Full-field digital mammography: Is the apparent increased detection of microcalcification leading to over-investigation and over-diagnosis?

INTRODUCTION: Modern full-field digital mammography (FFDM) appears to have increased the detection of breast microcalcification. This retrospective study aimed to assess whether this is associated with over-investigation and possible over-diagnosis of breast pathology of lesser significance. METHODS: Three 2-year periods were studied, in which different mammographic technologies were used exclusively viz., classical screen-film mammography (SFM) in 2003-04, computed radiography (CR) in 2009-10 and FFDM in 2012-13. The study was limited to women in whom biopsy was done for indeterminate, suspicious or malignant (ISM) calcification as the only mammographic abnormality. RESULTS: Between the first and the third time periods, the use of core biopsies and vacuum-assisted biopsies (VABs) for 'ISM calcification only' increased from 0. 6% to 1.4% of all mammograms, and biopsies with malignant results increased from 0.18% to 0.33% of all mammograms. VAB became the preferred technique for biopsy over the study period. The proportion of cores and VABs with a malignant result did not change significantly over the three time periods (24-28%), nor did the proportion of invasive cancers, ductal carcinoma in situ (DCIS) (60-63%) or atypia on subsequent excision. The proportion of DCIS which was of high grade was greatest in the FFDM era (69%). Less than 9% of DCIS were of low grade in all three time periods. CONCLUSIONS: Despite increased numbers of biopsies being performed, there was no increase in findings of breast pathology of lesser significance. Improved technology (FFDM and VAB) allows immediate biopsy of small clusters of indeterminate microcalcification, rather than using mammographic surveillance, and this study found no evidence that this has been associated with over-investigation or over-diagnosis.

Columnar cell change with atypia (flat epithelial atypia) on breast core biopsy-outcomes following open excision.

Columnar cell change with atypia (CCCA) is a relatively recently recognized pathologic breast entity considered to be a risk factor for subsequent development of breast carcinoma. The aim of this study was to investigate the significance of finding CCCA on breast core biopsy, by establishing the frequency of other breast pathology on subsequently performed surgical excision specimens. All cases with CCCA as the most advanced lesion on core biopsy were reviewed. After excision, another advanced proliferative lesion was identified in 17 (33%) patients, including three patients (6%) with in situ or invasive carcinoma. An additional five patients (10%) were concurrently diagnosed with primary breast carcinoma at other sites. These findings indicate that when CCCA is found on core biopsy, open surgical biopsy of the relevant area should be performed and that workup of both breasts should be undertaken to exclude coexistent breast carcinoma at alternative sites.