Six-Month Short-Interval Imaging Follow-Up for Benign Concordant Core Needle Biopsy of the Breast: Outcomes in 1444 Cases With Long-Term Follow-Up

[Interpretation of Image-Guided Biopsy Results and Assessment]

The success of image-guided breast biopsy depends on the biopsy method, needle selection, and appropriate technique based on the accurate judgment by the radiologist at biopsy. However, insufficient or inappropriate sampling of specimens may result in false-negative results or pathologic underestimation. Therefore, image-pathology concordance assessments after biopsy are essential for appropriate patient management. Particularly, the assessment of image-pathology concordance can avoid false-negative reports of breast cancer as a benign pathology. Therefore, this study aimed to discuss factors that impact the accurate interpretation of image-guided breast biopsy along with the appropriate assessments.

Pseudoangiomatous Stromal Hyperplasia: Radiologic-Pathologic Correlation

Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal proliferative lesion of the breast. PASH is postulated to be hormonally induced and predominantly occurs in premenopausal women and postmenopausal women on menopausal hormone therapy. Clinical presentation varies from screen-detected lesions to palpable masses. Imaging findings of PASH are nonspecific. The most common mammographic findings are an oval or round circumscribed non-calcified mass or developing asymmetry. On US, PASH is often seen as an oval hypoechoic mass that may be circumscribed and can have an echogenic rim, or, when manifest as mammographic asymmetry, US may show a corresponding non-mass focal area of echogenic tissue. Limited studies have investigated the MRI appearance, with PASH most often manifesting as non-mass enhancement, or, less often, as an oval or irregular mass with persistent kinetics. Histopathologically, PASH can be mistaken for a fibroadenoma or phyllodes tumor and has features overlapping low-grade angiosarcoma. Assessment of radiologic-pathologic concordance is particularly important as PASH is often an incidental finding, adjacent to the targeted lesion at histopathology. Surgical excision or repeat core-needle biopsy is necessary for discordant suspicious cases. After a benign, concordant diagnosis of PASH, the patient may resume routine screening.

Ultrasound Guided Core Breast Biopsies

Core needle biopsies are common procedures performed in breast imaging centers. Utilizing ultrasound guidance for biopsy of suspicious findings within the breast and axilla is the standard of care when lesions are visible on ultrasound. Most ultrasound guided breast biopsies are performed by radiologists interpreting breast imaging who correlate findings across modalities including mammography, ultrasound and breast MRI, however interventional radiologists may perform in some practice settings. Appropriate knowledge of complete breast imaging is important not only for localization, but for determining radiologic-pathologic concordance. Proper localization, technique, and post biopsy management are essential to the success of the procedure and providing proper care for patients. This article discusses indications, strategies for accurate targeting, how-to biopsy techniques, post biopsy considerations and radiologic-pathologic concordance incorporating recommendations from the American College of Radiology Practice Parameter for the Performance of Ultrasound-guided Percutaneous Breast Interventional procedures.

Compliance with Short-Interval Follow-up MRI after Benign Concordant MRI-guided Breast Biopsy

OBJECTIVE

To evaluate compliance with short-interval follow-up MRI after benign concordant MRI-guided breast biopsy.

METHODS

This institutional review board-approved retrospective study included all benign concordant MRI-guided biopsies performed between January 1, 2010, and May 1, 2018. The following was collected from the electronic medical record: patient and lesion characteristics, short-interval follow-up MRI recommendation, communication to referring physician, follow-up imaging, repeat biopsies, biopsy outcome, and patient insurance status. Compliance with recommendations was defined as follow-up MRI within 9 months of biopsy.

RESULTS

Among 98 patients, there were 107 lesions with benign concordant MRI-guided biopsy results that met study criteria. After excluding 7 patients who underwent subsequent mastectomy, 50/91 (54.9%) patients were recommended short-interval follow-up MRI. Of these, 33/50 (66.0%) had a short-interval follow-up MRI. Direct communication of the short-interval follow-up recommendation was documented in the biopsy report for 4/50 (8%) patients. Subsequent MRI was available for 77/107 (72%) lesions at a median of 29 months following MRI-guided biopsy (range, 3-96 months). Subsequent mammography was available for 21/30 (70%) remaining lesions at a median of 47 months following MRI-guided biopsy (range, 23-88 months). There were two repeat biopsies, with one subsequent malignancy, resulting in a false-negative rate of 0.9% (1/107).

CONCLUSION

When short-interval follow-up MRI was recommended following benign concordant MRI-guided breast biopsy, compliance was 66.0%. Lack of communication of the recommendation may at least partially explain the low compliance. The low false-negative rate (0.9%) suggests routine short-interval follow-up MRI may be unnecessary following benign concordant MRI-guided biopsy.

Image-guided Procedure Versus 2-year Follow-up for a BI-RADS 3 Probably Benign Lesion: A Cost Comparison Analysis

OBJECTIVE

Perform a comparison between the costs of image-guided breast procedures versus 2-year imaging follow-up for findings classified as BI-RADS assessment category 3-probably benign.

METHODS

The national payment amount costs at non-facility locations were obtained from the Centers for Medicare and Medicaid Services physician fee schedule for breast imaging-related Current Procedural Terminology codes. Total costs were calculated and compared for management algorithms of 2-year imaging follow-up of a BI-RADS 3 lesion from 2018 through 2019 versus performing an image-guided procedure of the lesion in 2018 after the initial diagnostic imaging.

RESULTS

Two-year mammographic follow-up of a BI-RADS 3 finding costs $484. This was less than a stereotactic-guided breast biopsy, which cost at least $1055. Two-year follow-up for a probably benign US finding cost $615 compared to $1173 for the least expensive US-guided breast biopsy scenario. For breast MRI, 2-year imaging follow-up cost $1510, which was also less than most MRI-guided breast biopsy scenarios. The one exception in which biopsy costs less than 2-year imaging follow-up was in the setting of an MRI-guided biopsy in the average-risk population without a post-benign biopsy follow-up breast MRI; in this setting, MRI biopsy cost $1235.

CONCLUSION

In 2018-2019, 2-year imaging follow-up of a BI-RADS 3 finding continues to be less costly than an immediate procedure, except for MRI-guided breast biopsy in the average-risk population without a post-benign biopsy follow-up MRI.

Breast biopsy navigation system with an assisted needle holder tool and 2D graphical user interface

Objective

This paper proposes the development of a breast biopsy navigation system with an assisted needle holder tool for a coaxial needle and a graphical user interface, which utilizes an optical tracking device to localize the needle position relative to the ultrasound image with the aim to improve performance especially for a new radiologist or an inexperienced group.

Materials and methods

The system consists of an assisted needle holder tool, which as an attachment for the 2D ultrasound transducer and the graphical user interface (GUI) that shows the needle pathway, needle line and warning signs. An optical tracking system is used to track the needle motion, ultrasound image and transform all information to with respect to the technique. The system is evaluated using a phantom made from gel candle. There were nine experienced and eight inexperienced participants who performed the breast biopsy intervention, using three methods: the freehand method, only the needle holder tool guidance, and the whole navigation guidance (GUI + assisted needle holder).

Results

The results demonstrate a success rate of over 90% using only assisted needle holder and the whole system to perform breast biopsy for the experienced and inexperienced groups, whereas for the inexperienced group a success rate of 57.5% was achieved using the freehand method. The use of only assisted needle holder for breast biopsy reduces the time for a procedure in the inexperienced group by 6 s when compared to the freehand method.

Conclusion

The authors believe that this navigation system can be applied in a clinical setting and give an advantage to inexperienced radiologists who must successfully perform clinical breast biopsy.

Evaluating imaging-pathology concordance and discordance after ultrasound-guided breast biopsy

Ultrasound (US)-guided breast biopsy has become the main method for diagnosing breast pathology, and it has a high diagnostic accuracy, approaching that of open surgical biopsy. However, methods for confirming adequate lesion retrieval after US-guided biopsy are relatively limited and false-negative results are unavoidable. Determining imaging-pathology concordance after US-guided biopsy is essential for validating the biopsy result and providing appropriate management. In this review article, we briefly present the results of US-guided breast biopsy; describe general aspects to consider when establishing imaging-pathology concordance; and review the various categories of imaging-pathology correlations and corresponding management strategies.