Core needle biopsy of challenging benign breast conditions: a comprehensive literature review

Neoplasm of uncertain behaviour of the breast-a retrospective study in a breast unit

Introduction

Breast lesions include a heterogeneous group of entities with variable clinical behaviour and morphological presentation, mostly classified as benign or malignant, with predictable behaviour. However, there are lesions with clinical, breast imaging and/or biopsy characteristics that do not clarify their nature. These lesions have an uncertain behaviour regarding their malignant potential at diagnosis.We intend to relate the preoperative diagnosis of neoplasm of uncertain behaviour of the breast (NUnBB) regarding the core needle biopsy and the histological result after excisional biopsy.

Methods

This is a retrospective study of patients submitted to local excision of breast lesions with a perioperative diagnosis of NUnBB, classified as 2383 at 'International Statistical Classification of Diseases and Related Health Problems' (ICD 9), between January 2007 and October 2016 in a breast unit.

Results

Ninety-two cases with the diagnosis of NUnBB were analysed: 91 females with a mean age of 59 ± 14 years. All were submitted to local excision of breast lesion as ambulatory surgery with the following histology: 64% benign, 3% malignant potential and 33% malignant. Of those who presented malignant results, 69% underwent a surgical re-intervention for local control of the disease.

Discussion

Regarding the considerable number of malignant lesions at final histology and the high percentage of which are re-operated, NUnBB should be treated with the same priority as a confirmed malignant neoplasm and whenever possible, using the most appropriate surgical technique.

Current Concepts in Diagnosis, Molecular Features, and Management of Lobular Carcinoma In Situ of the Breast With a Discussion of Morphologic Variants

Context.—

Lobular carcinoma in situ (LCIS) refers to a neoplastic proliferation of cells that characteristically shows loss of E-cadherin expression and has long been regarded as a risk factor for invasive breast cancer. Long-term outcome studies and molecular data have also implicated LCIS as a nonobligate precursor to invasive carcinoma. In the past few decades, pleomorphic and florid LCIS have been recognized as morphologic variants of LCIS with more-aggressive histopathologic features, less-favorable biomarker profiles, and more-complex molecular features compared with classic LCIS. There is still a lack of consensus regarding certain aspects of managing patients with LCIS.

Objectives.—

To review recently published literature on LCIS and to provide an overview of the current morphologic classification of LCIS, recent molecular advances, and trends in patient management.

Data Sources.—

Sources included peer-reviewed, published journal articles in PubMed (US National Library of Medicine, Bethesda, Maryland) and published guidelines from the National Comprehensive Cancer Network (Fort Washington, Pennsylvania).

Conclusions.—

Lobular carcinoma in situ represents a marker for increased risk of breast cancer, as well as a nonobligate precursor to invasive carcinoma. Morphologic variants of LCIS—florid and pleomorphic LCIS—are genetically more-complex lesions and are more likely to be associated with invasive carcinoma. Further investigation into which molecular alterations in LCIS are associated with progression to invasive carcinoma is needed to help guide medical and surgical management.

Papillary Breast Lesions: Association with Malignancy and Upgrade Rates on Surgical Excision

Intraductal papilloma falls under the category of benign breast mass. However, recent studies show that it can harbor occult carcinoma. The management of benign intraductal papilloma remains controversial because of its nonspecific radiologic and histological findings, as well as its association with surrounding malignant pathology. The purpose of this study is to investigate upgrade rates of a benign intraductal papilloma on surgical excision and the need for surgical excision of papillary lesions diagnosed at core needle biopsy. A retrospective review of a single institution's pathology database between 2011 and 2015 identified 43 core biopsies with benign papilloma. We followed the upgrade rates of these lesions on surgical excision. There were 90 biopsies with the diagnosis of benign intraductal papilloma. The average age was 55.2 (range from 24–87 years old). Forty-three had benign intraductal papilloma; 28 of the 43 core biopsies had surgical excision. Two (7.1%) had an upgrade from benign intraductal papilloma to intraductal papilloma with atypia. One (3.6%) had an upgrade to ductal carcinoma in situ. None had invasive cancer. Surgical findings were in agreement with core biopsies in 25 (89.3%) of 28 cases (κ = 0.80, P < 0.0001). Core biopsies have a statistically significant correlation with pathologies on surgical excision in detecting atypia in breast lesion as demonstrated by κ = 0.80. However, the study shows benign intraductal papillomas on core biopsy have an upgrade rate of 10.7 per cent after undergoing surgical excision. As such, we recommend a more aggressive approach including surgical excision of all benign intraductal papillary lesions.

First International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions)

The purpose of this study is to obtain a consensus for the therapy of B3 lesions. The first International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions) including atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), papillary lesions (PL), benign phyllodes tumors (PT), and radial scars (RS) took place in January 2016 in Zurich, Switzerland organized by the International Breast Ultrasound School and the Swiss Minimally Invasive Breast Biopsy group-a subgroup of the Swiss Society of Senology. Consensus recommendations for the management and follow-up surveillance of these B3 lesions were developed and areas of research priorities were identified. The consensus recommendation for FEA, LN, PL, and RS diagnosed on core needle biopsy or vacuum-assisted biopsy (VAB) is to therapeutically excise the lesion seen on imaging by VAB and no longer by open surgery, with follow-up surveillance imaging for 5 years. The consensus recommendation for ADH and PT is, with some exceptions, therapeutic first-line open surgical excision. Minimally invasive management of selected B3 lesions with therapeutic VAB is acceptable as an alternative to first-line surgical excision.

Lesion stiffness measured by shear-wave elastography: Preoperative predictor of the histologic underestimation of US-guided core needle breast biopsy

OBJECTIVES

To determine whether lesion stiffness measured by shear-wave elastography (SWE) can be used to predict the histologic underestimation of ultrasound (US)-guided 14-gauge core needle biopsy (CNB) for breast masses.

METHODS

This retrospective study enrolled 99 breast masses from 93 patients, including 40 high-risk lesions and 59 ductal carcinoma in situ (DCIS), which were diagnosed by US-guided 14-gauge CNB. SWE was performed for all breast masses to measure quantitative elasticity values before US-guided CNB. To identify the preoperative factors associated with histologic underestimation, patients' age, symptoms, lesion size, B-mode US findings, and quantitative SWE parameters were compared according to the histologic upgrade after surgery using the chi-square test, Fisher's exact test, or independent t-test. The independent factors for predicting histologic upgrade were evaluated using multivariate logistic regression analysis.

RESULTS

The underestimation rate was 28.3% (28/99) in total, 25.0% (10/40) in high-risk lesions, and 30.5% (18/59) in DCIS. All elasticity values of the upgrade group were significantly higher than those of the non-upgrade group (P<0.001). On multivariate analysis, the mean (Odds ratio [OR]=1.021, P=0.001), maximum (OR=1.015, P=0.008), and minimum (OR=1.028, P=0.001) elasticity values were independently associated with histologic underestimation. The patients' age, lesion size, and final assessment category on US of the upgrade group were higher than those of the non-upgrade group (P=0.046 for age; P=0.021 for lesion size; P=0.030 for US category), but these were not independent predictors of histologic underestimation on multivariate analysis.

CONCLUSION

Breast lesion stiffness quantitatively measured by SWE could be helpful to predict the underestimation of malignancy in US-guided 14-gauge CNB.

Underestimation of Atypical Lobular Hyperplasia and Lobular Carcinoma in Situ at Stereotaxic 11-Gauge Vacuum-Assisted Breast Biopsy

The aims of this study are to determine the frequency of diagnosis of atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS) at stereotaxic-guided 11-gauge vacuum-assisted breast biopsy (VABB) and to assess the rate of underestimation of these at subsequent surgical excision and follow-up. Moreover, we aimed to define clinical, radiological and histological features of nonpalpable lesions in core biopsies that predict the lesion upgrade. Retrospective review of 11-gauge VABB was performed to identify the underestimation rate of nonpalpable lesions diagnosed as ALH or LCIS at VABB. Thirteen cases of ALH and 36 cases of LCIS were sent to surgery, 29 cases of ALH and 14 cases of LCIS were sent to follow-up. The clinical, mammographic and histologic features were assessed. The correlation between mammographic BI-RADS score and histological B-classification for both ALH and LCIS lesions were performed by Pearson's test. Of 1,765 patients enrolled, lobular lesions (ALH and/or LCIS) occurred in 82 cases, and underestimation arose in 9 (10.9%). Two cases of underestimated ALH were upgraded to invasive lobular carcinoma and one to invasive ductal carcinoma. One case of underestimated LCIS was upgraded to ductal carcinoma in situ, two to invasive ductal carcinoma and three to invasive lobular carcinoma. The histology of the core and surgical specimens were compared. A significant difference was seen in the BI-RADS score (4–5 in 91% of underestimated lesions), and the size of the lesions (≥ 1.5 cm) for underestimated cases versus accurately diagnosed cases (p<0.001). Further significant parameters predictive for malignancy were the incomplete lesion removal by VABB and the presence of associated different breast lesions in the specimen. In conclusion, as far as ALH is concerned, we propose surgery as first choice when at least one of the following condition is respected: positive history for breast carcinoma, lesion >1.5cm, co-presence of high-risk lesions in the sample, signs of ductal involvement, high histological grading for atypia and follow-up in the other cases. Surgery is recommended in all cases of LCIS:

Breast intervention: how I do it

Breast imaging has undergone many changes since the early years of mammography. Screening mammography is credited with contributing to the substantial decrease in breast cancer mortality through early detection. Screening mammography programs allow depiction of nonpalpable, suspicious findings requiring histologic evaluation, but most of which eventually are proved benign. Widespread acceptance of percutaneous breast biopsy techniques represents the most important practice-changing development in breast imaging. The radiologist now plays a vital role not only in the detection and evaluation of breast disease, but also in the diagnosis and management of breast cancer. Descriptions of the advantages of percutaneous breast biopsy and the techniques of performing breast intervention are the focus of this review.

Effect of preoperative breast magnetic resonance imaging on surgical decision making and cancer recurrence rates

PURPOSE

To evaluate breast magnetic resonance imaging (MRI) for cancer staging and surgical planning in patients with known breast cancer, and to evaluate recurrence rates at long-term follow-up.

METHODS AND MATERIALS

Institutional review board approval and patient consent were obtained. Preoperative MRI with 0.1 mmol/kg gadobenate dimeglumine (MultiHance) was performed in 203/274 women with confirmed breast cancer. The sensitivity, accuracy, and positive predictive value of MRI compared with mammography/ultrasound for malignant lesion detection were calculated, and the effect of MRI on surgical decision making evaluated. The cancer recurrence rate was determined for 172 patients with available 2- to 8-year follow-up data.

RESULTS

Mammography/ultrasound detected 229 suspicious lesions. Breast MRI detected 159 additional lesions in 48/203 (23.6%) patients; of which 110/110 were correctly classified as malignant and 28/49 as benign, giving sensitivity, accuracy, and positive predictive values for malignant lesion detection of 100% (110/110), 86.8% (138/159), and 84.0% (110/131), respectively. MRI revealed unsuspected multifocal, multicentric, and synchronous contralateral lesions in 7/48, 16/48, and 16/48 patients, respectively, and pectoralis muscle infiltration in 3/38 patients. In 6/48 women, MRI revealed lesions not seen on conventional imaging (n = 5) or discounted suspected multifocal disease (n = 1). Therapy was changed for 50/203 (24.6%) patients: 38 patients underwent more extensive surgery and 12 less extensive surgery. Six (3.5%) recurrences occurred, in all cases at >4 years.

CONCLUSION

Breast MRI positively affects patient management and is recommended for mapping tumor extent in patients with newly diagnosed cancer. The cancer recurrence rate at long-term follow-up after MRI is low.

Underestimation of papillary breast lesions by core biopsy: correlation to surgical excision

BACKGROUND

The purpose of this study was to evaluate papillary lesions of the breast diagnosed at needle core biopsy and the outcomes of follow-up imaging and surgical findings.

METHODS

Retrospective review of 13,806 needle core biopsies performed from 2004 to 2010 revealed 352 patients with 368 papillary lesions; 137 of these lesions underwent surgical excision and 215 had a minimum of 2 year imaging follow-up. Outcomes of imaging follow-up and underestimation of carcinoma by comparison to surgical excision, as applicable, were determined. Patient demographics, clinical presentation, BI-RADS(®) breast density, palpability, biopsy methods, number of specimens, and pathology were recorded. A two-tailed Fisher exact test was used to assess associations between biopsy techniques and the results of surgical excision as well as the association between palpability and the results of surgical excision. SAS(®) V 9.1.3 was used to perform the calculations.

RESULTS

One hundred and thirty-seven lesions proceeded to surgical excision. A total of 28 lesions were underestimated; 21 of these were underestimated carcinomas. When comparing biopsy devices in the underestimated group, 64 % were biopsied with directional vacuum-assisted devices and 36 % with automated large core devices (p < 0.0706). In total 18 % of the palpable lesions were underestimated, whereas 17 % of the nonpalpable lesions were underestimated (p < 0.6560); this was not a significant difference.

CONCLUSIONS

Overall, carcinoma was underestimated at needle biopsy in 6 % (21/368) of papillary lesions diagnosed when compared to surgical excision. In cases that underwent excision, 34 % (47/137) revealed carcinoma; 45 % (21/47) of these were underestimated carcinomas. Lesion palpability and biopsy method did not affect underestimation in this study population.

Surgical excision of intraductal breast papilloma diagnosed on core biopsy

BACKGROUND

The need for surgical excision of benign papillary lesions diagnosed on core biopsy remains debatable. This lack of consensus arises because although there is a possibility of histological underestimation, there are as yet no reliable predictors of malignancy. We therefore aimed to evaluate the incidence of histological underestimation in our practice, and to identify factors that predict for this, in order to reduce unnecessary surgery without missing out on possible malignancy.

METHODS

Retrospective review of 106 patients diagnosed with a papillary lesion on percutaneous image-guided core biopsy was performed between 1 January 2005 and 31 December 2008. The presence of atypia on core biopsy and the presence of malignancy in the surgical specimen were correlated with standard clinical, radiological and pathological features.

RESULTS

Histological underestimation occurred in 15 of 81 patients (19%). Malignancy was more likely when atypia was present in the core biopsy (P= 0.04, OR 5.17). Otherwise, a final diagnosis of malignancy was not correlated with any clinical or radiological features (P > 0.05). The presence of atypia was also not correlated with any clinical or radiological features.

CONCLUSION

In our study, 19% of patients with a benign papillary lesion diagnosed on core biopsy were found to have atypical ductal hyperplasia or malignancy following surgery. In view of this, together with the absence of reliable predictive factors for malignancy, we recommend surgical excision of all papillary lesions diagnosed on core biopsy.

Clinical, demographic, and situational factors linked to distress associated with benign breast biopsy

Benign breast biopsy (BBB) can be distressing for many women. Few studies have examined specific aspects of the BBB more or less distressing or risk factors for distress. Women (N = 51) who had a recent BBB reported the magnitude of distress associated with specific aspects of their experience. Clinical and demographic variables were also examined as risk factors for distress. All women reported some distress associated with the BBB with one third reporting their experience was "very stressful." Generally, biopsy-specific events were more distressing than follow-up mammography. Distress risk factors included younger age, less education, nonsurgical biopsy, and no family history of breast cancer. Clinical efforts to better manage biopsy-related distress are warranted. The authors identified clinical and demographic risk factors that furnish a simple, efficient, and potentially cost-effective means of stratifying risk for distress in the breast biopsy setting.

[Evaluation of stereotactic core biopsies of the breast with the 10-gauge Vacora® biopsy device: a review of 541 procedures]

PURPOSE

To evaluate stereotactic core biopsies of the breast with the 10-gauge Vacora(®) biopsy device.

PATIENTS AND METHODS

Retrospective study of 541 procedures in 502 patients performed between 2007 and 2009.

RESULTS

The procedure failed in 2% of cases, non-complicated hematomas occurred in 5% of cases and unsightly scars in two cases. A clip was deployed in 70% of cases, successfully in 99% of cases. The procedure was well tolerated in 88% of cases. Core biopsies confirmed a benign lesion in 55% of cases, borderline lesions in 19% of cases and malignant lesions in 26% of cases with complementary surgery performed in 40% of cases. For surgical lesions, sensitivity, specificity, PPV and NPV were 89%, 100%, 100% and 84% respectively. Atypical ductal dysplasia was under-estimated in 8% of cases while DCIS was under-estimated in 14% of cases. After review of the mammograms, 3% of Bi-Rads 4 lesions were reclassified as Bi-Rads 3 lesions, all benign at core biopsy. Half of these results were from screening mammography programs.

CONCLUSION

Results with the 10-gauge Vacora(®) biopsy device are similar to reports from the literature, mainly using the Mammotome system, with regards to tolerability and reliability for a lesser cost.

Risk factors for malignancy in benign papillomas of the breast on core needle biopsy

BACKGROUND

This study was designed to evaluate the clinical and pathologic parameters of benign papillomas diagnosed on core needle biopsy (CNB) and predict malignancy risk after surgical excision.

METHODS

We retrospectively reviewed clinicopathologic findings for 160 CNB-diagnosed benign papillomas followed by surgical excision from 154 patients.

RESULTS

Ten (6.3%) of the excised lesions were diagnosed as malignant. Univariate analysis showed that those that were palpable on physical examination, detected as a mass on mammography, or >1 cm on sonography were significantly associated with malignancy. In multivariate analysis, lesions that were palpable (odds ratio (OR), 29.2; 95% confidence interval (CI), 4.06-209.58; P = 0.001) or detected as a mass (OR, 5.68; 95% CI 1.08-29.87; P = 0.04) remained significantly associated with malignancy. In a CART analysis, including all variables, lesions that were palpable and associated with a mass on mammogram were confirmed as malignant.

CONCLUSIONS

Breast lesions diagnosed as benign papillomas on CNB had a 6.3% risk of being malignant. The risk was highest for lesions that were palpable and detectable as a mass on a mammogram. In addition, the low-risk patients avoid immediate surgical excision, although they should be followed carefully.

Update on percutaneous needle biopsy of nonmalignant breast lesions

Certain nonmalignant lesions encountered on percutaneous breast biopsies pose dilemmas with regard to the most appropriate clinical management subsequent to needle biopsy (ie, surgical excision vs. follow-up). These lesions include columnar cell lesions, atypical ductal hyperplasia, lobular neoplasia, papillary lesions, radial scars, fibroepithelial lesions, and mucocele-like lesions. As minimally invasive diagnostic procedures are now standard it is more important than ever to be aware of the limitations of percutaneous biopsy, particularly with regard to apparently benign lesions because of the risk that the radiologically detected lesion may harbor malignant disease not represented in the biopsy specimen. This underscores the importance of radiologic-pathologic correlation. Increasingly, radiologists are adopting vacuum-assisted devices using larger gauge needles. The changing practices among radiologists are reflected in recent studies which have enriched the literature. In addition, magnetic resonance imaging is being used more frequently in breast imaging, resulting in pathologists more often encountering benign biopsies with uncertain imaging correlation. These changes prompted evaluation of the recent literature and its possible effect on management concerns. This review focuses on management issues following the diagnosis of nonmalignant lesions diagnosed on percutaneous breast biopsy and highlights imaging terms commonly used in breast radiology reports to facilitate accurate radiologic-pathologic correlation.

Columnar cell lesions of the breast: mammographic findings with histopathologic correlation

Because of advances in mammography and a concomitant rise in the number of breast biopsies being performed for mammographically detected abnormalities, increasing numbers of columnar cell lesions (CCLs) are being described by pathologists. However, these lesions can be challenging to manage, since their classification has changed over time and only limited research has been conducted regarding their clinical significance. CCLs may be characterized by a single layer of columnar cells (columnar cell change [CCC]), multiple layers with stratification and apical tufting (columnar cell hyperplasia [CCH]), or monomorphic cells with cytologic atypia (flat epithelial atypia [FEA]). The differentiation between CCC, CCH, and FEA is clinically significant: CCC and CCH are considered benign lesions, whereas FEA can be associated with, and even a precursor to, low-grade ductal carcinoma in situ and atypical ductal hyperplasia. Therefore, the identification of FEA at core biopsy should prompt excision of the remaining portion of the lesion.

Interventional breast imaging: current procedures and assessing for concordance with pathology

Minimally invasive breast biopsy procedures performed for suspicious imaging findings have expanded the role of breast imaging in the management of breast diseases. The first portion of this article reviews the current procedures for performing a core-needle biopsy under stereotactic, ultrasound, and MR imaging guidance. The second portion of the article addresses the management of the patient after the biopsy, including assessment for concordance of radiology and pathology findings and potential underestimation of disease.

Ultrasound-guided core needle biopsy of breast masses: How many cores are necessary to diagnose cancer?

PURPOSE

To investigate the number of cores required to diagnose breast cancer using ultrasound (US)-guided core needle biopsy.

METHODS

US-guided core biopsy of 150 masses was performed in 144 patients. For each mass, 6 cores were obtained and analyzed separately. The histopathologic diagnosis was classified as benign, malignant, or normal breast tissue. Each core was analyzed separately. For diagnostic purposes, the cases were grouped as follows: group G1 comprised the first core; group G2 comprised the first and second core; group G3 comprised the first 3 cores; up to group G6, which included all 6 cores. The results were also analyzed by tumor size (</=2 cm and >2 cm).

RESULTS

The sensitivity in the diagnosis of breast cancer was 90.1% in group G1 and 94.1% in the remaining groups (G2-G6). In tumors </=2 cm, the sensitivity was 88.4% for group G1 and 90.7% for the others, whereas for tumors >2 cm the sensitivity was 91.4% for group G1 and 96.6% when 2 or more cores were obtained.

CONCLUSION

It appears that 2 cores are sufficient to diagnose breast cancer in this study population assuming no technical error occurred in US guidance of the needle through the mass.

Medical directors of breast imaging centers: beyond films

Over the past decade, breast radiologists have been increasingly asked to fulfill a new dynamic role as medical directors of breast imaging centers. To our knowledge, there are no standardized job descriptions nor defined roles and responsibilities for this position. Job descriptions are usually crafted to fit unique institutional and individual situations. To be an effective medical director of a breast imaging center, breast imagers must be more than just film readers. In this article, the authors describe the diverse roles of contemporary medical directors of breast imaging centers.

Breast Papillomas in the Era of Percutaneous Needle Biopsy

BACKGROUND

The significance of breast papillomas detected on core needle biopsy (CNB) remains unclear. While those associated with malignancy or atypia are excised, no clear solution exists for benign papillomas. We sought to determine the indication for surgical excision, incidence of malignancy, significance, and natural history.

METHODS

In this retrospective review, patients were divided into benign, atypical, or malignant cohorts based on initial results. While patients with malignant or atypical features were encouraged to undergo surgical excision, no standard recommendation was given for benign papillomas. Mammographic features, method of initial diagnosis, pathology results, and follow-up data were analyzed.

RESULTS

Between January 1994 to December 2005, 5,257 CNBs were performed at our tertiary level medical center. 206 patients were diagnosed with 215 breast papillomas. 174 (81%) papillomas were benign, 26 (12%) were associated with atypia, and 15 (7%) were associated with malignancy. Two benign papillomas (1.1%) developed into cancer over an average of 53 months. Average follow-up of those patients not undergoing excision for benign papilloma was 41 months; we had 92 patients with greater than two year follow-up and 57 patients with greater than four year follow-up. Of patients with atypia or malignancy associated with papilloma, there was a 26% and 87% associated rate of malignancy, respectively.

CONCLUSIONS

Benign breast papillomas diagnosed by CNB have a low risk of malignancy and do not need excision. However, they should be considered high risk lesions which require serial radiographic monitoring. Papillomas associated with atypia or malignancy should continue to be excised.

Predictive Value of Breast Lesions of “Uncertain Malignant Potential” and “Suspicious for Malignancy” Determined by Needle Core Biopsy

BACKGROUND

The optimum management of patients whose needle core biopsy (NCB) results are of "uncertain malignant potential" (B3) or "suspicious for malignancy" (B4) is unclear. This study correlates B3 and B4 NCB findings with excision histology to determine associated rates of malignancy.

METHODS

All NCBs categorized as B3 or B4 were identified from a series of 3729 NCBs. Results of biopsies were reported as normal/nondiagnostic (B1), benign (B2), uncertain malignant potential (B3), suspicious but not diagnostic of malignancy (B4), or malignant (B5) according to the B classification system. B3 lesions included atypical intraductal epithelial proliferations (AIEPs), lobular neoplasia, papillary lesions, radial scars, and potential phyllodes tumors. Histological concordance between NCB and excision specimen was analyzed.

RESULTS

A total of 211 B3 lesions and 51 B4 lesions were identified during the study period. The open biopsy rate after a B3/B4 finding was 86% (n = 226). The overall rate of malignancy for B3 lesions after excision was 21%. The B3 lesion-specific rates of malignancy were 6% for radial scars, 14% for papillomas, 35% for AIEP, and 44% for lobular neoplasia. Of the patients with a B4 categorization, 90% (44 of 49) were diagnosed with carcinoma after surgery. Those that were "suspicious for ductal carcinoma-in-situ" and "suspicious for invasion" correlated accurately with excision findings in 81% and 89% of patients, respectively.

CONCLUSIONS

Management of lesions in the B3 categorization must be tailored to the patient because the specific lesion types are associated with highly variable rates of malignancy. A repeat biopsy or a therapeutic wide local excision should be undertaken in lesions with a B4 NCB categorization because such lesions are associated with a particularly high risk of malignancy at excision.

Lobular Neoplasia at 11-Gauge Vacuum-Assisted Stereotactic Biopsy: Correlation with Surgical Excisional Biopsy and Mammographic Follow-Up

OBJECTIVE

The objective of our study was to evaluate the outcome of lobular neoplasia diagnosed at 11-gauge stereotactic vacuum-assisted biopsy (SVAB).

MATERIALS AND METHODS

Retrospective review of 1,819 lesions sampled with 11-gauge SVAB yielded 27 patients with lobular neoplasia as the most severe pathologic entity diagnosed. Patients with lobular neoplasia associated with atypical ductal hyperplasia (ADH), ductal carcinoma in situ (DCIS), or infiltrating carcinoma were excluded. Twenty patients underwent surgical excisional biopsy, and seven patients were followed mammographically for a mean of 52 months (range, 14-67 months). Mammographic lesion type, number of specimens obtained per lesion, and specific histologic features related to lobular carcinoma in situ (LCIS) were assessed. Results were compared with histologic findings at surgery or mammographic follow-up.

RESULTS

Nineteen lesions presented mammographically as microcalcifications, four as masses, three as masses with associated microcalcifications, and one as architectural distortion. A mean of 13 specimens were obtained per lesion. Carcinoma was found at surgical excision in 19% of the lesions (5/27). Lesions were upgraded to DCIS (n = 2), invasive lobular carcinoma (n = 2), and mixed invasive ductal and lobular carcinoma (n = 1). In addition to the diagnosis of lobular neoplasia at SVAB, one patient presented with synchronous infiltrating ductal carcinoma in the contralateral breast, and two patients developed metachronous infiltrating ductal carcinoma in a different quadrant of the ipsilateral breast. Twelve of the 27 lesions included LCIS. These lesions were evaluated pathologically to distinguish the classic (10/12) from the pleomorphic (2/12) form of this entity. Ten of the 12 LCIS cases underwent surgical excisional biopsy with four of the five upgrades occurring in these patients. Only one of these patients was shown to have the pleomorphic type of LCIS. Lesions in seven patients who underwent mammographic follow-up remained stable.

CONCLUSION

The known association of lobular neoplasia with high-risk and malignant lesions at surgical biopsy requires careful consideration when lobular neoplasia is diagnosed as the most severe histologic entity at SVAB. The diagnosis of lobular neoplasia at 11-gauge SVAB is not reliable in view of the 19% upgrade rate at the time of surgical excisional biopsy in our study. No predictive mammographic features allowed distinction between the patients with lesions that were upgraded at the time of surgery from those whose lesions were not upgraded.

Guidelines from the European Society of Breast Imaging for diagnostic interventional breast procedures

The aim of the breast team is to obtain a definitive, nonoperative diagnosis of all potential breast abnormalities in a timely and cost-effective way. Percutaneous needle biopsy with its high sensitivity and specificity should now be standard practice, removing the need for open surgical biopsy or frozen section. For patients with cancer, needle biopsy provides a cost-effective and rapid way of providing not only a definitive diagnosis but prognostic information, allowing prompt discussion of treatment options, be they surgical or medical. Early removal of uncertainty also allows better psychosocial adjustment to the disease. Patients with benign conditions found either by themselves or as a result of population or opportunistic screening can be promptly reassured and discharged, removing the health care and psychological costs of surgical biopsy or repeated follow-up. Radiologists involved in breast imaging should ensure that they have the necessary skills to carry out core biopsy and/or fine-needle aspiration (FNA) under all forms of image guidance. This paper provides guidelines on best practice for diagnostic interventional breast procedures and standards, against which all practitioners should audit themselves, from the European Society of Breast Imaging.

Ultrasound-Guided Breast Interventions: Accuracy of Biopsy Techniques and Applications in Patient Management

Ultrasound (US) provides a versatile approach for guiding biopsies and other breast interventions. The wide availability, real-time capability, technical improvements, and increasing user experience have greatly expanded the role of US-guided interventions in the diagnosis and management of breast disease. This article reviews the accuracy of US-guided fine-needle aspiration biopsy, automated core biopsy, and vacuum-assisted biopsy. Some of the more specialized procedures that reflect the growing role of US-guided interventions in patient management will also be discussed.

Atypical ductal hyperplasia of the breast: The controversial management of a borderline lesion: Experience of 47 cases diagnosed at vacuum-assisted biopsy

The present paper describes our experience of 47 cases of atypical ductal hyperplasia (ADH) diagnosed at vacuum-assisted biopsy. From June 1999 to December 2003, 47 consecutive diagnoses of non-palpable ADH of the breast were made by 11-gauge vacuum-assisted biopsy (Mammotome). Of these, 17 were subjected to surgical excision and 11 underwent a second Mammotome at the site of the previous vacuum-assisted biopsy. Diagnostic underestimation occurred in only two cases, with a surgical diagnosis of ductal carcinoma in situ. In both patients, aged between 46 and 55 years, the radiological images showed microcalcifications of >20 mm, and the lesions were not completely removed by Mammotome. Despite the obvious limitations of the present study, it can be concluded that the probability of underestimating ADH diagnosis by Mammotome appears to be related to the radiological features of the lesion (>20 mm) and to the adequacy of specimens.

Quand se méfier des résultats des micro et macrobiopsies guidées mammaires ?

The development of imaging-guided biopsy techniques has considerably improved the early diagnosis of breast cancers following initial detection by screening. Nevertheless, in a small percentage of cases, histopathologic findings are unsatisfactory owing to false negative errors attributable to operator inexperience or inadequate sample material (this is especially true for microcalcifications with 20% underestimation rates for atypical hyperplasia); repeat biopsy is warranted in such situations. When a discrepancy exists with imaging findings and for cases of atypical epithelial hyperplasia, surgical excision is imperative so as not to overlook or underestimate a malignant lesion. Controversy continues concerning the best approach for radial scars (sclerosing ductal lesions), papillary lesions, atypical lobular hyperplasia and lobular carcinoma in situ: determination of which benign anomalies can merely be followed-up remains a problem. Better awareness of the limitations of percutaneous tissue sampling procedures should lead to refinement of the indications for these techniques and improvement of patient selection and thereby reduce delays in accurate diagnosis.

Les tumeurs papillaires non malignes du sein : quelle prise en charge après diagnostic percutané ?

PURPOSE

To assess the reliability of percutaneous breast biopsies in diagnosing and managing non malignant papillary lesions and determine if subsequent excision must be systematic. MATERIALS AND METHODS. Retrospective review of 2233 breast biopsies over a 43 months period (September 2001 to March 2005): sonographically guided core biopsies (n = 836), ultrasound (n = 346) or stereotactic (n:1051) guided vacuum biopsies. 86 non malignant papillary tumors were diagnosed (core biopsy:28, US:38 and stereotactic guided vacuum biopsy:20). A larger sample was systematic after core biopsy: lumpectomy (n = 19) or vacuum biopsy (n = 9). Surgical excision followed vacuum biopsy (n = 18) in case of atypia or sampling excision. Alternatively, yearly follow-up was advised (n = 40). Correlation with surgical findings (n = 37) or mammographic follow-up (n = 49) is presented. The influence of various factors on the risk of underestimation was analysed.

RESULTS

Surgical resection revealed an underestimation of 5/37 (13.5%): 4/19 with core- and 1/18 with vacuum-assisted biopsy corresponding to 4 low grade ductal carcinoma in situ and a microinvasive ductal carcinoma in situ. It was higher for core biopsies and related to age and size: higher when women<50 years and when radiological image>1 cm. The influence of the other factors was not significant. Of the 9 non operated papillomas after core biopsy, vacuum biopsy revealed an additional underestimation (low-grade ductal carcinoma in situ). Of the 49 papillary lesions that were not surgically biopsied, 40 were monitored at 2-42 months (average: 19 months). No carcinoma was detected during this follow-up.

CONCLUSION

Percutaneous biopsy is an accurate technique in managing papillary tumors. A larger histologic specimen is necessary after core biopsy. Vacuum biopsy is an attractive alternative to surgery for smaller papillomas (<1 cm), but in spite of nonsignificant results we advise subsequent excision in case of multiple papillomas, atypia or residual tumor.

Lésions mammaires impalpables et macrobiopsies stéréotaxiques avec le Mammotome® 11 G : faut-il opérer après diagnostic d’hyperplasie canalaire atypique ?

Atypical ductal hyperplasia (ADH) of the breast is a difficult histologic diagnosis. It is usually found, but not always, on clusters of microcalcifications. The subsequent risk of breast carcinoma is 4 to 5 times more important and the carcinoma can arise in the same breast or in the contralateral breast. Diagnosis can be establish on core needle biopsy with Mammotome 11G. The risk of under-estimation (ductal carcinoma in situ or invasive carcinoma) is about 20%. This risk is drastically decreased if the target (the calcifications) is completely removed by the Mammotome. This study includes 62 cases of ADH found on 633 calcifications biopsied by Mammotome 11G. In 31 cases, surgery was performed and ADH was confirmed in 25 cases (6 cases was under-estimated). In the other 31 cases, all calcifications were removed, there was no other risk factor and follow-up was suggested. Like after surgery, yearly bilateral mammography during about 20 years is recommended. In this last group, there was no false-negative result, median follow-up: 35,5 months (22-62).

Vacuum-assisted breast biopsies. Experience at the Antoine Lacassagne Cancer Center (Nice, France)

This article presents the results of the first 318 aspiration-guided breast macrobiopsies performed using a dedicated table at the Antoine Lacassagne Cancer Center (Nice, France) between January 2001 and November 2002. A total of 288 procedures (90%) was performed for microcalcifications whereas that of 30 (10%) was performed for isolated opacities. There were 170 American College of Radiology (ACR) Category 4 (53.45%), 35 ACR 5 (11%), 111 ACR 3 (34.9%), and 2 ACR 2 lesions. There were 233 benign lesions that included 19 cases of atypical epithelial hyperplasia. Of the 85 malignant lesions, 33 had an invasive component. Seven of the atypical epithelial hyperplasia cases and all of the malignant lesions were managed surgically. Atypical epithelial hyperplasia was underestimated in 28.57% of the cases; ductal carcinomas in situ, in 21.15%. The positive predictive value of ACR 4 for the diagnosis of malignancy was 24.7% (42/128 cases), versus that of 12.6% for ACR 3 (14/97 cases). Among the 233 benign lesions, 128 were classified as ACR 4 and 6 as ACR 5 (all of these procedures obviated surgery). The advantages, drawbacks, and limitations of the technique are analyzed and indications are discussed, particularly for ACR 3 lesions.

Image-Guided Tissue Sampling: Where Radiology Meets Pathology

Image-guided breast tissue sampling has become an acceptable alternative to open surgical biopsy for nonpalpable lesions. Advantages of minimally invasive core biopsy compared to open surgical biopsy include lower cost, lower complication rates, and less cosmetic deformity for patients. However, false-negative core biopsies can occur. Thus the imaging of a breast lesion and the histologic result of the core biopsy must be carefully correlated. This involves communication between radiology and pathology.

Image-guided breast biopsy and management of high-risk lesions

Across several series, the sensitivity of sonographically guided 14-gauge core biopsy is 95%, and the repeat biopsy rate averages 11%. Success of stereotactic biopsy requires obtaining larger volumes of tissue when sampling calcifications; use of vacuum-assisted devices results in comparable sensitivities. For MR imaging-guided percutaneous biopsy,success rates of 95% to 99% have been achieved. Independent of guidance method or the amounts of tissue acquired, the following diagnoses on percutaneous biopsy should generally prompt excision: atypical ductal hyperplasia, lobular neoplasia, radial sclerosing lesions, benign and atypical papillary lesions, and possible phyllodes tumor. Mucocele-like lesions may merit excision. Columnar alteration without atypia probably does not require excision, although further study is needed.

Three-dimensional ultrasound-validated large-core needle biopsy: is it a reliable method for the histological assessment of breast lesions?

OBJECTIVE

The use of three-dimensional (3D) ultrasound may help to determine the exact position of the needle during breast biopsy, thereby reducing the number of core samples that are needed to achieve a reliable histological diagnosis. The aim of this study was to demonstrate the efficacy of 3D ultrasound-validated large-core needle biopsy (LCNB) of the breast.

METHODS

A total of 360 core needle biopsies was obtained from 169 breast lesions in 146 patients. Additional open breast biopsy was performed in 111 women (127/169 breast lesions); the remaining 42 lesions were followed up for at least 24 months. 3D ultrasound visualization of the needle in the postfiring position was used to classify the biopsy as central, marginal or outside the lesion. Based on this classification it was decided whether another sample had to be obtained.

RESULTS

A median of two core samples per lesion provided for all the lesions a sensitivity for malignancy of 96.9%, specificity of 100%, false-positive rate of 0% and false-negative rate of 3.1%, and for the excised lesions a sensitivity of 96.5%, specificity of 100%, false-positive rate of 0%, false-negative rate of 3.5% and an underestimation rate of 3.4%.

CONCLUSIONS

3D ultrasound validation of the postfiring needle position is an efficient adjunct to ultrasound-guided LCNB. The advantages of 3D ultrasound validation are likely to include a reduction in the number of core samples needed to achieve a reliable histological diagnosis (and a possible reduction in the risk of tumor cell displacement), reduced procedure time and lower costs.

When is a diagnosis of sclerosing adenosis acceptable at core biopsy?

PURPOSE

To determine concordance of imaging findings and diagnosis of sclerosing adenosis at histopathologic core biopsy and to establish the accuracy of core biopsy when cancer was coexistent.

MATERIALS AND METHODS

From a database of 1,166 percutaneous biopsies in which sclerosing adenosis was reported, 88 (7.5%) lesions were identified, and imaging and histopathologic findings were reviewed for concordance. Sclerosing adenosis proved to be a minor component at core biopsy for 44 lesions, including one invasive ductal carcinoma, one ductal carcinoma in situ (DCIS), one focus of atypical ductal hyperplasia (ADH), and one atypical lobular hyperplasia. Sclerosing adenosis was a major (> or =50%) component for 44 lesions, including four malignancies, all DCIS manifested as clustered calcifications (pleomorphic [n = 2] or amorphous [n = 2]), and seven foci of ADH manifested as amorphous calcifications. In 30 patients with 33 lesions without atypia or malignancy, sclerosing adenosis was the major finding at core biopsy (21 lesions at 14-gauge core biopsy and 12 at 11-gauge vacuum-assisted biopsy); these patients formed the study population. Mammographic (33 lesions) and sonographic (18 lesions) features were recorded. Twenty-seven lesions had at least 20-month follow-up (n = 25) or excision (n = 2).

RESULTS

One spiculated mass was considered discordant and was excised, showing a prospectively unrecognized radial sclerosing lesion with several 2-5-mm foci of invasive tubular and lobular carcinoma. Seventeen (53%) of 32 lesions manifested as masses; 10 (59%) were circumscribed, five (29%) were indistinctly marginated (one with punctate calcifications), and two (12%) were partially circumscribed and partially obscured (one with amorphous calcifications). Fifteen (47%) lesions manifested as clustered calcifications; nine (60%) were amorphous and indistinct, four (27%) were pleomorphic, and two (13%) were punctate. Of 27 lesions with acceptable follow-up, 26 (96%) were believed to have been accurately sampled at core biopsy. Of six radial sclerosing lesions associated with the original 88 lesions, only three (50%) were prospectively recognized.

CONCLUSION

Sclerosing adenosis is an acceptable result at core biopsy of circumscribed masses and nonpalpable indistinctly marginated masses and for clustered amorphous, pleomorphic, and punctate calcifications. Recognition and reporting of coexistent radial sclerosing lesions is encouraged and may prompt excision. Malignancy can be seen with sclerosing adenosis; core biopsy was accurate in six (86%) of seven coexistent malignancies in this series.

Issues in the interpretation of breast core biopsies

Core biopsies are now widely used for the nonoperative diagnosis of breast masses and microcalcifications and have replaced fine-needle aspiration (FNA) cytology for most lesions in many centers. In the United Kingdom, a scoring system of 5 reporting categories, B1-B5, has been adopted, which is to some extent similar to that used in the interpretation of breast FNA. This article is based on the practice at Charing Cross Hospital, London, which is a major regional breast screening and treatment center covering the West of London area; as well as on a thorough review of the contemporary literature. It begins by discussing issues related to the adoption of the technique and to handling core biopsies, followed by a brief presentation of the reporting categories. The article then deals with some commonly encountered diagnostic problems.

Cystic lesions of the breast: sonographic-pathologic correlation

PURPOSE

To understand the pathologic basis for sonographic features of cystic lesions of the breast and determine appropriate assessment and management recommendations for these lesions based on sonographic appearance.

MATERIALS AND METHODS

From a database of 2,072 image-guided procedures performed from July 1995 through September 2001, 150 cystic lesions were identified. Diagnosis was established with fine-needle aspiration (n = 55), 14-gauge core-needle biopsy (n = 81), or both (n = 14). Excision was performed for all malignant (n = 18) and atypical (n = 2) lesions and for 11 benign lesions, which recurred or enlarged at follow-up. Imaging follow-up was available for 92 of 119 benign lesions. Targeted sonography was performed with high-frequency (10-MHz center frequency) transducers. Imaging and histopathologic, cytologic, and/or microbiologic findings were reviewed. Lesions were categorized as simple cysts, complicated cysts (imperceptible wall, acoustic enhancement, low-level echoes), clustered microcysts, cystic masses with a thick (perceptible) wall and/or thick (> or =0.5 mm) septations, intracystic or mixed cystic and solid masses (at least 50% cystic), or predominantly solid masses with eccentric cystic foci.

RESULTS

Of 150 lesions, 16 were simple cysts aspirated for symptomatic relief. Of 38 lesions characterized as complicated cysts and one cyst with thin septations, none proved malignant, nor did any of 16 lesions characterized as clustered microcysts. Of 23 masses with thick indistinct walls or thick septations, seven proved malignant. Of 18 intracystic or mixed cystic and solid masses, four proved malignant. Of 38 predominantly solid masses with eccentric cystic foci, seven proved malignant.

CONCLUSION

Symptomatic complicated cysts generally warrant aspiration. All clustered microcysts were benign, but further study is required. Cystic lesions with thick indistinct walls and/or thick septations (> or =0.5 mm), intracystic masses, and predominantly solid masses with eccentric cystic foci should be examined at biopsy; 18 of 79 of such complex cystic lesions proved malignant in this series.

Imaging-guided core needle biopsy of papillary lesions of the breast

OBJECTIVE

Our objective was to assess the incidence of papillary lesions of the breast diagnosed at imaging-guided core needle biopsy and the need for surgical excision after a benign diagnosis.

MATERIALS AND METHODS

This retrospective study included 1374 patients with consecutive suspicious breast lesions that underwent either mammography or sonographically guided large-core needle breast biopsy. Fifty-seven lesions (4%) were classified as papillary lesions. Eleven of the 57 cases were lost to follow-up (n = 6) or had not yet shown 2 years of stability (n = 5) and were excluded from this study. The remaining 46 papillary lesions constitute our study population.

RESULTS

Surgical excision was performed in 17 (37%) of 46 papillary lesions. In the group of patients whose lesions were recommended for excision because carcinoma was identified at core biopsy, surgical excision revealed one false-positive and two true-positive diagnoses. In four cases, histologic diagnoses of the excisional biopsy and the core needle biopsy were discordant. One false-positive finding at core needle biopsy initially was interpreted as invasive ductal carcinoma on the basis of core needle biopsy specimens. In three false-negative findings, the initial diagnosis at core needle biopsy was upgraded after surgical excision. Two cases of papilloma with adjacent atypical ductal hyperplasia and one of atypical papilloma were upgraded to ductal carcinoma in situ after surgical excision. Imaging follow-up was performed in the remaining 29 patients. All lesions were stable or had decreased in size during the 2-year follow-up period. The negative predictive value of core needle biopsy for excluding malignancy among the papillary lesions diagnosed in our study was 93%.

CONCLUSION

When the histologic diagnosis is benign, our data suggest that papillary lesions may be safely managed with imaging follow-up rather than with surgical excision. However, atypical papillary lesions or those associated with atypia require surgical excision because histologic underestimation occurs at a frequency similar to that in other atypical lesions undergoing core needle biopsy.