Triple Assessment of Breast Lump: Should We Perform Core Biopsy for Every Patient?

Table of Contents

Materials and methods

This was a cross-sectional retrospective study conducted at Tameside General Hospital Manchester, UK, between April 1, 2009, and March 30, 2010. We examined the records of 124 breast cancer patients aged from 18 to 83 years, who were initially assessed in a One-stop Triple Assessment Clinic and core biopsy was performed either on the same day or the day after. Approval from the institution’s ethical committee was obtained and informed consent was taken from patients for physical examination and investigations.

The study was done to assess the reliability, validity, sensitivity, and specificity of triple assessment and to compare it with core biopsy. To assess the diagnostic potential of the combination modalities (P, U, and M), we considered all cases with a score of 4 (probably malignant) and 5 (malignant) in any of the modalities positive for malignancy. All cases with a score of 3 (equivocal), 2 (benign), and 1 (normal) in any of the modalities were considered negative for malignancy. For FNAC, a score of 1 (insufficient sample), 2 (benign), and 3 (atypia/probably benign) were considered. All patients included in the study were diagnosed to have breast cancer on surgical biopsy. Among 124 patients, 12 were excluded. The reason for exclusion was unfitness for intervention, which is explained below in detail:

Nine patients were too frail and unfit who did not undergo the full triple assessment:

One patient was started on letrozole without triple assessment (patient’s wish, 83-year-old).

One patient had ulcerated and fungating breast cancer of the nipple-areola complex.

One patient failed to attend the clinic for a surgical biopsy despite reminders.

Each patient went through a physical examination of breast bilaterally. Skin changes, discharge or bleeding from the nipple, and lumps were noticed during the examination. All characteristics of a lump were recorded such as location, size, shape, edges, mobility, adherence to the skin or underlying structures and tenderness. Along with breast examination, axilla and supraclavicular fossae were examined bilaterally for assessment of lymphadenopathy, and any signs of distant metastasis were examined.

Mammography was performed according to standard guidelines, a craniocaudal view of each breast was taken, and two views were obtained: the lateral oblique view and a view with the tube angled at 45 degrees to the horizontal axis. To obtain these views successfully during mammography, the nipple should be seen in profile, the anterior surface of the pectoralis major should be visible, the breast should be lifted sufficiently and is compressed between compression plate and film to have evenly spread breast tissue, as it makes it easy to detect any changes. Irregular borders, micro-calcifications, speculated density, loss of breast architecture, and skin retraction suggests malignant disorder while a well-circumscribed mass with regular borders is suggestive of benign disorders.

High-definition ultrasonography breast (HDUSG) was used during this study. The patient should lie in a supine or oblique position, with the ipsilateral arm above the head. The breast has to be scanned in either a transverse or sagittal or radial and anti-radial planes. The transducer is used in multiple planes to evaluate the retro-areolar area, as it is shadowed by nipple artifact on ultrasound.

FNAC was done in all patients using a 22 gauge needle and 20 ml syringe. The mass was immobilized and the needle was inserted into the breast lump. The needle was moved back and forth inside the mass and the material was then expelled onto a glass slide, fixed by air drying, and stained with Giemsa and hematoxylin and eosin. Slides taken from patients were examined by the pathologist and the cytological diagnosis of the breast masses was given.