NEW ORLEANSIn selected patients with radiographically
identified nonpalpable breast abnormalities, ultrasound-guided
fine-needle aspiration (FNA) with follow-up mammograms is effective
and offers a cost savings over stereotactic mammotomy (directional
vacuum-assisted breast biopsy). S.S. Buchbinder, MD, of the
Department of Radiology, Albert Einstein College of Medicine, New
York, reported the results at the American Roentgen Ray Society
The study included 228 lesions from 198 consecutive patients with
nonpal-pable abnormalities identified by mammography and ultrasound.
Women had to have undergone excisional biopsy or have at least 6
months of follow-up with mammography to be included in the study.
Women with clustered microcalcifications were excluded.
A cytopathologist was immediately available to prepare slides and
assess the adequacy of the specimen. After discussion of the
findings, the information was often given immediately to the patient.
Of the 122 cases available for analysis, 88 (72%) were considered to
be benign. These women were not subjected to further surgical
procedures, but have had mammographic follow-up for an average of 15
months. In one case, the lesion grew in size and was found on
excisional biopsy to be malignant. Dr. Buchbinder said that the
sensitivity of ultrasound-guided fine-needle aspiration for a final
benign diagnosis was, therefore, 99%.
The accuracy for a positive malignant diagnosis was 100%: All 11
women with malignancy on fine-needle aspiration were found to have
invasive disease at definitive surgery. Overall sensitivity was 92%.
If these two groups of women are considered together, Dr.
Buchbinder said, more than 80% of the women in this study would
have been spared unnecessary invasive procedures.
A group of 23 women were considered to have atypical findings. Dr.
Buchbinder said that atypical cytopathology is distinctly different
from a histopathologic diagnosis of epithelial hyperplasia with
atypia. Cytologic evaluation identifies predominantly noncohesive
single cells as being atypical, although cells with large nuclei that
exhibit pleomorphism and complex cell arrangements would also fall
into this category.
In 4 of the 23 cases, the women chose careful mammographic follow-up
despite the recommendation for surgery; no malignant changes have
been detected at a mean follow-up of 20.7 months. The other 19 women
were referred for surgery, and 3 malignancies were detected. Thus,
Dr. Buchbinder recommends immediate surgical follow-up for women with
atypical cytology on aspiration. He emphasized that this was a small
proportion of the entire study population.
A cost-benefit analysis was conducted using 1998 Medicare
reimbursement for the Bronx, New York. Cost for routine stereotactic
Mammotome biopsy would have been $685.72, or $83,657.84 for the
population of 122 patients, excluding any follow-up. Since the
researchers wanted to give the most conservative cost estimate, Dr.
Buchbinder said, they made the assumption that no additional
procedures would be needed, even though the literature suggests that
is not the case.
For the 88 women with benign findings, the cost was
$288.10$210.46 for the ultrasound-guided fine-needle aspiration
and $77.64 for one unilateral follow-up mammogram. The single case
that changed on follow-up cost $454.55, with an additional $166.45
for the needle localization.
For the 11 women with malignancies and the 19 women with atypical
findings who underwent surgery, the cost was $376.91$210.46 for
the aspiration and $166.45 for the subsequent needle localization.
Thus, the total charges for the fine-needle aspiration population
were $37,281.10, a cost savings of 45% compared with mammotomy, he said.
In addition to cost savings, he said, the emotional savings,
physical savings, and scarring savings should be considered equally important.