Annual Trends in Ultrasonography-Guided 14-Gauge Core Needle Biopsy for Breast Lesions

Subsequent percutaneous breast biopsies after initial atypia diagnosis: The patient burden of long-term follow up

BACKGROUND

Breast atypia increases overall breast cancer risk, potentially necessitating future interventions. This study examines the frequency and outcomes of additional percutaneous biopsies after an atypia diagnosis.

METHODS

Adult patients with breast atypia (atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ) at a single institution were reviewed for subsequent core needle biopsies (CNBs) and corresponding malignant outcomes.

RESULTS

Among 432 patients, median age at diagnosis was 54.8 ​y. Seventy-one (71/432, 16.4 ​%) patients developed a breast malignancy. During a median follow-up of 7.4 ​y, 113 patients underwent 149 additional CNBs. Twenty-six patients (26/113, 23.0 ​%) had >2 additional CNBs. Approximately half (79/149, 53.0 ​%) of all additional CNBs occurred within 5 years after breast atypia diagnosis.

CONCLUSION

A considerable number of patients with breast atypia undergo additional percutaneous biopsies, especially within 5 years post-atypia diagnosis. Our study highlights the significant burden of surveillance and the need for tailored follow-up strategies.

Bleeding Events After Image-Guided Breast Biopsies: Comparison of Patients Temporarily Discontinuing Versus Maintaining Antithrombotic Therapy During Biopsy

BACKGROUND. Antithrombic (AT) therapy is commonly temporarily discontinued before breast core needle biopsy (CNB), introducing risks of thrombotic events and diagnostic delay. OBJECTIVE. The purpose of this article was to compare the frequency of postbiopsy bleeding events among patients without AT use, patients temporarily discontinuing AT therapy, and patients maintaining AT therapy during breast CNB. METHODS. This retrospective study included 5302 patients (median age, 52 years) who underwent image-guided breast or axillary CNB between January 1, 2014, and December 31, 2019. From January 1, 2014, to December 31, 2016, patients temporarily discontinued all AT therapy for 5 days before CNB; from January 1, 2017, to December 31, 2019, patients maintained AT therapy during CNB. Immediate postbiopsy mammograms were reviewed for imaging-apparent hematoma. Patients were called 24-48 hours after biopsy and asked regarding palpable hematoma and breast bruise. The EMR was reviewed for clinically significant postbiopsy hematoma (i.e., hematoma requiring drainage, primary care or emergency department visit for persistent symptoms, or hospital admission). Bleeding events were compared among groups, including Firth bias-reduced multivariable logistic regression analysis. RESULTS. During CNB, 4665 patients were not receiving AT therapy, 423 temporarily discontinued AT therapy, and 214 maintained AT therapy. Imaging-apparent hematoma occurred in 3% of patients without AT use, 6% of patients discontinuing AT therapy, and 7% of patients maintaining AT therapy (p = .60 [discontinuing vs maintaining]). Palpable hematoma occurred in 2% of patients without AT use, 4% of patients maintaining AT therapy, and 4% of patients discontinuing AT therapy (p = .92 [discontinuing vs maintaining]). Breast bruise occurred in 2% of patients without AT use, 1% of patients discontinuing AT therapy, and 6% of patients maintaining AT therapy (p < .001 [discontinuing vs maintaining]). In multivariable analysis adjusting for age, biopsy imaging modality, needle gauge, number of biopsy samples, and pathologic result, discontinued AT therapy (using maintained AT therapy as reference) was not a significant independent predictor of imaging-apparent hematoma (p = .23) or palpable hematoma (p = .91) but independently predicted decreased risk of bruise (OR = 0.11, p < .001). No patient developed clinically significant postbiopsy hematoma. CONCLUSION. Frequencies of imaging-apparent and palpable hematoma were not significantly different between patients temporarily discontinuing versus maintaining AT therapy. CLINICAL IMPACT. The findings support the safety of continuing AT therapy during CNB. Patients who maintain AT therapy should be counseled regarding risk of bruise.

A Machine Learning Ensemble Based on Radiomics to Predict BI-RADS Category and Reduce the Biopsy Rate of Ultrasound-Detected Suspicious Breast Masses

We developed a machine learning model based on radiomics to predict the BI-RADS category of ultrasound-detected suspicious breast lesions and support medical decision-making towards short-interval follow-up versus tissue sampling. From a retrospective 2015–2019 series of ultrasound-guided core needle biopsies performed by four board-certified breast radiologists using six ultrasound systems from three vendors, we collected 821 images of 834 suspicious breast masses from 819 patients, 404 malignant and 430 benign according to histopathology. A balanced image set of biopsy-proven benign (n = 299) and malignant (n = 299) lesions was used for training and cross-validation of ensembles of machine learning algorithms supervised during learning by histopathological diagnosis as a reference standard. Based on a majority vote (over 80% of the votes to have a valid prediction of benign lesion), an ensemble of support vector machines showed an ability to reduce the biopsy rate of benign lesions by 15% to 18%, always keeping a sensitivity over 94%, when externally tested on 236 images from two image sets: (1) 123 lesions (51 malignant and 72 benign) obtained from two ultrasound systems used for training and from a different one, resulting in a positive predictive value (PPV) of 45.9% (95% confidence interval 36.3–55.7%) versus a radiologists’ PPV of 41.5% (p < 0.005), combined with a 98.0% sensitivity (89.6–99.9%); (2) 113 lesions (54 malignant and 59 benign) obtained from two ultrasound systems from vendors different from those used for training, resulting into a 50.5% PPV (40.4–60.6%) versus a radiologists’ PPV of 47.8% (p < 0.005), combined with a 94.4% sensitivity (84.6–98.8%). Errors in BI-RADS 3 category (i.e., assigned by the model as BI-RADS 4) were 0.8% and 2.7% in the Testing set I and II, respectively. The board-certified breast radiologist accepted the BI-RADS classes assigned by the model in 114 masses (92.7%) and modified the BI-RADS classes of 9 breast masses (7.3%). In six of nine cases, the model performed better than the radiologist did, since it assigned a BI-RADS 3 classification to histopathology-confirmed benign masses that were classified as BI-RADS 4 by the radiologist.

Contrast-enhanced mammography for the assessment of screening recalls: a two-centre study

OBJECTIVES

To evaluate the potential of contrast-enhanced mammography (CEM) for reducing the biopsy rate of screening recalls.

METHODS

Recalled women were prospectively enrolled to undergo CEM alongside standard assessment (SA) through additional views, tomosynthesis, and/or ultrasound. Exclusion criteria were symptoms, implants, allergy to contrast agents, renal failure, and pregnancy. SA and CEM were independently evaluated by one of six radiologists, who recommended biopsy or 2-year follow-up. Biopsy rates according to SA or recombined CEM (rCEM) were compared with the McNemar's test. Diagnostic performance was calculated considering lesions with available final histopathology.

RESULTS

Between January 2019 and July 2021, 220 women were enrolled, 207 of them (median age 56.6 years) with 225 suspicious findings analysed. Three of 207 patients (1.4%) developed mild self-limiting adverse reactions to iodinated contrast agent. Overall, 135/225 findings were referred for biopsy, 90/225 by both SA and rCEM, 41/225 by SA alone and 4/225 by rCEM alone (2/4 being one DCIS and one invasive carcinoma). The rCEM biopsy rate (94/225, 41.8%, 95% CI 35.5-48.3%) was 16.4% lower (p < 0.001) than the SA biopsy rate (131/225, 58.2%, 95% CI 51.7-64.5%). Considering the 124/135 biopsies with final histopathology (44 benign, 80 malignant), rCEM showed a 93.8% sensitivity (95% CI 86.2-97.3%) and a 65.9% specificity (95% CI 51.1-78.1%), all 5 false negatives being ductal carcinoma in situ detectable as suspicious calcifications on low-energy images.

CONCLUSIONS

Compared to SA, the rCEM-based work-up would have avoided biopsy for 37/225 (16.4%) suspicious findings. Including low-energy images in interpretation provided optimal overall CEM sensitivity.

KEY POINTS

• The work-up of suspicious findings detected at mammographic breast cancer screening still leads to a high rate of unnecessary biopsies, involving between 2 and 6% of screened women. • In 207 recalled women with 225 suspicious findings, recombined images of contrast-enhanced mammography (CEM) showed a 93.8% sensitivity and a 65.9% specificity, all 5 false negatives being ductal carcinoma in situ detectable on low-energy images as suspicious calcifications. • CEM could represent an easily available one-stop shop option for the morphofunctional assessment of screening recalls, potentially reducing the biopsy rate by 16.4%.

Plasma extracellular vesicle long RNA profiles in the diagnosis and prediction of treatment response for breast cancer

A large number RNAs are enriched and stable in extracellular vesicles (EVs), and they can reflect their tissue origins and are suitable as liquid biopsy markers for cancer diagnosis and treatment efficacy prediction. In this study, we used extracellular vesicle long RNA (exLR) sequencing to characterize the plasma-derived exLRs from 112 breast cancer patients, 19 benign patients and 41 healthy participants. The different exLRs profiling was found between the breast cancer and non-cancer groups. Thus, we constructed a breast cancer diagnostic signature which showed high accuracy with an area under the curve (AUC) of 0.960 in the training cohort and 0.900 in the validation cohort. The signature was able to identify early stage BC (I/II) with an AUC of 0.940. Integrating the signature with breast imaging could increase the diagnosis accuracy for breast cancer patients. Moreover, we enrolled 58 patients who received neoadjuvant treatment and identified an exLR (exMSMO1), which could distinguish pathological complete response (pCR) patients from non-pCR with an AUC of 0.790. Silencing MSMO1 could significantly enhance the sensitivity of MDA-MB-231 cells to paclitaxel and doxorubicin through modulating mTORC1 signaling pathway. This study demonstrated the value of exLR profiling to provide potential biomarkers for early detection and treatment efficacy prediction of breast cancer.

Chronological Trends of Breast Ductal Carcinoma In Situ: Clinical, Radiologic, and Pathologic Perspectives

BACKGROUND

Because no prior studies have evaluated the chronological trends of ductal carcinoma in situ (DCIS) despite the increasing number of surgeries performed for DCIS, this study analyzed how the clinical, radiologic, and pathologic characteristics of DCIS changed during a 10-year period.

METHODS

Of 7123 patients who underwent primary breast cancer surgery at a single institution from 2006 to 2015, 792 patients with pure DCIS were included in this study. The chronological trends of age, symptoms, method for detecting either mammography or ultrasonography, tumor size, nuclear grade, comedonecrosis, and molecular markers were calculated using Poisson regression for all patients and asymptomatic patients.

RESULTS

During 10 years, DCIS surgery rates significantly increased (p < 0.001). Despite the high percentage of DCIS detected on mammography, the detection rate for DCIS by mammography significantly decreased (97.3% in 2006 to 67.6% in 2015; p = 0.025), whereas the detection rate by ultrasound significantly increased (2.7% to 31.0%; p < 0.001). Conservation surgery rates (odds ratio [OR], 1.058), low-to-intermediate nuclear grade rates (OR, 1.069), and the absence of comedonecrosis (OR, 1.104) significantly increased over time (all p < 0.05). Estrogen receptor (ER) negativity (OR, 0.935) and human epidermal growth factor receptor 2 (HER2) positivity rates (OR, 0.953) significantly decreased (all p < 0.05). The same trends were observed for the 613 asymptomatic patients.

CONCLUSION

The rate of DCIS detected on ultrasound only significantly increased during 10 years. Low-to-intermediate nuclear grade rates significantly increased, whereas ER negativity and HER2 positivity rates significantly decreased during the same period. These findings suggest that DCIS detected on screening ultrasound is less aggressive than DCIS detected on mammography.