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CMDT 2008
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Multiple nodules
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Dominant mass
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Not clinically malignant Mammogram; ultrasound
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Clinically malignant
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Cystic
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No abnormality, or solid mass but not suggestive of malignancy
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Appears malignant
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Aspirate
Biopsy1 or reexamine after next menses or 1 4 months Persistence Excision Resolution Routine follow-up
Biopsy1
Biopsy1
Nonbloody fluid
Preoperative evaluation and counseling
Completely resolves
Definitive procedure
Reexamine Recurrence Excision No recurrence Routine follow-up
1Biopsy
may be excisional or by needle cytology, but if cytology appears benign and the mass persists, it should be excised
Figure 16 4 Evaluation of breast masses in premenopausal women (Adapted, with permission, from Giuliano AE: Breast disease In: Berek JS, Hacker NF [editors], Practical Gynecologic Oncology, 3rd ed LWW, 2000)
tic mass, in a premenopausal woman Rather, these masses can be observed through one or two menstrual cycles However, if the mass does not completely resolve during this time, it must be biopsied Figures 16 4 and 16 5 present algorithms for management of breast masses in premenopausal and postmenopausal patients The simplest biopsy method is needle biopsy, either by aspiration of tumor cells (FNA cytology) or by obtaining a small core of tissue with a hollow needle (core biopsy) FNA cytology is a useful technique whereby cells are aspirated with a small needle and examined cytologically This technique can be performed easily with no morbidity and is much less expensive than excisional or open biopsy The main disadvantages are that it requires a pathologist skilled in the cytologic diagnosis of breast cancer and that it is subject to sampling problems, particularly because
deep lesions may be missed Furthermore, noninvasive cancers usually cannot be distinguished from invasive cancers The incidence of false-positive diagnoses is extremely low, perhaps 1 2% The false-negative rate is as high as 10% Most experienced clinicians would not leave a suspicious dominant mass in the breast even when FNA cytology is negative unless the clinical diagnosis, breast imaging studies, and cytologic studies were all in agreement, such as a fibrocystic lesion or fibroadenoma Large-needle (core needle) biopsy removes a core of tissue with a large cutting needle Hand-held biopsy devices make large-core needle biopsy of a palpable mass easy and cost effective in the office with local anesthesia As in the case of any needle biopsy, the main problem is sampling error due to improper positioning of the needle, giving rise to a false-negative test result
Breast
CMDT 2008
Palpable mass Clinically malignant Mammography Not clinically malignant Mammography
Biopsy1
Preoperative evaluation and counseling
2 Ultrasonography Ultrasonography is performed primarily to differentiate cystic from solid lesions Though not diagnostic, ultrasound may reveal features highly suggestive of malignancy such as irregular margins on a new solid mass Ultrasonography may show an irregular mass within a cyst in the rare case of intracystic carcinoma If a tumor is palpable and feels like a cyst, an 18-gauge needle can be used to aspirate the fluid and make the diagnosis of cyst If a cyst is aspirated and the fluid is nonbloody, it does not have to be examined cytologically If the mass does not recur, no further diagnostic test is necessary Nonpalpable mammographic densities that appear benign should be investigated with ultrasound to determine whether the lesion is cystic or solid These may even be needle biopsied with ultrasound guidance 3 Mammography When a suspicious abnormality is identified by mammography alone and cannot be palpated by the clinician, the lesion should be biopsied under mammographic guidance In the computerized stereotactic guided core needle technique, a biopsy needle is inserted into the lesion with mammographic guidance, and a core of tissue for histologic examination can then be examined Vacuum assistance increases the amount of tissue obtained and improves diagnosis Mammographic localization biopsy is performed by obtaining a mammogram in two perpendicular views and placing a needle or hook-wire near the abnormality so that the surgeon can use the metal needle or wire as a guide during operation to locate the lesion After mammography confirms the position of the needle in relation to the lesion, an incision is made and the subcutaneous tissue is dissected until the needle is identified Often, the abnormality cannot even be palpated through the incision as is the case with microcalcifications and thus it is essential to obtain a mammogram of the specimen to document that the lesion was excised At that time, a second marker needle can further localize the lesion for the pathologist Stereotactic core needle biopsies have proved equivalent to mammographic localization biopsies Core biopsy is preferable to mammographic localization for accessible lesions since an operation can be avoided 4 Other imaging modalities Other modalities of breast imaging have been investigated for diagnostic purposes Automated breast ultrasonography is useful in distinguishing cystic from solid lesions but should be used only as a supplement to physical examination and mammography Ductography may be useful to define the site of a lesion causing a bloody discharge, but since biopsy is almost always indicated, ductography may be omitted and the blood-filled nipple system excised Ductoscopy has shown some promise in identifying intraductal lesions, especially in the case of pathologic nipple discharge, but the utility of this procedure is still unclear MRI is highly sensitive but not specific and should not be used for screening It may be of value in highly selective cases For example, MRI is useful in differentiating scar from recurrence postlumpectomy and may be valuable to screen high-risk women (eg, women with BRCA mutations) It may also be of value to examine for multicentricity when there is a known primary
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