factors in the diagnosis of breast disease

GEORGE AND CHALSTREY: DIAGNOSIS OF BREAST DISEASE 337

SUMhURY Sixty-three cases of metastatic carcinoma of the

female breast who underwent trans-sphenoidal hypophysectomy are evaluated. Trans-sphenoidal hypophysectomy is a relatively minor and safe procedure in trained hands. It gives the most direct access to the pituitary. The operation is performed under direct vision and the excellent lighting system and magnification of the Zeiss operating microscope facilitates a thorough removal of the pituitary gland.

In the present state of our knowledge the actual performance of the operation is the only certain way to determine whether worthwhile palliation will be achieved in individual cases.

Acknowledgements.-We acknowledge with gratitude our indebtedness to the surgeons and the radiotherapists who referred their patients, to Dr. J. C. Bishop for help with postoperative radiological assessment, to Miss Levi and her staff of the Follow-up Department, and Mrs. H. Boulton for their help with medical records, and to Mrs. Valerie Kapur for her secretarial assistance.

REFERENCES ATKINS, H. J. B. (1963), Proc. R . SOC. Med., 56, 389. -- (1966), Ann. R. Coll. Surg., 38, 133. -- BULBROOK, R. D., FALCONER, M. A., HAYWARD,

T. L., MACLEAN, K. S., and SCHURR, P. H. (1964), Lancet, 2, 1133. -- FALCONER, M. A.. HAYWARD. 1. L.. and MACLEAN. _ - - K. S. (1957), ibid., 1,489. -__----- SCHURR. P. H.. and ARMITAGE. P. ,- I

(1960), Zbid., I, 1148. BARON, D. N., GURLING, K. J., and SMITH, E. J. R. (1958)~

Br. 3. Surg., 45, 593. BATEMAN, G. H. (Ig62),3. Lar. Otol., 76, 442. BEATSON, G. (1896), Lancet, 2, 104. BOESON, E., SMITH, E. J. R., and BARON, D. N. (1961)~

Br. med. J., 2, 790. BOYLAND, E., GODSMARK, B., GREENING, W. P., RIGBY-

JONES, P., STEVENSON, J. J., ~~~ABuL-FADL, M. A. M. (1958), in Endocrine Aspects of Breast Cancer (ed. CURRIE, A. R.), p. 170. Edinburgh: Livingstone.

BULBROOK, R. D., GREENWOOD, F. C., and HAYWARD, J. L. (1960), Lancet, I, 1154.

CADE, S. (1958), in Endocrine Aspects of Breast Cancer (ed. CURRIE, A. R.)? p. 3. Edinburgh: Livingstone.

CHIARI, 0. (1912), Wzen klin. Wschr., 25, 5. CLAIN, A., and HUNT, A. H. (1956), Br. med.,3., 2, 627.

DAO, T. L., TAN, E., and BROOKES, V. (1961)~ Cancer, 14,

DOBSON, L. (1962), Surg. Clins N . Am., 42, 861. EDELSTYN, G., GLEADHILL, C., and LYONS, A. (1969,

EVANS, J. P., FENGE, W., KELLY, W. A., and HARPER, P. V.

FAIRGRIEVE, J. (1969, Zbid., 120, 371. FALCONER, M. A. (1963), Proc. R . SOC. Med., 56, 390. HAMBERGER, C. A., HAMMER, G., NORLEN, G., and

SJOGREN, B. (1961), Archs Otolar., 74, 2. HIRSCH, 0. ( I~IO) , Wein. rned. Wsch., I, 749. -- (1952), Ibid., 55, 268. IRVINE, W. T. (1964),3. clin. Radiol., 15, 161. -- AITKEN, E. H., RENDLEMAN, D. F., and FOLCA,

JAMES, J. A. (1964),3. R. Coll. Surg. Zre., I, 83. TESSIMAN. A. G.. MATSON. D. D.. and MOORE. F. D.

1259.

Br. 3. Surg., 52, 953.

(1959), Surgery Gynec. Obstet., 108, 393.

P. J. (1961), Lancet, 2, 791.

- (1959),’New Ehg1.J. Med., 261, JOINT COMMITTEE ON ENDOCRINE ABLATIVE PROCEDURES

IN DISSEMINATED MAMMARY CARCINOMA (1961), J. Am. rned. Ass., 175, 787.

KENNEDY, B. J., FRENCH, L. A., and PEYTON, W. T. (1956), New Engl. 3. Med., 255, 1165.

LIPSETT, M. B. (1956),3. Clin. Endocrinol., 16, 183. LUFT, R., and OLIVECRONA, H. (1953),J. Neurosurg., 10, 301. _ _ _ - IKKOS, D., NILSSON, L., and LJUNGGREN, H. (1956)~ Am.J . Med., 21, 728.

MCALLISTER, R. A., SIM, A. W., HOBKIRK, R., STEWART, H., BLAIR, D. W., and FORREST, A. P. M. (1960), Lancet, I, 1102.

MCCALLISTER, A., WELBOURN, R. B., EDELSTYN, C. J. A., LYONS, A. R., TAYLOR, A. R., GLEADHILL, C. A., GORDON, D. S., and COLE, C.O.Y. (1961), Br. med.J., I, 613.

MACDONALD, I. (1962), Surgery Gynec. Obstet., I 15, 215. NISSEN-MEYER, R. (1964)~ J . clin. Radiol., 15, 152. OLIVECRONA, H., and LUFT, R. (I957), Ann. R. Coll. Surg.,

PEARSON, 0. H., and RAY, B. S. (19601, Am. J . Surg., 99,

RANDALL, H. T. (1960), Zbid., 99, 553. REED, P. I., and PIZEY, N. C. D. (1967)~ Br. J. Surg., 54,

RISKAER, N., FOG, C. V. M., and HOMMELGARD, T. (1961),

SCHLOFFER, H. (1906), quoted by HIRSCH, 0. (1952). -- (1907)~ quoted by HIRSCH, 0. (1952). STRONG, J. A,, BROWN, J. B., BRUCE, J., DOUGLAS, M.,

KLOPPER, A. I., and LORRAINE, J. A. (1956), Lancet, 2, 955.

WILSON, R. E., JESSIMAN, A. G., and MOORE, F. D. (1958), New Engl.3. Med., 258, 312.

20, 267.

544.

369.

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FACTORS IN THE DIAGNOSIS OF BREAST DISEASE BY PHYLLIS GEORGE AND L. J. CHALSTREY THE DEPARTMENT OF SURGERY, THE ROYAL FREE HOSPITAL, LONDON

EFFORTS to achieve earlier diagnosis of breast lesions are based on the belief that this is important in improving the prognosis of patients with breast cancer. Published data confirm that the earlier the clinical staging, the better is the prognosis (Bloom, 195oa, b; Bloom and Richardson, 1957; Bloom, Richardson, and Harries, 1962). Further, best results of all are obtained following treatment of intraduct and in situ carcinoma (Stein, 1967).

24

The records of 300 patients with breast lesions, admitted to hospital under the care of one surgeon, have been analysed to assess the accuracy of clinical findings and the value of frozen-section examination in the diagnosis of breast disease.

Table I shows the incidence of each type of lesion. Fibro-adenosis, carcinoma, and fibro-adenoma together accounted for 80 per cent of all the lesions.

338 BRIT. J. SURG., 1969, Vol. 56, No. 5, MAY

CLINICAL IMPRESSION HISTOLOGICAL DIAGNOSIS

Benign Benign Benign Cancer Cancer Cancer Cancer Benign Doubtful Benign Doubtful Malignant

Fig. I indicates the age incidence of fibro-adenosis, carcinoma, and fibro-adenoma.

CLINICAL FINDINGS Presenting Symptoms.-In 236 patients the

first abnormality noted was a lump in the breast. This and other presenting symptoms are shown in Table I I .

In 257 cases the abnormality was found by the patient. Two mentioned that they had discovered their lesion by self-examination after reading an

CASEF - I07

3 54 4

I 1 1 21

P 10

INVASIVE CANCER w’

0 1 0 11-20 21-30 31-40 41-50 51-60 61-70 71-80 El-90 Age Groups

FIG. ag age incidence of breast lesions.

article on this subject in a newspaper or magazine. One breast lump in this series was first noted by a general practitioner. In 42 patients the swelling was an incidental finding during an examination at the hospital and 13 of these were cancers. The majority came from gynaecological clinics; some from the ‘Well Women’s Clinic’.

Previous Breast Disease.-Thirty-three patients who presented with benign lesions had a past history of benign breast disease. Eight breast-cancer patients had a past history of benign breast lesions; 5 of these were fibro-adenosis, 2 were abscesses, and I a fibro- adenoma.

A past history of breast cancer was given by 5 women who presented with benign lesions and 4 who came with cancer in the other breast.

Previous Thyroid Disease.-Twenty of the patients also had thyroid disorder. Three of the breast-cancer patients had previously been treated for thyroid cancer and I of these had carcinoma of both breasts.

Family History of Malignant Disease.-The family history was known in 216 cases (165 benign, 5 I malignant). Twelve breast-cancer patients reported carcinoma in a parent or sibling and 9 of these were breast cancers. Twenty patients with benign breast lesions had a family history of malignant disease and 9 of these had breast cancer.

Physical Signs.-Table I I I compares the clinical impression with the final histological diagnosis.

RESULTS OF IMMEDIATE FROZEN-SECTION EXAMINATION

Immediate frozen-section examination of the locally excised lesion was done in 152 patients. In 148 cases subsequent examination of paraffin sections gave the same result (51 cancers, 97 benign lesions).

On 4 occasions no carcinoma was found by frozen- section examination but paraffin sections revealed cancer. Two of these were intraduct carcinoma, one a pre-invasive carcinoma, and the fourth was an early invasive scirrhous carcinoma. In no case when the frozen section was reported as cancer was this proved incorrect by examination of the paraffin sections.

Frozen-section examination was omitted in 28 cancer patients, 14 of whom had advanced primary lesions with skin involvement and obvious regional or distant metastases. In 4 of the 28 cases intraduct

Table Z.-INCIDENCE OF BREAST LESIONS

Fibro-adenosis only 121 Invasive cancer 69 Fibro-adenoma 50 Papilloma 18 -4bscess requiring in-patient treatment 18 Intraduct cancer (including 4 with Pager’s dinease) 9 Single cyst without fibro-adenosis 6 Galactocele 2 Sebaceous cyst 7. Gynaecomastia and mastitis 2 Fat necrosis I Tuberculosis I Lipoma I

Disease Cases

Table ZZ.-PRESENTING SYMPTOMS

FIRST SYMPTOMS NUMBER OF CASES

Benign Malignant Total I I Lump in the breast Pain Nipple discharge Bleeding from the nipple Inverted nipple Eczema of the nipple Symptomless

I79 8

3 I

I 0

30 43

carcinoma associated with Paget’s disease was diagnosed following biopsy of the nipple. A further 4 patients with clinically obvious carcinoma refused surgery. In 4 other patients without breast lumps, cancer was diagnosed following excision biopsy of an enlarged axillary lymph-node (2 cases) or after segmental excision for bleeding from the nipple (2 cases). One patient had a carcinoma within a cyst and in another a small cancer was discovered in tissue excised for reduction of breast size in a woman of 23 years.

RELATIONSHIP BETWEEN BREAST LESIONS AND BLOOD GROUPS

The blood group was recorded in 203 patients. Analysis of the blood groups of patients with benign

and malignant breast lesions showed a preponderance of Group A (Table IV). A formal statistical test comparing actual and expected blood-group distri- butions showed that the difference between these

GEORGE AND CHALSTREY: D I

gZp BENIGN LESIONS MALIGNANT LESIONS

A 67 (so per cent) 37 (52 per cent) B 9 (7 per cent) 7 (9 per cent) 0 52 (38 per cent) 25 (35 per cent) AB 5 (4 per cent) 2 (3 per cent)

patients and the general adult female population is statistically significant.

DISCUSSION In the majority of cases (236) the presenting symp-

tom was a lump. The patients themselves were responsible for detecting the first evidence of abnormality in the breast in all but 43 cases. This fact emphasizes the importance of educating the female population in self-examination.

The incidental discovery of 42 breast lumps in women who attended the hospital with other com- plaints indicates the value of including breast palpation in the routine physical examination of all female

p ~ m ~ & N

(per cent) 42 9

46 3

Table ZV.-BLOOD GROUPS OF PATIENTS WITH BREAST LESIONS

patients. Worth-while results have been reported by Barnes, Berry, Williams, Baum, Mackay, Howe, and Murray (1968) following a screening project in general practice.

TabZe ZZ shows that discharge or bleeding from the nipple in the absence of a lump is occasionally associated with an underlying carcinoma. This type of case should therefore be treated by prompt surgical exploration with segmental excision biopsy. In none of 8 patients whose first symptom was pain in the breast was cancer the causative lesion.

Previous Breast Disease.-Eight of the 41 patients with a past history of benign breast lesions developed cancer. This is much higher than the incidence of breast carcinoma in the general adult female population. For example, National Cancer Register figures indicate that the incidence of breast carcinoma in England and Wales in 1962 for women of 35 years and over was 107.8 per IOO,OOO or 0.1 per cent. I t may be argued that patients with a past history of breast disease form a highly selected group who are more keenly aware of the possibility of developing breast lesions and many of whom regularly attend follow-up clinics. However, although these factors undoubtedly cause the cancers in these patients to be found earlier, this does not invalidate the comparison between them and the general female population, since women in the latter group who do develop breast cancer will (with very few exceptions) all eventually present for diagnosis and treatment. Bonser (1968) reported that areas of cystic hyperplasia and proliferation are commoner in breasts excised for cancer than in routine autopsy specimens, the ratio being 3.8 : I.

Previous Thyroid Disease.-The fairly com- monly occurring relationship between breast cancer and thyroid disease is reflected in this series. Evidence on the subject of a causal relationship between thyroid dysfunction and breast cancer has been previously reviewed by one of us in a paper reporting

AGNOSIS OF BREAST DISEASE 339

a high incidence of breast carcinoma in thyroid-cancer patients (Chalstrey and Benjamin, 1966).

Family History of Malignant Disease.-The family history was known in 51 of our breast-cancer patients. In 12 cases there was a family history of a malignant neoplasm and 9 of these were breast cancers. In a much larger series Wynder, Bross, and Hirayama (1960) also reported an increased incidence of breast carcinoma among the female relatives of breast-cancer patients. Although this familial tendency is not sufficiently marked to be of diagnostic value, it indicates that these women should be included in the ‘greater than average risk’ group who must be care- fully observed and who might be selected for such screening procedures as urinary steroid examination, mammography, and breast thermography.

Physical Signs.-From a practical standpoint it is necessary to divide patients into three groups following physical examination:-

A. Those in whom the clinician is satisfied that the breast lesion is benign.

B. Those in whom there is doubt about the diagnosis.

C. Patients with physical signs of breast cancer. Of IIO patients in Group A, 3 were subseauentlv

found to have carcinoma (TableIII). One 4 thesk had a small cancer within a cyst. The second was 23 years old and an intraduct carcinoma was found in tissue removed for reduction of breast size. The third, an intraduct carcinoma, was found on histological examination of tissue deep to the areola, removed with a small skin papilloma.

These 3 cases demonstrate the occasional fallibility of physical examination and indicate the importance of thorough histological examination of all excised material, even if there was no previous suspicion of malignancy.

Cysts.-The majority of breast cysts are associated with fibro-adenosis and when multiple cyst formation occurs this is nearly always the underlying pathology. However, cystic dilatation of a duct sometimes results from its blockage by an intraduct neoplasm. Occa- sionally the wall of a true cyst contains a malignant papilloma, as seen in one of the patients in this series. Aspiration of a cyst, although dramatic in relieving the patient’s anxiety, does not show whether or not there is a small associated carcinoma. Although aspirated fluid can be sent for cytological examination, a negative result still does not exclude the presence of a neoplasm, and if carcinoma cells are seen in the fluid they may also have been implanted along the needle track. Further, attempted aspiration of a solid swelling may increase the incidence of metastases. It is conceded that the occurrence of cancer in a cyst is very uncommon and on these grounds many surgeons justify the aspiration of cysts. The decision to deprive the great majority of patients with cysts of the immediate mental relief which invariably follows successful aspiration is certainly a difficult one. However, in our opinion the risk of irrevocably worsening the prognosis in the occasional patient with an early carcinoma outweighs the above con- sideration. We believe that it is wiser to remove cysts together with the surrounding mammary tissue.

Discharge from the Nipple.-Discharges from the nipples are tested for blood using Haemotest tablets. A specimen is also sent for cytological examination.

340 BRIT. J. SURG., 1969, Vol. 56, No. 5, MAY

If both these investigations are negative and there is no associated lump the patient is reassured but seen at 3-monthly intervals.

A blood-stained discharge usually indicates the presence of a duct papilloma or carcinoma. The affected segment is identified by pressing on the areola in the direction of the nipple and the position recorded in the case notes. The patient is admitted for segmental excision of the duct and histological examination of the lesion.

Fibro-adenosis.-The breasts of many patients with symptoms of fibro-adenosis have multiple granular areas which are impalpable when examined with the flat of the hand. We reassure these patients, but examination is repeated in 6 weeks and then at 3- monthly intervals, preferably by the same clinician. Occasionally patients are found to have a persistent solitary area of granularity. When such a woman is over 30 and this is the only abnormality found on two examinations at different phases of the menstrual cycle, we feel strongly that the area should be excised for histological examination even though it is not palpable with the flat of the hand. Several early cancers have been found in this way.

The steep rise in the number of local excisions for fibro-adenosis after the age of 35 raises the question of whether many unnecessary operations were done (Fig. I). However, the following points must be made :-

I. Beyond this age, incidence of carcinoma also begins to rise more steeply (Fig. I).

2. No excised tissue was wholly normal on histological examination. The incidence of breast cancer in patients with fibro-adenosis is probably about four times greater than that in the general female population of equivalent ages (Bonser, Dossett, and Jull, 1961 ; Bonser, 1968). It is therefore possible that by excising these areas of fibro-adenosis we remove tissue which would later become malignant. Further, only by operating on these cases are we likely to find breast cancers at a pre-invasive stage of growth. Lewison and Smith (1963) established the fact that 5-10 per cent of all patients biopsied for benign lesions show evidence of carcinoma in situ. In this series no patient died as a result of an operation and there was no serious morbidity. I n many instances the woman left the hospital within 48 hours and returned for removal of sutures.

Indications for Excision Biopsy with Frozen- section Examination.-All patients in whom there is doubt about the diagnosis following physical examination (Group B) and the majority of those with the physical signs of carcinoma (Group C) should be admitted to hospital urgently for excision biopsy and immediate frozen-section examination.

As most breast lumps occurring in women under 30 are benign, we do not advocate frozen-section examination before this age unless there are suspi- cious clinical findings. However, beyond this age, it is done on all solid swellings. Lesions are excised with a margin of apparently normal breast tissue as cutting into a lump may cause spillage of cancer cells. In no case where a carcinoma has been reported on the frozen section has the paraffin section shown this to be incorrect. When frozen sections reveal no carcinoma the subsequent detailed histological examination includes sections taken from the

apparently normal tissue at the periphery of the specimen. The value of this policy is confirmed by the fact that in approximately 5 per cent of these cases minute cancers have been found (Scheuer, I 968).

We feel that it is essential to have all lesions examined by frozen section before proceeding to mastectomy, however obvious it seems that carcinoma is present. Four patients in this series whose physical signs were those of breast cancer might have been unnecessarily subjected to mastectomy for benign lesions if frozen-section examination had not been done.

Frozen-section examination is not necessary in cases of advanced breast cancer, where mastectomy is not indicated. Here, biopsy and paraffin-section examination may be required prior to radiotherapy or other types of palliative treatment.

Other Factors in the Diagnosis of Breast Lesions.-

Relationship between Breast Lesions and Blood Groups.-The statistically significant preponderance of blood group A noted among breast-cancer patients, though an interesting finding, is not sufficiently marked to be of value in diagnosis of breast lesions.

Mammography.-In our limited experience mammography has not often proved to be of value as a diagnostic tool. It has occasionally been of use in defecting a neoplasm when the large size of a breast and presence of scattered areas of fibro-adenosis have made clinical evaluation difficult. However, Samuel (1967), reviewing this subject, quoted a diagnostic accuracy of 84 per cent in 2000 mammograms. Reports by Shapiro, Strax, and Venet (1966) on the first z years of a screening programme for breast cancer using both mammography and clinical examination suggest that it is of value as a screening procedure. Although it is not practicable to screen the whole female population, it could be used for those groups of women who are known to run an abnor- mally high risk of developing breast cancer. This includes those with a past history of breast cancer (Bartlett, 1961; Samuel and Young, 1966), some cases of fibro-adenosis (Bonser and others, 1961 ; Davis, Simons, and Davis, 1964), and those with a family history of the disease. Also important in selecting these cases is the analysis of urinary steroids described by Bulbrook, Greenwood, and Hayward, 1960; Bulbrook, Hayward, Spicer, and Thomas, 1962a, b; Bulbrook and Thomas, 1964). In high-risk patients the ratio of urinary androgens to 17-hydroxy- corticosteroids differs from that in the general female population.

Changes in mammograms taken at different times are more significant than a single examination. However, we have hesitated to use repeated mammography because of the possible danger of inducing malignant change.

Thermography.-Reports from other centres and a recent personal trial of thermography have indicated that it may be of value as a screening procedure for breast cancer. An advantage of thermography is that it can be used any number of times with no dis- comfort or risk to the patient. On each occasion the thermographic pattern of the two breasts can be compared. Brasfield, Sherman, and Laughlin (1965) used thermography on 150 patients with known breast

STEWART ET AL.: MAMMOGRAPHY 341

carcinoma found amongst the former group are the ones most likely to be eradicated by prompt treatment.

Acknowledgements.-We wish to thank Dr. B. Benjamin, Director of Research and Intelligence, Greater London Council, for advice on statistics and Mrs. E. Sunderland for her secretarial help.

REFERENCES BARNES, S., BERRY, W. H. C., WILLIAMS, M. J., BAUM, M.,

MACKAY, W. D., HOWE, C. T., and MURRAY, J. G. (1968)~ Lancet, I, 1417.

BARTLETT, R. M. (1961), Ann. Surg., 154, 306. BLOOM, H. J. G. (~gsoa), Br. J . Cancer, 4, 259.

-- and RICHARDSON, W. W. (I957), Zbid., I I, 359. ---- and HARRIES, E. J. (1962), Br. rned. J., 2,

213. BONSER, G. M. (1968), Hosp. Med., 2, 390. -- DOSSETT, J. A., and JULL, J. W. (1961), in Human

and Experimental Breast Cancer, p. 362. London : Pitman.

BRASFIELD, R. D., SHERMAN, R. S., and LAUGHLIN, J. S. (1965), in Progress in Clinical Cancer, p. 258. New York: Grune and Stratton.

BULBROOK, R. D., GREENWOOD, F. C., and HAYWARD, J. L. (1960), Lancet, I, 1154. -- HAYWARD, J. L., SPICER, C. C., and THOMAS, B. S.

(1962a), Zbid., 2, 1235. - - - - - - - - (1962b), Zbid., 2, 1238. -- and THOMAS, B. S. (1964), Ibid., I, 945. CHALSTREY, L. J., and BENJAMIN, B. (1966), Br.J. Cancer,

DAVIS, H. H., SIMONS, M., and DAVIS, J. B. (1964), Cancer,

LEWISON, E. F., and SMITH, R. T. (1963), Surgery, St

SAMUEL, E. (1967), Hosp. Med., I, 343. -- and YOUNG, G. B. (1966), Br. med. J., 2, 886. SCHEUER, P. (1968), personal communication. SHAPIRO, S., STRAX, P., and VENET, L. (1966),J. Am. med.

(195ob), Ibid., 4, 347. - _

20, 670.

Philad., 17, 957.

Louis, 53, 644.

pathology, to assess its accuracy. When 38 breast- cancer patients were examined, 25 were reported as positive, 6 were negative, and 7 were equivocal. Increasing experience in the interpretation of thermo- grams may result in greater accuracy in the future.

CONCLUSIONS I. As the great majority of breast lumps are

discovered by the patients themselves, an intensive campaign is required to educate women in self- examination and in the importance of avoiding delay in seeking medical advice.

2. A significant number of breast lesions are discovered if breast palpation is included in the routine physical examination of all female patients.

3. Women with a greater-than-average risk of developing breast cancer include those with a past history or family history of carcinoma of the breast, patients with fibro-adenosis and those with a charac- teristic ratio of urinary steroids (negative discrimi- nants). These women should be selected for careful and regular follow-up. 4. There is a significant predominance of blood

group A among breast-cancer patients. 5. Immediate frozen-section examination following

local excision of a breast lesion is a valuable and accurate investigation. In no case where carcinoma was reported following frozen-section examination did the paraffin section show this to be incorrect. Mastectomy should not be done without prior confirmation of the diagnosis by local excision and frozen-section examination of the swelling.

6. The absence of mortality or serious morbidity in this series confirms that excision biopsy is a safe procedure.

7. In addition to discrete swellings, any persistent solitary area of granularity in women over 30 should be excised for histological examination.

8. Cysts should be removed with a margin of surrounding breast tissue. Aspiration should be avoided.

9. Patients with ‘doubtful’ lesions should be treated with the same urgency as overt cases of cancer. Early

Ass., 195, 73 I . STEIN, A. A. (1967)~ in Pathology Annual, 1967 (ed.

47. New York: Appleton-Century- . . ..

SOMMERS, S. C.), p. ,. Crofts.

WYNDER, E. L., BROSS, I. J., and HIRAYAMA, T. (1960), Cancer, N.Y. , 13, 559.

FIVE YEARS’ EXPERIENCE WITH MAMMOGRAPHY BY HELEN J. STEWART,

DEPARTMENT OF SURGERY, WELSH NATIONAL SCHOOL OF MEDICINE, CARDIFF

I. H. GRAVELLE, DEPARTMENT OF RADIODIAGNOSIS, CARDIFF ROYAL INFIRMARY

AND H. T. APSIMON* DEPARTMENT OF RADIODIAGNOSIS, CARDIFF ROYAL INFIRMARY

RADIOLOGY of the breast was first introduced to the Radiography Department, Cardiff Royal Infirmary, in 1962. From 1963 it has been part of the routine service of the department. This paper reports our 5-year experience with mammography in this hospital.

* Present address: Head of Department of Diagnostic Radiology, Royal Perth Hospital, Western Australia.

MATERIALS AND lMETHODS As well as an overall assessment of the diagnostic

accuracy of mammography, three special studies have been undertaken during this period. The first of these was carried out during the first 3 years, namely 1963-5 inclusive, and was a comparison of the radiological diagnosis with that made on clinical examination by the referring clinician. The second special study was planned as a a-year survey of the

factors in the diagnosis of breast disease

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