Open Access

Core biopsy as a tool in planning the management of invasive breast cancer

World Journal of Surgical Oncology20053:1

DOI: 10.1186/1477-7819-3-1

Received: 03 May 2004

Accepted: 04 January 2005

Published: 04 January 2005

Abstract

Background

Core biopsy is a method of choice for the triple assessment of breast disease as it can reliably distinguish between benign and malignant tumours, between in-situ and invasive cancers and can be useful to assess oestrogen receptor status. This study was carried out to assess the reliability of core biopsy in predicting the grade and type of cancer accurately as obtaining this information can influence initial therapeutic decisions.

Patients and methods

A total of 105 patients who had invasive breast carcinoma diagnosed by core biopsy in year 2001 and who subsequently underwent surgical management were included. The core biopsy results were compared with final histology with the help of kappa statastics.

Results

A moderate level of agreement between the predicted grades and final grades was noted (kappa = 0.585). The agreement was good between predicted and final type of tumour (kappa = 0.639).

Conclusions

Core biopsy as a predictor of grade and type has limited use at present. We suggest that initial clinical decisions should not be based on the results of core biopsy.

Background

Core biopsy is rapidly replacing fine needle aspiration cytology (FNAC) as a procedure of choice for the triple assessment of the breast problems. Where there is access to an experienced cytopathologist, the FNAC can provide a rapid and cost effective means of triage of patients who would benefit from more expensive core biopsy [1]. Core biopsy is, however, more reliable predictor of the pathology [24] and can distinguish between benign and malignant tumours and between in-situ and invasive cancers. Collins et al have shown that majority (83%) of core biopsies and excisional procedures demonstrate exact histological agreement [5]. Core biopsy may give a good guide to grade and type of the cancer and it can also be used to assess the oestrogen receptor (ER) status. Core biopsy has also been found to be a good tool to assess effect of neo-adjuvant chemotherapy on the grade of breast cancer [6].

As the range of options for the treatment of the breast cancer widens, it has become increasingly important that clinicians are provided with accurate prognostic information to base the initial therapeutic decisions on. Prognostic factors for breast cancer have been extensively studied. Histological grade and type can be used to predict biological behaviour as has been assessed by overall survival and local recurrence for women with primary breast carcinoma [79]. Histological grade is one of the three prognostic factors used in calculating the Nottingham Prognostic Index [10].

The aim of this study, therefore, was to see how reliable core biopsy is in predicting the grade and the type of cancers, as that could influence the further management of breast cancer.

Patients and methods

All patients with invasive breast cancer diagnosed by the core biopsy and treated subsequently by surgical excision in the year 2001, at a district general hospital were included in the study. Of the 105 patients whose records were studied retrospectively, 47 lesions were palpable and 58 lesions were screen detected. The core biopsies were performed under ultrasound guidance as a part of triple assessment and at least four cores were obtained from palpable lesions and six or more from screen detected lesions with a 22 mm automated core biopsy gun. Two dedicated breast pathologists had authorised all the reports. Age of patients ranged from 35 to 84 with a median age of 62 years. The histology reports for the core biopsy and final histology were extracted and compared. Carcinoma in-situ diagnosed by core biopsy and patients who underwent neo-adjuvant therapy were excluded from the study. Level of agreement between core and excision biopsy was assessed using kappa statistics.

Results

Of 105 patients there was no prediction of grade in 2 patients and in 19, a prediction of grade 1 or 2 or grade 2 or 3 was made. This left 84 where a clear prediction was made. On final histology 35 (33.3%) were categorised as grade I, 45 (42.8%) were grade II and 25 (23.8%) were grade III. The predicted grades versus final grade results are detailed in table 1.
Table 1

Cross tabulation showing predicted verses final grade

 

Final grade

 

Grade

1

2

3

Predicted grade

1

21

0

0

 

2

5

35

9

 

3

1

6

7

 

1 or 2

7

1

1

 

2 or 3

0

2

8

 

Not predicted

1

1

0

Kappa = 0.585

Of the 84 cores in which clear prediction of grade was made 63 (75%) were correct. All 21 of grade 1's were predicted correctly, 35 (71%) of grade 2's were predicted correctly but only 7 (50%) or grade 3's were predicted correctly on core biopsy. Of the predicted grade 2's which were reclassified, 5 (10%) were downgraded and 9 (18%) were upgraded. Of the reclassified grade 3's, 6 (43%) were downgraded to grade 2 and 1 (7%) was downgraded to grade 1.

Of 105 patients, 101 patients had a prediction of type made. Of 84 cases predicted to be ductal, 81 (96%) were correct and one case was reclassified as mixed histology. Of the 14 predicted to be lobular 9 (64%) were correct and one reclassified as mixed (Table 2). Of the three cases predicted as mixed only one was mixed on final pathology.
Table 2

Cross tabulation of predicted verses final tumour types.

 

Final type

 

Type

Lobular

Ductal

Ducto-lobular

Predicted type

Lobular

9

4

1

 

Ductal

2

81

1

 

Ducto-lobular

1

1

1

 

Uncertain

1

2

1

Kappa = 0.639

In general the level of agreement between the predicted grades and final grades was moderate (kappa = 0.585) and between predicted and final types was slightly better (kappa = 0.639).

Discussion

Fajardo et al reported percutaneous, image guided biopsy to be an accurate diagnostic alternative to surgical biopsy in women with mammographically detected suspicious breast lesions [11]. The false negative results occur to a lesser degree with image guided core biopsy [12]. However needle size [13] or amount of clinical material obtained [14] has not been found to influence the histology results. A recent study has shown that access to expert breast pathologists can avoid inconsistencies observed in the category of borderline lesions between the expert and general pathologists [15].

Histological grade and type, tumour size and presence or absence of axillary node metastases is well-recognised prognostic factors of breast cancer. Tumour grade, size and nodal involvement are three factors considered in Nottingham Prognostic Index [10]. Histological grade and type on their own can be helpful in predicting the biological behaviour of the tumour as regards to local recurrence and overall survival [79]. Preoperative grading and typing with core biopsy, therefore, can influence further management of the cancer this is all the more important as the sensitivity and specificity of mammogram for predicting grade or type is poor [16].

Green Hough (1925) was the first to categorise the breast tumours into three grades according to its differentiation. He also assessed the association of grades with "cure" though the term cure was not clearly defined [17]. Since then a clear association between grades and prognosis has been established [1723]. Higher the grade, greater is the chance of the tumour relapsing [24, 25]. It has also been noted that oestrogen receptor (ER) negative tumours are usually of higher grade [2628]. Higher the tumour grade more aggressive is the tumour and nodal involvement too is directly related to aggressiveness of the tumour [29]. All these factors suggest that higher the grade of tumour more radically should it be managed. Knowing the grade accurately, preoperatively, would help in planning out further management of the tumour. It is possible to identify all these prognostic factor in core biopsy. A small earlier study has shown 80% sensitivity of core biopsy for correct diagnosis and a poor (50%) sensitivity for diagnosing invasive cancers in mammographically detected cancers [30]. It is not possible to comment on this in present study as only invasive cancers were included in the present study.

Of the two major histological types, lobular is known for its multifocality and multicentricity and its diffusely infiltrating nature [31]. It is important to correctly identify lobular carcinoma, as these tumours are often hormone responsive [21].

Our results suggest that the prediction of grade and type of breast cancer from core biopsy has only limited use at present. The group of patients we would like to be predicted most accurately would have been those with a high-grade and lobular type, for the reasons stated above. Our results suggest that these patients are most difficult to predict in practice. However, present study being retrospective has its own drawbacks. A prospective study specifically aimed at Kappa statistics between core biopsy and final histopathology may be able to answer this question better. Further refinements are needed in technique of core biopsy and these technical innovations will ultimately improve the results of core biopsy.

Funding source

None

Declarations

Acknowledgements

The authors thank Ms Yen Chuah, statistician, University Hospital, Birmingham, for her help in statistical analysis.

Authors’ Affiliations

(1)
Department of General Surgery, University Hospital
(2)
Department of General Surgery, North Tees University Hospital
(3)
Department of Surgery, Prince Phillip Hospital

References

  1. Farshid G, Rush G: The use of fine-needle aspiration cytology and core biopsy in the assessment of highly suspicious mammographic calcifications: analysis of outcome for 182 lesions detected in the setting of a population-based breast cancer screening program. Cancer. 2003, 99: 357-364. 10.1002/cncr.11785.View ArticlePubMedGoogle Scholar
  2. Fersis N, Smyczek-Garagya B, Krainick U, Mielke G, Muller-Schimpfle M, Keisel L, Wallweiner D: Clinical experience with large-core needle biopsies of the breast and treatment and evaluation of histopathological results. Zentralbl Gynakol. 2001, 123: 132-135. 10.1055/s-2001-12509.View ArticlePubMedGoogle Scholar
  3. Clarke D, Sudhakaran N, Gately CA: Replace the fine needle aspiration cytologywith automated core biopsy in triple assessment of breast cancers. Ann R Coll Surg Engl. 2001, 83: 110-112.PubMed CentralPubMedGoogle Scholar
  4. Sun W, Li A, Abreo F, Turbat-Herrera E, Grafton WD: Comparison of fine needle aspiration cytology and core biopsy for diagnosis of breast cancer. Diagn Cytopathol. 2001, 24: 421-425. 10.1002/dc.1092.View ArticlePubMedGoogle Scholar
  5. Crowe JP, Rim A, Patrick RJ, Rybicki LA, Grundfest-Broniatowski SF, Kim JA, Lee KB: Does core needle breast biopsy accurately reflect breast pathology?. Surgery. 2003, 134: 523-528. 10.1016/S0039-6060(03)00269-1.View ArticlePubMedGoogle Scholar
  6. McIntosh SA, Panchalingam L, Payne S, Miller ID, Sarkar TK, Hutcheon AW, Heys SD: Freehand core biopsy in breast cancer: an accurate predictor of tumour grade following neo-adjuvant chemotherapy?. Breast. 2002, 11: 496-500. 10.1054/brst.2002.0466.View ArticlePubMedGoogle Scholar
  7. du Toit RS, Locker AP, Ellis IO, Elston CW, Nicholson RI, Blamey RW: Invasive lobular carcinomas of the breast- the prognosis of histopathological subtypes. Br J Cancer. 1989, 60: 605-609.PubMed CentralView ArticlePubMedGoogle Scholar
  8. Fisher ER, Redmond C, Fisher B: Prognostic factors in NSABP studies of women with node negative breast cancer. National Surgical Adjuvant Breast and Bowel project. Monogr Natl Cancer Inst. 1992, 11: 151-158.PubMedGoogle Scholar
  9. Dixon JM, Page DL, Anderson TJ, Lee D, Elton RA, Stewart HJ, Forest AP: Long-term survivors after breast cancer. Br J Surg. 1985, 72: 445-448.View ArticlePubMedGoogle Scholar
  10. Haybittle JL, Blamey RW, Elston CW, Johnson J, Doyle PJ, Campbell FC, Nicholson RI, Griffiths K: A prognostic index in primary breast cancer. Br J Cancer. 1982, 45: 361-365.PubMed CentralView ArticlePubMedGoogle Scholar
  11. Fajardo LL, Pisano ED, Caudry DJ, Gatsonis CA, Berg WA, Connolly J, Schnitt S, Page DL, McNeil BJ: Radiologist Investigators of the Radiologic Diagnostic Oncology Group V. Acad Radiol. 2004, 11: 293-308. 10.1016/S1076-6332(03)00510-5.View ArticlePubMedGoogle Scholar
  12. Shah VI, Raju U, Chitale D, Deshpande V, Gregory N, Strand V: False negative core biopsies of breast: an analysis of clinical, radiologic and pathologic findings in 27 consecutive cases of missed breast cancer. Cancer. 2003, 97: 1824-1831. 10.1002/cncr.11278.View ArticlePubMedGoogle Scholar
  13. Wong TE, Hisham AN: Core biopsy of palpable breast lump: the influence of needle size. Med J Malaysia. 2003, 58: 399-404.PubMedGoogle Scholar
  14. O'Leary R, Hawkins K, Beazley JC, Lansdown MR, Hanby AM: Agreement between preoperative and postoperative invasive breast cancer histopathology is not dependent on the amount of clinical material obtained. J Clin Pathol. 2004, 57: 193-195. 10.1136/jcp.2003.12914.PubMed CentralView ArticlePubMedGoogle Scholar
  15. Verkooijen HM, Peters JL, Schipper ME, Buskens E, Hendriks JH, Pijnappel RM, Peeters PH, Borel Rinkes IH, Mali WP, Holland R: Interobserver variability between general and expert pathologists during histopathological assessment of large-core needle and open biopsies of non-palpable lesions. Eur J Cancer. 2003, 39: 2187-2191. 10.1016/S0959-8049(03)00540-9.View ArticlePubMedGoogle Scholar
  16. de Roos MAJ, Pijnappel RM, Post WJ, de Vries J, Baas PC, Groote LD: Correlation between imaging and pathology in ductal carcinoma in situ of the breast. World J Surg Oncol. 2004, 2: 4-10.1186/1477-7819-2-4.PubMed CentralView ArticlePubMedGoogle Scholar
  17. Greenhough RB: Varying degree of malignancy in cancer of the breast. J Cancer Res. 1925, 9: 452-463.Google Scholar
  18. Bloom HJG: Prognosis in carcinoma of the breast. Br J Cancer. 1950, 4: 259-288.PubMed CentralView ArticlePubMedGoogle Scholar
  19. Bloom HJG, Richardson WW: Histological grading and prognosis in breast cancer. Br J Cancer. 1957, 11: 359-377.PubMed CentralView ArticlePubMedGoogle Scholar
  20. Hamlin IME: Possible host resistance in carcinoma of the breast: a histological study. Br J Cancer. 1968, 22: 383-401.PubMed CentralView ArticlePubMedGoogle Scholar
  21. Champion HR, Wallace IWJ, Prescott RJ: Histology in breast cancer prognosis. Br J Cancer. 1972, 26: 129-138.PubMed CentralView ArticlePubMedGoogle Scholar
  22. Elston CW: The assessment of histological differentiation in breast cancer. Aust N Z J. 1984, 54: 11-15.View ArticleGoogle Scholar
  23. Elston CW, Ellis IO: Pathological prognostic factors in breast cancer. I. The value of histological grade in breast cancer: experience from a large study with long-term follow up. Histopathology. 1991, 19: 403-410.View ArticlePubMedGoogle Scholar
  24. Harris JR, Connolly JL, Schnitt SJ, Silen W: The use of pathologic features in selecting the extent of surgical resection necessary for breast cancer patients treated by primary radiation therapy. Ann Surg. 1984, 201: 164-169.View ArticleGoogle Scholar
  25. Zafrani B, Vielh P, Fourquet A, Mosseri V, Durrand JC, Salmon RJ, Vilcoq JR: Conservative treatment of early breast: prognostic value of ductal in-situ and other pathological variables on local control and survival. Eur J Cancer. 1989, 25: 1645-1650.View ArticleGoogle Scholar
  26. Meyer JS, Rao BR, Stevens SC, White WL: Low incidence of oestrogen receptor in breast carcinomas with rapid rate of cellular proliferation. Cancer. 1977, 40: 2290-2298.View ArticlePubMedGoogle Scholar
  27. Bishop HM, Blamey RW, Elston CW, Haybittle JL, Nicholson RI, Griffiths K: Relationship of oestrogen receptor status to survival in breast cancer. Lancet. 1979, 2: 283-284. 10.1016/S0140-6736(79)90295-2.View ArticlePubMedGoogle Scholar
  28. Elston CW, Blamey RW, Johnson J, Bishop HM, Haybittle JL, Griffiths K: The relationship oestradiol receptors (ER) and histological tumour differentiation with prognosis in human primary breast carcinoma. In: Breast cancer-experimental and clinical aspects. Edited by: Mouridsen HT, Palshof R. 1980, Oxford: Pergamon Press, 59-62.Google Scholar
  29. Biopsy. In: Detection and treatment of breast cancer. Edited by: Fentiman IS. 1998, London: Martin Dunitz Ltd, 71-83.
  30. Yamamoto D, Yamada M, Okugawa H, Tanaka K: Predicting invasion in mammographically detected microcalcifcation: A preliminary report. World J Surg Oncol. 2004, 2: 8-10.1186/1477-7819-2-8.PubMed CentralView ArticlePubMedGoogle Scholar
  31. Greenall MJ: Cancer of the breast. In: Oxford Textbook of Surgery. Edited by: Morris PJ, Malt RA. 1994, Oxford University Press, 808-841.Google Scholar

Copyright

© Deshpande et al; licensee BioMed Central Ltd. 2005

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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