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Hospital Practice

ASPIRATION CYTOLOGY AND OUTPATIENTEXCISION OF BREAST LUMPS

S. N. JOFFEJ. N. PRIMROSE

HELENA E. HUGHESB. W. A. WILLIAMSON

University Department of Surgery and Department ofCytology, Royal Infirmary, Glasgow

Summary Fine-needle aspiration biopsy was per-formed in 30 consecutive women with

clinically non-malignant breast lumps. All aspirateswere shown to be benign on cytology and the lumps wereexcised under local anæsthetic at the outpatient depart-ment. Frozen section and paraffin section histology ofthe excised lump confirmed the diagnosis. Follow-up atthe outpatient department and a postal questionnairerevealed the following wound complications: redness

(70%), bruising (55%), and discharge (35%). Outpatientexcision of solid breast lumps is a safe, rapid, and eco-nomical method of treating non-malignant breast lumps,if it is preceded by an accurate cytological interpretationof a technically satisfactory aspirate.

INTRODUCTION

CURRENT management of solid breast lumps requiresinpatient excision biopsy under general anaesthesia withfrozen section. Preoperative investigations may includeaspiration cytology, needle biopsy, mammography, xero-graphy, thermography, isotopic bone scanning, and ser-ological tests.l-3 Since over 90% of breast lumps arebenign4 the necessity of a general anaesthetic for a biopsyis questionable. The choice of treatment is influenced bythe risk of anaesthesia, the extent of psychological stressrelated to frozen section histology with the possibility ofmastectomy, cost-effectiveness of the method, and pa-tient acceptability.

_

Fine-needle aspiration cytology of the breast is a safeprocedure with a high diagnostic accuracy.2.3 We eval-uated its usefulness in the outpatient surgical manage-ment of breast lumps.

PATIENTS AND METHOD

Thirty women presenting consecutively at the surgical clinicwith a solid breast lump, diagnosed clinically to be non-malig-nant, underwent aspiration cytology. A further eight patientswith a clinically malignant breast lump later confirmed bycytology and histology were excluded. The mean age of thethirty patients was 33 years (range 18-50 years), 70% weremarried with children, and 23% were on the oral contraceptivepill. The breast lump had been present for an average of 3weeks before outpatient consultation. In 30% of patients thelump was painful, and 25% gave a history of a previous benignbreast lump.The breast lump was aspirated with a 19-gauge needle

attached to a 20 ml disposable syringe without local anasthe-sia. The cellular material obtained was immediately smearedon slides, fixed with 95% ethanol, and stained by the Papanico-laou method. The residual contents of the needle and syringewere flushed with 5 ml physiological saline. ’Cytospin’ prep-arations and Millipore-filter preparations of the cell suspensionwere fixed and stained by the Papanicolaou method. All the

specimens were classified as malignant, benign, or unsuitablefor diagnosis (technically unsatisfactory) by one cytologist(H.E.H.).

In those cases in which aspiration cytology showed a benignlesion, the breast lump was excised under local anaesthetic (1%lignocaine) in the outpatient theatre and the wound was closedwith chromic catgut and 000 subcuticular ’Dexon’ withoutdrainage. Frozen-section histology was immediately performedto confirm that the disease was benign, and the patient wastold the result before leaving approximately 2 h after excision.Patients were seen at the surgical clinic 1 week postoperativelywhen the results of paraffin-section histology were available. Aquestionnaire was sent to all patients 3-6 months postopera-tively. Questions were asked about pain, discharge, infection,and also the patient’s reaction to aspiration cytology and exci-sion of a breast lump under local anaesthesia.

RESULTS

All excised lumps were benign as judged by paraffin-section histology. 28 (93%) of the 30 breast lesions wereclinically benign and in only two was malignancy ques-tioned. Technically satisfactory aspirates were obtainedin all thirty patients. Aspirates were all reported as beingbenign by cytological criteria, and this was subsequentlyconfirmed on both frozen and paraffin-section histology.

Data from the questionnaire revealed that post-operative pain and/or discomfort lasted for a mean of 6days. The wound complications were redness (70%); ’’bruising (55%), and discharge (35%). Despite these com-plications, 95% of the patients said that the wound hadhealed without any real difficulty and that the procedurehad not interfered with their usual activities. Thewound had to be dressed by the community nurse for 3days in five patients.77% (23/30) of the patients found the aspiration cyto-

logy unpleasant and 60% (18/30) stated that the lumpexcision was also unpleasant but not painful. In responseto the question "If you had another breast lump wouldyou have it removed under local anaesthetic rather thangeneral anxsthetic?" Only 48% answered "yes".

DISCUSSION

Aspiration cytology for the diagnosis of breast lumpsis more common in Europe and Scandinavia than in Bri-tain.2.3 Recent recommendations that breast lumps, ifshown to be benign by clinical, radiological, and cytolo-gical examination, need not be excised are not yetaccepted nor proven.3 All palpable solid breast lumpsshould be excised.We demonstrated, in the thirty patients studied, that

outpatient excision of solid breast lumps, with benignpreoperative cytology, is a safe and reliable procedurewhen performed under local anaesthesia, and is associ-ated with a low morbidity. This procedure was not associated with complications attributable to generalanaesthesia, was well tolerated, and patients could returnhome within 2 h knowing that the breast lump had beefremoved and was benign. This is of considerable comfortto the patient. This approach is also cost-effective sinCIit avoids 2-3 days inpatient treatment.5 Questions abou’the psychological advantages of aspiration cytology anclocal anaesthesia were not asked in the postal questionnaire. However, nearly half the patients said that the;would have a further breast lump removed under locaanaesthesia.

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A small but significant number of clinically benignbreast lumps may subsequently prove to be malignant,3but our series is probably too small to have includedsuch patients. Although it is usual to proceed directly tomastectomy after a frozen section diagnosis of malig-nancy on excision biopsy, there is insufficient evidencethat a delay of mastectomy for several days increasestumour-recurrence rate and mortality. If a carcinomahad been found on histology, then the patient wouldhave been immediately admitted for further investiga-tion and treatment.

In this study there were no technically unsatisfactoryaspirates and the reliability of aspiration cytology washigh, with no false-positive or false-negative results.Furnival et al. initially had 24.8% technically unsatis-factory aspirates and a diagnostic accuracy of over 90%in their study of aspiration cytology. 2.3

Although minor wound complications were commonin our series, they were of short duration, and surgeonsand patients generally thought that wound healing wassatisfactory. Excision of solid breast lumps under a localanaesthetic is a useful method of treating clinically non-malignant breast disease, provided the lump has beenshown to be benign on aspiration cytology.

REFERENCES

1. Strax P. Screening for breast cancer. Clin Obstet Gynecol 1977; 20:781-801.

2. Furnival CM, Hughes HE, Hocking MA, Reid MMW, Blumgart LH. Aspira-tion cytology in breast cancer, its relevance to diagnosis. Lancet 1975; ii:446-48.

3. Schöndorf H. Aspiration cytology of the breast. London: WB Saunders,1978: 129-31.

4. Haagensen CD. Diseases of the breast. 2nd ed. London: WB Saunders, 1974.5. Prescott RJ, Ruckley CV, Garraway WM, Cuthbertson CJC, Fenwick N.

Functional assessment of patients undergoing day-care surgery for vari-cose veins or hernia: results from a randomized controlled trial. HealthBulletin 1979; 37: 82-88.

Public Health

EPIDEMIC OF BREAST ENLARGEMENT IN ANITALIAN SCHOOL

G. M. FARA G. DEL CORVO

Institute of Hygiene, University of Milan, Italy

S. BERNUZZI A. BIGATELLO

School Medicine Service, City Health Department, Milan

C. DI PIETRO S. SCAGLIONIG. CHIUMELLO

Department of Pædiatrics, University of Milan

Summary An outbreak of breast enlargement ingirls and boys attending a school in

Milan, first noted in November, 1977, was followed upuntil the end of 1978. 213 boys aged 3-14 years and 110girls aged 3-7 years were studied; control children

attending five other schools were also examined. In total1647 boys and 476 girls were examined. Breast enlarge-ment was significantly more common in boys (29·0%)and girls (21·6%) aged 3-5 years, boys (58·0%) aged6-10, and girls (67·1%) aged 6-7 from the school inMilan, than in age and sex matched children at controlschools. Breast enlargement was not pronounced anddisappeared within 8 months. Hormonal determinationswere within normal limits except for 17 &bgr;-œstradiolwhich was slightly raised. Although oestrogen contami-nation was not detected when samples of school mealswere tested, an uncontrolled supply of poultry and beefwas suspected as being the cause of this outbreak.

INTRODUCTION

SLIGHT breast enlargement is common in boys duringpuberty; usually it is not very noticeable, and disappearsafter a year or two. It is more likely to occur in boys whoare developing rapidly. In most cases the reason for suchbreast enlargement is not understood. In girls, develop-ment of the breast without signs of sexual maturation isnot uncommon during infancy and childhood. Busul-phan, digitalis preparations, ethionamide, isoniazid,spironolactone, oestrogens, cimetidine, marihuana, andtricyclic antidepressants are all known to induce breastenlargement.’-’

THE OUTBREAK .

Between Nov. 19 and 24, 1977, parents of children at aschool in Milan told the physician in attendance that 1 girlaged 4, and 11 boys and girls aged 6-7 had breast enlarge-ment. A quick survey at the school disclosed that the pheno-menon was very common but was often unnoticed by parents.The school which is privately owned, state recognised, and runby nuns in the north-eastern outskirts of Milan (Via Folli), has102 nursery, 317 primary, and 223 junior high school pupils.

Children attending the school were examined by a paediatri-cian appointed by the City Health Department and the schooldoctor at the beginning of December, 1977, and in January,February, May, and June, 1978. Some of the children were °

also to be seen in October, 1978, on returning to school. Allboys (213) and girls up to 7 years of age (110) were studied.Gynaecomastia or telarche was diagnosed when diameter of themammary gland was increased by more than 0-5 cm. withlocal pain and increased areolar pigmentation. Tanner’s classi-fication of breast size at telarche and Nydick’s classification ofgynaecomastia were used: enlargement extending just to theareolar margins with considerable elevation of nipple is de-scribed as ++, and gynxcomastia and enlargement extendingbeyond the areolar margins is described as + + +, gynaecomastia.7The point prevalence of breast enlargement was assessed in

children examined in December; the six-month incidence wascalculated for a group of children who were negative on Dec.15 and were seen at least three times thereafter.

Plasma follicle-stimulating hormone, luteinising hormone,17(3-oestradiol, and prolactin were determined in a group ofchildren in December, 1977, and also in a group of new casesdetected in May, 1978. In December, 1977, mothers ofchildren with breast enlargement were sent a questionnaire todetermine whether siblings in the same age-range attendingother schools were similarly affected.

Only nursery and primary school pupils used the schoolcafeteria-at noon on Monday, Tuesday, Thursday, and Fri-day. Two poultry and two beef meals a week were suppliedfrom a city 70 miles away by a wholesaler who delivered frozensupplies every fortnight. When a veterinarian came to examinepoultry and beef for oestrogens, after the outbreak of breast endlargement had been recognised, nothing remained of the firsttwo consignments delivered since the opening of the cafeteriaonly three weeks before the first case of breast enlargementwas reported. No cestrogens were detected in beef and poultrydelivered on Nov. 23, 1977. Additional samples from thesupplier’s headquarters were also negative. No other schoolswere supplied from this source, and it was decided that furthersupplies should come from suppliers used for public schools’cafeterias.

Except for the meat supply, which had not been examinedby City Health Department before consumption, facilities at