Core needle aspiration biopsy of palpable breast masses

Development of Aspiration-Assisted End-Cut Coaxial Biopsy Needles

Needle biopsy procedures, such as fine-needle aspiration and core needle biopsy, are used to extract tissue samples for diagnosis, and collection of larger samples allows for more accurate diagnosis of cancers. The combination of lower needle insertion force, less needle deflection, and reduced friction between the tissue and needle surface also leads to a more efficient biopsy procedure. In this research, a new end-cut-type coaxial needle with a modified aspiration mechanism has been developed to extract large tissue with minimal damage. The study shows that the clearance between the inner stylette and external needle and the insertion speed are the key factors affecting the biopsy performance including syringe friction force and amount of tissue extracted. Larger tissue samples (gelatin and chicken breast are used as samples here) can be obtained when inserting at lower speeds and using coaxial needles with smaller clearances between the external needles and inner stylettes. For solid samples (gelatin), the space inside the external needle is nearly filled with the solid sample. For samples consisting of both solid (chicken meat) and liquid components, a slower needle insertion results in extraction of more liquid than solid. To extract larger solid samples, high-speed needle insertion is required. This paper presents the design and manufacture of the system, protocol to evaluate the needle biopsy, and evaluation of the needle biopsy performance using gelatin and chicken breast as tissue samples.

Spectral-domain low coherence interferometry/optical coherence tomography system for fine needle breast biopsy guidance

A novel technology and instrumentation for fine needle aspiration (FNA) breast biopsy guidance is presented. This technology is based on spectral-domain low coherence interferometry (SD-LCI). The method, apparatus, and preliminary in vitro/in vivo results proving the viability of the method and apparatus are presented in detail. An advanced tissue classification algorithm, preliminarily tested on breast tissue specimens and a mouse model of breast cancer is presented as well. Over 80% sensitivity and specificity in differentiating all tissue types and 93% accuracy in differentiating fatty tissue from fibrous or tumor tissue was obtained with this technology and apparatus. These results suggest that SD-LCI could help for more precise needle placement during the FNA biopsy and therefore could substantially reduce the number of the nondiagnostic aspirates and improve the sensitivity and specificity of the FNA procedures.

Augmentation mammoplasty: effect on diagnosis of breast cancer

Breast augmentation for cosmetic purposes is an increasingly common procedure in the USA and UK. In the USA in 2003, a total of 254 140 breast augmentation procedures were carried out [American Society of Plastic Surgeons, http://www.plasticsurgery.org/news_room/Procedural-Statistics-Press-Kit-Index.cfm9-1-2005; 2006.(1)]. It has been previously estimated that between 1 and 1.5 million women in the USA have prosthetic breast implants [Cook RR, Delongchamp RR, Woodbury M, et al. The prevalence of women with breast implants in the United States, 1989. J Clin Epidemiol 1995;48:519-25.(2)]. The UK National Breast Implant Registry has recorded a rise in the numbers of women receiving breast implants, with over 13 000 procedures registered in 2001; an estimated 77% of these were for cosmetic purposes. No association has been found between the presence of breast implants in a breast and an increased risk of breast cancer, and this subject has been comprehensively reviewed elsewhere [Hoshaw SJ, Klein PJ, Clark BD, et al. Breast implants and cancer: causation, delayed detection, and survival. Plast Reconstr Surg 2001;107:1393-407.(3)]. However, as the population of women with breast implants ages, an increasing number of them will develop breast cancer; a reflection of the fact that the incidence of the disease increases with increasing age. Debate continues on the effect of breast implants on the efficacy of mammography in diagnosing breast cancer, and the role of other imaging techniques for this purpose, as well as the limitations that the presence of implants place on percutaneous biopsy techniques. We review the literature on the radiological and tissue diagnosis of breast cancer in women with a history of previous augmentation mammaplasty.

Freehand core biopsy in breast cancer: an accurate predictor of tumour grade following neoadjuvant chemotherapy?

Core biopsy is an increasingly used technique in the pre-operative diagnosis of breast carcinoma, as it provides useful prognostic information with respect to tumour type and grade. Neoadjuvant chemotherapy is being used in the treatment of large and locally advanced breast cancers but little is known regarding the correlation between tumour histology on pre-treatment core biopsy and that in residual tumour following primary chemotherapy and surgery. This study aimed to evaluate the accuracy of core biopsy in predicting these features in patients treated with primary chemotherapy. One hundred and thirty-three patients with carcinoma of the breast diagnosed on clinical, radiological and cytological examination underwent core biopsy, followed by primary chemotherapy (with cyclophosphamide, vincristine, doxorubicin and prednisolone) and surgery. The false-negative rate for pre-treatment core biopsy was 14%, with 91% agreement between the grade demonstrated on core biopsy and that in the residual tumour following completion of chemotherapy. Tumour type in the residual post-chemotherapy tumour was predicted by core biopsy in 84%. This study suggests that pre-treatment core biopsy histology accurately predicts residual tumour histology following primary chemotherapy and surgery in patients with breast cancer.

Diagnosis of breast cancer in countries with limited resources

Accurate diagnosis is a necessary step in the management of breast cancer. In women with breast cancer, diagnosis can confirm the presence of the disease, reduce treatment delays, and clarify the predictive and prognostic features of the cancer, which help in planning treatment and counseling women. In women with benign breast conditions, accurate diagnosis avoids erroneous treatment for breast cancer, which can have devastating consequences for the woman and unnecessarily consumes resources. The panel distinguishes between a "clinical diagnosis" of breast cancer (one based on signs and symptoms and imaging findings) and a "pathologic diagnosis" of breast cancer (one based on microscopic examination of cellular or tissue samples). The panel agrees that all women should have a pathologic diagnosis of breast cancer before they are given definitive treatment for the disease, no matter how strongly their clinical findings suggest cancer. The tools for clinical diagnosis include history, clinical breast examination, ultrasound, and diagnostic mammography; these tools provide valuable information and play important supplemental roles in ascertaining the presence of breast cancer. Mammography and ultrasound also help determine the extent of disease within the breast, which is essential when breast-conserving therapy can be offered to women. The tools for pathologic diagnosis include fine-needle aspiration biopsy, core needle biopsy, and standard surgical biopsy. The panel noted that each of these tools has potential benefits and limitations in the limited-resource setting, and concluded that the choice among them must be based on the available tools and expertise. The triple test-checking for correlation of pathology findings, imaging findings, and clinical findings-was identified as a critical practice in diagnosing breast cancer. Panelists uniformly agreed that mastectomy should not be used to diagnose breast cancer, noting that accurate diagnosis can be made by less invasive means. Expertise in pathology was identified as a key requirement for ensuring reliable diagnostic findings. Several approaches were proposed for improving breast pathology, including training pathologists, establishing pathology services in centralized facilities, and organizing international pathology services.

The rationale of surgical treatment of invasive breast cancer and decision making of surgical procedures

Surgery plays a major role in the primary treatment of breast cancer. There has been a rapid development in breast surgery over the last 20 years. Breast conserving therapy is standard today for tumours up till 4 cm in diameter, and can be used in selected cases for larger tumours after preoperative down staging with chemotherapy. Breast conserving therapy with postoperative radiotherapy gives the same long-term overall survival as mastectomy. Axillary surgery has also developed conservatively, with the introduction of the new technique of sentinel node biopsy, which offers an alternative to axillary clearance for staging of the axilla, with less morbidity.

Core biopsy versus FNAC for palpable breast cancers. Is image guidance necessary?

The aim of this study was to assess the efficacy of free-hand percutaneous core biopsy (FHCB) and to determine the role of fine needle aspiration cytology (FNAC) as diagnostic tools for palpable radiologically-suspicious breast lumps. This retrospective study was based on reviewing the clinical records of all patients diagnosed as having breast cancer between January 1999 and December 2000 and patients who had benign lesions, but suspicious breast imaging at triple assessment. Absolute sensitivity of FHCB for diagnosing cancer in palpable lesions was 98.7% compared with 51.3% for FNAC. The difference in the sensitivity of FHCB and FNAC was statistically significant (P<0.005, Wilcoxon matched pair test). Since 94.8% of radiologically-suspicious lumps were shown to be cancers, we advocate FHCB for all patients presenting with radiologically suspicious palpable lumps to our breast clinic. We also conclude that the sensitivity of FHCB for the diagnosis of malignancy in palpable radiologically-suspicious breast lesions is so high that image-guidance is unnecessary.

State of the art of minimally invasive breast biopsy: principles and practice

In the last two decades, the increasing use of screening mammography with the early detection of breast cancer and the newly gained understanding of the biology and changing therapy of breast cancer, emphasizing systemic therapy and minimizing extensive local surgery, has contributed to the increasing development of minimally invasive techniques for the diagnosis of breast lesions. Minimally invasive techniques provide increased patient comfort, excellent cosmetic result and minimal morbidity They are also responsible for decreased costs and better medical care by allowing an informed discussion of breast cancer therapy and planning of surgery with an emphasis on negative margins and the dissection of the sentinel node. Techniques in use include Fine-Needle Aspiration Cytology, Core-Needle biopsy, Vacuum-Assisted Core biopsy (Mammotome) and Large Core biopsy (ABBI, Site-select). We present a balanced, evidence-based approach to the diagnosis of patients with palpable or mammographic abnormalities.

Palpable breast masses: is there a role for percutaneous imaging-guided core biopsy?

OBJECTIVE

The purpose of this study was to evaluate percutaneous imaging-guided core biopsy in the assessment of selected palpable breast masses.

MATERIALS AND METHODS

Of 1388 consecutive breast lesions that had percutaneous imaging-guided core biopsy, 155 (11%) were palpable. Palpable masses referred for percutaneous imaging-guided core biopsy included lesions that were small, deep, mobile, vaguely palpable, or multiple. Biopsy guidance was sonography in 140 lesions (90%) and stereotaxis in 15 (10%). Surgical correlation or minimum of 2 years follow-up is available in 115 palpable masses in 107 women. Medical records, imaging studies, and histologic findings were reviewed.

RESULTS

Of 115 palpable breast masses, 98 (85%) were referred by surgeons to the radiology department for percutaneous imaging-guided core biopsy and 88 (77%) had percutaneous imaging-guided core biopsy on the day of initial evaluation at our institution. Percutaneous imaging-guided core biopsy spared additional diagnostic tissue sampling in 79 (74%) of 107 women, including 57 women with carcinoma and 22 women with benign findings. Percutaneous imaging-guided core biopsy did not spare additional tissue sampling in 28 women (26%), including 15 women in whom surgical biopsy was recommended on the basis of percutaneous biopsy findings and 13 women with benign (n = 7) or malignant (n = 6) percutaneous biopsy findings who chose to undergo diagnostic surgical biopsy.

CONCLUSION

Percutaneous imaging-guided core biopsy is useful in the evaluation of palpable breast masses that are small, deep, mobile, vaguely palpable, or multiple. In this study, percutaneous imaging-guided core biopsy spared additional diagnostic tissue sampling in 74% women with palpable breast masses.

A study on the cost effectiveness of sestamibi scintimammography for screening women with dense breasts for breast cancer

The potential impact of Sestamibi scintimammography (SSMM) on the cost effective management of women with dense breasts is not known. This study addresses this issue quantitatively by examining the impact of SSMM based screening strategies on the approximately 3,000,000 women over 40 with very dense breasts (DY patterns) without palpable masses and who have had one or more prior mammograms, who undergo routine screening each year. Quantitative decision tree sensitivity analysis was used to compare the conventional mammography (MM) strategy (strategy A), which does not subject patients with negative mammograms to any further examination until their next screening, with two decision strategies for screening with SSMM; SSMM after a negative mammogram (strategy B) or SSMM as the only screening test for women already identified as having dense breasts by a previous mammogram (strategy C). Cost effectiveness was measured by calculating the incremental cost effectiveness ratio (ICER) of strategies B and C, which is the cost of achieving an additional year of life in the screening population by choosing a SSMM based decision strategy rather than the conventional strategy. Strategies B and C reduced the number of false negative diagnoses by 62% and 8%, respectively. The ICER was $632,000 and $3.18M per life year for strategy B and C, respectively. To be cost effective, the pre-test probability of cancer in the study population must be greater than 3% for strategy B or the cost of SSMM must be less than $50 for strategy C. These results show the ICER of an SSMM based breast cancer screening strategy in the management of patients with dense breasts is not currently within the range (approximately $50,000 per year life saved) of other commonly performed medical interventions that are considered cost effective.

Large core biopsy for diagnostic and prognostic evaluation of invasive breast carcinomas

Large core biopsy is a recently introduced method for pre-operative evaluation of breast lumps. The aim of this study was to evaluate the usefulness of this technique in providing pre-operative diagnostic and prognostic information that can lead to a correct line of treatment. We compared 41 cases of breast carcinomas diagnosed both by core biopsies and surgically removed samples. A high (93%) diagnostic agreement was obtained. Moreover, we found a significant correlation for mitotic count (r = 0.76), oestrogen receptor (r = 0.78), progesterone receptor (r = 0.80), p53 (r = 0.86) and c-erbB-2 (r = 0.90) analysis between core biopsy and definitive surgical pathology. An agreement for histological grading evaluation between the two techniques was obtained in 32 out of 40 cases (k = 0.65) whereas in the other cases, a lower grade was assigned by evaluating core biopsies. These findings suggest that percutaneous core breast biopsy is a valid tool for pre-operative management of breast lesions, but this should be confirmed in larger, prospective studies.