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Letters to the Editor |
Tristán Associates, 4518 Union Deposit Road, Harrisburg, PA 17111
Editor:
The recent articles by Dr Jackman and colleagues and Dr Lee and colleagues in the March and July issues, respectively, of Radiology (1,2) document the low repeat biopsy and false-negative rates for stereotactic core-needle biopsy of breast lesions, which compare favorably with the rates for surgical, needle-localized breast biopsy. These articles present the best proof yet that stereotactic core-needle biopsy is accurate, efficacious, and just plain good medicine.
These authors took the necessary step of letting their data mature so that an accurate false-negative rate could be calculated. An unfortunate but unavoidable by-product of this self-imposed delay in a changing field such as minimally invasive breast biopsy is that their methods are relatively outdated, and understandably so. The methods they describe were state of the art for the mid-1990s, the era in which the biopsies were performed. As implied by Dr Lee and colleagues, a similar study of the results obtained when a vacuum-assisted biopsy device is used, such as the Mammotome (Ethicon Endo-Surgery, Cincinnati, Ohio), should more closely reflect current practices. Since ample data indicate a higher sensitivity and lower false-negative rate when vacuum-assisted biopsy devices are compared with automated core biopsy needles (3,4), I anticipate that the results obtained from today’s biopsies will be even better than those reported by Dr Jackman and colleagues and Dr Lee and colleagues. I congratulate these authors on their meticulous methods and record keeping.
Three issues came to mind when I read these articles (1,2). First, the experience of my group with approximately 2,500 minimally invasive breast biopsies—the results of which are supported by articles by Harvey et al (5), Berg et al (6), and Venta et al (7)—suggests that Dr Lee and colleagues should add focal stromal fibrosis to the list of accepted specific benign diagnoses for circumscribed nodules. My colleagues and I initially were unaware of such an entity when we embarked on our breast biopsy program. However, it quickly became apparent that focal stromal fibrosis (also known as fibrous nodules or focal fibrosis, among other appellations) was an acceptable concordant diagnosis for a circumscribed solid nodule, and my colleagues and I currently accept such a diagnosis as readily as we accept the diagnosis of a fibroadenoma or intramammary node. I suspect that Dr Lee and colleagues currently accept this diagnosis, as well, but perhaps they did not in the era in which the study was conducted.
Second, these two articles (1,2) specifically addressed stereotactic biopsy; a similar study of ultrasonographically (US) guided breast biopsy would be equally valuable. I expect that a study of US-guided breast biopsy will yield results similar to those reported by Dr Jackman and colleagues and Dr Lee and colleagues. Perhaps the results will be even better with a lower false-negative rate, since most investigators agree that calcifications are more difficult than masses to diagnose with minimally invasive techniques and are accompanied by a higher false-negative or histologic underestimation rate, with histologic findings as the standard of reference. Since US-guided breast biopsy targets the easier of these two abnormalities (only masses, not calcifications), logic dictates that its false-negative rate ought to be lower than that of stereotactic biopsy.
Third, a similar study of imaging-guided breast biopsy of palpable lesions would be of great interest. There is no reason why minimally invasive techniques should be less accurate for palpable lesions. Now that the handheld Mammotome device has been recently approved, percutaneous removal of benign, palpable nodules will become a reality.
More work, as always, remains to be done.
REFERENCES
Department of Diagnostic Radiology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520
We agree with Dr Guenin’s comments, with one exception. Although we agree that stromal fibrosis is a concordant diagnosis for a solid mass, we still recommend short-interval follow-up mammography when we obtain this diagnosis at histologic evaluation of the core-needle biopsy specimen. This is prompted in part by the fact that the one false-negative result we obtained for a mass was reported as benign fibrous breast tissue. We are currently evaluating our results for lesions diagnosed as benign at stereotactic core-needle biopsy performed with the 11-gauge, vacuum-assisted device, and we should have information on our experience in the near future.
This article has been cited by other articles:
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  M. Sklair-Levy, T. H. Samuels, C. Catzavelos, P. Hamilton, and R. Shumak Stromal Fibrosis of the Breast Am. J. Roentgenol., September 1, 2001; 177(3): 573 - 577. [Abstract] [Full Text] [PDF]
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