Ultrasound-guided core-needle biopsy of breast lesions

A model combining BI-RADS® descriptors from pre-treatment B-mode breast ultrasound with clinicopathological tumor features shows promise in the prediction of residual disease after neoadjuvant chemotherapy

PURPOSE

To create a simple model using standard BI-RADS® descriptors from pre-treatment B-mode ultrasound (US) combined with clinicopathological tumor features, and to assess the potential of the model to predict the presence of residual tumor after neoadjuvant chemotherapy (NAC) in breast cancer (BC) patients.

METHOD

245 female BC patients receiving NAC between January 2017 and December 2019 were included in this retrospective study. Two breast imaging fellows independently evaluated representative B-mode tumor images from baseline US. Additional clinicopathological tumor features were retrieved. The dataset was split into 170 training and 83 validation cases. Logistic regression was used in the training set to identify independent predictors of residual disease post NAC and to create a model, whose performance was evaluated by ROC curve analysis in the validation set. The reference standard was postoperative histology to determine the absence (pathological complete response, pCR) or presence (non-pCR) of residual invasive tumor in the breast or axillary lymph nodes.

RESULTS

100 patients (40.8%) achieved pCR. Logistic regression demonstrated that tumor size, microlobulated margin, spiculated margin, the presence of calcifications, the presence of edema, HER2-positive molecular subtype, and triple-negative molecular subtype were independent predictors of residual disease. A model using these parameters demonstrated an area under the ROC curve of 0.873 in the training and 0.720 in the validation set for the prediction of residual tumor post NAC.

CONCLUSIONS

A simple model combining standard BI-RADS® descriptors from pre-treatment B-mode breast US with clinicopathological tumor features predicts the presence of residual disease after NAC.

Diagnostic performance of deep learning in ultrasound diagnosis of breast cancer: a systematic review

Deep learning (DL) has been widely investigated in breast ultrasound (US) for distinguishing between benign and malignant breast masses. This systematic review of test diagnosis aims to examine the accuracy of DL, compared to human readers, for the diagnosis of breast cancer in the US under clinical settings. Our literature search included records from databases including PubMed, Embase, Scopus, and Cochrane Library. Test accuracy outcomes were synthesized to compare the diagnostic performance of DL and human readers as well as to evaluate the assistive role of DL to human readers. A total of 16 studies involving 9238 female participants were included. There were no prospective studies comparing the test accuracy of DL versus human readers in clinical workflows. Diagnostic test results varied across the included studies. In 14 studies employing standalone DL systems, DL showed significantly lower sensitivities in 5 studies with comparable specificities and outperformed human readers at higher specificities in another 4 studies; in the remaining studies, DL models and human readers showed equivalent test outcomes. In 12 studies that assessed assistive DL systems, no studies proved the assistive role of DL in the overall diagnostic performance of human readers. Current evidence is insufficient to conclude that DL outperforms human readers or enhances the accuracy of diagnostic breast US in a clinical setting. Standardization of study methodologies is required to improve the reproducibility and generalizability of DL research, which will aid in clinical translation and application.

Sonographic Characteristics and Pathology Correlation of Breast Imaging Reporting and Data System (BI-RADS) Category 4 Lesions

INTRODUCTION

The Breast Imaging-Reporting and Database System (BI-RADS) category 4 is designated for breast lumps that do not display the typical features of malignancy but still raise enough suspicion to warrant a recommendation for a biopsy, as malignancy cannot be ruled out through imaging alone. The main objective of this study was to investigate the sonographic characteristics and pathology correlation of BI-RADS 4 breast lesions and determine the positive predictive rate of BI-RADS 4 lesions in diagnosing breast cancer, using histopathology as the gold standard.

METHODS

This was a cross-sectional study conducted at the Department of Radiology, Aga Khan University Hospital in Karachi, spanning from May 2021 to August 2022, with a duration of 15 months. The study focused on female patients over the age of 18 who presented with suspicious breast lesions on ultrasound. Both mammography and ultrasound-guided core needle biopsy were performed on these patients, followed by a detailed histopathological evaluation of the biopsy specimens. To calculate the positive predictive value (PPV), true positive cases were identified through both histopathology and ultrasonography.

RESULTS

A total of 227 cases were categorized as BI-RADS 4 lesions, with the patients' mean age being 47.8 ± 14.3 years (range: 17 - 88). Among the biopsied lesions, 101 cases were confirmed to be true positive for breast malignancies, resulting in a PPV for malignancy of 44.9%. Conversely, there were 124 false positive cases out of the 227 BI-RADS 4 category lesions (54.63%). The primary indication for presentation was a breast lump, and out of the 101 confirmed malignant cases, 70 (69.3%) were associated with malignancy.

CONCLUSION

BI-RADS 4 can be utilized to assess suspicious breast lumps; however, for more reliable results and to avoid false negatives, histopathological confirmation should complement the imaging findings.

The accuracy of ultrasound-guided fine-needle aspiration and core needle biopsy in diagnosing axillary lymph nodes in women with breast cancer: a systematic review and meta-analysis

Background

This study evaluates the diagnostic accuracy of ultrasound-guided fine needle aspiration (US-FNA) and core needle biopsy (US-CNB) for detecting axillary lymph nodes in women with breast cancer.

Methods

Eligible studies and pertinent literature resources were identified in Cochrane, PubMed, Embase, CNKI, VIP, and Wanfang databases using subject-specific keywords. Study outcomes were tested for heterogeneity, and meta-analyses were performed to estimate sensitivity, specificity, and diagnostic odds ratios (DORs). The summary receiver operating characteristic (SROC) curve analysis was also performed.

Results

A total of 22 studies involving 3,548 patients were included to evaluate the diagnostic accuracy of US-FNA and 11 studies involving 758 patients were included to evaluate the diagnostic accuracy of US-CNB in identifying axillary lymph nodes in women with breast cancer. The accuracy of US-FNA in identifying suspicious axillary lymph nodes was as follows: overall sensitivity, 79% (95% CI: 73%-84%); global specificity, 96% (95% CI: 92%-98%); overall positive likelihood ratio, 18.55 (95% CI: 10.53-32.69); overall negative likelihood ratio, 0.22 (95% CI: 0.17-0.28); DOR, 71.68 (95% CI: 37.19-138.12); and the area under the SROC curve, 0.94 (95% CI: 0.92-0.96). The accuracy of US-CNB in identifying suspicious axillary lymph nodes was as follows: overall sensitivity, 85% (95% CI: 81%-89%); global specificity, 93% (95% CI: 87%-96%); overall positive likelihood ratio, 11.88 (95% CI: 6.56-21.50); overall negative likelihood ratio, 0.16 (95% CI: 0.12-0.21); overall DOR, 66.83 (95% CI: 33.28-134.21), and the area under SROC curve 0.96 (95% CI: 0.94-0.97).

Conclusions

The results indicate that both US-FNA and US-CNB have high accuracy for suspicious axillary lymph nodes.

Impact of modern personalized treatment of breast cancer on surgical attitude and outcomes

Multimodal treatment of breast cancer has made steady progress in recent years. The involvement of modern oncology, diagnostic imaging techniques and surgical treatment, have brought a definite benefit to patients, defining the multidisciplinary treatment of breast cancer. The introduction of immunohistochemical testing and genetic screening has led to the prioritization of therapy according to their results and a correct approach to initiating treatment. The main aim of the present study was to conduct a comparative analysis through a retrospective study of the therapeutic means used in breast cancer with the statistical evaluation of the obtained results. To carry out the study, a group of 125 patients hospitalized during the period January 2015 to December 2020, were included, and the parameters were selected from the observation sheets. The results of the study demonstrated the superiority of multimodal treatment of breast cancer over surgical treatment as the only therapeutic management. The introduction of ultrasound-guided biopsies and conservative surgical options has led to increased diagnostic accuracy and a significant improvement in aesthetic outcome. The multidisciplinary approach to breast cancer allows an individualized treatment by performing immunohistochemical testing and through the use of neoadjuvant and adjuvant treatment combined with conservative surgical techniques with a more favorable cosmetic and oncological result, with reduced postoperative complications.

Development of a mechatronic guidance system for targeted ultrasound-guided biopsy under high-resolution positron emission mammography localization

PURPOSE

Image-guided needle biopsy of small, detectable lesions is crucial for early-stage diagnosis, treatment planning, and management of breast cancer. High-resolution positron emission mammography (PEM) is a dedicated functional imaging modality that can detect breast cancer independent of breast tissue density, but anatomical context and real-time needle visualization are not yet available to guide biopsy. We propose a mechatronic guidance system integrating an ultrasound (US)-guided core-needle biopsy (CNB) with high-resolution PEM localization to improve the spatial sampling of breast lesions. This paper presents the benchtop testing and phantom studies to evaluate the accuracy of the system and its constituent components for targeted PEM-US-guided biopsy under simulated high-resolution PEM localization.

METHODS

A mechatronic guidance system was developed to operate with the Radialis PEM system and a conventional US system. The system includes a user-operated guidance arm and end-effector biopsy device, integrating a US transducer and CNB gun, with its needle focused on a remote center of motion (RCM). Custom software modules were developed to track, display, and guide the end-effector biopsy device. Registration of the mechatronic guidance system to a simulated PEM detector plate was performed using a landmark-based method. Testing was performed with fiducials positioned in the peripheral and central regions of the simulated detector plate and registration error was quantified. Breast phantom experiments were performed under ideal detection and localization to evaluate for bias in the end-effector biopsy device. The accuracy of the complete mechatronic guidance system to perform targeted breast biopsy was assessed using breast phantoms with simulated lesions. Three-dimensional positioning error was quantified, and principal component analysis assessed for directional trends in 3D space within 95% prediction intervals. Targeted breast biopsies with test phantoms were performed and an overall in-plane needle targeting error was quantified.

RESULTS

The mean registration errors were 0.63 mm (N = 44) and 0.73 mm (N = 72) in the peripheral and central regions of the simulated PEM detector plate, respectively. A 3D 95% prediction ellipsoid shows an error volume <2.0 mm in diameter, centered on the mean registration error. Under ideal detection and localization, targets <1.0 mm in diameter can be sampled with 95% confidence. The complete mechatronic guidance system was able to successfully spatially sample simulated breast lesions, 4 mm and 6 mm in diameter and height (N = 20) in known 3D positions in the PEM image coordinate space. The 3D positioning error was 0.85 mm (N = 20) with 0.64 mm in-plane and 0.44 mm cross-plane component errors. Targeted breast biopsies resulted in a mean in-plane needle targeting error of 1.08 mm (N = 15) allowing for targets 1.32 mm in radius to be sampled with 95% confidence.

CONCLUSIONS

We demonstrated the utility of our mechatronic guidance system for targeted breast biopsy under high-resolution PEM localization. Breast phantom studies showed the ability to accurately guide, position, and target breast lesions with the accuracy to spatially sample targets <3.0 mm in diameter with 95% confidence. Future work will integrate the developed system with the Radialis PEM system toward combined PEM-US-guided breast biopsy.

Study Protocol on the Validation of the Quality of Sleep Data from Xiaomi Domestic Wristbands

(1) Background: Sleep disorders are a common problem for public health since they are considered potential triggers and predictors of some mental and physical diseases. Evaluating the sleep quality of a person may be a first step to prevent further health issues that diminish their independence and quality of life. Polysomnography (PSG) is the “gold standard” for sleep studies, but this technique presents some drawbacks. Thus, this study intends to assess the capability of the new Xiaomi Mi Smart Band 5 to be used as a tool for sleep self-assessment. (2) Methods: This study will be an observational and prospective study set at the sleep unit of a hospital in A Coruña, Spain. Forty-three participants who meet the inclusion criteria will be asked to participate. Specific statistical methods will be used to analyze the data collected using the Xiaomi Mi Smart Band 5 and PSG. (3) Discussion: This study offers a promising approach to assess whether the Xiaomi Mi Smart Band 5 correctly records our sleep. Even though these devices are not expected to replace PSG, they may be used as an initial evaluation tool for users to manage their own sleep quality and, if necessary, consult a health professional. Further, the device may help users make simple changes to their habits to improve other health issues as well. Trial registration: NCT04568408 (Registered 23 September 2020).

Breast pseudoaneurysm after core needle biopsy in a pregnant patient

Breast pseudoaneurysm is an extremely rare complication of interventional breast procedures. Pregnancy and lactation are associated with increased breast vascularization, which may act as a risk factor. We present the case of a 36-year-old woman in the third trimester of a spontaneous twin pregnancy, who presented with a newly-detected BI-RADS 4 mass in her right breast. The patient requested not to defer a biopsy until after the pregnancy, and an ultrasound-guided breast core biopsy was performed. The patient presented bleeding during the procedure, but no hematomas or other vascular lesions were immediately detected. During follow-up, a breast ultrasound revealed an anechoic circumscribed mass and high‐velocity blood flow. The color Doppler showed a spiral blood flow with the Yin-Yang sign, together with a communication channel between the sac and feeding artery. A diagnosis of breast pseudoaneurysm was made. The patient was managed conservatively, and breastfeeding continued normally. This case report highlights the importance of color Doppler in the detection of pseudoaneurysms, and the need to consider deferring invasive breast procedures in pregnant women when possible.

Classification of Breast Masses on Ultrasound Shear Wave Elastography using Convolutional Neural Networks

We aimed to use deep learning with convolutional neural networks (CNNs) to discriminate images of benign and malignant breast masses on ultrasound shear wave elastography (SWE). We retrospectively gathered 158 images of benign masses and 146 images of malignant masses as training data for SWE. A deep learning model was constructed using several CNN architectures (Xception, InceptionV3, InceptionResNetV2, DenseNet121, DenseNet169, and NASNetMobile) with 50, 100, and 200 epochs. We analyzed SWE images of 38 benign masses and 35 malignant masses as test data. Two radiologists interpreted these test data through a consensus reading using a 5-point visual color assessment (SWEc) and the mean elasticity value (in kPa) (SWEe). Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were calculated. The best CNN model (which was DenseNet169 with 100 epochs), SWEc, and SWEe had a sensitivity of 0.857, 0.829, and 0.914 and a specificity of 0.789, 0.737, and 0.763 respectively. The CNNs exhibited a mean AUC of 0.870 (range, 0.844-0.898), and SWEc and SWEe had an AUC of 0.821 and 0.855. The CNNs had an equal or better diagnostic performance compared with radiologist readings. DenseNet169 with 100 epochs, Xception with 50 epochs, and Xception with 100 epochs had a better diagnostic performance compared with SWEc (P = 0.018-0.037). Deep learning with CNNs exhibited equal or higher AUC compared with radiologists when discriminating benign from malignant breast masses on ultrasound SWE.

Local and Systemic Antitumor Effects of Photo-activatable Paclitaxel Prodrug on Rat Breast Tumor Models

We demonstrated that a large primary and a small untreated distant breast cancer could be controlled by local treatment with our light-activatable paclitaxel (PTX) prodrug. We hypothesized that the treated tumor would be damaged by the combinational effects of photodynamic therapy (PDT) and locally released PTX and that the distant tumor would be suppressed by systemic antitumor effects. Syngeneic rat breast cancer models (single- and two-tumor models) were established on Fischer 344 rats by subcutaneous injection of MAT B III cells. The rats were injected with PTX prodrug (dose: 1 umole kg-1 , i.v.), and tumors were treated with illumination using a 690-nm laser (75 or 140 mW cm-1 for 30 min, cylindrical light diffuser, drug-light interval [DLI] 9 h). Larger tumors (~16 mm) were effectively ablated (100%) without recurrence for >90 days. All cured rats rejected rechallenged tumor for up to 12 months. In the two-tumor model, the treatment of the local large tumor (~16 mm) also cured the untreated tumor (4-6 mm) through adaptive immune activation. This is our first demonstration that local treatment with our PTX prodrug produces systemic antitumor effects. Further investigations are warranted to understand mechanisms and optimal conditions to achieve clinically translatable systemic antitumor effects.

Ultrasound-Guided Core Biopsy of Breast Lesions in a Resource Limited Setting: Initial Experience of a Multidisciplinary Team

Objective

There is increasing tendency to multidisciplinary care of patients with of breast lesions. This study sought to evaluate the initial experience of the diagnostic arm of a new breast program in a resource limited setting.

Materials and Methods

In 2015, we commenced the pilot phase of an IRB-approved breast care protocol. As part of the protocol's diagnostic arm, an ultrasound-guided breast core biopsy training was implemented. Eligible patients were clinically evaluated and underwent CNB using 16G needle under US guidance. The procedure was rated by the participants and histopathological results compared with surgical specimens.

Results

Eighty six participants (18.22%) with 113 palpable breast lesions completed the study. The diagnostic accuracy, sensitivity, and specificity were 94.44%, 92.86%, and 95.83% respectively. Unweighted kappa-coefficient (k) agreement between histopathology of core biopsy and surgically excised specimens, were 0.798 (95% CI of 0.69 - 0.90) and 0.801 (95% CI of 0.71-0.92) for benign and malignant breast lumps respectively. The procedure was well accepted and all the patients were willing to accept a repeat CNB and would recommend it.

Conclusion

Despite the prevailing challenges, co-ordinated team diagnosis is feasible and may result in the modest improvement in the diagnostic accuracy of breast lesions and patient satisfaction.

Sociodemographic factors and clinical presentation of women attending Cancer Detection Centre, Kolkata for breast examination

BACKGROUND

Breast cancer is the most common cancer in Indian women.

AIM

The aim of the study was to report the sociodemographic factors, habits, personal history, gynecological and obstetric history, the clinical presentation of Indian women, and analyze those factors with the diagnosis of breast cancer.

METHODS

This study is based on retrospective data collection from case files of women who attended the Cancer Detection Centre during January1995-September 2016.

RESULTS

Data analysis for 1196 women showed 31.5% aged between 26 and 35 years; 90.7% were Hindus; 61.3% school-educated; 77.0% housewives/unemployed; 80.6% married and 98.2% were non-vegetarian. Physical activity, medical history and gynecologic history of menarche, menstrual type, menopause, marital age, and breast feeding history had a strong correlation with clinical diagnosis (p<0.05). About 8.4% of the total population was diagnosed with breast cancer using smear cytology, FNAC, mammography, and USG.

CONCLUSIONS

Age, lack of proper education, marital status, food habit, physical activity, age of menarche, menstrual type, menopause, marital age, and breastfeeding history were highlighted as significant risk factors of breast cancer in Indian women. Smears from nipple discharges, FNAC, mammography, and USG are effective methods for breast cancer detection in low-cost setting where routine organized screening programs are not available.

RELEVANCE FOR PATIENTS

The study will identify important risk factors among women in the Eastern region of India. Thus, background information of patients can be used to emphasize the importance of organizing breast cancer screening while making public health policies and implementing breast cancer control programs.

Image-guided breast biopsy and localisation: recommendations for information to women and referring physicians by the European Society of Breast Imaging

We summarise here the information to be provided to women and referring physicians about percutaneous breast biopsy and lesion localisation under imaging guidance. After explaining why a preoperative diagnosis with a percutaneous biopsy is preferred to surgical biopsy, we illustrate the criteria used by radiologists for choosing the most appropriate combination of device type for sampling and imaging technique for guidance. Then, we describe the commonly used devices, from fine-needle sampling to tissue biopsy with larger needles, namely core needle biopsy and vacuum-assisted biopsy, and how mammography, digital breast tomosynthesis, ultrasound, or magnetic resonance imaging work for targeting the lesion for sampling or localisation. The differences among the techniques available for localisation (carbon marking, metallic wire, radiotracer injection, radioactive seed, and magnetic seed localisation) are illustrated. Type and rate of possible complications are described and the issue of concomitant antiplatelet or anticoagulant therapy is also addressed. The importance of pathological-radiological correlation is highlighted: when evaluating the results of any needle sampling, the radiologist must check the concordance between the cytology/pathology report of the sample and the radiological appearance of the biopsied lesion. We recommend that special attention is paid to a proper and tactful approach when communicating to the woman the need for tissue sampling as well as the possibility of cancer diagnosis, repeat tissue sampling, and or even surgery when tissue sampling shows a lesion with uncertain malignant potential (also referred to as "high-risk" or B3 lesions). Finally, seven frequently asked questions are answered.

Imaging Features and Treatment Options for Breast Pseudoaneurysms After Biopsy: A Case-Based Pictorial Review

Pseudoaneurysm (PSA) formation is a potential complication of breast biopsies. Ultrasound is the most common imaging modality used for evaluation and treatment of a PSA. Color Doppler images show a cystic structure with swirling flow inside in a "to-and-fro" pattern. Treatment options for PSA include observation, ultrasound-guided focused compression, thrombin injection, open surgical repair, and percutaneous embolization. The risks and benefits of these treatment options will be discussed in the following cases.

Position-based modeling of lesion displacement in ultrasound-guided breast biopsy

PURPOSE

Although ultrasound (US) images represent the most popular modality for guiding breast biopsy, malignant regions are often missed by sonography, thus preventing accurate lesion localization which is essential for a successful procedure. Biomechanical models can support the localization of suspicious areas identified on a preoperative image during US scanning since they are able to account for anatomical deformations resulting from US probe pressure. We propose a deformation model which relies on position-based dynamics (PBD) approach to predict the displacement of internal targets induced by probe interaction during US acquisition.

METHODS

The PBD implementation available in NVIDIA FleX is exploited to create an anatomical model capable of deforming online. Simulation parameters are initialized on a calibration phantom under different levels of probe-induced deformations; then, they are fine-tuned by minimizing the localization error of a US-visible landmark of a realistic breast phantom. The updated model is used to estimate the displacement of other internal lesions due to probe-tissue interaction.

RESULTS

The localization error obtained when applying the PBD model remains below 11 mm for all the tumors even for input displacements in the order of 30 mm. This proposed method obtains results aligned with FE models with faster computational performance, suitable for real-time applications. In addition, it outperforms rigid model used to track lesion position in US-guided breast biopsies, at least halving the localization error for all the displacement ranges considered.

CONCLUSION

Position-based dynamics approach has proved to be successful in modeling breast tissue deformations during US acquisition. Its stability, accuracy and real-time performance make such model suitable for tracking lesions displacement during US-guided breast biopsy.

Ultrasound-Guided Needle Technique Accuracy: Prospective Comparison of Passive Magnetic Tracking Versus Unassisted Echogenic Needle Localization

Background and Objectives

Ultrasound-guided regional anesthesia facilitates an approach to sensitive targets such as nerve clusters without contact or inadvertent puncture. We compared accuracy of needle placement with a novel passive magnetic ultrasound needle guidance technology (NGT) versus conventional ultrasound (CU) with echogenic needles.

Methods

Sixteen anesthesiologists and 19 residents performed a series of 16 needle insertion tasks each, 8 using NGT (n = 280) and 8 using CU (n = 280), in high-fidelity porcine phantoms. Tasks were stratified based on aiming to contact (target-contact) or place in close proximity with (target-proximity) targets, needle gauge (no. 18/no. 22), and in-plane (IP) or out-of-plane (OOP) approach. Distance to the target, task completion by aim, number of passes, and number of tasks completed on the first pass were reported.

Results

Needle guidance technology significantly improved distance, task completion, number of passes, and completion on the first pass compared with CU for both IP and OOP approaches (P ≤ 0.001). Average NGT distance to target was lower by 57.1% overall (n = 560, 1.5 ± 2.4 vs 3.5 ± 3.7 mm), 38.5% IP (n = 140, 1.6 ± 2.6 vs 2.6 ± 2.8 mm), and 68.2% OOP (n = 140, 1.4 ± 2.2 vs 4.4 ± 4.3 mm) (all P ≤ 0.01). Subgroup analyses revealed accuracy gains were largest among target-proximity tasks performed by residents and for OOP approaches. Needle guidance technology improved first-pass completion from 214 (76.4%) per 280 to 249 (88.9%) per 280, a significant improvement of 16.4% (P = 0.001).

Conclusions

Passive magnetic NGT can improve accuracy of needle procedures, particularly among OOP procedures requiring close approach to sensitive targets, such as nerve blocks in anesthesiology practice.

Breast ultrasound: recommendations for information to women and referring physicians by the European Society of Breast Imaging

This article summarises the information that should be provided to women and referring physicians about breast ultrasound (US). After explaining the physical principles, technical procedure and safety of US, information is given about its ability to make a correct diagnosis, depending on the setting in which it is applied. The following definite indications for breast US in female subjects are proposed: palpable lump; axillary adenopathy; first diagnostic approach for clinical abnormalities under 40 and in pregnant or lactating women; suspicious abnormalities at mammography or magnetic resonance imaging (MRI); suspicious nipple discharge; recent nipple inversion; skin retraction; breast inflammation; abnormalities in the area of the surgical scar after breast conserving surgery or mastectomy; abnormalities in the presence of breast implants; screening high-risk women, especially when MRI is not performed; loco-regional staging of a known breast cancer, when MRI is not performed; guidance for percutaneous interventions (needle biopsy, pre-surgical localisation, fluid collection drainage); monitoring patients with breast cancer receiving neo-adjuvant therapy, when MRI is not performed. Possible indications such as supplemental screening after mammography for women aged 40-74 with dense breasts are also listed. Moreover, inappropriate indications include screening for breast cancer as a stand-alone alternative to mammography. The structure and organisation of the breast US report and of classification systems such as the BI-RADS and consequent management recommendations are illustrated. Information about additional or new US technologies (colour-Doppler, elastography, and automated whole breast US) is also provided. Finally, five frequently asked questions are answered.

TEACHING POINTS

• US is an established tool for suspected cancers at all ages and also the method of choice under 40. • For US-visible suspicious lesions, US-guided biopsy is preferred, even for palpable findings. • High-risk women can be screened with US, especially when MRI cannot be performed. • Supplemental US increases cancer detection but also false positives, biopsy rate and follow-up exams. • Breast US is inappropriate as a stand-alone screening method.

Correlation between invasive mammary carcinoma grade and size in ultrasound-guided core needle biopsy and subsequent surgical excision

The purpose of this study was to correlate the histologic grade, mitotic rate and size of invasive mammary carcinomas (IMC) on ultrasound (US) core needle biopsy (CNB) and the follow-up excision (FUE). The underestimation and overestimation of the grades by CNB were 11% and 8%. CNBs were more specific for grade 3 tumors. Tumors >10 mm by US examination showed greater concordance in grades. The size in the FUE was the best determinant of pT followed by US examination. The extent of IMC on CNB was larger than FUE in 8% resulting in pT upstaging in 3% of cases.

Breast ultrasound for the interventionalist

Ultrasound (US)-guided interventional procedures are routinely performed for lesions visualized on US and are the standard of care in the diagnosis and management of breast disease. When performed correctly, these procedures are safe, minimally invasive, and have a high diagnostic accuracy comparable to surgical biopsy. The most commonly performed US-guided procedures include fine-needle aspiration, core needle biopsy, and preoperative wire localization. The success of these procedures depends on a thorough understanding of the indications, strong technical skills, and appropriate postbiopsy management. This article reviews the indications and techniques for US-guided interventional procedures. Concordance of imaging and pathology results, potential challenges, and associated complications are also discussed.

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.

Ultrasound-guided endoscopic biliary drainage: a useful drainage method for biliary decompression in patients with biliary obstructions

BACKGROUND

Endoscopic retrograde cholangiopancreatography with fluoroscopy guidance is a well-established technique for providing biliary drainage in patients with biliary obstructions. However, fluoroscopic facilities may not always be available and fluoroscopy carries a risk of radiation exposure.

AIM

We retrospectively compared the procedure success rate and efficacy of ultrasound-guided endoscopic biliary drainage (UG-EBD) and fluoroscopy-guided endoscopic biliary drainage (FG-EBD) in patients with biliary obstructions.

METHODS

Patients who had received either UG-EBD or FG-EBD were included in the study. Main outcome measurements included the procedure success rate, procedure time, and clinical response.

RESULTS

A total of 125 patients who had undergone UG-EBD (n = 63) and FG-EBD (n = 62) were identified. The total procedure success rate was 93.7 % in the UG-EBD group and 96.8 % in the FG-EBD group without statistical difference. Also, no significant difference was found in the procedure success rate of lower or upper/middle obstructions of the common bile duct (CBD) between the 2 groups. The mean procedure time was not different between the 2 groups [UG-EBD group 24.54 (9.52) min vs. FG-EBD group 21.74 (8.77) min, p = 0.09]. There were no differences in the normalization of clinical and laboratory parameters and immediate complication between the 2 groups.

CONCLUSIONS

Endoscopic biliary drainage (EBD) under US-guidance and under fluoroscopy guidance is equally effective and safe for patients with lower or upper/middle obstructions of the CBD. The UG-EBD technique is especially suitable for special patients, such as critically ill patients, pregnant woman, etc.