Vol.2, No.4, 291-294 (2010) Health
doi:10.4236/health.2010.24042
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
The role of fine-wire localization breast biopsy in the
management of BI-RADS category 3-5 non-palpable
breast lesions in northeastern Chinese women
Bo Chen1, Cai-Gang Liu1, Feng Jin1, Ya-Nan Sun1, Ting-Ting Zhao1, Li-Na Zhang2,
Shu Li2, Sai-Ching J. Yeung3
1Breast Surgery Unit, Department of Surgical Oncology, First Hospital, China Medical University, Shenyang, China; angel- s205 @ 163.c om
2Department of Radiology, First Hospital, China Medical University, Shenyang, China
3Department of General Internal Medicine, Ambulatory Treatment and Emergency Care, The University of Texas M. D. Anderson
Cancer Center, Houston, USA
Received 14 October 2009; revised 25 December 2009; accepted 28 December 2009.
ABSTRACT
A blinded retrospective validation study was
performed in a university-based hospital in
northeastern China to determine whether the
breast imaging reporting and data system (BI-
RADS) defines a group of patients with non-
palpable breast lesions (NPBLs) in whom fine-
wire localization biopsy (FWLB) is appropriate.
We reviewed 182 consecutive patients with
NPBLs who underwent FWLB. The patients’
preoperative mammograms were categorized
according BI-RADS by 2 radiologists blinded to
the pathological findings. The positive predic-
tive values of BI-RADS categories 3-5 were 3.4%,
42.1%, and 76.9%, respectively. For category 4
NPBLs, the percentage of cancer for those aged
< 40 years was significantly lower than those
aged ≥ 40 years. For category 3 NPBLs, the
percentage of precancerous lesions for those
aged < 40 years was significantly lower than
those aged ≥ 40 years. Chinese NPBL patients
aged ≥ 40 years with category 4 mammographic
findings, and all patients with category 5 find-
ings should undergo FWLB. FWLB should be
offered as a treatment option for Chinese NPBL
patients aged < 40 years with category 4 find-
ings or aged ≥ 40 years with category 3 findings.
Keywords: Non-Palpable Breast Lesions;
Mammography; Fine-Wire Localization Biopsy
1. INTRODUCTION
Screening mammography has been shown to reduce
breast cancer mortality [1-3]. Unfortunately, traditional
mammography has a low positive predictive value (PPV)
for breast cancer [4], and thus many women with benign
breast lesions undergo open surgical biopsy. In this con-
text, the Breast Imaging Reporting and Data System
(BI-RADS) classification scheme was developed by the
American College of Radiology to improve mammo-
graphic reporting through the use of standardized de-
scriptive terms [5]. An important goal of BI-RADS is to
provide a clear management recommendation for women
with nonpalpable breast lesions (NPBLs). BI-RADS also
offers specific PPV for each category of mammographic
lesions and therefore is useful not only for discriminat-
ing many benign from malignant lesions but also for
potentially reducing the number of unnecessary open
breast biopsies performed. We retrospectively evaluated
the mammograms of 182 consecutive women who un-
derwent fine-wire localization breast biopsy (FWLB) of
NPBLs in a tertiary referral cancer center in northeastern
China to investigate whether the fourth edition of
BI-RADS [5] is appropriate for patients in northeastern
China with NPBLs and identify the BI-RADS-identified
patient subgroups appropriate for FWLB.
2. MATERIALS AND METHODS
In adherence to a research protocol approved by the In-
stitutional Review Board and institutional guidelines for
ethical human research, we retrospectively reviewed the
mammograms, histopathology and medical records of
182 consecutive women with NPBL who underwent
FWLB between January 1, 2005 and March 1, 2008 at
an affiliated hospital of China Medical University in
Liaoning Province of northeastern China. Fine wire lo-
calization was guided mammographically. Two trained
radiologists [L.Z. and S.L.], who were blinded to the
patients’ histopathologic diagnoses, categorized the pa-
tients’ lesions using the fourth edition of BI-RADS. [5]

B. Chen et al. / Health 2 (2010) 291-294
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
292
Histopathological results of FWLB were used as the
gold standard to calculate the positive predictive values
(PPVs) of malignancy. The PPV for each BI-RADS
category was calculated by dividing the number of ma-
lignant cases on histopathological examination by the
total number of patients who underwent FWLB in that
BI-RADS category. All data were analyzed with SPSS
statistics software (Version 13.0, SPSS, Inc., Chicago, IL,
USA). We used Fisher’s exact text for to compare ratios.
We considered a P value less than 0.05 to be statistically
significant.
3. RESULTS
182 consecutive cases were reviewed. The patients’
mean age was 45.6 years [range, 24-76 years; standard
deviation (SD) = 9.5 years]. According to the histopa-
thologic diagnosis, 40 patients (22%) had malignant
lesions and 142 (78%) had benign lesions (Table 1). The
mean age of patients with malignant lesions was 48.3
years (range, 30-76 years; SD = 8.8 years), and the mean
age of the patients with benign lesions was 45.6 years
(range, 24-67 years; SD = 9.5 years). The radiologists
identified 118 BI-RADS category 3 lesions (65%), 38
category 4 lesions (21%), and 26 category 5 lesions
(14%). Four category 3 lesions, 16 category 4 lesions,
and 20 category 5 lesions were malignant based on
histopathology. The PPVs were 3.4%, 42.1% and 76.9%
for category 3, 4, and 5 lesions, respectively (Ta b l e 2 ).
Among patients with category 4 lesions, the cancer PPV
for those aged < 40 years was significantly lower than
that for those aged ≥ 40 years (P = 0.02; Table 3).
Among patients with category 3 lesions, 20 (i.e., 17%)
had precancerous lesions on histopathology, and when
these patients were subdivided by age < 40 years and ≥
40 years, the difference in the rate of precancerous le-
sions between the two age groups was significant (P =
0.002; Table 4).
Table 1. Histopathologic diagnoses for 182 patients who un-
derwent fine-wire localization biopsy for nonpalpable breast
lesions.
Diagnosis Number of patients (%)
Benign (n = 142)
Mastopathy 96 (67.6)
Fibroadenoma 20 (14.1)
Sclerosing adenosis 2 (1.4)
Lymph node 2 (1.4)
Atypical ductal hyperplasia (precancerous) 20 (14.1)
Malignant (n = 40)
Ductal carcinoma in situ 22 (55)
Infiltrating ductal carcinoma 18 (45)
Table 2. Positive predictive values for cancer of BI-RADS
categories in the diagnosis of nonpalpable breast lesions.
Histopathologic diagnosis*
BI-RADS
category Malignant Benign PPV
3 4 114 3.4%
4 16 22 42.1%
5 20 6 76.9%
Total 40 142 22.0%
* Data are in numbers of patients.
Table 3. Relationship between the patients’ age and the per-
centage of malignancy in BI-RADS category 4 nonpalpable
breast lesions.
Age
Ratio of cancer to the total
number of cases in the
subgroup
Percentage of cancer
*
< 40 years2/16 12.5%
≥ 40 years14/22 63.6%
Total 16/38 42.1%
* P = 0.002, Fisher’s exact test
Table 4. Relationship between the patients’ age and the per-
centage of precancerous lesions in BI-RADS category 3 non-
palpable breast lesions.
Age Ratio of precancerous
lesions to the total number
of cases in the subgroup
Percentage of pre-
cancerous lesions *
< 40 years 2/48 4.2%
≥ 40 years 18/70 25.7%
Total 20/118 16.9%
* P = 0.02, Fisher’s exact test
4. DISCUSSION
In our study of patients with NPBLs who underwent
FWLB, the PPVs for category 3, 4 and 5 lesions were
3.4%, 42.1%, and 76.9%, respectively. For comparison,
a retrospective Pakistani study reported PPVs of 5% for
category 3 lesions, 34% for category 4 lesions and 83%
for category 5 lesions [6]. A retrospective Singaporean
study reported PPVs of 27% for category 4 lesions and
84% for category 5 lesions [7]. In a U.S. prospective
study of mammographically detected NPBLs that were
biopsied surgically, carcinomas were present in 34% of
category 4 lesions and in 81% of category 5 lesions [8].
Therefore, our results are in agreement with published
results from various geographic and ethnic backgrounds,
and the BI-RADS classification is appropriate for wo-
men with NPBLs in northeastern China.
As a screening tool, traditional mammography pro-
vides high-sensitivity and low specificity for identifying
breast cancer [9]. By providing distinct PPVs for each
final assessment category, BI-RADS [5] offers a prob-
ability of carcinoma for each category of mammographic

B. Chen et al. / Health 2 (2010) 291-294
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
293
findings. Category 5 lesions must be biopsied and trea-
ted. Categoreis 1 and 2 lesions do not require biopsy or
surgical intervention. Category 3 and 4 lesions are in the
grey zone where the ideal management strategy is con-
troversial. Given the low probability of malignancy in
category 3 and 4 and the imperative to limit the morbid-
ity associated with cancer screening, a conservative and
minimally invasive approach in certain subgroups within
these 2 BI-RADS categories may be appropriate. For
discrete lesions with category 3 mammographic findings,
a stepwise approach of fine needle aspiration biopsy
(FNAB) followed by core biopsy if FNAB is nondiag-
nostic would reduce the proportion of cases requiring
surgical biopsy [9]. Core needle biopsy is highly accu-
rate and safe in the diagnosis of mammographically de-
tected breast lesions [10]. Close periodic mammographic
surveillance is also an alternative way to manage NPBLs
that are probably benign based on mammographic find-
ings [11]. Among patients with category 4 lesions in our
Asian population, the cancer PPV for those aged < 40
years was 12.5% compared with 63.6% for those aged
≥ 40 years (Table 3 ). A Canadian study recommended
that stereotactic core needle biopsy should be applied to
BI-RADS categories 3 and 4 patients who are < 50 years
of age, and FWLB should be reserved for category 4
(> 50 years of age) and category 5 cases. However, this
recommendation was partially based on an unusually
low rate of malignancy in category 3 lesions (0%) which
might be due to a small sample size of category 3 pa-
tients (10 cases) in this study [12].
FWLB is more invasive than FNAB and core biopsy,
but FWLB is an accurate technique for diagnosis of
mammographically-detected NPBLs, and may also be
therapeutic for the NPBLs that are malignant or precan-
cerous. In our study of women in northeastern China,
there was a significantly higher incidence of precancer-
ous lesions in category 3 patients aged ≥ 40 years than in
those aged < 40 years. Taking into account other factors,
such as patient anxiety, patient preference, and future
breast cancer risk, surgeons may recommend for patients
aged ≥ 40 years with category 3 lesions to undergo
FWLB and for patients aged < 40 years with category 3
lesions to undergo stereotactic core needle biopsy.
There are many differences between breast cancer pa-
tients in Asia and those in Western countries. Compared
with Caucasians, the incidence of breast cancer and the
mortality from breast cancer are lower, and the age of
peak incidence is younger in Asian women. The median
age at diagnosis is 62 years for Swedish patients while
the median age at diagnosis is 50 years for Singaporean
patients [13]. With striking similarity to the Singaporean
patients, the median age at diagnosis of breast cancer is
49.5 years for Taiwanese women [14]. These differences
in incidence, mortality and the age of peak incidence
may be due to differences in certain modifiable risk fac-
tors (e.g., diet, life style and environmental factors), dif-
ferences in the biology of breast cancer (e.g., the preva-
lence of BRCA1/BRCA2 mutations) or differences in
breast cancer screening and treatment. The age of peak
breast cancer incidence is the most important difference
that would change the positive predictive value of
BI-RADS for Asian women. Since there is a difference
of about 10 years between the age of peak incidence, we
subdivided our patients with category 3 lesions into two
groups using a cutoff at 40 years of age instead of 50
[12], i.e., age < 40 years vs. ≥ 40 years. We found only
two malignant lesions in patients aged < 40 years, and
the difference in PPV between the two groups was sig-
nificant (Table 3). Except for the cutoff used in age
grouping, our findings are similar to those reported by
Ball et al. [15] who found that the PPV of category 4
was 4.5% for women aged < 50 years.
5. CONCLUSIONS
Therefore, BI-RADS categories appropriately predict the
risk of malignancy of NPBLs and aid in the deci-
sion-making process for biopsy in patients in northeast-
ern China. We recommend that Asian NPBL patients
aged ≥ 40 years with category 4 mammographic findings,
and all patients with category 5 findings should undergo
FWLB. FWLB should be offered as a treatment option,
the risks and benefits of which to be discussed with the
patient for Asian NPBL patients aged < 40 years with
category 4 and aged ≥ 40 years with category 3 mam-
mographic findings.
6. ACKNOWLEDGEMENTS
We would like to acknowledge grant support from the following find-
ing sources: U. S. Department of Defense Breast Cancer Research
Program of the Office of the Congressionally Directed Medical Re-
search Programs (DOD SIDA BC062166 P.I.: Yeung S J), Susan G.
Komen Foundation for Breast Cancer Research ( Promise Grant 2008
KG081048, P.I.: Yeung S J), China Foundation of Science and Tech-
nology Bureau of Liaoning Province of China (20061038, Chen B),
and Foundation of Educational Commission of Liaoning Province of
China (2008762, Chen B).
REFERENCES
[1] Tabar, L., Vitak, B., Chen, H.H., et al. (2001) Beyond
randomized controlled trials: Organized mammographic
screening substantially reduces breast carcinoma mortal-
ity. Cancer, 91, 1724-1731.
[2] Elmore, J.G., Armstrong, K., Lehman, C.D., et al. (2005)
Screening for breast cancer. Jama, 293, 1245-1256.
[3] Sarkeala, T., Heinavaara, S. and Anttila, A. (2008) Or-
ganized mammography screening reduces breast cancer
mortality: A cohort study from Finland. International
Journal of Cancer, 122, 614-619.
[4] Kopans, D.B. (1992) The positive predictive value of

B. Chen et al. / Health 2 (2010) 291-294
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
294
mammography. American Journal of Roentgenology, 158,
521-526.
[5] Virginia, American College of Radiology. (2003) Breast
imaging reporting and data system. 4th Edition, Reston.
[6] Masroor, I. (2005) Prediction of benignity or malignancy
of a lesion using BI-RADS. Journal of College of Physi-
cians and Surgeons Pakistan, 15, 686-688.
[7] Tan, Y.Y., Wee, S.B., Tan, M.P., et al. (2004) Positive
predictive value of BI-RADS categorization in an Asian
population. Asian Journal of Surgery, Asian Surgical
Association, 27, 186-191.
[8] Liberman, L., Abramson, A.F., Squires, F.B., et al. (1998)
The breast imaging reporting and data system: Positive
predictive value of mammographic features and final as-
sessment categories. American Journal of Roentgenology,
171, 35-40.
[9] Farshid, G., Downey, P., Gill, P., et al. (2008) Assessment
of 1183 screen-detected, category 3B, circumscribed
masses by cytology and core biopsy with long-term fol-
low up data. British Journal of Cancer, 98, 1182-1190.
[10] Nguyen, M., McCombs, M.M., Ghandehari, S., et al.
(1996) An update on core needle biopsy for radiologi-
cally detected breast lesions. Cancer, 78, 2340-2345.
[11] Sickles, E.A. (1991) Periodic mammographic follow-up
of probably benign lesions: Results in 3,184 consecutive
cases. Radiology, 179, 463-468.
[12] Chadwick, D.R. and Shorthouse, A.J. (1997) Wire-di-
rected localization biopsy of the breast: An audit of re-
sults and analysis of factors influencing therapeutic value
in the treatment of breast cancer. European Journal of
Surgical Oncology, 23, 128-133.
[13] Tan, B.K., Lim, G.H., Czene, K., et al. (2009) Do Asian
breast cancer patients have poorer survival than their
western counterparts? A comparison between Singapore
and Stockholm. Breast Cancer Research, 11, R4.
[14] Kuo, W.H., Yen, A.M., Lee, P.H., et al. (2009) Cumula-
tive survival in early-onset unilateral and bilateral breast
cancer: An analysis of 1907 Taiwanese women. British
Journal of Cancer, 100, 563-570.
[15] Ball, C.G., Butchart, M. and MacFarlane, J.K. (2002)
Effect on biopsy technique of the breast imaging report-
ing and data system (BI-RADS) for nonpalpable mam-
mographic abnormalities. Canadian Journal of Surgery,
45, 259-263.