Percutaneous ultrasound-guided vacuum-assisted excision of benign breast lesions: A learning curve to assess outcomes

Efficacy and safety of vacuum-assisted excision (VAE) of fibroadenomas: experience in a tertiary centre

PURPOSE

To evaluate the technical success and efficacy rates of US-guided percutaneous vacuum-assisted excision (VAE) of breast fibroadenomas, also assessing procedural complications and long-term patient satisfaction rates.

MATERIALS AND METHODS

The institutional database of a tertiary breast cancer referral centre was retrospectively reviewed to retrieve all women with fibroadenomas who underwent US-guided VAE between May 2011 and September 2019. We subsequently included in this study all fibroadenomas with a maximum diameter of 3 cm at US and an available histological confirmation obtained by core-needle biopsy before VAE. Immediately after VAE, technical success (defined as the correct VAE execution) and the occurrence of procedural complications were evaluated. Imaging follow-up (US ± mammography) after 6, 12, 24 and 36 months was performed to evaluate technical efficacy (defined as the absence of fibroadenoma recurrence at 6-month follow-up). Long-term patient satisfaction was evaluated with telephonic interviews in October 2022.

RESULTS

We retrospectively included 108 women (median age 46 years) with 110 fibroadenomas diagnosed at core-needle biopsy with a median lesion size at US of 12 mm. Technical success was obtained in 110/110 VAEs (100%). Minor procedural complications (haematomas) occurred in 7/110 VAEs (6%), whereas 8/110 patients had a fibroadenoma recurrence at 6-month follow-up, resulting in a 93% technical efficacy (102/110 VAEs). All patients available for telephonic follow-up (104/104, 100%) reported high satisfaction with VAE results.

CONCLUSION

US-guided VAE is a safe and effective procedure for the excision of fibroadenomas, representing a viable alternative to surgery, with a low complication rate and high patient satisfaction.

Implementation of vacuum-assisted excision as a management option for benign and high-risk breast lesions

OBJECTIVE

Previous studies have shown that vacuum-assisted excision (VAE) is a safe and effective alternative for surgical excision (SE) of benign breast lesions. However, the use of VAE in high-risk lesions is controversial and guidelines are ambiguous. This study describes the impact of the implementation of VAE in terms of management and outcomes compared to a cohort before implementation.

METHODS

A single centre retrospective study with two cohorts: 'before' and 'after' implementation of VAE was performed. All patients with a benign or high-risk lesion treated by VAE or SE between 2016 and 2019 were included. Excision, complication, and upgrade rates were compared between both cohorts. Cox regression was used for the evaluation of recurrences and re-excisions.

RESULTS

The overall excision rate of all benign and high-risk lesions was comparable in both cohorts (17% vs 16%, p = 0.700). After implementation, benign lesions were significantly more often managed by VAE (101/151, 67%, p < 0.001). Re-excision, recurrence, and complication rates were low and comparable between cohorts (4.3% vs 3.9%, p > 0.999; 3.0 vs 2.0%, p = 0.683; 3.4 vs 6.6%, p = 0.289, respectively).

CONCLUSION

SE could safely be replaced by VAE in 58% of patients treated for a benign or high-risk lesion. With this shift in management, the use of operating rooms and general anaesthesia can safely be omitted in this patient group. Further research on high-risk lesions is warranted since our data are exploratory.

ADVANCES IN KNOWLEDGE

This study provides supportive data for the use of VAE as a management option for both benign (up to 5 cm) and high-risk lesions. Outcomes on re-excision, recurrence should be confirmed in prospective studies especially in high-risk lesions.

An integrated radiomics nomogram based on conventional ultrasound improves discriminability between fibroadenoma and pure mucinous carcinoma in breast

Objective

To evaluate the ability of integrated radiomics nomogram based on ultrasound images to distinguish between breast fibroadenoma (FA) and pure mucinous carcinoma (P-MC).

Methods

One hundred seventy patients with FA or P-MC (120 in the training set and 50 in the test set) with definite pathological confirmation were retrospectively enrolled. Four hundred sixty-four radiomics features were extracted from conventional ultrasound (CUS) images, and radiomics score (Radscore) was constructed using the Least Absolute Shrinkage and Selection Operator (LASSO) algorithm. Different models were developed by a support vector machine (SVM), and the diagnostic performance of the different models was assessed and validated. A comparison of the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) was performed to evaluate the incremental value of the different models.

Results

Finally, 11 radiomics features were selected, and then Radscore was developed based on them, which was higher in P-MC in both cohorts. In the test group, the clinic + CUS + radiomics (Clin + CUS + Radscore) model achieved a significantly higher area under the curve (AUC) value (AUC = 0.86, 95% CI, 0.733-0.942) when compared with the clinic + radiomics (Clin + Radscore) (AUC = 0.76, 95% CI, 0.618-0.869, P > 0.05), clinic + CUS (Clin + CUS) (AUC = 0.76, 95% CI, 0.618-0.869, P< 0.05), Clin (AUC = 0.74, 95% CI, 0.600-0.854, P< 0.05), and Radscore (AUC = 0.64, 95% CI, 0.492-0.771, P< 0.05) models, respectively. The calibration curve and DCA also suggested excellent clinical value of the combined nomogram.

Conclusion

The combined Clin + CUS + Radscore model may help improve the differentiation of FA from P-MC.

Imaging of breast cancer-beyond the basics

Imaging of breast cancer is the backbone of breast cancer screening, diagnosis, preoperative/treatment assessment and follow-up. The main modalities are mammography, ultrasound and magnetic resonance imaging, each with its own advantages and disadvantages. New emerging technologies have also enabled each modality to improve on their weaknesses. Imaging-guided biopsies have allowed for accurate diagnosis of breast cancer, with low complication rates. The purpose of this article is to review the common modalities for breast cancer imaging in current practice with emphasis on the strengths and potential weaknesses, discuss the selection of the best imaging modality for the specific clinical question or patient population, and explore new technologies / future directions of breast cancer imaging.

Percutaneous vacuum-assisted excision (VAE) of breast lesions of uncertain malignant potential (B3 lesions): a preliminary single-centre Italian experience

PURPOSE

In recent years vacuum-assisted excision (VAE) has been described as an alternative treatment for some B3 lesions. This study aims to assess the effectiveness of using VAE to manage selected B3 lesions by quantifying the number of B3 lesions undergoing VAE, the malignant upgrade rate, and the complications encountered.

MATERIALS AND METHODS

Our department evaluated all B3 lesions diagnosed between January 2019 and October 2021 and treated them with VAE. The data were collected during the initial biopsy and final histology based on VAE image guidance, also considering initial lesions and complications. The exclusion criteria were: B3 lesion of size > 20 mm, presence of a concomitant malignant lesion, lesion < 5.0 mm distant from the skin, nipple or pectoral muscle, phyllodes tumours or indeterminate B3 lesions. Lesions that upgraded to malignancy underwent surgical excision, while benign lesions performed radiological follow-ups.

RESULTS

From 416 B3 lesions diagnosed, 67 (16.1%) underwent VAE. VAE was performed under X-ray (50/67) or ultrasound guidance (17/67). Five cases (7.5%) upgraded to a malignant lesion, 2 ADH, 2 LIN and one papillary lesion that underwent surgery. No malignancy or new lesions has occurred at the site of the VAE, with an average radiological follow-up of 14.9 months.

CONCLUSIONS

VAE could be a safe and effective pathway for managing selected B3 lesions. Lesions initially subjected to CNB with ADH and LN outcome, before undergoing VAE, should perform a VAB for better tissue characterization and management.

Learning curve in ultrasound-guided vacuum-assisted excision of breast lesions for surgeons and ultrasound physicians

Background

The varying experience of surgeons and ultrasound physicians, and their collaboration with physicians, may affect operation time and efficiency. We evaluated the learning curve of ultrasound-guided vacuum-assisted excision (VAE) of breast lesion with collaboration between different physicians, and assessed characteristics associated with operation time.

Methods

The sample population of this retrospective study was divided into two groups: 49 consecutive patient surgeries completed by skilled surgeons and novice ultrasound physicians (U group); and 30 consecutive patient surgeries completed by skilled ultrasound physicians and novice surgeons (S group). Cumulative summation graphs were used to evaluate operation time and calculate the turning point of the learning curve. Patients in the U and S groups were divided into exploration stage and proficiency stage according to the turning point, and the differences in influencing factors were compared. A total of 548 patients who underwent vacuum-assisted breast excision performed by a combination of skilled surgeons and skilled ultrasound physicians were selected as the reference group (R group). The differences among the three groups were compared. The relationship between the operation time and other factors in the different groups was analyzed using linear regression.

Results

The best learning curve of the sample population was the quadratic fitting equation, and the turning point was the 19th case in the U group and the 14th case in the S group. The total operation times in the proficiency stage were significantly shorter than those in the exploration stage in the U and S groups (P=0.012 and P=0.003, separately). Patient age, long diameter, short diameter, and depth of masses related to the operation time.

Conclusions

Our data suggest the existence of different learning curves in ultrasound-guided vacuum-assisted excision for the collaborations of different stages surgeons and ultrasound physicians. Through the accumulation of experience, it is feasible to safely perform ultrasound-guided VAE of breast lesions.

Comparison of ultrasound-guided microwave ablation and ultrasound-guided vacuum-assisted excision for treating breast lesions of uncertain malignant potential (B3 lesions): A retrospective study

AIMS

To compare the safety and therapeutic effect of ultrasound (US)-guided microwave ablation (MWA) and US-guided vacuum-assisted excision (VAE) for patients with B3 lesions of the breast.

METHODS

Patients who underwent US-guided MWA or US-guided VAE at Sichuan Tumor Hospital from January 2016 to December 2021 were retrospectively analyzed. The technical success rate and residual rate of the two minimally invasive surgeries were recorded. During follow-up, differences in symptom relief, recurrence or progression, re-intervention, incidence of adverse events, or personal satisfaction were observed between the two groups.

RESULTS

The follow-up time was comparable between the two groups. The technical success rate was similar between the two groups; no residue was found in the US-guided MWA group, and the residue rate in the US-guided VAE group was 3.4%. The symptoms of the two groups were improved after the operation. The incidence of postoperative adverse events in the US-guided MWA group was significantly lower than that in the US-guided VAE group. Additionally, the MWA group had a lower incidence of adverse events when the tumor diameter was >2.5 cm. Compared to the US-guided VAE group, the US-guided MWA group had a lower rate of tumor recurrence or progression, re-intervention rate, and higher personal satisfaction.

CONCLUSIONS

The technical success rate of US-guided MWA for B3 lesions was comparable to that of US-guided VAE, but US-guided MWA had a lower incidence of adverse events and a higher degree of personal satisfaction compared with US-guided VAE.

Efficacy and safety of percutaneous ultrasound-guided vacuum-assisted excision for the treatment of clinical benign breast lesions larger than 3 cm: a retrospective cohort study

Background

Breast ultrasound-guided vacuum-assisted excision (US-VAE) has become a scarless solution for the removal of benign breast lesions. This procedure is now favored by more and more female patients for its satisfactory cosmetic outcome and few postoperative complications. However, controversy have been raised regarding its efficacy and safety in treating larger benign breast lesions. This study aimed to evaluate whether US-VAE is sufficient for the treatment of clinical benign breast lesions larger than 3 cm and to investigate the lesion features that affect the complete excision rate and hematoma occurrence rate.

Methods

From January 2018 to July 2021, a total of 1,812 lesions in 1,367 patients underwent US-VAE at the Chinese People's Liberation Army General Hospital. A total of 89 benign breast lesions in 87 patients enrolled in this retrospective cohort study. The baseline clinical characteristics and ultrasonographic features of the lesions were recorded. Patients were followed up by US to record if there are any serious issues and the occurrence of hematoma and the recurrence of the lesions within 3 days and 6-12 months later, then at 1-year intervals. Lesions were classified to analyze the possible factors associated with complete excision rate and hematoma occurrence rate.

Results

The mean age was 35.9±9.5 years (range, 18-54 years), and the median maximum size of benign breast lesions was 3.5 cm (range, 3.1-5.0 cm). The complete excision rate was 91.0% (81/89). Histopathology (P=0.002) and vascularity (P=0.032) of lesions showed statistically significant differences in groups with or without recurrent lesions. A total of 17 cases (17/89, 19.1%) presented with hematoma after the procedure. The maximum lesion size in patients with hematoma was significantly larger than that in those without hematoma (P<0.001).

Conclusions

US-VAE is an effective and safe alternative method for the treatment of benign breast lesions larger than 3 cm, especially for fibroadenoma, adenosis, hamartoma. For benign phyllodes tumors and intraductal papillomas larger than 3 cm and lesions with hypervascularity, the possibility of recurrence after US-VAE should be noted. The size of lesions needs to be considered when evaluating the occurrence of hematoma after US-VAE.

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.

Efficacy and Safety of Vacuum-Assisted Excision for Benign Breast Mass Lesion: A Meta-Analysis

Background and Objective: Breast mass lesions are common; however, determining the malignant potential of the lesion can be ambiguous. Recently, to evaluate breast mass lesions, vacuum-assisted excision (VAE) biopsy has been widely used for both diagnostic and therapeutic purposes. This study aimed to investigate the therapeutic role of VAE. Materials and Methods: Relevant articles were obtained by searching PubMed and EMBASE on 3 September 2021. Meta-analyses were performed using odds ratios and proportions. To assess heterogeneity, we conducted a subgroup analysis and meta-regression tests. Results: Finally, 26 studies comprising 18,170 patients were included. All of these were observational studies. The meta-analysis showed that the complete resection rate of VAE was 0.930. In the meta-regression test, there was no significant difference. The meta-analysis showed a recurrence rate of 0.039 in the VAE group. The meta-regression test showed no statistical significance. Postoperative hematoma, pain, and ecchymosis after VAE were 0.092, 0.082, and 0.075, respectively. Conclusion: VAE for benign breast lesions showed favorable outcomes with respect to complete resection and complications. This meta-analysis suggested that VAE for low-risk benign breast lesions is a reasonable option for both diagnostic and therapeutic purposes.

Image-guided Microinvasive Percutaneous Treatment of Breast Lesions: Where Do We Stand?

Treatment of breast lesions has evolved toward the use of less-invasive or minimally invasive techniques. Minimally invasive treatments destroy focal groups of cells without surgery; hence, less anesthesia is required, better cosmetic outcomes are achieved because of minimal (if any) scarring, and recovery times are shorter. These techniques include cryoablation, radiofrequency ablation, microwave ablation, high-intensity focused US, laser therapy, vacuum-assisted excision, and irreversible electroporation. Each modality involves the use of different mechanisms and requires specific considerations for application. To date, only cryoablation and vacuum-assisted excision have received U.S. Food and Drug Administration approval for treatment of fibroadenomas and have been implemented as part of the treatment algorithm by the American Society of Breast Surgeons. Several clinical studies on this topic have been performed on outcomes in patients with breast cancer who were treated with these techniques. The results are promising, with more data for radiofrequency ablation and cryoablation available than for other minimally invasive methods for treatment of early-stage breast cancer. Clinical decisions should be made on a case-by-case basis, according to the availability of the technique. MRI is the most effective imaging modality for postprocedural follow-up, with the pattern of enhancement differentiating residual or recurrent disease from postprocedural changes. ^©RSNA, 2021.

Clinical Value of Ultrasound-Guided Minimally Invasive Biopsy in the Diagnosis or Treatment of Breast Nodules

Purpose

To explore the clinical value of ultrasound-guided minimally invasive biopsy of breast nodules for diagnosis and treatment of patients with no positive clinical signs on manual breast examination.

Methods

We performed a retrospective review of 136 patients with no signs on breast palpation who underwent ultrasound-guided minimally invasive biopsy. A total of 63 patients underwent breast nodule resection from October 2018 to December 2019 at the General Hospital of Central Theater Command of the People's Liberation Army. Clinical data, including indications for minimally invasive biopsy or resection, pathological and surgical results were retrospectively analyzed.

Results

A total of 199 patients were studied; 136 underwent minimally invasive biopsy and 63 underwent resection. No severe surgical complications occurred. Minimally invasive biopsy of breast nodules was superior to resection with respect to operation time, incision length, and postoperative complication rate.

Conclusion

Ultrasound-guided minimally invasive biopsy of breast nodules is feasible for treatment of patients with negative breast nodules and can achieve accurate diagnosis and satisfactory resection.

Surgeon-Performed Vacuum-Assisted Biopsy of the Breast: Results from a Multicentre Australian Study

BACKGROUND

Image-guided interventional techniques such as vacuum-assisted biopsy are being increasingly utilised in the diagnosis and management of breast conditions. The purpose of this study was to report the outcome of a series of vacuum-assisted biopsies and vacuum-assisted excisions performed by specialist breast surgeons in a largely outpatient setting.

METHODS

An Australian multicentre trial of ultrasound-guided surgeon-performed vacuum-assisted biopsy (VAB) and vacuum-assisted excision (VAE) of breast lesions was conducted involving three surgeons in three participating centres. VAEs were performed for presumed or proven benign breast lesions only.

RESULTS

A total of 225 surgeon-performed ultrasound-guided vacuum-assisted procedures were undertaken in 197 patients. Of the 225 VAB procedures, 51 (22.7%) were performed as diagnostic cores and 174 (77.3%) were undertaken as core excisions. Of the 174 VAE procedures undertaken with intent of completely excising the lesion, successful excision of the lesion was achieved in 165 of these cases (94.8%), with complete excision being judged by the absence of any lesion seen on ultrasound following the procedure or the absence of the lesion on a subsequent interval ultrasound examination. A total of 199 procedures were performed in the outpatients setting under local anaesthesia, and 26 procedures were performed in an operating theatre setting under neurolept anaesthesia. The average size of lesions was 19.3 mm in the diagnostic core group and 10.6 mm in the core excision group. The average time for either procedure was approximately 14 min.

CONCLUSION

Specialist breast surgeons familiar with ultrasound can be readily upskilled to perform vacuum-assisted procedures safely and expeditiously. VAE represents a minimally invasive method of breast lesion management and is a technique with which breast surgeons should become adept.

Patient reported cosmetic outcome after vacuum assisted excision of benign breast lesions: a cross-sectional study

OBJECTIVE

Better cosmetic outcome after vacuum assisted excision (VAE) compared to surgical excision of benign breast lesions is suggested in previous studies but has never been evaluated with validated outcome measures. In this study, patient reported cosmetic outcome after VAE was evaluated.

METHODS

Patients who underwent VAE between July 2017 and December 2018 were invited to complete the cosmetic subscale of the Dutch Breast Cancer Treatment Outcome Scale, comparing the treated with the untreated breast. Response mode ranged from 1 (no difference) to 4 (large difference) and cosmetic outcome was calculated as the unweighted mean. Clinical outcomes included: tumor size, number of cores, complications, residual lesions and recurrences.

RESULTS

Response rate was 73.4% (47 of 64 patients). Median tumor size was 15 mm (range 5-51 mm) and median number of cores 6.5 (range 1-85), complete excision was confirmed in all but two patients. Mean cosmetic outcome was good (mean score ≤1.75) in 74% of patients and no patients reported a poor cosmetic outcome (mean score >3.25). A hematoma occurred in five patients (one needed aspiration) and a skin rash in one patient, no patients developed an infection or seroma.

CONCLUSION

In this study VAE is safe and effective for tumors up to 5 cm and patient reported cosmetic outcome was good. Patients with benign lesions could benefit from VAE as an alternative for surgical excision.

ADVANCES IN KNOWLEDGE

A formal quantitative measurement of cosmetic outcome after vacuum assisted excision for benign breast lesions was still lacking. This study shows that this cosmetic outcome is overall good in benign lesions up to 5 cm.

A New Management Technique for Symptomatic Haematomas Following Therapeutic Vacuum-Assisted Biopsy

The aim of this study was to investigate the efficacy of the vacuum-assisted biopsy (VAB) system in evacuating symptomatic haematomas after VAB excision of benign breast lesions. We retrospectively analysed the data of eight patients with symptomatic and large haematomas who were treated with VAB evacuation between 10 and 14 days after VAB excision. Only one case underwent the procedure 24 h after VAB excision, due to the patient reporting intense pain, which was relieved after application of the technique, even though it had to be done twice. This new clinical application of the VAB system for evacuating symptomatic breast haematomas was successful in all the cases in the present study. No technique-related complications were observed. Conclusions: To the best of our knowledge, this is the first study to reveal that VAB evacuation of symptomatic haematomas is safe, effective, quick and well-tolerated by patients.