Faculty Bibliography

INTRODUCTION: With the adoption of routine screening mammography, breast cancers are being diagnosed at earlier stages, with DCIS now accouting for 22.5% of all newly diagnosed breast cancers. This has been attributed to both increased breast cancer awareness and improvements in breast imaging techniques. How have these changes, including the increased use of image-guided sampling techniques, influenced the clinical practice of breast surgery? METHODS: The institutional pathology database was queried for all breast surgeries, including breast reconstruction, performed in 1995 and 2005. Cosmetic procedures were excluded. The results were analysed utilizing the Chi-square test. RESULTS: Surgical indications changed during 10-year study period, with an increase in preoperatively diagnosed cancers undergoing definitive surgical management. ADH, and to a lesser extent, ALH, became indications for surgical excision. Fewer surgical biopsies were performed for indeterminate abnormalities on breast imaging, due to the introduction of stereotactic large core biopsy. While the rate of benign breast biopsies remained constant, there was a higher percentage of precancerous and DCIS cases in 2005. The overall rate of mastectomy decreased from 36.8% in 1995 to 14.5% in 2005. With the increase in sentinel node procedures, the rate of ALND dropped from 18.3% to 13.7%. Accompanying the increased recognition of early-stage cancers, the rate of positive ALND also decreased, from 43.3% to 25.0%. CONCLUSIONS: While the rate of benign breast biopsies has remained constant over a recent 10-year period, fewer diagnostic surgical image-guided biopsies were performed in 2005. A greater percentage of patients with breast cancer or preinvasive disease have these diagnoses determined before surgery. More preinvasive and Stage 0 cancers are undergoing surgical management. Earlier stage invasive cancers are being detected, reflected by the lower incidence of axillary nodal metastases

CONTEXT: Both atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS) have traditionally been considered to be risk factors for the development of invasive carcinoma and are followed by close observation. Recent studies have suggested that these lesions may represent true precursors with progression to invasive carcinoma. Due to the debate over the significance of these lesions and the small number of cases reported in the literature, the treatment for lobular neoplasia diagnosed by percutaneous core biopsy (PCB) remains controversial. OBJECTIVE: To review our experience with pure LCIS or ALH diagnosed by PCB and correlate the radiologic findings and surgical excision diagnoses to develop management guidelines for lobular neoplasia diagnosed by PCB. DESIGN: We searched the pathology database for patients who underwent PCB with a diagnosis of either pure LCIS or ALH and had subsequent surgical excision. We compared the core diagnoses with the surgical excision diagnoses and the radiologic findings. RESULTS: Thirty-eight PCBs with a diagnosis of ALH (18 cases) or LCIS (20 cases) were identified. Carcinoma was present at excision in 1 (6%) of the ALH cases and in 2 (10%) of the LCIS cases. In summary, 8% (3/38) of PCBs diagnosed as lobular neoplasia (ALH or LCIS) were upgraded to carcinoma (invasive carcinoma or ductal carcinoma in situ) at excision. CONCLUSIONS: Surgical excision is indicated for all PCBs diagnosed as ALH or LCIS, as a significant percentage will show carcinoma at excision

OBJECTIVE: We evaluated the benefit of placing a marker under sonographic guidance at the time of localization to aid in identifying mammographically occult lesions within the specimen at the time of surgical excision and to evaluate margin status. MATERIALS AND METHODS: We reviewed 135 sonographically guided needle localizations performed on mammographically occult lesions. Imaging during the localization procedure, marker placement, and specimen radiographs were reviewed, and the findings were correlated with the histopathologic findings. RESULTS: Of the 135 mammographically occult lesions, 77 were localized without marker placement and 58 with marker placement. The 58 localizations with marker placement were for masses with a mean lesion size of 9 mm. Specimen radiography of these lesions showed a marker within the specimen in 56 cases (97%) and visualization of the lesion in only seven cases (12%). Specimen radiography of localizations without marker placement showed visualization of the lesion in 18 cases (23%). Of the 11 malignant lesions (19%) localized with marker placement, none had a positive inked margin, but five (46%) had close margins necessitating reexcision. Of the 26 malignant lesions (34%) localized without marker placement, two (8%) had a positive inked margin, and eight (31%) had close margins necessitating reexcision. CONCLUSION: At needle localization of breast lesions, marker placement under sonographic guidance is beneficial because it enables immediate confirmation of accurate surgical removal of the localized lesion at surgical excision. Use of marker placement, however, does not reduce the percentage of cases with close margins necessitating reexcision