Radiologic-Pathologic Correlation
Microcalcifications of the breast: a mammographic-histologic correlation study using a newly designed Path/Rad Tissue Tray

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Abstract

The introduction of screening mammography has brought about a greater knowledge of early breast cancer characteristics. These improvements have led to a reduction in size of suspicious lesions and a shift from surgical to image-guided core needle biopsies (CNBs). Establishing correlation between histologic and imaging findings is required for accurate diagnosis. Currently, there are no standardized multidisciplinary protocols for evaluating such lesions. We correlated histologic and radiologic findings in mammographically detectable calcified lesions in CNBs using specially designed Path/Rad Tissue Trays (patent pending, University of Kansas). Evidence of calcification was analyzed in 440 with and without the use of tissue trays. After mammographic identification of the lesion, CNBs are harvested, placed in tissue trays, and x-rayed to confirm sampling of the lesion. Images of CNBs with calcifications are marked by the radiologists and sent to the pathologist along with the biopsies. Trays with CNBs are then placed into cassettes and sent to the laboratory where they are embedded without disturbing orientation. Identification and localization of targeted microcalcifications were accomplished by radiologists and pathologists in 68 of 71 cases when using the tissue trays compared with 292 of 369 without tissue trays. Confirmation of microcalcifications was accomplished after deeper sectioning into tissue blocks from discordant cases. In conclusion, a systematic approach is recommended to standardize reporting of calcifications. The use of Path/Rad Tissue Trays has created a level of concordance between pathologists and radiologists that previously did no exist. It improved diagnostic reliability, encouraged communication between pathologists and radiologists, and minimized false diagnoses and/or delays in cancer diagnosis.

Introduction

Over the course of the last 3 decades, the introduction of screening mammography and other imaging modalities has greatly increased awareness and knowledge of early-stage breast cancers. It has been shown that the core needle biopsy (CNB) procedure is considered to be the preferential next step after suspicious radiographic findings on screening mammography [1], [2], [3], [4].

As mammography screening has increased, imaging-histologic discordance has become a significant issue that, in the absence of an adequate multidisciplinary approach, can lead to incorrect or delayed diagnoses as well as unnecessary surgical interventions. Investigators have quickly realized the importance of a multidisciplinary approach with the collaboration of radiologists, pathologists, and surgeons for accurate diagnosis to ensure the success of any CNB program [5]. Hurdles such as workforce, time, and geographic constrains are classic examples for the reasons why interdisciplinary programs were shown to be difficult. However, we at the University of Kansas Medical Center (KUMC) overcame such hurdles through the use of weekly audio-video conferencing, which allowed simultaneous viewing of radiologic and histologic materials by both specialists [6]. In their meetings, the different specialists discuss their findings and resolve any differences between radiology images and pathology findings to create an integrated diagnostic report and treatment recommendation for each patient.

Previous studies have shown that histologic correlation with mammographically detected calcification is somewhere between 90% and 95% of cases, with 5% to 10% of cases being considered to be false negative [2], [7]. Currently, there is no standardized interdisciplinary protocol for evaluating microcalcifications in such samples. This is, in part, due to the lack of a clear understanding of either the radiologic or the histologic description of calcification, leading to interobserver and intraobserver variabilities in reporting such findings. In addition, some pathologists consider the presence of microcalcifications of any size, anywhere in the specimen as sufficient evidence of sampling of targeted lesion by the radiologist. Very few studies have attempted to address the issue of mammographic-histologic correlation of microcalcifications in CNB of the breast [8], [9], [10], [11], [12].

This study was undertaken to standardize the procedure of CNB program in correlating histologic mammographically detectable calcification using specially designed Path/Rad Tissue Trays (patent pending, University of Kansas).

Section snippets

Materials and methods

Four hundred forty CNBs with mammographic evidence of calcification were selected for the study. This retrospective study was approved by the institutional research committee at the University of Kansas Medical Center. The mean age of the patients was 56.4 years (range, 28-83 years). Cases were randomly divided into 2 groups: 369 biopsies obtained from 321 patients without the use of tissue trays and 71 biopsies obtained from 60 patients with the use of tissue trays. All patients underwent

Results

Table 1 shows the histologic description of all cases studied. Four hundred forty specimens were obtained from a total of 381 patients. Most cases were benign, varying from nonproliferative and proliferative fibrocystic changes to papillomas, fibroadenomas, fibrosis, fat necrosis, and cases with no diagnostic abnormalities. Sixty-one randomly selected malignant cases were included in this study, including 49 ductal carcinoma in situ cases, 10 invasive ductal carcinomas, and 2 invasive lobular

Discussion

We illustrate that a standard approach of incorporating a novel device, the Path/Rad Tissue Tray, can significantly increase rates of concordance between histology and radiology findings for CNB specimens. Currently, 36.7 million mammograms [13] result in more than 1 million radiologically guided biopsies for pathologic evaluation annually [14], [15], [16]. Overall rates of radiologic-pathologic discordance of CNB analysis have ranged from 1% to 6% [17]. We have reached across the traditional

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