Faculty calibration and students' self-assessments using an instructional rubric in preparation for a practical examination

PURPOSE

The purpose of this study was to investigate the effect of faculty calibration and students' self-assessments on students' performances in a periodontal practical examination.

METHODS

Before a new instructional rubric was implemented in the second-year periodontics course, faculty calibration was conducted with a pilot group of 32 third-year dental students. Afterwards, the new rubric was implemented in the second-year periodontics course. Second-year students used the rubric for their self-assessments before the practical examination. An intraclass correlation coefficient was used to test the reliability of the faculty members. A paired t test was used to compare scores between self-assessments of the pilot group (third-year students) and faculty evaluation. A two-way analysis of variance was performed to compare scores between self-assessments of second-year students and faculty evaluations. Chi-square tests were used to compare overall failure rates amongst four different classes.

RESULTS

The reliability amongst the faculty members was strong (the ICC = 0.75 at the first and 0.97 at the second calibration). The mean self-assessment score from the pilot group was significantly higher than the faculty evaluation. However, the mean self-assessment score of second-year students was significantly lower than the faculty evaluation. The class that practiced self-assessments with the validated instructional rubric exhibited the lowest overall failure rate compared to three past classes.

CONCLUSIONS

Using an instructional rubric and conducting faculty calibration improved the process of the periodontal practical examination. Improving the examination process and practicing self-assessments with feedback from faculty may have a positive impact on students' performances in the examination.

EZH2 promotes a bi-lineage identity in basal-like breast cancer cells

The mechanisms regulating breast cancer differentiation state are poorly understood. Of particular interest are molecular regulators controlling the highly aggressive and poorly differentiated traits of basal-like breast carcinomas. Here we show that the Polycomb factor EZH2 maintains the differentiation state of basal-like breast cancer cells, and promotes the expression of progenitor associated and basal-lineage genes. Specifically, EZH2 regulates the composition of basal-like breast cancer cell populations by promoting a ‘bi-lineage’ differentiation state, in which cells co-express basal- and luminal-lineage markers. We show that human basal-like breast cancers contain a subpopulation of bi-lineage cells, and that EZH2-deficient cells give rise to tumors with a decreased proportion of such cells. Bi-lineage cells express genes that are active in normal luminal progenitors, and possess increased colony-formation capacity, consistent with a primitive differentiation state. We found that GATA3, a driver of luminal differentiation, performs a function opposite to EZH2, acting to suppress bi-lineage identity and luminal-progenitor gene expression. GATA3 levels increase upon EZH2 silencing, mediating a decrease in bi-lineage cell numbers. Our findings reveal a novel role for EZH2 in controlling basal-like breast cancer differentiation state and intra-tumoral cell composition.

Use of high technology imaging for surveillance of early stage breast cancer

Guidelines do not support utilization of high technology radiologic imaging (HTRI) for surveillance after curative treatment for early stage breast cancer. Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data were used to identify 25,555 women diagnosed with stage I-II breast cancer between 1998 and 2003 who survived ≥ 48 months from diagnosis without evidence of second primary or recurrent cancer in this interval. HTRI utilization (computerized tomography scanning (CT), bone scan (BS), breast magnetic resonance imaging, and positron emission tomography scans) was measured in months 13-48 post-diagnosis. Cases were individually matched to 75,669 female Medicare enrollees without cancer. Factors associated with HTRI utilization were evaluated. Forty percent of women with stage I-II breast cancer and 25% of controls had ≥ 1 HTRI during the surveillance interval (P < 0.001). High utilization rates were observed for CT (30%) and BSs (19%). The proportion of women who had a CT during the surveillance period increased in both cancer survivors and controls. Among breast cancer cases age <80, higher comorbidity index, stage II disease, and more recent diagnosis were independently associated with receipt of HTRI. Paralleling patterns observed in controls, HTRI utilization for surveillance following diagnosis of early stage breast cancer has steadily increased among Medicare beneficiaries. Strategies to foster judicious utilization of HTRI should be a priority.

Negative Estrogen Receptor and HER2 Assays at Core Biopsy of Invasive Cancers Should Be Confirmed in the Surgical Specimens

Background: Management of patients with invasive breast carcinoma is determined by the expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) in the tumor cells. It is therefore critical to accurately assess ER, PR, and HER2 (ERPRH2) and avoid false-negative results that could lead to withholding of potentially beneficial therapy. Most laboratories, including ours, evaluate ERPRH2 status of invasive carcinoma on core biopsy (CB) material. We also routinely retest the cancer in the surgical specimen (SS) for any marker negative on CB. Our study evaluates discrepancies in ER and HER2 results in CB and SS to determine if repeat testing is necessary.Methods: Retrospective review of the pathology database found 186 invasive carcinomas from 181 patients in which ERPRH2 had been performed on the CB, and negative stains repeated on the SS. For the purpose of this study, immunoperoxidase stains (IHC) were repeated simultaneously on the CB and SS for the marker with discordant result, using the same antibody. Two study pathologists reviewed all IHC. HER2 FISH was performed on the SS for all cases with a discordant HER2 IHC result.Results: The concordance rate between CB and SS results was 97.3% (181/186) and discordant results were found in 5/186 (2.7%) cases (Table 1). Three cases were discordant in ER (including 2 cases that were PR(-) on CB and SS) and two cases were discordant for HER2. Discrepancy was due to intratumoral heterogeneity in 2 cases. The CB sampled the HER2(-) area of the tumor in one case, but staining of a larger section unveiled the positive focus; the positive result was confirmed by amplification of HER2 detected by FISH. The second case was an invasive lobular carcinoma (IL) with mixed classical and histiocytoid morphology; only the classical IL was ER(+), but the CB had sampled the histiocytoid IL. In two other cases the discrepancy resulted from technical error. Both cases had been prospectively interpreted as ER(-) on CB and ER(+) on SS, but repeat IHC for ER showed positive staining in both the CB and SS. The fifth case was HER2 (0/1+) on CB but equivocal (1-2+) in the SS, where a larger portion of tumor was evaluated; the equivocal result led to reflex HER2 FISH with detection of low level HER2 amplification. Relying solely on the CB would have resulted in the misclassification of 2 tumors as triple negative; repeat stains on the SS showed that one was HER2(+) and the other ER(+).Conclusions: Concordance in the ER and HER2 results between CB and SS was high (97.3%), but 2.7% of cases showed discordant findings. Factors associated with discordance included intratumoral heterogeneity tumor, technical error, and equivocal findings. A triple negative profile on CB converted to either ER(+) or HER2(+) after staining on SS in 2 cases (40% of discordant cases and 1.1% of all cases), impacting patient management. Our findings suggest that any ER and/or HER2 negative result obtained at CB should be confirmed on the SS to ensure appropriate patient management.Findings of discordant casesCaseER (%)HER2HER2 FISH CBSSCBSSSS1OOO3+4.42O951+1+N/P3O1001+1+N/P45501+1+N/P590N/P0-1+1-2+2.6N/P- not performed

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6008.

Breast MRI Screening of Women with a Prior High-Risk Lesion: Preliminary Results

Purpose: To determine the frequency of breast cancer detection in women at increased risk due to a prior high-risk lesion.Materials and methods: An IRB approved retrospective review was performed of the records of 2184 breast MRIs starting from 1999, to identify patients who commenced screening breast MRI who had a history of a prior high risk lesion. Eighty-three women were identified who had a prior biopsy demonstrating a high-risk lesion such as atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS). History, imaging, and pathologic findings were reviewed.Results: Histologies of prior high-risk lesions in these 83 women were ADH in 24, LCIS in 54 and ALH in 5. The median length of MRI follow-up was four (range, 1-9) years. Biopsies were recommended based on MRI findings in 39 (47%) of 83 women, yielding cancer in seven (8%) women (four of whom also had benign biopsies), and benign findings only in 32 (39%) women. Six of the seven women who developed a breast cancer also had a family history of breast cancer. Histologic findings in these seven cancers were ductal carcinoma in situ (DCIS) in 4 (57%) and invasive cancer in three (43%). Invasive cancer histologies (n=3) were ductal in one and lobular in two; maximal histologic size was 2.0 cm. This large invasive cancer had a mammographic, sonographic, and palpable correlate, and was node-positive; the other cancers were identified by MRI only. Among these seven cancers, two (29%) were detected in screening year 1, two (29%) in screening year 2, two (29%) in screening year 3 and one in screening year 4 (14%). Three (43%) of the seven cancers were in the contralateral breast. In these 83 women, the likelihood of detecting cancer by MRI was higher in those with, rather than without, a family history of breast cancer (6/54=11% vs. 1/29=3%) and in women with prior LCIS rather than prior ADH (6/54=11% vs. 1/24=4%).Conclusion: Breast MRI detected cancer in 7 (8%) of 83 women with a prior high-risk lesion, six (86%) of whom also had a family history of breast cancer. Among these cancers, all were detected during the first four years of screening and less than half were invasive (43%). Further work with more patients is needed to determine the utility of breast MRI screening in women with specific prior high-risk lesions, with and without additional risk factors.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4002.

Left coronary artery arising from the non-coronary sinus: a rare congenital coronary anomaly

Anomalous origin of the left coronary artery is a cause of sudden death in adolescents and young adults. Most commonly, it originates from the right coronary sinus or the pulmonary artery. Origin of the left main coronary artery from the non-coronary sinus of Valsalva is extremely rare. We report a case of a child with anomalous origin of the left main coronary artery from the non-coronary sinus diagnosed during the evaluation of a ventricular arrhythmia.

Effectiveness of prostaglandin E1 in relieving obstruction in coarctation of the aorta without opening the ductus arteriosus

The two main theories regarding the pathogenesis of coarctation of the aorta are the Skodaic hypothesis of ductal tissue constricting the aorta at the level of the insertion of the ductus arteriosus and the flow theory of decreased ascending aortic blood flow in the fetus, which results in associated isthmic narrowing and a localized shelf. To document that ectopic ductal tissue constriction can cause coarctation of the aorta in the absence of a patent ductus arteriosus, we report three cases of infants presenting with critical coarctation who responded to prostaglandin E1 infusion without opening the ductus arteriosus.

Sonographically guided directional vacuum-assisted breast biopsy: preliminary experience in Venezuela

OBJECTIVE

The purpose of this study was to evaluate the use of sonographically guided directional vacuum-assisted biopsy in the histologic diagnosis of breast lesions.

MATERIALS AND METHODS

Eighty-eight lesions in 83 women underwent sonographically guided 11-gauge directional vacuum-assisted breast biopsy during a 26-month period. Biopsies were performed using high-resolution sonography equipment with a 7.5-MHz transducer, obtaining a median of 17 specimens per lesion. Imaging studies, medical records, and histologic findings were reviewed.

RESULTS

Median patient age was 48 years (range, 25-78 years). Median lesion size was 1.2 cm (range, 0.4-2.5 cm). Twenty-four (27.3%) of 88 lesions were palpable. The median time required to perform biopsy was 17 min (range, 10-40 min). Complete removal of the lesion seen at sonography occurred in 78 (88.6%) of 88 lesions and was significantly more frequent in lesions measuring 1.5 cm or less than in larger lesions (68/71 = 95.8% vs 10/17 = 58.8%,p < 0.0003). A surgical procedure was spared in 79 (95.2%) of 83 women. In 36 lesions with imaging and clinical follow-up after sonographically guided biopsy with benign findings (range, 4-24 months; median, 11.3 months), we found no evidence of cancer or scarring in the breast.

CONCLUSION

In our small series, sonographically guided directional vacuum-assisted biopsy was a fast and accurate method for breast diagnosis. This technique resulted in complete removal of 95.8% of lesions shown at sonography measuring 1.5 cm or less and spared a surgical procedure in 95.2% of women. Further work is necessary to refine indications, evaluate cost-effectiveness, and assess long-term outcome.

Percutaneous biopsy and sentinel lymphadenectomy: minimally invasive diagnosis and treatment of nonpalpable breast cancer

OBJECTIVE

The purpose of this study was to determine the usefulness of the combination of percutaneous imaging-guided large-core breast biopsy and sentinel lymphadenectomy in the diagnosis and treatment of nonpalpable invasive breast cancer.

MATERIALS AND METHODS

Retrospective review revealed 200 consecutive nonpalpable breast cancers diagnosed by percutaneous imaging-guided large-core biopsy and treated with surgery that included sentinel lymphadenectomy. Percutaneous breast biopsy was performed with stereotactic or sonographic guidance with an automated core needle or vacuum-assisted biopsy probe. Sentinel lymphadenectomy was performed with intradermal injection of a radioisotope and intraparenchymal injection of blue contrast agent. Technical success was defined as identification of sentinel nodes at surgery. Medical records were reviewed.

RESULTS

Technical success rate was 200 (100%) of 200. In 158 (79%) of 200 cancers, sentinel nodes were tumor-free, and axillary dissection was avoided. In three (2%) of 200 carcinomas, the sentinel nodes were negative for tumor, but nonsentinel nodes suspicious on intraoperative palpation were excised and found by frozen section analysis to contain tumor. Tumor was found in sentinel nodes in 39 (20%) of 200 carcinomas; axillary dissection, performed in 31 of these 39 women, revealed additional tumor in nonsentinel nodes in seven (23%). A single surgical procedure was performed for 164 (82%) of 200 carcinomas; the breast was preserved in 191 (96%) of these 200 carcinomas.

CONCLUSION

Percutaneous imaging-guided large-core breast biopsy and sentinel lymphadenectomy provide a minimally invasive approach to the diagnosis and treatment of women with nonpalpable invasive breast cancers.

Observer variability and applicability of BI-RADS terminology for breast MR imaging: invasive carcinomas as focal masses

OBJECTIVE

The purpose of this study was to assess whether the descriptive terminology and final assessment categories of the Breast Imaging Reporting and Data System (BI-RADS) lexicon can be used for breast carcinomas detected on MR imaging and to assess the inter- and intraobserver variabilities in the use of the descriptors and final assessment categories.

MATERIALS AND METHODS

In 82 patients, 101 masses, including 68 infiltrating carcinomas and 33 benign lesions, were interpreted independently by four radiologists and described by BI-RADS terminology with respect to mass shape and margin and BI-RADS final assessment categories. The enhancement pattern of the mass was also reported. In addition, two radiologists interpreted each case twice to evaluate intraobserver variability. The final case set for analysis was the 68 infiltrating carcinomas.

RESULTS

Most of the infiltrating carcinomas were described as irregular, spiculated, and heterogeneously enhancing masses. The final impression of the 68 carcinomas was BI-RADS category 5 (highly suggestive of malignancy) in 41 (61%), category 4 (suspicious abnormality) in 24 (35%), and category 3 (probably benign) in three (4%). Enhancement pattern was heterogeneous in 40 (59%), homogeneous in 14 (21%), and rim in 14 (21%). Interobserver agreement was moderate for mass margin, shape, enhancement, and final assessment category.

CONCLUSION

This study suggests that the mammographic BI-RADS lexicon with some modifications may be applied to describe the features of infiltrating carcinoma seen on breast MR imaging.

Bracketing wires for preoperative breast needle localization

OBJECTIVE

The purpose of this study was to evaluate the outcomes of bracketing wire placement during preoperative breast needle localization.

SUBJECTS AND METHODS

We prospectively examined mammograms of 1057 consecutive lesions that had preoperative needle localization and surgical excision and classified the lesions according to Breast Imaging Reporting and Data System (BI-RADS) final assessment categories. Bracketing wires, defined as multiple wires placed to delineate the boundaries of a single lesion, were used in 103 (9.7%) of 1057 lesions. Medical records, imaging studies, and histologic findings in these 103 lesions were reviewed.

RESULTS

Of 103 bracketed lesions, median lesion size was 3.5 cm (range, 1.5-9.5 cm). Ninety-three lesions (90.3%) contained calcifications; 65 lesions (63.1%) were BI-RADS category 5 (highly suggestive of malignancy); and 33 lesions (32.0%) were percutaneously proven cancers. The median number of wires placed was two (range, 2-5). Surgical histologic findings were carcinoma in 75 lesions (72.8%), atypical hyperplasia in eight lesions (7.8%), and benign in 20 lesions (19.4%). Of 42 calcific lesions that were bracketed and had postoperative mammograms available for review, complete removal of suspicious calcifications was accomplished in 34 (81.0%). Of 75 cancers that were bracketed, clear histologic margins of resection were obtained in 33 (44.0%).

CONCLUSION

Bracketing wires were used during preoperative needle localization primarily for larger calcific lesions that were proven cancers or were highly suggestive of malignancy (BI-RADS category 5). Bracketing wires may assist the surgeon in achieving complete excision of calcifications, but bracketing wires do not ensure clear histologic margins of resection.

Calcifications highly suggestive of malignancy: comparison of breast biopsy methods

OBJECTIVE

The purpose of this study was to compare the usefulness of, and cost of diagnosing with, different breast biopsy methods for women with calcifications highly suggestive of malignancy.

MATERIALS AND METHODS

One hundred thirty-nine women with calcifications highly suggestive of malignancy underwent diagnostic biopsy. Of these, 89 women had stereotactic biopsy with a 14-gauge automated needle (n = 25), 14-gauge vacuum-assisted probe (n = 17), or 11-gauge vacuum-assisted probe (n = 47); and 50 women had diagnostic surgical biopsy. Medical records were reviewed. Cost savings for stereotactic biopsy were calculated using Medicare data.

RESULTS

The median number of operations was one for women who had stereotactic biopsy versus two for women who had diagnostic surgical biopsy. The likelihood of undergoing a single operation was significantly greater for women who had stereotactic rather than surgical biopsy, among all women (61/89 [68.5%] vs. 19/50 [38.0%], p < 0.001) and among women treated for breast cancer (55/77 [71.4%] vs. 6/37 [16.2%], p = 0.0000001). Stereotactic 11-gauge vacuum-assisted biopsy, as compared with 14-gauge automated core or 14-gauge vacuum-assisted biopsy, was significantly more likely to spare a surgical procedure (36/47 [76.6%] vs. 16/42 [38.1%], p = 0.0005). Stereotactic 11-gauge vacuum-assisted biopsy resulted in the greatest cost reduction, yielding savings of $315 per case compared with diagnostic surgical biopsy; for women with solitary lesions, stereotactic 11-gauge biopsy decreased the cost of diagnosis by 22.2% ($334/$1502).

CONCLUSION

For women with calcifications highly suggestive of malignancy, the use of stereotactic rather than surgical biopsy decreases the number of operations. Stereotactic 11-gauge vacuum-assisted biopsy, as compared with 14-gauge automated core or 14-gauge vacuum-assisted biopsy, is significantly more likely to spare a surgical procedure and has the highest cost savings.

Ultrasound-assisted cannulation of the right internal jugular vein during electrophysiologic studies in children

Percutaneous access of the right internal jugular vein for coronary sinus cannulation in pediatric patients undergoing electrophysiologic studies may be technically difficult. We report the use of an ultrasound-guided technique for obtaining jugular venous access. Forty-five pediatric patients who underwent electrophysiologic study were analyzed. Access was obtained in 100 % of the patients using this technique with no major complications. Ultrasound guidance for access of the internal jugular vein for coronary sinus cannulation during electrophysiologic studies in pediatric patients, may increase the success rate and prevent the development of complications.

Bulboventricular foramen resection: hemodynamic and electrophysiologic results

BACKGROUND

The two major surgical approaches to the relief of bulboventricular foramen (BVF) obstruction in patients with single left ventricle (LV) are the Damus-Kaye-Stansel (DKS) procedure or direct BVF resection. Theoretical advantages of the DKS include better out-flow gradient relief, lower potential incidences of postoperative heart block and lower incidences of reoperation. Potential disadvantages of this approach include increased semilunar valvar insufficiency, lack of feasibility when attempting septation-type operations for univentricular hearts, and a technically more difficult operation. We report the results of direct surgical BVF resection.

METHODS

From June 1990 to June 1999, 9 patients had direct BVF resection performed at our institution. The median age at surgery was 16.5 years (range 1 month to 27 years). Diagnoses in these patients were [S,L,L] single LV (n = 8) and [S,D,D] single LV tricuspid atresia (n = 1). Eight of 9 patients had pulmonary artery bands placed either before BVF resection or at the same time as this procedure. Three patients required reoperation for reobstruction at the BVF (12 total operations in 9 patients).

RESULTS

Median preoperative peak systolic gradient across the BVF measured at cardiac catheterization was 47 mm Hg (range 10 to 63 mm Hg). The median peak gradient measured by Doppler echocardiography was 44 mm Hg (range 5 to 125 mm Hg). Eight of 9 patients survived the operation to discharge from the hospital and 7 of 9 are alive at follow-up. At a median follow-up of 22 months (range 5 to 76 months), 8 of 8 surviving patients had an unobstructed BVF as determined by qualitative two-dimensional echocardiography and Doppler color flow imaging. There was one perioperative and one late death 5 months postoperatively (secondary to fungal sepsis). No patient developed new or worsened aortic insufficiency after BVF resection. Eight of 9 patients had no change in AV nodal conduction after surgery. One patient developed Mobitz II heart block requiring postoperative implantation of a pacemaker.

CONCLUSIONS

Direct resection of an obstructive BVF can be performed with total relief of obstruction although reoperation may be required. Atrioventricular nodal function can be preserved in most patients with this operative approach, including those with [S,L,L] segmental anatomy.

Learning curve for stereotactic breast biopsy: how many cases are enough?

OBJECTIVE

The objective of this study was to evaluate the learning curve for stereotactic breast biopsy.

MATERIALS AND METHODS

Retrospective review was performed of 923 consecutive lesions that underwent stereotactic breast biopsy performed by one of six radiologists. Four hundred fourteen lesions had 14-gauge automated core biopsy, and 509 subsequent lesions had vacuum-assisted biopsy (14-gauge in 163 and 11-gauge in 346). Medical records were reviewed to determine the technical success rate and false-negative rate as a function of operator experience.

RESULTS

For 14-gauge automated core biopsy, a significantly lower technical success rate was seen for the first five cases of each radiologist than for subsequent cases (25/30 = 83.3% versus 366/384 = 95.3%, p < 0.02) and for the first 20 cases than for subsequent cases (90/100 = 90% versus 284/296 = 95.9%, p < 0.05). For 11-gauge vacuum-assisted biopsy, a significantly lower technical success rate was seen for the first five cases than for subsequent cases (17/20 = 85.0% versus 310/322 = 96.3%, p < 0.05) and for the first 15 cases than for subsequent cases (54/60 = 90.0% versus 273/283 = 96.5%, p = 0.03). The false-negative rate was higher for the first 15 cases compared with subsequent cases both for stereotactic 14-gauge automated core biopsy (4/31 = 12.9% versus 3/115 = 2.6%, p < 0.04) and for stereotactic 11-gauge vacuum-assisted biopsy (2/27 = 7.4% versus 0/85 = 0%, p < 0.06).

CONCLUSION

A learning curve exists for stereotactic breast biopsy. Significantly higher technical success rates and lower false-negative rates were observed after the first five to 20 cases for 14-gauge automated core biopsy and after the first five to 15 cases for 11-gauge vacuum-assisted biopsy. Even after a radiologist has experience with stereotactic biopsy, changes in equipment may result in a new learning curve.

Torsade de pointes in a child with acute rheumatic fever

Ventricular arrhythmias are uncommon in acute rheumatic carditis. We report the case of a child who presented with rheumatic carditis, prolonged corrected QT interval, and torsade de pointes. The episodes of torsade were controlled with beta-blockade and cardiac pacing. The child subsequently died as a result of brain injury; the autopsy revealed classic findings of acute rheumatic carditis.

Percutaneous core biopsy of nonpalpable breast lesions: utility and impact on cost of diagnosis

Percutaneous image-guided core breast biopsy is faster, less invasive, less deforming, and less expensive than surgical biopsy for diagnosing nonpalpable breast lesions. Percutaneous biopsy may be performed using different imaging guidance modalities (e.g., stereotaxis or ultrasound) and different tissue acquisition devices (e.g., automated needles or vacuum-assisted biopsy probes). Stereotactic biopsy may be used for all lesion types (masses and calcifications). Stereotactic 14-gauge automated core biopsy spared a surgical procedure in 76-85% of cases, decreasing the cost of diagnosis by 40-56%. Annual national savings from use of stereotactic 14-gauge automated core biopsy rather than surgical biopsy for nonpalpable lesions would exceed 100 million dollars. Stereotactic 11-gauge vacuum-assisted biopsy yields significant improvement in diagnosis of calcifications and may be used in lesions that are not amenable to stereotactic 14-gauge automated core biopsy. Stereotactic 11-gauge vacuum-assisted biopsy spared a surgical procedure in 76% cases, decreasing cost of diagnosis by 20%. Use of stereotactic 11-gauge vacuum-assisted biopsy for calcifications and for nonpalpable masses not amenable to stereotactic 14-gauge automated core biopsy would yield annual national savings exceeding 50 million dollars. Ultrasound-guided biopsy, used primarily for masses, has several advantages including speed, comfort, lack of radiation exposure, and real-time needle visualization. Ultrasound-guided core biopsy spared a surgical procedure in 85% cases, decreasing the cost of diagnosis by 56%. Although both ultrasound-guided core biopsy and stereotactic biopsy are less expensive than surgery, cost savings are greater for ultrasound-guided core biopsy. An annual national savings over $50 million could be realized with the use of ultrasound-guided core biopsy for nonpalpable masses. Future work should include evaluating the emerging new technologies for percutaneous breast biopsy and optimizating the choice of biopsy method for different clinical scenarios. Society may benefit from cost reduction as women benefit from a faster, less invasive, and less deforming approach to diagnosis.

Imaging-histologic discordance at percutaneous breast biopsy

BACKGROUND

The purpose of the current study was to determine the frequency of imaging-histologic discordance at percutaneous breast biopsy and to assess the likelihood of carcinoma in these discordant lesions.

METHODS

Percutaneous imaging guided breast biopsy was performed on 1785 consecutive lesions during a 7-year period under stereotactic (n = 1205) or sonographic (n = 580) guidance, using an automated needle (n = 1044) or directional vacuum-assisted probe (n = 741). Lesions were prospectively classified according to the Breast Imaging Reporting and Data System (BI-RADS) as Category 3 (probably benign), Category 4 (suspicious), or Category 5 (highly suggestive of malignancy). Imaging-histologic discordance was considered to have occurred when the percutaneous biopsy histology did not provide a sufficient explanation for the imaging features; in such cases, repeat biopsy was recommended. Medical records, imaging studies, and histologic findings were reviewed.

RESULTS

Imaging-histologic discordance was present in 56 of 1785 (3.1%) lesions. The frequency of discordance was significantly higher in our first 2 years of experience with percutaneous biopsy than in later years (18 of 361 = 5.0% vs. 38 of 1424 = 2.7%; P < 0.04) and was significantly higher for lesions that were BI-RADS Category 5 rather than BI-RADS Category 4 (20 of 416 = 4.8% vs. 36 of 1366 = 2. 6%; P < 0.04). The frequency of discordance was significantly lower with the 11-gauge vacuum-assisted probe than other devices for calcifications (7 of 414 = 1.7% vs. 16 of 251 = 6.8%; P = 0.001) but not for masses (6 of 161 = 3.7% vs. 26 of 959 = 2.7%; P = 0.44). Repeat biopsy, performed in 45 discordant lesions revealed carcinoma in 11 (24.4%; 95% confidence intervals, 12.9-39.5%). The frequency of carcinoma was significantly higher among discordant BI-RADS Category 5 than discordant BI-RADS Category 4 lesions (7 of 16 = 43. 8% vs. 4 of 29 = 13.7%; P < 0.04).

CONCLUSIONS

Imaging-histologic discordance occurred in 3.1% of lesions that had percutaneous breast biopsy. Imaging-histologic discordance was an indication for surgical excision because of the high (24.4%) prevalence of carcinoma in these lesions.

Sentinel lymph node biopsy: is it indicated in patients with high-risk ductal carcinoma-in-situ and ductal carcinoma-in-situ with microinvasion?

BACKGROUND

Axillary lymph node status is the strongest prognostic indicator of survival for women with breast cancer. The purpose of this study was to determine the incidence of sentinel node metastases in patients with high-risk ductal carcinoma-in-situ (DCIS) and DCIS with microinvasion (DCISM).

METHODS

From November 1997 to November 1999, all patients who underwent sentinel node biopsy for high-risk DCIS (n = 76) or DCISM (n = 31) were enrolled prospectively in our database. Patients with DCIS were considered high risk and were selected for sentinel lymph node biopsy if there was concern that an invasive component would be identified in the specimen obtained during the definitive surgery. Patients underwent intraoperative mapping that used both blue dye and radionuclide. Excised sentinel nodes were serially sectioned and were examined by hematoxylin and eosin and by immunohistochemistry.

RESULTS

Of 76 patients with high-risk DCIS, 9 (12%) had positive sentinel nodes; 7 of 9 patients were positive for micrometastases only. Of 31 patients with DCISM, 3 (10%) had positive sentinel nodes. 2 of 3 were positive for micrometastases only. Six of nine patients with DCIS and three of three with DCISM and positive sentinel nodes had completion axillary dissection; one patient with DCIS had an additional positive node detected by conventional histological analysis.

CONCLUSIONS

This study documents a high incidence of lymph node micrometastases as detected by sentinel node biopsy in patients with high-risk DCIS and DCISM. Although the biological significance of breast cancer micrometastases remains unclear at this time, these findings suggest that sentinel node biopsy should be considered in patients with high-risk DCIS and DCISM.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Continuous intravenous diltiazem infusion for short-term ventricular rate control in children

Intravenous diltiazem was administered to 10 pediatric patients with primary atrial tachyarrhythmias with rapid ventricular response. Rapid, consistent, and safe temporary ventricular rate control was obtained in all patients given this medication.

Metastatic lobular carcinoma of the breast: patterns of spread in the chest, abdomen, and pelvis on CT

OBJECTIVE

We determined the pattern of spread of metastatic lobular carcinoma in the chest, abdomen, and pelvis on CT.

MATERIALS AND METHODS

We identified 57 women (age range, 30-79 years; mean age, 57 years) with metastatic lobular carcinoma of the breast who underwent CT of the chest, abdomen, or pelvis between 1995 and 1998. Then two experienced oncology radiologists retrospectively reviewed 78 CT examinations of those patients to identify sites of metastatic disease and to identify complications caused by metastases.

RESULTS

Metastases were identified in bone in 46 patients (81%), lymph nodes in 27 patients (47%), lung in 19 patients (33%), liver in 18 patients (32%), peritoneum in 17 patients (30%), colon in 15 patients (26%), pleura in 13 patients (23%), adnexa in 12 patients (21%), stomach in nine patients (16%), retroperitoneum in nine patients (16%), and small bowel in six patients (11%). Eighteen patients (32%) had gastrointestinal tract involvement that manifested as bowel wall thickening. Hydronephrosis was present in six patients (11%).

CONCLUSION

Although lobular carcinoma metastasized to common metastatic sites of infiltrating ductal carcinoma, lobular carcinoma frequently metastasized to unusual sites, including the gastrointestinal tract, peritoneum, and adnexa. Gastrointestinal tract involvement was as frequent as liver involvement, appearing as bowel wall thickening on CT. Hydronephrosis was a complication of metastatic lobular carcinoma.

Clinical management issues in percutaneous core breast biopsy

Percutaneous imaging-guided core biopsy is a less invasive and less expensive alternative to surgical biopsy for the evaluation of breast lesions. Percutaneous core biopsy is most often used for evaluation of BI-RADS category 4 lesions, but may also be helpful in the evaluation of some BI-RADS category 5 lesions. Stereotactic guidance is particularly useful for calcifications; for masses that can be seen with ultrasound, ultrasound guidance may be preferable because of the absence of radiation and lower cost. The automated core biopsy needle is excellent for mass lesions, but directional vacuum-assisted biopsy is superior for calcifications. Directional vacuum-assisted biopsy may also be preferable for small lesions that may require placement of a localizing clip and lesions that are superficial or in thin breasts. The more expensive ABBI device has substantial limitations, and its role in percutaneous breast biopsy has not been demonstrated. Complete removal of the mammographic target can occur at percutaneous biopsy, and is a more frequent event when the larger tissue acquisition devices are used. Complete removal of the mammographic target does not ensure complete excision of the histologic process. Further investigation is necessary to determine in which lesions, if any, complete removal of the target is advantageous. Epithelial displacement can occur during all breast needling procedures, but may be less frequent at directional vacuum-assisted biopsy than at fine-needle aspiration or automated core biopsy. There is no evidence that displaced cells are of biologic significance, but displaced DCIS can mimic infiltrating carcinoma. The pathologist should be aware of the findings of epithelial displacement, to avoid misdiagnosing DCIS as infiltrating ductal carcinoma. Some lesions warrant repeat biopsy or surgical excision after percutaneous core biopsy. Repeat biopsy is warranted if histologic findings and imaging findings are discordant. Surgical excision is warranted for lesions yielding a percutaneous diagnosis of ADH or possible phyllodes tumor. Controversy exists regarding the need for surgical excision after percutaneous diagnosis of radial scar, papillary lesion, ALH, or LCIS. Follow-up is necessary if percutaneous biopsy yields benign findings concordant with imaging characteristics. Follow-up protocols vary, but all require substantial commitment of time and resources. We have an embarassment of riches for performing percutaneous core biopsy of the breast. It can be estimated that approximately 1 million breast biopsies will be performed this year to diagnose approximately 200,000 breast cancers. Percutaneous core biopsy may spare many of these women the need for a more deforming, invasive, and expensive surgical biopsy. Further work is necessary to optimize criteria for patient selection, develop and define the role of new technologies for tissue acquisition, refine protocols for management after percutaneous breast biopsy, and assess long-term outcome, so that more women can benefit from this minimally invasive approach to breast diagnosis.

Cost-effectiveness of stereotactic 11-gauge directional vacuum-assisted breast biopsy

OBJECTIVE

The purpose of our study was to determine the frequency with which stereotactic 11-gauge directional vacuum-assisted breast biopsy obviated a surgical procedure and to calculate cost savings attributable to that biopsy method.

MATERIALS AND METHODS

We retrospectively reviewed 200 consecutive solitary nonpalpable lesions on which stereotactic 11-gauge directional vacuum-assisted breast biopsy was performed. Cost savings were calculated using Medicare reimbursements. Mammograms, histologic findings, and medical records were reviewed.

RESULTS

Stereotactic 11-gauge directional vacuum-assisted biopsy obviated a surgical procedure in 151 (76%) of 200 lesions, including 112 (73%) of 154 calcific lesions and 39 (85%) of 46 masses. Reasons for not obviating a surgical procedure in 49 lesions (25%) included recommendation for surgical biopsy in 35 lesions (18%), small carcinomas treated by excision in 10 lesions (5%), and histologic underestimation in four lesions (2%). Stereotactic 11-gauge directional vacuum-assisted biopsy decreased the cost of diagnosis by S264 per case, a 20% ($264/$1289) decrease in the cost of diagnosis compared with surgical biopsy. Of 200 lesions that had stereotactic 11-gauge directional vacuum-assisted biopsy, 106 (53%) would not have been amenable to 14-gauge automated core biopsy because of their small size, their superficial location, or inadequate breast thickness.

CONCLUSION

Stereotactic 11-gauge directional vacuum-assisted breast biopsy obviated a surgical procedure in 76% of lesions, yielding a 20% decrease in cost of diagnosis compared with surgical biopsy. Although savings per case are modest, 11-gauge directional vacuum-assisted biopsy expands the spectrum of lesions amenable to stereotactic biopsy, increasing cost savings in the population.

Noninvasive prediction of pulmonary artery pressure in patients with isolated ventricular septal defect

Management of patients with isolated ventricular septal defect (VSD) requires information regarding pulmonary artery pressure (PAP). The purpose of this study was to evaluate the individual predictive value of noninvasive methods for assessment of PAP and to determine if any combination of techniques significantly improved their predictive power. We reviewed the clinical history, electrocardiogram, and echocardiogram of 31 patients (age 1.9 +/- 1. 73 years) who underwent catheterization for isolated VSD. Noninvasive data were compared for patients with mean PAP <20 mmHg (group 1) and those with mean PAP > or =20 (group 2) at catheterization. Fourteen (45%) patients were in group 1 and 17 (55%) in group 2. Doppler estimation of VSD gradient, right ventricular hypertrophy by echocardiogram, interventricular septal orientation, and VSD size had predictive value for elevated mean PAP (p < 0.01). All patients (n = 6) with normal findings in all four variables had normal PAP. All patients (n = 12) with at least three of four abnormal findings had elevated PAP. Six patients in group 1 had at least one variable that incorrectly predicted high PAP, whereas 3 patients with normal findings on three of the four variables nevertheless had elevated PAP. No single noninvasive variable accurately predicted PAP in all cases. However, normal findings for all four significant variables did predict normal PAP and suggest that cardiac catheterization is unnecessary in that setting. However, any other combination of normal and abnormal findings for the four significant variables did not reliably predict PAP and such patients may require catheterization to directly measure PAP.

Radiofrequency ablation of an accessory pathway in a surgically created atrioventricular Fontan anastomosis: case report and review of previous published cases

Supraventricular tachyarrhythmias following the Fontan procedure can be life-threatening. Though most are commonly due to intraatrial reentry, orthodromic reentrant tachycardia may also be present. Atrioventricular accessory pathways may develop across suture lines following right atrial to right ventricular anastomosis in patients with tricuspid atresia. We report a case of a patient who underwent this type of Fontan who developed orthodromic reentrant tachycardia and heart failure. An electrophysiological study revealed the presence of an atrioventricular accessory pathway traversing the Fontan anastomosis suture line. Successful radiofrequency ablation of the accessory pathway led to control of the tachyarrhythmia and improvement of heart failure.

Evaluation of pectoralis major muscle in patients with posterior breast tumors on breast MR images: early experience

PURPOSE

To evaluate the ability to use breast magnetic resonance (MR) imaging to assess disease extent in patients with posterior breast masses who are suspected to have tumor invasion into underlying muscle.

MATERIALS AND METHODS

Nineteen patients with posterior breast masses underwent three-dimensional, gradient-echo, 1.5-T MR imaging before and after the administration of gadopentetate dimeglumine. Thirteen had deep palpable masses that were clinically determined to be fixed to the underlying chest wall. Twelve had mammographic findings that caused muscle involvement to be suspected, and seven had normal mammograms. All patients underwent surgery. MR images were reviewed and were correlated with histologic findings.

RESULTS

Enhancing masses were identified on MR images in all 19 patients. Five (26%) of the 19 patients had masses that abutted the muscles, with obliteration of the fat plane and muscle enhancement. All five had muscle involvement at surgery. In the remaining 14 (74%) patients, no enhancement of muscle was seen; none of these had invasion of the muscle at surgery.

CONCLUSION

Extension of adjacent tumor into underlying musculature was indicated by abnormal enhancement within these structures. Violation of the fat plane between tumor and muscle, without other findings, did not indicate tumor involvement of these deep structures.

Complete percutaneous excision of infiltrating carcinoma at stereotactic breast biopsy: how can tumor size be assessed?

OBJECTIVE

The purpose of this study was to determine the frequency of complete excision of infiltrating carcinoma at stereotactic 11-gauge directional vacuum-assisted breast biopsy and to evaluate the feasibility of measuring tumor size in stereotactic biopsy specimens in infiltrating carcinomas that were percutaneously excised.

MATERIALS AND METHODS

We performed retrospective review of 51 infiltrating carcinomas diagnosed using stereotactic 11-gauge directional vacuum-assisted biopsy that underwent subsequent surgery. For lesions yielding no residual infiltrating carcinoma at surgery, the maximal dimension of the tumor was measured in stereotactic biopsy specimens using ocular micrometry.

RESULTS

In 10 (20%) (95% confidence intervals, 9.8-33.1%) of 51 infiltrating carcinomas diagnosed at stereotactic biopsy, surgery revealed no residual infiltrating carcinoma. Complete excision of infiltrating carcinoma was more frequent if 14 or more specimens were obtained (32% versus 0%, p < .004), if the mammographic lesion was removed (35% versus 7%, p < .03), and if the mammographic lesion size measured 0.7 cm or less (50% versus 16%, p = .08). Tumor size in stereotactic biopsy specimens was within 3 mm of mammographic lesion size in six (60%) of 10 lesions, including five (71%) of seven masses and one (33%) of three calcification lesions, but was smaller than the mammographic lesion size in eight (80%) of 10 lesions.

CONCLUSION

Surgery revealed no residual infiltrating carcinoma in 10 (20%) of 51 infiltrating carcinomas diagnosed at stereotactic 11-gauge biopsy. Although tumor size can be assessed in stereotactic biopsy specimens in these lesions, such measurements may underestimate the maximal dimension of the tumor. Further study is needed to evaluate the usefulness of these measurements in guiding treatment decisions.

Long term follow-up of women with ductal carcinoma in situ treated with breast-conserving surgery: the effect of age

BACKGROUND

Although in recent years there has been a dramatic increase in both the incidence of ductal carcinoma in situ (DCIS) and breast-conserving therapy for patients who have this disease, the optimal treatment for these patients remains controversial. Most data regarding outcomes have come from small, retrospective studies, with little data published from prospective, randomized studies. This study investigates the effects of age, postoperative breast irradiation, and other factors on local relapse free survival after breast-conserving surgery for women with DCIS in a large, single-institution series.

METHODS

A review was performed of all patients with DCIS who underwent breast-conserving surgery at Memorial Sloan-Kettering Cancer Center from 1978 through 1990. Of the 171 cases identified, data on follow-up and radiation therapy were available for 157. All available pathology slides (132 of 157) were rereviewed to determine histologic subtype, nuclear grade, presence of necrosis, and microscopic tumor size. Sixty-five patients (41%) received postoperative radiation therapy; selection criteria evolved over the time period. The median follow-up was 74 months.

RESULTS

Factors that were significantly (P< or =0.05) associated with a lower recurrence rate were older age, noncomedo subtype, lower nuclear grade, negative margins, and postoperative radiation therapy. The 6-year actuarial recurrence rate was 9.6% for patients who received postoperative radiation therapy and 20.7% for patients who had excision only (P = 0.05). Comparison of patients of ages > or =70, 40-69, and <40 years revealed a significantly lower risk of recurrence with increasing age. Actuarial 6-year local relapse rates were 10.8%, 14.0%, and 47.2%, respectively (P = 0.047). A benefit from radiation therapy was suggested for each age group. There was no statistically significant correlation between age group and any histologic factor examined. In multivariate analysis, only margin status was statistically significant (P = 0.05).

CONCLUSIONS

In addition to margin status, pathologic factors, and the use of radiation therapy, age is another factor that should be considered in assessing the risk of local recurrence after breast-conserving surgery for patients with DCIS.

Lobular carcinoma in situ at percutaneous breast biopsy: surgical biopsy findings

OBJECTIVE

The purpose of this study was to review surgical histologic findings in women with lobular carcinoma in situ (LCIS) at percutaneous breast biopsy.

MATERIALS AND METHODS

Retrospective review was performed of 1315 consecutive lesions that underwent percutaneous breast biopsy. Percutaneous biopsy yielded LCIS in 16 (1.2%) lesions. Subsequent surgical biopsy was performed in 14 lesions in 13 women. Histologic findings were reviewed.

RESULTS

In five of the 14 lesions, percutaneous biopsy yielded LCIS and a high-risk lesion (radial scar in three and atypical ductal hyperplasia in two); in one (20%) of these five lesions, surgery revealed ductal carcinoma in situ (DCIS). In four of the 14 lesions, the LCIS in the percutaneous biopsy had features that overlapped with those of DCIS; in two (50%) of these four lesions, surgery revealed DCIS (n = 1) or infiltrating lobular carcinoma (n = 1). In the remaining five of the 14 lesions, surgery revealed no DCIS or infiltrating carcinoma. Five (38%) of 13 women with LCIS lesions had synchronous or metachronous infiltrating carcinoma (three ductal, one lobular, one mixed) in the ipsilateral (n = 1) or contralateral (n = 4) breast.

CONCLUSION

Surgical excision was warranted in lesions in which LCIS was found at percutaneous breast biopsy when the percutaneous biopsy histologic features overlapped with those of DCIS, when a high-risk lesion was present, or when there was imaging-histologic discordance. LCIS without these factors was not shown to require surgical excision in our small series, but a larger study is needed. Diagnosis of LCIS at percutaneous biopsy is a marker for women who are at increased risk of ductal or lobular carcinoma in either breast.

Sentinel lymph node biopsy after percutaneous diagnosis of nonpalpable breast cancer

PURPOSE

To determine the technical success rate of sentinel lymph node biopsy in women with nonpalpable infiltrating breast cancer diagnosed by using percutaneous core biopsy and to determine the frequency with which sentinel lymph node biopsy obviated axillary dissection.

MATERIALS AND METHODS

Retrospective review revealed 33 women who underwent sentinel node biopsy after percutaneous core biopsy diagnosis of nonpalpable infiltrating breast cancer. Sentinel nodes were identified with radioisotope and blue dye; the procedure was technically successful if sentinel nodes were found at surgery. All sentinel nodes were excised. Axillary dissection was performed if tumor was present in sentinel nodes.

RESULTS

Sentinel nodes were found at surgery in 30 women (91%). Sentinel nodes were identified with both radioisotope and blue dye in 22 (73%) of these women, with only radioisotope in six (20%), and with only blue dye in two (7%). Sentinel nodes were found in 12 (80%) of 15 women in the first half of the study versus all 18 (100%) women in the second half (P = .08). Sentinel nodes were free of tumor in 23 (77%) of 30 women. In six (86%) of seven women with tumor in sentinel nodes, the sentinel nodes were the only nodes with tumor.

CONCLUSION

Sentinel node biopsy was successful in 30 women (91%) with nonpalpable infiltrating carcinoma diagnosed with percutaneous core biopsy and obviated axillary dissection in 23 women (70%). Using both radioisotope and blue dye may increase the success rate. A learning curve exists, and success improves with experience.

Epithelial displacement after stereotactic 11-gauge directional vacuum-assisted breast biopsy

OBJECTIVE

Displaced epithelial fragments at percutaneous biopsy of ductal carcinoma in situ (DCIS) may mimic stromal invasion. This study was undertaken to determine the frequency of epithelial displacement in DCIS lesions of patients who underwent stereotactic 11-gauge directional vacuum-assisted breast biopsy.

MATERIALS AND METHODS

We retrospectively reviewed 28 consecutive DCIS lesions in patients who underwent stereotactic 11-gauge directional vacuum-assisted breast biopsy followed by surgery. Surgical specimens were examined for histologic evidence of epithelial displacement, consisting of fragments of epithelium in artifactual spaces in breast parenchyma or in lymphovascular channels, accompanied by hemorrhage, fat necrosis, inflammation, hemosiderin-laden macrophages, or granulation tissue.

RESULTS

The median number of specimens obtained per lesion was 14 (range, seven to 45). The median interval from stereotactic biopsy to surgery was 27 days (range, 10-59 days). Surgery revealed DCIS in 19 (68%) of 28 lesions, DCIS and infiltrating carcinoma in four lesions (14%), and no residual carcinoma in five lesions (18%). Reactive changes at the biopsy site were identified in all cases. Displacement of benign epithelium into granulation tissue at the stereotactic biopsy site was identified in two cases (7%). We found no evidence of displacement of malignant epithelium.

CONCLUSION

Epithelial displacement is uncommon after stereotactic 11-gauge directional vacuum-assisted biopsy of the breast. We observed displacement of benign epithelium in two (7%) of 28 DCIS lesions and no displacement of malignant epithelium.

Percutaneous large-core biopsy of papillary breast lesions

OBJECTIVE

This study was undertaken to assess the accuracy of percutaneous large-core biopsy in evaluating papillary breast lesions.

MATERIALS AND METHODS

A retrospective review of imaging-guided large-core breast biopsy of 1077 consecutive lesions revealed that papillary lesions were diagnosed in 34 (3%) cases. Surgical correlation (n = 22) or minimum 2 years' mammographic follow-up (n = 4) were available for 26 papillary lesions. Mammographic and histologic findings in these 26 cases were reviewed.

RESULTS

Percutaneous biopsy histology had benign findings in nine lesions, atypical in 10, and malignant in seven. Of seven lesions yielding benign papilloma at percutaneous biopsy, none (0%) had carcinoma at surgery or mammographic follow-up. Surgery revealed carcinoma in one of two lesions yielding papillomatosis at percutaneous biopsy. This lesion was a spiculated mass; surgical biopsy, recommended because of mammographic-histologic discordance, revealed a radial sclerosing lesion and ductal carcinoma in situ (DCIS). Of 10 papillary lesions with atypical ductal hyperplasia at percutaneous biopsy, surgery revealed DCIS in three (30%). Of seven lesions in which percutaneous biopsy yielded papillary DCIS, surgery revealed DCIS in all seven; three (43%) also had invasive carcinoma.

CONCLUSION

Among our patients, diagnosis by percutaneous core biopsy of benign papillary lesions proved to be accurate when concordant with imaging findings. Surgical excision was indicated when diagnosis by percutaneous biopsy revealed atypical papillary lesions or papillary DCIS. A larger series with longer follow-up is required to assess the clinical course of benign papillary lesions without atypia that are not excised after percutaneous large-core breast biopsy.

US-guided core breast biopsy: use and cost-effectiveness

PURPOSE

To determine the frequency with which ultrasonographically (US) guided core biopsy obviated diagnostic surgical biopsy of nonpalpable breast masses, to calculate the cost savings of diagnosis attributable to US-guided core biopsy, and to compare the costs of US-guided versus stereotactically guided core biopsy.

MATERIALS AND METHODS

US-guided core biopsy was performed in 151 consecutive solitary, nonpalpable breast masses in 151 women (age range, 23-80 years) by using a 14-gauge automated gun and needle. Clinical follow-up data were obtained. Cost savings were assessed by using national Medicare reimbursement costs of +385 for US-guided core biopsy, +610 for stereotactic core biopsy, and +1,332 for needle localization and surgical biopsy.

RESULTS

US-guided core biopsy obviated a surgical procedure in 128 (85%) of 151 women. The mean adjusted direct cost saving per US-guided core biopsy was +744 per case. Use of US-guided biopsy decreased the cost of diagnosis by 56% (+744/+1,332) over the cost of surgical biopsy. If biopsy had been performed with stereotactic rather than with US guidance, the mean adjusted direct cost saving would have been +519 per case, a 39% (+519/1,332) decrease in the cost of diagnosis compared with the cost of surgical biopsy.

CONCLUSION

Percutaneous biopsy of a nonpalpable breast mass with either US or stereotactic guidance is less expensive than surgery, but cost savings are greater with US-guided biopsy.

The breast imaging reporting and data system: positive predictive value of mammographic features and final assessment categories

OBJECTIVE

The purpose of the study was to assess the positive predictive value of mammographic features and final assessment categories described in the Breast Imaging Reporting and Data System (BI-RADS) for lesions on which biopsies have been performed.

SUBJECTS AND METHODS

We prospectively evaluated 492 impalpable mammographically detected lesions on which surgical biopsy (as opposed to percutaneous biopsy) was performed. Each lesion was classified according to BI-RADS descriptors for masses (margins and shape) and calcifications (morphology and distribution) and was categorized by the BI-RADS final assessment categories as category 3 ("probably benign"), category 4 ("suspicious abnormality"), or category 5 ("highly suggestive of malignancy"). Mammographic and pathologic findings were reviewed.

RESULTS

Carcinoma was present in 225 (46%) of 492 lesions. For the 492 lesions subject to biopsy, BI-RADS final assessment categories were category 3 in eight lesions (2%), category 4 in 355 (72%), and category 5 in 129 (26%). The features with highest positive predictive value for carcinoma were spiculated margins (81%), irregular shape (73%), linear calcification morphology (81%), and segmental or linear calcification distribution (74% and 68%, respectively). Carcinoma was present in 105 (81%) of 129 category 5 lesions compared with 120 (34%) of 355 category 4 lesions (p < .001). The frequency of carcinoma was higher in category 5 than in category 4 lesions for all mammographic lesion types and all interpreting radiologists.

CONCLUSION

The standardized terminology of the BI-RADS lexicon allows quantification of the likelihood of carcinoma in an impalpable breast lesion. The features with highest positive predictive value--spiculated margins, irregular shape, linear morphology, and segmental or linear distribution--warrant designation of a lesion as category 5.

Calcification retrieval at stereotactic, 11-gauge, directional, vacuum-assisted breast biopsy

PURPOSE

To determine the frequencies of calcification retrieval and histologic underestimates at stereotactic, 11-gauge, directional, vacuum-assisted breast biopsy.

MATERIALS AND METHODS

Retrospective review of records revealed 112 calcific lesions in 80 women (aged 31-85 years) who underwent stereotactic, 11-gauge, directional, vacuum-assisted biopsy; a mean of 14 specimens per lesion were obtained. Calcification retrieval was defined as identification of calcifications on radiographs of specimens. Atypical ductal hyperplasia (ADH) underestimates were lesions that yielded ADH at stereotactic biopsy and carcinoma at surgery. Ductal carcinoma in situ (DCIS) underestimates were lesions that yielded DCIS at stereotactic biopsy and infiltrating carcinoma at surgery. Mammograms, stereotactic images, radiographs of specimens, and histologic findings were reviewed.

RESULTS

Stereotactic, 11-gauge, directional, vacuum-assisted biopsy removed all calcifications in 51 (46%) lesions, some calcifications in 55 (49%) lesions, and no calcifications in six (5%) lesions. Failure to retrieve calcifications was significantly more likely in lesions 5 mm or smaller (12% [five of 43] vs 1% [one of 69], P = .03), in calcifications with amorphous morphology (21% [three of 14] vs 3% [three of 98], P < .03), or if the probe was fired outside the breast (12% [five of 40] vs 1% [one of 72], P = .02). Surgery revealed DCIS in one (10%) of 10 lesions that yielded ADH at stereotactic biopsy. Surgery revealed infiltrating carcinoma in one (5%) of 21 lesions that yielded DCIS at stereotactic biopsy. No underestimation occurred when all calcifications were removed.

CONCLUSION

Stereotactic, 11-gauge, directional, vacuum-assisted biopsy resulted in successful calcification retrieval in 106 (95%) of 112 cases. Histologic underestimation was infrequent.

Stereotactic breast biopsy: indications and results

Imaging-guided breast biopsy performed with large-core needles can accurately diagnose most breast pathologies, often allowing a diagnosis to be made more quickly and less expensively than with surgical biopsy. Major complications, such as hemorrhage and infection, are extremely rare, although post-biopsy ecchymosis and tenderness are not unusual. Because less tissue is removed, post-biopsy cosmetic deformity does not occur. Stereotactic biopsy is performed by triangulating the position of a breast lesion and by obtaining views angled equally off a central axis. This can be done using dedicated tables or add-on equipment. Stereotactic core biopsy has a reported accuracy of at least 90%. All lesions for which biopsy would ordinarily be recommended are amenable to stereotactic techniques, but those near the chest wall or in the axilla may be more difficult to biopsy with some equipment. Lesions characterized by calcifications are sometimes more difficult to sample. A biopsy diagnosis of ductal atypia, because of its histologic heterogeneity, requires surgical excision to exclude coexistent carcinoma, which has been found in half of women at subsequent surgical excision. A core biopsy diagnosis of ductal carcinoma in situ does not preclude the discovery of invasive carcinoma at surgery. In rare instances, the small tissue volume removed at stereotactic biopsy does not permit a final diagnosis to be made; this occurs most commonly when differentiating phyllodes tumor from fibroadenoma.

A comparison of screening mammography results from programs for women of different socioeconomic status

BACKGROUND

The ability of screening mammography programs serving women of different socioeconomic status (SES) to diagnose early stage breast carcinoma in a comparably effective fashion has been questioned.

METHODS

Results of screening 50,653 women of lower SES were compared with those of screening 45,923 more socioeconomically advantaged women during the same period in New York State. Results were compared with those reported for the general population to the New York State cancer registry.

RESULTS

Additional workup was required for approximately 12% of the women in each group. Although more women of lower SES underwent biopsy, the positive predictive value of a biopsy recommendation was almost the same for the two populations (27% for women of higher SES vs. 25% for women of lower SES). Among women with breast carcinoma, ductal carcinoma in situ was diagnosed in 27% of more affluent women and 15% of women of lower SES, a considerable improvement from the 10% rate of diagnosis in the general population in New York State. Minimal cancers accounted for 54% of those diagnosed in more affluent women and at least 31% of those diagnosed in women of lower SES.

CONCLUSIONS

Screening mammography programs can be effective for women of lower SES and can be conducted as efficiently as they are for more affluent women. Differences in diagnosis of small cancers in the two groups reported in this article may reflect differences in age and patterns of prior screening experience in the two populations.

Percutaneous removal of malignant mammographic lesions at stereotactic vacuum-assisted biopsy

PURPOSE

To determine whether complete percutaneous removal of a malignant lesion detected at mammography ensures complete excision of the carcinoma histopathologically.

MATERIALS AND METHODS

A retrospective review was performed of 135 lesions in which stereotactic biopsy was performed with a directional, vacuum biopsy instrument and an 11-gauge probe followed by mammography. Carcinoma was diagnosed at stereotactic biopsy in 51 (38%) lesions. In 15 (29%) carcinomas, the lesion seen at mammography was removed at stereotactic biopsy. Surgical findings were available for correlation with biopsy and imaging findings in all 15 cases. Mammographic and histopathologic findings were reviewed.

RESULTS

Mammographic findings were calcifications in 11 lesions and a mass in four lesions. The median lesion size was 0.7 cm (range, 0.2-1.4 cm), and the median number of biopsy specimens was 15 (range, 10-22 specimens). Histopathologic findings at stereotactic biopsy were ductal carcinoma in situ in 12 lesions and infiltrating ductal carcinoma in three. Surgery revealed residual carcinoma in 11 (73%) of 15 lesions, including all three infiltrating ductal carcinomas and eight of 12 ductal carcinoma in situ lesions.

CONCLUSION

Complete removal of the mammographic lesion does not ensure complete excision of the carcinoma.