The Dershaw/Liberman Article Reviewed
RICHARD C. FRAZEE, MD
Scott & White Clinic and Memorial Hospital
Texas A&M University Health Science Center
College of Medicine
Methods for detecting breast cancer are evolving as new technology provides a wider range of options for screening and definitive diagnosis. In addition to mammography and physical examination, screening techniques now include ultrasonography, technetium-99m sestamibi nuclear scanning, and magnetic resonance imaging. Despite the availability of these newer modalities, physical examination and screening mammography remain the standards for detecting suspicious breast abnormalities.
Core-needle biopsy has been used for many years by surgeons to evaluate palpable breast abnormalities and is now a well-accepted technique for the definitive diagnosis of breast carcinoma. With this procedure, sufficient tissue can be obtained to perform histologic studies and determine hormone-receptor status. The diagnostic accuracy of core-needle biopsy exceeds that of fine-needle aspiration cytology, which carries a false-negative rate of approximately 15% and a false-positive rate of approximately 0.5%.
"Advantages" of Stereotactic Biopsy Over Open Biopsy
Refinements in breast ultrasound and stereotactic imaging have now led to image-guided core-needle biopsy. Drs. Dershaw and Liberman are to be complimented for presenting a thorough review of the literature on the indications and results of stereotactic core-needle biopsy. As with many articles on this subject, the authors point out the "advantages" of stereotactic biopsy over open surgical biopsy.
According to the authors, one "advantage" is the ability to streamline the evaluation process by eliminating the need for evaluation of the patient by the surgeon prior to stereotactic biopsy. Eliminating prebiopsy physical examination by an experienced breast surgeon is not necessarily desirable, for several reasons:
1) A significant number of mass lesions initially detected on screening mammogram are palpable on direct physical examination, and these lesions can be further evaluated by palpation-guided biopsy at a lower cost than stereotactic biopsy.
2) Hematoma formation following stereotactic biopsy, which occurs in 2% to 5% of patients, impairs the surgeons ability to judge the size of lumpectomy required in breast-conserving therapy.
3) Prebiopsy discussion with the surgeon allows the patient to receive more complete information regarding the choice of biopsy procedure.
Thus, the potential benefits of a thorough prebiopsy evaluation by the surgeon outweigh any advantage in time savings afforded by stereotactic biopsy.
The authors also state that there can be long delays in obtaining pathologic reports following surgical biopsy, leading to increased patient anxiety. Such delays are likely a function of institutional obstacles, as no medical reason exists to preclude timely diagnosis following surgical biopsy.
Retrospective reports have noted higher satisfaction and less pain with stereotactic biopsy than with open biopsy.[1,2] This finding was not borne out in a prospective evaluation performed at Texas A&M University Health Science Center. We saw no differences between 51 women who underwent an open biopsy and 52 who had stereotactic biopsy with regard to patient satisfaction, procedural pain, or return to activities following biopsy.
Accuracy of Stereotactic Biopsy vs Open Biopsy
The accuracy of stereotactic biopsy approaches that of open biopsy, with a few recognized pathologic exceptions. Dershaw and Liberman correctly point out that biopsy results that are discordant with the physical examination and mammographic findings raise the concern that a lesion may have been missed. Reports of carcinoma in situ, atypical ductal hyperplasia, and radial scar on stereotactic biopsy also should be viewed with caution and should prompt performance of an open biopsy to rule out invasive carcinoma. All patients, regardless of the type of biopsy that they received, should return in 6 months for a follow-up examination and mammogram to provide a new baseline and ensure that the abnormality has not progressed.
One of Several Acceptable Options
Although stereotactic biopsy has a few recognized limitations, it is one of several acceptable options for diagnosing breast cancer. As is the case for the expanded options for treating breast cancer, patients can play an increased role in the selection of biopsy type. It is important that patients are educated about the various biopsy types so that they can make an informed decision as to which technique will best serve their needs.
--Richard C. Frazee, MD
1. Parker SH, Burbank F, Jackman FJ, et al: Percutaneous large core breast biopsy: A multi-institutional study. Radiology 193:359-364, 1994.
2. Liberman L, Fahs MC, Dershaw DD, et al: Impact of stereotaxic core breast biopsy on cost of diagnosis. Radiology 195:633-637, 1995.
3. Frazee RC, Roberts JW, Symmonds RE, et al: Open vs stereotactic breast biopsy. Am J Surg 172:491-493, 1996.