentric and two had nipple involvement (P = less than 0.05 for multicentricity and occult invasion). Twenty patients with lesions averaging 8 mm in extent are being followed after excision only in an experimental program. There have been three local recurrences at an average follow-up of 44 months. All recurrences occurred ipsilaterally, two were within the prior biopsy site. All patients with recurrence are free of disease following local resection in two and modified radical mastectomy in one. For lesions with associated microcalcifications, the distribution of the mammographic microcalcifications closely approximates the extent of disease as confirmed histologically. These findings suggest that an important predictive factor for the presence of occult invasion and multicentricity in the resected breast is the extent of the noninvasive lesion.

Percutaneous core biopsy of the breast: effect of operator experience and number of samples on diagnostic accuracy.R J Brenner, L Fajardo, P R Fisher, D D Dershaw, W P Evans, L Bassett, S Feig, E Mendelson, V Jackson and F R MargolinAudio Available | Share

PURPOSE: To assess the accuracy of stereotactic core-needle biopsy (CNB) of nonpalpable breast lesions within the context of clinically important parameters of anticipated tissue-sampling error and concordance with mammographic findings. MATERIALS AND METHODS: CNB was performed in 1,003 patients, with results validated at surgery or clinical and mammographic follow-up. Mammographic findings were scored according to the American College of Radiology Breast Imaging Reporting and Data System with a similar correlative scale for histopathologic samples obtained at either CNB or surgery. Agreement of CNB findings with surgical findings or evidence of no change during clinical and mammographic follow-up (median, 24 months) for benign lesions was used to determine results. Three forms of diagnostic discrimination measures (strict, working [strict conditioned by tissue sampling error], applied [working conditioned by concordance of imaging and CNB findings) were used to evaluate the correlation of CNB, surgical, and follow-up results. RESULTS: Strict, working, and applied sensitivities were 91% +/- 1.9; 92% +/- 1.8, and 98% +/- 0.9, respectively; strict, working, and applied specificities were 100%, 98% +/- 0.8, and 73% +/- 0.9; strict, working, and applied accuracies were 97%, 96%, and 79%. CONCLUSION: Percutaneous stereotactic CNB is an accurate method to establish a histopathologic diagnosis of nonpalpable breast lesions. Accuracy increases when additional surgery is performed for lesions with anticipated sampling error or when CNB findings are discordant with mammographic findings. An understanding of the interrelationship among these parameters is necessary to properly assess results.

Seventeen tubular carcinomas occurred among 211 consecutive mastectomies (7.6%). The relative frequencies of multicentric involvement in the ipsilateral breast (56%), history of bilateral mammary cancer (38%) (P less than .01), and family history of mammary cancer in a first-degree relative (40%) (P less than .05) were all significantly greater in patients with tubular carcinomas than among patients with other carcinomas studied in a review of serial subgross examined mastectomy specimens. Patients with tubular carcinomas also tended to be somewhat younger (56 vs. 59 years) than those with other forms of mammary cancer. These features suggest that tubular carcinoma may be a histologic marker for a subpopulation of patients with mammary carcinomas strongly associated with multicentricity, bilaterality, and familial history of mammary carcinoma.