Breast cancer detection with short-interval follow-up compared with return to annual screening in patients with benign stereotactic or US-guided breast biopsy results

PURPOSE

To compare the cancer detection rate and stage after benign stereotactic or ultrasonography (US)-guided core breast biopsy between patients with short-interval follow-up (SIFU) and those who return to annual screening.

MATERIALS AND METHODS

The Breast Cancer Surveillance Consortium (BCSC) registry and the BCSC Statistical Coordinating Center received institutional review board approval for active and passive consent processes and a waiver of consent. All procedures were HIPAA compliant. BCSC data for 1994-2010 were used to compare ipsilateral breast cancer detection rates and tumor characteristics for diagnoses within 3 months after SIFU (3-8 months) versus return to annual screening (RTAS) mammography (9-18 months) after receiving a benign pathology result from image-guided breast biopsy.

RESULTS

In total, 17 631 biopsies with benign findings were identified with SIFU or RTAS imaging. In the SIFU group, 27 ipsilateral breast cancers were diagnosed in 10 715 mammographic examinations (2.5 cancers per 1000 examinations) compared with 16 cancers in 6916 mammographic examinations in the RTAS group (2.3 cancers per 1000 examinations) (P = .88). Sixteen cancers after SIFU (59%; 95% confidence interval [CI]: 39%, 78%) were invasive versus 12 after RTAS (75%; 95% CI: 48%, 93%). The invasive cancer rate was 1.5 per 1000 examinations after SIFU (95% CI: 0.9, 2.4) and 1.7 per 1000 examinations (95% CI: 0.9, 3.0) after RTAS (P = .70). Among invasive cancers, 25% were late stage (stage 2B, 3, or 4) in the SIFU group (95% CI: 7%, 52%) versus 27% in the RTAS group (95% CI: 6%, 61%). Positive lymph nodes were found in seven (44%; 95% CI: 20%, 70%) invasive cancers after SIFU and in three (25%; 95% CI: 5%, 57%) invasive cancers after RTAS.

CONCLUSION

Similar rates of cancer detection were found between SIFU and RTAS after benign breast biopsy with no significant differences in stage, tumor size, or nodal status, although the present study was limited by sample size. These findings suggest that patients with benign radiologic-pathologic-concordant percutaneous breast biopsy results could return to annual screening.

Status quo and development trend of breast biopsy technology

Triple assessment is a standard method for assessment of breast diseases, which includes clinical evaluation, radiographic assessment and pathological assessment. Biopsy for breast disease is the gold standard for pathological assessment, including incisional biopsy, excisional biopsy, core needle biopsy, vacuum-assisted biopsy and bite biopsy. With the continuous advancement of diagnostic and treatment technology for breast cancer, collection of diseased tissue has also undergone a gradual transition from traditional open surgery to biopsy. This review summarizes the current situation and development of breast biopsy technology to provide an insight into the latest details such as the safety and reliability as the basis for selection of the most appropriate techniques for specific settings.

Vacuum-assisted breast biopsy under ultrasonographic guidance: analysis of a 10-year experience

PURPOSE

To determine the indications and the diagnostic accuracy of vacuum-assisted breast biopsy (VABB) under ultrasonographic (US) guidance based on a 10-year period of clinical use.

METHODS

This was a retrospective analysis of 2,920 breast lesions in 2,477 consecutive patients who underwent US-guided VABB between February 2002 and December 2011. The proportions of each indication for VABB were analyzed as well as the trend of its use over divided time periods. Histopathological diagnosis and the malignancy rate of the lesions with VABB were analyzed. A comparison of the pathological diagnosis of VABB and the gold standard diagnosis revealed the false negative rate, the underestimation rate, and the agreement rate.

RESULTS

Palpable lesions (44.4%), low-suspicion lesions (15.7%), high-risk lesions (12.4%), and calcifications (10.3%) were the most common indications for US-guided VABB. The malignancy rate of lesions submitted to VABB was 5.4%. The false negative rate was only 0.1%, while the underestimation rate of high-risk lesions and ductal carcinoma in situ was 3.1% and 13.8%, respectively, with a 98.7% agreement rate. Among 1,512 therapeutic VABB cases, 84.9% showed no residual or recurrent lesions on long term follow-up US for more than a year. Complications occurred in 1% of the patients without need for surgical intervention.

CONCLUSION

US-guided VABB is an accurate and safe method that can help decision-making in the diagnostic process and can be an alternative for excisional surgery in some therapeutic circumstances.

Benign core biopsy of probably benign breast lesions 2 cm or larger: correlation with excisional biopsy and long-term follow-up

Purpose:

To evaluate the accuracy of benign core biopsy of probably benign breast lesions (category 3) 2 cm or larger on the basis of excisional biopsy and long-term follow-up.

Methods:

We retrospectively reviewed 146 category 3 lesions in 146 patients 2 cm or larger which were diagnosed as benign by ultrasound (US)-guided core biopsy. Patients were initially diagnosed as benign at core needle biopsy and then followed up with excisional biopsy (surgical excision, n=91; US-guided vacuum assisted excision, n=35) or breast ultrasonography (n=20).

Results:

Of the 126 patients who underwent surgical excision or US-guided vacuum-assisted excision, 114 patients were diagnosed with benign lesions, 10 patients with borderline lesions (benign phyllodes tumor), and two patients with malignant phyllodes tumors. The probabilities of lesions being benign, borderline and malignant were 91.8% (134/146), 6.8% (10/146), and 1.4% (2/146), respectively. Of 13 patients who had growing masses on follow-up ultrasonography, three (23.1%) were non-benign (two benign phyllodes tumors and one malignant phyllodes tumor).

Conclusion:

US-guided core needle biopsy of probably benign breast mass 2 cm or larger was accurate (98.6%) enough to rule out malignancy. But, it was difficult to rule out borderline lesions even when they were diagnosed as benign.

Ductal carcinoma in situ diagnosed using an ultrasound-guided 14-gauge core needle biopsy of breast masses: can underestimation be predicted preoperatively?

Purpose:

This study was designed to determine the rate of ductal carcinoma in situ (DCIS)underestimation diagnosed after an ultrasound-guided 14-gauge core needle biopsy (US-14G-CNB) of breast masses and to compare the clinical and imaging characteristics between trueDCIS and underestimated DCIS identified following surgical excision.

Methods:

Among 3,124 US-14G-CNBs performed for breast masses, 69 lesions in 60 patients were pathologically-determined to be pure DCIS. We classified these patients according to the final pathology after surgical excision as those with invasive ductal carcinoma (underestimated group) and those with DCIS (non-underestimated group). We retrospectively reviewed and compared the clinical and imaging characteristics between the two groups.

Results:

Of the 69 lesions, 21 were shown after surgery to be invasive carcinomas; the rateof DCIS underestimation was 30.4%. There were no statistically significant differences withrespect to the clinical symptoms, age, lesion size, mammographic findings, and ultrasonographic findings except for the presence of abnormal axillary lymph nodes as detected on ultrasound. The lesions in 2 patients in the non-underestimated group (2/41, 4.9%) and 5 patients in the underestimated group (5/19, 26.3%) were associated with abnormal lymph nodes on axillary ultrasound, and the presence of abnormal axillary lymph nodes on ultrasound was tatistically significant (P=0.016).

Conclusion:

We found a 30.4% rate of DCIS underestimation in breast masses based on a US-14G-CNB. The presence of abnormal lymph nodes as detected on axillary ultrasound may be useful to preoperatively predict underestimation.

Accuracy of 16/18G core needle biopsy for ultrasound-visible breast lesions

Background

To assess the accuracy of ultrasound-guided 16G or 18G core needle biopsy (CNB) for ultrasound-visible breast lesions, and to analyze the effects of lesion features.

Methods

Between July 2005 and July 2012, 4,453 ultrasound-detected breast lesions underwent ultrasound-guided CNB and were retrospectively reviewed. Surgical excision was performed for 955 lesions (566 with 16G CNB and 389 with 18G CNB) which constitute the basis of the study. Histological findings were compared between the ultrasound-guided CNB and the surgical excision to determine sensitivity, false-negative rate, agreement rate, and underestimation rate, according to different lesion features.

Results

Final pathological results were malignant in 84.1% (invasive carcinoma, ductal carcinoma in situ, lymphoma, and metastases), high-risk in 8.4% (atypical lesions, papillary lesions, and phyllodes tumors), and benign in 7.5%. False-negative rates were 1.4% for 16G and 18G CNB. Agreement rates between histological findings of CNB and surgery were 92.4% for 16G and 92.8% for 18G CNB. Overall underestimate rates (high-risk CNB becoming malignant on surgery and ductal carcinoma in situ becoming invasive carcinoma) were 47.4% for 16G and 48.9% for 18G CNB. Agreements were better for mass lesions (16G: 92.7%; 18G: 93.7%) than for non-mass lesions (16G, 85.7%; 18G, 78.3%) (P <0.01). For mass lesions with a diameter ≤10 mm, the agreement rates (16G, 83.3%; 18G, 86.7%) were lower (P <0.01).

Conclusions

Ultrasound-guided 16G and 18G CNB are accurate for evaluating ultrasound-visible breast mass lesions with a diameter >10 mm.

An ultra-sensitive immunoassay for quantifying biomarkers in breast tumor tissue

Urokinase-type plasminogen activator (uPA) and plasminogen activator inhibitor type-1 (PAI-1) have been validated at the highest level of evidence as clinical biomarkers of prognosis in breast cancer. The American Society of Clinical Oncology recommends using uPA and PAI-1 levels in breast tumors for deciding whether patients with newly diagnosed node-negative breast cancer can forgo adjuvant chemotherapy. The sole validated method for quantifying uPA and PAI-1 levels in breast tumor tissue is a colorimetric ELISA assay that takes 3 days to complete and requires 100-300 mg of fresh or frozen tissue. In this study we describe a new assay method for quantifying PAI-1 levels in human breast tumor tissue. This assay combines pressure-cycling technology to extract PAI-1 from breast tumor tissue with a highly sensitive liposome polymerase chain reaction immunoassay for quantification of PAI-1 in the tissue extract. The new PAI-1 assay method reduced the total assay time to one day and improved assay sensitivity and dynamic range by >100, compared to ELISA.

Step-by-step of ultrasound-guided core-needle biopsy of the breast: review and technique

Ultrasound-guided core-needle biopsy has high sensitivity in the diagnosis of breast cancer. The present study is aimed at detailing the main steps of such procedure, including indications, advantages, limitations, follow-up and description of the technique, besides presenting a checklist including the critical steps required for an appropriate practice of the technique. In the recent years, an increasing number of patients have required breast biopsy, indicating the necessity of a proportional increase in the number of skilled professionals to carry out the procedures and histological diagnoses. A multidisciplinary approach involving the tripod clinical practice-radiology-pathology is responsible for the highest rate of accuracy of the technique and must always be adopted.

Examining the sensitivity of ultrasound-guided large core biopsy for invasive breast carcinoma in a population screening programme

INTRODUCTION

To evaluate the sensitivity of ultrasound-guided core-needle biopsy (UCB) in invasive breast carcinoma and to establish causes of false-negative biopsy in a population screening programme.

METHOD

We identified 571 consecutive women diagnosed with surgically proven invasive breast cancer. Histology from 14-gauge UCB was compared with surgical histology to identify true-positive and false-negative ultrasound core biopsies. True-positive and false-negative groups were compared for tumour size and histology. On blinded review of UCB images and pathology reports from false negative (n = 20) and a random sample of true-positive cases (n = 80), we compared core sample number and needle visualisation in the lesion.

RESULTS

Of 571 carcinomas sampled with UCB, 551 (96.5%) were true positive and 20 (3.5%) were false negative. The mean core number was 2.0 (range 1-3) for false negatives and 2.25 (range 1-4) for true positives (P = 0.27). Mean tumour sizes were 13.3 and 16.2 mm for the false-negative and true-positive groups, respectively (P = 0.25). Tubular carcinomas represented 30% (6/20) of false-negative cases compared with 5.1% (28/551) of the true-positive cases (P < 0.001). On blinded review, needle visualisation within the lesion was demonstrated in 47.4% (9/19) of false-negative cases and 76.3% (61/80) of true-positive cases (P = 0.02).

CONCLUSION

We demonstrated a sensitivity of 96.5% with a mean of 2.21 cores. False-negative results were more likely in the absence of post-fire needle position verification and with tubular carcinomas. Neither tumour size nor core number predicted diagnostic accuracy.

Mammotome® biopsy system for the resection of breast lesions: Clinical experience in two high-volume teaching hospitals

Ultrasound-guided vacuum-assisted breast biopsy (VABB) is regarded as a feasible, effective, minimally invasive and safe method for the removal of benign breast lesions, without the occurrence of serious complications. The aim of this study was to evaluate the feasibility, efficacy and safety of ultrasound-guided VABB using the Mammotome^® biopsy system in the treatment of breast lesions. The clinical outcomes of 3,681 patients with breast lesions were evaluated following excisions by ultrasound-guided VABB in two high-volume teaching hospitals. From January 2008 to December 2012, a total of 4,867 ultrasound-guided VABB procedures were performed in the 3,681 patients, who had a mean age of 37.8 years (range, 16-73 years). The parameters examined in this analysis included lesion size, lesion location in the inner breast, Breast Imaging Reporting and Data System (BI-RADS) ultrasound category and histopathological diagnosis. Ultrasonography follow-up was performed at 3-6 month intervals in order to assess recurrence. The size of the investigated lesions ranged between 6 and 62 mm and a histopathological diagnosis was made in 100% of cases. The results indicated that the majority of specimens (98.89%) were benign. On average, the ultrasound-guided VABB was performed in 10.3 min (range, 7.5-43 min) and the mean number of cores removed in the procedure was 8.1 (range, 3-32). A complete excision was achieved in the majority of cases (99.7%). The presence of a hematoma was the most common complication following the biopsy, and was observed in 27.5% of patients. The mean follow-up period was 25.5 months (range, 1-60 months), during which the rate of recurrence was 4.4%. The results indicated that ultrasound-guided VABB using the Mammotome biopsy system is an effective and safe procedure that is able to rapidly remove the majority of benign breast lesions using a small incision and without the occurrence of scarring or complications.

Vacuum-assisted core biopsy in diagnosis and treatment of intraductal papillomas

BACKGROUND

The aim of this study was to assess the value of mammographically-guided and ultrasonographically-guided vacuum-assisted core biopsy (VACB) in the diagnosis and treatment of intraductal papillomas of breast and to answer the question of whether biopsy with the Mammotome (Mammotome; Cincinnati, OH) allows the avoidance of surgery in these patients.

PATIENTS AND METHODS

In the period 2000 to 2010, a total of 1896 vacuum-assisted core biopsies were performed, of which 1183 were ultrasonographically guided and 713 were mammographically guided (stereotaxic).

RESULTS

In 62 patients (3.2%) histopathologic examination confirmed intraductal papilloma, and in 12 patients (19.4%) atypical lesions were also found. Open surgical biopsy specimens revealed invasive cancer in 2 women these 12 women (false-negative rate, 16.7%; negative predictive value, 83.3%). Biopsy specimens from the remaining 50 patients (80.6%) revealed papilloma without atypia, and further clinical observation and imaging examinations did not show recurrence or malignant transformation of lesions. Hematoma developed in 3 (4.8%) patients as a complication of biopsy; surgical intervention was not required in any of the patients.

CONCLUSION

VACB is a minimally invasive and efficient method for diagnosing intraductal papilloma of the breast. If histopathologic examination confirms a benign lesion and corresponds to the clinical presentation, surgery may be avoided. However in all cases, histopathologic diagnosis of papilloma with atypical hyperplasia or a suspected malignant lesion in imaging examinations, despite negative biopsy results, should always be an indication for surgical excision.

The negative predictive value of ultrasound-guided 14-gauge core needle biopsy of breast masses: a validation study of 339 cases

PURPOSE

To determine the negative predictive value of sonographically guided 14-gauge core needle biopsy of breast masses, with detailed analysis of any false-negative cases.

MATERIALS AND METHODS

We reviewed 669 cases of sonographically guided 14-gauge core needle biopsies that had benign pathologic findings. Given a benign pathology on core biopsy, true-negatives had either benign pathology on surgical excision or at least 2 years of stable imaging and/or clinical follow-up; false-negatives had malignant histology on surgical excision.

RESULTS

Follow-up was available for 339 breast lesions; 117 were confirmed to be benign via surgical excision, and 220 were stable after 2 years or more of imaging or clinical follow-up (mean follow-up time 33.1 months, range 24-64 months). The negative predictive value was determined to be 99.4%. There were 2 false-negative cases, giving a false-negative rate of 0.1%. There was no delay in diagnosis in either case because the radiologist noted discordance between imaging and core biopsy pathology, and recommended surgical excision despite the benign core biopsy pathology.

CONCLUSIONS

Sonographically guided 14-gauge core needle biopsy provides a high negative predictive value in assessing breast lesions. Radiologic/pathologic correlation should be performed to avoid delay in the diagnosis of carcinoma.

Is Ductal Carcinoma in Situ with “Possible Invasion” More Predictive of Invasive Carcinoma than Pure Ductal Carcinoma in Situ?

Objectives

To compare the underestimation of ductal carcinoma in situ (DCIS) vs DCIS with “possible invasion” at breast biopsy and to determine if any factors related to clinical indication, imaging abnormality, biopsy, or DCIS-grade affected the likelihood of underestimation.

Methods

Of 3836 consecutive lesions that were biopsied by using a 14-gauge needle, 117 lesions revealed DCIS. Surgical pathology results of invasive carcinoma were compared with needle biopsy results of DCIS or DCIS with possible invasion. Clinical indication, imaging abnormality, biopsy guidance modality, sample number, and histologic grade were recorded. Yates corrected χ2 and Fisher exact tests were used to determine differences between groups.

Results

A total of 101 lesions were DCIS and 16 were DCIS with possible invasion at biopsy. Thirty-six of 117 lesions (31%) revealed invasive carcinoma at resection pathology. Invasive carcinoma was present more often when DCIS with possible invasion was diagnosed compared with pure DCIS (7/16 [44%] vs 29/101 [29%], P = .36). No factor, including clinical indication, imaging abnormality, biopsy guidance method, sample number, or grade, was found to significantly affect the likelihood of underestimation for lesions diagnosed as DCIS vs DCIS with “possible invasion.” The likelihood of pure DCIS underestimation significantly increased when lesions were high grade compared with either intermediate or low grade (18/44 [41%] vs 9/44 [21%] vs 2/10 [20%], P = .03).

Conclusion

For lesions biopsied by using a 14-gauge needle, there is a trend towards underestimation of the presence of invasive carcinoma when pathology reveals DCIS with possible invasion compared with pure DCIS. High-grade DCIS was significantly more likely to be underestimated.

Comparison of the underestimation rate in cases with ductal carcinoma in situ at ultrasound-guided core biopsy: 14-gauge automated core-needle biopsy vs 8- or 11-gauge vacuum-assisted biopsy

OBJECTIVE

The objective of this study was to compare the underestimation rate of invasive carcinoma in cases with ductal carcinoma in situ (DCIS) at percutaneous ultrasound-guided core biopsies of breast lesions between 14-gauge automated core-needle biopsy (ACNB) and 8- or 11-gauge vacuum-assisted biopsy (VAB), and to determine the relationship between the lesion type (mass or microcalcification on radiological findings) and the DCIS underestimation rate.

METHODS

We retrospectively reviewed imaging-guided biopsies of breast lesions performed from February 2003 to August 2008. 194 lesions were diagnosed as DCIS at ultrasound-guided core biopsy: 138 lesions in 132 patients by 14-gauge ACNB, and 56 lesions in 56 patients by 8- or 11-gauge VAB. The histological results of the core biopsy samples were correlated with surgical specimens. The clinical and radiological findings were also reviewed. The histological DCIS underestimation rates were compared between the two groups and were analysed for differences according to the clinical and radiological characteristics of the lesions.

RESULTS

The DCIS underestimation rate was 47.8% (66/138) for 14-gauge ACNB and 16.1% (9/56) for VAB (p<0.001). According to the lesion type on sonography, DCIS underestimation was 43.4% (63/145) in masses (47.6% using ACNB and 15.8% using VAB; p=0.012) and 24.5% (12/49) in microcalcifications (50.0% using ACNB and 16.2% using VAB; p=0.047).

CONCLUSION

The underestimation rate of invasive carcinoma in cases with DCIS at ultrasound-guided core biopsies was significantly higher for ACNB than for VAB. Furthermore, this difference does not change according to the lesion type on ultrasound. Therefore, ultrasound-guided VAB can be a useful method for the diagnosis of DCIS lesions presented as either mass or microcalcification.

US follow-up protocol in concordant benign result after US-guided 14-gauge core needle breast biopsy

To determine the time when follow-up ultrasound (US) should begin for concordant benign lesions after US-guided 14-gauge core needle breast biopsy (CNB). This was an IRB-approved retrospective study, with a waiver of informed consent. Among 3,888 consecutive US-guided CNBs performed between August 2005 and March 2008, 1,492 breast masses in 1,309 women with concordant benign results and follow-up US after CNB were included. Their medical records were reviewed. Statistical comparisons for the result of first follow-up US and malignant rates among 6-month, 12-month, and long-term intervals were performed by using Fisher exact test. Results dichotomized for symptom, lesion size (10 mm), and CNB result (specific or not), were also analyzed. In 1,492 masses, seven malignancies (0.5%) were diagnosed by interval growth at first follow-up US performed at 6-month (n = 3), 12-month (n = 1), and long-term interval (n = 3). No significant difference in results of follow-up US and malignant rates was found among follow-up intervals. At 6-month interval, malignant rate in symptomatic group (1.9%, 3/162) was significantly higher than in asymptomatic group (0%, 0/819) (P = 0.004). The size of malignancy at long-term interval tended to be larger than at shorter interval, and metastasis was developed in one patient with malignancy at long-term interval. Concordant benign lesions after US-guided 14-gauge CNB should be recommended to begin US follow-up at least at 12 months to detect early-stage cancers. However, for concordant benign lesion associated with any clinical symptoms, follow-up US should begin earlier, at 6 months after CNB.

US-guided vacuum-assisted percutaneous excision for management of benign papilloma without atypia diagnosed at US-guided 14-gauge core needle biopsy

PURPOSE

To assess the diagnostic accuracy of ultrasound (US)-guided vacuum-assisted excision (VAE) for the postbiopsy management of benign papilloma without atypia after US-guided 14-gauge core needle biopsy (CNB).

METHODS

This was an institutional review board-approved retrospective study, with a waiver of informed consent. After a review of the histologic results and postbiopsy management of US-guided CNB performed from January 2007 through April 2009, 122 benign papillomas without atypia were diagnosed at CNB and excised percutaneously with US-guided VAE. Among them, a total of 67 papillomas having surgical excision (n = 5) or at least 2 years' US follow-up (n = 62) after VAE were enrolled onto this study. We reviewed the medical records, US findings, and pathologic results obtained before and after VAE. Over the follow-up period, whether any malignancy at the site of the VAE was diagnosed was evaluated.

RESULTS

The pathologic results of 67 VAEs were benign in 63 (94%) and atypical in four (6%). None of 63 benign lesions proved to be malignant after surgical excision (n = 1) or US follow-up (n = 62). Of four atypical lesions, however, one was upgraded to ductal carcinoma-in-situ (25%) after surgical excision. Of 62 benign VAE results having US follow-up, 56 (90.3%) showed no residual lesion at the site of the VAE.

CONCLUSIONS

For the postbiopsy management of benign papilloma without atypia after US-guided CNB, US-guided VAE was accurate and could be alternative to surgery. In cases of diagnosis of atypical lesion at VAE, however, surgery should be performed for a definitive diagnosis.

Ultrasound-guided diagnostic breast biopsy methodology: retrospective comparison of the 8-gauge vacuum-assisted biopsy approach versus the spring-loaded 14-gauge core biopsy approach

Background

Ultrasound-guided diagnostic breast biopsy technology represents the current standard of care for the evaluation of indeterminate and suspicious lesions seen on diagnostic breast ultrasound. Yet, there remains much debate as to which particular method of ultrasound-guided diagnostic breast biopsy provides the most accurate and optimal diagnostic information. The aim of the current study was to compare and contrast the 8-gauge vacuum-assisted biopsy approach and the spring-loaded 14-gauge core biopsy approach.

Methods

A retrospective analysis was done of all ultrasound-guided diagnostic breast biopsy procedures performed by either the 8-gauge vacuum-assisted biopsy approach or the spring-loaded 14-gauge core biopsy approach by a single surgeon from July 2001 through June 2009.

Results

Among 1443 ultrasound-guided diagnostic breast biopsy procedures performed, 724 (50.2%) were by the 8-gauge vacuum-assisted biopsy technique and 719 (49.8%) were by the spring-loaded 14-gauge core biopsy technique. The total number of false negative cases (i.e., benign findings instead of invasive breast carcinoma) was significantly greater (P = 0.008) in the spring-loaded 14-gauge core biopsy group (8/681, 1.2%) as compared to in the 8-gauge vacuum-assisted biopsy group (0/652, 0%), with an overall false negative rate of 2.1% (8/386) for the spring-loaded 14-gauge core biopsy group as compared to 0% (0/148) for the 8-gauge vacuum-assisted biopsy group. Significantly more (P < 0.001) patients in the spring-loaded 14-gauge core biopsy group (81/719, 11.3%) than in the 8-gauge vacuum-assisted biopsy group (18/724, 2.5%) were recommended for further diagnostic surgical removal of additional tissue from the same anatomical site of the affected breast in an immediate fashion for indeterminate/inconclusive findings seen on the original ultrasound-guided diagnostic breast biopsy procedure. Significantly more (P < 0.001) patients in the spring-loaded 14-gauge core biopsy group (54/719, 7.5%) than in the 8-gauge vacuum-assisted biopsy group (9/724, 1.2%) personally requested further diagnostic surgical removal of additional tissue from the same anatomical site of the affected breast in an immediate fashion for a benign finding seen on the original ultrasound-guided diagnostic breast biopsy procedure.

Conclusions

In appropriately selected cases, the 8-gauge vacuum-assisted biopsy approach appears to be advantageous to the spring-loaded 14-gauge core biopsy approach for providing the most accurate and optimal diagnostic information.

BI-RADS categorisation of 2,708 consecutive nonpalpable breast lesions in patients referred to a dedicated breast care unit

OBJECTIVES

To determine the malignancy rate of nonpalpable breast lesions, categorised according to the Breast Imaging Reporting and Data System (BI-RADS) classification in the setting of a Breast Care Unit.

METHODS

All nonpalpable breast lesions from consecutive patients referred to a dedicated Breast Care Unit were prospectively reviewed and classified into 5 BI-RADS assessment categories (0, 2, 3, 4, and 5).

RESULTS

A total of 2708 lesions were diagnosed by mammography (71.6%), ultrasound (8.7%), mammography and ultrasound (19.5%), or MRI (0.2%). The distribution of the lesions by BI-RADS category was: 152 in category 0 (5.6%), 56 in category 2 (2.1%), 742 in category 3 (27.4%), 1523 in category 4 (56.2%) and 235 in category 5 (8.7%). Histology revealed 570 malignant lesions (32.9%), 152 high-risk lesions (8.8%), and 1010 benign lesions (58.3%). Malignancy was detected in 17 (2.3%) category 3 lesions, 364 (23.9%) category 4 lesions and 185 (78.7%) category 5 lesions. Median follow-up was 36.9 months.

CONCLUSION

This pragmatic study reflects the assessment and management of breast impalpable abnormalities referred for care to a specialized Breast Unit. Multidisciplinary evaluation with BI-RADS classification accurately predicts malignancy, and reflects the quality of management. This assessment should be encouraged in community practice appraisal.

Breast lesions with imaging-histologic discordance during 16-gauge core needle biopsy system: would vacuum-assisted removal get significantly more definitive histologic diagnosis than vacuum-assisted biopsy?

The aim of this study was to determine the role of vacuum-assisted biopsy (VAB) in patients with ultrasound imaging-histologic discordance during 16-gauge core needle biopsy (CNB) and to compare VAB with vacuum-assisted removal (VAR) in diagnostic accuracy in patients with ultrasound imaging-histologic discordance. From January 2006 to October 2008, a consecutive biopsy was performed on 1532 lesions with ultrasound-guided 16-gauge CNB. Sixty two lesions were considered to be ultrasound imaging-histologic discordant. Among the 62 lesions, 55 lesions underwent subsequent VAB or VAR, which made up our study population. Among the 55 cases, 22 underwent subsequent US-guided VAR, and the other 33 lesions underwent subsequent US-guided VAB. All malignant lesions at VAB and VAR got subsequent surgery, and all benign lesions at VAR or VAB were followed up for at least 1 year. Five lesions of the VAR group were diagnosed as having carcinoma (5/22, 22.7% of pathologic changing rate). Seven lesions of the VAB group were diagnosed as having carcinoma (7/33, 21.2% of pathologic changing rate). Subsequent surgery further demonstrated the diagnosis of VAB for all the lesions with pathologic change. There was no significant difference in pathologic changing rate between these two groups (p < 0.05). A US-guided VAB was a valuable alternative to VAR or surgery excision to obtain definitive diagnosis in patients with breast lesions showing imaging-histologic discordance during 16-gauge CNB.

Minimally Invasive Biopsy Methods - Diagnostics or Therapy? Personal Opinion and Review of the Literature

SUMMARY: This article provides an overview of different minimally invasive biopsy (MIB) methods for preoperative assessment of suspicious and indeterminate breast lesions. Accuracy depends on the choice of method and on lesion characteristics. An additional aspect deals with the question whether or not MIB is a suitable therapeutic approach in selected lesions.

Image-guided methods for biopsy of suspicious breast lesions

The widespread use of breast imaging has resulted in the increased detection of clinically occult suspicious breast lesions. Between 1999 and 2004 the number of breast biopsies in the United States has increased steadily. The armamentarium of methods to biopsy suspicious breast lesions has also increased significantly since the early 1990s with technological advancements for both surgical breast biopsy and percutaneous image guided breast biopsies.

ACR Appropriateness Criteria® on nonpalpable mammographic findings (excluding calcifications)

Screening mammography can detect breast cancer before it becomes clinically apparent. However, the screening process identifies many false-positive findings for each cancer eventually confirmed. Additional tools are available to help differentiate spurious findings from real ones and to help determine when tissue sampling is required, when short-term follow-up will suffice, or whether the finding can be dismissed as benign. These tools include additional diagnostic mammographic views, breast ultrasound, breast MRI, and, when histologic evaluation is required, percutaneous biopsy. The imaging evaluation of a finding detected at screening mammography proceeds most efficiently, cost-effectively, and with minimization of radiation dose when approached in an evidence-based manner. The appropriateness of the above-referenced tools is presented here as they apply to a variety of findings often encountered on screening mammography; an algorithmic approach to workup of these potential scenarios is also included. The recommendations put forth represent a compilation of evidence-based data and expert opinion of the ACR Appropriateness Criteria(®) Expert Panel on Breast Imaging.

Ultrasound-guided core-needle biopsy of breast lesions

Objective

To review the role of ultrasound-guided core-needle biopsy (CNB) in the management of breast lesions.

Methods

Review of the most relevant literature on this topic.

Results

This technique shows a high sensitivity value of about 97.5% and it offers many advantages over other imaging techniques to guide a biopsy: non-ionising radiation, low cost, full control of the needle in real time, accessibility in difficult locations, multidirectional punctures and excellent comfort for patients and radiologists. All of these advantages have made this technique the most widespread used to perform a biopsy for a suspicious breast lesion. The most important limitation is the failure to perform a biopsy for lesions that are not seen on ultrasound. An adequate radiological–pathological correlation is necessary to minimise the false-negative results.

Conclusion

Ultrasound-guided CNB has proven to be a reliable technique for performing a biopsy for breast lesions that can be clearly seen on ultrasound.

Papillary lesions initially diagnosed at ultrasound-guided vacuum-assisted breast biopsy: rate of malignancy based on subsequent surgical excision

PURPOSE

To prospectively determine the rate of malignancy after surgery in papillary lesions initially diagnosed at ultrasound (US)-guided 11-gauge vacuum-assisted breast biopsies.

METHODS

Between May 2007 and December 2009, a total of 85 papillary lesions, including 73 benign papillomas and 12 atypical papillomas were diagnosed in 83 patients by US-guided 11-gauge vacuum-assisted breast biopsy. Surgical excision was recommended for all patients and 60 nonmalignant papillary lesions (49 benign papillomas and 11 atypical papillomas) in 60 patients (age range, 24-66 years; mean age, 45.0 years) were surgically excised. On a per-lesion basis, the upgrade rate to malignancy was calculated. Associations between clinical, lesion, and biopsy variables and the results of surgical excision were examined with a χ(2) test.

RESULTS

Surgical excision revealed the presence of benign papillomas in 34 cases, no residual lesion in 15 cases, atypical papillomas in nine cases, and ductal carcinoma-in-situ in two cases. The upgrade rate was 0% (0 of 49; 95% confidence interval 0-7.2) for benign papillomas and 18.2% (2 of 11; 95% confidence interval 2.3-51.8) for atypical papillomas. The core findings of atypical papillomas (P = 0.031) and age (P = 0.046) were associated with malignancy at excision, whereas personal or family history, presence of symptoms, multiplicity, lesion type, size, distance from the nipple, Breast Imaging Reporting and Data System (BI-RADS) category, and lesion removal at US showed no correlation to upgrade.

CONCLUSIONS

Surgical excision may not be required for lesions with a diagnosis of benign papilloma after US-guided 11-gauge vacuum-assisted breast biopsy, and a diagnosis of atypical papilloma should prompt excision for a definitive diagnosis.

The wide spectrum of hyperechoic lesions of the breast

Although breast lesions are commonly detected because of their hypoechogenicity, some lesions may present with hyperechogenicity due to their histological components. Hyperechogenicity has been shown to be highly predictive of benignity; however, hyperechoic lesions can occasionally be malignant. This article reviews hyperechoic lesions of the breast, describes the underlying histological causes associated with hyperechogenicity, and the sonographic features useful for the differential diagnosis between benign and malignant hyperechoic lesions.

Utility of 6-month follow-up imaging after a concordant benign breast biopsy result

PURPOSE

To determine the utility of 6-month follow-up imaging after benign concordant image-guided percutaneous breast biopsy results.

MATERIALS AND METHODS

The institutional review board approved this retrospective, HIPAA-compliant study; informed consent was waived. Findings from consecutive stereotactic and ultrasonographically guided core breast biopsies performed from 2001 to 2005 were analyzed and included lesions with benign pathologic findings without atypia found to be concordant with imaging at a consensus conference. Rebiopsy recommendation rates and positive predictive values (PPVs) for detecting malignancy at each follow-up interval were measured and compared by using a two-tailed Fisher exact test.

RESULTS

In 2244 biopsies, lesions in 1465 were benign, concordant, and not excised. In 1057 of 1465 (72.2%) biopsies with imaging follow-up (average, 26.4 months; range, 4.0-49.9 months), recommended rebiopsy rates were 0.8% (four of 526), 0.5% (three of 588), and 1.0% (eight of 802) at 6-month, 12-month, and long-term follow-up intervals, respectively. When the initial follow-up did not occur until 12 months, the recommended rebiopsy rate was 0.9% (three of 322), compared with 0.8% (four of 526) at 6 months (P > .99), and no malignancies were found in either group. One malignancy was detected at the long-term follow-up interval (PPV for excision recommended, 12% [one of eight]; PPV for excision performed, 20% [one of five]).

CONCLUSION

Because rebiopsy recommendation rates and PPVs did not differ in the 6- and 12-month groups, a 6-month follow-up imaging examination, in the context of a formal concordancy consensus conference, may not contribute to improved breast cancer diagnosis.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10091824/-/DC1.

Breast lesions with ultrasound imaging-histologic discordance at 16-gauge core needle biopsy: can re-biopsy with 10-gauge vacuum-assisted system get definitive diagnosis?

The aim of this study was to evaluate if re-biopsy with 10-gauge vacuum-assisted biopsy (VAB) could get definitive diagnosis for breast lesions with ultrasound (US) imaging-histologic discordance at 16-gauge core needle biopsy (CNB). From January 2007 to June 2008, a consecutive biopsy was performed on 1069 lesions with US-guided 16-gauge CNB. A total of 28 lesions were considered to be US imaging-histologic discordant and all of them underwent subsequent 10-gauge VAB. All malignant lesions located at VAB were treated with subsequent surgery and all benign lesions at VAB were followed up for at least 1 year. Six of the 28 lesions (21.4%) had pathologic upgrade after VAB. In them, one case upgraded from adenosis to ductal carcinoma in situ (DCIS); one case upgraded from adenosis to infiltrating ductal carcinoma (IDC); one case upgraded from atypical ductal hyperplasia to IDC; two cases upgraded from intraductal papilloma to DCIS; and one case upgraded from sclerosing adenosis to invasive lobular carcinoma (ILC). The subsequent surgery further demonstrated the diagnosis of VAB for all the lesions with histologic upgrade. Re-biopsy could improve diagnostic accuracy in patients with breast lesions showing imaging-histologic discordance during CNB, and 10-gauge VAB was a valuable method to deal with re-biopsy.

Image-guided breast biopsy: state-of-the-art

Percutaneous image-guided breast biopsy is widely practised to evaluate predominantly non-palpable breast lesions. There has been steady development in percutaneous biopsy techniques. Fine-needle aspiration cytology was the original method of sampling, followed in the early 1990s by large core needle biopsy. The accuracy of both has been improved by ultrasound and stereotactic guidance. Larger bore vacuum-assisted biopsy devices became available in the late 1990s and are now commonplace in most breast units. We review the different types of breast biopsy devices currently available together with various localization techniques used, focusing on their advantages, limitations and current controversial clinical management issues.

Screen-detected malignant breast lesions diagnosed following benign (B2) or normal (B1) needle core biopsy diagnoses

Breast needle core biopsy (NCB) is now a standard diagnostic procedure in the triple assessment of screen detected breast lesions. However, unlike fine needle aspiration (FNA) cytology, information on the miss rate including false-negative diagnoses (FN) of malignancy (benign 'B2' or normal 'B1' NCB with a malignant outcome) is limited.

METHODS

A large series of NCBs (121,742) performed over an 8-year period has been studied to assess the frequency and causes of missing a malignant diagnosis on NCB and to evaluate their impact on patients' management in the screening service.

RESULTS

During the period of this study, 50,691 were diagnosed as B2 and 9599 were diagnosed as B1. Of those, 779 B2 and 919 B1 were diagnosed as malignant on the subsequent surgical specimens, respectively, giving a FN rate of 3.0%. However when year of diagnosis was taken into consideration, we found that during the period 1999-2001, the FN rate for B2 was 2.7% while the miss rate for B1 was 4.0%. This showed marked improvement over time to reach a figure of 0.5% and 0.5% for B2 and B1, respectively, during the period 2005-2007. On detailed review of cases from a single screening region diagnosed during the last 3 years (2005-2008), 14 cases (0.17% of all NCBs) with malignant surgery were diagnosed as B2 (seven cases; FN rate 0.19%) and B1 (seven cases; B1 biopsy rate from cancer 0.19%). In these cases, NCB was unsatisfactory, there was a discrepancy between radiological abnormalities and histological findings with recommendation for excision or suspicious/malignant cytological diagnosis on concurrent FNA material. Therefore, our results indicate that the malignancy miss rate on NCB is rare and FN NCB diagnoses had no impact on patient management.

A combined high temporal and high spatial resolution 3 Tesla MR imaging protocol for the assessment of breast lesions: initial results

PURPOSE

To develop a 3.0 Tesla breast imaging protocol that combines high temporal and spatial resolution three-dimensional MR sequences for quantitative time course and morphologic analysis of breast lesions.

MATERIALS AND METHODS

Thirty-four patients were included in the study (age range, 31-82; mean age, 54.3). The study protocol was approved by the Institutional Review Board and written informed consent was obtained from all patients. The magnetic resonance imaging protocol included: a coronal T1-weighted volume-interpolated-breathhold-examination sequence, focused on high temporal resolution for optimal assessment of the contrast-enhancement behavior of lesions (SI 1.7 mm isotropic; TA 3.45 minutes for 17 measurements); a coronal T1-weighted turbo fast-low-angle-shot-three-dimensional sequence, with water-excitation and fat suppression, focused on high spatial resolution for morphologic analysis (SI 1 mm isotropic; TA 2 minutes); and a repeated coronal volume-interpolated-breathhold-examination sequence for detection of washout. Lesion size and morphology were assessed. Region-of-interests for suspicious areas were manually drawn and evaluated for contrast-enhancement behavior by plotting intensity courses against time. Sensitivity and specificity with a 95% confidence interval and the negative predictive value and positive predictive value were calculated. Diagnostic accuracy was assessed. The histopathological diagnoses were used as a standard of reference.

RESULTS

Fifty-five lesions were detected in 34 patients. All malignant breast lesions were identified correctly. There were 5 false-positive lesions. The sensitivity of contrast-enhanced magnetic resonance imaging of the breast at 3 T was 100%, with a 95% confidence interval (CI) of 90.6% to 100%. The specificity was 72.2%, with a 95% CI of 49.1% to 87.5%. The positive predictive value was 0.88 and the negative predictive value was 1. Diagnostic accuracy was 91% with a 95% CI of 80.4% to 96.1%.

CONCLUSION

Our prospective study demonstrates that the presented 3 Tesla MR imaging protocol, comprising both high temporal and high spatial resolution, enables accurate detection and assessment of breast lesions.

Analysis of false-negative results after US-guided 14-gauge core needle breast biopsy

OBJECTIVES

To determine the false-negative rate and to evaluate the clinical, radiologic or histologic features of false-negative results at ultrasound (US)-guided 14-gauge core needle biopsy (CNB).

METHODS

A total of 3,724 masses from 3,308 women who had undergone US-guided 14-gauge CNB and who had a rebiopsy or at least 2 years' follow-up were included. The histology of CNB was correlated with the rebiopsy or long-term imaging follow-up. In cases of missed cancer, the time interval between CNB and rebiopsy, the reasons for rebiopsy, and the procedural or lesion characteristics were analysed.

RESULTS

Of 1,706 benign CNBs, 50 additional malignancies were found at excision (false-negative rate, 2.5% of 1,982 with a final diagnosis of malignancy). Of 50 false negatives, 41 were found immediately of which 28 had rebiopsy because of imaging-histological discordance. Regarding the frequency of malignancy according to the reasons for rebiopsy, suspicious imaging finding (24%) showed significantly higher frequency than suspicious clinical findings or request (1%). Regarding the characteristics except invasiveness, no significant differences in false-negative rates were found.

CONCLUSIONS

Most false negatives were found immediately and imaging-histological discordance was the most important clue. Careful correlation of clinical, radiological and histological results as well as appropriate follow-up is essential.

An evaluation of a 10-gauge vacuum-assisted system for ultrasound-guided excision of clinically benign breast lesions

The aim of this study was to evaluate a 10-gauge vacuum-assisted system for the excision of clinically benign breast lesions. The minimal excision of 245 lesions in 162 patients was performed with VACORA vacuum-assisted system under the guidance of ultrasound between July 2007 and April 2008. The lesions were category 3 lesions as determined by ultrasound imaging according to Breast Imaging Reporting and Data System (BI-RADS) (n=208) or had been confirmed as benign by a previous core-needle biopsy (n=37). As many as 244 lesions were demonstrated to be benign and one case was demonstrated to be malignant by pathology after resection. In the 244 benign lesions, 220 lesions were excised completely as demonstrated by the follow-up ultrasound examination. The malignant lesion was managed with surgical excision. The 10-gauge vacuum-assisted system is highly successful for the excision of benign breast lesions; it is an alternative tool for minimal treatment of benign breast lesions.