Two-year follow-up of stereotactically guided 9-G breast biopsy: a multicenter evaluation of a self-contained vacuum-assisted device

Bleeding Complications After Breast Core-needle Biopsy-An Approach to Managing Patients on Antithrombotic Therapy

Image-guided core-needle breast and axillary biopsy (CNB) is the standard-of-care procedure for the diagnosis of breast cancer. Although the risks of CNB are low, the most common complications include bleeding and hematoma formation. Post-procedural bleeding is of particular concern in patients taking antithrombotic therapy, but there is currently no widely established standard protocol in the United States to guide antithrombotic therapy management. In the face of an increasing number of patients taking antithrombotic therapy and with the advent of novel classes of anticoagulants, the American College of Radiology guidelines recommend that radiologists consider cessation of antithrombotic therapy prior to CNB on a case-by-case basis. Lack of consensus results in disparate approaches to patients on antithrombotic therapy undergoing CNB. There is further heterogeneity in recommendations for cessation of antithrombotic therapy based on the modality used for image-guided biopsy, target location, number of simultaneous biopsies, and type of antithrombotic agent. A review of the available data demonstrates the safety of continuing antithrombotic therapy during CNB while highlighting additional procedural and target lesion factors that may increase the risk of bleeding. Risk stratification of patients undergoing breast interventional procedures is proposed to guide both pre-procedural decision-making and post-procedural management. Radiologists should be aware of antithrombotic agent pharmacokinetics and strategies to minimize post-procedural bleeding to safely manage patients.

Pure Ductal Carcinoma In Situ of the Breast: Analysis of 270 Consecutive Patients Treated in a 9-Year Period

Simple Summary

Ductal carcinoma in situ (DCIS) accounts for 20 to 25% of all breast cancers and its incidence of progression to invasive ductal carcinoma is at least 13 to 50%. The aim of our retrospective observational analysis is to review the issues of this histological type of cancer. We confirmed in a wide population of 270 consecutive patients who underwent surgery in a single institute that the management of DCIS can be difficult and particularly complex. There are many variables to be taken into consideration such as the choice of the diagnostic and bioptical technique. This delicate management must be carried out in specialized centres such as Breast Units involving multiple professional figures to define and guarantee the best possible treatment for each patient.

Abstract

Introduction: Ductal carcinoma in situ (DCIS) is an intraductal neoplastic proliferation of epithelial cells that are confined within the basement membrane of the breast ductal system. This retrospective observational analysis aims at reviewing the issues of this histological type of cancer. Materials and methods: Patients treated for DCIS between 1 January 2009 and 31 December 2018 were identified from a retrospective database. The patients were divided into two groups of 5 years each, the first group including patients treated from 2009 to 2013, and the second group including patients treated from 2014 to 2018. Once the database was completed, we performed a statistical analysis to see if there were significant differences among the 2 periods. Statistical analyses were performed using GraphPad Prism software for Windows, and the level of significance was set at p < 0.05. Results: 3586 female patients were treated for breast cancer over the 9-year study period (1469 patients from 2009 to 2013 and 2117 from 2014 to 2018), of which 270 (7.53%) had pure DCIS in the final pathology. The median age of diagnosis was 59-year-old (range 36–86). In the first period, 81 (5.5%) women out of 1469 had DCIS in the final pathology, in the second, 189 (8.9%) out of 2117 had DCIS in the final pathology with a statistically significant increase (p = 0.0001). From 2009 to 2013, only 38 (46.9%) were in stage 0 (correct DCIS diagnosis) while in the second period, 125 (66.1%) were included in this stage. The number of patients included in clinical stage 0 increased significantly (p = 0.004). In the first period, 48 (59.3%) specimen margins were at a greater or equal distance than 2 mm (negative margins), between 2014 and 2018; 137 (72.5%) had negative margins. Between 2014 and 2018 the number of DCIS patients with positive margins decreased significantly (p = 0.02) compared to the first period examined. The mastectomies number increased significantly (p = 0.008) between the 2 periods, while the sentinel lymph node biopsy (SLNB) numbers had no differences (p = 0.29). For both periods analysed all the 253 patients who underwent the follow up are currently living and free of disease. We have conventionally excluded the 17 patients whose data were lost. Conclusion: The choice of the newest imaging techniques and the most suitable biopsy method allows a better pre-operative diagnosis of the DCIS. Surgical treatment must be targeted to the patient and a multidisciplinary approach discussed in the Breast Unit centres.

A retrospective observational study of intraductal breast papilloma and its coexisting lesions: A real-world experience

Background

Breast intraductal papilloma is a heterogeneous group. The aim of the study is to investigate the intraductal breast papilloma and its coexisting lesions retrospectively in real‐world practice.

Methods

We retrospectively identified 4450 intraductal breast papilloma and its coexisting lesions.

Results

About 18.36% of intraductal papilloma coexisted with malignant lesions of the breast, 37.33% coexisted with atypia hyperplasia (AH), 25.24% coexisted with benign lesions, and only 19.10% coexisted without concomitant lesions. In addition, 36.80% of intraductal breast papilloma had nipple discharge, 51.46% had a palpable breast mass, and 16.45% had both nipple discharge and a palpable breast mass. About 28.18% experienced discomfort or were asymptomatic. Furthermore, 98.99% had ultrasound abnormalities, and 53.06% had intraductal hypoechogenicity upon ultrasound. 31.89% had mammographic distortion, and 14.45% had microcalcification upon mammography. Intraductal breast papilloma with malignancy had significant correlations with clinical manifestations.

Conclusion

Coexisting malignancy was also related to ultrasound abnormality (BIRADS 4C and 5), mammographic distortion, and microcalcification upon mammography but was not related to the intraductal hypoechoic upon ultrasound. Coexisting atypical hyperplasia correlated with nipple discharge but not palpable mass, mammographic distortion, or intraductal hypoechoic upon ultrasound. The coexisting AH was also related to abnormality upon ultrasound or microcalcification compared with the benign lesions. The intraductal papilloma coexists with malignancy or AH accounted for more than 50%, and the clinical information on papilloma and its coexisting lesions is nonspecific. We recommended surgical treatment for benign intraductal papillary lesions.

Stereotactic 9-gauge vacuum-assisted breast biopsy, how many specimens are needed?

PURPOSE

To determine the minimum number of stereotactic 9-gauge vacuum-assisted biopsy specimens required to establish a final histopathological biopsy diagnosis of mammographically suspicious breast lesions.

METHODS

This prospective single-center observational cohort study included 120 women referred for stereotactic vacuum-assisted biopsy of 129 mammographically suspicious lesions between December 2017 and October 2018. Stereotactic 9-gauge vacuum-assisted biopsy was performed, acquiring twelve specimens per lesion. Calcification retrieval was assessed with individual specimen radiography. Each specimen was histologically analyzed in chronological order and findings were compared with the final histopathological result after assessment of all twelve specimens and with results of surgical excision. Cumulative diagnostic yield per specimen was calculated.

RESULTS

In total, 131 biopsy procedures were performed in 120 women (mean age 59 years). In 95% (95%CI 90%-98%) of the procedures a final histopathological diagnosis was reached after six specimens. After nine specimens the final biopsy diagnosis was established in all 131 cases. In the subgroup of 41 patients with a DCIS or invasive diagnosis at biopsy there were eight procedures (20%) where calcifications were retrieved before the diagnostic specimen was obtained. Underestimation of subsequent resection diagnosis occurred in six out of 30 excised lesions classified as DCIS (20%) and in one out of four excised high-risk lesions.

CONCLUSIONS

With six stereotactic 9-gauge vacuum-assisted biopsy specimens a final histopathological biopsy diagnosis could be established in 95% (95%CI 90%-98%) of the biopsy procedures. Taking nine 9-gauge specimens seems to be optimal. Ending the stereotactic vacuum-assisted breast biopsy procedure as soon as calcifications are retrieved may cause false negative results.

Outcome of breast lesions diagnosed as lesion of uncertain malignant potential (B3) or suspicious of malignancy (B4) on needle core biopsy, including detailed review of epithelial atypia

AIMS

To provide updated evidence of the outcome of breast lesions of uncertain malignant potential (B3) and suspicious of malignancy (B4) diagnosed on needle core biopsy (NCB) and analyse the outcome of the different types of intraductal epithelial atypia.

METHODS AND RESULTS

One-hundred and forty-nine B3 and 26 B4 NCBs diagnosed over a 2-year period (2007-2008) were compared with those diagnosed over a previous 2-year period (1998-2000). The proportion of B3 diagnoses increased from 3.1% to 4.5%, and the positive predictive value (PPV) of malignancy of a B3 core decreased from 25% to 10%. Increased diagnosis of radial scar and reductions in the PPV of lobular neoplasia and of atypical intraductal proliferation may explain the reduction in the PPV of the B3 group as a whole. There were no significant changes in the proportion of B4 diagnosis (1.1% and 0.8%) or the PPV of B4 (83% and 88%). Review of cores with intraductal atypia showed a wide range of PPVs, from 100% for suspicious of ductal carcinoma in situ, to 40% for atypical ductal hyperplasia categorized as B3, and 14% for isolated flat epithelial atypia.

CONCLUSION

The study has found a decrease in the PPV for a B3 diagnosis and suggests possible explanations.

Assessment of microcalcifications with limited number of high-precision macrobiopsies

Stereotactic biopsy assessment of microcalcification clusters with direct and frontal macrobiopsies was performed in a population of 46 women screened for breast cancer. The only clinical finding in these women was microcalcification. Sensitivity of the procedure was 98% and calcifications were detected in 107 out of 148 tissue specimens (73%). This is the highest reported ratio so far. Interestingly, the total number of cores was inversely correlated with the success rate, suggesting that the accuracy of the direct and frontal approach is high. Four out of 46 women underwent surgery for malignancy indicating that 41 women escaped intervention with a mean follow-up of at least 1 year. Patient satisfaction is high, in particular regarding reported pain, fear and overall appreciation. No complications were seen. The data suggest that a lower number of macrobiopsies for microcalcifications could be acceptable with direct and frontal biopsy methods without reducing sensitivity. Lowering the number of biopsies can optimize the interpretation of surgical margin and reduce the number of biopsy-related mastectomies.