I was concerned with some of the BCCA guidelines listed on page 199 (Breast cancer screening and diagnosis in British Columbia, BCMJ 2008;50:198-205). They are out of date, and do not include use of Breast Imaging Reporting and Data Systems (BIRADS) final assessment categories or current standards for further investigation and follow-up.
I have since learned that the BCCA web site is in the process of being updated, but I am concerned that family physicians reading this article may start requesting the wrong tests, or insisting on unnecessary procedures.
The important changes to the original article are as follows:
• If there is an abnormality that is not clearly malignant but is new, further imaging with additional views, +/- magnification views, +/- ultrasound should be undertaken, based on the radiologist’s assessment.
• A new suspicious finding should be further assessed with imaging and a pathological diagnosis. A core biopsy done with either stereotactic or ultrasound guidance may be undertaken.
• If a mass is seen on mammography, ultrasound is appropriate. It can distinguish between a cyst and a solid lesion. There are also criteria to distinguish a benign from an indeterminate from a malignant lesion.
• If the lesion meets the criteria for a simple cyst, then aspiration is not required. If the lesion meets the criteria for a “complicated cyst” either aspiration or short interval (usually 6 months) ultrasound follow-up can be undertaken. If the lesion is symptomatic it can be aspirated. It is also reasonable to aspirate a cyst if necessary for mammographic/sonographic correlation.
• If the lesion is solid, it is not always mandatory to proceed to biopsy. If it meets the imaging criteria for a “probably benign” lesion (positive predicative value for malignancy less than 2%), then short interval follow-up is preferable to biopsy. If the solid mass does not meet these criteria, then ultrasound-guided biopsy is appropriate. Fine needle aspiration biopsy (FNAB) has limited usefulness in image-guided breast biopsy.
Unlike core biopsy, it cannot distinguish in-situ from invasive malignancy. Another reason core biopsies are preferred for suspicious lesions is that they also provide sufficient tissue for receptor analysis. Even for benign masses, core biopsy is more easily interpretable and therefore often yields more definitive diagnoses than FNAB. The appropriate use of FNAB is to rule out a complicated cyst, or to sample an axillary node suspicious for metastasis.
• When a lesion is visible both mammographically and sonographically, then ultrasound-guided intervention is generally preferable to stereotactic, unless the location of the lesion dictates that it would be safer to perform with stereotactic guidance. This is at the discretion of the radiologist.
• Any calcifications which do not meet the criteria for “probably benign” should be biopsied, usually stereotactically. “Sufficiently suspicious” is defined as a positive predictive value greater than 2%. Occasionally, suspicious calcification seen mammographically can be visible with ultrasound, but this is much less common.
—Paula Gordon, MD, FRCPC
Above is the information needed to cite this article in your paper or presentation. The International Committee
of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally
accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
About the ICMJE and citation styles
The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.
An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.
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For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org