‫עבודה מדעי יסוד‬
‫ממוטומיה לאיבחון וטיפול בממצאים חשודים בלתי‬
‫נמושים בריקמת השד‬
‫‪Mammotomy for non-palpable breast lesions‬‬
‫בהדרכת ד"ר גד לוטן ‪ ,‬מחלקה כירורגיה ילדים‬
‫ד"ר יצחק פפו‪ ,‬מכון השד‬
‫ביה"ח אסף הרופא‬
‫מגיש‪ :‬ד"ר ספרוב ולרי‬
‫‪2102‬‬
‫הצעת מחקר למדעי יסוד‬
‫שם המבצע ‪ :‬ד"ר ספרוב ולרי‬
‫‪105745700‬‬
‫ת‪.‬ז‪.‬‬
‫כתובת‪:‬‬
‫הרצל ‪ ,72/05‬בת‪-‬ים ; ‪70715‬‬
‫דוא"ל ‪:‬‬
‫‪valerysafarov@yahoo.com‬‬
‫טלפון ‪:‬‬
‫‪1755147127 ;1744751541‬‬
‫מקצוע ‪:‬‬
‫כירורגיה כללית‬
‫מקום התמחות ‪ :‬חטיבה כירורגית ‪ ,‬כירורגית א' ‪ ,‬ביה"ח "אסף הרופא"‬
‫מס' פנקס התמחות ‪:‬‬
‫נושא העבודה ‪:‬‬
‫ממוטומיה לאיבחון וטיפול ממצאים בבלוטת השד אשר‬
‫אינם נמושים‬
‫‪Mammotomy for non-palpable breast lesions‬‬
‫שם המדריכים ‪ :‬ד"ר גד לוטן* ; ד"ר פפו יצחק**‬
‫מקום עבודת המדריך ‪* :‬מחלקה כירורגיה ילדים ‪** ,‬המכון לבריאות השד‪ ,‬מרכז‬
‫רפואי אסף הרופא‬
‫מקום בצוע העבודה ‪ :‬המכון לבריאות השד ‪ ,‬מרכז רפואי אסף הרופא‬
‫חתימת המבצע ‪________________ :‬‬
‫חתימת המנחים ‪ ________________ :‬ד"ר גד לוטן ; ד" פפו יצחק‬
: ‫תאריך‬
Mammotomy for non-palpable breast lesions
1. INTRODUCTION
The increased use of screening mammography and the constant
increased incidence of breast cancer during the last years, have led to a
higher rate of detection of non-palpable breast lesions (NPBLs)
comparing to the past.
The routine use of mammography (in women 50 years or older) can
detect many NPBLs, such as nodular opacities, nodular opacities with
microcalcifications, architectural distortions, architectural distortions
with microcalcifications, and microcalcifications alone, in a large group
of patients.
The literature reports that 15-30% of NPBLs are positive for malignancy
[1] and the survival rate of these patients may raise to 95-98% [Cady].
The number of detected NPBLs is estimated to increase in the near
future due to the probable extension of screening mammography in
women 40-50 years’ old and adjunctive technologies such as the digital
mammography. This will represent a diagnostic and procedural dilemma
for the radiologist and the surgeon.
The traditional diagnostic method in the management of NPBLs
detected by mammography is stereotactic needle biopsy, either by fine
needle aspiration (FNA), or by large bore needle (Trucut biopsy). The
use of FNA has gained acceptance as the initial step in the diagnostic
assessment of NPBL, but its accuracy depends largely on the experience
of the operator, the method by which the smear is prepared, and the
experience of the cytologist. The results reported in the literature for
FNA are controversial and some authors question the role of FNA in the
diagnosis of NPBLs. Furthermore, it is difficult, and may be impossible,
to diagnose typical or atypical hyperplasia, carcinoma in situ, or invasive
carcinoma.
Therefore a histological diagnosis is required to establish the correct
diagnostic classification of the lesions, and a result choosing the most
appropriate therapy to be used. The open breast biopsy has long been
considered the gold standard to determine whether malignancy exists in
NPBL. However, the surgical procedure may be involved with anxiety,
morbidity or even mortality, and may leave women with a permanent
deformation and scar of the breast. Women may need to be hospitalized
and high-cost of surgical and anesthetic resources should be used. In the
search for clinically equivalent, but less invasive diagnostic procedures,
radiological (stereotactic or ultrasound) sampling techniques have been
introduced. These have resulted in cost saving and greater patient
satisfaction [2].
ABBI (Advanced Breast Biopsy Instrumentation) system or VACB
(Vacuum Assisted Core Biopsy) represent innovative valid alternatives
to the surgical biopsy, both due to their relative simplicity and for the
possibility to conduct the appropriate therapy following more accurate
diagnosis obtained [2].
ABBI (United States Surgical Corp., Norwalk CT) combines the
accuracy of stereotactic lesion localization with the benefit of removing
the whole suspicious lesion in a single step. However the costs incurred
are even higher than using VACB, the skin cut is bigger, and
furthermore, a greater mass of glandular tissue is removed. Although
several studies report the diagnostic accuracy of this new technique,
describing its advantages and disadvantages [3, 4], a general consent has
not yet been reached.
Based on data obtained from literature, an analytical approach suggested
that core biopsy and open-breast biopsy might be clinically equivalent,
with core biopsy being less costly than open breast biopsy [5, 6].
With the understanding that screening mammography reduces breast
cancer mortality by as much as 30% [8, 9] enrolment in early detection
programs is at an all time high [7]. Unfortunately, as a result of this
increased use and mammography's historically low positive predictive
value (PPV) [10, 11] many women who are found to have benign lesions
are subjected to the discomfort, anxiety, morbidity and potential
complications of an open surgical biopsy. (The reported frequency of
cancer for fine-wire localization biopsy (FWLB) of nonpalpable,
a mammographically detected abnormality ranges from 9% to 47% [12,
13]. Because of this, alternative diagnostic procedures have been
developed. Although excisional biopsy remains the "standard,"' data
supporting stereotactic core needle biopsy (SCNB) as an accurate [1416] safe, cost-effective [17] and less invasive diagnostic technique
is strong.
Although FWLB and SCNB techniques have been independently
validated, the appropriate patient population for each procedure is still
extensively debated [16]. In this context, the breast imaging reporting
and data system (BI-RADS) was developed by the American College of
Radiology primarily to improve the communication of mammographic
reporting by utilizing a universally accepted complement of descriptive
terms [18]. Equally important is the BI-RADS mandate to provide a
clear management recommendation for women with nonpalpable breast
lesions.
Breast Imaging Reporting and Data System Categories,
interpretation and Recommended Actions.
By offering specific PPVs for given mammographic lesions, the
BI-RADS are useful not only in discriminating benign from malignant
lesions but in potentially reducing the number of unnecessary open
breast biopsies performed.
With the introduction of new biopsy methods there is a danger of
incremental costs related to additional procedures with their attendant
risks and delays. Because SCNB provides an excellent sample of the
tissue in question, it is postulated that the sampling of low-risk lesions
with this technique could allow for accurate and timely diagnosis
without the need for further surgical confirmation. If the technique is
applied to patients with mammographically suspicious lesions, however,
a second procedure then becomes necessary to remove the lesion,
making SCNB an additional step in diagnosis and management.
A recent article from the Division of Clinical Epidemiology, [7, 19]
McGill University Health Centre, indicates that the median waiting time
for definitive cancer treatment increases with the number of diagnostic
procedures from 24 days with 1 procedure to 72 days with 4 procedures.
Additional diagnostic procedures that cannot replace existing diagnostic
maneuvers, such as FWLB, merely delay the ultimate management of
the breast cancer.
2.Breast Procedures
The procedures used to diagnose, stage, and treat breast disease are
rapidly becoming less radical, less invasive, and, possibly, more precise.
Breast imaging procedures-such as mammography, ultrasonography, and
magnetic resonance imaging-are playing increasingly important roles in
management, and any surgeon currently treating patients with breast
disease should have a working knowledge of all of these modalities. In
many surgical practices, breast ultrasonography and ultrasound-guided
biopsy are now routinely performed. Ductoscopy and ductal lavage,
though less well established than ultrasonography, are nonetheless
promising: their predictive value and clinical utility are not yet clearly
defined, but it appears that they can provide important information
regarding the status of the breast duct epithelium [21]. Excisional breast
biopsy has largely been supplanted by fine-needle aspiration (FNA)
biopsy for palpable breast lesions and by percutaneous biopsy for
nonpalpable breast lesions. Stereotactic and ultrasound-guided coreneedle biopsies are less invasive and less costly alternatives to open
surgical biopsies for most patients with nonpalpable breast lesions from
which tissue must be acquired [22].
Options for the diagnosis of Nonpalpable Masses
The increasingly widespread use of screening mammography has led to
the identification of more and more nonpalpable breast masses and
microcalcifications for which tissue diagnosis is required. In most series,
15% to 30% of such lesions prove to be malignant [23-25].Nonpalpable
masses and microcalcifications may be approached via core-needle
biopsy or open biopsy with wire localization.
Image-Guided Core-Needle Biopsy. Needle biopsy techniques are
increasingly being used to diagnose nonpalpable breast lesions. In
general, FNA biopsy of nonpalpable lesions is inadvisable because of its
high false negative rate. Little is lost by attempting an FNA biopsy of a
palpable lesion in the office setting, but performing a stereotactic or
ultrasound-guided FNA biopsy of a nonpalpable mass carries a
significant cost in terms of time, patient discomfort, and expense. The
diagnostic accuracy currently achievable with FNA biopsy in this setting
does not justify this cost. Consequently, image-guided core-needle
biopsy is the preferred approach for needle biopsy of nonpalpable
lesions.
In choosing core-needle biopsy, both patient and physician must be
comfortable with the fact that the lesion will only be sampled rather than
excised, must recognize that the possibility of a sampling error that will
cause the examiner to miss the lesion is higher with core-needle biopsy
than with open biopsy, and must realize that equivocal findings will
necessitate follow-up with open biopsy. The trade-off for these
limitations is that core-needle biopsy generally costs less than open
biopsy, takes less time, and leaves only a tiny scar. After a core-needle
diagnosis of malignancy, the surgeon may proceed directly to wide local
excision and will often be able to obtain clean margins with a single
open procedure [20].
Stereotactic mammographic versus ultrasound-guided core-needle
biopsy. Whenever feasible, core-needle biopsy is performed with
ultrasonographic guidance, which permits real-time documentation of
needle position within the lesion. Stereotactic mammography-guided
core-needle biopsy is performed if the lesion is not visualized
ultrasonographically. Stereotactic biopsy is appropriate for lesions that
are favorably located within the breast (i.e., that can be stably positioned
in the biopsy window of the machine). Lesions very close to the chest
wall or the areola may not be accessible to stereotactic biopsy and are
best approached via open biopsy with needle localization.
Clustered microcalcifications may also be approached by stereotactic
core-needle biopsy. If the cluster is not large enough for calcifications to
remain to guide subsequent wide excision if a malignancy is found, a
clip should be placed to mark the biopsy site. Alternatively, if the
surgeon has experience with breast ultrasonography, this imaging
modality may be used intraoperatively to identify the hematoma that
results from stereotactic core-needle biopsy.
Interpretation of results. The introduction of large core-biopsy needles
(11 and 14 gauge), coupled with the use of vacuum assistance to draw
additional tissue into the needle, has markedly improved the false
negative rate for core-needle biopsy. Currently, false negative rates for
this procedure fall into the 1% to 2% range [24], results that compare
favorably with those reported for wire-localized open biopsy. It is now
routine to perform radiography of core-needle biopsy specimens to
confirm that targeted calcifications have been removed. When the
targeted lesion comprises dense tissue rather than calcifications, care
must be taken to confirm that the lesion was adequately sampled and
thus ensure that the findings can be interpreted reliably. Immediate post
biopsy radiography may be performed to demonstrate that a hole was
made in the lesion. A finding of benign or fibrocystic tissue on such a
biopsy should be viewed with some suspicion and interpreted in relation
to the lesion sampled. One must decide whether the pathologic findings
adequately account for the lesion visualized. If any concern remains,
open biopsy is indicated.
Because false positive results are rare, a diagnosis of malignancy may be
believed and acted on without further biopsy. In planning treatment after
core-needle biopsy that shows only carcinoma in situ, one should
remember that the lesion was only sampled and that invasive tumor may
still be found when the lesion is completely excised. The likelihood of
finding invasive tumor on surgical excision after a core-needle biopsy
indicative of ductal carcinoma may be as high as 20% [25].
A finding of atypical ductal hyperplasia on core-needle biopsy is an
indication for wire-localized open biopsy. Open biopsy after a coreneedle biopsy indicative of atypical ductal hyperplasia may reveal ductal
carcinoma in situ (DCIS) in as many as 50% of patients; this may be a
less frequent finding when a larger (e.g., 11 gauge) needle was used for
the core-needle biopsy.
Follow-up. Whether short-interval mammographic follow-up is
necessary after core-needle biopsy depends on the pathologic findings
and the mammographic appearance of the lesion. With a wellcircumscribed lesion that pathologic evaluation shows to be a
fibroadenoma or with calcifications that pathologic evaluation shows to
be located in benign fibrocystic tissue, no special follow-up is required,
and routine screening at normal intervals may be resumed. In general, if
the pathologic findings are equivocal or discordant with the appearance
of the lesion, immediate open excision is preferable to a 6-month repeat
mammogram. To ensure appropriate follow-up, there should be close
communication between the physician ordering the core-needle biopsy,
the physician performing the biopsy, and the pathologist analyzing the
specimen.
Open Biopsy with Needle (Wire) Localization. As is the case for open
biopsy of palpable lesions, the vast majority of needle-localized breast
biopsies are now performed with local anesthesia or local anesthesia
with intravenous sedation [26]. General anesthesia is reserved for
excision of multiple lesions or other special circumstances.
Technique. The lesion to be excised is localized by inserting a thin
needle and a fine wire under mammographic or ultrasonographic
guidance immediately before operation. To facilitate incision placement,
images should be sent to the OR with the wire entry site indicated on
them. With superficial lesions, the wire entry site is usually close to the
lesion and thus may be included in the incision. With some deeper
lesions, the wire entry site is on the shortest path to the lesion and so
may still be included in the incision. The incision is placed as directly as
possible over the mass to minimize tunneling through breast tissue.
Once the incision is made, a core of tissue is excised around and along
the wire in such a way as to include the lesion. This process is easier and
involves less excision of tissue if the localizing wire has a thickened
segment several centimeters in length that is placed adjacent to or within
the lesion. One then follows the wire itself into breast tissue until the
thick segment is reached and only then extends the excision away from
the wire to include the lesion in a fairly small tissue fragment.
With many lesions, the wire entry site is in a fairly peripheral location
relative to the position of the lesion, which means that including the wire
entry site in the incision would result in excessive tunneling within
breast tissue. In such cases, the incision is placed over the expected
position of the lesion, the dissection is extended into breast tissue to
identify the wire a few centimeters away from the lesion itself, and the
free end of the wire is pulled up into the incision. A generous core of
tissue is then excised around the wire. Again, this process is easier if the
thick segment of the localizing wire is placed adjacent to or within the
lesion.
Radiography should immediately be performed on all wire-localized
biopsy specimens to confirm that the lesion has been excised. The
patient should remain on the operating table with the sterile field
preserved until such confirmation has been received. If the mass was
missed and the surgeon has some idea of the likely location of the
missed lesion, another tissue sample may be excised immediately. If,
however, the surgeon suspects that the wire was dislodged before or
during the procedure, the incision should be closed. After the patient has
healed sufficiently to be able to tolerate repeat mammography, another
mammogram is obtained, and repeat localization and biopsy are
performed.
Directional Vacuum-Assisted Breast Biopsy (Mammotomy).
Directional vacuum-assisted biopsy (DVAB), or mammotomy, is a
special procedure for obtaining specimens from single or multiple breast
lesions (e.g., microcalcifications, circumscribed masses, and speculated
masses) [27]. DVAB is a diagnostic procedure and is not intended for
therapeutic purposes. On the whole, it is safe, and the complication rate
is acceptably low.
In comparison with core-needle biopsy, DVAB is more successful at
removing microcalcifications, it can obtain more specimens in the
course of a single procedure, and is more sensitive in detecting DCIS
and atypical duct hyperplasia. DVAB also appears to diagnose
nonpalpable breast lesions more effectively than stereotactically guided
core-needle biopsy does. It may, in fact, be helpful to perform DVAB
after core-needle biopsy when the diagnosis of atypical duct hyperplasia
is being considered; this practice may lead to a decrease in the number
of open biopsies performed.
The Aim of the Study
A. To study the characteristics of the patients who are biopsied by
Mammotomy.
B. To examine the accuracy of the procedure.
C. To try to identify sub-populations of patients who may have higher
probability of malignancy in their lesions, and may need open
biopsy following the Mammotomy.
Material and Methods
Mammotomy-Description of the Procedure
Suitable candidates for DVAB include patients with non-palpable
lesions as follows:
1. mammographically visible clusters of suspicious calcifications
2. Patients with well-defined non-palpable masses that are suspicious
for malignancy.
Mammotomy was used also to place a clip If the cluster/ mass is not
large enough to guide subsequent wide excision when malignancy is
found or - If neo-adjuvant therapy was initiated previously.
Target lesions must be clearly visible on digital images and identifiable
on stereotactic projections. DVAB is not recommended for patients with
certain lesions located very posteriorly or very anteriorly in the breast,
those with very small or very thin breasts, and those who, for one reason
or another, cannot be properly positioned for the procedure or cannot
cooperate with the surgeon. The procedure is done on an outpatient basis
and usually can be completed in 1 hour or less. Patients are restricted
from engaging in strenuous activity for 24 hours after DVAB.
The probe employed for the procedure consists of an outer trocar
cannula, a sliding inner hollow coaxial cutter, a so-called knockout
shaft, a distal sampling notch, and a proximal tissue retrieval chamber;
in addition, it has a thumbwheel, which is used for manual advancement,
cutting, and retrieval of biopsy specimens. It must be used under the
guidance of an imaging modality (e.g., ultrasonography or
roentgenography), and it may be either mounted or handheld. The device
is connected to a suction machine, which acts first to draw the target
tissue into the sampling notch and then to facilitate retrieval of tissue
into the proximal collection chamber.
Stereotactic digital imaging is then performed to visualize the target and
calculate its location in three dimensions, and a suitable trocar insertion
site is identified. The skin is prepared, and a small amount of buffered
1% lidocaine with epinephrine (usually 10 ml or less) is administered.
The skin at the insertion site is punctured with a No. 11 blade, the probe
is manually advanced to the prefire site, and the position of the probe is
confirmed by means of stereotactic imaging. The device is then fired,
repeatedly cutting, rotating, and retrieving samples until the desired
amount has been removed. If the lesions being removed are
calcifications, the sufficiency of the sampling may be confirmed through
x-rays of the specimens.
Once the biopsy is complete, an inert metallic clip is deployed into the
biopsy site through the trocar so as to mark the lesion for future
reference in case it can no longer be visualized after biopsy; deployment
and positioning are confirmed by stereotactic imaging. The biopsy
device is then removed, the edges of the skin incision are approximated
with Steri-Strips, and a compressive bandage is applied. Any bleeding
occurring after removal of the biopsy device should be controlled by
manual pressure before the final bandage is applied. Typically, 1 g of
tissue (equivalent to approximately 10 to 12 samples with an 11-gauge
probe) is sufficient for diagnosis of benign disease, atypical ductal
hyperplasia, or carcinoma.
Complications are uncommon. Brisk bleeding may occur during and
immediately after the procedure. Bruising and discoloration may result
but generally resolve within days. Less frequently still, hematomas may
form, fat necrosis may occur, or the patient may note a palpable lump.
Caution is advisable in women who are receiving anticoagulants.
Surgical site infection has been reported as well, but it is rare [20].
Population of Patients
All patients with non-palpable breast lesions who were diagnosed in
The Breast clinic during the period 2001-2008 following a biopsy
performed with the aid of the Mammotomy were reviewed
retrospectively .
Demographics, personal and menstrual data were retrieved from a
questionnaire that every patient answered when first examined.
The clinical, pathological and follow-up data were collected and
evaluated retrospectively.
All findings were evaluated statistically ( one way test, anova – test
and chi-square test)
Results
Results 1:
Demographics and menstrual data
Mean Age (y)
55.3
Range: 28-89
Family history of
breast cancer (n)
171
30.1%
Mean age at
Menarche (y)
12.8
Range: 9 - 18
Mean age of Last
menstruation (y)
49.2
Range: 28 - 59
HRT use (n)
121
21.3%
Mean N
of children
2.8
Range: 0-10
The mean age of the women examined in this study was lower than the
mean age of breast cancer patients in our institute as was described in
previous studies – 55.3 years compared to 58.73 This fact may reflect
few phenomena: a. The median age of women who are screened is lower
than that who suffer from breast cancer , which include old breast cancer
patients who are not included in the screened population. B. The group
of women who are having breast biopsies is younger than those who
have pre-malignant lesions and are biopsied.
The rate of women with family history was also different. The rate of
women with family history of first degree relatives with breast cancer
was higher – 30.3% compared to 24.7% in the whole group of women in
our institute. This fact can be explained by the high index of suspicion in
any woman with breast calcifications which made the indication to
biopsy her more liberal.
The median length of fertility period (the time elapsed between
menarche and menopause) was 36.4 years which is not different from
the usual period which is observed in the population of patients in our
institute.
The rate of users of HRT was relatively high in the group of women who
underwent biopsy , 21.3% , specifically when we take into account the
fact that in recent years a significant drop in the rate of users was noted
in the western world, as well as in Israel. This reduced rate of HRT
users happened following the warning of a possible increase in breast
cancer as the result of using HRT. This high rate may reflect the higher
awareness of HRT users to the risks of breast cancer and the higher
screening rate of this group of patients.
Results 2:
The nature of the examined lesions
N
%
Lump
( non-palpable )
114
20 %
Calcifications
( + mass)
509
89.5%
New finding
530
91.8%
Prev. operation
47
8.2%
Most of the women who underwent mammotomy biopsies were
diagnosed to have suspicious calcifications (89.5%). In only 10.5% the
suspicious finding there was a lump only , without calcifications , which
was so small that the most appropriate method to biopsy it was by using
the mammotomy. An additional 9.5% of the women had a combination
of lump and calcifications.
In the majority of the women who underwent biopsy, the suspicious
lesion was a new one and this biopsy was the first to be done from that
lesion. Only in less than 7% of the patients the biopsy was done on
lesions who were observed and diagnosed earlier as probably benign
few months before the biopsy, and the decision was made to follow
them.
Previous operation was performed in only a little more than 8% of the
women.
Results 3:
Pathological results ( on mammotomy)
N
%
43
7.8
Fibrocystic
123
22.3
Fibroadenoma
43
7.8
Sclerosing
adenosis
101
18.3
ADH
67
12.1
LCIS
4
0.7
DCIS
119
21.5
Invasive
carcinoma
52
9.5
Total
552
100
Benign
Results 4
Definite Pathological results (on surgery)
N
%
Benign
8
4
Fibrocystic
5
5.2
Sclerosing
adenosis
52
5.2
5
2.5
ADH
55
2.2
LCIS
3
5.2
DCIS
79
39.5
Invasive carcinoma
74
37
511
511
Fibroadenoma
Total
Among 552 women who had biopsies’ and the pathological answer was
definite, in 165 women a malignancy was diagnosed ( including LCIS).
However, malignancy was found in only 156 women on open biopsy. In
9 patients in which malignancy was demonstrated in the biopsy , no
malignant lesion was found in surgery. As all women were followed for
at least 2 years after the biopsy by half-annual mammography to the
biopsied breast , and no malignant tumor was detected later, we presume
that in these women in which malignancy was not found, the whole
lesion was removed by the mammotomy biopsy.
The factors which predicted malignancy:
Older age of the patients:
Before Mammotomy The mean age of women who underwent
mammotomy followed by surgery was 57.9 years compared to 54.1 in
those with definite benign lesion who were only followed and did not
underwent surgery (p<0.001).
Before surgery :Among patient who underwent surgery, as a result of
suspicious biopsy (but not definite malignancy), there was also a
significant age difference. In 9 malignancy was found ( mean age :
58.1y) and in 36 the final analysis of the lesion was benign (mean age:
50.8y) (p<0.018).
A new lesion on diagnosis:
A new mammographic lesion on diagnosis was an independent
predicting factor for malignancy both before mammotomy and and
before open biopsy:
• Before mammotomy: An old lesion vs. new finding ( p=0.031)
• Before surgery ( in those patients who were operated) : An old lesion
vs. new finding (p=0.038)
The other factors which were examined were: family history, age at
menarche, age at menopause, nursing, the use of HRT, other malignancy
None was found to be predictive for malignancy, before mammotomy or
before surgery.
There was also no difference in the rate of malignancy between definite
mammographic masses vs. a cluster of suspicious calcifications, or
calcifications found within masses. This lack of significant difference in
the rate of malignancy was demonstrated before mammotomy in the
whole group of biopsied patients, and in the smaller group who
underwent open surgery following the mammotomy.
CONCLUSIONS:
1. The patients who are biopsied by mammotomy are younger, have
higher rate of family history and rate of them used HRT, compared
to patients who are diagnosed with breast cancer.
2. The main reason to perform mammotomy biopsy is suspicious
calcifications, only the minority had non-palpable masses.
3. Most patients who were biopsied by mammotomy had new
mammographic lesions, only minority had lesions which were
detected in the past and changed.
4. The rate of malignancy among our patients who underwent biopsy
was around third of patients' arte which is similar to the rates
described in other series.
5. The factors which predicted malignancy in the patients who were
biopsied' before biopsy , were age and new mammographic lesion.
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