96
CYTOPATHOLOGY
Invasive Carcinoma in Clinically Suspicious Breast
Masses Diagnosed as Adenocarcinoma by Fine-
Needle Aspiration
David C. Chhieng, M.B.B.S.1
Gerardo Fernandez, M.D.2
Joan F. Cangiarella, M.D.1
Jean-Marc Cohen, M.D.1
Jerry Waisman, M.D.1
Matthew N. Harris, M.D.3
Daniel F. Roses, M.D.3
Richard L. Shapiro, M.D.3
W. Fraser Symmans, M.D.1
1
Department of Pathology, New York University
Medical Center, New York, New York.
2
Department of Pathology, Hudson Valley Hospital,
Peekskill, New York.
3 RESULTS. Three hundred forty-three (97.7%) palpable tumors diagnosed as ade-
Department of Surgery, New York University
Medical Center, New York, New York.
Presented at the 22nd International Congress of
the International Academy of Pathology, Nice,
France, October 1998.
Address for reprints: W. Fraser Symmans, M.D.,
Department of Pathology, U.T. M.D. Anderson Can-
cer Center, 1515 Holcombe Blvd, Room G1.
3617-C, Houston, TX 77030-4009.
Received May 24, 1999; revision received July 12,
1999; accepted July 21, 1999.
© 2000 American Cancer Society
CANCER
BACKGROUND. Fine-needle aspiration (FNA) biopsy of palpable breast masses
along with clinical and radiologic findings can provide rapid distinction between
benign and malignant lesions. A preoperative determination of invasive or in situ
carcinoma assists in the planning of definitive treatment. Previous studies have
concentrated on whether cytologic features adequately distinguish invasion, but to
the authors’ knowledge the predictive value of clinicopathologic correlation has
not been investigated. The authors attempted to determine whether a malignant
cytologic diagnosis for a palpable breast mass is sufficient for its definitive surgical
management as an invasive neoplasm.
METHODS. The authors reviewed 351 FNAs from palpable breast lesions with a
cytologic diagnosis of “adenocarcinoma.” The presence of invasive disease was
determined by histologic demonstration of invasive carcinoma in the correspond-
ing surgical specimen or by identifying metastatic carcinoma in the absence of
another primary source.
nocarcinoma by FNA proved to be invasive adenocarcinoma. The remaining eight
tumors contained high grade ductal carcinoma in situ, and two of these contained
foci suggestive of microinvasion.
CONCLUSIONS. A palpable breast mass with an FNA diagnosis of adenocarcinoma
usually represents invasive carcinoma. A definitive treatment plan therefore can be
planned based on these clinical and FNA findings. Cancer (Cancer Cytopathol)
2000;90:96 –101. © 2000 American Cancer Society.
KEYWORDS: needle, biopsy, breast, carcinoma, invasion.
F ine-needle aspiration (FNA) biopsy of clinically palpable breast
lesions is a safe, accurate, and cost-effective procedure to differ-
entiate benign lesions from malignant ones.1-4 The positive predictive
value ranges from 95–100%.4-7 The procedure is minimally invasive
and, in practice settings with experienced cytologists, the diagnosis is
immediate. This helps to expedite the preoperative workup, relieve
the patient of the anxiety of waiting for results, and enable the patient
and physician to decide on the management plan at the same visit at
which the diagnosis is made.
For malignant neoplasms of the breast, surgical management
depends in large part on whether the carcinoma is invasive or in
situ.8,9 Alternatively, neoadjuvant chemotherapy and/or radiotherapy
may be offered for locally advanced invasive carcinoma. There is an
opinion that invasion in breast carcinoma cannot be assessed reliably
using cytologic criteria by FNA,10-14 leading to the conclusion that
core needle biopsies (CNBs) are required.15,16 We propose that cyto-

logic criteria should not be used alone but, when
considered with clinical and radiologic findings, can
lead to an accurate diagnosis of invasive carcinoma.
We calculated the probability of invasive disease for
patients who presented with a clinically suspicious
palpable breast mass and an FNA diagnosis of adeno-
carcinoma.
MATERIALS AND METHODS
A computer-based search identified all breast FNAs
performed between 1991–1998 at the New York Uni-
versity Medical Center. Women were included in this
study if they presented with a palpable breast mass
and had received an FNA diagnosis of “adenocarcino-
ma.” Aspirations were performed by cytopathologists
using 25-gauge or 27-gauge needles with two to three
passes. In some patients FNA also was performed on
suspicious, palpable, ipsilateral axillary lymph nodes.
The aspirated cellular material immediately was ex-
pelled onto glass slides, smeared, and air-dried. The
slides then were stained by a modified Giemsa (Diff-
Quik) method. Standard cytologic criteria were used to
diagnose adenocarcinoma.17
Histologic sections of primary breast tumors were
examined after surgical excision and the presence of
invasion was determined. For patients who did not
undergo surgery, documentation of metastatic breast
carcinoma was accepted as evidence of invasiveness
of the primary tumor.
RESULTS
Three hundred fifty-one FNAs from 350 women (1
patient had bilateral palpable breast lesions) were in-
cluded in the current study. The age range of the
patients was 24 –96 years (mean age, 65 years). The
size of the palpable lesions ranged from 1–13 cm, with
a mean of 2.6 cm. Histologic confirmation in 337 cases
(96.0%) and/or metastatic workup in 14 cases (4.0%)
were obtained. There were no false-positive FNA re-
sults. Histologic evidence of invasive carcinoma or
metastatic disease was found in 343 of the 351 cases
(97.7%). This was considered as indirect evidence of
invasiveness. The positive predictive value for inva-
sion was 97.7%. The histologic diagnoses for the 337
excised masses are presented in Table 1.
Ductal carcinoma in situ (DCIS) without evidence
of invasion was found in 8 tumors (2.3%) after exten-
sive sampling. The clinicopathologic features of these
eight tumors are summarized in Table 2. Breast imag-
ing demonstrated a mass in two cases and an ill-
defined density with or without microcalcification in
four cases. In the remaining two cases, only microcal-
cification without associated soft tissue density was
noted. The pathologic size of the DCIS lesions ranged
FNA of Palpable Breast Carcinoma/Chhieng et al. 97
TABLE 1
Histologic Diagnosis of the Resected Breast Carcinoma
Histologic subtypes No. of cases
Ductal carcinoma in situ 8 (2.3%)
Invasive adenocarcinoma
Ductal 243 (69.4%)
Lobular 47 (13.4%)
Mixed ductal and lobular 20 (5.7%)
Tubular 7 (2.0%)
Mucinous (colloid) 5 (1.4%)
Medullary (typical) 3 (0.9%)
Metaplastic 3 (0.9%)
Cases not excised but with evidence of metastatic disease 14 (4.0%)
Total 351 (100%)
from 1–9 cm. Seven of the eight DCIS lesions were
high grade and comedo-type. Although there was no
definitive evidence of invasive carcinoma, foci suspi-
cious for microinvasion were identified in two lesions.
Suspicion of microinvasion was defined as the pres-
ence of microscopic foci of possible invasion ⬍ 1 mm
in greatest dimension or uncertainty regarding
whether a focus represented a tangentially sectioned
cancerous lobule or an invasive focus.18 One patient
had a noncomedo DCIS involving a papillary lesion
and a synchronous contralateral infiltrating ductal
carcinoma. All eight patients underwent at least lim-
ited axillary lymph node dissection at the time of
resection for the primary breast lesion. No regional
lymph node or systemic metastases were detected in
these eight women.
DISCUSSION
FNA of the breast is simple, quick, minimally invasive,
and accurate.1,3,19 In our experience and that of oth-
ers, FNA of palpable breast lesions can differentiate
malignant from benign conditions accurately.1-7 Con-
fidence in this procedure may lead to definitive treat-
ment. We agree with Kern20 that false-positive diag-
noses are unacceptable if the selection of the
appropriate treatment plan is to be based on the cy-
tologic diagnosis alone. In the current study there
were no false-positive cytologic diagnoses of carci-
noma. Our practice is to reserve a malignant diagnosis
for instances in which there is no doubt of malignancy
and use the diagnosis “suspicious for carcinoma”
when most, but not all, of the cytologic criteria for
carcinoma are met.
Axillary lymph node dissection is performed in
patients with invasive breast carcinoma to provide
prognostic information and to assess the need for
adjuvant chemotherapy.21,22 Randomized prospective
trials demonstrated equivalent survival irrespective of
 98

TABLE 2
Clinicopathologic Features of the 8 Palpable Ductal Carcinomas In Situ

Case Age Size of palpable Intraoperative Location of Pathologic Histologic Nuclear Axillary lymph
no. (yrs) Radiologic findings mass Other clinical findings consultation Surgical procedures DCIS size of DCIS subtype grade node status Comments

1 38 5 cm area of diffuse 1.5 cm None ND Total mastectomy and UOQ 2.0 cm Comedo 2/3 Neg (0/14) Pagetoid spread to a
pleomorphic calc ALND, Level I/II lactiferous duct; NED at 8
with an ill-defined mos
mass; 2nd
separate area of
calc
2 67 Irregular soft tissue 3.5 cm None ND Total mastectomy and UIQ, LIQ, and 3.5 cm Comedo, 3/3 Neg (0/13) NA
density ALND UOQ papillary,
and solid
3 56 Dense parenchyma; 2.0 cm None ACA (TP) Total mastectomy and UOQ 2.5 cm Comedo, 3/3 Neg (0/21) Suspicious for microinvasion;
bilateral calc ALND cribriform, Pagetoid spread to a
and lactiferous duct; NED at
papillary 72 mos
4 38 3 cm mass 2.0 cm H/O of Hodgkin ACA (TP) Total mastectomy and NS 3.5 cm Comedo 3/3 Neg (0/17) Suspicious for microinvasion;
lymphoma, status ALND, Level I NED at 24 mos
postradiotherapy
5 75 1 cm mass 1.0 cm Synchronous, DCIS (FS) Total mastectomy and NS 1.0 cm Cribriform and 2/3 Neg (0/15) Patient desired bilateral
contralateral 3 cm ALND solid within mastectomy with
CANCER (CANCER CYTOPATHOLOGY) April 25, 2000 / Volume 90 / Number 2

infiltrating ductal a papillary reconstruction; NED at 16

carcinoma lesion mos
6 45 Extensive area of calc; 6.0 cm Patient was 6 months DCIS (FS) Total mastectomy and UOQ and LOQ 9.0 cm Comedo, solid, 3/3 Neg (0/28) NED at 7 mos
3 cm, ill-defined postpartum; a 2 cm ALND and
mass on palpable ipsilateral papillary
ultrasound axillary LN
7 49 Area of calc 3.0 cm Presented with Paget’s DCIS (FS) Total mastectomy and UOQ 3.0 cm Comedo 3/3 Neg (0/0) Paget’s disease of the nipple;
corresponded to disease ALND limited to NED at 33 mos
the palpable lesion Level I
8 82 9-cm area of calc with 9.0 cm nodularity Core needle biopsy ND Total mastectomy and UOQ 7.0 cm Comedo and 3/3 Neg (0/22) Pagetoid spread to a
ill-defined mass with no showed DCIS ALND papillary lactiferous duct; NED at
discrete mass 22 mos

DCIS: ductal carcinoma in situ; calc: calcification; ND: not done; ALND: axillary lymph node dissection; UOQ: upper outer quadrant; Neg: negative; NED: no evidence of disease; UIQ: upper inner quadrant; LIQ: lower inner quadrant; NA: not available; ACA: adenocarcinoma; TP:
touch preparation; H/O: history of; NS: not specified; FS: frozen section; LN: lymph node; LOQ: lower outer quadrant.

axillary lymph node dissection.23-25 In a recent study
of 955 patients with invasive breast carcinoma who
underwent conservative surgery and radiation, Haffty
et al. found there was no significant difference in the
rates of distant metastasis, disease free survival, or
overall survival between those patients who under-
went axillary lymph node dissection and those who
did not.25 Because of the minimal rate of incidence of
lymph node metastases from DCIS, surgeons usually
do not perform axillary lymph node dissection.26-28
Therefore, preoperative knowledge of whether inva-
sive disease is present influences the surgical planning
and may obviate the need for a second surgery.
Published reports concerning the accuracy of pre-
dicting invasiveness using cytologic criteria are not
uniform. Bondeson and Lindholm29 studied 300 FNAs
of nonpalpable breast tumors and achieved a high
positive predictive value (96%) for invasiveness. Oth-
ers state that there are no well defined cytologic fea-
tures that separate in situ from invasive carcinoma
reliably.10-14 Observed differences between the two
entities were noted to be quantitative, and therefore
do not allow for precise distinction.10 Early compari-
son of FNA and CNB for palpable breast carcinoma
favored CNB as a more reliable technique16,30; how-
ever, operator and interpreter experience with both
procedures was limited at that time and particularly
influenced the results from FNA.31 A recent compari-
son of FNA and CNB for palpable breast carcinoma in
124 women showed that the specificity values for both
FNA and CNB were comparable (100%), yet FNA was
more sensitive than CNB (97.5% vs. 90.0%).32 Similar
findings by Shin and Sneige14 also showed that FNA
was equivalent or superior to CNB as a means of
detecting carcinoma in palpable lesions. CNB is valu-
able in the detection of invasive disease in patients
with lymph node negative breast carcinoma, but the
main limitation of CNB is sampling. Failure to show
invasive disease accounts for a 20 –30% false-negative
rate for detecting invasiveness in stereotaxic CNB of
nonpalpable carcinoma.33,34
The results of the current study indicate that
97.7% of palpable breast masses with an FNA diagno-
sis of adenocarcinoma are proven to be invasive car-
cinoma. These patients can be managed with one-step
surgical treatment including axillary lymph node dis-
section. The role of axillary lymph node dissection in
women with palpable DCIS is less clear. The published
incidence rate of microinvasion in patients with pure
DCIS ranges from 6 –21%.35 The rate of incidence ap-
pears to be related to the size, the histologic subtype,
and whether the DCIS is palpable. In 1 series, patients
with DCIS lesions ⬎ 2.5 cm were more likely (29%) to
have occult invasion compared with patients with
FNA of Palpable Breast Carcinoma/Chhieng et al. 99
smaller DCIS lesions (2%).36 Microinvasion is more
common in comedo-type DCIS. Patchefsky et al.
noted microinvasion in 12 of 19 comedo-type DCIS
specimens (63%) and in only 4 of 36 noncomedo-type
DCIS specimens (12%); however, they did not specify
the criteria used for determining microinvasion.37 Pa-
tients with DCIS presenting as a palpable mass were 3
times (15% vs. 5%) more likely to have microinvasive
disease than patients with DCIS detected mammo-
graphically.38 The clinical implication of microinva-
sion is the risk of metastases. Patients with microin-
vasive disease are 10 times more likely (10% vs. 1%) to
have axillary lymph node metastases than patients
with pure DCIS.39,40 In the current study, eight pa-
tients had pure DCIS; these generally were extensive,
ill-defined masses (with associated microcalcification)
that had high nuclear grade and comedo histology.
Two of these eight patients had microscopic foci sus-
picious for microinvasion. These patients underwent
at least limited axillary lymph node dissection because
the risk of lymph node metastases was sufficiently
high. We noted that four of these eight patients had
received a diagnosis of DCIS from either CNB (one
patient) or frozen section biopsy (three patients).
Krag et al. and Giuliano et al. have demonstrated
that biopsy of the physiologically determined entrance
lymph node(s) to the axillary lymph node basin or the
sentinel lymph node(s) provides useful information
for predicting the regional axillary lymph node sta-
tus.41,42 By ink staining and/or radionuclide injection,
the sentinel lymph node(s) can be labeled accurately
and sampled under local anesthesia.41-43 In more re-
cent reports, both the positive and negative predictive
values of sentinel lymph node biopsy have been re-
ported to be high.44-47 With this simple, less morbid,
and accurate approach to the study of the regional
axillary lymph nodes, the preoperative decision of
which patients merit an axillary lymph node dissec-
tion may become a moot point. Certainly, all patients
with a palpable breast lesion and a corresponding FNA
diagnosis of adenocarcinoma have a very high rate of
incidence of infiltrating carcinoma and therefore
would qualify for sentinel lymph node biopsy.
An FNA diagnosis of adenocarcinoma in a clini-
cally suspicious, palpable breast lesion usually indi-
cates invasive carcinoma. A definitive treatment plan
therefore can be planned based on these clinical and
FNA findings. If a clinically suspicious axillary lymph
node is palpable at the time of FNA of the breast mass,
it should be sampled by FNA as well. Although a small
number of patients (2.3%) will have pure DCIS without
evidence of invasion, there may be justification for
treating such patients with sentinel lymphadenectomy
or axillary lymph node dissection because of the risk
100 CANCER (CANCER CYTOPATHOLOGY) April 25, 2000 / Volume 90 / Number 2
for microinvasive disease and regional lymph node
metastases.
REFERENCES
1. Hermansen C, Poulsen HS, Jensen J, Langfeldt B, Steenskov
V, Frederiksen P, et al. Diagnostic reliability of combined
physical examination, mammography, and fine needle
puncture (“triple test”) in breast tumors. Cancer 1987;60:
1866 –71.
2. Silverman JF, Lanin DR, O’Brien K, Norris HT. The triage
role of fine needle aspiration biopsy of palpable breast
masses. Diagnostic accuracy and cost effectiveness. Acta
Cytol 1987;31:731– 6.
3. Wanebo HJ, Feldman PS, Morton C, Wilhelm MC, Covell JL,
Binns RL. Fine needle aspiration cytology in lieu of open
biopsy in management of primary breast cancer. Ann Surg
1984;199:569 –79.
4. Palombini L, Fulciniti F, Vetrani A, De Rosa G, Di Benedetto
G, Zeppa P, et al. Fine needle aspiration biopsies of breast
masses: a critical analysis of 1956 cases in 8 years (1976-
1984). Cancer 1988;61:2273–7.
5. Sneige N. Fine needle aspiration of the breast: a review of
1,995 cases with emphasis on diagnostic pitfalls. Diagn Cy-
topathol 1993;9:106 –12.
6. Frable WJ. Needle aspiration of the breast. Cancer 1984;53:
671– 6.
7. Thomas PA, Vazquez MF, Waisman J. Comparison of fine
needle aspiration and frozen section of palpable mammary
lesions. Mod Pathol 1990;3:570 – 4.
8. Kurtz JM, Jacquemier K, Torhorst J, Spitalier JM, Amalric R,
Hunig R, et al. Conservation therapy for breast cancers other
than infiltrating ductal carcinoma. Cancer 1989;63:1630 –5.
9. Hortobagyi GN, Ames FC, Buzdar AU, Kay SW, McNeese
MD, Paulus D, et al. Management of stage III primary breast
cancer with primary chemotherapy, surgery and radiation
therapy. Cancer 1988;62:2507–16.
10. Silverman JF, Masood S, Ducatman BS, Wang HH, Sneige N.
Can FNA biopsy separate atypical hyperplasia, carcinoma in
situ and invasive carcinoma of the breast: cytomorphologic
criteria and limitations in diagnosis. Diagn Cytopathol 1993;
9:713–28.
11. Wang HH, Ducatman BS, Eick D. Comparative features of
ductal carcinoma in situ and infiltrating ductal carcinoma of
the breast on fine needle aspiration biopsy. Am J Clin Pathol
1989;92:736 – 40.
12. Sneige N, White VA, Katz R, Troncoso P, Libshitz HI, Hor-
tobagyi GN. Ductal carcinoma in situ of the breast: fine
needle aspiration cytology of 12 cases. Diagn Cytopathol
1989;5:371–7.
13. Masood S, Frykberg ER, McLellan GL, Dee S, Bullard JB.
Cytologic differentiation between proliferative and nonpro-
liferative breast disease in mammographically guided fine-
needle aspirates. Diagn Cytopathol 1991;7:581–90.
14. Shin HJ, Sneige N. Is a diagnosis of infiltrating versus in situ
ductal carcinoma of the breast possible in fine needle aspi-
ration specimens? Cancer (Cancer Cytopathol) 1998;84:186 –
91.
15. Shabot MM, Goldberg IM, Schick P, Nieberg R, Pilch YH.
Aspiration cytology is superior to Tru-cut needle biopsy in
establishing the diagnosis of clinically suspicious breast
masses. Ann Surg 1982;96:122– 6.
16. Elston CW, Cotton RE, Davies CJ, Blamey RW. A comparison
of the use of the ‘Tru-Cut’ needle and fine needle aspiration
cytology in the pre-operative diagnosis of carcinoma of the
breast. Histopathology 1978;2:239 –54.
17. Oertel YC. Fine needle aspiration of the breast. Stoneham,
MA: Butterworths Publishers, 1987.
18. Silverstein MJ, Waisman JR, Gamagami P, Gierson ED, Col-
burn WJ, Rosser RJ, et al. Intraductal carcinoma of the breast
(208 cases): clinical factors influencing treatment choice.
Cancer 1990;66:102– 8.
19. Barrows GH, Anderson TJ, Lamb JL, Dixon JM. Fine needle
aspiration of breast cancer: relationship of clinical factors to
cytology results in 689 primary malignancies. Cancer 1986;
58:1493– 8.
20. Kern WH. The diagnosis of breast cancer by fine needle
aspiration smears. JAMA 1979;241:1125–7.
21. Alderson MR, Hamlin I, Staunton MD. The relative signifi-
cance of prognostic factors in breast carcinoma. Br J Cancer
1971;25:646 –55.
22. Hutter RVP. The influence of pathologic factors on breast
cancer management. Cancer 1980;46:961–70.
23. Fisher B, Redmond C, Fisher ER. Ten year results of a ran-
domized clinical trial comparing radical mastectomy and
total mastectomy with or without irradiation. An overview of
the randomized trials. N Engl J Med 1989;32:491– 6.
24. Early Breast Cancer Trialists’ Collaborative Group. Effects of
radiotherapy and surgery in early breast cancer. N Engl
J Med 1995;333:1444 –55.
25. Haffty BG, Ward B, Pathare P, Salem R, McKhann C, Bein-
field M, et al. Reappraisal of the role of axillary lymph node
dissection in the conservative treatment of breast cancer.
J Clin Oncol 1997;15:691–700.
26. Lagios MD, Westdahl PR, Margolin FR, Rose MR. Duct car-
cinoma in situ: relationship of extent of noninvasive disease
to the frequency of occult invasion, multicentricity, lymph
node metastatses, and short term treatment failures. Cancer
1982;50:1309 –14.
27. Silverstein MJ, Rosser RJ, Gierson ED, Waisman JR, Gam-
agami P, Hoffman RS, et al. Axillary lymph node dissection
for intraductal breast carcinoma—is it indicated? Cancer
1987;59:1819 –24.
28. Silverstein MJ, Gierson ED, Colburn WJ, Rosser RJ, Waisman
JR, Gamagami P. Axillary lymphadenectomy for intraductal
carcinoma of the breast. Surg Gynecol Obstet 1991;172:211– 4.
29. Bondeson L, Lindholm K. Prediction of invasiveness by as-
piration cytology applied to nonpalpable breast carcinoma
and tested in 300 cases. Diagn Cytopathol 1997;17:315–20.
30. Owen AWM, Anderson TJ, Forrest APM. “Closed” biopsy for
breast cancer. J R Coll Surg Edinb 1980;25:237– 41.
31. Dixon JM, Lamb J, Anderson TJ. Fine needle aspiration of
the breast: importance of the aspirator [letter]. Lancet 1983;
2:564.
32. Ballo MS, Sneige N. Can core needle biopsy replace fine
needle aspiration cytology in the diagnosis of palpable
breast carcinoma: a comparative study of 124 women. Can-
cer 1996;78:773–7.
33. Jackman RJ, Nowels KW, Shepard MJ, Finkelstein SI, Mar-
zoni FA. Stereotactic large core needle biopsy of 450 non-
palpable breast lesions with surgical correlation in lesions with
cancer or atypical hyperplasia. Radiology 1994;193:91–5.
34. Liberman L, Dershaw DD, Rosen PP, Giess CS, Cohen MA,
Abramson AF, et al. Stereotactic core biopsy of breast car-
cinoma: accuracy at predicting invasion. Radiology 1995;
194:379 – 81.
35. Tavassoli FH. Pathology of the breast. 1st edition. Norwalk,
CT: Appleton and Lange, 1992.

36. Lagios MD, Margolin PR, Westdahl PR, Rose MR. Mammo-
graphically detected duct carcinoma in situ: frequency of
local recurrence following tylectomy and prognostic effect
of nuclear grade on local recurrence. Cancer 1989;63:618 –
24.
37. Patchefsky AS, Schwartz GF, Finkelstein SD, Prestipino A,
Sohn SE, Singer JS, et al. Heterogeneity of intraductal car-
cinoma of the breast. Cancer 1989;63:731– 41.
38. Fentiman IS, Fagg N, Mills RR, Hayward JL. In situ ductal
carcinoma of the breast. Implications of disease pattern and
treatment. Eur J Surg Oncol 1986;12:261– 6.
39. Kinne DW, Petrek JA, Osborne MP, Fracchia AA, Depalo AA,
Rosen PP. Breast carcinoma in situ. Arch Surg 1989;124:
33– 6.
40. Schuh ME, Nemoto T, Penetrante RB, Rosner D, Dao TL.
Intraductal carcinoma. Analysis of presentation, pathologic
findings, and outcome of disease. Arch Surg 1986;121:1303–7.
41. Krag DN, Weaver DL, Alex JC, Fairbank JT. Surgical resection
and radiolocalization of sentinel lymph node in breast can-
cer using a gamma probe. Surg Oncol 1993;2:335– 40.
FNA of Palpable Breast Carcinoma/Chhieng et al. 101
42. Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lym-
phatic mapping and sentinel lymphadenectomy for breast
cancer. Ann Surg 1994;220:391– 8.
43. O’Hea BJ, Hill AD, El-Shirbiny AM, Yeh SD, Rosen PP, Coit
DG, et al. Sentinel lymph node biopsy in breast cancer:
initial experience at Memorial Sloan-Kettering Cancer Cen-
ter. J Am Coll Surg 1998;186:423–7.
44. Rubio IT, Korourian S, Cowan C, Krag DN, Colvert M, Klim-
berg VS. Sentinel lymph node biopsy for staging breast
cancer. Am J Surg 1998;176:532–7.
45. Nwariaku FE, Euhus DM, Beitsch PD, Clifford E, Erdman W,
Mathews D, et al. Sentinel lymph node biopsy, an alterna-
tive to elective axillary dissection for breast cancer. Am J
Surg 1998;176:529 –31.
46. Barnwell JM, Arrendondo MA, Kollmorgen D, Gibbs JF, La-
monica D, Carson W, et al. Sentinel node biopsy in breast
cancer. Ann Surg Oncol 1998;5:126 –30.
47. Krag D, Weaver D, Ashikaga T, Moffat F, Klimberg VS,
Shriver C, et al. The sentinel node in breast cancer—a mul-
ticenter validation study. N Engl J Med 1998;339:941– 6.