Contemporary breast imaging and concordance assessment: a surgical perspective

Safety and efficacy of tomosynthesis-guided breast biopsies in the prone position: monocentric study and review of the literature

PURPOSE

The purpose of this study is to describe the safety and efficacy of 9G needle biopsy under tomosynthesis guidance with the patient in the prone position.

MATERIALS AND METHODS

This is a retrospective observational study conducted on patients with non-palpable breast mass exclusively detectable through tomosynthesis, performed from the 1st January 2018 to the 1st August 2020. The procedures were performed by taking 12 tissue samples from each mass. The evaluated technical success was considered as a conclusive sample for histological diagnosis. We performed a comparison between the procedural data of interventions in patients who have a lesion < or = 10 mm and > 10 mm and between high-contrast and low-contrast masses. The histological data of the samples were analyzed.

RESULTS

Five hundred biopsies of the total 1500 performed from the 1st January 2018 to the 1st August 2020 were included in the study; repetitions for inadequate withdrawal occurred 0.4% (3/500). No major complications have ever been observed. Two cases (0.2%) of minor bleeding were observed with self-limited bleeding from the skin breach at 90 min without clinical sequelae in an asymptomatic patient. The biopsy samples showed carcinoma in 55.2% (276/500).

CONCLUSION

Our study suggests that the 9G needle sampling biopsy procedure through tomosynthesis guide with prone patient is a safe and effective procedure for the characterization of indeterminate breast mass.

Unveiling the histopathologic spectrum of MRI-guided breast biopsies: an institutional pathological-radiological correlation

PURPOSE

Breast magnetic resonance imaging (MRI) has high sensitivity but suffers from low specificity, resulting in many benign breast biopsies for MRI-detected lesions. We sought to compare histologic findings between patients who underwent MRI-guided breast biopsy versus biopsy via other imaging modalities as well as to examine features associated with malignancy in the MRI cohort to help inform MRI-biopsy practice.

METHODS

A 2-year (2018-2019) retrospective review of breast biopsies at our enterprise was conducted. Biopsies were categorized as stereotactic, ultrasound, MRI, or palpation guided. Pathology was categorized as benign (further divided into nine categories), atypical, or malignant (subdivided into in situ and invasive carcinoma). Pathology was compared between biopsy groups. Clinical, pathologic, and imaging features were compared between pathology groups within the MRI cohort.

RESULTS

5828 biopsies from 4154 patients were reviewed, including 548 MRI-guided biopsies with stratification of MRI-biopsy pathology as follows: 69% benign, 13.8% atypical, and 17.2% malignant. Among benign MRI biopsies, there was higher frequency of "clustered cysts with papillary apocrine metaplasia" (56/548; 10.2%) and lower rate of fibroadenoma/fibroadenomatous change (55/548; 10%) compared to other modalities (158 or 3% and 1144 or 21.7% of 5280 biopsies, respectively). Multivariate analysis revealed indication of breast cancer (p < .0001), ipsilateral cancer (p < .0001) and rapid initial phase kinetics (p = .017) to remain significantly associated with malignant MRI-biopsy pathology.

CONCLUSIONS

A concurrent or recent breast cancer diagnosis was most predictive of malignancy on MRI-guided breast biopsy. Combined MRI feature evaluation and radiologic-pathologic concordance activities may allow for prognostic refinement and improved risk stratification.

Clumped vs non-clumped internal enhancement patterns in linear non-mass enhancement on breast MRI

OBJECTIVE

To compare positive predictive values (PPVs) of clumped vs non-clumped (homogenous and heterogeneous) internal enhancement on MRI detected linear non-mass enhancement (NME) on MRI-guided vacuum-assisted breast biopsy (MRI-VABB).

METHODS

With IRB (Institutional Review Board) approval, we retrospectively reviewed 598 lesions undergoing MRI-VABB from January 2015 to April 2018 that showed linear NME. We reviewed the electronic medical records for MRI-VABB pathology, any subsequent surgery and clinical follow-up. The X² test was performed for univariate analysis.

RESULTS

There were 120/598 (20%) linear NME MRI-VABB lesions with clumped (52/120, 43%) vs non-clumped (68/120, 57%) internal enhancement, average size 1.8 cm (range 0.6-7.6 cm). On MRI-VABB, cancer was identified in 22/120 (18%) lesions, ductal carcinoma in situ (DCIS) was found in 18/22 (82%) and invasive cancer in 4 (18%). 3/31 (10%) high-risk lesions upgraded to DCIS at surgery, for a total of 25/120 (21%) malignancies. Malignancy was found in 12/52 (23%) clumped lesions and in 13/68 (19%) of non-clumped lesions that showed heterogeneous (5/13, 38%) or homogenous (8/13, 62%) internal enhancement. The PPV of linear NME with clumped internal enhancement (23.1%) was not significantly different from the PPV of non-clumped linear NME (19.1%) (p = 0.597). The PPV of linear NME lesions <1 cm (33.3%) was not significantly different from the PPV of lesions ≥1 cm (18.6%) (p = 0.157).

CONCLUSIONS

Linear NME showed malignancy in 21% of our series. Linear NME with clumped or non-clumped internal enhancement patterns, regardless of lesion size, might need to undergo MRI-VABB in appropriate populations.

ADVANCES IN KNOWLEDGE

Evaluation of linear NME lesions on breast MRI focuses especially on internal enhancement pattern.

When Does Atypical Ductal Hyperplasia Require Surgical Excision?

Atypical ductal hyperplasia (ADH) is a proliferative, nonobligate precursor breast lesion and a marker of increased risk for breast carcinoma. Surgical excision remains the standard recommendation following a core needle biopsy result consistent with ADH. Recent research suggests that women with no mass lesion or discordance, removal of greater than or equal to 90% of calcifications at the time of core needle biopsy, involvement of less than or equal to 2 terminal duct lobular units, and absence of cytologic atypia or necrosis are likely to have a less than 5% chance of a missed cancer.

Pathologic Findings of Breast Lesions Detected on Magnetic Resonance Imaging

CONTEXT

- Breast magnetic resonance imaging (MRI) is now used routinely for high-risk screening and in the evaluation of the extent of disease in newly diagnosed breast cancer patients. Morphologic characteristics and the kinetic pattern largely determine how suspicious a breast lesion is on MRI. Because of its high sensitivity, MRI identifies a large number of suspicious lesions. However, the low to moderate specificity and the additional cost have raised questions regarding its frequent use.

OBJECTIVES

- To identify the pathologic entities that frequently present as suspicious enhancing lesions and to identify specific MRI characteristics that may be predictive of malignancy.

DESIGN

- One hundred seventy-seven MRI-guided biopsies from 152 patients were included in the study. The indication for MRI, MRI features, pathologic findings, and patient demographics were recorded. The MRI findings and the pathology slides were reviewed by a dedicated breast radiologist and breast pathologists.

RESULTS

- Seventy-one percent (126 of 177) of MRI-guided breast biopsies were benign, 11% (20 of 177) showed epithelial atypia, and 18% (31 of 177) showed malignancy. The vast majority (84%; 62 of 74) of MRI lesions with persistent kinetics were benign. However, 57% (17 of 30) of lesions with washout kinetics and 65% (62 of 95) of mass lesions were also benign.

CONCLUSIONS

- Magnetic resonance imaging detects malignancies undetected by other imaging modalities but also detects a wide variety of benign lesions. Benign and malignant lesions identified by MRI share similar morphologic and kinetic features, necessitating biopsy for histologic confirmation.

Toolbox to Reduce Lumpectomy Reoperations and Improve Cosmetic Outcome in Breast Cancer Patients: The American Society of Breast Surgeons Consensus Conference

BACKGROUND

Multiple recent reports have documented significant variability of reoperation rates after initial lumpectomy for breast cancer. To address this issue, a multidisciplinary consensus conference was convened during the American Society of Breast Surgeons 2015 annual meeting.

METHODS

The conference mission statement was to "reduce the national reoperation rate in patients undergoing breast conserving surgery for cancer, without increasing mastectomy rates or adversely affecting cosmetic outcome, thereby improving value of care." The goal was to develop a toolbox of recommendations to reduce the variability of reoperation rates and improve cosmetic outcomes. Conference participants included providers from multiple disciplines involved with breast cancer care, as well as a patient representative. Updated systematic reviews of the literature and invited presentations were sent to participants in advance. After topic presentations, voting occurred for choice of tools, level of evidence, and strength of recommendation.

RESULTS

The following tools were recommended with varied levels of evidence and strength of recommendation: compliance with the SSO-ASTRO Margin Guideline; needle biopsy for diagnosis before surgical excision of breast cancer; full-field digital diagnostic mammography with ultrasound as needed; use of oncoplastic techniques; image-guided lesion localization; specimen imaging for nonpalpable cancers; use of specialized techniques for intraoperative management, including excisional cavity shave biopsies and intraoperative pathology assessment; formal pre- and postoperative planning strategies; and patient-reported outcome measurement.

CONCLUSIONS

A practical approach to performance improvement was used by the American Society of Breast Surgeons to create a toolbox of options to reduce lumpectomy reoperations and improve cosmetic outcomes.

Evaluation of office ultrasound usage among Australian and New Zealand breast surgeons

BACKGROUND

Surgeon performed ultrasound (US) is being increasingly embraced by breast surgeons worldwide as an integral part of patient assessment. The extent of its application within Australia and New Zealand is not well documented. The present study aimed to evaluate its current usage patterns and to determine suitable future training models.

METHODS

An online survey was sent to members of Breast Surgeons of Australia and New Zealand (BreastSurgANZ) between July and September 2010, with emphases on practice demographics, access to US equipment, usage, biopsy patterns, and training.

RESULTS

Of the 126 surveys sent, 59 were returned. The majority of respondents were metropolitan based (64 %), worked in both public and private sectors (71 %), and practiced endocrine or general surgery (85 %), as well as breast surgery. A preponderance of surgeons had access to equipment (63 %), performed at least 1 US monthly (63 %), but did not perform regular guided biopsies. Rural practice did not affect access or usage patterns. Most respondents underwent structured US training (73 %), which was associated with greater US and biopsy usage, biopsy complexity, intraoperative applications, and cross discipline applications (p < 0.03). Most surgeons favored a structured training program for future trainees (83 %).

CONCLUSIONS

The majority of breast surgeons from Australia and New Zealand have adopted office US to varying degrees. Geographic variation did not lead to access inequity and variation in scanning patterns. Formal US training may result in a wider scope of clinical applications by increasing operator confidence and is the preferred model within a specialist breast surgical curriculum.

Surgical management of high-risk breast lesions

High-risk lesions of the breast are lesions that confer an increased risk of breast cancer, either because of an increased probability of finding cancer associated with percutaneous biopsy findings or because of an increased probability of developing breast cancer over the long term. Atypical ductal hyperplasia found on percutaneous biopsy is generally excised, whereas lobular neoplasia lesions, including both atypical lobular hyperplasia and lobular carcinoma in situ, may be observed if radiologic and pathologic findings are concordant and there is no other high-risk lesion present.

Single-photon-emission computed tomography (SPECT) with technetium-99m sestamibi in the diagnosis of small breast cancer and axillary lymph node involvement

BACKGROUND

In a prospective study we evaluated the accuracy, sensitivity, and specificity of single-photon-emission computed tomography (SPECT) technetium-99m (99Tcm) sestamibi scintimammography to differentiate between benign and malignant small solid lesions of the breast, and to diagnose axillary node involvement in patients with small breast tumors.

METHODS

We prospectively evaluated 172 women with a solid lesion of the breast less than 3 cm in diameter and no evidence of axillary lymph node involvement on physical examination, ultrasound, and mammography. Thereafter, all patients underwent excision of the lesion, and, if pathology was positive for cancer, quadrantectomy and axillary lymph node dissection independently by the results of scintimammography.

RESULTS

There were 92 patients with a benign lesion and 80 patients with cancer. SPECT scintimammography correctly identified all 80 patients with cancer; there were six false-positive cases and no false-negative cases for a test efficacy of 96.5%, sensitivity of 100%, and specificity of 93.5%. Forty-five of the 80 patients with cancer had axillary lymph node involvement and scintimammography correctly identified 39 of the 45 patients. There was one false-positive case and six false-negative cases for a test efficacy of 90%, sensitivity of 86.4%, and specificity of 97.5%.

CONCLUSION

SPECT scintimammography should be considered selectively in the preoperative evaluation of patients with small solid lesions of the breast. It allows correct identification of patients with cancer and identification of a significant number of patients with axillary lymph node involvement.