Showing papers on "Mammography published in 1999"

BI-RADS Categorization As a Predictor of Malignancy

Abstract: PURPOSE: To determine the positive predictive value (PPV) of the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) categories 0, 2, 3, 4, and 5 by using BI-RADS terminology and by auditing data on needle localizations. MATERIALS AND METHODS: Between April 1991 and December 1996, 1,400 mammographically guided needle localizations were performed in 1,109 patients. Information entered into the mammographic database included where the initial mammography was performed (inside vs outside the institution), BI-RADS category, mammographic finding, and histopathologic findings. A recorded recommendation was available for 1,312 localizations in 1,097 patients, who composed the study population. RESULTS: The 1,312 localizations yielded 449 (34%) cancers (139 [31%] were ductal carcinoma in situ [DCIS]; 310 [69%] were invasive cancers) and 863 (66%) benign lesions. There were 15 (1%) category 0 lesions; the PPV was 13% (two of 15 lesions). There were 50 (4%) category 2 lesions; the PPV w...

Utility of magnetic resonance imaging in the management of breast cancer: evidence for improved preoperative staging.

Abstract: PURPOSE: The staging and treatment for breast cancer are changing; there is an increase in the incidence of ductal carcinoma-in-situ, the use of fine-needle aspiration and stereotactic biopsy for diagnosis, and the use of neoadjuvant chemotherapy. Thus, there is a need for a tool to assess more precisely the extent of cancer in the breast before surgery. To better plan surgical and chemotherapeutic interventions, we evaluated high-resolution magnetic resonance imaging (MRI) as such a tool. PATIENTS AND METHODS: Fifty-seven patients with 58 cases of breast cancer were evaluated preoperatively with MRI using a technique called the triple-acquisition rapid gradient echo technique to maximize anatomic detail. Imaging results were compared with mammography and subsequent pathology results. RESULTS: Magnetic resonance imaging correctly identified residual or primary cancer in 55 of 58 cases and accurately predicted the extent of the cancer in 54 of 58 cases. The anatomic extent was more accurately defined with ...

Does This Patient Have Breast Cancer?: The Screening Clinical Breast Examination: Should It Be Done? How?

Abstract: ContextThe clinical breast examination (CBE) is widely recommended and practiced as a tool for breast cancer screening; however, its effectiveness is dependent on its precision and accuracy.ObjectiveTo collect evidence on the effectiveness of CBE in screening for breast cancer and information on the best technique to use.Data SourcesWe searched the English-language literature using the MEDLINE database (1966-1997) and manual review of all reference lists, as well as contacting investigators of several published studies for clarifications and unpublished data.Study Selection and Data ExtractionTo study CBE effectiveness, we included all controlled trials and case-control studies in which CBE was at least part of the screening modality; for technique, we included both clinical studies and those that used silicone breast models. All 3 authors reviewed and agreed on the studies selected for inclusion in the pooled analyses.Data SynthesisRandomized clinical trials demonstrated reduced breast cancer mortality rates among women screened by both CBE and mammography. Evidence of CBE's independent contribution was less direct; CBE alone detected between 3% and 45%of breast cancers found that screening mammography missed. The precision of CBE was difficult to determine because of the lack of consistent and standardized examination techniques. Studies on CBE precision reported fair agreement (κ=0.22-0.59). Pooling trial data, we estimated CBE sensitivity at 54% and specificity at 94%. The likelihood ratio of a positive CBE result is 10.6 (95% confidence interval [CI], 5.8-19.2), while the likelihood ratio of a negative test result is 0.47 (95% CI, 0.40-0.56). Longer duration of CBE and a higher number of specific techniques used were associated with greater accuracy. The preferred technique for CBE includes proper positioning of the patient, thoroughness of search, use of a vertical-strip search pattern, proper position and movement of the fingers, and a CBE duration of at least 3 minutes per breast. The value of inspection is unproved. Professional and lay examiners improved their sensitivity on silicone breast models after being taught this technique.ConclusionsIndirect evidence supports the effectiveness of CBE in screening for breast cancer. Although the screening clinical examination by itself does not rule out disease, the high specificity of certain abnormal findings greatly increases the probability of breast cancer.

Diagnosis of breast cancer: contribution of US as an adjunct to mammography.

Abstract: PURPOSE: To determine the value of ultrasonography (US) as an adjunct to mammography for the diagnosis of breast cancer. MATERIALS AND METHODS: In a 2-year prospective study, 4,811 mammograms were classified according to level of suspicion of malignancy. Targeted US was performed to analyze (a) circumscribed lesions, possibly cysts; (b) palpable lesions visible at mammography; (c) palpable lesions not visible at mammography; and (d) nonpalpable lesions visible at mammography. After US was performed in 1,103 cases (23%), cases were reclassified for level of suspicion. RESULTS: In 338 cases, breast cancer was diagnosed. The sensitivity of mammography for all 4,811 cases was 83%; the specificity was 97%. After US, the combined sensitivity increased to 91%, with a specificity of 98%. The increase was significant (P < .001). The increase in sensitivity was highest among women younger than 50 years. The positive predictive value for mammography was high (72%), which reflects a high threshold for biopsy; this ma...

Clinical optical tomography and NIR spectroscopy for breast cancer detection

Abstract: The results of the first set of clinical trials with the Philips optical mammography prototype system are summarized. This optical mammo prototype is designed to image the interior of the female breast with the help of near-infrared (NIR) laser light transmission measurements. This study is expected to lead to optical tomography systems for breast cancer detection. This paper presents information on the design of the optical mammo system, the clinical measurements and the imaging results from an initial group of ten patients, and discussions about ongoing research on optical tomography.

Large-Core Needle Biopsy of Nonpalpable Breast Lesions

Abstract: ContextAn increasing number of nonpalpable abnormalities requiring breast biopsy are being identified due to the widespread use of screening mammography. Large-core needle biopsy (LCNB) has become an alternative to surgical excision.ObjectiveTo determine whether LCNB is a safe and accurate technique to evaluate nonpalpable abnormalities found on breast imaging studies.Design and SettingCase series at an institutional referral center from August 1, 1991, to December 31, 1997.PatientsA total of 1643 women with 1 or more suspicious breast abnormalities received LCNBs (n=1836 lesions).InterventionThe LCNB of the breast uses a 14- or 11-gauge needle with stereotactic localization or ultrasound guidance.Main Outcome MeasureUtility and potential limitations of LCNB compared with the criterion standard, surgical excision after wire localization.ResultsOf the 1836 breast lesions sampled, 444 (24%) were found to be malignant. A total of 412 (22%) were found to be malignant on the initial LCNB and 202 repeat biopsies yielded 32 additional malignancies. Complications were infrequent: 1 patient experienced a superficial infection and 1 developed a pneumothorax after LCNB.ConclusionImage-guided LCNB is a reliable diagnostic alternative to surgical excision of suspicious nonpalpable breast abnormalities.

Mammographic Image Analysis

Abstract: We describe our recent progress aimed at computer analysis of mammograms. The overall aim is to provide the clinician with reliable quantitative information. We summarise a representation we have developed of the ‘interesting’ (non-adipose) tissue in a breast, then put the representation to work in three ways: (i) to propose a new quantitative measure to aid in diagnosing masses; (ii) to explore the possibility of reducing by half the radiation dose required for a mammogram; and (iii) recalling some of the results that can be provided by differential compression mammography, in which mammograms are taken at two slightly different compressions.

Incidental findings on sonography of the breast: clinical significance and diagnostic workup.

Abstract: The purpose of this study was to determine how often physician-performed high-resolution sonography can detect nonpalpable breast lesions not revealed by mammography. A sonographic classification scheme was tested for its accuracy in predicting malignancy of incidentally detected breast lesions.Six thousand one hundred thirteen asymptomatic women with breast density grades 2-4 and 687 patients with palpable or mammographically detected breast masses underwent sonography as an adjunct to mammography. All sonographically detected, clinically and mammographically occult breast lesions that were not simple cysts were prospectively classified into benign, indeterminate, or malignant categories. Diagnoses were confirmed by sonographically guided fine-needle aspiration or core needle biopsy.In 6113 asymptomatic women, 23 malignancies in 21 patients were detected with sonography only (prevalence, 0.31%). Five additional malignant lesions were found in patients with a malignant (n = 3) or a benign (n = 2) palpable...

Specific worry about breast cancer predicts mammography use in women at risk for breast and ovarian cancer.

Abstract: This longitudinal study examined predictors of mammography use among women with a family history of breast cancer participating in a risk assessment and surveillance program (N = 213). Assessed were background variables (age, prior mammography utilization), cognitive variables (perceived vulnerability), and affective variables (cancer worry and general distress). Results of logistic regression analyses predicting adherence 1 year after baseline contact, in which variables of prior utilization, feelings of vulnerability, and general distress were controlled for, indicated that cancer worry and age were significant predictors of mammography adherence. Results suggest that moderate levels of cancer worry facilitate, rather than undermine, adherence. The results have implications for the construction of educational messages that should be designed to acknowledge feelings of cancer-specific worry and to provide guidance in health protective behaviors.

Continuing screening mammography in women aged 70 to 79 years: impact on life expectancy and cost-effectiveness.

Abstract: ContextMammography is recommended and is cost-effective for women aged 50 to 69 years, but the value of continuing screening mammography after age 69 years is not known. In particular, older women with low bone mineral density (BMD) have a lower risk of breast cancer and may benefit less from continued screening.ObjectiveTo compare life expectancy and cost-effectiveness of screening mammography in elderly women based on 3 screening strategies.DesignDecision analysis and cost-effectiveness analysis using a Markov model.PatientsGeneral population of women aged 65 years or older.InterventionsThe analysis compared 3 strategies: (1) Undergoing biennial mammography from age 65 to 69 years; (2) undergoing biennial mammography from age 65 to 69 years, measurement of distal radial BMD at age 65 years, discontinuing screening at age 69 years in women in the lowest BMD quartile for age, and continuing biennial mammography to age 79 years in those in the top 3 quartiles of distal radius BMD; and (3) undergoing biennial mammography from age 65 to 79 years.Main Outcome MeasuresDeaths due to breast cancer averted, life expectancy, and incremental cost-effectiveness ratios.ResultsCompared with discontinuing mammography screening at age 69 years, measuring BMD at age 65 years in 10,000 women and continuing mammography to age 79 years only in women with BMD in the top 3 quartiles would prevent 9.4 deaths and add, on average, 2.1 days to life expectancy at an incremental cost of $66,773 per year of life saved. Continuing mammography to age 79 years in all 10,000 elderly women would prevent 1.4 additional breast cancer deaths and add only 7.2 hours to life expectancy at an incremental cost of $117,689 per year of life saved compared with only continuing mammography to age 79 years in women with BMD in the top 3 quartiles.ConclusionsThis analysis suggests that continuing mammography screening after age 69 years results in a small gain in life expectancy and is moderately cost-effective in those with high BMD and more costly in those with low BMD. Women's preferences for a small gain in life expectancy and the potential harms of screening mammography should play an important role when elderly women are deciding about screening.

Mammographic appearances of male breast disease.

Abstract: Various male breast diseases have characteristic mammographic appearances that can be correlated with their pathologic diagnoses. Male breast cancer is usually subareolar and eccentric to the nipple. Margins of the lesions are more frequently well defined, and calcifications are rarer and coarser than those occurring in female breast cancer. Gynecomastia usually appears as a fan-shaped density emanating from the nipple, gradually blending into surrounding fat. It may have prominent extensions into surrounding fat and, in some cases, an appearance similar to that of a heterogeneously dense female breast. Although there are characteristic mammographic features that allow breast cancer in men to be recognized, there is substantial overlap between these features and the mammographic appearance of benign nodular lesions. The mammographic appearance of gynecomastia is not similar to that of male breast cancer, but in rare cases, it can mask malignancy. Gynecomastia can be mimicked by chronic inflammation. All mammographically lucent lesions of the male breast appear to be benign, similar to such lesions in the female breast.

Follow-up of breast lesions diagnosed as benign with stereotactic core-needle biopsy: frequency of mammographic change and false-negative rate.

Abstract: PURPOSE: To determine how often lesions diagnosed as benign with stereotactic core-needle biopsy (SCNB) change at follow-up mammography and to determine the optimal follow-up strategy and the delayed false-negative rate. MATERIALS AND METHODS: From July 1992 through December 1995, 355 of 540 cases (66%) in which SCNB yielded benign results were managed with follow-up mammography. Mammographic follow-up was available for 298 of these cases (84%). Follow-up mammography reports were reviewed. When a change was reported, pre- and postbiopsy mammograms, pathology reports, and results of subsequent mammographic follow-up were reviewed. RESULTS: Mammographic change occurred in 21 of 298 cases (7%) at intervals of 6–55 months (mean, 20 months). Change occurred after initial mammographic stability in 10 of 21 cases. Repeat biopsy was performed in 18 of 21 cases. Malignancy was diagnosed in two cases: one mass that changed at 6 months and one case of microcalcifications that changed at 24 months. This represented a...

Unusual breast lesions: radiologic-pathologic correlation.

Abstract: Unusual lesions of the breast can present a diagnostic challenge. These lesions include systemic diseases, benign tumors, and primary and metastatic malignancies. Lymphadenopathy is the most common mammographic finding associated with collagen vascular disease. Wegener granulomatosis may manifest as an irregular, high-density mass simulating breast cancer. Diabetic fibrous mastopathy manifests at mammography as very dense breast tissue and at ultrasonography (US) as an irregular, hypoechoic mass with striking posterior acoustic shadowing simulating malignancy. Fibromatosis simulates malignancy at mammography as an irregularly shaped, uncalcified, high-density mass and at US as an irregular, hypoechoic mass with posterior acoustic shadowing. At US, granular cell tumor may manifest as a solid, poorly marginated mass with marked posterior acoustic shadowing or may appear more benign. At mammography, hamartomas are typically well-circumscribed, round to oval masses with a thin, radiopaque pseudocapsule; at US...

Breast cancer: computer simulation method for estimating optimal intervals for screening.

Abstract: PURPOSE: To develop and evaluate a mathematic method that can be used to determine the optimal screening interval for detection of breast cancer prior to distant metastatic spread. MATERIALS AND METHODS: A computer simulation was developed with the use of biologically based data from the literature on the rates of tumor growth and spread, which can be used to calculate the course of breast cancer growth and metastasis. RESULTS: On the basis of the data available at this time, the results of the simulations suggested that a screening interval of 2 years would result in a 22% reduction in the rate of distant metastatic disease, an interval of 1 year would result in a 51% reduction, and an interval of 6 months would result in an 80% reduction. CONCLUSION: These findings suggest that more frequent screening could dramatically reduce the death rate from breast cancer.

Health beliefs, health locus of control, and women's mammography behavior

Abstract: Research has shown that routine mammography screening can significantly reduce mortality from breast cancer. The use of mammography screening, however, remains well below national goals. In an effort to understand the factors that influence women's mammography behaviors, this study explored the rela

Effect of age and breast density on screening mammograms with false-positive findings.

Abstract: The objective of this study was to examine the effect of breast density and age on screening mammograms with false-positive findings.The study sample was taken from the Washington State Mammography Tumor Registry, which links data from participating radiologists with the Puget Sound Cancer Surveillance System and the Washington State Cancer Registry. Participants (n = 73,247) were women 35 years old and older who underwent screening mammography for which an assessment and a four-category density rating were coded. A total of 46,340 mammograms were sampled to avoid interpreter bias. In this study of false-positive mammograms, only women with no diagnosis of breast cancer within 12 months of the index mammogram were included. Logistic regression was used to estimate the odds ratios of a false-positive mammogram being associated with each category of breast density or age, adjusting for the other factor as a covariate.After controlling for breast density, we found that the risk of a false-positive mammogram ...

Silicone breast implant rupture: pitfalls of magnetic resonance imaging and relative efficacies of magnetic resonance, mammography, and ultrasound.

Abstract: The objective of this study was to evaluate the relative efficacies of magnetic resonance (MR) imaging, ultrasonography, and mammography in implant rupture detection and to illustrate pitfalls in MR image interpretation. Thirty patients referred by plastic surgeons with suspected breast implant rupture were prospectively evaluated using MR, ultrasonography, and mammography. Imaging examinations were interpreted independently and blindly for implant rupture and correlated to operative findings. Surgical correlation in 16 patients (53 percent) with 31 implants showed 13 (42 percent) were intact, 5 (16 percent) had severe gel bleed, and 13 (42 percent) were ruptured. MR sensitivity was 100 percent and specificity was 63 percent. Accuracy for rupture was 81 percent with MR, higher than with ultrasonography and mammography (77 and 59 percent, respectively). We describe a specific pitfall in MR interpretation, the "rat-tail" sign, composed of a medial linear extension of silicone along the chest wall. Seen in eight cases (four intact, three ruptures, one gel bleed), the rat-tail sign may lead to misdiagnosis of implant rupture if seen in isolation. Magnetic resonance imaging is more accurate and sensitive than ultrasonography and mammography in detecting breast implant rupture. We describe a new sign (rat-tail sign) composed of medial compression of the implant simulating silicone extrusion as a potential false-positive MR finding for rupture. This article presents clinical experience with magnetic resonance, mammography, and ultrasound in the diagnosis of implant rupture and defines and illustrates potential pitfalls of MR interpretation, including the new rat-tail sign.

Mammographic Densities and Risk of Breast Cancer Among Subjects With a Family History of This Disease

Abstract: Background: A family history of breast cancer is known to increase risk of the disease, but other genetic and environmental factors that modify this risk are likely to exist. One of these factors is mammographic density, and we have sought evidence that it is associated with increased risk of breast cancer among women with a family history of breast cancer. Methods: We used data from a nested case-control study based on the Canadian National Breast Screening Study (NBSS). From 354 case patients with incident breast cancer detected at least 12 months after entry into the NBSS and 354 matched control subjects, we analyzed subjects who were identified as having a family history of breast cancer according to one of three, nonmutually exclusive, criteria. We compared the mammographic densities of case patients and control subjects by radiologic and computer-assisted methods of measurement. Results: After adjustment for other risk factors for breast cancer, the relative risks (RRs) between the most and least extensive categories of breast density were as follows: For at least one first-degree relative with breast cancer, RR = 11.14 (95% confidence interval [CI] = 1.54-80.39); for at least two affected first- or second-degree relatives, RR = 2.57 (95% CI = 0.23-28.22); for at least one first- or second-degree relative with breast cancer, RR = 5.43 (95% CI = 1.85-15.88). Conclusions: These results suggest that mammographic density may be strongly associated with risk of breast cancer among women with a family history of the disease. Because mammographic densities can be modified by dietary and hormonal interventions, the results suggest potential approaches to the prevention of breast cancer in women with a family history of breast cancer.

Changes in mammographic breast density and concomitant changes in breast cancer risk.

Abstract: Among participants of the biennial Nijmegen breast cancer screening programme, we examined whether diminution of mammographic breast density lowered breast cancer risk. Post-menopausal breast cancer cases (n = 108), who had to have participated in all the five screening rounds prior to their diagnosis, were matched to 400 controls on year of birth and screening history. Controls had to be free of breast cancer at the time of the case's diagnosis. Changes in breast density were measured over a 10-year period, by a fully computerized method. Women in whom 5-25% or >25% of the breast was composed of fibro-glandular density showed a threefold increased 10-year risk compared to women with 25% density the OR was 6.9 (95% CI = 2.1-22.9). In women with >25% density initially, diminishing density was not clearly associated with lowering risk, which may be partly explained by the low number of women who decreased to <5% (n = 12). Due to the limited size of the study these results have to be interpreted with caution. Although the results are not conclusive, they could indicate a trend of decreasing risk with diminishing breast density. Should this effect be real, it may have great implications for the primary prevention of breast cancer or for the identification of high-risk groups who would benefit by more frequent screening. Therefore, large-scale, long-term follow-up studies on the effects of changes in breast density are needed.

Laser opto-acoustic imaging of the breast: detection of cancer angiogenesis

Abstract: First clinical prototype laser optoacoustic imaging system (LOIS) for breast cancer detection was designed and fabricated using a compact Nd:YAG laser, fiberoptic light delivery system, a linear array of 12 wide-band acoustic transducers, and a data acquisition card operated by computer with original signal processing and image reconstruction code. Initially images of small absorbing spheres were recorded in the milk with optical properties resembling those of the breast at the wavelength of 1064-nm. The system was optimized for contrast, sensitivity and axial (in-depth) resolution. The small number of acoustic transducers (12), which in turn was determined by the system cost and the time of image acquisition limited the lateral resolution of the images. Clinical ex-vivo studies on radical mastectomy specimens were performed and compared with x-ray radiography, MRI and ultrasound imaging. The results of our pilot clinical studies showed pronounced opto-acoustic contrast of ~300% between breast tumors and normal breast tissues. This contrast substantially exceeds any other endogenous tissue contrast currently utilized in clinical ultrasonography, MRI and x-ray mammography. Based on literature data and our gross observations of tumor cross-sections we hypothesize that the opto-acoustic contrast results primarily from increased optical absorption in the dense microvascularity of the tumors. In patients receiving radiotherapy, tumors were found to contain enhances concentration of dense highly scattering fiberotic tissue.

Psychologic distress in women with abnormal findings in mass mammography screening

Abstract: This study was conducted to explore the psychologic morbidity of women recalled for diagnostic assessment during population-based mammographic screening.This study prospectively attempted to measure physical, social, and emotional well-being by the administration of a questionnaire before screening, at the time of recall; and 1 month later to women recalled and matched women with those not recalled.Of the 224 women who were recalled for further diagnostic assessment and their matches, complete follow-up was obtained on 182 pairs (81.3%). In contrast to those women not recalled, recalled women exhibited increased levels of concern at the time of recall. These levels had not decreased to the initial level after 1 month, even though breast carcinoma was not diagnosed. Similar negative short term effects also were evident in the areas of physical well-being, social functioning, and anxiety and insomnia levels, although these were not sustained.Women with normal results after mass mammographic breast screening experienced no increase in psychologic distress and a decrease in their concern regarding breast carcinoma. However, those women who were recalled to follow-up after abnormal findings experienced an increase in their level of concern regarding breast carcinoma and this concern was sustained, as determined by repeat questionnaire, 1 month after a negative result had been determined.

Breast cancer screening.

Abstract: Breast cancer screening is a major public health issue. Decisions concerning breast cancer screening should be based upon the results of randomized controlled trials, not observational studies. There are three important biases associated with observational studies that examine the effect of screening: lead time, length, and selection biases. Randomized trials have shown that mammography screening reduces breast cancer-specific mortality in postmenopausal women. Additionally, randomized trials are underway to assess the efficacy of screening clinical breast examination (CBE) and screening breast ultrasound. Two large randomized trials have failed to demonstrate a benefit of screening breast self-examination (BSE) in reducing breast cancer-specific mortality. Screening breast MRI is often utilized in mutation carriers and those with increased risk of breast cancer based upon family history, but there are no randomized trials that have examined its efficacy. There are also potential hazards of screening that should be considered: lead time, false-positives, radiation exposure (from screening mammography), overdiagnosis, and cost. Women should be informed about both the potential risks and the benefits of breast cancer screening.

Comparison of mammographically guided breast biopsy techniques.

Abstract: Objective To determine which mammographically guided breast biopsy technique is the most efficient in making a diagnosis in women with suspicious mammograms. Background Data Mammographically guided biopsy techniques include stereotactic 14-gauge core-needle biopsy (SC bx), stereotactic 11-gauge suction-assisted core biopsy (Mammotome [Mbx]), stereotactic coring excisional biopsy (Advanced Breast Biopsy Instrument [ABBI]), and wire-localized biopsy (WL bx). Controversy exists over which technique is best. Methods All patients undergoing any one of these biopsy methods over a 15-month period were reviewed, totaling 245 SC bx, 107 Mbx, 104 ABBI, and 520 WL bx. Information obtained included technical success, pathology, discordant pathology, and need for open biopsy. Results Technical success was achieved in 94.3% of SC bx, 96.4% of Mbx, 92.5% of ABBI, and 98.7% of WL bx. The sensitivity and specificity were 87.5% and 98.6% for SC bx, 87.5% and 100% for Mbx, and 100% and 100% for ABBI. Discordant results or need for a repeat biopsy occurred in 25.7% of SC bx, 23.2% of Mbx, and 7.5% of ABBI biopsies. In 63.6% of ABBI and 50.9% of WL bx, positive margins required reexcision; of the cases with positive margins, 71.4% of ABBI and 70.4% of WL bx had residual tumor in the definitive treatment specimen. Conclusion Although sensitivities and specificities of SC bx and Mbx are good, 20% to 25% of patients will require an open biopsy because a definitive diagnosis could not be reached. This does not occur with the ABBI excisional biopsy specimen. The positive margin rates and residual tumor rates are comparable between the ABBI and WL bx. The ABBI avoids operating room and reexcision costs; therefore, in appropriately selected patients, this appears to be the most efficient method of biopsy.