Now or Later? Patient Satisfaction and Anxiety Among Women Undergoing Breast Biopsies Performed the Same Day as Recommended Versus a Later Day

PURPOSE

The aim of this study was to determine differences in patient satisfaction and anxiety among women undergoing core-needle breast biopsies performed the same day as recommended versus a future date.

METHODS

After institutional review board exemption was granted, a survey was administered to patients at four sites on the day of imaging-guided core-needle breast biopsy. The survey was available from November 2020 through January 2022. Questions pertained to biopsy timing (same day versus later day), pre- and postbiopsy satisfaction with overall breast-care experience, biopsy wait-time satisfaction, pre- and postbiopsy anxiety, radiologist-patient communication, demographics, life stressors, breast cancer history, and risk factors. Comparisons were made between same-day and later-day biopsies by multivariable analysis.

RESULTS

Of 974 respondents (response rate 65.6%), almost half were scheduled for same-day biopsies (47.8% [466 of 974]). In multivariate analyses, same-day biopsies were associated with higher prebiopsy overall breast-care satisfaction (P < .001), higher wait-time satisfaction (P < .001), and higher prebiopsy (P = .001) and postbiopsy anxiety (P = .001). Better radiologist-patient communication was associated with lower prebiopsy anxiety (P < .001) and greater prebiopsy overall (P < .001) and wait-time (P < .001) satisfaction. Compared with White women, Black women reported lower postbiopsy anxiety (P < .001) but also lower prebiopsy satisfaction (P = .03) and wait-time satisfaction (P < .001).

CONCLUSIONS

Same-day versus later-day biopsies resulted in better prebiopsy overall breast-care and wait-time patient satisfaction scores; however, no satisfaction differences were noted after biopsy. Clinically significant anxiety was associated with both same- and later-day biopsies but was higher for same-day biopsies. Higher anxiety levels correlated with lower overall satisfaction, suggesting that interventions to reduce anxiety and improve communication could improve patient experiences during same-day biopsies.

[Extensive transfixing skin necrosis after breast biopsy under local anesthesia: About four cases]

INTRODUCTION

Local anesthetics with adrenaline are widely used in routine practice and have long proven their benefits and safety. The rare complications due to their use mainly concern immuno-allergic and vascular mechanisms.

DESCRIPTION

In this article, we present four similar cases of early transfixing skin necrosis occurring after radioguided breast biopsy under local anesthesia using epinephrine local anesthetics in the context of a diagnostic approach to breast cancer.

DISCUSSION

Although the literature is comforting about the use of local anesthetics, even on the extremities, severe skin complications continue to be reported sporadically. The analysis and understanding of these phenomena would allow, in the long run, to avoid them and to reduce their importance.

CONCLUSION

The occurrence of skin necrosis after breast biopsy under radiographic control is rare and seems to be related to the local anesthetic procedure. Although similar cases have been reported in the literature, it does not seem possible today to conclude on the exact physiopathology of these complications. A better knowledge of the pathophysiology of these complications would help to avoid their occurrence in the future.

Construction of Low-Cost Simulators for Training in Minimally Invasive Breast Procedures

Objective

The aim of this work was to describe a technique for building low-cost simulators for training in minimally invasive breast procedures guided by ultrasound (US) and stereotactic mammography (MMG), focusing mainly on training medical professionals studying related areas.

Materials and Methods

Low-cost phantoms were developed using organic structures that mimic breast tissue, such as chicken breast and eggplant, and materials that simulate breast lesions. A step-by-step description of the preparation and use of these simulators was made, enabling the reproducibility of the technique by the physicians in training themselves.

Results

The low-cost phantoms showed a high degree of echogenic and radiological similarity with human breast tissue, allowing adequate training in minimally invasive procedures.

Conclusion

It was possible to build low-cost phantoms that allow training in US- and stereotactic MMG-guided minimally invasive breast procedures.

Robotics in Screening, Diagnosis and Treatment of Breast Cancer: A Perspective View

This perspective article aims to summarize and provide an outlook for developments around the use of robotics in the screening, diagnosis and treatment of breast cancer. We searched existing literature on the design and development of new systems and the current use of pre-existing surgical robotic systems. Robotic interventions for breast palpation and biopsy under ultrasound and MRI guidance are being developed and tested on simulated breast phantoms. Results are comparable to those achieved by clinicians; however, there are yet to be any human trials. Existing robotic surgical systems have been evaluated in human trials to perform nipple-sparing mastectomy and harvesting of autologous tissue for breast reconstruction. Results are comparable to traditional NSM and demonstrate positive short-term outcomes for patients. Robotic devices could revolutionize the clinical workflow around breast cancer through less invasive surgery, greater accuracy in biopsies and microsurgery and a potential reduction in clinicians' workload. However, more research into the practical deployment of these devices and concrete scientific evidence of better patient outcomes is needed.

Impact of a brochure and empathetic physician communication on patients' perception of breast biopsies

PURPOSE

This study investigated the effect of an intervention designed to reduce patients' emotional distress associated with breast biopsy.

METHODS

125 breast biopsy patients receiving standard of care (control group, CG) were compared to 125 patients (intervention group, IG) who received a brochure with information prior to the biopsy and were biopsied by physicians trained in empathic communication. Anxiety was assessed by the State-Anxiety Inventory (STAI-S) at four time points (pre- and post-procedural, pre- and post-histology). All participants completed pre- and post-procedural questionnaires addressing worries, pain and comprehension. We evaluated the impact of the intervention on STAI-S levels using a log-transformed linear mixed effects model and explored patients' and physicians' perceptions of the procedure descriptively.

RESULTS

Post-procedural and post-histology timepoints were associated with 13% and17% lower with STAI-S levels than at the pre-procedural timepoint on average. The histologic result had the strongest association with STAI-S: malignancy was associated with 28% higher STAI-S scores than a benign finding on average. Across all time points, the intervention did not affect patient anxiety. Nevertheless, IG participants perceived less pain during the biopsy. Nearly all patients agreed that the brochure should be handed out prior to breast biopsy.

CONCLUSION

While the distribution of an informative brochure and a physician trained in empathic communication did not reduce patient anxiety overall, we observed lower levels of worry and perceived pain regarding breast biopsy in the intervention group. The intervention seemed to improve patient's understanding of the procedure. Moreover, professional training could increase physicians' empathic communication skills.

TRIAL REGISTRATION NUMBER

NCT02796612 (March 19, 2014).

A cohort study of mammography-guided vacuum-assisted breast biopsy in patients with compressed thin breasts (≦ 3 cm)

OBJECTIVES

In the women with compressed thin thickness (≦ 3 cm), mammographic guiding vacuum-assist breast biopsy (MG-VABB) is a technical challenge. We herein report their performance of MG-VABB on suspicious microcalcification by modern mammography.

METHODS

We retrospectively reviewed the consecutive MG-VABB in our hospital from February 2019 to January 2021. All the patients received biopsy because of suspicious microcalcifications discovered by mammography and had at least one-year post-biopsy follow-up.

RESULTS

We reviewed 745 consecutive patients revealing 195 with compressed thin breasts ≦ 3 cm (mean age: 50.12 ± 7.0; breast thickness: 24.99 mm range 11.6-30 mm). Of the 191 patients received biopsy, the microcalcification retrieval rate was 97.9%. Using the half-open notch biopsy or horizontal needle approach, the biopsies were technically achieved in 30.4% and 9.4% of patients respectively. Regarding to the gold standard of surgicohistology, the cancer sensitivities was 88.46% and the atypia upgrade rate was 16.67%. There was no statistical difference of the procedure time between stereotactic guided and tomosynthesis guided.

CONCLUSIONS

The modern MG-VABB has technically improve the performance of biopsy to the patients with compressed thin breasts (≦ 3 cm), revealing approximate results to those breasts > 3 cm. The diagnosis helps the management of suspicious microcalcifications discovered by mammography.

BIRADS 4 - Is it possible to downgrade lesions that do not enhance on recombinant contrast-enhanced mammography images?

PURPOSE

Analysis of the morphology of lesions classified into the BI-RADS 4 category and assessment of the possibility of downgrade the BI-RADS category in those that did not show enhancement on recombinant contrast-enhanced mammography (CEM) images.

METHOD

The retrospective, single-center study included 528 patients who underwent a core needle biopsy performed from January 2017 to November 2022 due to a breast lesion classified as BI-RADS 4 on CEM. Patients' electronic records and imaging examinations were reviewed. Individual lesions were classified into the morphological categories of mass, non-mass, and microcalcifications. Sensitivity, specificity, positive as well as negative predictive values were calculated for the whole group and individual morphological categories. The influence of the lesions' diameter on the results was analyzed.

RESULTS

CEM NPV for the whole group was 93.9% (±95% CI: 90.0-96.4), for mass lesions 100% (±95% CI: 94.5-100), for non-mass lesions 97.8% (±95% CI: 87.0-99.9) and 87.9% (±95% CI: 80.3-93.0) for microcalcifications. Given that 230 out of 383 benign lesions were not contrast-enhancing, 60.1% of unnecessary CNBs would have been correctly avoided. CEM sensitivity for lesions < 20 mm was lower than for lesions ≥ 20 mm and was respectively 86.6% (±95% CI: 76.8-92.8) vs 94.6% (±95% CI: 86.0-98.2), respectively.

CONCLUSION

CEM is characterized by high sensitivity in the detection of malignant lesions in the case of lesions with mass and non-mass morphology. The high NPV for recombinant images suggests that in the case of these lesions, the lack of enhancement supports the benign nature of the lesion and may lead to a downgrade of the BI-RADS category.

An unusual site for breast clip migration: A case report

Clip migration following breast biopsy is a known complication. However, the migrated clip is usually found within the breast. We describe a rare case of delayed clip migration to the skin, following a magnetic resonance guided biopsy of the breast, highlighting its natural history of presentation and its treatment.

Percutaneous vacuum-assisted excision (VAE) of breast lesions of uncertain malignant potential (B3 lesions): a preliminary single-centre Italian experience

PURPOSE

In recent years vacuum-assisted excision (VAE) has been described as an alternative treatment for some B3 lesions. This study aims to assess the effectiveness of using VAE to manage selected B3 lesions by quantifying the number of B3 lesions undergoing VAE, the malignant upgrade rate, and the complications encountered.

MATERIALS AND METHODS

Our department evaluated all B3 lesions diagnosed between January 2019 and October 2021 and treated them with VAE. The data were collected during the initial biopsy and final histology based on VAE image guidance, also considering initial lesions and complications. The exclusion criteria were: B3 lesion of size > 20 mm, presence of a concomitant malignant lesion, lesion < 5.0 mm distant from the skin, nipple or pectoral muscle, phyllodes tumours or indeterminate B3 lesions. Lesions that upgraded to malignancy underwent surgical excision, while benign lesions performed radiological follow-ups.

RESULTS

From 416 B3 lesions diagnosed, 67 (16.1%) underwent VAE. VAE was performed under X-ray (50/67) or ultrasound guidance (17/67). Five cases (7.5%) upgraded to a malignant lesion, 2 ADH, 2 LIN and one papillary lesion that underwent surgery. No malignancy or new lesions has occurred at the site of the VAE, with an average radiological follow-up of 14.9 months.

CONCLUSIONS

VAE could be a safe and effective pathway for managing selected B3 lesions. Lesions initially subjected to CNB with ADH and LN outcome, before undergoing VAE, should perform a VAB for better tissue characterization and management.

The New Coronavirus Pandemic and the Trend of Breast Cancer Diagnosis according to Age-Group: Total and Interrupted Time Series Study

OBJECTIVE

There is a lack of studies evaluating the COVID-19 pandemic effect on breast cancer detection according to age-group. This study aimed to assess the pandemic impact on the trend of mammograms, breast biopsies, and breast cancer stage at diagnosis according to age-group.

METHODS

This was an ecological time series study by inflection point regression model. We used data from women aged between 30 and 49, 50 and 69, and 70 years or more available in an open-access dataset of the Brazilian public healthcare system (2017-2021). We analyzed the trend of the variables in the pre-pandemic and the pandemic effect on the total time series.

RESULTS

The decreasing or stationary trend of mammograms in the pre-pandemic has changed to a decreasing trend in the total time series in all age-groups. Before the pandemic, the increasing trend of breast biopsies has changed to stationary in the total time series in all age-groups. The increasing trend of tumors at stages 0 to II in the pre-pandemic has changed to decreasing or stationary in the total time series. Finally, the increasing trend of tumors at stage III or IV remained increasing in the total time series in all age-groups.

CONCLUSION

The pandemic has changed the stationary or increasing trend to a decreasing or stationary trend of mammograms, breast biopsies, and tumors at stages 0 to II but has not influenced the increasing trend of tumors at stages III and IV in all age-groups.

Preferred music lowers anxiety levels and pain perception while promoting patient satisfaction in women undergoing ultrasound-guided breast biopsy: randomized controlled study

BACKGROUND

Image-guided breast biopsies are well accepted, yet stressful procedures for patients in radiology clinics.

PURPOSE

To investigate the effect of music on anxiety, pain, and patient satisfaction related to a breast biopsy session.

MATERIAL AND METHODS

After approval of institutional review board and giving informed consent, 93 women scheduled for ultrasound-guided breast biopsy or stereotactic wire localization were prospectively enrolled in this randomized controlled study. Patients were referred into two groups either listening to music of their own choice from three options of genre list during the procedure or not. Immediately before and after the biopsy session, participants were asked to complete questionnaires for measuring anxiety (State-Trait Anxiety Inventory, Beck Anxiety Inventory), pain, and patient satisfaction (visual analog scale). Sociodemographic data were described, and the duration was noted at the end. Statistical analysis was made using paired samples t-test, chi-square test, independent samples t-test, and Mann-Whitney U test.

RESULTS

Except for the duration, demographic characteristics were statistically similar between the two groups. Trait and preprocedural state anxiety scores did not have significant difference between the groups. Both groups showed lowered state anxiety values after the biopsy (P < 0.05) and there was statistically significant reduction in state anxiety levels of music group (10.35 ± 7.5 music vs. 7 ± 7.98 control; P = 0.024). Pain perception was fewer (P < 0.05) and patient satisfaction was greater (P < 0.05) through the implementation of music.

CONCLUSION

Music intervention reduces anxiety and pain and thereby increases patient satisfaction during ultrasound-guided breast biopsies.

A Multilayered, Lesion-Embedded Ultrasound Breast Phantom with Realistic Visual and Haptic Feedback for Needle Biopsy

Anthropomorphic phantoms have been used to provide residents with training in ultrasound-guided breast biopsy. However, different individuals differ in terms of the acoustic properties and stiffness of their breast tissues. The individual differences should be reflected in the training breast phantoms. This study aimed to develop a breast tissue-mimicking phantom that offers realistic haptic feedback and ultrasound imaging during needle insertion. We investigated the tunability of the mechanical and acoustic properties of breast tissue-mimicking materials (TMMs) to emulate fat, glandular and tumor tissues. The Design of experiments (DOE) methods and physician's feedback were used to reveal the effect of component concentration on Young's modulus and acoustic properties of breast TMMs. Furthermore, the relative backscatter power of the TMM was studied to adjust the contrast between the simulated tumor and background glandular tissue. The results indicated that Young's moduli of TMMs could be altered by adjusting the concentrations of glycerol, agar and olive oil. Changing the concentration of silicon carbide in a TMM could enhance the contrast between the target and the background materials in an ultrasound image. Finally, a series of TMMs were suggested for fat, glandular, benign tumor and malignant tumor tissues. A breast phantom with a tunability appropriately reflecting the individual differences of breast tissues was developed.

An integrated navigation system based on a dedicated breast support device for MRI-guided breast biopsy

PURPOSE

Breast cancer is currently the cancer type with the highest incidence in the world, and it is extremely harmful to women's health. MRI-guided breast biopsy is a common method in clinical examination of breast cancer. However, traditional breast biopsy is less accurate and takes a long time. In this study, an integrated navigation system (INS) based on a dedicated breast support device (DBSD) was proposed to assist doctors in biopsy.

METHODS

The grid-shaped DBSD can reduce the displacement and deformation of the breast during the biopsy operation and is convenient for puncture. The robot system based on the DBSD is designed to assist doctors in performing puncture action. The software system has functions such as registration, path planning, and real-time tracking of biopsy needles based on the DBSD, which can assist doctors in completing the entire biopsy procedure. A series of experiments are designed to verify the feasibility and accuracy of the system.

RESULTS

Experiments prove that the robot system has reasonable structure and meets the requirements of MR compatibility. The latency of the INS during intraoperative navigation is 0.30 ± 0.03 s. In the phantom puncture experiment, the puncture error under the navigation of the INS is 1.04 ± 0.15 mm.

CONCLUSION

The INS proposed in this paper can be applied to assist doctors in breast biopsy in MR environment, improve the accuracy of biopsy and shorten the time of biopsy. The experimental results show that the system is feasible and accurate.

Is music intervention effective in reducing anxiety and pain during breast biopsy procedure? A systematic review and meta-analysis of randomized controlled trials

PURPOSE

To evaluate the evidence from randomized clinical trials (RCTs) about the effect of music intervention in reducing patients' anxiety during breast biopsy.

METHODS

Electronic databases including PubMed, Cochrane Library, Scopus, and Web of Science were searched using the relevant MeSH terms. The inclusion criteria were all RCTs assessing the effect of music therapy versus no music in reducing anxiety during breast biopsy. The extracted outcomes were anxiety and pain during breast biopsy. They were pooled as mean difference (MD) with a 95% confidence interval (CI) in a fixed-effects model, using Review Manager 5.3 software for windows. The quality of included studies was assessed with the Cochrane risk of bias assessment tool (RoB 1.0). Then, the outcomes of our meta-analyses were independently evaluated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to know the grade of their evidence.

RESULTS

The final analysis included five RCTs. We found a positive effect of music therapy in reducing anxiety levels compared with control group (MD =  - 2.11; 95% CI (- 4.16 to - 0.06); p = 0.04). No difference between music and control groups regarding pain associated with breast biopsy (MD = 0.22; 95% CI (- 0.81 to 1.25); p = 0.68). The GRADE rating of our outcomes was low for anxiety levels and very low for pain during the biopsy.

CONCLUSIONS

Music therapy could be an effective, simple, non-pharmacological option in relieving anxiety during breast biopsy; however, it had no effect on procedure-associated pain. More large and high-quality studies are needed to confirm our results.

Preoperative MRI in breast cancer: effect of breast density on biopsy rate and yield

PURPOSE

Preoperative breast MRI is used to evaluate for additional cancer and extent of disease for newly diagnosed breast cancer, yet benefits and harms of preoperative MRI are not well-documented. We examined whether preoperative MRI yields additional biopsy and cancer detection by extent of breast density.

METHODS

We followed women in the Breast Cancer Surveillance Consortium with an incident breast cancer diagnosed from 2005 to 2017. We quantified breast biopsies and cancers detected within 6 months of diagnosis by preoperative breast MRI receipt, overall and by breast density, accounting for MRI selection bias using inverse probability weighted logistic regression.

RESULTS

Among 19,324 women with newly diagnosed breast cancer, 28% had preoperative MRI, 11% additional biopsy, and 5% additional cancer detected. Four times as many women with preoperative MRI underwent additional biopsy compared to women without MRI (22.6% v. 5.1%). Additional biopsy rates with preoperative MRI increased with increasing breast density (27.4% for extremely dense compared to 16.2% for almost entirely fatty breasts). Rates of additional cancer detection were almost four times higher for women with v. without MRI (9.9% v. 2.6%). Conditional on additional biopsy, age-adjusted rates of additional cancer detection were lowest among women with extremely dense breasts, regardless of imaging modality (with MRI: 35.0%; 95% CI 27.0-43.0%; without MRI: 45.1%; 95% CI 32.6-57.5%).

CONCLUSION

For women with dense breasts, preoperative MRI was associated with much higher biopsy rates, without concomitant higher cancer detection. Preoperative MRI may be considered for some women, but selecting women based on breast density is not supported by evidence.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02980848; registered 2017.

Evaluation of computer-aided diagnosis in breast ultrasonography: Improvement in diagnostic performance of inexperienced radiologists

PURPOSE

To evaluate if a computer-aided diagnosis (CAD) system on ultrasound (US) can improve the diagnostic performance of inexperienced radiologists.

METHODS

We collected ultrasound images of 256 breast lesions taken between March and May 2020. We asked two experienced and two inexperienced radiologists to retrospectively review the US features of each breast lesion according to the Breast Imaging Reporting and Data System (BI-RADS) categories. A CAD examination with S-Detect™ software (Samsung Healthcare, Seoul, South Korea) was conducted retrospectively by another uninvolved radiologist blinded to the BIRADS values previously attributed to the lesions. Diagnostic performances of experienced and inexperienced radiologists and CAD were compared and the inter-observer agreement among radiologists was calculated.

RESULTS

The diagnostic performance of the experienced group in terms of sensitivity was significantly higher than CAD (p < 0.001). Conversely, the diagnostic performance of inexperienced group in terms of both sensitivity and specificity was significantly lower than CAD (p < 0.001). We obtained an excellent agreement in the evaluation of the lesions among the two expert radiologists (Kappa coefficient: 88.7%), and among the two non-expert radiologists (Kappa coefficient: 84.9%).

CONCLUSION

The US CAD system is a useful additional tool to improve the diagnostic performance of the inexperienced radiologists, eventually reducing the number of unnecessary biopsies. Moreover, it is a valid second opinion in case of experienced radiologists.

Recalibrating the decision for MRI-directed breast ultrasound in patients with newly diagnosed breast cancer, factors predicting sonographic success

OBJECTIVE

Evaluate utilization of MRI-directed breast ultrasound (US) in patients with newly diagnosed breast cancer and refine practices to increase success of sonographic lesion detection.

METHODS

This retrospective single-institution review was restricted to women with breast cancer who underwent MRI from November 2006 to January 2017. Enhancing breast lesions, separate from the index tumor, recommended for MRI-directed US were assessed to see which were detected and which characteristics predicted success in detection. Univariate mixed-effects logistic modeling predicted likelihood of finding breast lesions with US, with odds ratios reported. All tests were two-sided with p < 0.05 considered significant.

RESULTS

A total of 275 patients underwent MRI-directed US for 361 breast lesions, of which 187 (51.8%) were found on US. Of those detected, 171 (91.4%) were masses and 16 (8.6%) were nonmass enhancement (NME), with masses 14 times more likely to be seen (p < 0.001). Size alone was not a significant predictor but achieved significance when associated with lesion type (mass size, p < 0.001). Masses with irregular shapes or margins and invasive carcinomas were more frequently detected. Patient age, internal enhancement pattern, and distribution of NME were not significant predictors in sonographic detection. A presumed sonographic correlate for NME was found for 16 (16.2%) of 99 attempted lesions.

CONCLUSION

As MRI access expands, utilization of MRI-directed US should be scrutinized to avoid downstream practice inefficiencies. Sonographic detection rates for NME remain low for women undergoing MRI for disease extent, with NME often better suited for MRI-guided biopsy.

Unusual Presentation of a Post-procedural Breast Hematoma: A Case Report

BACKGROUND/AIM

Hematoma is the most frequent complication after Vacuum-Assisted Breast Biopsy (VABB) in 13% of cases. A direct communication channel with patients eases the diagnosis of VABB complications and ensures treatment at an early stage, as outpatients, in most cases. In 2020, due to the COVID-19 pandemic, we observed a reduction of self-reported postoperative complication leading to delay in the identification of harmful complications, therefore leading to need for more invasive treatment.

CASE REPORT

A 50-year-old patient was admitted to the Emergency Department for dry cough, fever, chest discomfort, dyspnea, and slight confusion four days after VABB. Due to the reported symptoms, the patient was sent to our COVID-19 Emergency Department. The COVID-19 swab was negative. Ultrasound revealed a large hematoma at the biopsy site, with active bleeding. Open evacuation with accurate hemostasis was planned with rapid and complete resolution of the clinical symptoms. After surgery, the patient reported that she intentionally avoided admittance in the hospital due to the risk of COVID-19 infection. The patient was discharged in the first postoperative day and maintained in quarantine for 14 days.

CONCLUSION

In the COVID-19 era due to the risk of hospital cross-infections, reduction of patient-doctor communication could lead to misdiagnosis, delay in recognition of procedural complications thus leading to requirement for invasive treatment, hospitalization, while also further multiplying the risk of COVID-19 infection.

Effectiveness of percutaneous vacuum-assisted excision (VAE) of breast lesions of uncertain malignant potential (B3 lesions) as an alternative to open surgical biopsy

OBJECTIVES

Traditionally B3 breast lesions are treated surgically, but overtreatment is a concern, as the majority have a final benign diagnosis. A national screening program introduced vacuum-assisted excision (VAE) for managing B3 lesions in late 2016. This retrospective study aimed to assess the outcomes associated with this approach.

METHODS

All B3 lesions diagnosed between 01/2017 and 12/2019 were identified at two centres. Information was obtained on the initial biopsy and final histology, and method of VAE image guidance, needle size and number of cores. Lesions were excluded if there was cancer elsewhere in the breast at the time of diagnosis; the lesion was not suitable for VAE due to position in the breast or had B3 pathology for which open biopsy was still required. The final decision to offer VAE was always made at a multidisciplinary meeting (MDM). Risk difference was used to test the significance at p ≤ .05.

RESULTS

In total, 258 B3 lesions were diagnosed, 105 (40.7%) met the inclusion criteria and underwent VAE. VAE was performed under X-ray (89/105) or ultrasound guidance (16/105), taking an average of 18.5 cores with the 10-G needle or 10.8 cores with the 7-G needle. Nine cases (8.6%) were upgraded to a malignant diagnosis following VAE. Malignancy was found in 15.5% (9/58) of B3 lesions with epithelial atypia, but in none without atypia (0/47) (p = .004). No new lesions or malignancy has occurred at the site of the VAE with an average mammographic follow-up of 2.2 years.

CONCLUSION

Upgrade to malignancy following VAE was uncommon (8.6%) and associated with atypia in the initial biopsy. VAE is an alternative approach to the management of B3 lesions, reducing open surgical procedures.

KEY POINTS

• Upgrade to malignancy after a vacuum-assisted excision of a B3 breast lesion is uncommon with an 8.6% upgrade rate. • The risk of a malignant diagnosis after a vacuum-assisted excision was significantly higher for B3 lesions with atypia compared to those without (+15.5% difference, p = .004).

Upgrade Rate of Atypical Ductal Hyperplasia: Ten Years Experience and Predictive Factors

BACKGROUND

Atypical ductal hyperplasia (ADH) is a benign epithelial proliferative lesion with histologic features resembling those seen in low grade ductal carcinoma in situ (DCIS). Surgical excision of the biopsy site is the standard management approach. The objective of this study was to determine the upgrade rate from ADH on stereotactic breast biopsies to DCIS or invasive carcinoma (IC) in our institution. We also sought to identify clinical, pathologic and radiologic predictive factors associated with risk of upgrade.

MATERIALS AND METHODS

Clinical charts, mammograms and pathology reports were reviewed for all women with a stereotactic breast biopsy showing ADH and subsequent surgery at our institution between 2008 and 2018. When available, mammograms were re-reviewed by a radiologist for this study.

RESULTS

295 biopsies were analyzed in 290 patients. Mean age was 56 y old. Upgrade rate was 10.5% of which 7.5% were DCIS and 3.1% IC. Mammograms were reviewed by a radiologist in 161 patients from 2013 to 2018. In this subset of patients, the rate of upgrade was 8.7% (4.35% DCIS and 4.35% IC). A statistically significant difference he largest size of the microcalcification clusters on mammogram was observed between the upgraded and the non-upgraded subgroups (14.2 mm versus 8.9 mm, P = 0.03) CONCLUSIONS: The evaluation of the largest size of microcalcification clusters on mammogram as a cut-off feature could be considered to choose between an observational versus a surgical approach. This large series provides contemporary data to assist informed decision making regarding the treatment of our patients.

Utilizing Time-Driven Activity-Based Costing to Increase Efficiency in Ultrasound-Guided Breast Biopsy Practice

PURPOSE

In this study, we used time-driven activity-based costing to increase efficiency in our ultrasound-guided breast biopsy practice by understanding costs associated with this procedure.

METHODS

We assembled a multidisciplinary team of all relevant stakeholders involved in ultrasound-guided breast biopsies, including a radiologist, a lead technologist, a clinical assistant, a licensed practical nurse, and a procedural support assistant. The team mapped each step in an ultrasound-guided breast biopsy from the time of scheduling a biopsy to patient checkout. We completed on average 20 time observations of each step involved in these biopsies from a provider's perspective. Using capacity cost rate, we calculated the cost of all resources including personnel, supply, room, and equipment costs. Several costly steps were identified in the process, which led to the intervention of changing our overlapping biopsy times to staggered biopsy times. Time observations for each step and cost calculations were repeated postintervention.

RESULTS

Our postintervention data showed that the total time spent by the radiologist in an ultrasound breast biopsy decreased by 28%, accounting for 56% of the total cost in comparison with 63% pre-intervention. The radiologist's wait time decreased by 38%, accounting for 28% of the total cost in comparison with 35% pre-intervention. Our total cost of the procedure decreased by 20%, and the personnel cost decreased by 25%.

CONCLUSIONS

Time-driven activity-based costing is a practical way to calculate costs and identify non-value-added steps, which can foster strategies to improve efficiency and minimize waste.

[Diagnosis of breast diseases in a certified breast center]

The beginning of the 21st century has seen immense improvements in the quality of diagnosis and treatment of breast cancer due to several, simultaneous developments. In particular, the introduction of a certification program from the German Cancer Society based on level III guidelines has enhanced the transparency and quality of treatment of breast diseases for all actors. As a result, patients have benefited from intensified cooperation especially between core disciplines in breast disease, gynecology, pathology, and radiology. The standardized and synoptic reading of multiple diagnostic modalities has enabled precise sampling of histologic specimen, which has improved prognosis and the successful individualization of therapy. In this article the benefits of breast cancer diagnosis and therapy in a certified breast center are illustrated using four case examples.

Discrepancies between radiological and histological findings in preoperative core needle (CNB) and vacuum-assisted (VAB) breast biopsies

Background

Ultrasound (US)-guided breast biopsy is a routine diagnostic method used to correlate imaging finding to a histological diagnosis which is still the gold standard in preoperative diagnostics. The accuracy of US-guided breast biopsies relies on a precise radiologic-histopathologic correlation, which is discussed amongst an interdisciplinary team of gynecologists, radiologists and pathologists. However, false-negative or non-diagnostic biopsy results occur. Hence, a thorough and honest discussion to clarify the reason for discrepancies and to decide the next diagnostic step between specialists of the different disciplines is warranted. In this retrospective study, we analyzed discrepant findings between imaging and pathology results on preoperative breast biopsies.

Methods

Core and vacuum-assisted breast biopsies from 232 patients were included in this study. Inclusion criteria were (1) non-diagnostic (B1) category on histology independent from imaging category and (2) histological benign (B2) category with a BIRADS 5 (Breast Imaging Reporting and Data System) rating on imaging. Histological diagnoses were retrieved from all cases. Follow-up data were available in most cases.

Results

138 biopsies were classified as B1, 94 biopsies as B2 category. 51 of 138 B1 cases (37%) underwent re-biopsy. Re-biopsy found malignancy (B5) in 19 of 51 cases, and B3/4 (premalignant) lesions in 3 of 51 cases. All B2 cases underwent second-look imaging-diagnosis, in 57 of 94 cases (66%) consecutive direct surgery or re-biopsy. Of these, malignancy was diagnosed histologically in 26 of 57 cases (45.6%).

Conclusion

Determining imaging-pathology concordance after US-guided breast biopsy is essential. Discrepant cases and further diagnostic steps need to be discussed with an interdisciplinary approach.

Simultaneous Augmentation Mammoplasty and Vacuum-Assisted Breast Biopsy for Enhanced Cosmesis and Efficacy

BACKGROUND

In this era of expanding life expectancy and popularity of aesthetic breast surgeries, more women are likely to live more years with their augmented breasts. Thus, consistent attention to general breast health is crucial, and preoperative ultrasound is helpful to locate suspicious lesions. In this study, we present a combinative procedure of augmentation mammoplasty and vacuum-assisted breast biopsy (VABB).

METHODS

From January of 2018 to December of 2019, a total of 102 patients received simultaneous augmentation mammoplasty and VABB in our institute. Only patients of primary augmentation mammoplasty who received VABB on unilateral breasts were included. We sought to investigate the results of each breast and safety of adding VABB before performing augmentation within the same incision.

RESULTS

Among 204 breasts and implants, 28.43% were done via endoscopic transaxillary approach and 71.57% via inframammary approach. The mean implant volume was 329.34 ± 44.79 ml, and the mean follow-up period was 14.23 ± 4.64 months. All of the complication rates exhibited no statistically significant differences between the two groups.

CONCLUSION

Simultaneous augmentation mammoplasty and VABB prevented unnecessary scars and pain, and the complication rates did not statistically differ from those of augmentation only group. This co-operation is a safe and simple method potentially beneficial to many women interested in breast surgery.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Hydrodissection - Practical applications in ultrasound-guided breast interventions

Hydrodissection is a procedural tactic utilized in various interventions. It is a technique which helps separate structures in order to safely perform a certain procedure. This article will provide a review of hydrodissection, how to perform this technique, and why it can be useful in breast interventions.

Breast pseudoaneurysm after core needle biopsy in a pregnant patient

Breast pseudoaneurysm is an extremely rare complication of interventional breast procedures. Pregnancy and lactation are associated with increased breast vascularization, which may act as a risk factor. We present the case of a 36-year-old woman in the third trimester of a spontaneous twin pregnancy, who presented with a newly-detected BI-RADS 4 mass in her right breast. The patient requested not to defer a biopsy until after the pregnancy, and an ultrasound-guided breast core biopsy was performed. The patient presented bleeding during the procedure, but no hematomas or other vascular lesions were immediately detected. During follow-up, a breast ultrasound revealed an anechoic circumscribed mass and high‐velocity blood flow. The color Doppler showed a spiral blood flow with the Yin-Yang sign, together with a communication channel between the sac and feeding artery. A diagnosis of breast pseudoaneurysm was made. The patient was managed conservatively, and breastfeeding continued normally. This case report highlights the importance of color Doppler in the detection of pseudoaneurysms, and the need to consider deferring invasive breast procedures in pregnant women when possible.

Benign breast papillomas without atypia diagnosed with core needle biopsy: Outcome of surgical excision and imaging follow-up

PURPOSE

To evaluate the surgical upgrade rate to malignancy and high-risk lesions in cases of papilloma without atypia diagnosed with imaging-guided percutaneous core needle biopsy (CNB) and to determine whether any lesion imaging features, biopsy techniques, and pathological factors can predict lesion upgrade to help guide clinical management.

MATERIALS AND METHODS

Benign papillomas without atypia (n = 399) diagnosed with CNB were retrospectively reviewed. The surgical upgrade rate to malignancy or high-risk lesion (atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in-situ, flat epithelial atypia and atypical papilloma) was determined. Detection modality (i.e. mammography, ultrasonography (US), magnetic resonance imaging (MRI)), lesion type and size, biopsy-guidance modality (US, stereotactic, MRI), biopsy needle size (<14 G vs ≥14 G), use of vacuum assistance, and presenting symptoms were statistically analyzed. The reference standard for evaluation of upgrade was either excision or at least 24 months of imaging follow-up. Chi Square test and Fisher exact tests were performed for categorical variables, and the Mann-Whitney-U test was used for continuous variables.

RESULTS

Ultrasound was the predominant biopsy modality (78.4 %, p < 0.001). Of the 399 benign papilloma lesions in 329 women, 239 (59.9 %) were excised and 93 others were followed for at least 24 months (total of 332). Of these 332 lesions, 7 (2.1 %) were upgraded to ductal carcinoma in-situ and 41 (12.3 %) to high-risk lesions at excision. Larger lesion size (≥15 mm, p = 0.009), smaller biopsy needle size (≥14 G, p = 0.027), and use of spring-loaded biopsy device (p = 0.012) were significantly associated with upgrade to atypia. Only lesion size (≥15 mm, p = 0.02) was associated with upgrade to cancer.

CONCLUSION

Upgrade to malignancy of biopsy-proven benign papillomas without atypia at the time of surgery was sufficiently low (2.1 %) to support non-operative management. Surgery may be performed for selected cases- those with larger lesion size and those whose biopsies were performed with smaller spring-loaded biopsy needles.

Contrast Enhanced Digital Mammography (CEDM) Helps to Safely Reduce Benign Breast Biopsies for Low to Moderately Suspicious Soft Tissue Lesions

RATIONALE AND OBJECTIVES

To preliminarily asses if Contrast Enhanced Digital Mammography (CEDM) can accurately reduce biopsy rates for soft tissue BI-RADS 4A or 4B lesions.

MATERIALS AND METHODS

Eight radiologists retrospectively and independently reviewed 60 lesions in 54 consenting patients who underwent CEDM under Health Insurance Portability and Accountability Act compliant institutional review board-approved protocols. Readers provided Breast Imaging Reporting & Data System ratings sequentially for digital mammography/digital breast tomosynthesis (DM/DBT), then with ultrasound, then with CEDM for each lesion. Area under the curve (AUC), true positive rates and false positive rates, positive predictive values and negative predictive values were calculated. Statistical analysis accounting for correlation between lesion-examinations and between-reader variability was performed using OR/DBM (for SAS v.3.0), generalized linear mixed model for binary data (proc glimmix, SAS v.9.4, SAS Institute, Cary North Carolina), and bootstrap.

RESULTS

The cohort included 49 benign, two high-risk and nine cancerous lesions in 54 women aged 34-74 (average 50) years. Reader-averaged AUC for CEDM was significantly higher than DM/DBT alone (0.85 versus 0.66, p < 0.001) or with US (0.85 versus 0.75, p = 0.001). CEDM increased true positive rates from 0.74 under DB/DBT, and 0.89 with US, to 0.90 with CEDM, (p = 0.019 DM/DBT versus CEDM, p = 0.78 DM/DBT + US versus CEDM) and decreased false positive rates from 0.47 using DM/DBT and 0.61 with US to 0.39 with CEDM (p = 0.017 DM/DBT versus CEDM, p = 0.001 DM/DBT+ US versus CEDM). For an expected cancer rate of 10%, CEDM positive predictive values was 20.5% (95% CI: 16%-27%) and negative predictive values 98.3% (95% CI: 96%-100%).

CONCLUSION

Addition of CEDM for evaluation of low-moderate suspicion soft tissue breast lesions can substantially reduce biopsy of benign lesions without compromising cancer detection.

Recent Progress for the Techniques of MRI-Guided Breast Interventions and their applications on Surgical Strategy

With a high sensitivity of breast lesions, MRI can detect suspicious lesions which are occult in traditional breast examination equipment. However, the lower and variable specificity of MRI makes the MRI-guided intervention, including biopsies and localizations, necessary before surgery, especially for patients who need the treatment of breast-conserving surgery (BCS). MRI techniques and patient preparation should be first carefully considered before the intervention to avoid lengthening the procedure time and compromising targeting accuracy. Doctors and radiologists need to reconfirm the target of the lesion and be very familiar with the process approach and equipment techniques involving the computer-aided diagnosis (CAD) tools and the biopsy system and follow a correct way. The basic steps of MRI-guided biopsy and localization are nearly the same regardless of the vendor or platform, and this article systematically introduces detailed methods and techniques of MRI-guided intervention. The two interventions both face different challenging situations during procedures with solutions given in the article. Post-operative statistics show that the complications of MRI-guided intervention are infrequent and mild, and MRI-guided biopsy provides the pathological information for the subsequent surgical decisions and MRI-guided localization fully prepared for follow-up surgical biopsy. New techniques for MRI-guided intervention are also elaborated in the article, which leads to future development. In a word, MRI-guided intervention is a safe, accurate, and effective technique with a low complication rate and successful MRI-guided intervention is truly teamwork with efforts from patients to surgeons, radiologists, MRI technologists, and nurses.

Cost-effectiveness of stereotactic vacuum-assisted biopsy for nonpalpable breast lesions

PURPOSE

To examine the potential cost-savings of stereotactic vacuum-assisted biopsy (SVAB) over open surgical biopsy (OSB) in diagnosis of nonpalpable lesions on mammography and to estimate the cost-saving effect on lesions at different levels of malignant probability.

METHODS

This retrospective study was approved by our Institutional Review Board. We retrospectively reviewed 276 (33.8 %) SVAB and 541 (66.2 %) OSB medical records at a medical center. Direct costs included patients' self-paid and national health insurance claim charges. Indirect costs were calculated using sick days, average salary, and age-adjusted employment rate. One-way and two-way sensitivity analyses were conducted. Lesion classification was determined by the assessment categories of Breast Imaging Reporting and Data System (BI-RADS), 4th or 5th editions.

RESULTS

SVAB decreased the direct cost by $90.3 (10.1 %) per diagnosis. The indirect cost was decreased by $560.2 (96.0 %). Overall, SVAB saved 43.9 % of resource utilization for each biopsy. Taking the cost of the subsequent malignant surgery into account, from the healthcare providers' perspective, SVAB was cost-effective if a lesion had less than 19 % likelihood of malignancy. From the societal perspective, SVAB reduced productivity loss for all the lesions. Based on the positive predictive value of the BI-RADS categories, SVAB was more suitable for the lesions of category 4A and category 3, resulting in greater savings in both medical and societal resources.

CONCLUSIONS

SVAB is a cost-effective diagnostic option for nonpalpable breast lesions. The cost-saving effect is greater for the lesions of category 4A and category 3.

Imaging properties of 3D printed breast phantoms for lesion localization and Core needle biopsy training

Background

Breast cancer is the most commonly diagnosed malignancy in females and frequently requires core needle biopsy (CNB) to guide management. Adequate training resources for CNB suffer tremendous limitations in reusability, accurate simulation of breast tissue, and cost. The relatively recent advent of 3D printing offers an alternative for the development of breast phantoms for training purposes. However, the feasibility of this technology for the purpose of ultrasound (US) guided breast intervention has not been thoroughly studied.

Methods

We designed three breast phantom models that were printed in multiple resins available through Stratasys, including VeroClear, TangoPlus and Tissue Matrix. We also constructed several traditional breast phantoms using chicken breast and Knox gelatin for comparison. These phantoms were compared side-by-side for ultrasound penetrance, simulation of breast tissue integrity, anatomic accuracy, reusability, and cost.

Results

3D printed breast phantoms were more anatomically accurate models than traditional breast phantoms. The chicken breast phantom provided acceptable US beam penetration and material hardness for simulation of human breast tissue integrity. Sonographic image quality of the chicken breast phantom was the most accurate overall. The gelatin-based phantom also had acceptable US beam penetration and image quality; however, this material was too soft and poorly simulated breast tissue integrity. 3D printed phantoms were not visible under US.

Conclusions

There is a large unmet need for a printable material that is truly compatible with multimodality imaging for breast and other soft tissue intervention. Further research is warranted to create a realistic, reusable and affordable material to 3D print phantoms for US-guided intervention training.

Relative apparent diffusion coefficient (rADC) in breast lesions of uncertain malignant potential (B3 lesions) and pathologically proven breast carcinoma (B5 lesions) following breast biopsy

PURPOSE

To assess relative apparent diffusion coefficient (rADC) and ADC in B3 and B5 lesions in premenopausal female patients, added to standard morpho-dynamic breast contrast-enhanced MRI.

METHODS

104 patients with histologically confirmed B3 (N1 = 52) and matched B5 lesions (N2 = 52), were examined on MRI (1.5 T, full diagnostic protocol, diffusion weighted imaging - b50, b850) in a retrospective analysis following the IRB approval: Atypical ductal hyperplasia (ADH, n1 = 20), Flat epithelial atypia (FEA, n2 = 11), Classic lobular neoplasia (CLN, n3 = 8), Papillary lesion (PL, n4 = 6) and Phyllodes tumor (PT, n5 = 7). rADC and ADC were computed for each lesion. The two-tailed Mann-Whitney U test was used for comparison with B5 lesions.

RESULTS

Mean rADC value for B3 lesions, (N1 = 52): 0.81+/-0.08 mm2/s x 10-3 and B5 lesions, (N2 = 52): 0.58+/-0.07 mm2/s x 10-3 is statistically different (p < 0.00001). Mean rADC values [mm2/s x 10-3], per entity in B3 are: ADH, 0.82+/-0.06; FEA, 0.75+/-0.03; CLN, 0.73+/-0.03; PL, 0.94+/-0.02; PT 0.86+/-0.05.

CONCLUSIONS

Although morpho-dynamic features of borderline and malignant lesions may overlap, the initial results in this research, suggest the highly significant difference in both ADC and rADC between B3 and B5 lesions. Larger trials are needed to confirm the initial data.

Charcoal granuloma mimicking breast cancer: an emerging diagnosis

BACKGROUND

Image-guided charcoal injection in suspicious breast lesions for preoperative localization is a procedure that has been increasing over the years because it is safer, faster, and more affordable when compared to needle-wire preoperative localization. To date, no complications have been associated with the method. However, in recent years there have been some reports about charcoal granulomas mimicking malignant lesions in some postoperative patients or in a conservative follow-up.

PURPOSE

To report a series of 11 cases which had suspicious imaging findings for malignancy and resulted in charcoal granulomas on histopathological analysis.

MATERIAL AND METHODS

A database of 1650 patients that attended our center from January 2007 to June 2018 was reviewed and detected 495 patients who had been previously submitted to ultrasound-guided charcoal marking in a breast lesion. Then, patients whose imaging studies were compatible with new suspicious lesions on mammography, breast ultrasound, and/or magnetic resonance imaging and biopsy of this new lesion indicating charcoal granuloma were selected.

RESULTS

From 495 patients who had undergone charcoal localization injections in previous biopsies, we selected 11 who had new lesions with malignant characteristics on imaging studies but histopathological analysis resulted in charcoal granuloma.

CONCLUSION

Charcoal granuloma should be considered in patients with previous preoperative injection localization, since the residual charcoal in the breast tissue may form granulomas and mimic malignant lesions on follow-up imaging studies.

Extremely brief mindfulness interventions for women undergoing breast biopsies: a randomized controlled trial

PURPOSE

Mindfulness-based programs can reduce stress and help practitioners to have positive attitudes in their daily lives. This randomized controlled trial evaluated the impact of brief Mindfulness interventions on quantitative and qualitative stress parameters in patients undergoing imaging-guided breast biopsies.

METHODS

Eighty-two women undergoing percutaneous imaging-guided breast biopsy were randomized into two groups: MBI group or standard care group. One week before the biopsy procedure, on the waiting room and during the biopsy procedure, the MBI group was exposed to mindfulness techniques and the standard care group received supportive dialogue from the biopsy team. Participants completed questionnaires measuring depression, anxiety and stress, demographics, and medical history, besides evaluating their pain experience through a visual analogue scale for pain and had their systolic and diastolic blood pressure, initial and final temperate, heart rate, oxygen saturation, and salivary cortisol measured.

RESULTS

Participation in the mindfulness intervention group was associated with reduced levels of perceived stress, blood pressure, heart rate, and oxygen saturation compared to participation in the standard care group (P values < 0.05). No difference was observed regarding salivary cortisol levels, peripheral temperature, and pain perception between the two studied groups.

CONCLUSION

Results indicate that an extremely brief mindfulness intervention is a feasible intervention, suggesting that Mindfulness-based programs may be beneficial to reduce discomfort in acutely stressful settings.

MR Imaging-Guided Breast Interventions: Indications, Key Principles, and Imaging-Pathology Correlation

MR imaging is now routinely performed for breast cancer screening and staging. For suspicious MR imaging-detected lesions that are mammographically and sonographically occult, MR imaging-guided breast interventions, including biopsy, clip placement, and preoperative needle localization, have been developed to permit accurate tissue diagnosis and aid in surgical planning. These procedures are safe, accurate, and effective when performed according to key principles, including proper patient selection, use of appropriate technique, adequate preprocedure preparation and postprocedure patient care, and postprocedure imaging-pathology correlation. Imaging-pathology correlation after MR imaging-guided biopsy is essential to confirm accurate sampling and guide development of a comprehensive management plan.

Atypical ductal hyperplasia: Our experience in the management and long term clinical follow-up in 71 patients

INTRODUCTION

Atypical ductal hyperplasia (ADH) is a high-risk benign lesion found in approximately 1-10% of breast biopsies and associated with a variable incidence of carcinoma after surgical excision. The main goal of our study is to present our experience in the management and long-term follow-up of 71 patients with ADH diagnosed on breast biopsy.

MATERIALS AND METHODS

Results of 3808 breast biopsy specimens from 1 January 2000 to 31 December 2005 were analyzed to identify all biopsies which resulted in a diagnosis of ADH. The histopathological results of the 45 patients who underwent surgery were analyzed. Long-term follow-up for the remaining patients was carried out.

RESULTS

45 of 71 (63.4%) patients with histological diagnosis of ADH on breast biopsy underwent surgery. Definitive histological results revealed invasive carcinoma in 7 cases (15.6%), high grade Ductal Carcinoma in situ (DCIS) in 10 (22.2%) patients, Lobular Carcinoma in situ (LCIS) in 4 cases (8.9%) and benign findings in 24 cases (53.3%). 12 of 71 (16.9%) patients underwent only long term follow-up; one (8,3%) of these developed invasive breast carcinoma after 6 years.

CONCLUSION

Atypical ductal hyperplasia diagnosed on breast biopsy is associated with a relatively high incidence of invasive carcinoma and high grade ductal carcinoma in situ at the time of surgical excision. Certain radiological and cytological criteria can be used to help determine which patients should forgo surgery and be followed up with good results. Long term follow-up is always crucial for patients who have not undergone surgery.

Role of BI-RADS Ultrasound Subcategories 4A to 4C in Predicting Breast Cancer

BACKGROUND

The Breast Imaging Reporting and Data System (BI-RADS) ultrasound (US) categorization revised in 2013 by the American College of Radiology resulted in unquestionable standardization of reports and confirmed category 3 and 5 as benign and malignant lesions, respectively. In contrast, suspected images (category 4) have subcategorization criteria, although theses have been detailed difficult to apply. The aim of the present study was to determine the role of the US 4A to 4C BI-RADS subcategories in predicting malignancy.

PATIENTS AND METHODS

We performed a cross-sectional study of diagnostic tests to estimate the performance of the US BI-RADS categorization to clearly differentiate benign from malignant lesions. A total of 975 US examinations performed at the Hospital Femina, Grupo Hospitalar Conceição teaching hospitals from January 2012 through March 2015 were included in the present study. The US BI-RADS lexicon was used to classify the examination findings. Suspicious lesions underwent core needle biopsy, and the US and histology reports were compared to determine the performance using receiver operating characteristic curves.

RESULTS

Overall, the BI-RADS US categorization showed good discriminating accuracy with a receiver operating characteristic curve of 91% (95% confidence interval [CI], 88%-93%). However, BI-RADS subcategory 4b had a positive predictive value of 25% (95% CI, 20%-31%) and subcategory 4A had a positive predictive value of only 6% (95% CI, 3.5%-9.8%).

CONCLUSION

Our results have shown that US BI-RADS subcategories 4A and 4B are clearly unfit for use in screening tests, because they cannot rule out the need for biopsy. Therefore, management will not be improved by subcategorizing category 4, because all suspicious lesions will still require definite biopsy.

Initial Experience with a Cone-beam Breast Computed Tomography-guided Biopsy System

Objective:

To evaluate our initial experience with a cone-beam breast computed tomography (BCT)-guided breast biopsy system for lesion retrieval in phantom studies for use with a cone-beam BCT imaging system.

Materials and Methods:

Under the Institutional Review Board approval, a phantom biopsy study was performed using a dedicated BCT-guided biopsy system. Fifteen biopsies were performed on each of the small, medium, and large anthropomorphic breast phantoms with both BCT and stereotactic guidance for comparison. Each set of the 45 phantoms contained masses and calcification clusters of varying sizes. Data included mass/calcium retrieval rate and dose and length of procedure time for phantom studies.

Results:

Phantom mass and calcium retrieval rate were 100% for BCT and stereotactic biopsy. BCT dose for small and medium breast phantoms was found to be equivalent to or less than the corresponding stereotactic approach. Stereotactic-guided biopsy dose was 34.2 and 62.5 mGy for small and medium breast phantoms, respectively. BCT-guided biopsy dose was 15.4 and 30.0 mGy for small and medium breast phantoms, respectively. Both computed tomography biopsy and stereotactic biopsy study time ranged from 10 to 20 min.

Conclusion:

Initial experience with a BCT-guided biopsy system has shown to be comparable to stereotactic biopsy in phantom studies with equivalent or decreased dose.

MRI-guided breast vacuum biopsy: Localization of the lesion without contrast-agent application using diffusion-weighted imaging

OBJECTIVE

In magnetic resonance-guided breast vacuum biopsies, the contrast agent for targeting suspicious lesions can typically be applied only once during an intervention, due to the slow elimination of the gadolinium chelate from the extracellular fluid space. This study evaluated the feasibility of diffusion-weighted imaging (DWI) for lesion targeting in vacuum assisted magnetic resonance imaging (MRI) biopsies.

CONCLUSION

DWI may be used as an alternative to dynamic contrast-enhanced MRI with the advantage of reproducibility. However, the targeted lesion requires the characteristics of a mass-like lesion, substantial diffusion restriction, and a minimum size of approximately 1cm.

Localization Methods for Excisional Biopsy in Women With Nonpalpable Mammographic Abnormalities

INTRODUCTION

With the advent and proliferation of breast cancer screening programs, more women are being diagnosed with mammographic abnormalities that require tissue diagnosis. If imaged-guided biopsy is not possible or previous image-guided biopsies reveal pathologies that require more extensive surgery, guided excisional biopsy/lumpectomy may be necessary.

METHODS

Fifteen women were enrolled in the study of the feasibility of off-site or day-before wire-localization excisional biopsy of the breast with mammographic abnormalities. Five patients had their localization wire placed the day before, whereas 10 patients had their localization the same day with surgery in a distant procedure room under straight local anesthesia.

RESULTS

Two of the 15 patients had an eventual cancer diagnosis from their wire-localized excisional breast biopsy. All patients had their mammographic abnormality removed with the previously placed core biopsy clip, and there was 100% radiologic/clinical correlation. All patients' wounds healed primarily without any surgical site infections.

CONCLUSION

The protocol answers 2 questions concerning the wire-localized excisional breast biopsy technique. The series shows that the wire-localization technique can be performed the night before or in a location away from the procedure room that would allow better synchronization with surgical schedules or allow the procedure to take place in low-cost settings away from the expense of the hospital operating room.

Mapping breast tissue types by miniature radio-frequency near-field spectroscopy sensor in ex-vivo freshly excised specimens

Background

Receiving real-time information on tissue properties while performing biopsy procedures has the potential of improving biopsy accuracy. The study goal was to test the ability of a miniature flexible Radio-Frequency (RF) sensor (Dune Medical Devices), designed to be mounted on the surface of surgical tools, in measuring and mapping the various breast tissue types and abnormalities in terms of electrical properties.

Methods

Between January and October 2012, 102 patients undergoing lumpectomy, open-biopsy or mastectomy, in 3 medical centers, were enrolled in this study. The device was applied to freshly excised specimens, with registration between device measurements and histology analysis. Based on histology, the dielectric properties of the various tissue types were derived. Additionally, the ability of the device to differentiate between malignant and non-malignant tissue was assessed.

Results

A total of 4322 measurements from 106 specimens from 102 patients were analyzed. The dielectric properties of 10 tissue types in the low RF-frequency range were measured, showing distinct differences between the various types. Based on the dielectric properties, a score variable was derived, which showed a correlation of 90 % between the RF measurements and the tissue types. Differentiation ability between tissue types was characterized using ROC curve analysis, with AUC of 0.96, and sensitivity and specificity of 90 and 91 % respectively, for tissue feature sizes at or above 0.8 mm.

Conclusions

Using a radio-frequency near-field spectroscopy miniature flexible sensor the dielectric properties of multiple breast tissue types, both normal and abnormal, were evaluated. The results show promise in differentiating between various breast tissue types, and specifically for differentiation between cancer and normal tissues.

[Shall all lobular intraepithelial neoplasia diagnosed on image-guided biopsy require a surgical management?]

OBJECTIVE

Lobular intraepithelial neoplasia (LIN) diagnosed on image-guided biopsy may be associated with an undiagnosed cancer. This is called under-diagnosis. The consequence is that management of these lesions is often surgical. But many surgeries finally are unnecessary. The aim of our study was to define criteria to avoid unnecessary surgery.

MATERIALS AND METHODS

This is a single-center, retrospective after a database collected prospectively study. Fourteen thousand biopsies were analyzed, including 456 diagnosed NLI. Under-diagnosis rates were analyzed according to many criteria. The average duration of following was 45 months.

RESULTS

For atypical lobular hyperplasia (ALH), we obtained 7.6% under-diagnosis and combining several criteria, we got a low risk of cancer (2%). For LCIS, this rate was 23% and any low-risk group could be identified.

CONCLUSION

ALH with calcifications≤20 mm, without any atypical lesion associated, histologically focal and whose removal is representative may be safely observed. For other LIN, surgery remains indicated.

Breast histopathology image segmentation using spatio-colour-texture based graph partition method

This paper proposes a novel integrated spatio-colour-texture based graph partitioning method for segmentation of nuclear arrangement in tubules with a lumen or in solid islands without a lumen from digitized Hematoxylin-Eosin stained breast histology images, in order to automate the process of histology breast image analysis to assist the pathologists. We propose a new similarity based super pixel generation method and integrate it with texton representation to form spatio-colour-texture map of Breast Histology Image. Then a new weighted distance based similarity measure is used for generation of graph and final segmentation using normalized cuts method is obtained. The extensive experiments carried shows that the proposed algorithm can segment nuclear arrangement in normal as well as malignant duct in breast histology tissue image. For evaluation of the proposed method the ground-truth image database of 100 malignant and nonmalignant breast histology images is created with the help of two expert pathologists and the quantitative evaluation of proposed breast histology image segmentation has been performed. It shows that the proposed method outperforms over other methods.

Improving Patient Care by Incorporation of Multidisciplinary Breast Radiology-Pathology Correlation Conference

PURPOSE

It is well known that radiologic-pathologic correlation is critical in managing patients with breast disease. Although regular multidisciplinary conferences addressing radiologic-pathologic correlation are common at most major academic institutions, this approach is not universal in community-based settings or even some of the smaller academic practices. This study was performed to assess the impact of a weekly multidisciplinary conference on patient care to determine whether all breast practices should adopt this approach as a means to streamline and improve the quality of patient care.

METHODS

We reviewed cases of percutaneous breast core biopsies presented at our weekly breast radiology-pathology correlation conference from July 1, 2008, to June 30, 2012. Each reviewed case was assigned to 1 of 4 categories (concordant → concordant, concordant → discordant, discordant → discordant, and discordant → concordant) based on the "initial" and "final" impressions of concordance between radiology and pathology. Changes in concordance, histopathological diagnosis, or management that occurred during the conference were recorded prospectively and analysed. Changes in management that were considered significant included changes in recommendations for surgery, repeat core biopsy, or follow-up imaging.

RESULTS

Of 1387 presented at the conference, 1313 (94.7%) had no change during the meeting, confirming 1279 (92.2%) concordant and 34 (2.4%) discordant cases. A total of 74 (5.3%) cases had a change during the conference: 22 of 74 (29.7%) were changed from discordant to concordant, avoiding surgical excision in 15 and short interval imaging in 7; 23 of 74 (31.1%) were changed from concordant to discordant; on excision 3 were cancer, 3 atypia, 10 benign, 2 stable on follow-up imaging, and 5 lost to follow-up; the remaining 29 of 74 (39.2%) stayed concordant after review, but had a change in management, avoiding surgery in 14 and short interval imaging in 15. Overall, as a result of this conference, repeat biopsy or excision was recommended in 23, surgery was avoided in 29, short interval imaging avoided in 22, and cancer detected in 3 cases.

CONCLUSIONS

Our weekly breast radiology-pathology correlation conference impacted patient management in up to 5.3% of cases. These results support the need to incorporate a weekly multidisciplinary case review of breast core biopsies into all breast care practices. Such a conference maximizes cancer detection, identifies discordant cases in a timely manner, decreases follow-up imaging, and avoids unnecessary surgical intervention.

Effectiveness of hemostasis with Foley catheter after vacuum-assisted breast biopsy

BACKGROUND

Interventional bleeding and post-interventional hematoma are the most common complications following vacuum-assisted breast biopsy (VABB). The aim of the current study was to evaluate the effectiveness of Foley catheter-induced hemostasis in VABB.

METHODS

A randomized prospective controlled trial was conducted using a total of 437 consecutive 8-gauge ultrasound-guided VABB procedures that were performed in 282 patients from June 2012 to October 2013. In each procedure, hemostasis was induced with either a Foley catheter or with external compression. Bleeding during intervention, hematoma post-intervention and the time of procedure were recorded. Statistical analysis included a Chi-Square test and an independent-samples t-test, and P value <0.05 was considered to be significant.

RESULTS

Significantly less bleeding and post-interventional hematoma resulted when hemostasis was induced using a Foley catheter vs. compression (7.6% vs. 17.4%, P=0.002; 8.9% vs. 27.9%, P<0.001). The mean time of breast biopsy was significantly less when using a Foley catheter vs. compression (33.6 vs. 45.5 min, P<0.001). No post-procedural infectious was encountered. In stratification analysis, there were no significantly different bleeding rates between the Foley catheter and compression methods in cases of single lesions (6.7% vs. 14.1%, P=0.346). In cases of multiple lesions, the Foley catheter method produced less bleeding/hematoma than compression (10.4% vs. 47.4%, P=0.018; 16.7% vs. 52.6%, P=0.020). Whether using a Foley catheter or compression to induce hemostasis, no significant difference was found in the rate of bleeding or hematoma when lesions <15 mm were removed (3.8% vs. 6.1%, P=0.531; 6.1% vs. 11.4%, P=0.340). When lesions ≥15 mm were excised, the rates of interventional bleeding and post-interventional hematoma were significantly lower in the Foley catheter study group than the compression control group (12.5% vs. 32.2%, P=0.034; 12.5% vs. 49.4%, P<0.001). There was significantly less bleeding (P=0.004) and hematoma (P<0.001) in the upper external quadrant when using a Foley catheter compared with compression (4.5% vs. 15.7%, P=0.004; 9.8% vs. 40.2%, P<0.001), but no significant differences for other quadrants.

CONCLUSIONS

Inducing hemostasis with a Foley catheter after VABB is a very effective and safe alternative to hemostasis with compression.

Apparent diffusion coefficient (ADC) value to evaluate BI-RADS 4 breast lesions: correlation with pathological findings

Diffusion-weighted imaging and apparent diffusion coefficient (ADC) of 36 breast lesions previously categorized as 4 according to the Breast Imaging Reporting and Data System (BI-RADS) were prospectively studied. The pathological results were 21 benign lesions and 15 malignant. The ADC of malignant lesions was significantly lower than that of the benign ones (0.87 ± 0.12 × 10(-3) mm(2)/s vs. 1.41 ± 0.22 × 10(-3) mm(2)/s, respectively) (P<.001). Using a threshold ADC value of 1.08 × 10(-3) mm(2)/s, a sensitivity of 95% and specificity of 100% were obtained.

Development of an electronic breast pathology database in a community health system

Background:

Health care systems rely on electronic patient data, yet access to breast tissue pathology results continues to depend on interpreting dictated free-text reports.

Objective:

The objective was to develop a method to electronically search and categorize pathologic diagnoses of patients’ breast tissue specimens from dictated free-text pathology reports in a large health system for multiple users including clinicians.

Design:

A database integrating existing patient-level administrative and clinical information for breast cancer screening and diagnostic services and a web-based application for comprehensive searching of pathology reports were developed by a health system team led by pathologists. The Breast Pathology Assessment Tool and Hierarchy for Diagnosis (BPATH-Dx) provided search terms and guided electronic transcription of diagnoses from text fields on breast pathology clinical reports to standardized categories.

Approach:

Breast pathology encounters in the pathology database were matched with administrative data for 7332 women with breast tissue specimens obtained from an initial procedure in the health system from January 1, 2008 to December 31, 2011. Sequential queries of the pathology text based on BPATH-Dx categorized biopsies according to their worst pathological diagnosis, as is standard practice. Diagnoses ranged from invasive breast cancer (23.3%), carcinoma in situ (7.8%), atypical lesions (6.39%), proliferative lesions without atypia (27.9%), and nonproliferative lesions (34.7%), and were further classified into subcategories. A random sample of 5% of reports that were manually reviewed indicated 97.5% agreement.

Conclusions:

Sequential queries of free-text pathology reports guided by a standardized assessment tool in conjunction with a web-based search application provide an efficient and reproducible approach to accessing nonmalignant breast pathology diagnoses. This method advances the use of pathology data and electronic health records to improve health care quality, patient care, outcomes, and research.

A tissue stabilization device for MRI-guided breast biopsy

We present a breast tissue stabilization device that can be used in magnetic resonance imaging-guided biopsy. The device employs adjustable support plates with an optimized geometry to minimize the biopsy target displacement using smaller compression than the conventional parallel plates approach. It is expected that the reduced compression will cause less patient discomfort and improve image quality by enhancing the contrast intake. Precomputed optimal positions of the stabilization plates for a given biopsy target location are provided in a look-up table. The results of several experiments with a prototype of the device carried out on chicken breast tissue demonstrate the effectiveness of the new design when compared with conventional stabilization methods. The proposed stabilization mechanism provides excellent flexibility in selecting the needle insertion point and can be used in manual as well as robot-assisted biopsy procedures.