Mammotome core biopsy for mammary microcalcification: analysis of 160 biopsies from 142 women with surgical and radiologic followup

The positive predictive value of vacuum assisted biopsy (VAB) in predicting final histological diagnosis for breast lesions of uncertain malignancy (B3 lesions): A systematic review & meta-analysis

INTRODUCTION

High-risk or B3 breast lesions are considered lesions of uncertain malignant potential and comprise between 5 and 12% of initial biopsy results. We sought to perform a systematic review and meta-analysis of studies published within the last twenty years to determine the pooled Positive Predictive Value (PPV) of VAB in selected B3 lesions.

METHODS

The study report is based on the guidelines of PRISMA and Meta-Analysis of Observational Studies in Epidemiology.

OUTCOMES

The primary outcome of this study was to determine the PPV of VAB in determining final histological diagnosis in B3 breast lesions using pooled estimates. The secondary outcomes were to determine if needle gauge or the re-classification of Lobular Carcinoma in Situ(LCIS) introduced in 2012 influenced pooled estimates.

RESULTS

78 studies incorporating 6,377 B3 lesions were included in this review, 1214 of which were upgraded to DCIS or invasive malignancy following surgical excision(19%). The pooled PPV of VAB in Atypical Ductal Hyperplasia(ADH) and Lobular Neoplasia(LN) were 0.79(CI 0.76-0.83) and 0.84(CI 0.8-0.88). VAB of Flat Epithelial Atypia(FEA), radial scar and papillary lesions with/without atypia all had a pooled PPV >90% (underestimation rates 7%, 1%, 5% and 3% respectively). Needle gauge size and the change in LCIS classification did not appear to influence underestimation rates on subgroup analysis.

CONCLUSION

Results from this meta-analysis suggests it is reasonable to perform VAB as definitive treatment for certain B3 lesions, specifically LN, FEA, radial scar, and papillary lesions when specific criteria are fulfilled. Surgical excision should continue as the mainstay of treatment for ADH.

Ten years follow-up of histologically benign calcifications in the breast after vacuum-assisted stereotactic biopsy (VASB): Is additional mammographic follow-up warranted?

Objective

This study assessed the short-term and the long-term breast cancer rate in patients with benign histopathologic results after a vacuum-assisted stereotactic biopsy (VASB) for calcifications.

Methods

In a retrospective cohort study, all consecutive patients who had a benign diagnosis after VASB to analyze breast calcifications. Data of breast cancer development at short-term (four years) and long-term follow-up was gathered. Breast cancer rates in our cohort were compared to the breast cancer incidence in the general population.

Results

Of 1376 patients who underwent VASB to analyze breast calcifications, 823 had a benign histopathologic diagnosis. During short-term follow-up, eight patients developed breast cancer. During the mean long-term follow-up period of 9.3 ± 3.1 years, 22 patients were diagnosed with ipsilateral breast cancer. The incidence rate of breast cancer after benign biopsy was comparable to the rate in the general population.

Conclusion

In patients with VASB-confirmed benign calcifications of the breast, we found no excess incidence of ipsilateral breast cancer during ten years follow-up. Therefore, in patients with an increased risk of breast cancer (due to a history of breast cancer or familial risk) annual mammography should be sufficient. Patients with a population-based risk may be monitored via biennial mammography by the national screening program. More frequent screening would provide no benefit.

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1% developed ipsilateral breast cancer in four-year follow-up after biopsy.

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3% developed ipsilateral breast cancer in ten-years follow-up after biopsy.

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No statistically significant excess incidence of breast cancer after benign calcifications.

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A benign histopathologic result after VASB can be considered a safe decision tool.

Upgrade Rate of Percutaneously Diagnosed Pure Atypical Ductal Hyperplasia: Systematic Review and Meta-Analysis of 6458 Lesions

Background Management of percutaneously diagnosed pure atypical ductal hyperplasia (ADH) is an unresolved clinical issue. Purpose To calculate the pooled upgrade rate of percutaneously diagnosed pure ADH. Materials and Methods A search of MEDLINE and EMBASE databases was performed in October 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, guidelines were followed. A fixed- or random-effects model was used, along with subgroup and meta-regression analyses. The Newcastle-Ottawa scale was used for study quality, and the Egger test was used for publication bias. Results Of 521 articles, 93 were analyzed, providing data for 6458 ADHs (5911 were managed with surgical excision and 547 with follow-up). Twenty-four studies used core-needle biopsy; 44, vacuum-assisted biopsy; 21, both core-needle and vacuum-assisted biopsy; and four, unspecified techniques. Biopsy was performed with stereotactic guidance in 29 studies; with US guidance in nine, with MRI guidance in nine, and with mixed guidance in eight. Overall heterogeneity was high (I² = 80%). Subgroup analysis according to management yielded a pooled upgrade rate of 29% (95% confidence interval [CI]: 26%, 32%) for surgically excised lesions and 5% (95% CI: 4%, 8%) for lesions managed with follow-up (P < .001). Heterogeneity was entirely associated with surgically excised lesions (I² = 78%) rather than those managed with follow-up (I² = 0%). Most variability was explained by guidance and needle caliper (P = .15). At subgroup analysis of surgically excised lesions, the pooled upgrade rate was 42% (95% CI: 31%, 53%) for US guidance, 23% (95% CI: 19%, 27%) for stereotactic biopsy, and 32% (95% CI: 22%, 43%) for MRI guidance, with heterogeneity (52%, 63%, and 56%, respectively) still showing the effect of needle caliper. When the authors considered patients with apparent complete lesion removal after biopsy (subgroups in 14 studies), the pooled upgrade rate was 14% (95% CI: 8%, 23%). Study quality was low to medium; the risk of publication bias was low (P = .10). Conclusion Because of a pooled upgrade rate higher than 2% (independent of biopsy technique, needle size, imaging guidance, and apparent complete lesion removal), atypical ductal hyperplasia diagnosed with percutaneous needle biopsy should be managed with surgical excision. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Brem in this issue.

Stereotactic 9-gauge vacuum-assisted breast biopsy, how many specimens are needed?

PURPOSE

To determine the minimum number of stereotactic 9-gauge vacuum-assisted biopsy specimens required to establish a final histopathological biopsy diagnosis of mammographically suspicious breast lesions.

METHODS

This prospective single-center observational cohort study included 120 women referred for stereotactic vacuum-assisted biopsy of 129 mammographically suspicious lesions between December 2017 and October 2018. Stereotactic 9-gauge vacuum-assisted biopsy was performed, acquiring twelve specimens per lesion. Calcification retrieval was assessed with individual specimen radiography. Each specimen was histologically analyzed in chronological order and findings were compared with the final histopathological result after assessment of all twelve specimens and with results of surgical excision. Cumulative diagnostic yield per specimen was calculated.

RESULTS

In total, 131 biopsy procedures were performed in 120 women (mean age 59 years). In 95% (95%CI 90%-98%) of the procedures a final histopathological diagnosis was reached after six specimens. After nine specimens the final biopsy diagnosis was established in all 131 cases. In the subgroup of 41 patients with a DCIS or invasive diagnosis at biopsy there were eight procedures (20%) where calcifications were retrieved before the diagnostic specimen was obtained. Underestimation of subsequent resection diagnosis occurred in six out of 30 excised lesions classified as DCIS (20%) and in one out of four excised high-risk lesions.

CONCLUSIONS

With six stereotactic 9-gauge vacuum-assisted biopsy specimens a final histopathological biopsy diagnosis could be established in 95% (95%CI 90%-98%) of the biopsy procedures. Taking nine 9-gauge specimens seems to be optimal. Ending the stereotactic vacuum-assisted breast biopsy procedure as soon as calcifications are retrieved may cause false negative results.

Vacuum-Assisted Core Biopsy (Mammotome) for the Diagnosis of Non-Palpable Breast Lesions: Four-Year Experience in an Italian Center

Aims and background

Microinvasive biopsy techniques are increasingly employed in the diagnostic assessment of non-palpable breast lesions (NPBLs). This study reports the four-year experience of an Italian surgical center in the evaluation of the diagnostic effectiveness versus adverse effects of vacuum-assisted core biopsy (Mammotome).

Methods

314 NPBLs with a dubious ultrasound and/or radiographic appearance were subjected to mammography-guided (86) or ultrasound-guided (228) Mammotome biopsy.

Results

The procedure could be completed and was diagnostic in 305 cases (P <0.0001). Adverse events were transient lightheadedness. in two cases and moderate bleeding in three cases. Histological processing of the biopsies showed 227 cases of benign disease (74.42%), 68 cases of carcinoma (20 carcinomas in situ and 48 infiltrating carcinomas) (22.29%), nine cases of atypical ductal hyperplasia (2.95%) and one atypical lobular hyperplasia (0.33%). Only 12 patients reported mild discomfort relative to the procedure. The difference between the number of patients reporting discomfort and that of patients reporting no discomfort at all was highly significant (P <0.0001).

Conclusions

The results confirm that Mammotome biopsy is a highly effective procedure for the diagnosis of NPBLs, with minimal negative effects.

When Does Atypical Ductal Hyperplasia Require Surgical Excision?

Atypical ductal hyperplasia (ADH) is a proliferative, nonobligate precursor breast lesion and a marker of increased risk for breast carcinoma. Surgical excision remains the standard recommendation following a core needle biopsy result consistent with ADH. Recent research suggests that women with no mass lesion or discordance, removal of greater than or equal to 90% of calcifications at the time of core needle biopsy, involvement of less than or equal to 2 terminal duct lobular units, and absence of cytologic atypia or necrosis are likely to have a less than 5% chance of a missed cancer.

Vacuum assisted breast biopsy (VAB) excision of subcentimeter microcalcifications as an alternative to open biopsy for atypical ductal hyperplasia

OBJECTIVE

Atypical ductal hyperplasia (ADH) is a proliferative lesion associated with a variable increased risk of breast malignancy, but the management of the patients is still not completely defined, with mandatory surgical excision in most cases. To report the results of the conservative management with mammographic checks of patients with ADH diagnosed by vacuum assisted breast biopsy (VAB), without residual calcifications.

METHODS

The authors accessed the institutional database of radiological, surgical and pathological anatomy. Inclusion criteria were: ADH diagnosed by VAB on a single group of microcalcifications, without residual post-procedure; follow-up at least of 12 months. Exclusion criteria were the presence of personal history of breast cancer or other high-risk lesions; association with other synchronous lesions, both more and less advanced proliferative lesions.

RESULTS

The 65 included patients were all females, with age range of 40-79 years (mean 54 years). The maximum diameter range of the groups of microcalcifications was 4-11 mm (mean 6.2 mm), all classified as BI-RADS 4b (Breast Imaging Reporting and Data System 4b) and defined as fine pleomorphic in 29 cases (45%) or amorphous in 36 cases (55%). The range of follow-up length was 12-156 months (mean 67 months). Only one patients developed new microcalcifications, in the same breast, 48 months after and 15 mm from the first VAB, interpreted as low-grade ductal carcinoma in situ (DCIS) at surgical excision.

CONCLUSION

These results could justify the conservative management, in a selected group of patients, being the malignancy rate lower than 2%, considered in the literature as the "probably benign" definition. Advances in knowledge: Increasing the length of follow-up of selected patients conservatively managed can improve the management of ADH cases.

Vacuum-assisted stereotactic breast biopsy in the diagnosis and management of suspicious microcalcifications

PURPOSE

We aimed to present our biopsy method and retrospectively evaluate the results, upgrade rate, and follow-up findings of stereotactic vacuum-assisted breast biopsy (VABB) procedures performed in our clinic.

METHODS

Two hundred thirty-four patients with mammographically detected nonpalpable breast lesions underwent VABB using a 9 gauge biopsy probe and prone biopsy table. A total of 195 patients (median age 53 years, range 32-80 years) with 198 microcalcification-only lesions with a follow-up of at least one year were included in the study. The location of the lesion relative to the needle was determined from the postfire images, and unlike the conventional technique, tissue retrieval was predominantly performed from that location, followed by a complete 360° rotation, if needed.

RESULTS

The median core number was 8.5. Biopsy results revealed 135 benign, 24 atypical, and 39 malignant lesions. The total upgrade rate at surgery was 7.7% (6.1% for ductal carcinomas in situ and 10.5% for atypical lesions). Patients with benign lesions were followed up for a median period of 27.5 months, with no interval change. At the follow-up, scar formation was seen in 23 patients (17%); three of the scars were remarkable for resembling a malignancy.

CONCLUSION

Our biposy method is fast and practical, and it is easily tolerated by patients without compromising accuracy. Patients with a diagnosis of atypia still need to undergo a diagnostic surgical procedure and those with a malignancy need to undergo curative surgery, even if the lesion is totally excised at biopsy. VABB may leave a scar in the breast tissue, which may resemble a malignancy, albeit rarely.

Vacuum-assisted stereotactic biopsy for isolated BI-RADS 4 microcalcifications: evaluation with histopathology and midterm follow-up results

PURPOSE

The aim of this study was to evaluate the 10-gauge vacuum-assisted stereotactic biopsy (VASB) of isolated Breast Imaging Reporting and Data System (BI-RADS) 4 microcalcifications, using histology and follow-up results.

METHODS

From January 2011 to June 2013, VASB was performed on 132 lesions, and 66 microcalcification-only lesions of BI-RADS 4 were included into our study. VASB was performed using lateral decubitis stereotaxy for all patients. Pathologic results of VASB and further surgical biopsies were reviewed retrospectively. Patients who were diagnosed to have benign lesions by VASB were referred for follow-up. VASB and surgical histopathology results were compared to determine the underestimation ratios.

RESULTS

Fifteen out of 66 lesions from 63 patients (median age, 47 years; range, 34-88 years) were identified as malignant by VASB. Pathological results after surgery revealed three cases of invasive ductal carcinoma among the 12 VASB-diagnosed ductal carcinoma in situ (DCIS) lesions, for a DCIS underestimation rate of 25%. The atypical ductal hyperplasia underestimation rate was 0% for the three lesions. The follow-up period was at least 10 months, with an average of 22.7 months for all patients and 21.2 months for patients with VASB-diagnosed benign lesions. None of the patients had malignancy during the follow-ups. The false-negative rate was 0% in the follow-up of 48 patients.

CONCLUSION

VASB should be the standard method of choice for BI-RADS 4 microcalcifications. This method obviates the need for a surgical procedure in 73% of BI-RADS 4 microcalcification-only patients.

Non-stereotactic method involving combination of ultrasound-guided wire localization and vacuum-assisted breast biopsy for microcalcification

BACKGROUND

Stereotactic breast biopsy is a standard intervention for evaluation of "microcalcification-only" lesions. However, an expensive stereotactic device and radiologic expertise are necessary for this procedure. We herein report a non-stereotactic technique involving the combination of wire localization and vacuum-assisted breast biopsy (VABB) under ultrasound (US) guidance.

METHODS

Twenty-two consecutive patients with category 3 or 4a microcalcification only as shown by mammography underwent the above-mentioned non-stereotactic combination method involving US-guided wire localization and VABB. The location of the microcalcification was measured by manual stereotaxis, and the microcalcification was confirmed by specimen mammography after the procedure.

RESULTS

The mean number ± standard deviation of removed cores and calcified cores was 28.4±13.4 and 2.2±0.9, respectively. In one case, the procedure was repeated 3 times. The histologic diagnoses were fibrocystic change (n=14), fibroadenoma (n=4), sclerosing adenosis (n=1), usual ductal hyperplasia (n=2), and atypical ductal hyperplasia (n=1).

CONCLUSIONS

"Microcalcification-only" breast lesions can be easily evaluated with the combination of non-stereotactic US-guided wire localization and VABB. This would be an effective diagnostic technique for breast lesion which reveals only microcalcification.

Distinct breast cancer characteristics between screen- and self-detected breast cancers recorded in the Japanese Breast Cancer Registry

The rate of breast cancer screening for women of all ages in Japan is increasing. However, little is known about the biological differences between screen- and self-detected tumors. We used data from the Japanese Breast Cancer Registry (JBCR), a nationwide registry of newly diagnosed breast cancer cases in Japan, to investigate patients diagnosed between January 1, 2004 and December 31, 2011. We compared the clinicopathological features of tumors and assessed yearly trends regarding the proportion of screen-detected cases during the study period. We found that 31.8 % (65,358/205,544) of cancers were detected by screening. Asymptomatic tumors detected by screening (asymptomatic) were more likely to have favorable prognostic features than those that were self-detected (ductal carcinoma in situ [DCIS]: 19.8 versus 4.1 %, node-negative: 77.0 versus 61.6 %, and estrogen receptor-positive [ER+]: 82.0 versus 72.9 %, respectively). All these findings were statistically significant (p < .001). The proportion of breast cancers detected by screening among all cases increased from 21.7 % in 2004 to 37.1 % in 2011. During the same time period, the proportion of screen-detected DCIS increased from 41.5 to 66.0 % and that of ER+ cancers increased from 23.2 to 39.7 %. This study demonstrated that low-risk tumors, including DCIS, ER+, and lower TNM stage, account for a substantial proportion of clinical screening-detected cancers. The differences in biological characteristics between screen- and self-detected cancers may account in part for the limited efficacy of breast cancer screening programs aimed at improving breast cancer mortality.

Randomized controlled trial of stereotactic 11-G vacuum-assisted core biopsy for the diagnosis and management of mammographic microcalcification

OBJECTIVE

To compare the accuracy of 11-G vacuum-assisted biopsy (VAB) with 14-G core needle biopsy (CNB) to diagnose mammographic microcalcification (MM) and effect on surgical outcomes.

METHODS

Following ethical approval, VAB and CNB (control) were compared in a randomized prospective study for first-line diagnosis of MM and subsequent surgical outcomes in two breast-screening units. Participants gave written informed consent. Exclusions included comorbidity precluding surgery, prior ipsilateral breast cancer and lesions >40 mm requiring mastectomy as first surgical procedure. The final pathological diagnosis was compared with the initial biopsy result. Quality-of-life (QOL) questionnaires were administered at baseline, 2, 6 and 12 months. 110 participants were required to show a 25% improvement in diagnosis with VAB compared with CNB (90% power).

RESULTS

Eligibility was assessed for 787 cases; 129 females recalled from the National Health Service breast screening programme were randomized. Diagnostic accuracy of VAB was 86% and that of CNB was 84%. Using VAB, 2/14 (14.3%) cases upgraded from ductal carcinoma in situ to invasion at surgery and 3/19 (15.8%) using CNB. Following VAB 7/16 (44%) cases required repeat surgery vs 7/24 (29%) after CNB. Both groups recorded significant worsening of functional QOL measures and increased breast pain at follow-up.

CONCLUSION

VAB and CNB were equally accurate at diagnosing MM, and no significant differences in surgical outcomes were observed.

ADVANCES IN KNOWLEDGE

The first randomized controlled study of VAB for diagnosis of microcalcification using digital mammography showed no difference in diagnostic accuracy of VAB and CNB, or in the proportion of participants needing repeat non-operative biopsy or second therapeutic operation to treat malignancy.

Mammotome(®) and EnCor (®): comparison of two systems for stereotactic vacuum-assisted core biopsy in the characterisation of suspicious mammographic microcalcifications alone

PURPOSE

The authors sought to compare the diagnostic performance of the Mammotome(®) and EnCor(®) vacuum-assisted breast biopsy (VABB) systems in the assessment of suspicious mammographic microcalcifications.

MATERIALS AND METHODS

Between January 2011 and July 2012, a total of 169 VABB were performed by stereotactic guidance on a prone table. The Mammotome(®) 11G (S1) or EnCor(®) 10G (S2) probes were used randomly. Sampling time and the number of frustules collected were considered; sensitivity, specificity, diagnostic accuracy, positive and negative predictive value (PPV, NPV) of both procedures were evaluated, considering the final histological examination as reference (B1, B3, B5 lesions underwent surgical excision; B2 lesion were considered confirmed after a negative follow-up of at least 1 year).

RESULTS

There were no statistically significant differences between the two groups of patients according to the number of procedures (S1 82/169; S2 87/169), average age, BIRADS category (4a, b), and average size of the lesions. The two systems did not differ statistically for correlation with the final histology (S1 k = 0.94 ± 0.06; S2 k = 0.92 ± 0.08) and underestimation of B3 lesions or in situ (S1 4.5%; S2 4.3%). Sensitivity, specificity, PPV, NPV, diagnostic accuracy of S1 and S2 were also not statistically different. The systems differed only in sampling time (S1 80; S2 63 s), but not in total procedure time.

CONCLUSIONS

Our study confirms the effectiveness of VABB in the assessment of microcalcifications and highlights the lack of significant differences between the two systems in terms of diagnostic performance.

Atypical ductal hyperplasia diagnosed at 11-gauge vacuum-assisted breast biopsy performed on suspicious clustered microcalcifications: could patients without residual microcalcifications be managed conservatively?

OBJECTIVE

The purpose of our study was to establish whether it might be safe for women with a diagnosis of atypical ductal hyperplasia (ADH) at stereotactically guided vacuum-assisted breast biopsy without any residual microcalcification after the procedure to undergo mammographic follow-up instead of surgical biopsy.

MATERIALS AND METHODS

From October 2003 to January 2009, 1173 consecutive 11-gauge vacuum-assisted breast biopsy procedures were performed. ADH was found in the specimens of 114 patients who underwent vacuum-assisted breast biopsy for a single cluster of suspicious microcalcifications smaller than 15 mm; 49 had residual microcalcifications, and 65 had microcalcifications completely removed by the procedure. Of 49 patients with residual microcalcifications, 41 underwent surgical biopsy. Of 65 patients without residual microcalcifications, 26 underwent surgical biopsy, 35 were not surgically treated and were managed conservatively with mammographic follow-up, and 4 had follow-up of less than 24 months.

RESULTS

In 41 patients with residual microcalcifications who underwent surgical biopsy, 8 malignant lesions were found at surgery. The underestimation rate was 20% (8/41). In 26 patients without residual microcalcifications who underwent surgical biopsy, no malignant lesions were found. One malignant lesion was found in the 35 patients managed conservatively at follow-up. The underestimation rate in patients without residual microcalcifications using surgical biopsy or mammographic follow-up as the reference standard was 1.6% (1/61).

CONCLUSION

Patients without residual microcalcifications after vacuum-assisted breast biopsy could possibly be managed in a conservative way with mammographic follow-up.

Ductal carcinoma in situ at core-needle biopsy: meta-analysis of underestimation and predictors of invasive breast cancer

PURPOSE

To perform a meta-analysis to report pooled estimates for underestimation of invasive breast cancer (where core-needle biopsy [CNB] shows ductal carcinoma in situ [DCIS] and excision histologic examination shows invasive breast cancer) and to identify preoperative variables that predict invasive breast cancer.

MATERIALS AND METHODS

Studies were identified by searching MEDLINE and were included if they provided data on DCIS underestimates (overall and according to preoperative variables). Study-specific and pooled percentages for DCIS underestimates were calculated. By using meta-regression (random effects logistic modeling) the association between each study-level preoperative variable and understaged invasive breast cancer was investigated.

RESULTS

Fifty-two studies that included 7350 cases of DCIS with findings at excision histologic examination as the reference standard met the eligibility criteria and were included. There were 1736 underestimates (invasive breast cancer at excision); the random-effects pooled estimate was 25.9% (95% confidence interval: 22.5%, 29.5%). Preoperative variables that showed significant univariate association with higher underestimation included the use of a 14-gauge automated device (vs 11-gauge vacuum-assisted biopsy, P = .006), high-grade lesion at CNB (vs non-high grade lesion, P < .001), lesion size larger than 20 mm at imaging (vs lesions ≤ 20 mm, P < .001), Breast Imaging Reporting and Data System (BI-RADS) score of 4 or 5 (vs BI-RADS score of 3, P for trend = .005), mammographic mass (vs calcification only, P < .001), and palpability (P < .001).

CONCLUSION

About one in four DCIS diagnoses at CNB represent understaged invasive breast cancer. Preoperative variables significantly associated with understaging include biopsy device and guidance method, size, grade, mammographic features, and palpability.

Stereotactic vacuum-assisted breast biopsy is not a therapeutic procedure even when all mammographically found calcifications are removed: analysis of 4,086 procedures

OBJECTIVE

The purpose of our study was to assess whether in case of total removal of microcalcifications there is still residual tumor on the surgical specimen and, secondarily, to assess whether complete rather than partial excision of the imaging target with microcalcifications may result in increased diagnostic accuracy.

MATERIALS AND METHODS

We retrospectively reviewed 4,086 stereotactic vacuum-assisted breast biopsy (VABB) procedures for microcalcifications and histologic findings to determine the frequency of malignancy, histologic underestimation, and complete removal of cancer.

RESULTS

No residual microcalcifications on postbiopsy mammograms were seen in 1,594 of 4,047 (39.4%) procedures successfully completed: 351 of 1,594 lesions were malignant, 1,109 benign and 134 atypical. After partial removal of microcalcifications at VABB, the postsurgical specimen had infiltrating carcinoma in 130 of 566 cases (23%), whereas in case of total removal of microcalcifications, the underestimation occurred in 13 of 234 (5.5%) cases. The atypical ductal hyperplasia underestimation rate was 6.6% when the mammography target was completely removed and 38.7% when the target was only sampled. The percentage of lobular carcinoma in situ underestimation was the same for the two groups with partial and total removal of microcalcifications (21.2%). Among 1,016 VABB procedures with pathologic result of malignancy, 882 (86.6%) had residual cancer at surgery. In the group with complete removal of microcalcifications at VABB, residual cancer was found in 70% of cases.

CONCLUSION

VABB may not be considered a therapeutic procedure, even in the case of complete removal of microcalcifications. However, a complete removal of microcalcifications may result in low rates of underestimation of malignancy and may consequently increase the diagnostic accuracy of the diagnostic procedure.

Early Breast Cancer Precursor Lesions: Lessons Learned from Molecular and Clinical Studies

Atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), and lobular neoplasia (LN) form a group of early precursor lesions that are part of the low-grade pathway in breast cancer development. This concept implies that the neoplastic disease process begins at a stage much earlier than in situ carcinoma. We have performed a review of the published literature for the upgrade risk to ductal carcinoma in situ or invasive carcinoma in open biopsy after a diagnosis of ADH, FEA, or LN in core needle biopsy. This has revealed the highest upgrade risk for ADH (28.2% after open biopsy), followed by LN (14.9%), and FEA (10.2%). With LN, the pleomorphic subtype is believed to confer a higher risk than classical LN. With all types of precursor lesions, careful attention must be paid to the clinicopathological correlation for the guidance of the clinical management. Follow-up biopsies are generally indicated in ADH, and if there is any radiological-pathological discrepancy, also in LN or FEA.

Factors associated with upgrading to malignancy at surgery of atypical ductal hyperplasia diagnosed on core biopsy

Previous studies have shown that 4-54% of breast lesions reported on core biopsies as atypical ductal hyperplasia (ADH) are upgraded on further excision to ductal carcinoma in situ (DCIS) or invasive carcinoma. We evaluated the rate of upgrading ADH to carcinoma at surgery for ADH diagnosed by percutaneous biopsy, and examined characteristics associated with malignancy. We identified 13,488 consecutive biopsies conducted at one center over a nine-year period. A total of 422 biopsies with ADH in 415 patients were included. DCIS or invasive carcinoma was found in 132 cases (31.3% upgrading). Multivariate model revealed that ipsilateral breast symptoms, mammographic lesion other than microcalcifications alone, 14G core needle biopsy, papilloma co-diagnosis, severe ADH and pathologists with lower volume of ADH diagnosis were factors statistically associated with malignancy. However, no subgroups were identified for safe clinical-only follow-up. Surgery is recommended in all cases of ADH diagnosed by percutaneous breast biopsy.

Lobular neoplasia: morphology, biological potential and management in core biopsies

Lobular neoplasia has been traditionally recognized as a marker of increased risk for subsequent breast carcinoma development; however, molecular studies suggest that it also behaves in a non-obligate precursor manner. We do not know, as yet, how to identify the subgroup of cases that is most likely to progress, but the epidemiological data would indicate that this progression occurs after a long period of time. Thus, the current approach of conservative management of these lesions when identified in excision specimens is justified. Recently, several variants of lobular carcinoma in situ (LCIS), most notably pleomorphic LCIS, have been recognized and these can be difficult to differentiate from ductal carcinoma in situ. Application of strict diagnostic criteria and the judicial use of immunohistochemistry, particularly E-cadherin, can be helpful in this differential diagnosis. Another challenging issue is the management of lobular neoplasia when diagnosed on core biopsy. This controversial issue will be discussed in detail. The goals of this review are (1) to describe the morphological criteria used to diagnose the spectrum of lobular neoplastic lesions, including atypical lobular hyperplasia, LCIS and variants of LCIS; (2) to discuss the data exploring the biological potential of lobular neoplasia from an epidemiological and molecular viewpoint; and (3) to outline the recommendations for management of lobular neoplasia when encountered in core biopsies.

The Treatment of Radial Scars in the Modern Era—Surgical Excision is not Required

The clinical significance of isolated radial scars (RS) diagnosed on core needle biopsy (CNB) remains unclear. By determining the pathologic concordance rate, we sought to define the indications for surgical excision for RS diagnosed on CNB. Between January 1994 and December 2007, 38 RS were diagnosed by CNB. Twenty-eight underwent surgical excision with 27 (96%) patients having further benign diagnoses. One patient, who was found to have invasive cancer on CNB, was also found to have malignancy on open biopsy. Fourteen lesions were diagnosed by 8-gauge, 13 lesions by 11-gauge, and one lesion by 14-gauge biopsy needles. Seven studies met inclusion criteria for analysis; 341 lesions with follow-on surgical biopsy were identified. Sixteen (5%) radial scars were found to harbor malignancy and all were percutaneously biopsied with 14-gauge needles. With the inclusion of the current study, none of the isolated radial scars diagnosed by the larger 11- or 8-gauge biopsy needles resulted in upgraded lesions on follow-on surgical biopsy. Based on the current review, histologic radial scars are infrequently associated with occult malignancy and do not mandate surgical excision. Indications for excision include the mammographic diagnosis of RS and specimens associated with atypia that would otherwise require open biopsy.

Risk of upgrade of atypical ductal hyperplasia after stereotactic breast biopsy: effects of number of foci and complete removal of calcifications

PURPOSE

To determine if patients with fewer than three foci of atypical ductal hyperplasia (ADH) who have all of their calcifications removed after stereotactic 9- or 11-gauge vacuum-assisted breast biopsy (VABB) have a rate of upgrade to malignancy that is sufficiently low to obviate surgical excision.

MATERIALS AND METHODS

An institutional review board-approved, HIPAA-compliant retrospective review of 991 cases of consecutive 9- or 11-gauge stereotactic VABB performed during a 65-month period revealed 147 cases of atypia. One pathologist performed a blinded review of the results of procedures performed to assess for calcifications and confirmed ADH in 101 cases with subsequent surgical excision. Each large duct or terminal duct-lobular unit containing ADH was considered a focus and counted. Postbiopsy mammograms were reviewed to determine whether all calcifications were removed. Upgrade to malignancy was determined from excisional biopsy pathology reports. Upgrade rates as a function of both number of foci and presence or absence of residual calcifications were calculated and compared by using chi(2) tests.

RESULTS

Upgrade to malignancy occurred in 20 (19.8%) of the 101 cases. The upgrade rate was significantly higher in cases of three or more foci of ADH (15 [28%] of 53 cases) than in cases of fewer than three foci (five [10%] of 48 cases) (P = .02). Upgrade rates were similar, regardless of whether all mammographic calcifications were removed (seven [17%] of 41 cases) or all were not removed (nine [20%] of 45 cases) (P = .77). Upgrade occurred in two (12%) of 17 cases in which there were fewer than three ADH foci and all calcifications were removed.

CONCLUSION

The upgrade rate is significantly higher when ADH involves at least three foci. Surgical excision is recommended even when ADH involves fewer than three foci and all mammographic calcifications have been removed, because the upgrade rate is 12%.

US-guided vacuum-assisted biopsy of microcalcifications in breast lesions and long-term follow-up results

OBJECTIVE

To evaluate the diagnostic accuracy of the use of an ultrasonography (US)-guided vacuum-assisted biopsy for microcalcifications of breast lesions and to evaluate the efficacy of the use of US-guided vacuum-assisted biopsy with long-term follow-up results.

MATERIALS AND METHODS

US-guided vacuum-assisted biopsy cases of breast lesions that were performed between 2002 and 2006 for microcalcifications were retrospectively reviewed. A total of 62 breast lesions were identified where further pathological confirmation was obtained or where at least two years of mammography follow-up was obtained. These lesions were divided into the benign and malignant lesions (benign and malignant group) and were divided into underestimated group and not-underestimated lesions (underestimated and not-underestimated group) according to the diagnosis after a vacuum-assisted biopsy. The total number of specimens that contained microcalcifications was analyzed and the total number of microcalcification flecks as depicted on specimen mammography was analyzed to determine if there was any statistical difference between the groups.

RESULTS

There were no false negative cases after more than two years of follow-up. Twenty-nine lesions were diagnosed as malignant (two invasive carcinomas and 27 carcinoma in situ lesions). Two of the 27 carcinoma in situ lesions were upgraded to invasive cancers after surgery. Among three patients diagnosed with atypical ductal hyperplasia, the diagnosis was upgraded to a ductal carcinoma in situ after surgery in one patient. There was no statistically significant difference in the number of specimens with microcalcifications and the total number of microcalcification flecks between the benign group and malignant group of patients and between the underestimated group and not-underestimated group of patients.

CONCLUSION

US-guided vacuum-assisted biopsy can be an effective alternative to stereotactic-guided vacuum-assisted biopsy in cases where microcalcifications are visible with the use of high-resolution US.

The significance of lobular neoplasia on needle core biopsy of the breast

The management of a core biopsy diagnosis of lobular neoplasia is controversial. Detailed radiological–pathological review of 47 patients with cores showing classical lobular neoplasia was performed (patients with pleomorphic lobular carcinoma in situ (LCIS) or associated risk lesions were considered separately). Immediate surgical excision in 25 patients showed invasive carcinoma in 7, ductal carcinoma in situ (DCIS) in 1 and pleomorphic LCIS in 1; radiological–pathological review showed that the core biopsy missed a mass in 5, missed calcification in 2 and that calcification appeared adequately sampled in 2. Nineteen patients had follow-up of at least 2 years. Four patients developed malignancy at the site of the core biopsy (invasive carcinoma in three, DCIS in one); one carcinoma was mammographically occult, one patient had dense original mammograms and two had calcifications apparently adequately sampled by the core. In conclusion, most carcinomas identified at the site of core biopsy showing lobular neoplasia were the result of the core missing the radiological lesion, emphasising the importance of multidisciplinary review and investigation of any discordance. Some carcinomas were found after apparently adequate core biopsy, raising the question of whether excision biopsy should be considered after all core biopsy diagnoses of lobular neoplasia.

Intermediate to highly suspicious calcification in breast lesions: a radio-pathologic correlation

Breast calcification is an important feature in the radiological assessment of breast lesions. There are well established diagnostic criteria basing on the morphology and distribution of the calcifications radiologically with recommendation protocols. Pathologically, calcifications in breast lesions are of dystrophic type, and may occur in either the secretory materials or necrotic debris, with inflammation and osteopontin being plausible mediators. Detection of calcium phosphate (hydroyapaptite) is considerably easier than calcium oxalate. Radiologically amorphous calcification represents a borderline type of calcification, and occurs in both benign and malignant (low grade) lesions, and warrants careful follow up and investigation. Clustering of calcification alone may not be an accurate predictor for malignancy, but when there are associated features like pleomorphism, branching, architectural distortion, and associated mass or density, the predictive value for malignant increases. Adequate sampling of calcification in the biopsy is crucial in the management of patients; in general, needle core biopsy or mammotome biopsy achieve satisfactory calcification retrieval. In a benign biopsy that fails to identify the calcifications visible in the mammography, further evaluation or cutting of the histologic block is recommended to minimize the potential of a false negative investigation.

Vacuum-assisted breast biopsy: The value and limitations of cores with microcalcifications

The aim of this study was to assess cores with microcalcifications (CM) and without microcalcifications (CWM) obtained from vacuum-assisted breast biopsy (VABB). The study included 12 atypical ductal hyperplasias (ADH), 37 ductal carcinomas in situ (DCIS), and seven invasive ductal carcinomas (IDC) diagnosed by VABB (11G) on the Fischer's table. More than 24 cores were excised. For CM/CWM, a separate pathology report was given. Open surgery followed, and underestimation was calculated. The CM/CWM discrepancy was evaluated (superiority, identity, and inferiority). CWM failed to make the diagnosis in 8.3% and 35.1% of ADH and DCIS, respectively. In 28.6% of IDC, diagnosis was made through CWM. CM volume was 1.2+/-0.3 cm(3) for the two IDCs missed by CM, 1.0+/-0.4 cm(3) for the 40 cases of identical diagnoses, and 1.4+/-0.5 cm(3) for the 14 cases of CM superiority (p=0.048, Kruskal-Wallis test). CWM volume was 6.3+/-1.8 cm(3) for the two IDCs missed by CM, 2.6+/-1.8 cm(3) for cases with identical diagnoses, and 3.4+/-1.6 cm(3) for cases of CM superiority (p=0.018, Kruskal-Wallis test). The underestimation rate was 8.3% in ADH, and 10.8% in DCIS. CMs are superior in DCIS/ADH diagnosis. However, CWM may be valuable for the diagnosis of the invasive component.

Minimizing underestimation rate of microcalcifications excised via vacuum-assisted breast biopsy: a blind study

PURPOSE

The main disadvantage of Vacuum Assisted Breast Biopsy (VABB) is the probability of underestimating atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS). This study evaluates a modified way of performing VABB.

METHODS

266 women with microcalcifications graded BI-RADS 3&4 underwent VABB (11G) on the Fischer's table. 133 women were allocated to the "standard" protocol and 24 cores were obtained (1 offset-main target and one additional offset). 133 women were randomly allocated to the "extended" protocol and 96 cores were excised (one offset- main target and 7 peripheral offsets). A preoperative diagnosis was established, and the removed volume was calculated. When precursor or malignant lesions were diagnosed, open surgery was performed. A second pathologist, blind to the preoperative results and to the protocol made the postoperative diagnosis. The discrepancy between preoperative and postoperative diagnoses was evaluated.

RESULTS

When the standard protocol was applied, the underestimation rate for preoperative ADH, lobular neoplasia (LN), DCIS was 16.7%, 50% and 14.3% correspondingly. In the extended protocol, no underestimation was present in LN, ADH, but the underestimation rate for DCIS was 6.3%. In the extended protocol, no precursor/malignant tissue was left after VABB in all ADH cases, in 87.5% of LN cases, in 73.3% of DCIS, and in 50% of invasive carcinomas. The volume excised was 2.33 +/- 0.60 cc and 6.14 +/- 1.30 cc for the standard and the extended protocol, respectively. The rate of hematoma formation did not differ between the two protocols.

CONCLUSIONS

This recently introduced, "extended" way of performing VABB in microcalcifications safely minimizes the underestimation rate, which may lead to a modified management of ADH lesions.

Atypical Ductal Hyperplasia: Improved Accuracy with the 11-Gauge Vacuum-Assisted versus the 14-Gauge Core Biopsy Needle

BACKGROUND

Percutaneous stereotactic core needle biopsy (CNB) has become the primary diagnostic modality for evaluating nonpalpable, mammographically detected breast lesions. Atypical ductal hyperplasia (ADH) uncovered by CNB confers a significant risk of harboring an occult malignancy in the excisional biopsy specimen; therefore, we sought to determine the benefits of upsizing biopsy needles from 14- to 11-gauge.

METHODS

Patients with isolated ADH diagnosed by CNB were included for analysis in this retrospective review. Mammographic description, number of needle passes, pathology results, and follow-up data were analyzed and compared to our previously published institutional results with the 14-gauge needle.

RESULTS

From June 1996 until July 2006, 4,579 CNBs were performed at our tertiary level medical facility. Seventy eight of 88 patients (89%) diagnosed with ADH on CNB with an 11-gauge vacuum-assisted needle underwent open surgical excision. Of these patients, nine (11%) were upgraded to ductal carcinoma in-situ (DCIS) while five (6%) had invasive cancer (IC), giving a total underestimation rate of 17%. These results differ from our previously published series of 14-gauge CNB which revealed an underestimation rate of 36%. Mean number of passes obtained at time of biopsy, mean age of patients, and characteristic radiographic abnormalities were similar for malignant and benign diagnoses.

CONCLUSION

11-gauge CNB technique reduces sampling error and improves accuracy, but does not eliminate the risk of missing an underlying malignancy. Surgical excision of ADH identified by CNB is required for definitive diagnosis.

Is zero underestimation feasible? Extended Vacuum-Assisted Breast Biopsy in solid lesions - a blind study

BACKGROUND

Vacuum-Assisted Breast Biopsy (VABB) is effective for the preoperative diagnosis of non-palpable mammographic solid lesions. The main disadvantage is underestimation, which might render the management of atypical ductal hyperplasia (ADH), and ductal carcinoma in situ (DCIS) difficult. This study aims to develop and assess a modified way of performing VABB.

PATIENTS AND METHODS

A total of 107 women with non-palpable mammographic breast solid tumors BI-RADS 3 and 4 underwent VABB with 11G, on the stereotactic Fischer's table. 54 women were allocated to the recommended protocol and 24 cores were obtained according to the consensus meeting in Nordesterdt (1 offset-main target in the middle of the lesion and one offset inside). 53 women were randomly allocated to the extended protocol and 96 cores were excised (one offset-main target in the middle of the lesion and 7 peripheral offsets). A preoperative diagnosis was established. Women with a preoperative diagnosis of precursor/preinvasive/invasive lesion underwent open surgery. A second pathologist, blind to the preoperative results and to the protocol made the postoperative diagnosis. The percentage of the surface excised via VABB was retrospectively calculated on the mammogram. The discrepancy between preoperative and postoperative diagnoses along with the protocol adopted and the volume removed were evaluated by Fisher's exact test and Mann-Whitney-Wilcoxon test, respectively.

RESULTS

Irrespectively of the protocol adopted, 82.2% of the lesions were benign. 14.0% of the lesions were malignancies (5.1% of BI-RADS 3, 5.3% of BI-RADS 4A, 25% of BI-RADS 4B, and 83.3% of BI-RADS 4C lesions). 3.7% of the biopsies were precursor lesions. There was no evidence of underestimation in either protocols. In the standard protocol, the preoperative/postoperative diagnoses were identical. In the extended protocol, the postoperative diagnosis was less severe than the preoperative in 55.5% of cases (55.5% vs. 0%, p = 0.029), and preoperative ADH was totally removed. The phenomenon of discrepancy between diagnoses was associated with larger volume removed (8.20 +/- 1.10 vs. 3.32 +/- 3.50 cm3, p = 0.037) and higher removed percentage of the lesion (97.83 +/- 4.86% vs. 74.34 +/- 23.43%, p = 0.024)

CONCLUSION

The extended protocol seems to totally excise precursor lesions, with minimal underestimation. This might possibly point to a modified management of ADH lesions.

Imprint cytology on microcalcifications excised by vacuum-assisted breast biopsy: a rapid preliminary diagnosis

BACKGROUND

To evaluate imprint cytology in the context of specimens with microcalcifications derived from Vacuum-Assisted Breast Biopsy (VABB).

PATIENTS AND METHODS

A total of 93 women with microcalcifications BI-RADS 3 and 4 underwent VABB and imprint samples were examined. VABB was performed on Fischer's table using 11-gauge Mammotome vacuum probes. A mammogram of the cores after the procedure confirmed the excision of microcalcifications. For the application of imprint cytology, the cores with microcalcifications confirmed by mammogram were gently rolled against glass microscope slides and thus imprint smears were made. For rapid preliminary diagnosis Diff-Quick stain, modified Papanicolaou stain and May Grunwald Giemsa were used. Afterwards, the core was dipped into a CytoRich Red Collection fluid for a few seconds in order to obtain samples with the use of the specimen wash. After the completion of cytological procedures, the core was prepared for routine histological study. The pathologist was blind to the preliminary cytological results. The cytological and pathological diagnoses were comparatively evaluated.

RESULTS

According to the pathological examination, 73 lesions were benign, 15 lesions were carcinomas (12 ductal carcinomas in situ, 3 invasive ductal carcinomas), and 5 lesions were precursor: 3 cases of atypical ductal hyperplasia (ADH) and 2 cases of lobular neoplasia (LN). The observed sensitivity and specificity of the cytological imprints for cancer were 100% (one-sided, 97.5% CI: 78.2%-100%). Only one case of ADH could be detected by imprint cytology. Neither of the two LN cases was detected by the imprints. The imprints were uninformative in 11 out of 93 cases (11.8%). There was no uninformative case among women with malignancy.

CONCLUSION

Imprint cytology provides a rapid, accurate preliminary diagnosis in a few minutes. This method might contribute to the diagnosis of early breast cancer and possibly attenuates patients' anxiety.

Breast interventions: a primer for interventional radiologists

Breast cancer is the second leading cause of cancer related deaths in the United States. The area of breast interventions has benefited from recent advances in devices and imaging quality. Ultrasound, MRI, and stereotactic guided vacuum assisted and mechanical rotating stick freeze biopsy are the preferred methods for histologic diagnosis of breast lesions. Ablation techniques are available for the treatment of benign and malignant breast disease. The MammoSite balloon catheter can be placed percutaneously for delivering high dose short term brachytherapy. Interventional Radiologists can and should perform all of these procedures to improve the quality of women's health.

Atypical ductal hyperplasia of the breast: The controversial management of a borderline lesion: Experience of 47 cases diagnosed at vacuum-assisted biopsy

The present paper describes our experience of 47 cases of atypical ductal hyperplasia (ADH) diagnosed at vacuum-assisted biopsy. From June 1999 to December 2003, 47 consecutive diagnoses of non-palpable ADH of the breast were made by 11-gauge vacuum-assisted biopsy (Mammotome). Of these, 17 were subjected to surgical excision and 11 underwent a second Mammotome at the site of the previous vacuum-assisted biopsy. Diagnostic underestimation occurred in only two cases, with a surgical diagnosis of ductal carcinoma in situ. In both patients, aged between 46 and 55 years, the radiological images showed microcalcifications of >20 mm, and the lesions were not completely removed by Mammotome. Despite the obvious limitations of the present study, it can be concluded that the probability of underestimating ADH diagnosis by Mammotome appears to be related to the radiological features of the lesion (>20 mm) and to the adequacy of specimens.

Breast Microcalcifications: Retrieval Failure at Prone Stereotactic Core and Vacuum Breast Biopsy—Frequency, Causes, and Outcome

PURPOSE

To retrospectively determine the frequency and causes of failure to retrieve microcalcifications in nonpalpable lesions, as judged on a radiograph of the specimen, and to determine outcome in patients with those lesions.

MATERIALS AND METHODS

Informed consent was obtained from each patient prior to biopsy. The institutional review board approved this HIPAA-compliant study and granted a waiver of informed consent. Retrospective review was performed of 1701 consecutive nonpalpable microcalcification lesions in 1511 women aged 29-92 years (median age, 54 years) who underwent percutaneous stereotactic biopsy on a prone biopsy table. Biopsy was successively performed with 14-gauge core, 14-gauge vacuum, and 11-gauge vacuum devices, with mild selection bias, and for each lesion, biopsy was performed with one device. Radiographs of the specimen were obtained to see whether microcalcifications were retrieved. Patient, mammographic, and biopsy variables were correlated with negative radiographs of the specimen. At repeat biopsy or mammographic follow-up, outcome was evaluated in patients with benign histologic results and negative radiographs of the specimen by using Fisher exact test P values.

RESULTS

Radiographs of the specimen were negative in 16% (30 of 182) of lesions at 14-gauge core biopsy, in 4% (four of 96) of lesions at 14-gauge vacuum biopsy, and in 1% (19 of 1423) of lesions at 11-gauge vacuum biopsy (P < .001). Substantial bleeding was a significant factor (P < .001) in failure to retrieve microcalcifications at only 11-gauge vacuum biopsy. Histologic results in 53 lesions with negative radiographs of the specimen were malignant (n = 6), indicated atypical hyperplasia (n = 6), or were benign (n = 41). Follow-up in patients with 40 benign lesions was performed with repeat biopsy (n = 17, with malignancy in three lesions) or mammography (n = 23) for 15-128 months (median, 70 months); one patient with one lesion was lost to follow-up.

CONCLUSION

Failure to retrieve microcalcifications was least common with 11-gauge directional vacuum-assisted biopsy and occurred in 1% (19 of 1423) of lesions. Cancer was missed in 8% (three of 40) of benign lesions in patients who were followed up.

Lésions mammaires impalpables et macrobiopsies stéréotaxiques avec le Mammotome® 11 G : faut-il opérer après diagnostic d’hyperplasie canalaire atypique ?

Atypical ductal hyperplasia (ADH) of the breast is a difficult histologic diagnosis. It is usually found, but not always, on clusters of microcalcifications. The subsequent risk of breast carcinoma is 4 to 5 times more important and the carcinoma can arise in the same breast or in the contralateral breast. Diagnosis can be establish on core needle biopsy with Mammotome 11G. The risk of under-estimation (ductal carcinoma in situ or invasive carcinoma) is about 20%. This risk is drastically decreased if the target (the calcifications) is completely removed by the Mammotome. This study includes 62 cases of ADH found on 633 calcifications biopsied by Mammotome 11G. In 31 cases, surgery was performed and ADH was confirmed in 25 cases (6 cases was under-estimated). In the other 31 cases, all calcifications were removed, there was no other risk factor and follow-up was suggested. Like after surgery, yearly bilateral mammography during about 20 years is recommended. In this last group, there was no false-negative result, median follow-up: 35,5 months (22-62).

Vacuum-assisted breast biopsies. Experience at the Antoine Lacassagne Cancer Center (Nice, France)

This article presents the results of the first 318 aspiration-guided breast macrobiopsies performed using a dedicated table at the Antoine Lacassagne Cancer Center (Nice, France) between January 2001 and November 2002. A total of 288 procedures (90%) was performed for microcalcifications whereas that of 30 (10%) was performed for isolated opacities. There were 170 American College of Radiology (ACR) Category 4 (53.45%), 35 ACR 5 (11%), 111 ACR 3 (34.9%), and 2 ACR 2 lesions. There were 233 benign lesions that included 19 cases of atypical epithelial hyperplasia. Of the 85 malignant lesions, 33 had an invasive component. Seven of the atypical epithelial hyperplasia cases and all of the malignant lesions were managed surgically. Atypical epithelial hyperplasia was underestimated in 28.57% of the cases; ductal carcinomas in situ, in 21.15%. The positive predictive value of ACR 4 for the diagnosis of malignancy was 24.7% (42/128 cases), versus that of 12.6% for ACR 3 (14/97 cases). Among the 233 benign lesions, 128 were classified as ACR 4 and 6 as ACR 5 (all of these procedures obviated surgery). The advantages, drawbacks, and limitations of the technique are analyzed and indications are discussed, particularly for ACR 3 lesions.