Journal of Surgical Oncology 40:152-154 (1989)

Enhanced Detection of Preinvasive Breast Cancer: Combined Role of Mammography and

Needle Localization Biopsy

MARK MOLLOY, MD, KENNETH AZAROW, MD, VICTOR F. GARCIA, MD, AND

JAMES R. DANIEL, MD

From the Department o f General Surgery, Walter Reed Army Medical Center, Washington, DC

Several recent reports have described an increase in the incidence of preinvasive carcinoma of the breast. To determine the incidence of pre- invasive breast cancer at our institution, the results of 469 consecutive outpatient breast biopsies performed at Walter Reed Army Medical Center between July 1, 1985, and January 1, 1987, were reviewed. During this time period, 256 biopsies were performed on palpable masses, and 213 needle localization biopsies were performed on mammographically sus- picious lesions. The overall incidence of cancer was 15.4%. Needle lo- calization biopsies yielded a diagnosis of cancer in 17.8% of cases, as did 13.3% of biopsies performed on palpable masses. Eight of 38 (21.1%) carcinomas identified by mammography were preinvasive at the time of diagnosis. Only one of 34 (2.9%) cancers identified because of a breast mass was preinvasive. We conclude that screening mammography is an invaluable tool for the detection of preinvasive carcinoma of the breast and that the increased use of mammography will result in an increase in the incidence of detection of this lesion.

KEY WORDS: intraductal carcinoma, breast biopsy, breast imaging

INTRODUCTION

Current estimates are that 9% of American women will develop breast cancer sometime during their lives. Breast cancer causes more deaths among U.S. women than any malignancy other than lung cancer. Numerous studies [ 1-31 have shown that those women with prein- vasive carcinoma of the breast have a significantly better prognosis than their counterparts who have invasive breast cancer at the time of diagnosis. Preinvasive car- cinoma of the breast has traditionally been regarded as an unusual lesion, constituting 2-3% of most series re- ported prior to 1981 [4,5]. Several recent reports of niammographically identified breast carcinomas have de- scribed a much higher incidence of preinvasive lesions, with figures ranging between 20% and 44% [6-91. We have reviewed our recent experience with outpatient breast biopsy to determine the incidence of preinvasive breast cancer at our institution and to evaluate the effi- cacy of mammography in detecting such lesions.

MATERIALS AND METHODS The clinical records of 477 consecutive patients who

underwent outpatient, open breast biopsies in the Gen- eral Surgery Clinic at Walter Reed Army Medical Center between July 1, 1985, and January 1, 1987, were re- viewed. Eight patients had incomplete records with re- spect to either age or type of biopsy performed and were therefore excluded from consideration. The remaining 469 records were reviewed for information regarding the age of the patient, the date and type of biopsy performed, and the diagnosis rendered on the specimen obtained. Data regarding hematoma formation, wound infection, and missed lesions in needle localization biopsies were also recorded.

Accepted for publication June 18, 1988 Address reprint requests to Mark Molloy, CPT, MC, Department of General Surgery, Walter Reed Army Medical Center, Washington, DC 20307-500 I .

c 1989 Alan R. I h , Inc.

Enhanced Detection of Preinvasive Breast Cancer 153

in situ. Of the nine noninfiltrating carcinomas, eight (89%) were diagnosed by needle localization biopsy.

In all, eight of the 38 cancers (21.1%) identified by needle localization biopsy were preinvasive lesions, whereas only one of the 34 malignancies (2.9%) identi- fied by biopsy of a palpable lesion was found to be preinvasive. The difference in incidence of preinvasive carcinoma between the two groups was found to be sta- tistically significant ( P = .O2, x2 analysis).

Nine of the 213 (4.2%) needle localization biopsies had failed to excise the suspicious lesion when specimen mammograms were obtained, and this represented the single most frequent complication encountered in the re- view. Either hematomas or wound infections requiring subsequent drainage developed in eight patients (3.7%) who underwent needle localization biopsies and in 11 of the 256 patients (4.3%) operated on for palpable masses. The overall complication rate was 6.0%. The complica- tion rate for biopsies on palpable masses was 4.3%, and the complication rate for needle localization biopsies was 8.0%.

DISCUSSION The use of roentgenograms in evaluation of the breast

for carcinoma was first suggested in 1930 by Warren [ 111. Interest in the technique was rekindled in the early 1970s, and during that time the Breast Cancer Detection Demonstration Project was developed. The 5 year sum- mary report of this project was published in 1982 [12], and it established the importance of mammography in the detection of breast cancer. More than 200,000 women were enrolled in the study, and 42% of the carcinomas identified in patients over 50 years of age were detected by mammography alone.

In 1983, the American Cancer Society extended the recommendation for annual screening mammography to include those women between 40 and 50 years of age. In addition, a baseline study was recommended between the ages of 35 and 40 years [13]. Previous studies [14,15] have demonstrated an increased 5 year survival for those women whose cancers were detected by mammography before a palpable mass was present. This extension of the use of screening mammography may therefore be ex- pected to impact favorably on the natural history of breast cancer.

The incidence of preinvasive carcinoma of 12.5% noted among the 72 cases of carcinoma identified during this study is much higher than the incidence of 3.2% described in the American College of Surgeons survey of 10,054 cases of breast cancer reported in 1980 [4]. Other authors have also described an increasing incidence of preinvasive carcinoma associated with more widespread use of mammography [6,16,17]. In our population, over half of the cancers diagnosed by open biopsy during the

All the biopsies were performed under local anesthesia in an outpatient operating room located in our clinic. Those patients who underwent needle localization biop- sies had preoperative localization of their lesions per- formed in the mammography suite using the Kopans hook wire technique [lo]. These patients were then transported to the surgery clinic, where the biopsy itself was performed. When needle localization biopsy was performed for suspicious calcifications, a specimen mammogram to confirm the presence (or absence) of those calicifications was obtained prior to processing the tissue for histologic examination. Statistical analysis of the data obtained was performed by either Student’s t test or x2 analysis, which ever was more appropriate for the data.

RESULTS A total of 469 open, outpatient breast biopsies per-

formed during the 18 month period described were re- viewed. There were 256 biopsies performed on palpable breast masses (54 -6%). The remaining 2 13 biopsies (45.4%) were performed on mammographically suspi- cious lesions that were not palpable on physical exami- nation.

The patients ranged in age from 17 to 89 years; the mean age of all patients was 51.5 years. There was no significant difference between the mean age of those pa- tients who underwent needle localization biopsies (58.0 years) and those who had biopsies performed on palpable masses (45.8 years), although those patients with palpa- ble masses tended to be younger.

A total of 72 breast carcinomas were identified among the 469 specimens removed (incidence of 15.4%). Can- cer was identified in 38 of the 213 needle localization biopsies (17.8%) and in 34 of the 256 biopsies of pal- pable masses (1 3.3%), Needle localization biopsy was responsible for the diagnosis of 52.7% of the cancers identified in the population studied.

The mean age of all patients who were found to have cancer was 58.5 years and was not significantly different from the mean age of the total biopsy population (5 1.5 years; P = 0.16, Student’s t test). Similarly, no signif- icant difference was seen between the mean age of those patients who had needle localizations positive for carci- noma (60.9 years) and the mean age of those whose cancers presented as palpable masses (56.3 years; P = 0.20, Student’s t test).

Infiltrating ductal carcinoma was identified in 54 of the 72 specimens positive for cancer (75%), and nine (12.5%) cases of infiltrating lobular carcinoma were found. Nine (12.5%) of the 72 malignancies identified were determined to be preinvasive. Seven (9.7%) of these were intraductal carcinomas, and the remaining two specimens (2.8%) demonstrated lobular carcinoma

154 Molloy et al.

study period were identified by mammography alone, and 21.1% of these lesions were detected in a preinva- sive stage. Overall, 89% of the preinvasive cancers iden- tified at our institution were first detected by mammog- raphy.

In this series, needle localization biopsies yielded a diagnosis of cancer in 17.8% of cases. This figure com- pares favorably with positivity rates reported in other series of similar populations [16-181. The yield of 13.3% in biopsies performed on palpable masses is lower than anticipated and may in part be explained by a recent increase in the use of true-cut needle biopsies at our facility. Presumably, many of the larger (i.e., 2 2.0 cm.) tumors referred to our clinic were diagnosed by this latter technique, and only less discrete lesions eventually came to open biopsy.

The complication rate encountered with needle local- ization biopsy is identical, in our experience, to that observed in biopsies of palpable masses if the complica- tion of failed localization is excluded. Both groups de- veloped wound infections and hematomas at a rate of approximately 4%. Other authors have reported compli- cation rates at or near this figure [16-181. Some inci- dence of failed localizations will inevitably be encoun- tered, and the benefits in terms of potentially diagnosing an otherwise occult breast cancer more than outweigh the risks and inconvenience involved with a repeated attempt at needle localization.

CONCLUSIONS

Preinvasive carcinoma of the breast is a lesion that is being identified more frequently than previous studies would suggest. We have found that 12.5% of the breast cancers diagnosed by open biopsy at our facility between July 1, 1985, and January 1, 1987, were identified dur- ing a preinvasive stage. Of those cancers detected by mammography, 21.1 % were preinvasive at the time of biopsy, whereas only 2.9% of the palpable breast cancers identified were preinvasive.

As the use of screening mammography continues to increase, the number of preinvasive carcinomas identi- fied should also increase. Since both patients with pre- invasive carcinomas [ 1-31 and those with mammograph- ically detected lesions [ 14,151 have been shown to have

a better prognosis than their counterparts who first come to surgical attention because of a palpable mass, the ex- tended use of mammography may be expected to pro- duce some improvement in the results of currently avail- able therapy for carcinoma of the breast.

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