Does core needle breast biopsy accurately reflect breast pathology?

Photon Absorption Remote Sensing Imaging of Breast Needle Core Biopsies Is Diagnostically Equivalent to Gold Standard H&E Histologic Assessment

Photon absorption remote sensing (PARS) is a new laser-based microscope technique that permits cellular-level resolution of unstained fresh, frozen, and fixed tissues. Our objective was to determine whether PARS could provide an image quality sufficient for the diagnostic assessment of breast cancer needle core biopsies (NCB). We PARS imaged and virtually H&E stained seven independent unstained formalin-fixed paraffin-embedded breast NCB sections. These identical tissue sections were subsequently stained with standard H&E and digitally scanned. Both the 40× PARS and H&E whole-slide images were assessed by seven breast cancer pathologists, masked to the origin of the images. A concordance analysis was performed to quantify the diagnostic performances of standard H&E and PARS virtual H&E. The PARS images were deemed to be of diagnostic quality, and pathologists were unable to distinguish the image origin, above that expected by chance. The diagnostic concordance on cancer vs. benign was high between PARS and conventional H&E (98% agreement) and there was complete agreement for within-PARS images. Similarly, agreement was substantial (kappa > 0.6) for specific cancer subtypes. PARS virtual H&E inter-rater reliability was broadly consistent with the published literature on diagnostic performance of conventional histology NCBs across all tested histologic features. PARS was able to image unstained tissues slides that were diagnostically equivalent to conventional H&E. Due to its ability to non-destructively image fixed and fresh tissues, and the suitability of the PARS output for artificial intelligence assistance in diagnosis, this technology has the potential to improve the speed and accuracy of breast cancer diagnosis.

Comparison of Core Needle Biopsy and Excision Specimens for the Accurate Evaluation of Breast Cancer Molecular Markers: a Report of 1003 Cases

In this study, we compared the accuracy of marker evaluation in core needle biopsy (CNB) specimens versus excision specimens (ESs) from breast cancer patients. This retrospective study used data collected from the breast cancer database at the West China Hospital, China. Immunohistochemistry (IHC) results from CNB specimens and ESs were compared, using estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), and Ki-67 as markers. Molecular subtyping and endocrine therapy usage correlations based on CNB samples and ESs were evaluated. The results obtained from CNB samples and ESs exhibited substantial agreement for the detection of ER (κ = 0.522), PR (κ = 0.441), and HER2 (κ = 0.451), and also influenced endocrine therapy usage. Fair and poor correlations were observed for Ki-67 staining and molecular subtyping (κ = 0.195), respectively. This disagreement might be attributable to a combination of heterogeneity and large tumor size. This study indicates that the discordance rate in molecular marker staining between CNB specimens and ESs is significant enough that results obtained with CNB specimens should be used cautiously or verified using ESs.

Ductal carcinoma in situ and sentinel lymph node biopsy

PURPOSE

Axillary lymph node status is the strongest prognostic indicator of survival for women with breast cancer. The purpose of this study was to evaluate whether sentinel lymph node biopsy (SLNB) is required in patients with an initial diagnosis of ductal carcinoma in situ (DCIS).

METHODS

A retrospective analysis was performed of 78 patients with an initial diagnosis of DCIS between December 2002 and April 2010 and who proceeded to have either SLNB or axillary node dissection performed as part of their primary surgical procedure. The study focused on the rates of axillary node metastasis and the underestimation of invasive carcinoma at an initial diagnosis.

RESULTS

Forty-eight patients underwent SLNB and 18 patients underwent axillary node dissection. Only 1 of 66 patients (1.5%) had a positive sentinel lymph node. After definite surgery, the final diagnosis was changed to invasive ductal carcinoma (IDC) in 12 patients and DCIS with microinvasion in 2 patients; 14 of 78 patients (17.9%) were therefore underestimated at preoperative histological examinations. In 35 patients who were diagnosed DCIS by core needle biopsy (CNB), 13 patients (37.1%) were upstaged into IDC or DCIS with microinvasion in the final diagnosis. The statistically significant factors predictive of invasive breast cancer were a large tumor size and HER2 overexpression.

CONCLUSION

The rates of SLNB positivity in pure DCIS are very low, and there is continuing uncertainty about its clinical importance. However in view of the high rate of underestimation of invasive carcinoma in patients with an initial diagnosis of DCIS, SLNB appears to be appropriate in these patients, especially in the case when DCIS is diagnosed by a core needle biopsy. In patients with an initial diagnosis of DCIS by CNB, SLNB should be considered as part of the primary surgical procedure, when preoperative variables show a tumor larger than 2.35 cm and with HER2 overexpression.

Imaging-histologic discordance after sonographically guided percutaneous breast biopsy: a prospective observational study

The objective of this study was to determine the frequency of imaging-histologic discordance and to compare the frequency of carcinoma between concordant and discordant lesions in sonographically (US)-guided 14-gauge core needle biopsies (CNBs). From January 2005 to December 2006, we performed US-guided 14-gauge automated CNB on 3339 breast lesions and obtained benign results in 2194 cases. Five radiologists prospectively reviewed the pathologic reports in conjunction with the imaging. We included a total of 1588 lesions that were either excised (n = 658) or followed up for at least 2 years (n = 930) after CNB. We evaluated the rate of discordance and the clinical findings for both discordant and concordant lesions. We also analyzed the clinical and imaging differences between the upgrade and non-upgrade groups. Imaging-histologic discordance was present in 103 of 1588 (6.5%) lesions. The upgrade rate was 6.8% (7/103) in discordant lesions and 0.4% (6/1485) in concordant lesions (p < 0.01). Lesion size, Breast Imaging, Reporting and Data System (BI-RADS) category and the presence or absence of symptoms was statistically significant between the upgrade and non-upgrade groups in discordant cases (p < .05). Imaging-histologic discordance is an indication for excision because it has a higher upgrade rate than concordant lesions.

Implementation of a percutaneous core needle biopsy training program: results from the University of Michigan-Komfo Anokye Teaching Hospital breast cancer research partnership

PURPOSE

To describe a training program in percutaneous core needle biopsy implemented in conjunction with a breast cancer research collaboration between the University of Michigan (UM) and the Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana.

METHODS

In July 2007 a Ghana-based training program for performance of core needle biopsy was jointly coordinated by the UM and KATH principal investigators (L.N. and B.A.). This course required less than 1 week for implementation.

RESULTS

Following the training course (July 2007 through August 2008), 82 core needle biopsies of breast masses were performed at KATH. Of these, 56 had tissue specimens available for review at UM for comparison with KATH primary pathology reports. Forty-six of the 56 UM-reviewed cases (82%) had a KATH diagnosis of breast cancer; UM pathology review was in agreement with the cancer diagnosis in all 46 cases (100%). Ten of the 56 UM-reviewed cases (18%) had a KATH diagnosis of benign fibroadenoma/fibrocystic breast tissue; UM review was concordant in all ten cases (100% concordance for benign lesions). For the remaining 26 procedures we were unable to retrieve either the KATH pathology report or tissue blocks for UM review.

DISCUSSION

The design and implementation of appropriate diagnostic biopsy programs is important for delivery of high-quality, efficient breast cancer care in developing nations. This study demonstrates a successful 1-week training program in percutaneous core needle biopsy for a multidisciplinary group of physicians. Further work is needed for similar programs to accurately identify and classify breast cancer internationally.

Integrated optical coherence tomography and microscopy for ex vivo multiscale evaluation of human breast tissues

Three-dimensional (3D) tissue imaging methods are expected to improve surgical management of cancer. In this study, we examined the feasibility of two 3D imaging technologies, optical coherence tomography (OCT) and optical coherence microscopy (OCM), to view human breast specimens based on intrinsic optical contrast. Specifically, we imaged 44 ex vivo breast specimens including 34 benign and 10 malignant lesions with an integrated OCT and OCM system developed in our laboratory. The system enabled 4-μm axial resolution (OCT and OCM) with 14-μm (OCT) and 2-μm (OCM) transverse resolutions, respectively. OCT and OCM images were compared with corresponding histologic sections to identify characteristic features from benign and malignant breast lesions at multiple resolution scales. OCT and OCM provide complimentary information about tissue microstructure, thus showing distinctive patterns for adipose tissue, fibrous stroma, breast lobules and ducts, cysts and microcysts, as well as in situ and invasive carcinomas. The 3D imaging capability of OCT and OCM provided complementary information to individual 2D images, thereby allowing tracking features from different levels to identify low-contrast structures that were difficult to appreciate from single images alone. Our results lay the foundation for future in vivo optical evaluation of breast tissues, using OCT and OCM, which has the potential to guide core needle biopsies, assess surgical margins, and evaluate nodal involvement in breast cancer.

Can concurrent core biopsy and fine needle aspiration biopsy improve the false negative rate of sonographically detectable breast lesions?

Background

The aims of this study were to determine the accuracy of concurrent core needle biopsy (CNB) and fine needle aspiration biopsy (FNAB) for breast lesions and to estimate the false-negative rate using the two methods combined.

Methods

Over a seven-year period, 2053 patients with sonographically detectable breast lesions underwent concurrent ultrasound-guided CNB and FNAB. The sonographic and histopathological findings were classified into four categories: benign, indeterminate, suspicious, and malignant. The histopathological findings were compared with the definitive excision pathology results. Patients with benign core biopsies underwent a detailed review to determine the false-negative rate. The correlations between the ultrasonography, FNAB, and CNB were determined.

Results

Eight hundred eighty patients were diagnosed with malignant disease, and of these, 23 (2.5%) diagnoses were found to be false-negative after core biopsy. After an intensive review of discordant FNAB results, the final false-negative rate was reduced to 1.1% (p-value = 0.025). The kappa coefficients for correlations between methods were 0.304 (p-value < 0.0001) for ultrasound and FNAB, 0.254 (p-value < 0.0001) for ultrasound and CNB, and 0.726 (p-value < 0.0001) for FNAB and CNB.

Conclusions

Concurrent CNB and FNAB under ultrasound guidance can provide accurate preoperative diagnosis of breast lesions and provide important information for appropriate treatment. Identification of discordant results using careful radiological-histopathological correlation can reduce the false-negative rate.

Diagnostic Accuracy and Prognostic Value of Core Biopsy in the Management of Breast Cancer: A Series of 542 Patients

Purpose. Core biopsy is considered to be a highly accurate method for gaining preoperative diagnosis of breast cancer. The purpose of this study is to compare the results of core biopsy with those of the surgical excision specimen. Experimental design. A total of 567 core biopsies with subsequent surgical excision were performed. Results. In 488 patients, invasive breast cancer was diagnosed in the preoperative biopsy and in 486 patients (99.6%) the surgical specimen showed identical results. In 160 of the 502 patients (32%) with invasive breast cancer, DCIS was found in the surgical specimen but was not diagnosed in the biopsy. Estrogen and progesterone receptor demonstrated a high rate of agreement, Her2/neu analysis showed a complete concordance in 54% of patients. Conclusions. Core biopsies allow diagnosis of invasive breast cancer with high accuracy. Levels of agreement have to be improved for the detection of DCIS and Her2/neu status.

Imaging-histologic discordance at sonographically guided percutaneous biopsy of breast lesions

OBJECTIVE

To determine the frequency of imaging-histologic discordance at percutaneous breast biopsy and to evaluate differences in clinical and radiologic findings between pathologically upgraded lesions and non-upgraded lesions.

MATERIALS AND METHODS

From February 2000 to June 2005, we reviewed 386 cases that had suspicious imaging findings but yielded benign histology at US-core needle biopsy and that underwent subsequent excisional biopsy. In 74 of 386 cases, the benign histology at core needle biopsy could not provide a satisfactory explanation for the radiologically suspicious lesions. The clinical, radiologic and histologic findings were reviewed for those 74 cases that were classified as the upgrade group and the non-upgrade group after excisional biopsy.

RESULTS

The upgrade rate was 17.6% (95% confidence interval, 10.6-27.8%, 13 of 74 cases) revealed upgraded pathology at the subsequent excisional biopsy. Besides the size of masses, there were no statistically significant differences in imaging findings between the upgrade and non-upgrade groups at excisional biopsy.

CONCLUSION

This upgrade rate of 17.6% suggests that excisional biopsy or re-biopsy is warranted in those cases presenting imaging-histologic discordance at US-guided core biopsy.

Needle core biopsy in the diagnosis of phyllodes neoplasm

BACKGROUND

Accurate identification of phyllodes neoplasms without surgical intervention is difficult, reducing the ability to manage "benign" lumps non-operatively and impacting on the open benign biopsy rate. Needle core biopsy is considered to be a highly accurate technique in the diagnosis of breast carcinoma. Its accuracy in the diagnosis of phyllodes neoplasm has not been established.

METHODS

A series of 3729 core biopsies performed between January 1999 and July 2005 were examined. All core biopsies followed by surgical excision were identified. Histologic concordance between core biopsy and excision specimen was analyzed.

RESULTS

Twenty-three patients had phyllodes neoplasm on excisional biopsy with prior core biopsy findings as follows: phyllodes neoplasm (n=2), "equivocal" for phyllodes neoplasm (n=12), fibroadenoma (n=3), benign (n=6). The false negative rate for phyllodes neoplasm was therefore 39% (n=9/23). Of the total biopsy series, 35 patients had a core biopsy suggesting the possibility of phyllodes neoplasm. Of these, 32% (n=11) were found to be phyllodes neoplasm on excision, 3% (n=1) phyllodes neoplasm with breast carcinoma, 6% (n=2) breast carcinoma, and 3% (n=1) sarcoma. When a preference for phyllodes neoplasm (n=4) was stated on the equivocal core biopsies, excision correlated with the stated preference; this correlation also occurred in 90% (n=9/10) of core biopsies where fibroadenoma was favored.

CONCLUSIONS

Needle core biopsy rarely produces a definite preoperative diagnosis of phyllodes neoplasm. A diagnosis of fibroadenoma or equivocal phyllodes neoplasm on core biopsy should not prevent excision if clinical suspicion remains.

MR-guided breast biopsy and hook wire marking using a low-field (0.23 T) scanner with optical instrument tracking

The purpose of this study was to evaluate the technical feasibility of MR-guided percutaneous breast biopsy (LCNB) and breast hook wire marking in a low-field (0.23 T) MRI system with optical instrument tracking. MR-guided core biopsy and/or hook wire marking was performed on 13 lesions observable at MR imaging only. Seven breast LCNBs and 10 hook wire markings were performed under MR guidance on 11 patients. The diagnosis was confirmed by excision biopsy or mastectomy in 12 lesions and with histopathological and cytological diagnosis and 12-month clinical follow-up in one lesion. All lesions seen in the high-field scanner were also successfully identified and targeted in the low-field scanner. The following procedures were typically technically successful. There were difficulties due to unsatisfactory functioning of some core biopsy guns. Detailed description of low-field MR guidance and optical tracking in breast biopsies is provided. The procedure seems accurate and safe and provides means to obtain a histological diagnosis of a breast lesion only seen with MRI. The low-field biopsy system is comparable to the high-field MRI system. MR-compatible biopsy guns need to be improved.

Diagnostic accuracy of core biopsy for ductal carcinoma in situ and its implications for surgical practice

BACKGROUND

Core biopsy is considered to be a highly accurate method of gaining a preoperative histological diagnosis of breast cancer. Ductal carcinoma in situ (DCIS) is often impalpable and is a more subtle form of breast cancer.

AIM

To investigate the accuracy of core biopsy in the diagnosis of cancer in patients with DCIS.

METHODS

All patients who had invasive cancer (n = 959) or DCIS (n = 92) that was confirmed by excision between 1999 and 2004 were identified. The diagnostic methods, histology of the core biopsy specimen and excision histology were reviewed in detail.

RESULTS

Core biopsy was attempted in 88% (81/92) of patients with DCIS and in 91% (874/959) of those with invasive disease. Of those patients who underwent core biopsy, a diagnosis of carcinoma on the initial core was made in 65% (53/81) of patients with DCIS compared with 92% (800/874) of patients with invasive disease (p<0.0001). Smaller lesion size (p = 0.005) and lower grade (p = 0.03) were associated with increased risk for a negative or non-diagnostic core in patients with DCIS. The nature of the mammographic lesion or the method of biopsy did not affect the probability of an accurate core biopsy. Patients who had a preoperative diagnosis of DCIS by core biopsy had a reoperation rate of 36% compared with 65% of those that did not have a preoperative diagnosis (p = 0.007).

CONCLUSION

Although core biopsies are highly accurate forms of obtaining a preoperative diagnosis in patients with invasive breast cancer, this is not the case in DCIS. As the number of surgical procedures can be reduced by core biopsy, it is still of considerable value in the management of DCIS.

Follow-Up Recommendations for Benign Breast Biopsies

Histologically proven benign breast disease increases a woman's relative risk for subsequent cancer development. Yet follow-up guidelines for mammogram and clinical breast examination after a benign breast biopsy are lacking. Our objective was to determine if increased surveillance is indicated following a benign breast biopsy. Following institutional review board approval, a retrospective database review was conducted of prospectively gathered patients who had a benign breast biopsy (core or excisional) for an abnormality detected on mammogram, ultrasound, or clinical breast examination. Follow-up, for all subjects, was a clinical breast examination and mammogram or ultrasound at 6 months, 1 year, and 2 years after benign breast biopsy by a breast surgeon. End points were the need for additional biopsies or cancer detection. Statistical analysis was performed using chi-squared analysis. From January 2000 to July 2003, 156 patients age 18-86 years had a benign breast biopsy. During the 2 year follow-up, 20 patients (13%) required a subsequent biopsy. No significant difference was observed in mean age, race, menarche, menopause, parity, age at first live birth, use of oral contraceptives, history of prior biopsy, or the pathology of the initial lesion between those who needed a subsequent biopsy and those who did not. Seven excisional biopsies were performed (one at 6 months, four at 1 year, and two at 2 years follow-up) for growth of the benign breast biopsy lesion, and pathology remained concordant with the original diagnosis. Thirteen biopsies were done for new findings on mammogram or ultrasound. Three of these (1.9%) yielded a cancer diagnosis (one at 6 months, one at 1 year, and one at 2 years follow-up). No new lesions were identified on follow-up by clinical breast examination alone. Increased surveillance following a benign breast biopsy is necessary because of the increased need for subsequent biopsy or risk of cancer development. This should include imaging (mammography or ultrasound) and a clinical breast examination 6 months, 1 year, and 2 years after a benign breast biopsy.

Breast surgery: minimally invasive diagnosis and treatment

The increasingly large proportion of elderly women in the United States population carries a disproportionate burden of breast cancer. The advent of minimally invasive surgical techniques applicable to breast disease has brought new opportunities to diagnose and treat breast cancer in the older population. This article reviews issues important to the evolving field of breast cancer management in older women: cancer risk and screening considerations, diagnosis and biopsy approaches, and surgical treatment options based on current studies and recommendations.

The accuracy of ultrasound, stereotactic, and clinical core biopsies in the diagnosis of breast cancer, with an analysis of false-negative cases

OBJECTIVE

Preoperative core biopsy in breast cancer is becoming the standard of care. The aim of this study was to analyze the various methods of core biopsy with respect to diagnostic accuracy and to examine the management and outcome of those patients with false-negative biopsies.

METHODS

All patients undergoing core biopsy for breast abnormalities over a 5-year period (1999-2003) were reviewed. The accuracy rates for each method of core biopsy, the histologic agreement between the core pathology and subsequent excision pathology, and the length of follow-up for cases of benign disease were studied. Patients whose biopsies were benign but who were subsequently diagnosed with cancer underwent detailed review.

RESULTS

There were 2427 core biopsies performed over the 5-year period, resulting in a final diagnosis of cancer in 1384 patients, benign disease in 954 patients, and atypical disease in 89 patients. Biopsy type consisted of 1279 ultrasound-guided cores, 739 clinically guided cores, and 409 stereotactic-guided cores. The overall false-negative rate was 6.1%, with specific rates for ultrasound-, clinical-, and stereotactic-guided cores of 1.7%, 13%, and 8.9%, respectively. False-negative biopsies occurred in 85 patients, and in 8 of these patients the diagnosis was delayed by greater than 2 months. In all other false-negative cases, "triple assessment" review allowed prompt recognition of discordant biopsy results and further evaluation.

CONCLUSION

Ultrasound guidance should be used to perform core biopsies in evaluating all breast abnormalities visible on ultrasound. Adherence to principles of triple assessment following biopsy allows for early recognition of the majority of false-negative cases.

Ultrasound-guided large-core needle biopsies of breast lesions: analysis of 962 cases to determine the number of samples for reliable tumour classification

The objective of this one-institutional study was to determine the number of large-core needle biopsies (LCNB), under three-dimensional ultrasound (3D-US) validation, that are sufficient to obtain a reliable histological diagnosis of a sonographically detectable breast lesion. Over an 28-month period, 962 sonographically guided LCNB were performed under 3D-US validation to assess 962 breast lesions. All biopsies were carried out with an automated core biopsy device fitted with 14-gauge (22 mm excursion) needles. Data of 962 biopsied breast lesions were gathered. Surgical follow-up was available for 659 lesions. Breast malignancies were diagnosed by ultrasound-guided LCNB with a sensitivity of 98.2% by performing three cores per lesion. In few cases, the open surgical specimen revealed the presence of invasive carcinomas in contrast to initial LNCB-based classification as ductal carcinomas in situ (DCIS, 11 lesions), lobular carcinoma in situ (one lesion), and atypical ductal hyperpasia (one lesion). Owing to disagreement between classification based on breast-imaging and histological findings, eight of these tumours were subsequently excised. Of the lesions that were removed at the patients’ requests despite benign LCNB diagnosis, two were infiltrating carcinoma and one a DCIS. We demonstrate that three 3D-US-guided percutaneous core specimens are sufficient to achieve tissue for a reliable histological assessment of sonographically detectable breast lesions and allow the detection of malignancies with high sensitivity and low rate of false-negative diagnoses.

Core biopsy as a tool in planning the management of invasive breast cancer

Background

Core biopsy is a method of choice for the triple assessment of breast disease as it can reliably distinguish between benign and malignant tumours, between in-situ and invasive cancers and can be useful to assess oestrogen receptor status. This study was carried out to assess the reliability of core biopsy in predicting the grade and type of cancer accurately as obtaining this information can influence initial therapeutic decisions.

Patients and methods

A total of 105 patients who had invasive breast carcinoma diagnosed by core biopsy in year 2001 and who subsequently underwent surgical management were included. The core biopsy results were compared with final histology with the help of kappa statastics.

Results

A moderate level of agreement between the predicted grades and final grades was noted (kappa = 0.585). The agreement was good between predicted and final type of tumour (kappa = 0.639).

Conclusions

Core biopsy as a predictor of grade and type has limited use at present. We suggest that initial clinical decisions should not be based on the results of core biopsy.