Potential application of ultrasound-guided vacuum-assisted excision (US-VAE) for well-selected intraductal papillomas of the breast: single-institutional experiences

Ultrasound-guided 8-Gauge vacuum-assisted excision for selected B3 breast lesions: a preliminary experience

PURPOSE

Nowadays, surgical excision is no longer justified for all B3 lesions and a minimally-invasive therapeutic treatment has been encouraged. The aim of this study was to evaluate the feasibility and the therapeutic efficacy of ultrasound-guided vacuum-assisted excision (US-VAE) for the treatment of selected breast lesions of uncertain malignant potential (B3).

MATERIAL AND METHODS

From July 2018 to December 2019, 11/48 breast lesions classified as B3 after ultrasound-guided core needle biopsy were treated with US-VAE in our Institution. Inclusion criteria were: B3 nodules ultrasonographically detectable for which VAE is recommended by international guidelines², size ranging between 5 and 25 mm, circumscribed margins, and lesion position at least 5 mm from the skin and the nipple. A radiological follow-up to evaluate the completeness of excision, the presence of post-procedural hematoma or of residual disease/recurrence was performed after 10 and 30 days and 6 and 12 months. 12-month ultrasound was considered the gold standard. All patients were asked to complete a satisfaction survey and a full assessment of the costs of US-VAE was performed.

RESULTS

Complete excision was achieved in 81.8% of US-VAE. No lesions were upgraded to carcinoma and no patients had to undergo surgery. No complications occurred during or after US-VAE. All patients were satisfied with the procedure and the cosmetic result (100%). US-VAE cost approximately 422 Euros per procedure.

CONCLUSION

US-VAE has proven to be an optimal tool for the therapeutic excision of selected B3 lesions, with high success rate, good patient compliance and considerable money savings compared to surgery. This technique has the potential to reduce unnecessary surgery and healthcare costs.

Prediction of postoperative hematoma occurrence after ultrasound-guided vacuum-assisted breast biopsy in minimally invasive surgery for percutaneous removal of benign breast lesions

Background

The exact factors and mechanisms involved in the development of hematoma after breast ultrasound (US)-guided vacuum-assisted biopsy (VAB) are not clear. This study aimed to analyze the occurrence, prognosis, and risk factors of hematoma after US-guided VAB for the removal of benign breast lesions.

Methods

This was a retrospective study of consecutive female patients with breast lesions (BI-RADS 3/4a/4b and confirmed as benign by core needle biopsy) removed by percutaneous excisional biopsy by US-guided VAB at the Beijing Chaoyang Hospital from April 2016 to December 2018. Univariable analyses were conducted to identify the factors associated with hematoma (age, nodule size, laterality, nodule location, number of nodules, BI-RADS classification of ultrasound, pathology, breast shape, menstrual period, efficacy time of bandage, and hemostatic agents). Multivariable analysis was performed to identify the factors independently associated with hematoma.

Results

A total of 293 patients (343 breast lesions) were included. Lesion removal was successful in all cases. Hematomas ≥1 cm were found in 39 patients. Finally, 38 (97.4%) hematomas were absorbed completely within 6 months. The multivariable logistic regression analysis revealed that lesion size (P<0.001; OR: 5.775; 95% CI: 2.752-12.121), number of lesions (P=0.011; OR: 3.205, 95% CI: 1.311-7.834), and the efficacy time of bandage 12-24 h (P=0.003; OR: 5.257, 95% CI: 1.792-15.421) were independently associated with hematoma occurrence after US-guided VAB excision of breast lesions. A lesion size cut-off of 23.4 mm (AUC 0.764, 95% CI: 0.692-0.837; 59.0% sensitivity; 80.3% specificity; 77.5% accuracy; P<0.001) could predict hematoma occurrence.

Conclusions

US-guided excisional VAB can effectively remove benign breast lesions. The factors independently associated with postoperative hematoma are lesion size, lesion number, and effective postoperative compression time of bandage.

Ultrasound-guided 7-gauge vacuum-assisted core biopsy: Could it be sufficient for the diagnosis and treatment of intraductal papilloma?

The aim of this study was to evaluate whether ultrasound-guided 7-gauge vacuum-assisted core biopsy is sufficient for the diagnosis and treatment of intraductal papilloma and to evaluate the lesion characteristics and histologic features affecting the excision rate of papilloma with vacuum-assisted core biopsy. Between March 2008 and October 2016, 2816 patients underwent US-guided, 7-gauge vacuum-assisted core biopsy (VACB). In them, 101 (3.6%) were demonstrated to have intraductal papilloma by pathology. The accurate diagnostic rate and excision rate of intraductal papilloma after vacuum-assisted core biopsy were evaluated by open surgical biopsy or follow-up US. The lesion characteristics and histologic features were analyzed to identify factors affecting the excision rate of papilloma after VACB. Of the 101 intraductal papillomas, 83 (82.2%) cases were benign papilloma. Two cases were intraductal papilloma accompanied by invasive carcinoma. Sixteen (15.8%) cases were with signs of atypical hyperplasia. In them, one intraductal papilloma accompanied by severe atypical hyperplasia underwent further surgery, and it was demonstrated to have intraductal papilloma accompanied by invasive carcinoma. The accurate diagnostic rate of intraductal papillomas by 7-gauge VACB was 99.0% (100/101). There was no recurrence or malignant transformation in 85.1% (86/101) intraductal papillomas after 7-gauge vacuum-assisted core biopsy. Intraductal papilloma with largest diameter <1 cm, with clear margin, without branch involvement or calcification had a significantly higher excision rate. Seven-gauge VACB is an effective method for the diagnosis of intraductal papilloma of the breast. If histopathological examination confirms a benign character of the lesion, surgery may be avoided but regular follow-up is recommended. If histopathological examination confirms a papilloma with moderate to severe atypical hyperplasia, it was strongly recommended for surgical excision. Lesion characteristics and histologic features could affect the excision rate of intraductal papillomas with VACB.

Percutaneous Removal of Benign Breast Lesions with an Ultrasound-guided Vacuum-assisted System: Influence Factors in the Hematoma Formation

Objective To explore the influence factors in hematoma formation after removing benign breast lesions with an ultrasound-guided vacuum-assisted system.Methods A total of 232 females with 312 benign breast masses received excisional biopsy with ultrasound- guided vacuum-assisted system. The pathology of patients, Results of hematoma development and outcome, influence factors for hematoma occurrence (nodule size, nodule location, number of nodule, breast shape, menstrual period, efficacy time of bandage, and application of hemostatic agents during the procedure) were recorded.Results Pathologic examination revealed fibroadenomas in 138 lesions, fibroadenosis in 127 lesions, intraductal papillomas in 39 lesions, inflammatory change in 4 lesions, retention cyst of the breast in 3 lesions, and benign phyllodes tumor in 1 lesion. Thirty hematomas were observed in patients (9.6%). Finally, 97.0% hematomas were absorbed completely within 6 months follow-up. The incidence rates of hematoma were increased by 24.7%, 10.0%, 63.2%, 13.9% in the nodule diameter larger or equal to 25 mm group, removal of larger or equal to two nodules once time from one patient group, menstrual period group, and larger and loose breast group, respectively (all P<0.05). However, the incidences were decreased by 60.6% in the bandage performed for 12-24 hours or beyond 24 hours group (P<0.05). The multiple logistic regression models revealed that nodule size (χ²=15.227, P<0.001), number of nodule (χ²=7.767, P=0.005), menstrual period (χ²=24.530, P<0.001), and breast shape (χ²=9.559, P=0.002) were independent risk factors associated with hematoma occurrence, but efficacy time of bandage was a protective factor associated with hematoma occurrence.Conclusion The occurrence of hematoma after the minimally invasive operation was associated with nodule size, number of nodule, menstrual period, breast shape, and efficacy time of bandage.

Breast Cancer Risk Associated With Benign Intraductal Papillomas Initially Diagnosed on Core Needle Biopsy

BACKGROUND

The long-term risk for patients with benign intraductal papillomas (IDPs) on core needle biopsy (CNB) who are not upgraded on excision is not well-defined. The goal of this study was to determine the cumulative breast cancer (BC) incidence for patients with benign IDP on CNB.

MATERIALS AND METHODS

There were 152 benign IDPs diagnosed on CNB between 2003 and 2008. Radiology and pathology data were reviewed by breast radiologists and pathologists. Clinical follow-up was obtained from the electronic medical record (Epic).

RESULTS

Excision results were: 96 (63%) not upgraded, 9 (6%) with BC on excision (6 ductal carcinoma in situ, 3 invasive carcinoma), and 5 (3%) lacked correlation with the CNB site. Excision reports were unavailable for 42 (28%). Excluding cases with Breast Imaging Reporting and Data System (BI-RADS) 5 or discordant imaging, there were 6 (4%) true upgrades (all ductal carcinoma in situ). After the exclusion of patients with other major risk factors, follow-up was available for 55 of 58 patients with benign IDPs, and 8 (14%) developed BC after a median of 112 months (range, 11-159 months). None of the benign IDP patients without an excision report developed BC after a median of 97 months (range, 5-164 months).

CONCLUSIONS

The upgrade rate for benign IDP diagnosed on CNB was 4%, similar to recent studies. The cumulative BC incidence for those who were not upgraded and who had no history of BC was 14% at a median of 9 years. When combined with patients without an excision pathology report, the overall BC incidence was 9%. The findings support continued breast cancer surveillance in this patient population.

Shear-Wave Elastography for the Differential Diagnosis of Breast Papillary Lesions

OBJECTIVE

To evaluate the diagnostic performance of shear-wave elastography (SWE) for the differential diagnosis of breast papillary lesions.

METHODS

This study was an institutional review board-approved retrospective study, with a waiver of informed consent. A total of 79 breast papillary lesions in 71 consecutive women underwent ultrasound and SWE prior to biopsy. Ultrasound features and quantitative SWE parameters were recorded for each lesion. All lesions were surgically excised or excised using an ultrasound-guided vacuum-assisted method. The diagnostic performances of the quantitative SWE parameters were compared using the area under the receiver operating characteristic curve (AUC).

RESULTS

Of the 79 lesions, six (7.6%) were malignant and 12 (15.2%) were atypical. Orientation, margin, and the final BI-RADS ultrasound assessments were significantly different for the papillary lesions (p < 0.05). All qualitative SWE parameters were significantly different (p < 0.05). The AUC values for SWE parameters of benign and atypical or malignant papillary lesions ranged from 0.707 to 0.757 (sensitivity, 44.4-94.4%; specificity, 42.6-88.5%). The maximum elasticity and the mean elasticity showed the highest AUC (0.757) to differentiate papillary lesions.

CONCLUSION

SWE provides additional information for the differential diagnosis of breast papillary lesions. Quantitative SWE features were helpful to differentiate breast papillary lesions.

Completely removing solitary intraductal papillomas using the Mammotome system guided by ultrasonography is feasible and safe

BACKGROUND

Because of the potential for an intraductal papilloma to progress to malignancy and the likelihood of detecting unexpected coexisting malignant disease, complete removal of the intraductal papilloma is safer than merely sampling it. The purpose of this study was to estimate the feasibility and safety of excising a solitary intraductal papilloma using the Mammotome system guided by ultrasonography (US).

METHODS

We retrospectively reviewed the clinical information of 136 patients who underwent excision of solitary intraductal papillomas using the 8-gauge probe with the US-guided Mammotome system between December 2005 and December 2011 at our institution. Their lesions had been suspected preoperatively or were occasionally diagnosed postoperatively.

RESULTS

There were no local recurrences during the follow-up period. Of the patients who showed atypia and underwent re-excision, only 2 (6.1 %) had local ductal atypia. The patients with atypia were significantly older than the patients without atypia (p < 0.05).

CONCLUSIONS

Using the US-guided 8-gauge probe Mammotome system to completely remove a solitary intraductal papilloma is feasible and safe. Close follow-up may be considered for those whose lesions exhibit atypia.

Benign papillomas without atypia diagnosed on core needle biopsy: experience from a single institution and proposed criteria for excision

BACKGROUND

The management of benign papilloma (BP) without atypia identified on breast core needle biopsy (CNB) is controversial. In this study, we determined the upgrade rate to malignancy for BPs without atypia diagnosed on CNB and whether there are factors associated with upgrade.

METHODS

Through our pathology database search, we studied 80 BPs without atypia identified on CNB from 80 patients from 1997 to 2010, including 30 lesions that had undergone excision and 50 lesions that had undergone ≥ 2 years of radiologic follow-up. Associations between surgery or upgrade to malignancy and clinical, radiologic, and pathologic features were analyzed.

RESULTS

Mass lesions, lesions sampled by ultrasound-guided CNB, and palpable lesions were associated with surgical excision. All 3 upgraded cases were mass lesions sampled by ultrasound-guided CNB. None of the lesions with radiologic follow-up only were upgraded to malignancy. The overall upgrade rate was 3.8%. None of the clinical, radiologic, or histologic features were predictive of upgrade.

CONCLUSION

Because the majority of patients can be safely managed with radiologic surveillance, a selective approach for surgical excision is recommended. Our proposed criteria for excision include pathologic/radiologic discordance or sampling by ultrasound-guided CNB without vacuum assistance when the patient is symptomatic or lesion size is ≥ 1.5 cm.

Characterisation of breast papillary neoplasm on automated breast ultrasound

Intraductal papillary neoplasms of the breast form a wide spectrum of pathological changes with benign intraductal papilloma and papillary carcinoma. They can occur anywhere within the breast ductal system. This review illustrates some characteristic appearances of breast papillary neoplasms on coronal planes reconstructed by automatic breast volume scan. Such manifestations are not uncommon in papillary neoplasms, and familiarity will enable confident diagnosis.

Comparison of sonographically guided core needle biopsy and excision in breast papillomas: clinical and sonographic features predictive of malignancy

OBJECTIVES

The aim of this study was to evaluate the clinical factors and sonographic features of benign papillomas of the breast proven by sonographically guided 14-gauge core needle biopsy and their upgrade or malignancy rate after sonographically guided vacuum-assisted excision or surgical excision.

METHODS

We reviewed the medical records of patients who underwent core needle biopsy from July 2005 to December 2011. We evaluated 39 benign papillomas without atypia in 34 patients. The papillomas were diagnosed by core needle biopsy and underwent surgical or vacuum-assisted excision. After core needle biopsy, imaging-histologic correlation was performed to determine concordance. The upgrade and malignancy rates were assessed after surgical or vacuum-assisted excision, and associated clinical and radiologic factors, including patient age, lesion size, distance from the nipple, sonographic features, and American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) category were evaluated.

RESULTS

Three lesions (7.7 %) among 39 papillomas were upgraded to papilloma with atypia after surgical excision. There was no malignancy after excision. The upgrade rates for BI-RADS categories 3, 4a, 4b, and 4c were 0%, 6.9%, 0%, and 20%, respectively. There were no significant differences in the upgrade to papilloma with atypia in terms of the presence of symptoms, lesion size, distance from the nipple, BI-RADS category, or imaging-histologic correlation.

CONCLUSIONS

Prediction of papilloma with atypia, not malignancy, was challenging because there were no associated clinical or radiologic factors to predict papilloma with atypia before excision. However, there was no malignancy after excision. Therefore, intensive surveillance is preferable to immediate surgical excision for benign papillomas diagnosed on core needle biopsy.

Microcalcification is an important factor in the management of breast intraductal papillomas diagnosed on core biopsy

The follow-up excision (FUE) results were analyzed from 370 cases diagnosed as intraductal papilloma on breast core needle biopsy (CNB) with no history of malignancy or other risk factors. Of these cases, 98.6% were rendered a Breast Imaging Reporting and Data System score of 4 on mammography before the CNB. Fifty-one cases (13.8%) were found to have microcalcifications on microscopic examination of CNB. A total of 7 (1.9%) of 370 cases were upgraded to invasive carcinoma, ductal carcinoma in situ, or pleomorphic lobular carcinoma in situ on FUE. Six of 51 (11.8%) cases with microcalcifications found on imaging and CNB were upgraded to ductal carcinoma in situ or invasive carcinoma, whereas only 1 (0.3%) of 319 cases without microcalcifications was upgraded to pleomorphic lobular carcinoma in situ (P = .003). Results of a multivariate analysis adjusted for age confirmed that microcalcifications was a risk factor for upgrading to cancer, independent of age. Our results indicate that surgical excision is required for intraductal papilloma diagnosed on CNB if microcalcifications are present. However, excision may not be required for those who have no microcalcifications on CNB and no other known risk factors.