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Letters to the Editor |
Breast Center, St Barnabas Ambulatory Care Center, 200 South Orange Avenue, Livingston, NJ 07039
Editor:
I read with great interest the recent article by Dr Dennis and colleagues in the April 2001 issue of Radiology (1). As an experienced mammographer (more than 10 years) and breast interventionalist (more than 7 years), it has been my experience as well that, in general, a negative mammogram and sonogram at the site of clinical concern usually indicate a benign process, which does not require biopsy. I would like to recall a very recent case, which occurred since your article was published, that emphasizes an important point.
A patient was examined at my breast center for a palpable lump. Her mammogram showed heterogeneous parenchyma and was interpreted (correctly) as negative. As is our protocol, all patients with lumps undergo additional mammography, with a metallic marker "BB" placed over the site of the lump by the patient. The extra views are routine at our center, as they must be in your practice. Subsequent ultrasonography (US) was performed by an experienced US technologist, who imaged two simple cysts that were present within the area of concern. The tissue surrounding the cysts would be classified as type 1 according to the images in your article. In accordance with the management algorithm in use at your institution, the patient would have returned for screening; however, she requested aspiration of the cysts, and this was scheduled. At the time of cyst aspiration (2 days later), as I examined the patient, I was appalled to find that the palpable area amid the cysts was rock hard. Yet, undeniably, there were no US findings (I confirmed a type I parenchymal pattern) except for two simple cysts, which I aspirated. Using clinical judgment, I performed biopsy on the area of palpable hardness. The pathologic finding was infiltrating ductal carcinoma. Breast magnetic resonance imaging performed for staging demonstrated a 5-cm enhancing mass.
That mammography is not 100% sensitive in the diagnosis of breast cancer has, of course, been documented. Many mammography centers include this statement of caution at the bottom of the mammography reports. Although the rate of a false-negative sonogram is unknown, all dedicated mammographers are aware of its ability to depict cancer at the site of palpable concern when the mammogram is negative. However, your article suggests that the actual incidence of breast cancer is 0% when both the mammogram and sonogram are normal or at least it was in your 486 patients. I emphasize strongly that this will not always be the case, as evidenced by my recent clinical experience. Dedicated breast surgeons anecdotally report similar experiences.
My main point is this: The management algorithm for women with a palpable finding must include the mammographer’s clinical analysis of the palpable finding. This step was not explicitly performed in your analysis. In the Materials and Methods section, you state that "when available," a physical findings descriptor was recorded. A physical examination by the mammographer did not seem to occur in all of the patients in your study, but perhaps it was just not recorded. I would like characterization of the 600 lumps in the 486 women with palpable findings in your study. Did they all have minimal clinical findings? In my experience, it is true that a normal mammogram and sonogram usually help predict that my clinical examination will reveal little of concern. In the Materials and Methods section of your article, it is implied that if the technologist finds at US that a simple cyst is the cause of the lump, the patient is returned for screening, and that only if a mass is found, or no findings are present, the radiologist examines the patient. Up to now, this has been our tendency as well. However, it is obvious that cysts, which are common, may be present in the same area as a breast cancer.
The recent case that I describe emphasizes the rule that all patients with palpable concern should be examined by the radiologist (easily and quickly performed at the time of the US). This rule is not negotiable regardless of the time constraints that this rule will impose. The technologist’s US examination is not a substitute for a physician’s examination. The results of a directed physical examination are an indispensable part of the decision algorithm. Therefore, I would alter the conclusion of the article to suggest that breast biopsy may be avoided in women with palpable abnormalities when both US and mammography depict normal tissue and the palpable findings are considered minimal by a dedicated breast specialist.
REFERENCES
Sally Jobe Breast Centers, Radiology Imaging Associates, 8200 East Belleview Avenue, Suite 102, Englewood, CO 80111. e-mail: mark.dennis@riaco.com
Thank you for your thoughtful comments. Your commentary points out the importance of not allowing benign focal findings on sonograms to distract the sonographer from performing a thorough US examination of the surrounding tissue when there is a clinically detected lump. It also emphasizes that a palpable finding should correspond exactly to the documented US finding, which was almost certainly not the case with the simple cysts in your example, even prior to aspiration.
Physical examination is fraught with inaccuracies; however, using it as an adjunct to imaging evaluation by the breast radiologist cannot be criticized and, as you pointed out, may help prevent the rare cancer miss at US. However, we continue to be of the opinion that imaging is superior to physical examination as the primary triage in women who present with a breast lump and with either a normal or abnormal mammogram.
Mistakes in image interpretation, geographic scanning misses, and sonographically invisible invasive or in situ carcinomas are among the causes of failure of US, as described in our article (1). From our experience and that of others (see original references), it appears that the latter problem is uncommon. Again, individual case experience, although helpful in increasing the level of vigilance during an imaging examination, should be viewed in the proper context relative to examining large numbers of patients over time.
REFERENCES
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