Expert: Claes-Gustaf Nordquist, M.D. - 4/27/2007

Question
QUESTION: Hi,

I am 48 years of age with 3 children. There is no history of breast cancer in the family. Today, I went for my first mammogram. These are the results and I would appreciate your comment.

BILATERAL MAMMOGRAM/ULTRASOUND

The mamographic appearances are unremarkable with no evidence of a suspicious mass or malignant type microcalcification.

A small well defined mass is seen on the right side which correspons on ultrasound examination to a well defined ovoid 8mm lesion at 2 o'clock 6 cm from the nipple which is most likely to be a small fibroadenoma. This has very similar echo characteristics to the adjacent fatty tissue but is clearly a solid lesion on the mammogram.

Ultrasound esamination of the left side is normal apart from a pair of small cysts at 12 0'clock measuring up to 6mm in maximal diameter.

No stellate mass is seen on either side and there is no evidence of maligant type microcalcifications.

CONCLUSION

1. Small solid lesion on the right which is most likely to be a fibroadenoma. Given that this not identified on the patient's only previous breast imaging which is an ultrasound examination 28-4-1995, consideration could be given to fairly close follow up to ensure stability (repeat ultrasound in 6 months)

2. No evidence of maligancy is detected.


My question:

From reading all of your responses to previous questions, it appears that whenever there is a solid mass, fine needle biopsy should be performed.

The radiologist is not recommending this but rather a wait and see. Can he be that confident from the ultrasound appearance that it is indeed only a fibroadenoma.

You also advise an MRI, what further information would this give.

Your response would be greatly appreciated.
ANSWER: MRI scans may give further confirmation of the nature of these lesions. A thin needle biopsy of the suspected fibroadenoma may or may not give support to the suspected diagnosis. If it gives support I do not think any further action is necessary until it is time for the next regular check up. If it does not then a surgical biopsy should be done! So I do recommend both MRI scans AND a thin needle biopsy! Personally I do not understand this wait & see procedure. I think the patient has the right of KNOWING the state of his/her own body as soon as possible. Unfortunately the thin needle aspiration biopsy to a large extent suffers from the "not-invented-here" syndrome in large parts of the USA (it is a technique developed to a large extent in Europe, especially in Scandinavia and particularly so in my native Sweden) BUT it IS used extensively in some US university centers for example the MD Andersson Cancer Center of the University of Texas, Houston, Texas. If it is good enough for that center it should be good enough for the rest of the USA, do you not think so?! It also suffers from being simple and cheap, which means less income from surgical biopsies. US doctors very often argue against the procedure by saying that it increases the risk of spreading the cancer. However 50 years of clinical university use of it in Sweden has not shown any increased risk compared to surgical biopsies. Good luck! Please do keep me posted!


---------- FOLLOW-UP ----------

QUESTION: Hi,

Thank you for your response.

Could you please explain what is involved when one has a fine needle aspiration and a percutaneous core biopsy. What is the difference. Is a local or general anaesthetic used. Ultrasound guided?? or Xray guided??
ANSWER: A thin neele biopsy uses a very thin injection needle to reach the lesion to be examined. CELLS from the lesion are then sucked out then "smeared" on to a thin glass and stained then studied under a microscope. So with this technique you are studying CELLS just like in a gynecological Pap smear. No anesthetic procedures are normally necessary - at least not here in Sweden. Why should it? Also a local anesthetic is an injection. In that case you would need 2 injections and the first one would give some pain anyway. So here we think it is better to use just ONE injection, the biopsy itself. A core biopsy uses a much wider needle. So here you get a tissue sample - just like in a surgical biopsy - but smaller & easier. Anesthetic may be used (much bigger needle so more pain). For examination under a microscope you use standard pathology techniques NOT cytological CELL studies. In both cases it can be done stereotactically based on X-ray or MRI pictures or guided by X-rays, ultrasound or MRI or in the case of the thin needle just by palpation - the touch sense of the dr. who performs it. The thin needle is generally faster & easier. And cheaper. Both techniques were mainly developed in Sweden. The core technique by a professor of diagnostic radiology at the Royal Karolinska University Hospital and the Royal Karolinska Institute, Stockholm, Sweden. The thin needle technique was mainly developed by my former boss Professor Sixten Franzén, M.D., Ph.D. - actually a radiation therapist & medical oncologist - at the Radiumhemmet (Department of medical oncology & radiation therapy), the Royal Karolinska University Hospital. Dr. Franzén is a very inventive and creative person who personally developed several instruments for doing these biopsies. The one still used for rectal prostate biopsies is still internationally known as the "Franzén instrument". Dr Franzén is still alive though now in his late 80-ies. Which technique to use is to a large extent a matter of "taste". Good luck!


---------- FOLLOW-UP ----------

QUESTION: I understand that for a definite diagnosis a biopsy needs to be performed. If it is not done via ultra sound guided, how accurate can it be. How can you be sure that the needle has penetrated the correct site.

Also, if the result comes back negative, am I in the all clear or is still monitoring required. As the needle picks up only a few cells, how representative is it of the entire lesion.

What are your thoughts.  Thank you once again.
ANSWER: Well, as I explained it can be guided stereotactically by previous mammograms or breast MRI scans OR via x-ray guiding, or MRI guiding or ultrasound guiding or by the sense of touch if the lesion is palpable. In experienced hands ALL these methods are very good! You can even "feel" via the needle when you enter the lesion (like "feeling" via a stick). So all these methods are in experienced hands very accurate. The important thing here is to exclude a cancer. Now by their very nature cancer cells DO NOT stick together they are rather loose so in the case of a cancer you will actually get quite a lot of cells in your sample and they will be very representative. However, by moving the needle back and forth inside the lesion while sucking out cells you get an enough & representative number of cells even from a non malignant lesion. If the tests are negative you are in the clear for the time being. The tests show the situation now. We can not really predict the future. So regular screening - once a year or so - is still necessary. I do hope this answers your questions.


---------- FOLLOW-UP ----------

QUESTION: Hi,

An update, I have been to two doctors, one says fine needle biopsy and the other says core biopsy. I have been told that the core biopsy is supposed to be more accurate. What is your opinion.

If I have the fine needle biopsy and it shows malignancy, what is the next step: Excision biopsy to check the margins or core biopsy to check if invasive.

I appreciate your feedback and thank you in anticipation.

Regards, Eve
ANSWER: Well, as I have written once before it is actually more a matter of taste than anything else. A thin needle biopsy is a CYTOLOGY (cell) biopsy while a core biopsy is a histopathological (tissue) biopsy. A core biopsy does give you knowledge of the tissue architecture which the thin needle one can not give you. But the core biopsy does not give you complete knowledge of any tumor borders for example. For that you need the real surgical specimen. In order to decide if a surgical procedure should be done or not it is sufficient to know the result of a thin needle biopsy - either it IS a cancer or the result is unclear in which case a surgical biopsy should be made OR it is clearly not a cancer but instead for example a fibroadenoma in which case nothing more needs to be done for the time being. There is one subgroup of fibroadenoma - sclerosing adenosis - where it is difficult to differentiate between a cancer and a benign fibroadenoma with a thin needle biopsy and where a core biopsy can tell you the difference (you can also be helped by an MRI scan in such a case). But otherwise I see no real advantage of the core method over the thin needle one. In your case I believe a thin needle procedure would be quite enough - it is also simpler & faster to do! You are becoming quite an expert in this field! Right? Good luck!
Please rate my answers!


---------- FOLLOW-UP ----------

QUESTION: I had the fine needle aspiration. I phoned today. My doctor was not there. Secretary had to get approval from another doctor to give results over the phone.

She told me the results were inconclusive "No ductal cells in the fluid retrieved." I had the FNA done 3 times, ultrasound guided. My husband observed and each time the needle had hit the mark, especially on one occasion where it hit the middle of the lesion and she jiggled the needle about.

I cannot speak to my doctor till Monday.

How can no cells have not been obtained? Is this good or bad. I would really appreciate your opinion on this.

Thanks again, Eve
ANSWER: I can only conclude that they are not very good in doing this procedure - which actually is not very difficult to do! Due to this unfortunate fact - with the result that we still do not have a biopsy diagnosis - I have to recommend that you have a surgical biopsy done. Hope you have better luck with that!


---------- FOLLOW-UP ----------

QUESTION: If there are  no ductal cells in the fluid retrieved, can you please explain how that is related to not being able to do the procedure well.

Thanks again, Eve
ANSWER: If it had been properly done there SHOULD be enough cellular material there to permit a diagnosis! To make it easier for you and since the cancer risk most probably is low I think that a wide bore needle core biopsy would be sufficient in this situation. I'm sorry you have to & have had to go through all this trouble without a clear result so far!


---------- FOLLOW-UP ----------

QUESTION: Is there a period of time that I should wait before having a core biopsy done, to allow any trauma from the FNA to have subsided. I am thinking of going elsewhere to have core done. Is it essential that I let them know I have had the FNA done and if so why.
The FNA was done 3 times and my husband saw the needle penetrate the lesion. I cannot understand it.

I am sorry for asking so many questions but I did not expect such a result . The waiting was excruciating and I have to go through it again.

Thank you so much once again. Eve

Answer
A couple of weeks should be enough. No not really though it is generally best to give your dr. all facts of a case, but you do not need to push that to extremes! Nor did I! But I'm here in order to answer! Sorry that you find yourself in this situation! Good luck! Please do keep me posted!