Preferential use of sonographically guided biopsy to minimize patient discomfort and procedure time in a percutaneous image-guided breast biopsy program

Reducing False Negatives in Biopsy of Suspicious MRI Findings

Breast MRI is a highly sensitive imaging modality that often detects findings that are occult on mammography and US. Given the overlap in appearance of benign and malignant lesions, an accurate method of tissue sampling for MRI-detected findings is essential. Although MRI-directed US and correlation with mammography can be helpful for some lesions, a correlate is not always found. MRI-guided biopsy is a safe and effective method of tissue sampling for findings seen only on MRI. The unique limitations of this technique, however, contribute to false negatives, which can result in delays in diagnosis and adverse patient outcomes; this is of particular importance as most MRI examinations are performed in the high-risk or preoperative setting. Here, we review strategies to minimize false negatives in biopsy of suspicious MRI findings, including appropriate selection of biopsy modality, use of meticulous MRI-guided biopsy technique, management after target nonvisualization, assessment of adequate lesion sampling, and determination of radiology-pathology concordance. A proposed management algorithm for MRI-guided biopsy results will also be discussed.

Comparison of prone and upright, stereotactic, and tomosynthesis-guided biopsies with secondary analysis of ultrasound-occult architectural distortions

OBJECTIVES

Compare prone and upright, stereotactic, and tomosynthesis-guided vacuum-assisted breast biopsies (prone DM-VABB, prone DBT-VABB, upright DM-VABB, and upright DBT-VABB) in a community-practice setting and review outcomes of ultrasound-occult architectural distortions (AD).

METHODS

Consecutive biopsies performed at two community-based breast centers from 2016 to 2019 were retrospectively reviewed. Technical details of each procedure and patient outcomes were recorded. Separate analyses were performed for ultrasound-occult ADs. Two sample t-tests and Fisher's exact test facilitated comparisons.

RESULTS

A total of 1133 patients underwent 369 prone DM-VABB, 324 prone DBT-VABB, 437 upright DM-VABB, and 123 upright DBT-VABB with 99.2%, 100%, 99.3%, and 99.2% success, respectively (p-values > 0.25). Mean lesion targeting times were greater for prone biopsy (minutes: 6.94 prone DM-VABB, 8.54 prone DBT-VABB, 5.52 upright DM-VABB, and 5.51 upright DBT-VABB; p-values < 0.001), yielding longer total prone procedure times for prone biopsy (p < 0.001). Compared to DM-VABB, DBT-VABB used fewer exposures (p < 0.001) and more commonly targeted AD, asymmetries, or masses (p < 0.001). Malignancy rates were similar between procedures: prone DM-VABB 22.4%, prone DBT-VABB 21.9%, upright DM-VABB 22.8%, and upright DBT-VABB 17.2% (p-values > 0.19). One hundred forty of the 1133 patients underwent 145 biopsies for ultrasound-occult AD (143 DBT-VABB and 2 DM-VABB). Biopsy yielded 27 malignancies and 47 high-risk lesions (74 of 145, 51%). Malignancy rate was 20.7% after surgical upgrade of one benign-discordant and two high-risk lesions.

CONCLUSIONS

All biopsy procedure types were extremely successful. The 20.7% malignancy rate for ultrasound-occult AD confirms a management recommendation for tissue diagnosis. Upright biopsy was faster than prone biopsy, and DBT-VABB used fewer exposures than DM-VABB.

CLINICAL RELEVANCE

Our results highlight important differences between prone DM-VABB, prone DBT-VABB, upright DM-VABB, and upright DBT-VABB. Moreover, the high likelihood of malignancy for ultrasound-occult AD will provide confidence in recommending tissue diagnosis in lieu of observation or clinical follow-up.

KEY POINTS

• Upright and prone stereotactic and tomosynthesis-guided breast biopsies were safe and effective in the community-practice setting. • The malignancy rate for ultrasound-occult architectural distortion of 20.7% confirms the management recommendation for biopsy. • Upright procedures were faster than prone procedures, and tomosynthesis-guided biopsy used fewer exposures than stereotactic biopsy.

Low-grade adenosquamous carcinoma of the breast: a review with focus on imaging and management

Low-grade adenosquamous carcinoma is a less frequent variant of metaplastic breast carcinoma, incidentally detected during screening and has an age distribution similar to other breast carcinomas. It shares characteristics with both benign and malignant carcinomas: its mammographic and sonographic features are therefore nonspecific. Breast conserving surgery with adjuvant radiation therapy is currently the preferred therapeutic approach. The aim of this review is to describe the imaging and clinical features of low-grade adenosquamous carcinoma for appropriate identification and diagnosis. The associated pitfalls, histopathologic and epidemiologic factors, natural course, and management of low-grade adenosquamous carcinoma are also discussed.

Interventional Radiology for Local Immunotherapy in Oncology

Human intratumoral immunotherapy (HIT-IT) is under rapid development, with promising preliminary results and high expectations for current phase III trials. While outcomes remain paramount for patients and the referring oncologists, the technical aspects of drug injection are critical to the interventional radiologist to ensure optimal and reproducible outcomes. The technical considerations for HIT-IT affect the safety, efficacy, and further development of this treatment option. Image-guided access to the tumor allows the therapeutic index of a treatment to be enhanced by increasing the intratumoral drug concentration while minimizing its systemic exposure and associated on-target off-tumor adverse events. Direct access to the tumor also enables the acquisition of cancer tissue for sequential sampling to better understand the pharmacodynamics of the injected immunotherapy and its efficacy through correlation of immune responses, pathologic responses, and imaging tumor response. The aim of this article is to share the technical insights of HIT-IT, with particular consideration for patient selection, lesion assessment, image guidance, and technical injection options. In addition, the organization of a standard patient workflow is discussed, so as to optimize HIT-IT outcome and the patient experience.

Assessment and management of B3 breast lesions with atypia: a focused review

Breast lesions with atypia are a spectra of diseases that confer increased risk of breast cancer because of an increased probability of finding concomitant cancer after excision, or evolution toward in situ or invasive cancer over the long term. The widespread use of radiologic tools and core needle breast biopsies, in recent years, has led to an increase in the diagnosis of these atypical breast lesions. Concurrent with this has been an improvement in the classification and pathogenesis of these lesions. Current evidence suggests that the recognition and treatment of patients with atypical histology after biopsy and surgical excision requires a multidisciplinary approach to decrease the overdiagnosis and overtreatment risks. This focused review investigates the controversy and current management of atypical ductal hyperplasia, lobular neoplasia, flat epithelial atypia, and intraductal papilloma with atypia along with the risk-reducing strategies.

A new risk stratification score for the management of ultrasound-detected B3 breast lesions

To develop a predictive scoring system for ultrasound-detected B3 lesions at ultrasound-guided core needle biopsy (US-CNB). A total of 2724 consecutive US-CNBs performed in our Institution (January 2011 to December 2014) were retrospectively reviewed. Inclusion criteria were as follows: (a) histopathological examination of the entire lesion or (b) availability of radiologic follow-up (FUP) ≥24 months. Patient- and lesion-related variables-patients' age, lesion consistency, lesion size, vascularization, BI-RADS category, and US-CNB result-were analyzed. Positive predictive values (PPVs) for malignancy were calculated correlating US-CNB results with excision histology or FUP. A scoring system for underlying malignancy was developed using risk factors weighting. A total of 102 B3 lesions were included: 27 atypical ductal hyperplasia (26.5%), 5 lobular intraepithelial neoplasia (4.9%), 32 radial scar (31.4%), 37 papillary lesions (36.3%), and 1 fibroepithelial lesion (0.9%). Surgery was performed on 71/102 (69.6%) lesions, and 22/71 were malignant; the remaining 31/102 lesions (30.4%) were unchanged at FUP. The overall PPV for malignancy was 21.6%. Patients' age (odds ratio [OR] = 3.63, P = 0.008), lesion consistency (OR = 5.96, P = 0.001), BI-RADS category (OR = 17.52, P < 0.001), and CNB result (OR = 3.6, P = 0.008) were associated with a higher risk of malignancy underestimation and selected as risk factors in the score definition. Two risk groups were identified: low (0-2 points) and high risk (3-5 points), with significantly different risk of malignancy underestimation (8.0% vs 59.3%, P < 0.001). The proposed score helps to predict the risk of malignancy underestimation and choose the management of B3 lesions at US-CNB.

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

Objective

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

Materials and methods

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

Results

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

Conclusion

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

An evaluation of patient experience during percutaneous breast biopsy

OBJECTIVE

Percutaneous breast biopsy in a tertiary referral high volume breast centre: can we improve the patient experience?

PURPOSE

The study was performed to evaluate patient experience during ultrasound-guided (UGB) and vacuum-assisted stereotactic breast biopsy (SBB) and determine what factors could improve the patient experience.

METHODS

Consecutive patients who underwent image guided breast biopsy from 01- 05/30, 2015 were approached in a structured telephone interview to evaluate pain and bruising from the procedure. Three hundred and fifty-one patients were interviewed (116 SBB and 235 UGB). Information about the radiologist performing the biopsy, biopsy type, needle gauge, and number of cores was collected from the biopsy reports. Correlation was done using Spearman rank test.

RESULTS

Average patient scores of pain with UGB and SBB were 2.3 and 3.1 (out of 10). There was a significant correlation between pain during SBB and physician experience (p = 0.013), and no correlation with pain during UGB (p > 0.05). No correlation was found between needle gauge and pain experienced during breast biopsy or between numbers of cores and pain (p > 0.05). Body position during SBB was mentioned to cause discomfort and pain in 28% of patients while during UGB was mentioned by 0.4% of patients.

CONCLUSION

SBB was inferior to UGB for patient experience, but years of radiologists' experience correlated with improved patient scores of pain for SBB.

KEY POINTS

• To achieve high quality, an institution must emphasise patient-centred care. • Increased radiologist training with stereotactic biopsy may contribute to improved patient experience. • Stereotactic breast biopsy was inferior to ultrasound biopsy for patient experience. • Radiologists' experience correlated with improved patient scores of pain for stereotactic biopsy.

Impact of Sodium Bicarbonate-Buffered Lidocaine on Patient Pain During Image-Guided Breast Biopsy

PURPOSE

This randomized, double-blind controlled study evaluated the effectiveness of sodium bicarbonate-buffered lidocaine on reducing pain during imaging-guided breast biopsies.

MATERIALS AND METHODS

This prospective, HIPAA-compliant study randomly assigned 85 women undergoing ultrasound- or stereotactic-guided core-needle breast biopsies to receive intradermally and intraparenchymally either 1% lidocaine buffered with sodium bicarbonate (9:1 ratio) (bicarbonate study group) or 1% lidocaine alone (control group). Pain was evaluated using a 0-to-10 Likert pain scale during both intradermal and intraparenchymal anesthesia injections and during tissue sampling. Prebiopsy breast pain, anxiety, medical history, demographics, biopsy type, radiologist level of training, breast density, and lesion histology were recorded. Data were analyzed using analysis of variance and analysis of covariance.

RESULTS

Unadjusted mean pain scores were 1.47 and 2.07 (study and control groups, respectively; P = .15) during intradermal injections, and 1.84 and 2.98 (study and control groups, respectively; P = .03) during intraparenchymal injections. Tissue sampling mean pain scores were .81 and 1.71 (study and control groups, respectively; P = .07). Moderator analyses found (1) among patients with preprocedural pain, those in the bicarbonate group experienced less intradermal injection pain (0.85 ± 1.23) than patients in the control group (2.50 ± 2.09); (2) among patients with fatty or scattered fibroglandular tissue, those in the bicarbonate group (1.35 ± 1.95) experienced less intraparenchymal injection pain than the control group (3.52 ± 3.13); and (3) during ultrasound-guided biopsies, patients in the bicarbonate group experienced less tissue-sampling pain (0.23 ± 0.63) than the control group (1.79 ± 3.05).

CONCLUSIONS

Overall, buffering lidocaine with sodium bicarbonate significantly reduced pain during intraparenchymal injections, and additional pain reduction was found in certain patient subgroups during intradermal injections, intraparenchymal injections, and tissue sampling.

Preoperatively diagnosed ductal cancers in situ of the breast presenting as even small masses are of high risk for the invasive cancer foci in postoperative specimen

Background

In ductal carcinoma in situ of the breast (DCIS), histologic diagnosis obtained before the definitive treatment is related to the risk of underestimation if the presence of invasive cancer is found postoperatively. These patients need a second operation to assess the nodal status. We evaluated the upstaging rate in patients with mass-forming DCIS.

Methods

Sixty-three women with pure DCIS presenting as sonographic mass lesion underwent vacuum-assisted or core-needle biopsy and subsequent surgery. Rates of postoperative upstaging to invasive cancer were calculated and compared with clinical character and size of DCIS.

Results

Median age of patients (range) was 63 years (27–88) while median diameter of DCIS was 11 mm (6–60). Fifty-six percent of DCIS were upstaged. Patient age did not differ significantly between groups with and without final invasion (median, mean, SD): 63, 61.4, 12.5 vs 62, 61.2, 10.6 years, respectively (P = 0.659). The difference of DCIS size between these groups was statistically important (median, mean, SD): 13, 17.3, 11.4 vs 9.5, 9.8, 3.2 mm, respectively (P = 0.0003). Mass size and palpability were significant risk factors (P < 0.001 and P < 0.01, respectively). Rate of underestimation for mass with diameter ≤10 mm, 10–20 mm and >20 mm was 37, 64 and 91 %, respectively.

Conclusions

DCIS diagnosed on minimal-invasive biopsy of even small sonographic mass is of high risk for the upstaging to invasive cancer after final surgical excision. In these patients, subsequent intervention is needed for nodal status assessment. They are good candidates for the sentinel node biopsy during the breast operation to avoid multi-step surgery.

Breast cancer detection with short-interval follow-up compared with return to annual screening in patients with benign stereotactic or US-guided breast biopsy results

PURPOSE

To compare the cancer detection rate and stage after benign stereotactic or ultrasonography (US)-guided core breast biopsy between patients with short-interval follow-up (SIFU) and those who return to annual screening.

MATERIALS AND METHODS

The Breast Cancer Surveillance Consortium (BCSC) registry and the BCSC Statistical Coordinating Center received institutional review board approval for active and passive consent processes and a waiver of consent. All procedures were HIPAA compliant. BCSC data for 1994-2010 were used to compare ipsilateral breast cancer detection rates and tumor characteristics for diagnoses within 3 months after SIFU (3-8 months) versus return to annual screening (RTAS) mammography (9-18 months) after receiving a benign pathology result from image-guided breast biopsy.

RESULTS

In total, 17 631 biopsies with benign findings were identified with SIFU or RTAS imaging. In the SIFU group, 27 ipsilateral breast cancers were diagnosed in 10 715 mammographic examinations (2.5 cancers per 1000 examinations) compared with 16 cancers in 6916 mammographic examinations in the RTAS group (2.3 cancers per 1000 examinations) (P = .88). Sixteen cancers after SIFU (59%; 95% confidence interval [CI]: 39%, 78%) were invasive versus 12 after RTAS (75%; 95% CI: 48%, 93%). The invasive cancer rate was 1.5 per 1000 examinations after SIFU (95% CI: 0.9, 2.4) and 1.7 per 1000 examinations (95% CI: 0.9, 3.0) after RTAS (P = .70). Among invasive cancers, 25% were late stage (stage 2B, 3, or 4) in the SIFU group (95% CI: 7%, 52%) versus 27% in the RTAS group (95% CI: 6%, 61%). Positive lymph nodes were found in seven (44%; 95% CI: 20%, 70%) invasive cancers after SIFU and in three (25%; 95% CI: 5%, 57%) invasive cancers after RTAS.

CONCLUSION

Similar rates of cancer detection were found between SIFU and RTAS after benign breast biopsy with no significant differences in stage, tumor size, or nodal status, although the present study was limited by sample size. These findings suggest that patients with benign radiologic-pathologic-concordant percutaneous breast biopsy results could return to annual screening.

Interventional radiology in the diagnosis and treatment of diseases of the breast: a historical review and future perspective based on currently available techniques

OBJECTIVE

The topic of imaging-guided breast interventions spans more than 30 years. Radiologists pioneered procedures such as needle or wire localization and ultrasound and stereotactic-guided biopsy. Using recently developed devices and technology, the opportunity exists to treat lesions of the breast with minimally invasive imaging-guided techniques.

CONCLUSION

Breast imagers and interventional radiologists, along with our surgical and oncologic colleagues, are best qualified to participate together in the research and development of these procedures.

Breast ultrasonography: state of the art

Ultrasonography (US) is an indispensable tool in breast imaging and is complementary to both mammography and magnetic resonance (MR) imaging of the breast. Advances in US technology allow confident characterization of not only benign cysts but also benign and malignant solid masses. Knowledge and understanding of current and emerging US technology, along with the application of meticulous scanning technique, is imperative for image optimization and diagnosis. The ability to synthesize breast US findings with multiple imaging modalities and clinical information is also necessary to ensure the best patient care. US is routinely used to guide breast biopsies and is also emerging as a supplemental screening tool in women with dense breasts and a negative mammogram. This review provides a summary of current state-of-the-art US technology, including elastography, and applications of US in clinical practice as an adjuvant technique to mammography, MR imaging, and the clinical breast examination. The use of breast US for screening, preoperative staging for breast cancer, and breast intervention will also be discussed.

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.

The negative predictive value of ultrasound-guided 14-gauge core needle biopsy of breast masses: a validation study of 339 cases

PURPOSE

To determine the negative predictive value of sonographically guided 14-gauge core needle biopsy of breast masses, with detailed analysis of any false-negative cases.

MATERIALS AND METHODS

We reviewed 669 cases of sonographically guided 14-gauge core needle biopsies that had benign pathologic findings. Given a benign pathology on core biopsy, true-negatives had either benign pathology on surgical excision or at least 2 years of stable imaging and/or clinical follow-up; false-negatives had malignant histology on surgical excision.

RESULTS

Follow-up was available for 339 breast lesions; 117 were confirmed to be benign via surgical excision, and 220 were stable after 2 years or more of imaging or clinical follow-up (mean follow-up time 33.1 months, range 24-64 months). The negative predictive value was determined to be 99.4%. There were 2 false-negative cases, giving a false-negative rate of 0.1%. There was no delay in diagnosis in either case because the radiologist noted discordance between imaging and core biopsy pathology, and recommended surgical excision despite the benign core biopsy pathology.

CONCLUSIONS

Sonographically guided 14-gauge core needle biopsy provides a high negative predictive value in assessing breast lesions. Radiologic/pathologic correlation should be performed to avoid delay in the diagnosis of carcinoma.

Utilizing a PACS-integrated ultrasound-guided breast biopsy simulation exercise to reinforce the ACR practice guideline for ultrasound-guided percutaneous breast interventional procedures during radiology residency

RATIONALE AND OBJECTIVES

A picture archiving and communication system (PACS)-integrated ultrasound-guided (USG) breast intervention simulation exercise was designed for radiology residency education. The purpose of this study was to describe the initial experience and determine if resident understanding of the American College of Radiology (ACR) practice guideline for the performance of USG percutaneous breast interventional procedures and procedural confidence is improved with the implementation of this simulation exercise.

MATERIALS AND METHODS

Radiology residents (n = 11) volunteered to perform percutaneous USG cyst aspiration, 14-gauge automated core biopsy, and 10-gauge vacuum core biopsy on turkey breast phantoms, with an emphasis on capturing ultrasound images demonstrating appropriate documentation of the procedure and image annotation according to the ACR practice guideline for USG percutaneous interventions. The images were transmitted to the PACS for subsequent attending radiologist review. Survey responses regarding procedural confidence and knowledge of the ACR practice guideline were compared between residents with and without the simulator experience.

RESULTS

Residents with simulation exercise experience showed statistically significant increases in confidence performing USG core biopsies, operating biopsy devices and ultrasound equipment, and knowledge of appropriate needle positioning and image annotation and documentation according to the ACR practice guideline. The increased confidence seen in performing USG cyst aspiration barely missed statistical significance (P = .056), likely because of residents' baseline familiarity with the procedure.

CONCLUSIONS

A PACS-integrated USG breast intervention simulation exercise increases residents' procedural confidence and understanding of the ACR practice guideline for the performance of USG percutaneous breast interventional procedures.

Duration time of vacuum-assisted biopsy for nonpalpable breast masses: Comparison between stereotactic and ultrasound-guided procedure

Aims and background

Minimally invasive biopsy should be a standard practice in the non-operative diagnosis of breast lesions that are suspicious for or highly suggestive of malignancy. The aim of this study was to compare the procedure duration time for different methods of minimally invasive image-guided vacuum-assisted breast biopsy (VABB).

Methods

Six hundred and ninety-one women with nonpalpable breast masses classified as BI-RADS IV or V were studied. All of them underwent minimally invasive percutaneous VABB with an 11-gauge needle. In 402 patients an ultrasound-guided procedure with a hand-held device was performed while in 289 women stereotactic biopsy was carried out using a dedicated prone table unit with digital imaging. In each case the duration of biopsy was measured in terms of the total procedure time, room time and physician time.

Results

There were no significant differences between the stereotactic and ultrasound-guided groups with regard to patient age, body mass index, menopausal status, history of parity, hormone replacement therapy, breast parenchymal pattern (according to Wolfe's classification), family history of breast cancer, mass size and number of samples. Ultrasound-guided biopsy was found to take significantly less time than prone stereotactic biopsy in every aspect of procedure duration. Mean total procedure time, room time, and physician time in minutes were 26.7 ± 8.2 vs 47.5 ± 9.4 (P <0.01), 23.1 ± 8.5 vs 36.5 ± 9.2 (P <0.05), and 12.3 ± 5.6 vs 18.6 ± 5.9 (P <0.05), respectively.

Conclusions

Ultrasound-guided breast biopsy is less time-consuming than the stereotactic procedure for both the patient and the physician. Because of the shorter procedure time (as well as other well-known advantages: real-time imaging, lower cost), ultrasound-guided biopsy should be considered the method of choice for sampling suspicious nonpalpable breast masses.

Ultrasound-guided biopsy of focal lesions using three-dimensional ultrasound with a matrix array transducer: comparison with 2-dimensional ultrasound in a phantom study

OBJECTIVES

To investigate the feasibility of biopsy-guided 3-dimensional (3D) ultrasound (US) with a matrix array transducer (3D US-MAT), using the lateral and/or elevation tilt modes.

MATERIALS AND METHODS

Both inexperienced and experienced examiners performed biopsy experiments using a freehand technique on agar-based phantoms with 2-dimensional (2D) US guidance and 3D US-MAT guidance allowing real-time biplane imaging, using the lateral tilt mode and/or elevation tilt mode. Each phantom contained 4 targets of different sizes, and there were 3 different types of phantom, each having a different distance between the target and the surface. In every session, each target was aimed at 3 times, with 3 different distances between the transducer and puncture site, which resulted in 36 biopsies (3 biopsies per target × 4 targets × 3 phantoms, each of which was uniquely identified by size, depth, and angle). This procedure was carried out by each of 2 examiner twice by 2D US and twice by 3D US-MAT, resulting in paired data for each biopsy and each examiner. Target variables were target specimen length (TSL), procedure time, and agreement between the TSL of the first and second procedure by each examiner with identical biopsy parameters as a reliability measure.

RESULTS

The intraexaminer agreements between the TSLs with the 3D US-MAT in both inexperienced (r = 0.84) and experienced (r = 0.93) examiners were higher than with the 2D US (r = 0.59 with P = 0.0066, and r = 0.87 with P = 0.06, respectively). However, the procedure time with the 3D US-MAT was significantly longer than with the 2D US. The TSL were significantly longer with 3D US-MAT than with 2D US for both the examiners; the inexperienced examiner (P < 0.001) benefited more than his experienced colleague (P = 0.024). In addition, the 3D US-MAT had significant benefits for the acquisition of TSL with small target diameters and for targets with shallow locations; with more acute puncture angles for both the examiners (all P < 0.05).

CONCLUSIONS

Using a 3D US-MAT guidance improves the reliability and precision of biopsies, particularly under difficult conditions and for inexperienced examiners.

Pain experienced by patients during minimal-invasive ultrasound-guided breast biopsy: vacuum-assisted vs core-needle procedure

AIMS

To evaluate comparatively the pain associated with ultrasound-guided core-needle (CN) and vacuum-assisted (VA) biopsy for non-palpable breast lesions.

METHODS

723 women undergoing ultrasound-guided breast biopsy for BIRADS IV and V lesions according to the same standardised protocol were prospectively studied. 14-gauge CN biopsy with an automated gun was performed in 321 patients. In 402 women biopsy was made using 11-gauge VA hand-held probe. Immediately after the procedure patients were interviewed about the pain experienced during the biopsy and were asked to indicate at the pain intensity on a eleven-point scale: from 0 (none) to 10 (extreme, worst possible pain).

RESULTS

The median rate of pain experienced by women during biopsy was 4 (range 2-7). There were no significant differences between CN and VA groups with regard to age, body mass index, menopausal status, history of parity, hormone replacement therapy, menopausal status, breast parenchymal pattern (according to Wolfe's classification), family history of breast cancer, lesion size and number of samples. CN biopsy with an automated gun was significantly more painful (P < 0.01) than procedure with VA hand-held device as evaluated by patients: median 6 (4-7) vs 3 (2-5), respectively.

CONCLUSIONS

Despite using the larger needle VA procedure results in less pain experienced by women in comparison to CN biopsy with automated gun. Reduced patient discomfort should be one of the reasons for the preferential use of VA biopsy in the assessment of non-palpable breast masses.

Can concurrent core biopsy and fine needle aspiration biopsy improve the false negative rate of sonographically detectable breast lesions?

Background

The aims of this study were to determine the accuracy of concurrent core needle biopsy (CNB) and fine needle aspiration biopsy (FNAB) for breast lesions and to estimate the false-negative rate using the two methods combined.

Methods

Over a seven-year period, 2053 patients with sonographically detectable breast lesions underwent concurrent ultrasound-guided CNB and FNAB. The sonographic and histopathological findings were classified into four categories: benign, indeterminate, suspicious, and malignant. The histopathological findings were compared with the definitive excision pathology results. Patients with benign core biopsies underwent a detailed review to determine the false-negative rate. The correlations between the ultrasonography, FNAB, and CNB were determined.

Results

Eight hundred eighty patients were diagnosed with malignant disease, and of these, 23 (2.5%) diagnoses were found to be false-negative after core biopsy. After an intensive review of discordant FNAB results, the final false-negative rate was reduced to 1.1% (p-value = 0.025). The kappa coefficients for correlations between methods were 0.304 (p-value < 0.0001) for ultrasound and FNAB, 0.254 (p-value < 0.0001) for ultrasound and CNB, and 0.726 (p-value < 0.0001) for FNAB and CNB.

Conclusions

Concurrent CNB and FNAB under ultrasound guidance can provide accurate preoperative diagnosis of breast lesions and provide important information for appropriate treatment. Identification of discordant results using careful radiological-histopathological correlation can reduce the false-negative rate.

Preliminary in vivo validation of a dedicated breast MRI and sonographic coregistration imaging system

OBJECTIVE

Sonographic correlation of breast MRI findings is often challenging. We present a preliminary in vivo feasibility study evaluating the degree of error of a new MRI-sonography coregistration system for showing MRI and sonographically visible breast lesions.

CONCLUSION

In 10 patients with 13 lesions, the system was found to be an accurate means for targeting sonography to MRI of the same breast lesions.

Accuracy of ultrasound-guided, large-core needle breast biopsy

Ultrasound-guided, large-core needle biopsy (US-LCNB) of suspicious breast lesions is acknowledged as less invasive and less expensive and less time consuming than surgical biopsy, and provides a histologic diagnosis with a comparable high degree. US-LCNB has been proven to help reduce the number of unnecessary surgeries for benign disease. Its limitations, however, are false-negative results and underestimation of disease. Thus, the demand for breast teams is to carefully adhere to the principles of triple assessment and imaging-histologic correlation, and follow-up of lesions with a specific benign histology after biopsy. Also, the acceptance of guidelines and rigorous quality controls help to reliably minimize the delay in the diagnosis of breast cancer in patients with false-negative biopsies. This paper aims to summarize the equipment and methods as well as the benefits and limitations of US-LCNB. Also, guidelines of quality assessment are suggested. Finally, recent developments which may help to overcome the limitations of US-LCNB will be discussed, i.e., directional vacuum-assisted biopsy (VAB), three-dimensional (3D) US-guided biopsy, as well as the use of tissue harmonic imaging (THI) and compound imaging (CI) during biopsy.

Stereotactic large-core needle breast biopsy: analysis of pain and discomfort related to the biopsy procedure

The purpose of this study was to determine the significance of variables such as duration of the procedure, type of breast tissue, number of passes, depth of the biopsies, underlying pathology, the operator performing the procedure, and their effect on women’s perception of pain and discomfort during stereotactic large-core needle breast biopsy. One hundred and fifty consecutive patients with a non-palpable suspicious mammographic lesions were included. Between three and nine 14-gauge breast passes were taken using a prone stereotactic table. Following the biopsy procedure, patients were asked to complete a questionnaire. There was no discomfort in lying on the prone table. There is no relation between type of breast lesion and pain, underlying pathology and pain and performing operator and pain. The type of breast tissue is correlated with pain experienced from biopsy (P = 0.0001). We found out that patients with dense breast tissue complain of more pain from biopsy than patients with more involution of breast tissue. The depth of the biopsy correlates with pain from biopsy (P = 0.0028). Deep lesions are more painful than superficial ones. There is a correlation between the number of passes and pain in the neck (P = 0.0188) and shoulder (P = 0.0366). The duration of the procedure is correlated with pain experienced in the neck (P = 0.0116) but not with pain experienced from biopsy.

The accuracy of ultrasound, stereotactic, and clinical core biopsies in the diagnosis of breast cancer, with an analysis of false-negative cases

OBJECTIVE

Preoperative core biopsy in breast cancer is becoming the standard of care. The aim of this study was to analyze the various methods of core biopsy with respect to diagnostic accuracy and to examine the management and outcome of those patients with false-negative biopsies.

METHODS

All patients undergoing core biopsy for breast abnormalities over a 5-year period (1999-2003) were reviewed. The accuracy rates for each method of core biopsy, the histologic agreement between the core pathology and subsequent excision pathology, and the length of follow-up for cases of benign disease were studied. Patients whose biopsies were benign but who were subsequently diagnosed with cancer underwent detailed review.

RESULTS

There were 2427 core biopsies performed over the 5-year period, resulting in a final diagnosis of cancer in 1384 patients, benign disease in 954 patients, and atypical disease in 89 patients. Biopsy type consisted of 1279 ultrasound-guided cores, 739 clinically guided cores, and 409 stereotactic-guided cores. The overall false-negative rate was 6.1%, with specific rates for ultrasound-, clinical-, and stereotactic-guided cores of 1.7%, 13%, and 8.9%, respectively. False-negative biopsies occurred in 85 patients, and in 8 of these patients the diagnosis was delayed by greater than 2 months. In all other false-negative cases, "triple assessment" review allowed prompt recognition of discordant biopsy results and further evaluation.

CONCLUSION

Ultrasound guidance should be used to perform core biopsies in evaluating all breast abnormalities visible on ultrasound. Adherence to principles of triple assessment following biopsy allows for early recognition of the majority of false-negative cases.

An Audit of Pain/Discomfort Experienced during Image-Guided Breast Biopsy Procedures

A prospective audit of 221 breast biopsies was carried out to assess the pain/discomfort experienced during image-guided breast biopsies. The only significant factor in pain scores was the size of the needle used. Fine-needle aspiration cytology using a 21-gauge needle was found to cause the most discomfort.

Accuracy of sonographically guided 14-gauge core-needle biopsy: results of 715 consecutive breast biopsies with at least two-year follow-up of benign lesions

PURPOSE

The objective of this study was to examine the diagnostic accuracy of sonographically guided 14-gauge core-needle biopsy (CNB).

METHODS

Sonographically guided 14-gauge CNBs of 715 breast lesions were performed in 652 patients. Histopathologic results were correlated with imaging findings, and repeat biopsy was recommended in the cases of discordance between the radiologic and pathologic results. Long-term follow-up was used for patients with CNB findings of a benign lesion.

RESULTS

Sonographically guided CNB revealed malignancy in 311 lesions (43%). Thirty-one lesions with CNB findings indicating benign conditions underwent additional image-guided or excisional biopsy because of indeterminate pathologic features, disagreement between radiologic and pathologic results, surgeon preference, or patient request. Within these 31 cases, 9 malignancies were diagnosed. The duration of follow-up for the remaining 373 benign lesions varied from 27 to 60 months. In 3 of these 373 cases, carcinoma was diagnosed at the site of CNB. The false-negative rate of 14-gauge sonographically guided CNB was 3.7%, and the sensitivity of sonographically guided CNB for the diagnosis of breast cancer was 96.3%.

CONCLUSIONS

Sonographically guided 14-gauge CNB is a safe and accurate method for evaluating breast lesions that require tissue sampling. Radiologic-pathologic correlation and follow-up of benign lesions are essential for a successful breast biopsy program.

Cost minimization study of image-guided core biopsy versus surgical excisional biopsy for women with abnormal mammograms

PURPOSE

To describe the clinical and economic consequences of image-guided core biopsy versus surgical excisional biopsy of mammographically identified breast lesions.

PATIENTS AND METHODS

Clinical and economic data were collected for 1121 patients undergoing core biopsies and 501 patients undergoing surgical biopsies between 1996 and 1998. Lesions were classified according to mammographic degree of suspicion and type of radiographic abnormality. Costs were measured from the societal perspective. A decision analytic model was constructed, with probabilistic sensitivity analysis.

RESULTS

Lesions diagnosed via core versus surgical biopsy were less likely to be masses (39% v 55%), less likely to be classified as high cancer suspicion (17% v 26%), and less likely to be treated with a single procedure (74% v 81%; P <.001 for each). Cancers diagnosed by a surgical biopsy were less likely to have had a single operative procedure (33% v 84%) and were associated with higher total costs whether mastectomy (US dollars 2775 v US dollars 1849) or lumpectomy (US dollars 2112 v US dollars 1365) was used. Sensitivity analysis showed core biopsy optimal in 95.4% of trials. Core biopsy was favored for low-suspicion lesions, calcifications, and masses, and overall for patients who underwent lumpectomy alone.

CONCLUSION

Image-guided core biopsy can be cost-saving compared with surgical biopsy, particularly when the mammographic abnormality is classified as low suspicion or consists of calcifications or masses. Moving to a policy in which core biopsy is the preferred approach in these settings has the potential to result in significant cost savings.