Table of Contents  

Salem, Ghazi, and Eltayeb: The diagnostic utility of ultrasound-guided core needle biopsy in breast lumps

Introduction

Breast cancer is the most common site-specific cancer in women1,2 and is the leading cause of death from cancer for women aged 20–59 years. It accounts for 26% of all newly diagnosed cancers and 15% of cancer-related deaths in women.1

In 33% of breast cancer cases, the woman discovers a lump in her breast, but up to 50% of women presenting with breast complaints have no physical signs of breast pathology. Breast pain usually is associated with benign disease,1 and the most common types are invasive ductal carcinoma (80%) and invasive lobular carcinoma (10%).3

According to the literature, delayed diagnosis is a major factor predicting prognosis4 and is common. In previous studies, delayed diagnosed by a physician affected 6–16% of women with breast cancer5,6 and was linked to patients being incorrectly reassured on the basis of only a radiological finding, without biopsy, that they have a benign lesion.7

Core needle biopsy (CNB) is one of the most common surgical procedures of the breast. CNB has replaced fine-needle aspiration as the gold standard for establishing the true nature of a breast lesion by providing a pathological assessment of a palpable or radiological breast abnormality. It avoids inadequate tissue sampling, providing enough tissue for diagnosis. Pre-operative diagnosis of breast cancer enables planning for one-stage surgery.2,810

A few studies from Gulf countries1113 have addressed the sensitivity and specificity of CNB; however, there is lack of such studies from the United Arab Emirates. The aim of our study is to address the accuracy of CNB among our patients.

Methods and materials

The study was a retrospective study of all adult female patients who underwent ultrasound-guided CNB of a breast lump at the surgical departments of Dubai Hospital and Rashid Hospital, followed by surgical excision of the lump, between December 2009 and December 2012. A total of 245 patients underwent ultrasound-guided CNB. Patients aged < 13 years, males and those who did not undergo an operation were excluded. Patients operated on outside the Dubai Health Authority (DHA) area were excluded unless their histopathology slides were reviewed in the DHA’s pathology department. The total number of CNBs was 245, with only 79 cases fulfilling our inclusion criteria (Figure 1); therefore, the final analysis included only these 79 cases. The histological results of the surgically excised specimens were compared with those obtained by CNB, retrieved from an online hospital database (SAM system; Shared Medical Systems-Albabtain Trading, Dubai, United Arab Emirates, version 2.9.62). The CNB results were grouped into three categories – benign, malignant and possible – based on pathologist’s report. Possible specimens were those either clearly stated to be so by the pathologist or specimens showing atypia and/or a high mitotic rate. The final histopathology results of surgically excised breast lumps were categorized into either benign or malignant. CNB was performed by the general surgery team, dedicated to dealing with breast diseases and with 2–7 years’ experience. Other than using a 14G size needle, there is no standardization of the procedure in our institute, which may have had a negative impact on the accuracy of CNB.

FIGURE 1

Breast CNB, performed and histological results.

HMJ-656-fig1.jpg

The statistical analysis of data was performed using SPSS (version 13, IBM Corporation, Armonk, NY, USA) to calculate sensitivity and specificity for CNB compared with histopathology.

Results

Of the 79 CNB samples, 47 were malignant, 28 benign and four possible (Figure 2); possible cases were not included in the calculation of the sensitivity and specificity of CNB. Of the 79 CNB cases, 56 were malignant on final histopathology. The false-positive rate, i.e. a diagnosis of a malignant tumour on CNB but final histopathology showing a benign tumour, was 4.2%. The false-negative rate, i.e. a diagnosis of a benign tumour by CNB but histopathology determining it to be malignant, was 28%. CNB was calculated to have a sensitivity and specificity of 84.9% [95% confidence interval (CI) 72.4% to 93.23%) and 90.9% (95% CI 70.80% to 98.62%), respectively (Figure 3). The positive and negative predictive values were 95.75% and 71.43%, respectively. The positive predictive value is the probability that the disease is present when the test is positive and the negative predictive value is the probability that the disease is not present when the test is negative.

FIGURE 2

Histology results of CNB.

HMJ-656-fig2.jpg
FIGURE 3

Sensitivity and specificity of CNB.

HMJ-656-fig3.jpg

The majority of cases of malignant tumour on the final histopathological results were invasive ductal carcinomas (39/65). Others included ductal carcinoma in situ, invasive lobular carcinoma, invasive tubular carcinoma and lymphoma (Figure 4); one case was reported as a mixed tumour of sarcoma and invasive ductal carcinoma.

FIGURE 4

Final histopathology results of surgically excised breast lump. DCIS, ductal carcinoma in situ; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma.

HMJ-656-fig4.jpg

Discussion

In this study CNB showed medium sensitivity for a diagnosis of cancer in the final histopathology; this is not consistent with the sensitivity of the test reported in many published studies.1416 In our study, we found a sensitivity of 84.91%, meaning that there is 84.91% probability that CNB will show cancer in patients who do have cancer. This sensitivity rate could be explained by the fact that some procedures were performed by less experienced junior doctors at the start of their training. This emphasizes the importance of experience in performing the procedure, as it requires advanced ultrasonography skills that must be mastered to increase the accuracy of the test. Three cases diagnosed by CNB as non-invasive carcinoma (i.e. in situ) were finally diagnosed as invasive carcinomas. This underestimation should be considered when approaching and managing such patients. We recommend that this study be repeated with a larger sample size, when junior doctors have achieved an appropriate level of experience and when the procedure has been standardized. The results of CNB showed medium sensitivity in diagnosing breast cancer, below internationally reported figures, with non-standardization of the procedure and less experienced junior doctors being the main contributing factors. CNB should be properly planned and performed by a trained specialist who has reasonable ultrasound skills or by a radiologist. As there is a high false-negative rate for CNB, radiological findings need to be interpreted cautiously, preferably in a multidisciplinary meeting.

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