Experience with breast biopsies using the Advanced Breast Biopsy Instrumentation system

Management of Nonpalpable Breast Lesions in a Modern Functional Breast Unit

During the last 20 years an ever increasing number of nonpalpable breast lesions (NPBL) have been identified. A cytohistological definition is required to establish the correct diagnostic classification of these lesions and the suitable therapy to be used. The Fine-Needle Aspiration Cytology (FNAC), the Advanced Breast Biopsy Instrumentation (ABBI) system or the Vacuum Assisted Core Biopsy (VACB) represent valid alternatives to the surgical excision with needle localisation. 591 NPBL have been included in the present study. The suspected grade of each lesion was then assigned according to the Breast Imaging Reporting and Data System (BI-RADS) of the American College of Radiology. All the BI-RADS 4 and 5, and all the BI-RADS 3 lesions, which after 6-month follow-up showed altered morphology, were sampled for cytological and/or histological examinations by FNAC, VACB or biopsy by ABBI system. The diagnostic algorithm used in this study obviated a surgical procedure in 574 women (97.1%), yielding a 73.9% decrease in the cost of diagnosis compared with surgical biopsy, and a 48.1% decrease in cost if all lesions had been histologically tested using ABBI or VACB procedure. Compared to surgical biopsy, VACB and ABBI system are less expensive, and have smaller emotional and aesthetical impact on patients; however they retain the same sensitivity and specificity.

Stereotactic radioguided surgery by siteSelect for subclinical mammographic lesions

BACKGROUND

We defined the indications for and evaluated the results of a new technique for radioguided surgery, the SiteSelect system. The procedure allows en-bloc resection of the breast parenchyma under local anesthesia.

METHODS

This prospective study was based on 167 patients operated on between December 2000 and October 2003 with 2 phases. The first step was an evaluation of the feasibility of the procedure with the 15-mm cannula, and the second was therapeutic with the 22-mm cannula.

RESULTS

The mean duration of the procedure was 42 minutes. In 96.9% of procedures, the lesion was excised successfully. Only one complication (hematoma) and two failures and were observed. Histological examination revealed benign disease in 65.8% of cases and cancer in 34.2% of cases. In the latter cases, the specimen margins were histologically involved in 86.2% of cases with the 15-mm procedure and in 41% with the 22-mm procedure. During the first evaluation, all patients with a cancer underwent systematic surgical re-excision: residual tumor was present in 18 cases (64.2%). The biopsy was painless for 88 patients, and the cosmetic result was good in all cases.

CONCLUSIONS

This study shows that the SiteSelect procedure allows resection of the lesion in 96.9% of cases. Combined with complementary surgical lumpectomy during the same operation, this procedure achieved a success rate of 98.7%. In the case of cancer, the 15-mm cannula is not wide enough to allow free margins. The use of a new 22-mm cannula, currently under evaluation, might solve this problem.

Percutaneous stereotactic en bloc excision of nonpalpable breast carcinoma: a step in the direction of supraconservative surgery

Recently, the advanced breast biopsy instrumentation (ABBI) system has been introduced as an alternative to conventional breast biopsy techniques. This study was prospectively conducted to evaluate the potential of the ABBI method in locoregional management of a consecutive series of patients with nonpalpable mammographically detected breast carcinomas. Sixty-one consecutive patients underwent an ABBI procedure as a first step before possible surgery for nonpalpable breast lesions that would in any case require complete excision. For the 27 patients in whom the ABBI biopsy revealed malignancy further surgery was recommended, including re-excision of the biopsy site and axillary dissection in cases of infiltrating carcinoma. We calculated the probabilities that the ABBI specimen would have tumor-free margins and that a definitely complete excision had been achieved as a function of the mammographic or pathological diameter of the cancer. For cancer with a pathological diameter less than 10 mm measured on the ABBI specimen, the probability (92%) of obtaining complete resection was significantly better than for larger lesions (P=0.01, Fisher's exact test). Although the therapeutic perspectives for the ABBI method are limited at present, we suggest that this approach is a first step in the direction of a surgical strategy that is better adapted to the pathological characteristics peculiar to these small tumors, whose incidence is increasing.

Percutaneous image-guided core breast biopsy

Percutaneous image-guided core biopsy is an accurate, fast, minimally invasive, and less expensive alternative to surgery for the diagnosis of breast lesions. Percutaneous core biopsy is usually performed under stereotactic or ultrasound guidance, using an automated needle or vacuum-assisted biopsy probe. Use of percutaneous core biopsy spares the need for surgery in most women with benign disease and expedites treatment in women with breast cancer. This article reviews advantages, limitations, controversies, and future directions in percutaneous image-guided core breast biopsy.

Image-guided surgery of small breast cancers

BACKGROUND

Widespread screening mammography has resulted in detection of many breast cancers smaller than one cm. Image-guided percutaneous needle sampling provides accurate diagnostic and prognostic information for adjuvant therapy. Less invasive methods based on imaging techniques are emerging as an alternative to wire localization and lumpectomy.

DATA SOURCES

Information presented in this overview was provided by seven investigators from five medical centers in the United States. These researchers are currently developing various techniques of image-guided percutaneous therapy of small (Tis, 1) breast cancers.

CONCLUSIONS

Several percutaneous treatment modalities for treatment of early breast cancer, either excisional or in-situ ablative, are described in this overview and their potential applications are discussed.

Minimal access breast surgery

Minimal access procedures have great potential for providing patients with equal, if not superior, forms of breast cancer diagnosis and treatment. Many of these procedures are in a process of evolution. The reliability of each method probably depends heavily on the training, ability, and experience of the operator. Surgeons should be aware of the advantages and pitfalls of these techniques and exercise caution during the initial phases of their learning experience.

Advanced breast biopsy instrumentation device: percentages of lesion and surrounding tissue removed

OBJECTIVE

This study reports the percentage of tissue in breast biopsy specimens from the lesion, and from the surrounding tissue, in 101 cases of Advanced Breast Biopsy Instrumentation (ABBI) biopsies. It also reports the status of the histologic margins for the malignant biopsies.

MATERIALS AND METHODS

One hundred one consecutive ABBI biopsies were reviewed. The ABBI specimen radiographs were used to measure the area occupied by the entire specimen, the area excluding the lesion, and the area of the lesion alone. These areas, the length, and the width of all specimens were statistically analyzed using computer software.

RESULTS

Of the 101 biopsies, histologic diagnosis was malignant in 27 and benign in 74. Of the 27 malignancies, four had negative margins and 23 had positive margins. Of the 23 with positive margins, eight were ductal carcinoma in situ (tumor within 0.5 mm or less of the surgical margin), and 15 were not ductal carcinoma in situ (tumor at the surgical margin). The average specimen length was 5.51 cm and the average width was 1.65 cm. The average percentage of lesion tissue was 9.9%.

CONCLUSION

An average of 90.1% of tissue removed by ABBI biopsies was from surrounding tissue only. Uninvolved tissue is unfortunately included because of the cylindric geometry of the ABBI cannula. The ABBI biopsy has a high percentage (85.2%) of positive margins for malignant lesions and is poor excisional tool. For diagnostic biopsies, core needle biopsy is preferable because a smaller tissue volume is resected directly from the lesion site.

Clinical management issues in percutaneous core breast biopsy

Percutaneous imaging-guided core biopsy is a less invasive and less expensive alternative to surgical biopsy for the evaluation of breast lesions. Percutaneous core biopsy is most often used for evaluation of BI-RADS category 4 lesions, but may also be helpful in the evaluation of some BI-RADS category 5 lesions. Stereotactic guidance is particularly useful for calcifications; for masses that can be seen with ultrasound, ultrasound guidance may be preferable because of the absence of radiation and lower cost. The automated core biopsy needle is excellent for mass lesions, but directional vacuum-assisted biopsy is superior for calcifications. Directional vacuum-assisted biopsy may also be preferable for small lesions that may require placement of a localizing clip and lesions that are superficial or in thin breasts. The more expensive ABBI device has substantial limitations, and its role in percutaneous breast biopsy has not been demonstrated. Complete removal of the mammographic target can occur at percutaneous biopsy, and is a more frequent event when the larger tissue acquisition devices are used. Complete removal of the mammographic target does not ensure complete excision of the histologic process. Further investigation is necessary to determine in which lesions, if any, complete removal of the target is advantageous. Epithelial displacement can occur during all breast needling procedures, but may be less frequent at directional vacuum-assisted biopsy than at fine-needle aspiration or automated core biopsy. There is no evidence that displaced cells are of biologic significance, but displaced DCIS can mimic infiltrating carcinoma. The pathologist should be aware of the findings of epithelial displacement, to avoid misdiagnosing DCIS as infiltrating ductal carcinoma. Some lesions warrant repeat biopsy or surgical excision after percutaneous core biopsy. Repeat biopsy is warranted if histologic findings and imaging findings are discordant. Surgical excision is warranted for lesions yielding a percutaneous diagnosis of ADH or possible phyllodes tumor. Controversy exists regarding the need for surgical excision after percutaneous diagnosis of radial scar, papillary lesion, ALH, or LCIS. Follow-up is necessary if percutaneous biopsy yields benign findings concordant with imaging characteristics. Follow-up protocols vary, but all require substantial commitment of time and resources. We have an embarassment of riches for performing percutaneous core biopsy of the breast. It can be estimated that approximately 1 million breast biopsies will be performed this year to diagnose approximately 200,000 breast cancers. Percutaneous core biopsy may spare many of these women the need for a more deforming, invasive, and expensive surgical biopsy. Further work is necessary to optimize criteria for patient selection, develop and define the role of new technologies for tissue acquisition, refine protocols for management after percutaneous breast biopsy, and assess long-term outcome, so that more women can benefit from this minimally invasive approach to breast diagnosis.