Internal mammary lymph node (IMN) coverage by standard radiation tangent fields in patients showing IMN drainage on lymphoscintigraphy: therapeutic implications.

The purpose of this report is to evaluate the variability in coverage of the internal mammary nodal chain (IMN) by standard radiation tangential fields in those patients with medial drainage on lymphoscintigraphy. Twenty-two patients who showed lymphoscintigraphic IMN drainage underwent radiation simulation planned with computed tomography (CT). Standard tangent fields were placed and CT scans were reviewed to assess IMN inclusion and correlation with presternal fat thickness. Of the 22 patients who showed IMN drainage on lymphoscintigraphy, 10 (45%) had lateral primary lesions, 9 (41%) had medial lesions and 3 (14%) had subareolar lesions. Of these 22 women, 4 (19%) had the IMN completely within the standard tangent fields. Twelve women (55%) had only partial coverage of the IMN and the remaining 6 women (27%) had the IMN region completely outside. Presternal fat thickness greater than 10 mm was less likely associated with complete IMN coverage than fat thickness 10 mm or less, P = 0.001. Lymphoscintigram drainage to the IMN in breast cancer patients may suggest an increased risk of IMN involvement. Our data show that a majority (73%) of these patients had complete or partial incidental inclusion of the IMNs with standard tangents, which may in part explain the historically low IMN failure rate.

Microtome shaving radiography: demonstration of loss of mammographic microcalcifications during histologic sectioning.

Mammographic-pathologic correlation of suspicious microcalcifications is essential for optimal diagnosis and local staging of early breast carcinoma. Loss of microcalcifications during histologic sectioning has been suggested as one reason for the occasional lack of microscopic visualization of microcalcifications in routinely processed breast biopsy specimens obtained for suspicious mammographic microcalcifications. Two case reports utilizing radiography of histologic shavings of stereotactic core biopsies and surgical excisional biopsies of mammographic microcalcifications provide concrete evidence of the loss of large calcific particles during the microtome process.

Mammographic predictors of the presence and size of invasive carcinomas associated with malignant microcalcification lesions without a mass.

OBJECTIVE: Our objective was to determine the degree with which mammographic features predict the presence and size of invasive carcinomas associated with malignant mammographic microcalcification lesions without a mass. MATERIALS AND METHODS: Mammographic features were correlated with pathologic features in 304 consecutive breast carcinomas manifested by mammographic calcifications only in a prospective evaluation. RESULTS: Mammographic calcifications associated with breast carcinoma had the final pathologic diagnoses of pure ductal carcinoma in situ (DCIS) in 65% of patients, DCIS with a focus of invasion in 32%, and invasive carcinoma only in 4%. Invasive foci were more likely associated with mammographic calcification size of 11 mm and greater (40%, 77/194) compared with 1-10 mm (26%, 29/110; p = 0.019). Invasive foci were also more likely associated with linear calcifications (44%, 55/126) compared with granular calcifications (29%, 51/178; p = 0.007). The frequency of invasion did not increase with calcification extents greater than 10 mm. The frequency of invasion ranged from 22% for less than or equal to 5-mm granular calcifications to 45% for linear calcifications of 11 mm and greater. Only 11% of cancers characterized by fine granular calcifications were associated with invasion as compared with 32% of those with coarse and mixed granular calcifications (p = 0.002). CONCLUSION: Mammographic calcification features of malignant lesions cannot predict the absence of invasion with greater than 90% predictive value or predict the presence of invasion with greater than 45% predictive value. Increased extent of calcifications greater than 10 mm was not associated with greater likelihood of invasion.

Mammographic and clinical predictors of drainage patterns in breast lymphoscintigrams obtained during sentinel node procedures.

PURPOSE: The authors' purpose was to explore the association between mammographic findings and drainage patterns on lymphoscintigrams obtained during sentinel node procedures for breast carcinoma. MATERIALS AND METHODS: From July 1997 to March 2000, 132 patients with breast cancer who were included in a prospective mammography-pathology correlation and staging database were imaged 2 hours after perilesional injection of 1 mCi filtered (0. 22 microm) Tc-99m sulfur colloid (4 ml volume) before sentinel node procedures. RESULTS: Sixty-four percent of the scans showed axillary drainage only, 9% showed axillary and internal mammary drainage, and 4% revealed internal mammary drainage only. Twenty-three percent of scans showed no drainage. Of the patients who showed drainage, 17% showed drainage to the internal mammary basin, and 5% showed this exclusively. Internal mammary drainage was seen in 18% (10 of 57) of lateral, 21% (6 of 29) of medial, and 14% (1 of 7) of subareolar lesions (P = NS). No drainage was seen in 22% of patients with predominantly fatty mammographic parenchymal density (>50%) compared with only 8% of patients with predominantly dense (>50%) parenchyma (P < 0.05). Failure to show drainage was more common in women older than 50 years (P < 0.05). Axillary sentinel nodes were identified surgically in 73% of patients with negative scan findings. There was no significant association between scintigraphic drainage and mammographic soft tissue tumor size and appearance, histologic findings, or axillary node status. CONCLUSIONS: Dense mammographic parenchyma and age less than 50 years are associated with identification of lymphatic drainage on lymphoscintigrams performed before sentinel node procedures in 91% to 92% of patients. Internal mammary drainage, present in 18% of lateral and 21% of medial lesions, may direct therapy to include internal mammary lymph nodes.

Effect of stereotactic core needle biopsy on pathologic measurement of tumor size of T1 invasive breast carcinomas presenting as mammographic masses.

BACKGROUND: Stereotactic core needle biopsy (SCNB) may change the size of the tumor defined pathologically at excision. This may alter tumor stage and affect recommendations for adjuvant systemic therapy. This study evaluated the effect of SCNB on assessment of pathologic tumor size and staging for invasive breast carcinomas presenting as mammographic masses. METHODS: The authors reviewed the mammographic and pathologic size of 138 mammographically detected invasive carcinomas manifested as a measurable mass lesion on mammography and as a 20 mm or smaller lesion on pathologic evaluation. Group A included 61 patients with SCNB before surgical excision and the Group B (the control group) included 77 patients who had surgical excision without SCNB. The size of the mammographic central mass was compared with the pathologic tumor size. The difference between the mammographic and pathologic size was determined and the findings in Group A and B were compared by the Mann-Whitney U test. RESULTS: The mean mammographic size was 12.2 and 11.83 mm and the mean pathologic size was 9.85 and 9.87 mm for Groups A and B, respectively. The mean difference between mammographic and pathologic size in Groups A and B was 2.3 mm and 1.96 mm, respectively (P = not significant). CONCLUSIONS: For soft tissue masses, the difference between mammographic size and pathologic size of invasive carcinoma at excision does not appear to be affected by the use of SCNB. Except in the circumstance of complete removal of the cancer by SCNB, the pathologic size and stage of the excised tumor after SCNB is not altered significantly by SCNB.

Breast epithelium procurement from stereotactic core biopsy washings: flow cytometry-sorted cell count analysis.

PURPOSE: Molecular studies of breast lesions have been constrained by difficulties in procuring adequate tissues for analyses. Standard procedures are restricted to larger, palpable masses or the use of paraffin-embedded materials, precluding facile procurement of fresh specimens of early lesions. We describe a study to determine the yield and characteristics of sorted cell populations retrieved in core needle biopsy specimen rinses from a spectrum of breast lesions. EXPERIMENTAL DESIGN: Cells from 114 consecutive stereotactic core biopsies of mammographic lesions released into saline washes were submitted for flow cytometric analysis. For each specimen, epithelial cells were separated from stromal and blood tissue based on the presence of cytokeratin 8 and 18 markers. Epithelial cell yields based on pathological diagnoses of the biopsy specimen, patient age, and mammographic appearance of the lesion were determined. RESULTS: Biopsies containing malignant lesions yielded significantly higher numbers of cells than were obtained from benign lesion biopsies. Significantly greater cell counts were observed from lesions from women age 50 or above compared with those of younger women. Mammographic density surrounding the biopsy site, the mammographic appearance of the lesion, and the number of cores taken at the time of biopsy appeared to have little effect on the yield of epithelial cells. CONCLUSIONS: We demonstrate the use of flow cytometric sorting of stereotactic core needle biopsy washes from lesions spanning the spectrum of breast pathology to obtain epithelial cells in sufficient numbers to meet the requirements of a variety of molecular and genetic analyses.

Yield of Terminal Duct Lobule Units in Normal Breast Stereotactic Core Biopsy Specimens: Implications for Biomarker Studies.

The purpose of this study was to assess the potential value of large-needle core biopsies of normal breast tissue for immunohistochemical studies of epithelial risk assessment. A retrospective analysis was performed to determine the yield of nonatrophic terminal duct lobule units (TDLUs) in 11-gauge vacuum-assisted core biopsies of normal adjacent breast tissue which were included in routine stereotactic core biopsies of benign lesions. Fifty-one patients had a median of two normal tissue cores (range 1-7); 82% of the patients had two or more normal tissue cores; 47% had three or more normal tissue cores. Nonatrophic TDLUs were present in only 47% of patients and in 31% (42 of 137) of all cores. Patients with heterogeneous or dense normal mammographic parenchyma at the site of the biopsy were more likely to have nonatrophic TDLUs, 45% (20 of 44), than patients with fatty normal mammographic parenchyma at the biopsy site, 0% (0 of 7), p = 0.007. Seventy percent (7 of 10) of postmenopausal women on hormone replacement therapy had nonatrophic TDLUs as compared to 41% (11 of 27) of premenopausal and postmenopausal women not on hormones (p = not significant). Eleven-gauge vacuum-assisted core biopsies of normal breast tissue have a low yield of nonatrophic TDLUs suitable for histochemical studies of epithelial risk assessment.

Breast MRI in the Evaluation of Patients with Occult Primary Breast Carcinoma.

Occult primary breast carcinoma presenting as isolated ipsilateral axillary lymph node metastases in patients with normal mammograms and normal physical exams accounts for less than 1% of all breast carcinomas. Contrast-enhanced magnetic resonance imaging (MRI) may identify the site of primary breast carcinoma and effect management of these patients. We report on eight consecutive women evaluated in our multidisciplinary clinic who had biopsy-proven metastatic adenocarcinomas to axillary lymph nodes and occult primary carcinomas. Each patient underwent MRI at 1.5 T with a volumetric fast-spoiled gradient-echo (3D FSPGR) pulse sequence before and after injection of gadopentetate dimeglumine. Wire localization of suspicious areas of enhancement was performed under MRI or mammography guidance followed by surgical excision. Seven (88%) of the eight normal mammograms showed dense (>50%) breast parenchyma. In two (25%) of the eight patients, suspicious focal or regional enhancement was seen on MRI. Following wire localization and excision, pathologic exam showed an invasive ductal carcinoma and ductal carcinoma in situ with invasion corresponding to the MRI enhancement in the two cases. Breast MRI can identify the primary tumor site and influence management of patients presenting with clinically and mammographically occult primary breast carcinomas.