Stereotactic core-needle breast biopsy: a multi-institutional prospective trial

Assessment of 142 Stellate Lesions With Imaging Features Suggestive of Radial Scar Discovered During Population-based Screening for Breast Cancer

Because some lesions diagnosed as radial scars (RS) on core biopsy have been found to be malignant on excision, core biopsy has not had an established role in the assessment of RS. In our breast cancer-screening program, we have avoided core biopsy if RS is suspected on imaging. Recently, two reports have expanded the experience with core biopsy of RS, prompting this review of our assessment protocols for lesions suspected as being RS. Between January 1996 and January 2003, stellate lesions with imaging features of RS in which core biopsy was omitted because of a presumptive radiologic diagnosis of RS are included. Demographic, radiologic, and cytologic data were correlated with the histologic findings in the excised specimen. On imaging, 9% (142) of all stellate lesions were suspected to be RS. Only 66.2% (94) were confirmed as RS on histology; 38 cases (28.6%) were carcinomas (36 invasive, 2 in situ) and 7% showed benign fibrocystic changes; 87.1% of the carcinomas required further surgery for positive margins. Axillary staging was also needed for the invasive cancers. Among the histologically proven RS, 28 of 94 (29.8%) showed areas of atypical ductal hyperplasia, lobular neoplasia, ductal carcinoma in situ, or invasive carcinoma. These proliferations were typically focal and unpredictable and were usually completely excised by the initial diagnostic biopsy. Core biopsy would be valuable in the assessment of lesions with imaging features suggestive of RS since 28.6% of such lesions are indeed carcinomas that mimic RS. Identification of these cancers would permit one stage breast and axillary surgery to be planned. The policy of mammographic surveillance for lesions with nonmalignant core biopsies remains controversial because of the paucity of data. Ongoing evaluation is needed as more experience is reported.

Stereotactic and sonographic large-core biopsy of nonpalpable breast lesions

RATIONALE AND OBJECTIVES

To determine the diagnostic accuracy of stereotactically and sonographically guided core biopsy (CB) for the diagnosis of nonpalpable breast lesions.

MATERIALS AND METHODS

Twenty-two institutions enrolled 2,403 women who underwent imaging-guided fine needle aspiration followed by imaging-guided large-CB of nonpalpable breast abnormalities. All mammograms were reviewed for study eligibility by one of two breast imaging radiologists. The protocol for image-guided biopsy, using either ultrasound (USCB) or stereotactic (SCB) guidance, was standardized at all institutions and all biopsy specimens were over-read by one of three expert pathologists. Patients with atypical ductal hyperplasia (ADH), atypical lobular hyperplasia, or lobular neoplasia on CB underwent surgical excision. Those with negative CB but suspicious ("discordant") pre-biopsy mammography also underwent surgical excision. Patients having a negative CB that was concordant with the pre-biopsy mammography suspicion were assigned to follow-up mammography at 6, 12, and 24 months following CB.

RESULTS

A gold standard diagnosis based on definitive histopathologic diagnosis, mammography follow-up, or an imputed gold standard diagnosis was established for 1,681 patients. Of 310 cases with a gold standard diagnosis of invasive breast carcinoma, 261 (84.2%) were invasive carcinoma, 31 (10%) were ductal carcinoma in situ (DCIS), four (1.3%) were ADH, one (0.3%) was a non-breast cancer, and 13 (4.2%) were benign on CB. For 138 cases with a gold standard diagnosis of DCIS, 113 (81.9%) were DCIS, 20 (14.5%) were ADH, and five (3.6%) were benign on CB. For 57 cases (13 masses, 44 calcifications) with an initial CB diagnosis of ADH, atypical lobular hyperplasia or lobular neoplasia, 20 (35.1%) had a gold standard diagnosis of DCIS (4 masses, 16 calcifications) and four (7.0%) had a gold standard diagnosis of invasive cancer (4 calcifications). Of 144 cases (22 masses, 122 calcifications) with an initial CB diagnosis of DCIS, 31 (21.5%) had a gold standard diagnosis of invasive cancer (10 masses, 21 calcifications). The sensitivity, specificity and accuracy for CB by either imaging guidance method in this trial were .91, 1.00, and .98, respectively. The sensitivity, predictive value negative, and accuracy of CB for diagnosing masses (.96, .99, and .99, respectively) were significantly greater (P < .001) than for calcifications (.84, .94, and .96, respectively). The sensitivity (.89) of SCB for diagnosing all lesions was significantly lower (P = 0.029) than that of USCB (.97) because of the preponderance of calcifications biopsied by SCB versus USCB. There was no difference between USCB and SCB in sensitivity, predictive value negative, or accuracy for the diagnosis of masses (97.3, 98.9, and 99.2, respectively for USCB; 95.6, 98.5, and 98.9 respectively for SCB).

CONCLUSION

Percutaneous, imaged-guided core breast biopsy is an accurate diagnostic alternative to surgical biopsy in women with mammographically detected suspicious breast lesions.

Diagnostic agreement in the evaluation of image-guided breast core needle biopsies: results from a randomized clinical trial

BACKGROUND

Image-guided core needle biopsies (CNBs) are commonly used as the initial sampling method for nonpalpable, mammographically detected breast lesions. Although prior studies have shown that this procedure is a highly sensitive and accurate method for the detection of breast cancer, the level of diagnostic agreement between pathologists in the analysis of CNB has not been previously studied in detail.

METHODS

To address this, we reviewed the pathologic findings in 2004 CNB from patients enrolled in the Radiologic Diagnostic Oncology Group 5 study, a randomized, multicenter trial designed to determine the role of CNB and fine needle aspiration biopsy in the evaluation of nonpalpable breast lesions. Slides of CNB specimens were initially diagnosed by pathologists at the 22 participating institutions (local diagnosis) and were then sent to the study pathologists for central review (central diagnosis). Local and central diagnoses were compared.

RESULTS

Overall, the central diagnosis and local diagnosis were concordant in 1925 cases (96%), indicating an excellent level of agreement by kappa statistic analysis (kappa = 0.90; 95% confidence interval 0.88-0.92). The level of agreement between local and central pathologists did not vary with the image guidance system (stereotactic mammography vs. ultrasound) or with the mammographic findings (soft tissue density vs. microcalcifications). The level of diagnostic agreement observed for CNB was comparable to that observed among 596 open surgical biopsies obtained from patients in this study and subjected to central pathology review (93% agreement; kappa = 0.89, 95% confidence interval 0.86-0.92).

CONCLUSIONS

The level of diagnostic agreement in interpretation of breast CNB is extremely high among pathologists and is comparable to that seen for open surgical biopsy.

The use of fine-needle aspiration cytology and core biopsy in the assessment of highly suspicious mammographic microcalcifications: analysis of outcome for 182 lesions detected in the setting of a population-based breast cancer screening program

BACKGROUND

Fine-needle aspiration biopsy (FNAB) is used as the first-line diagnostic test for lesions that require morphologic assessment in the authors' breast cancer screening program. A positive cytologic diagnosis is an indication to proceed to definitive surgery. Core biopsy is used if FNAB is not diagnostic. In the context of increased use of core biopsy at other centers, the authors reviewed their experience with the cytologic assessment of highly suspicious microcalcifications.

METHODS

Between January 1996 and June 2000, the dominant radiologic abnormality was classified prospectively as high-grade microcalcifications in 182 lesions. Data were recorded on patient demographics, radiologic features, and the findings of FNAB and core biopsy, if performed. The results of the screening assessment were then compared with the final histologic findings.

RESULTS

Overall, 15.6% of all radiologically high-grade lesions were microcalcifications. The mean patient age was 58.76 years. The lesions had a mean size of 38.49 mm (range, 5-200 mm), and 92.31% of high-grade microcalcifications proved to be malignant. Among the cases evaluated by FNAB, a positive cytologic diagnosis of malignancy was made in 70.93% of lesions, without any false-positive diagnoses and obviating the need for diagnostic core biopsy. FNAB had a sensitivity of 77.22% and a positive predictive value (PPV) of 100%. When core biopsy was performed due to the absence of a positive cytologic diagnosis, it averted the need for open biopsy in 76% of lesions.

CONCLUSIONS

Where there is access to skilled cytopathologists, FNAB can provide a highly accurate, rapid, and cost-effective means of triage of patients who would benefit most from the more expensive core biopsy.

Stereotactic core needle biopsy of nonpalpable breast lesions using a conventional mammography unit with an add-on device

OBJECTIVE

The purpose of this prospective study was to assess the accuracy of an add-on stereotactic unit for core needle biopsy of mammographic lesions. SUBJECTS AND METHODS. Between September 1994 and February 2001, 506 stereotactic core needle biopsies of mammographic lesions in 492 patients were performed in our center on a mammography unit with add-on stereotactic equipment. Of the initial 92 patients, 80 underwent stereotactic core needle biopsy and surgical excision simultaneously. In subsequent cases, surgical biopsy was performed after core biopsy in patients who had malignant or atypical histologic results or discordance between mammographic and pathologic findings. Follow-up mammography was advised for all patients whose core biopsy results were diagnosed as benign lesions.

RESULTS

Histologic results for 506 lesions undergoing stereotactic core needle biopsy were as follows: 113 (22.3%) were malignant; 369 (72.9%), benign; and 24 (4.7%), atypical. Of 113 malignant lesions identified at stereotactic core needle biopsy, 111 were confirmed as malignant, whereas two showed no evidence of malignancy at surgical excision. Of 369 lesions diagnosed as benign at stereotactic core needle biopsy, 172 (46.6%) showed no change on follow-up mammography, 114 (30.9%) were lost to follow-up, and 83 (22%) underwent surgical excision. Of 24 lesions with atypical histology, 23 had surgical follow-up, six were malignant, nine were benign, and eight were confirmed as showing atypical histology. Stereotactic core needle biopsy of the 506 lesions was complicated by five (1.0%) cases of vasovagal attack and four (0.8%) cases of bleeding. The resulting sensitivity, specificity, and positive and negative predictive values were 98.3%, 93.0%, 86.0%, and 99.2% respectively.

CONCLUSION

Biopsy with an add-on unit is safe, reliable, accurate, and cost-effective with results comparable to those reported for dedicated prone biopsy devices.

Vacuum-assisted breast biopsy: a critical review

Vacuum-assisted biopsy is an image-guided technique introduced in 1995 that is thought to be superior to 14G automated-needle biopsy for the evaluation of non-palpable breast lesions. However, prospective randomised studies evaluating its accuracy are unavailable. We conducted a critical review of the currently available literature on the accuracy of vacuum-assisted biopsy and compared it with published data on the accuracy of 14G automated-needle biopsy. The diagnostic performance of vacuum-assisted biopsy was evaluated by reviewing all available English-language literature published in Medline between 1995 and November 2001. Four independent reviewers used standard forms to extract the data. Twenty-two published studies were included. High-risk and DCIS underestimate rates, as well as the miss-rate of cancer, were assessed. High-risk and DCIS underestimate rates for 11G vacuum biopsy were 16% (95% Confidence Interval (CI) 12-20%) and 11% (95% CI 9-12%), respectively, and both were lower than the rates reported for 14G automated-needle biopsy (40% (95% CI 26%;56%) and 15% (95% CI 8%;26%), respectively). Due to incomplete follow-up of the benign lesions, it was impossible to calculate the miss-rates and the sensitivity rate. The results of this review indicate that vacuum-assisted biopsy can decrease the high-risk and DCIS underestimate rates, but it is unclear whether it can also decrease the miss-rates of cancer.

Benign breast lesions: minimally invasive vacuum-assisted biopsy with 11-gauge needles patient acceptance and effect on follow-up imaging findings

PURPOSE

To evaluate patient acceptance of stereotactic or ultrasonographically (US) guided directional vacuum-assisted 11-gauge needle biopsy of breast lesions and short- and long-term changes at mammography and US resulting from the procedure.

MATERIALS AND METHODS

For 91 benign lesions that had been sampled at either stereotactic or US-guided directional vacuum-assisted breast biopsy performed with 11-gauge needles, clinical, mammographic, and US changes were evaluated 1 week after biopsy; 6-month follow-up findings were available for 74 lesions. The subjective outcome of the procedure and patient satisfaction were assessed on the basis of a patient-completed questionnaire that incorporated a multistage scoring system. Statistical analysis of scores for condition for both biopsy methods was performed with the chi2 test.

RESULTS

Adverse events occurred during the procedure in four patients. Clinically visible hematomas were observed at 1-week follow-up in 79% of patients. Densities were observed on mammograms in 46% of patients 1 week after biopsy; hematomas with a maximum diameter of 2 cm were seen on sonograms in 74%. Six months after biopsy, mammography revealed discrete architectural changes in one case. No abnormalities were found at 6-month follow-up US. Fifteen patients had various complaints during the procedure; six reported feeling constrained during the first few days after biopsy, and one patient was not satisfied with the cosmetic result. No patient reported a retrospective preference for surgical biopsy instead of directional vacuum-assisted biopsy. Analysis of scores for the stereotactic and US-guided methods revealed a significant difference (P <.001) in favor of the stereotactic method for condition during biopsy, while scores for condition in the first days after biopsy were more equally distributed between the two methods (P =.386).

CONCLUSION

Directional vacuum-assisted 11-gauge needle biopsy of the breast is well accepted by patients and rarely produces changes that may alter the mammographic or sonographic appearance of the breast at 6-month follow-up.

Fourteen-gauge needle core biopsy of mammographically evident radial scars: is excision necessary?

BACKGROUND

Radial scars are benign lesions that may mimic breast carcinoma on mammography and usually are managed by excision biopsy. The authors report their experience with stereotactic needle core biopsy (SNCB) in sampling these lesions.

METHODS

A prospective study examined a consecutive series of 75 mammographically detected radial scars from a population-based screening program. In patients who were sampled by SNCB followed by surgical biopsy, the histologic findings of core biopsy and the gold standard of excision biopsy were compared.

RESULTS

Sixty-three patients were sampled by core biopsy: SNCB was used in 55 patients (87.0%), and ultrasound-guided needle core biopsy (UNCB) was used in 8 patients (13%). One patient who underwent SNCB did not undergo a follow-up excision biopsy. Radial scars were diagnosed preoperatively by core biopsy in 51 of 62 patients who underwent excision (82%; 95% confidence interval [95%CI], 70-91%). The sensitivity for SNCB was 85% (95%CI, 73-94%), and the sensitivity for UNCB was 63% (95%CI, 24-91%). Of 54 patients who underwent SNCB and excision, 4 patients had coexistent ductal carcinoma in situ (DCIS) at the time they underwent surgical excision: SNCB identified DCIS in 1 patient and identified atypical ductal hyperplasia (ADH) in 3 patients. In the entire group of 75 radial scars, 5 scars were associated with DCIS (7%), and there were no invasive carcinomas. ADH was present in association with 42 of 74 radial scars that were excised surgically (57%). Twenty-nine of those radial scars were sampled preoperatively by SNCB. ADH was found in 21 patients (72%; 95CI, 53-87%).

CONCLUSIONS

The sensitivity of SNCB in the identification of radial scars was 85%. In four patients with associated DCIS, SNCB revealed either ADH or DCIS, both of which required excision. These findings suggest that patients with SNCB-proven radial scars among a screened population can be managed safely by mammographic follow-up, provided there is no associated DCIS, ADH, or lobular carcinoma in situ. Spiculated abnormalities with discordant SNCB results require surgical biopsy.

Retrieval of lost microcalcifications during stereotactic vacuum-assisted core biopsy

OBJECTIVE

The purpose of our report was to describe patients in whom calcifications in the breast that were unequivocally removed during stereotactic core biopsy using the Mammotome device were not detected on the initial specimen radiograph. The lost calcifications in each instance were subsequently found when the tubing and contents of the debris canister were strained through a nonadhering dressing and radiographed. Additional situations in which calcifications are not seen on the initial specimen radiograph are described and recommendations are made.

CONCLUSION

When vacuum-assisted core biopsy procedures are performed, it is important to be aware of the possibility that calcifications may be aspirated into the debris canister, thus compromising the accuracy of the histopathologic diagnosis. We recommend changing the tubing and the debris canister after each procedure and, in certain situations, sending the strained canister contents to pathology for evaluation.

Percutaneous core needle biopsy of radial scars of the breast: when is excision necessary?

OBJECTIVE

. This study was conducted to evaluate the outcome of cases of radial scar diagnosed by percutaneous core needle biopsy.

MATERIALS AND METHODS

Of 198 nonpalpable lesions diagnosed with radial scars found at core needle biopsy, 157 lesions constituting the study group had undergone surgical excision (n = 102) or mammographic surveillance after biopsy for at least 24 months (median, 38 months; n = 55). Mammographic lesion type, lesion size, biopsy guidance method, biopsy device, number of specimens per lesion, and presence of atypical hyperplasia at percutaneous biopsy were retrospectively analyzed. Results were compared with histologic findings at surgery or mammographic findings during surveillance.

RESULTS

. Carcinoma was found at excision in 28% (8/29) of lesions with associated atypical hyperplasia at percutaneous biopsy and 4% (5/128) of lesions without associated atypia (p < 0.0001). In the latter group, carcinoma was found at excision in 3% (2/60) of masses, 8% (3/40) of architectural distortions, and 0% (0/28) of microcalcification lesions. Malignancy was missed in 9% (5/58) of lesions biopsied with a spring-loaded device and in 0% (0/70) of lesions biopsied with a directional vacuum-assisted device (p = 0.01); and in 8% (5/60) of lesions sampled with less than 12 specimens per lesion and 0% (0/68) sampled with 12 or more specimens (p = 0.015). Lesion type, maximal lesion diameter, and type of imaging guidance (stereotactic or sonographic) were not significant factors in determining the presence of malignancy.

CONCLUSION

. Diagnosis of radial scar based on core needle biopsy is likely to be reliable when there is no associated atypical hyperplasia at percutaneous biopsy, when the biopsy includes at least 12 specimens, and when mammographic findings are reconciled with histologic findings. When the lesion diagnosed by core needle biopsy as radial scar does not meet these criteria, excisional biopsy is indicated.

Diagnostic accuracy of stereotactic large-core needle biopsy for nonpalpable breast disease: results of a multicenter prospective study with 95% surgical confirmation

Stereotactic large-core needle biopsy is increasingly applied for the diagnosis of nonpalpable breast disease. Our study examines whether this minimally invasive technique is sufficiently accurate to replace surgical breast biopsy. In a prospective multicenter study, 973 consecutive women with 1,029 nonpalpable breast lesions were offered stereotactic 14-gauge needle biopsy. If the needle biopsy yielded breast cancer, the patient was offered therapeutic surgery. Surgical biopsy was proposed in cases of needle biopsies without malignancy. An expert panel reviewed all discrepancies in histologic diagnosis between the needle biopsy and open biopsy. Forty-five patients withdrew from participation and 113 (11%) planned needle biopsy procedures were cancelled. Of the 871 successful biopsy procedures, 95% were confirmed surgically. In 13 cases (1.5%), insufficient material was obtained for histologic assessment. Fifty-five percent of the needle biopsies were diagnosed as malignant (290 invasive cancers, 190 ductal carcinoma in situ). Thirteen of the 322 lesions (4%, 95% CI 2-7%) with a benign needle biopsy diagnosis contained malignancy after surgery. Six of the 26 (23%, 95% CI 9-44%) lesions with a high-risk diagnosis (atypical ductal or lobular hyperplasia or lobular carcinoma in situ) were diagnosed as malignant after surgery. Five of the 30 lesions containing normal breast tissue held malignancy (17%, 95% CI 6-35%). Guidelines for the management of different categories of needle biopsy diagnoses were made. Application of these guidelines to the present findings resulted in sensitivity and specificity rates of 97% (95% CI 95-98%) and 99% (95% CI 97-100%), respectively. Stereotactic large-core needle biopsy is an accurate diagnostic instrument for nonpalpable breast disease. It may safely replace needle localised open-breast biopsy provided that high-risk and normal breast tissue diagnoses are followed by needle or open-breast biopsy.

Stereotactic large core needle biopsy for all nonpalpable breast lesions?

BACKGROUND

Stereotactic large-core needle biopsy (SLCNB) is a minimally invasive method for histological diagnosis of nonpalpable breast disease. We studied differences in cancer prevalence between a group of women referred through the national screening program and a non-screening group, and assessed whether the validity of SLCNB differed between these groups.

METHODS

A group of non-selective, consecutive patients presenting with a nonpalpable mammographic lesion, who participated in a recently conducted multicenter study regarding the accuracy of SLCNB in The Netherlands, were the basis for this study. Prevalence of carcinoma, predictive value of a benign diagnosis, sensitivity, and specificity rate of SLCNB were compared between the two groups.

RESULTS

Of the 1029 lesions in 972 patients included, 858 were evaluable. In 850/858 lesions (99.1%) the reason for referral was clear. The prevalence of cancer in the screening group (n = 511 lesions) was 64.0% (95%CI 59.8-68.2), versus 49.6% in the non-screening group (n = 339) (95%CI 44.2-54.9). Respective predictive values of a benign diagnosis on SLCNB were 97.0 versus 94.8% (non-significant). The sensitivity rates of SLCNB were 98.5% (screening; 95%CI 96.5-99.5) versus 95.2% (non-screening; 95%CI 90.8-97.9). Specificity rates were 97.8 (95%CI 94.5-99.4) and 99.4% (95%CI 96.8-100), respectively.

CONCLUSION

Despite a significant difference in the prevalence of carcinoma, the accuracy of SLCNB did not show a statistically significant difference between both patient groups. Therefore, SLCNB appears accurate in diagnosing nonpalpable breast lesions both in screening and non-screening patient groups.

Diagnosing non-palpable breast disease: short-term impact on quality of life of large-core needle biopsy versus open breast biopsy

BACKGROUND

One of the alleged advantages of stereotactic large-core needle biopsy of non-palpable breast lesions is that it entails less inconvenience for the patient. In this prospective study, the quality of life of patients undergoing large-core needle biopsy was compared with that of patients undergoing open breast biopsy prior to learning the definitive diagnosis.

METHODS

Thirty patients with non-palpable breast lesions underwent stereotactic large-core needle biopsy as initial diagnostic procedure (needle biopsy group). Quality of life as perceived by these patients was compared with that of 27 patients who underwent open breast biopsy as initial diagnostic procedure (control group). Both groups completed quality of life questionnaires (EuroQol and SF-36) 1 day before and 4 days after the diagnostic intervention.

RESULTS

One day before the diagnostic procedure, the overall estimate for quality of life (measured with the EuroQol) was slightly higher in the needle biopsy group than in the control group (73 versus 69 resp.). Four days after the diagnostic procedure, the quality of life score remained approximately unchanged in the needle biopsy group, but was reduced in the control group (71 versus 61 resp.). Results of the SF-36 questionnaire demonstrated that patients in the needle biopsy group had higher quality of life scores on physical functioning, physical performance, pain and social performance after the diagnostic intervention.

CONCLUSION

Stereotactic large-core needle biopsy seems to affect quality of life to a lesser extent than open breast biopsy. This difference is mainly attributable to a reduction of physical discomfort and pain.

Histological findings in surgical specimens after core biopsy of the breast

Pathological changes induced by needling procedures found in breast surgical specimens are rare but can induce misinterpretation or compromise the definitive histological analysis. These abnormal findings depend on the interval between the core biopsy and excision. Early findings are local haemorrhage, disrupted tissue and epithelial cell displacement, whereas, fibrosis, fat necrosis and inflammatory reaction are observed later in time. The radiologists must be aware of these histological pitfalls and must consider the benefits of their core biopsies (indications, surgeon's question, number of samples).

Nonpalpable breast lesions: biopsy methods and patient management

Mammography has become a major, if not the best available, diagnostic tool for the early detection of breast cancer. Screening has progressed substantially from the anecdotes of physicians in the early 1970s, that is, the assumption that "if I can't feel it, it's not there." Although controversy continues regarding the earliest age at which screening mammography truly lowers the death rate from breast cancer, the fact that mammography detects breast cancer years before it might be discovered as a mass in the breast cannot be challenged. Mammographic techniques have improved to the point at which smaller and smaller areas of suspicion can be identified, and mammographers have gained greater experience in the interpretation of these minute radiographic abnormalities. The ability to detect these changes has inevitably led to an increase in procedures designed to explain them. The incurred costs, both emotional and economic, of patient recalls for positive mammographic findings are considerable. Regardless of whether the physician practices medicine as a patient advocate or exercises politically correct and cost-effective mandates, the management of nonpalpable breast lesions requires the correlation of cognitive and procedural skills and cooperation among physicians and reflects the technical achievements of contemporary medicine.

Histologic and radiographic analysis of ductal carcinoma in situ diagnosed using stereotactic incisional core breast biopsy

BACKGROUND

Stereotactic incisional core breast biopsy (SCBB) is a highly specific technique for diagnosing ductal carcinoma in situ (DCIS) in patients with suspicious mammographic microcalcifications. However, its sensitivity for excluding the presence of coexisting occult invasive disease in this setting is not fully established.

DESIGN

We correlated SCBB findings to subsequent lumpectomy/mastectomy (lx/mx) results in 122 cases of DCIS. In 29 of these cases, the SCBB showed microscopic invasion (n = 15) or foci that were suspicious for invasion (n = 14). Likelihood for invasive disease in subsequent lx/mx samples from each case then was compared with various parameters, including DCIS grade, extent and mammographic findings.

RESULTS

Overall, 13% of cases in which the SCBB showed DCIS only (i.e., without any evidence of invasion), had invasive disease in the subsequent excision. This finding was significantly correlated with DCIS grade (low: 0/26 [0%], intermediate: 2/31 [6%], high: 10/36 [28%], P <.001). Invasive lesions were usually small (nine T1a, one T1b, and two T1c) and typically present within more extensive fields of DCIS (no invasion: 1.5 cm DCIS size; invasion: 2.8 cm mean DCIS size, P =.01). This was reflected by greater extent of involvement in the SCBB (5/8 cases with invasion had >15 ducts involved, versus 4/23 with <15 ducts involved, P =.03). SCBB that were suspicious or positive for microinvasion demonstrated invasion in most subsequent excision (susp: 7/14 [50%], microinv: 11/15 [73%]), generally of significant extent (11/18 T(1b-c)).

CONCLUSIONS

1. Patients with SCBB showing high grade DCIS and DCIS suspicious or positive for microinvasion have a significant and high likelihood, respectively, of harboring occult invasive neoplasm. They should accordingly be carefully evaluated radiographically, and possibly with sentinel node biopsy to facilitate axillary staging. 2. Likelihood of occult invasion is correlated with overall DCIS size/extent.

Current surgical management of breast cancer

Breast cancer surgery continues to become more conservative. Supporting this conservatism are (1) earlier diagnosis through mammographic screening, (2) an increasing role for diagnostic ultrasound and magnetic resonance imaging, (3) the further development of image-guided core-needle biopsy, and (4) the advent of sentinel lymph node biopsy as an alternative to conventional axillary dissection. For patients with duct carcinoma in situ, the addition of radiotherapy and tamoxifen to surgical excision reduces local recurrence but has not yet improved survival over the rate observed with excision alone. There may be low-risk subgroups of duct carcinoma in situ patients for whom conservative surgery alone is adequate treatment. For patients with invasive cancer, breast conservation remains underutilized. A small survival benefit from post-mastectomy adjuvant radiotherapy is offset by an increased incidence of cardiovascular mortality, a phenomenon which has not yet been demonstrated for radiotherapy following breast conservation. Sentinel lymph node biopsy represents a new standard of care for axillary lymph node staging in the large majority of breast cancer patients with high-risk duct carcinoma in situ and stage I-II invasive cancers. The procedure is feasible, accurate, and works best with a combination of blue dye and radioisotope mapping. After proper validation studies, patients with negative sentinel lymph nodes do not require axillary dissection. The prognostic significance of sentinel lymph node micrometastases identified by enhanced pathologic techniques remains a matter of debate. Prophylactic mastectomy reduces breast cancer incidence and mortality among those with a high-risk family history, and mutations of BRCA1-2, but has significant adverse psychosocial sequelae for a small and unpredictable fraction of patients and should not be undertaken lightly. Prophylactic oophorectomy should be offered to all women with BRCA1-2 mutations, especially those beyond the years of childbearing.

Intraoperative localization after stereotactic breast biopsy without a needle

BACKGROUND

Needle localization breast biopsy (NLBB) is the standard for the removal of breast lesions after vacuum-assisted breast biopsy (VABB). Disadvantages include a miss rate of 0% to 22%, risk of vasovagal reactions, and scheduling difficulties. We hypothesized that the hematoma resulting from VABB could be used to localize the VABB site with intraoperative ultrasonography (US) for excision.

METHODS

Twenty patients had VABB followed by intraoperative US-guided excision.

RESULTS

The previous VABB site in 19 patients was successfully visualized with intraoperative US and excised at surgery. One patient had successful removal of the targeted area under US guidance, but failed to show removal of the clip on initial specimen mammogram.

CONCLUSION

This study demonstrates the effectiveness of US in identifying hematomas after VABB for excision. This technique, which can be performed weeks after VABB, improves patient comfort and allows easier scheduling.

Magnetic resonance imaging-guided core needle biopsy and needle localized excision of occult breast lesions

BACKGROUND

Breast magnetic resonance imaging (MRI) has been reported to be twice as sensitive and three times more specific in detecting breast cancer. We report a series of MRI-guided stereotactic breast biopsies (SCNBB) and needle localized breast biopsies (NLBB) to evaluate MRI as a localization tool.

METHODS

Forty-one breast lesions were identified in 39 patients who subsequently had SCNBB or NLBB. Suspicious areas of enhancement were stereotactically biopsied with 16-G core biopsy needles or localized with 22-G wires for excision under laser guidance.

RESULTS

Forty-one breast lesions were identified from 1,292 breast MRIs. SCNBB identified three malignancies and two areas of atypia. Two additional cancers were found after NLBB. In patients having NLBB alone, five cancers and two areas of atypia were identified.

CONCLUSIONS

In this initial series, breast MRI-guided SCNBB and NLBB were valuable tools in the management of patients with suspicious abnormalities seen only on MRI.

Percutaneous imaging-guided core breast biopsy: 5 years' experience in a community hospital

OBJECTIVE

This study reports the results of a percutaneous imaging-guided core breast biopsy program in a community hospital.

MATERIALS AND METHODS

We reviewed the prospectively collected results of our imaging-guided core biopsy program during its first 5 years (1994-1998). A total of 1333 lesions (94% of which were Breast Imaging Reporting and Data System (BI-RADS) assessment category 4) were sampled in 1183 patients. Patients with BI-RADS assessment category 5 lesions were referred to surgeons. Stereotactic guidance was used for the core biopsy of 506 lesions, and sonography was used to guide the predominantly 16-gauge needle core biopsy of 827 solid masses.

RESULTS

One hundred forty-seven cancers were diagnosed in 1333 biopsies, resulting in a positive yield of 11%. Of 1020 patients with benign, concordant core biopsy results, 981 (96%) had at least one follow-up imaging examination within 36 months of the biopsy. Nineteen (2%) of these 1020 patients had a suspicious change at follow-up; 18 of these patients underwent surgical excision with benign findings. No cancers were found at imaging follow-up or by tumor registry linkage. All malignant core biopsy results were confirmed as malignant at surgical excision (positive predictive value 100%). Twenty-two patients with atypical ductal hyperplasia at core biopsy had subsequent surgery, and 12 (55%) of them were found to have cancer at surgery.

CONCLUSION

An imaging-guided core biopsy program, developed and implemented by a small group of radiologists in a community hospital, can achieve successful results and provide an important service to patients and a cost-effective alternative to surgical biopsy. Our program emphasized sonographic guidance and achieved high follow-up compliance.