Stereotactic vacuum-assisted breast biopsy in 268 nonpalpable lesions

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.

Diagnostic accuracy of tomosynthesis-guided vacuum assisted breast biopsy of ultrasound occult lesions

This study aims to evaluate the diagnostic accuracy of digital breast tomosynthesis-guided vacuum assisted breast biopsy (DBT-VABB) of screening detected suspicious mammographic abnormalities comprising of calcifications, asymmetric densities, architectural distortions and spiculated masses. In this institutionally approved study, a total of 170 (n = 170) DBT-VABB were performed, 153 (90%) were for calcifications, 8 (4.7%) for spiculated mass, 5 (2.9%) for asymmetric density and 4 (2.4%) for architectural distortion. All these lesions were not detected on the corresponding ultrasound. Histopathology results revealed 140 (82.4%) benign, 9 (5.3%) borderline and 21 (12.4%) malignant lesions. The total upgrade rate at surgery was 40% for atypical ductal hyperplasia and 5.9% for ductal carcinoma in-situ. 3.6% discordant benign lesions showed no upgrade. DBT-VABB showed 100% specificity, 91.3% sensitivity and 100% positive predictive value (PPV) for detecting malignant lesions. The negative predictive value (NPV) was 80%. 2 (1.2%) patients had mild complications and 1 (0.6%) had severe pain. Our study showed that DBT-VABB was a safe and reliable method, with high sensitivity, specificity, PPV and NPV in the diagnosis of non-palpable benign and malignant breast lesions. Our data also confirmed the accuracy of DBT-VABB in detecting malignant lesions and we suggest further surgical excision in borderline lesions for a more accurate diagnostic evaluation.

Transition to digital breast tomosynthesis-guided biopsies: Results and complications compared to stereotactic biopsies

This study evaluates targeting success, pathologic results, and complications of upright digital breast tomosynthesis-guided biopsies (DBTB) compared to prone stereotactic breast biopsies (PSBB) performed during the same time period. In this retrospective study, 252 consecutive mammographically guided vacuum-assisted 9-gauge breast biopsies performed at a single institution from December 2017 to August 2018 were evaluated. This included 153 DBTBs compared to 99 PSBBs. A total of 153 DBTBs (in 139 patients) and 99 PSBBs (in 96 patients) were performed during the study period. Targeting success was similar for DBTB (99%) and PSBB (99%). DBTB was used to target both calcifications (110) as well as non-calcified targets (43), while PSBB only targeted calcifications. Malignant biopsies from DBTB were more likely to be invasive (n = 12, 8%) than PSBB (n = 2, 2%), with P = .03. Moreover, DBTB targets classified as calcifications only were less likely to yield invasive malignancy (2/109, 2% vs 10/43, 23%), with P = .0001. PPV3 was similar for DBTB (24%) and PSBB (27%) as were high-risk pathology results (23% and 18%, respectively). Tissue marker migration > 1cm occurred at a similar frequency (14% vs 13%). Hematomas were slightly more frequent with DBTB (19/152, 13%) than with PSBB (4/98, 4%), with P = .026. Finally, the average number of core biopsies with DBTB was higher than with PSBB (8.32 vs 7.39, respectively), with P = .02. Compared to prone stereotactic breast biopsy, upright digital breast tomosynthesis biopsy has a similar high targeting success frequency, low complication frequency, and additionally allows targeting of calcified and non-calcified targets.

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 vacuum-assisted core biopsy results for non-palpable breast lesions

BACKGROUND

The increase in breast cancer awareness and widespread use of mammographic screening has led to an increased detection of (non-palpable) breast cancers that cannot be discovered through physical examination. One of the methods used in the diagnosis of these cancers is vacuum-assisted core biopsy, which prevents a considerable number of patients from undergoing surgical procedures. The aim of this study was to present the results of stereotactic vacuum-assisted core biopsy for suspicious breast lesions.

MATERIALS AND METHODS

Files were retrospectively scanned and data on demographic, radiological and pathological findings were recorded for patients who underwent stereotactic vacuum-assisted core biopsy due to suspicious mammographic findings at the Interventional Radiology Centre of the Florence Nightingale Hospital between January 2010, and April 2013. Statistical analysis was carried out using Pearson's Chi-square, continuity correction, and Fisher's exact tests.

RESULTS

The mean age of the patients was 47 years (range: 36-70). Biopsies were performed due to BIRADS 3 lesions in 8 patients, BIRADS 4 lesions in 77 patients, and BIRADS 5 lesions in 3 patients. Mammography elucidated clusters of microcalcifications in 73 patients (83%) and focal lesions (asymmetrical density, distortion) in 15 patients (17%). In terms of complications, 1 patient had a hematoma, and 2 patients had ecchymoses (3/88; 3.3%). The histopathologic results revealed benign lesions in 63 patients (71.6%) and malignant lesions in 25 patients (28.4%). The mean duration of the procedure was 37 minutes (range: 18-55). Although all of the BIRADS 3 lesions were benign, 22 (28.6%) of the BIRADS 4 lesions and all of the BIRADS 5 lesions were malignant. Among the malignant cases, 80% were in situ, and 20% were invasive carcinomas. These patients underwent surgery.

CONCLUSIONS

In cases where non-palpable breast lesions are considered to be suspicious in mammography scans, the vacuum-assisted core biopsy method provides an accurate histopathologic diagnosis thus preventing a significant number of patients undergoing unnecessary surgical procedures.

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.

BI-RADS categorisation of 2,708 consecutive nonpalpable breast lesions in patients referred to a dedicated breast care unit

OBJECTIVES

To determine the malignancy rate of nonpalpable breast lesions, categorised according to the Breast Imaging Reporting and Data System (BI-RADS) classification in the setting of a Breast Care Unit.

METHODS

All nonpalpable breast lesions from consecutive patients referred to a dedicated Breast Care Unit were prospectively reviewed and classified into 5 BI-RADS assessment categories (0, 2, 3, 4, and 5).

RESULTS

A total of 2708 lesions were diagnosed by mammography (71.6%), ultrasound (8.7%), mammography and ultrasound (19.5%), or MRI (0.2%). The distribution of the lesions by BI-RADS category was: 152 in category 0 (5.6%), 56 in category 2 (2.1%), 742 in category 3 (27.4%), 1523 in category 4 (56.2%) and 235 in category 5 (8.7%). Histology revealed 570 malignant lesions (32.9%), 152 high-risk lesions (8.8%), and 1010 benign lesions (58.3%). Malignancy was detected in 17 (2.3%) category 3 lesions, 364 (23.9%) category 4 lesions and 185 (78.7%) category 5 lesions. Median follow-up was 36.9 months.

CONCLUSION

This pragmatic study reflects the assessment and management of breast impalpable abnormalities referred for care to a specialized Breast Unit. Multidisciplinary evaluation with BI-RADS classification accurately predicts malignancy, and reflects the quality of management. This assessment should be encouraged in community practice appraisal.

Mammographic characteristics and vacuum-assisted breast biopsy (VABB) of non-palpable breast lesions

BACKGROUND

The new imaging technology made available today allows for an early detection of small subclinical breast lesions which frequently call for guided presurgical micro-histology.

PURPOSE

To evaluate the relationship between vacuum-assisted breast biopsy (VABB) histopathological diagnoses and mammographic findings in non-palpable breast lesions.

MATERIAL AND METHODS

The breast lesions of 1393 women who had received consecutive screening mammograms between 2001 and 2007 were assessed by VABB. The mammographic breast lesions, classified according to the Breast Imaging Reporting and Data System (BI-RADS), were subjected to VABB only if rated as highly suspicious (2%), suspicious (64.5%) for malignancy, or probably benign (33.5%).

RESULTS

VABB findings included 981 (70.5%) probably benign lesions, 407 (29.2%) suspicious/malignant lesions, and five (0.3%) cases which were considered as inappropriate for diagnostic purposes. At histology, 10.2% of the suspicious/malignant lesions were classified as proliferative lesions, 11.1% as ductal carcinoma in situ (DCIS), and 8% as invasive ductal carcinoma (IDC). The positive predictive value (PPV) of BI-RADS assessment categories 3, 4 and 5 was 4.1%, 25.3% and 75%, respectively. The occurrence of obscured or spiculated masses was found to exhibit the highest PPV for malignancy (12.5% in BI-RADS 3 and 63% in BI-RADS 4), followed by microcalcifications which showed a malignancy rate of 6.4% in BI-RADS 3, and 20% in BI-RADS 4.

CONCLUSION

VABB turns out to be effective in the assessment of many malignant and benign preclinical tumour lesions thus allowing for a significant reduction of the number of surgical biopsies.

Biopsy sampling of breast lesions: comparison of core needle- and vacuum-assisted breast biopsies

Needle biopsy is now the initial investigation of choice for the pre-operative diagnosis of breast lesions. This includes core needle biopsy (CNB) and vacuum-assisted biopsy (VAB) with or without radiologic assistance. The performance indices of both of these biopsy techniques were evaluated. In a large cohort of patients with breast lesions including 464 cases (285 CNB and 179 VAB), with confirmed outcomes, the diagnostic accuracy was compared using parameters including quantitation of the sampling based on the total number of cores taken, cores containing breast parenchyma, and cores with lesion; and non-epithelial changes including necrosis and calcification. CNB showed a 99% PPV, 94% NPV, 96% sensitivity, and 99% specificity, whereas VAB demonstrated a 100% PPV, 100% NPV, 100% sensitivity, and 100% specificity. The correct diagnosis in CNB was proportional to the number of cores extracted, whereas accuracy of VAB was independent of the total number of cores taken. There was a positive correlation between the presence of calcification and malignancy in CNB, but not detected under VAB. CNB and VAB were equally efficient in palpable lesions, in detecting necrosis, and calcification. Large calcification was found to be associated with malignancy in both CNB and VAB. In non-palpable lesions, VAB was more effective in the detection of calcification. The diagnostic accuracy of VAB appeared to be independent of number of cores sampled, whereas CNB required a minimum of 3-4 cores to achieve high diagnostic accuracy.

[Evaluation of stereotactic core biopsies of the breast with the 10-gauge Vacora® biopsy device: a review of 541 procedures]

PURPOSE

To evaluate stereotactic core biopsies of the breast with the 10-gauge Vacora(®) biopsy device.

PATIENTS AND METHODS

Retrospective study of 541 procedures in 502 patients performed between 2007 and 2009.

RESULTS

The procedure failed in 2% of cases, non-complicated hematomas occurred in 5% of cases and unsightly scars in two cases. A clip was deployed in 70% of cases, successfully in 99% of cases. The procedure was well tolerated in 88% of cases. Core biopsies confirmed a benign lesion in 55% of cases, borderline lesions in 19% of cases and malignant lesions in 26% of cases with complementary surgery performed in 40% of cases. For surgical lesions, sensitivity, specificity, PPV and NPV were 89%, 100%, 100% and 84% respectively. Atypical ductal dysplasia was under-estimated in 8% of cases while DCIS was under-estimated in 14% of cases. After review of the mammograms, 3% of Bi-Rads 4 lesions were reclassified as Bi-Rads 3 lesions, all benign at core biopsy. Half of these results were from screening mammography programs.

CONCLUSION

Results with the 10-gauge Vacora(®) biopsy device are similar to reports from the literature, mainly using the Mammotome system, with regards to tolerability and reliability for a lesser cost.

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.

Vacuum-assisted biopsy diagnosis of atypical ductal hyperplasia and patient management

PURPOSE

This study sought to evaluate the accuracy of vacuum-assisted biopsy (VAB) in the diagnosis of atypical ductal hyperplasia (ADH) by determining the rate of VAB underestimation compared with definitive histology. In addition, an attempt was made to identify parameters that could help determine the most appropriate patient management.

MATERIALS AND METHODS

We retrospectively reviewed 1,776 VAB procedures performed between November 1999 and January 2008 for suspicious subclinical breast lesions visible only at mammography. A total of 177 patients with a VAB diagnosis of pure ADH were studied. Patients with a diagnosis of ADH associated with other lesions (lobular intraepithelial neoplasia, papilloma), atypical lobular hyperplasia, lobular carcinoma in situ and any lesions with a microhistological diagnosis other than ADH were excluded. Mammographic appearance of lesions was as follows: 152 mostly clustered microcalcifications (86%); five opacities with microcalcifications (3%); 12 single opacities (3%); and eight parenchymal distortions (4%), of which five were without and three were with microcalcifications. In cases underestimated by VAB, we evaluated the extent of ADH within ducts and lobules. Based on results, patients were subdivided into two groups: ≤2 ADH foci; >2 ADH foci. Patients were subdivided into two groups: one was referred for surgery and the other for follow-up care. The decision to either perform or not perform surgery was based on combined analysis of the following parameters: patient age; risk factors in the patient's history; mammographic extent of microcalcifications; complete excision of microcalcifications at VAB; and final Breast Imaging Reporting and Data System (BI-RADS) assessment.

RESULTS

In the first group (n=98), comparison of microhistology with final histology revealed that 19 cases of ADH had been underestimated by VAB. In the second group (n=79), six cases of ADH showed progression of the mammographic abnormality, which was subsequently confirmed by surgical biopsy.

CONCLUSIONS

The most relevant parameters affecting the decision to proceed to surgical excision were lesion diameter >7 mm on mammography, >2 ADH foci, incomplete removal of the calcifications and a family and/or personal history of breast cancer. Although there are no definite mammographic predictors of malignancy, a radiological assessment of suspicious lesion in the presence of an additional equivocal parameter always warrants surgical management.