Diagnostic accuracy of large-core needle biopsy for nonpalpable breast disease: a meta-analysis

Continuity of Radiologists Between Diagnostic Breast Imaging and Image-Guided Breast Biopsy: Impact on Patient-Reported Biopsy Morbidity Experiences

OBJECTIVE

To determine whether continuity of care between diagnostic breast imaging and subsequent image-guided breast biopsy could reduce patient-reported biopsy-related morbidity.

METHODS

This was a prospective, pragmatically randomized, 2-arm health utilities analysis of 200 women undergoing diagnostic breast imaging followed by US- or stereotactic-guided breast biopsy at a single quaternary care center from September 3, 2019, to April 10, 2023. Breast biopsy-naive women with a BI-RADS 4 or 5 finding at diagnostic imaging were randomly scheduled for the typically first available biopsy appointment. One day after biopsy, enrolled patients were administered the Testing Morbidities Index (TMI). The primary outcome was the difference in TMI summary utility scores in patients who did vs did not have the same radiologist perform diagnostic imaging and biopsy.

RESULTS

Response rates were 63% (100/159) for the different radiologist cohort and 71% (100/140) for the same radiologist cohort; all respondents answered all questions in both arms. Mean time to biopsy was 7 ± 6 days and 10 ± 9 days, and the number of participating radiologists was 11 and 18, respectively. There was no difference in individual measured domains (pain, fear, or anxiety before procedure; pain, embarrassment, fear, or anxiety during procedure; mental or physical impact after procedure; all P >.00625) or in overall patient morbidity (0.83 [95% CI, 0.81-0.85] vs 0.82 [95% CI: 0.80-0.84], P = .66).

CONCLUSION

Continuity of care between diagnostic breast imaging and image-guided breast biopsy did not affect morbidity associated with breast biopsy, suggesting that patients should be scheduled for the soonest available biopsy appointment rather than waiting for the same radiologist.

Photon Absorption Remote Sensing Imaging of Breast Needle Core Biopsies Is Diagnostically Equivalent to Gold Standard H&E Histologic Assessment

Photon absorption remote sensing (PARS) is a new laser-based microscope technique that permits cellular-level resolution of unstained fresh, frozen, and fixed tissues. Our objective was to determine whether PARS could provide an image quality sufficient for the diagnostic assessment of breast cancer needle core biopsies (NCB). We PARS imaged and virtually H&E stained seven independent unstained formalin-fixed paraffin-embedded breast NCB sections. These identical tissue sections were subsequently stained with standard H&E and digitally scanned. Both the 40× PARS and H&E whole-slide images were assessed by seven breast cancer pathologists, masked to the origin of the images. A concordance analysis was performed to quantify the diagnostic performances of standard H&E and PARS virtual H&E. The PARS images were deemed to be of diagnostic quality, and pathologists were unable to distinguish the image origin, above that expected by chance. The diagnostic concordance on cancer vs. benign was high between PARS and conventional H&E (98% agreement) and there was complete agreement for within-PARS images. Similarly, agreement was substantial (kappa > 0.6) for specific cancer subtypes. PARS virtual H&E inter-rater reliability was broadly consistent with the published literature on diagnostic performance of conventional histology NCBs across all tested histologic features. PARS was able to image unstained tissues slides that were diagnostically equivalent to conventional H&E. Due to its ability to non-destructively image fixed and fresh tissues, and the suitability of the PARS output for artificial intelligence assistance in diagnosis, this technology has the potential to improve the speed and accuracy of breast cancer diagnosis.

How Reliable Are Gene Expression-Based and Immunohistochemical Biomarkers Assessed on a Core-Needle Biopsy? A Study of Paired Core-Needle Biopsies and Surgical Specimens in Early Breast Cancer

In early breast cancer, a preoperative core-needle biopsy (CNB) is vital to confirm the malignancy of suspected lesions and for assessing the expression of treatment predictive and prognostic biomarkers in the tumor to choose the optimal treatments, emphasizing the importance of obtaining reliable results when biomarker status is assessed on a CNB specimen. This study aims to determine the concordance between biomarker status assessed as part of clinical workup on a CNB compared to a medically untreated surgical specimen. Paired CNB and surgical specimens from 259 patients that were part of the SCAN-B cohort were studied. The concordance between immunohistochemical (IHC) and gene expression (GEX) based biomarker status was investigated. Biomarkers of interest included estrogen receptor (ER; specifically, the alpha variant), progesterone receptor (PgR), Ki67, HER2, and tumor molecular subtype. In general, moderate to very good correlation in biomarker status between the paired CNB and surgical specimens was observed for both IHC assessment (83–99% agreement, kappa range 0.474–0.917) and GEX assessment (70–97% agreement, kappa range 0.552–0.800), respectively. However, using IHC, 52% of cases with low Ki67 status in the CNB shifted to high Ki67 status in the surgical specimen (McNemar’s p = 0.011). Similarly, when using GEX, a significant shift from negative to positive ER (47%) and from low to high Ki67 (16%) was observed between the CNB and surgical specimen (McNemar’s p = 0.027 and p = 0.002 respectively). When comparing biomarker status between different techniques (IHC vs. GEX) performed on either CNBs or surgical specimens, the agreement in ER, PgR, and HER2 status was generally over 80% in both CNBs and surgical specimens (kappa range 0.395–0.708), but Ki67 and tumor molecular subtype showed lower concordance levels between IHC and GEX (48–62% agreement, kappa range 0.152–0.398). These results suggest that both the techniques used for collecting tissue samples and analyzing biomarker status have the potential to affect the results of biomarker assessment, potentially also impacting treatment decisions and patient survival outcomes.

Diagnosis and prognosis of breast cancer by high-performance serum metabolic fingerprints

Breast cancer (BrCa) is the most common cancer worldwide, and high-performance metabolic analysis is emerging in diagnosis and prognosis of BrCa. Here, we used nanoparticle-enhanced laser desorption/ionization mass spectrometry to record serum metabolic fingerprints of BrCa in seconds, achieving high reproducibility and low consumption of direct serum detection. Our analytical method, combined with the aid of machine learning algorithms, was demonstrated to provide high diagnostic efficiency with accuracy of 88.8% and desirable prognostic prediction (P < 0.005). Furthermore, seven metabolic biomarkers differentially enriched in BrCa serum and their related pathways were identified. Together, our findings provide a tool to characterize BrCa and highlight certain metabolic signatures as potential diagnostic and prognostic factors of diseases including but not limited to BrCa.

High-performance metabolic analysis is emerging in the diagnosis and prognosis of breast cancer (BrCa). Still, advanced tools are in demand to deliver the application potentials of metabolic analysis. Here, we used fast nanoparticle-enhanced laser desorption/ionization mass spectrometry (NPELDI-MS) to record serum metabolic fingerprints (SMFs) of BrCa in seconds, achieving high reproducibility and low consumption of direct serum detection without treatment. Subsequently, machine learning of SMFs generated by NPELDI-MS functioned as an efficient readout to distinguish BrCa from non-BrCa with an area under the curve of 0.948. Furthermore, a metabolic prognosis scoring system was constructed using SMFs with effective prediction performance toward BrCa (P < 0.005). Finally, we identified a biomarker panel of seven metabolites that were differentially enriched in BrCa serum and their related pathways. Together, our findings provide an efficient serum metabolic tool to characterize BrCa and highlight certain metabolic signatures as potential diagnostic and prognostic factors of diseases including but not limited to BrCa.

Advantages and Challenges of Using Breast Biopsy Markers

Percutaneous image-guided biopsy procedures are the standard of care for histologic assessment of suspicious breast lesions. Post-biopsy tissue markers (clips) optimize patient management by allowing for assessment on follow-up imaging and precise lesion localization. Markers are used to ensure accurate correlation between imaging modalities, guide preoperative localization for malignant and high-risk lesions, and facilitate accurate identification of benign lesions at follow-up. Local practices differ widely, and there are no data detailing the exact frequency of use of clips for different breast biopsies. There are many indications for biopsy marker deployment, and some difficulties may be encountered after placement. The placement of biopsy markers has many advantages and few disadvantages, such that deployment should be routinely used after percutaneous biopsy procedures with rare exception.

A systematic review and meta-analysis: value of ultrasound-guided vacuum-assisted biopsy in the diagnosis and treatment of breast lesions

Background

In recent years, according to global statistics, breast cancer is the main disease affecting women. Ultrasound-guided vacuum-assisted biopsy (VAB) has become a frequently used method for breast cancer detection because of its accuracy, simplicity, and fewer complications.

Methods

In PubMed, Medline, EMbase and Cochrane central register of controlled trials, the retrieval time was from the establishment of the database to March 2021, and the keywords included breast tumor, breast cancer-related diseases, breast lesions, vacuum-assisted breast biopsy, sensitivity and specificity. Meta-analysis was performed using RevMan5.3 software provided by the Cochrane Collaboration.

Results

A total of 10 articles were included using a random-effects model that pooled the sensitivity, specificity, and other accuracy measures of VAB. The summary receiver operating characteristic (SROC) characteristic curve was used to summarize the overall accuracy. The sensitivity range was 0.94 to 1.00 (mean, 0.981; 95% CI, 0.972-0.987) with a specificity range of 0.87-1.00 (mean, 0.999; 95% CI, 0.997-0.999). The preoperative platelet-lymphocyte ratio (PLR) was 93.84 (95% CI, 41.55-211.95), the neutrophil to lymphocyte ratio (NLR) was 0.05 (95% CI, 0.03-0.09), the sensitivity and specificity of χ² were 37.10 (P=0.011) and 32.00 (P=0.043), respectively, while those of PLR, NLR, and duration of response (DOR) were 46.98 (P=0.001), 54.92 (P=0.001), and 43.49 (P=0.002), respectively. Differences were considerable.

Discussion

In this meta-analysis, a total of 10 articles were included. VAB is an accurate type of biopsy to detect female breast cancer. The results of the meta-analysis were stable, and VAB had high sensitivity (98%) and specificity (nearly 100%).

Systematic tissue collection during clinical breast biopsy is feasible, safe and enables high-content translational analyses

Systematic collection of fresh tissues for research at the time of diagnostic image-guided breast biopsy has the potential to fuel a wide variety of innovative studies. Here we report the initial experience, including safety, feasibility, and laboratory proof-of-principle, with the collection and analysis of research specimens obtained via breast core needle biopsy immediately following routine clinical biopsy at a single institution over a 14-month period. Patients underwent one or two additional core biopsies following collection of all necessary clinical specimens. In total, 395 patients were approached and 270 consented to the research study, yielding a 68.4% consent rate. Among consenting patients, 238 lesions were biopsied for research, resulting in 446 research specimens collected. No immediate complications were observed. Representative research core specimens showed high diagnostic concordance with clinical core biopsies. Flow cytometry demonstrated consistent recovery of hundreds to thousands of viable cells per research core. Among a group of HER2 + tumor research specimens, HER2 assessment by flow cytometry correlated highly with immunohistochemistry (IHC) staining, and in addition revealed extensive inter- and intra-tumoral variation in HER2 levels of potential clinical relevance. Suitability for single-cell transcriptomic analysis was demonstrated for a triple-negative tumor core biopsy, revealing substantial cellular diversity in the tumor immune microenvironment, including a prognostically relevant T cell subpopulation. Thus, collection of fresh tissues for research purposes at the time of diagnostic breast biopsy is safe, feasible and efficient, and may provide a high-yield mechanism to generate a rich tissue repository for a wide variety of cross-disciplinary research.

Clinicopathological Features and Disease Outcome in Breast Cancer Patients with Hormonal Receptor Discordance between Core Needle Biopsy and Following Surgical Sample

Background

There are limited data about how to manage patients with discordant hormonal receptor (HR) status between core needle biopsy (CNB) and following surgical sample (FSS). This study aimed to evaluate clinicopathological features and disease outcome for these HR discordance patients.

Patients and Methods

Invasive breast cancer patients with paired HR between CNB and FSS were retrospectively analyzed, being classified into three groups: HR positive, HR negative, and HR discordance. Patient characteristics, treatment decisions, and disease outcome were compared among above groups.

Results

A total of 1710 patients (1233 HR positive, 417 HR negative, and 60 HR discordance patients) were enrolled. Compared with the HR positive group, HR discordance patients were associated with more human epidermal growth factor receptor 2 positivity (P < 0.001) and higher Ki67 level (P = 0.001) tumors. The fraction of patients receiving adjuvant chemotherapy was 95.0% and 93.8% in the HR discordance or HR negative groups, much higher than in the HR positive group (66.7%, P < 0.001). Of 60 HR discordance patients, 34 (56.7%) received adjuvant endocrine therapy. The 5-year disease-free survival (DFS) rate was 90.4% for HR discordant patients, showing no statistical difference compared with HR positive (87.0%, P = 0.653) or HR negative (83.2%, P = 0.522) groups. For HR discordance patients, there was no difference in DFS between patients who received adjuvant endocrine therapy or not (P = 0.259).

Conclusions

HR discordance patients had similar tumor characteristics, adjuvant chemotherapy treatment, and DFS compared with HR negative patients. The benefit of endocrine therapy in these HR discordance patients is uncertain and deserves further clinical evaluation.

Electronic supplementary material

The online version of this article (10.1245/s10434-019-07480-y) contains supplementary material, which is available to authorized users.

Core needle biopsy as an alternative to whole section in IHC4 score assessment for breast cancer prognostication

AIMS

IHC4 score, based on expression of four routine markers (oestrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2) and proliferation marker, Ki67), is a recently developed, cost-effective prognostic tool in breast cancer. Possibly, the score may be useful also in advanced diseases where only core needle biopsy (CNB) is available and neoadjuvant therapy. However, its studies on CNB are scant. This study examined whether IHC4 score assessment on CNB is comparable to that from whole section (WS).

METHODS

Immunohistochemical (IHC) analysis was performed for ER, PR, HER2 and Ki67 on 108 paired CNB and WS to evaluate IHC4 score (with follow-up range 1-230 months and 5 relapse/death). Concordance between the two was examined. Factors that affected the concordance were analysed. Additionally, IHC4 score was compared with Nottingham Prognostic Index (NPI).

RESULTS

There was moderate concordance between IHC4 score on CNB and WS (all cases: κ=0.699, p<0.001; ER+ cases: κ=0.595, p<0.001). Among the IHC4 components, concordance for HER2 was the poorest (κ=0.178, p<0.001 in all cases; ER+ cases: κ=0.082, p<0.097). Significant factors affecting concordance between CNB and WS included number of cores, total core length and percentage of tumour cells in cores (p≤0.030), indicating the importance of sufficient sampling. Interestingly, the concordance was also affected by patients' age (p=0.039). There was poor agreement between IHC4 score and NPI (κ≤0.160).

CONCLUSION

Our results suggested that IHC4 score can be used on adequately sampled CNB. Its poor agreement with NPI highlights the independence of the two factors.

Analysis of Diagnostic Methods for Focal Lesions in Breast Glands with Use of Open Surgical Biopsies and Core-Needle Biopsies in Poland

Background

Numerous studies confirm the benefits of using core-needle biopsy (CNB) for diagnosing patients with suspected breast cancer, thus reducing the costs and the stress, and allowing optimum treatment planning. The present study examined the number of patients in Poland who had been diagnosed with breast cancer through inpatient open surgical biopsy (OSB) and CNB by province.

Material/Methods

This retrospective study used a health needs map to identify patients in 2014 and partially in 2015 who had had OSB or CNB of the breast performed on an inpatient basis due to benign breast lesions and whose diagnosis had been changed from benign to malignant.

Results

Among the total number of hospitalizations (13 718 cases with OSB) due to benign lesions of the breast, 1506 patients had their diagnosis changed to malignant, constituting 8.59% of new breast cancer diagnoses across the country. The resulting diagnosis change from benign to malignant varied significantly across provinces, from 5.3% to 23.4%. Among the total of 7205 hospitalizations in 2014 with CNB performed using different methods, there were 1574 malignancies, amounting to 8.9% of new diagnoses in Poland. The use of inpatient CNB to diagnose breast cancer differed significantly across provinces, from 0.6% to 34.4%.

Conclusions

OSBs are too often used to diagnose focal lesions in breast glands in Poland. In some regions, CNBs are too frequently performed on an inpatient rather than outpatient basis, thereby requiring an analysis of the quality of and access to modern diagnostic methods.

Radiomics Based on Adapted Diffusion Kurtosis Imaging Helps to Clarify Most Mammographic Findings Suspicious for Cancer

Purpose To evaluate a radiomics model of Breast Imaging Reporting and Data System (BI-RADS) 4 and 5 breast lesions extracted from breast-tissue-optimized kurtosis magnetic resonance (MR) imaging for lesion characterization by using a sensitivity threshold similar to that of biopsy. Materials and Methods This institutional study included 222 women at two independent study sites (site 1: training set of 95 patients; mean age ± standard deviation, 58.6 years ± 6.6; 61 malignant and 34 benign lesions; site 2: independent test set of 127 patients; mean age, 58.2 years ± 6.8; 61 malignant and 66 benign lesions). All women presented with a finding suspicious for cancer at x-ray mammography (BI-RADS 4 or 5) and an indication for biopsy. Before biopsy, diffusion-weighted MR imaging (b values, 0-1500 sec/mm²) was performed by using 1.5-T imagers from different MR imaging vendors. Lesions were segmented and voxel-based kurtosis fitting adapted to account for fat signal contamination was performed. A radiomics feature model was developed by using a random forest regressor. The fixed model was tested on an independent test set. Conventional interpretations of MR imaging were also assessed for comparison. Results The radiomics feature model reduced false-positive results from 66 to 20 (specificity 70.0% [46 of 66]) at the predefined sensitivity of greater than 98.0% [60 of 61] in the independent test set, with BI-RADS 4a and 4b lesions benefiting from the analysis (specificity 74.0%, [37 of 50]; 60.0% [nine of 15]) and BI-RADS 5 lesions showing no added benefit. The model significantly improved specificity compared with the median apparent diffusion coefficient (P < .001) and apparent kurtosis coefficient (P = .02) alone. Conventional reading of dynamic contrast material-enhanced MR imaging provided sensitivity of 91.8% (56 of 61) and a specificity of 74.2% (49 of 66). Accounting for fat signal intensity during fitting significantly improved the area under the curve of the model (P = .001). Conclusion A radiomics model based on kurtosis diffusion-weighted imaging performed by using MR imaging machines from different vendors allowed for reliable differentiation between malignant and benign breast lesions in both a training and an independent test data set. ^© RSNA, 2018 Online supplemental material is available for this article.

Current Approaches to Diagnosis and Treatment of Ductal Carcinoma In Situ and Future Directions

The presentation and treatment of ductal carcinoma in situ (DCIS) has changed substantially over the years. While previously an incidental pathologic finding in more advanced, palpable tumors, the institution of screening mammography has repositioned this disease entity as one largely diagnosed as a non-palpable lesion, often prior to any invasive disease. As DCIS is a precursor to invasive carcinoma, evolution in the approach to treatment has followed in the footsteps of that for invasive disease, including breast conservation therapy, adjuvant radiation, and use of antihormonal therapy. Survival outcomes for DCIS are very high and more recent literature has investigated tailoring therapeutic approaches to avoid overtreatment. Two important areas of ongoing clinical debate concerning overtreatment include use of preoperative MRI and the role of adjuvant radiation. The heterogeneity of the disease makes it difficult to differentiate lesions that would benefit from more aggressive treatment from those in which overtreatment could be avoided. Clinical characteristics, such as histologic appearance, age at diagnosis, and margin status at tumor excision have been established as moderate predictors of disease recurrence, but none has provided strong enough evidence as to guide consensus decisions on adjuvant therapy. Continuing research seeks to define the genetic and molecular characteristics that can predict disease course and serve as the potential targets for novel therapeutic agents. While several markers have shown promise in differentiating tumor aggressiveness, there is still much to be discovered about the precise mechanisms of disease progression and how this can be applied clinically to optimize treatment.

JOURNAL CLUB: Ultrasound-Guided Breast Interventions: Low Incidence of Infectious Complications With Use of an Uncovered Probe

OBJECTIVE

The purpose of this study was to determine the incidence of infectious complications after ultrasound-guided breast interventions performed with an intermediate-level disinfection protocol without an ultrasound probe cover.

MATERIALS AND METHODS

Two independent institutional databases were searched to identify breast infections in patients who underwent ultrasound-guided interventions between January 2005 and July 2013. The departments of radiology and infectious diseases independently maintained these databases. A comprehensive retrospective chart review based on periprocedural antibiotic use and clinical documentation of infection was also performed to reduce the likelihood of missing potential infectious complications.

RESULTS

A total of 12,708 ultrasound-guided breast procedures were performed in the time frame of this study. All potential cases of procedure-related infection were included for subspecialist review in an effort to give the most conservative (highest) estimate of infectious complications. Among these cases, 14 documented cases of possible procedure-related infection were identified, for an overall incidence of 0.11%. All infections were localized skin or soft-tissue infections and adequately treated with a short course of oral antibiotics. No cases of more serious infections or sepsis were found. None of the reported infections required IV antibiotic therapy, percutaneous intervention, surgical intervention, or hospitalization.

CONCLUSION

The incidence of infectious complications after an ultrasound-guided breast intervention without an ultrasound probe cover is extremely low. Physicians can use this information in the development of their disinfection protocols and to provide accurate information in counseling patients during preprocedural consultation.

Article Commentary: Surgical Management of the Axilla in Breast Cancer

This article offers a review of the literature on current surgical management of the axilla in breast cancer. This includes the decision-making process involved in clinically node-negative patients versus clinically node-positive patients, with discussion of the indications for sentinel lymph node biopsy versus axillary dissection. It also examines the surgical axillary management of patients who receive neoadjuvant chemotherapy. This article will help update practicing surgeons on the evolving research and guidelines for the management of breast cancer axillary disease.

MR-guided vacuum-assisted breast biopsy of MRI-only lesions: a single center experience

PURPOSE

The purpose of this study was to compare three different biopsy devices on false-negative and underestimation rates in MR-guided, vacuum-assisted breast biopsy (VABB) of MRI-only lesions.

METHODS

This retrospective, single-center study was IRB-approved. Informed consent was waived. 467 consecutive patients underwent 487 MR-guided VABB using three different 8-10-gauge-VABB devices (Atec-9-gauge,A; Mammotome-8-gauge,M; Vacora-10-gauge,V). VABB data (lesion-type, size, biopsy device, histopathology) were compared to final diagnosis (surgery, n = 210 and follow-up, n = 277). Chi-square, and Kruskal-Wallis tests were applied. P values < 0.05 were considered significant.

RESULTS

Final diagnosis was malignant in 104 (21.4 %), high risk in 64 (13.1 %) and benign in 319 (65.5 %) cases. Eleven of 328 (3.4 %) benign-rated lesions were false-negative (1/95, 1.1 %, A; 2/73, 2.7 %, M; 8/160 5.0 % V; P = 0.095). Eleven high-risk (11/77, 14.3 %) lesions proved to be malignant (3/26, 11.5 % A; 4/12, 33.3 % M; 4/39, 10.3 % V; P = 0.228). Five of 34 (14.7 %) DCIS were upgraded to invasive cancer (2/15, 13.3 %, A; 1/6, 16.6 % M; 2/13, 15.3 %, V; P = 0.977). Lesion size (P = 0.05) and type (mass vs. non-mass, P = 0.107) did not differ significantly.

CONCLUSION

MR-guided VABB is an accurate method for diagnosis of MRI-only lesions. No significant differences on false-negative and underestimation rates were observed between three different biopsy devices.

KEY POINTS

• MR-guided VABB is an accurate procedure for the diagnosis of MRI-only lesions. • Similar false-negative and underestimation rates allow all three different MR-guided VABB devices for clinical application. • High-risk lesions should undergo surgery due to a substantial underestimation rate. • Agreement between MR-guided VABB and final diagnosis (benign/malignant) was 95.5% (465/487).

Meta-analysis of the concordance of histological grade of breast cancer between core needle biopsy and surgical excision specimen

BACKGROUND

With the increasing use of neoadjuvant chemotherapy and minimally invasive ablative therapy in breast cancer, pretreatment assessment of tumour grade on core needle biopsy (CNB) is increasingly needed. However, grading on CNB is possibly less accurate than grading based on the surgical excision specimen. A systematic review and meta-analysis of the literature was conducted to derive a reliable estimate of the agreement in tumour grading between CNB and subsequent surgical excision.

METHODS

Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) criteria, Embase, PubMed and the Cochrane Library were searched. Pooled proportions of agreement in grading between CNB and the excision specimen, Cohen's κ and percentages of overestimation and underestimation were calculated. Random-effects models were applied because of substantial heterogeneity, assessed by I² test. Determinants of the level of agreement in grading were explored with meta-regression.

RESULTS

Thirty-four articles were included in the systematic review (6029 patients) and 33 in the meta-analysis (4980 patients). Pooled agreement and κ were 71·1 (95 per cent c.i. 68·8 to 73·3) per cent and 0·54 (0·50 to 0·58) respectively. Underestimation and overestimation occurred in 19·1 (17·1 to 21·3) and 9·3 (7·7 to 11·4) per cent respectively. Meta-regression showed associations between agreement of histological type (positive association) and proportion of patients with oestrogen receptor-positive disease (negative association) and grade agreement.

CONCLUSION

Grading on CNB corresponds moderately with grading based on excision specimens, with underestimation in about one in five patients. Incorrect CNB tumour grading has limited clinical implications, as multiple factors influence decision-making for adjuvant systemic therapy.

Histopathology of breast cancer after magnetic resonance-guided high-intensity focused ultrasound and radiofrequency ablation

AIMS

Magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) ablation and radiofrequency ablation (RFA) are being researched as possible substitutes for surgery in breast cancer patients. The histopathological appearance of ablated tissue has not been studied in great detail. This study aimed to compare histopathological features of breast cancer after MR-HIFU ablation and RFA.

METHODS AND RESULTS

MR-HIFU ablation and RFA were performed in- and ex-vivo. Tumours in six mastectomy specimens were partially ablated with RFA or MR-HIFU. In-vivo MR-HIFU ablation was performed 3-6 days before excision; RFA was performed in the operation room. Tissue was fixed in formalin and processed to haematoxylin and eosin (H&E) and cytokeratin-8 (CK-8)-stained slides. Morphology and cell viability were assessed. Ex-vivo ablation resulted in clear morphological changes after RFA versus subtle differences after MR-HIFU. CK-8 staining was decreased or absent. H&E tended to underestimate the size of thermal damage. In-vivo MR-HIFU resulted in necrotic-like changes. Surprisingly, some ablated lesions were CK-8-positive. Histopathology after in-vivo RFA resembled ex-vivo RFA, with hyper-eosinophilic stroma and elongated nuclei. Lesion borders were sharp after MR-HIFU and indistinct after RFA.

CONCLUSION

Histopathological differences between MR-HIFU-ablated tissue and RF-ablated tissue were demonstrated. CK-8 was more reliable for cell viability assessment than H&E when used directly after ablation, while H&E was more reliable in ablated tissue left in situ for a few days. Our results contribute to improved understanding of histopathological features in breast cancer lesions treated with minimally invasive ablative techniques.

Iodine seed- versus wire-guided localization in breast-conserving surgery for non-palpable ductal carcinoma in situ

Background

Breast-conserving surgery for isolated non-palpable ductal carcinoma in situ (DCIS) is associated with high rates of incomplete surgical resection in comparison with unifocal invasive breast cancer. Therefore, accurate preoperative localization of the lesion is very important to facilitate adequate resection. Wire-guided localization (WGL) remains the standard for localization of DCIS. Recently, iodine-125 seed-guided localization (I-125 GL) was introduced as an alternative localization technique. The aim of this study was to compare the efficacy of these localization techniques in the resection of DCIS by breast-conserving surgery.

Methods

Between March 2006 and June 2013, 169 patients with non-palpable DCIS were treated with breast-conserving surgery. Only patients with pure DCIS on both preoperative core biopsy and definitive pathology were included.

Results

WGL was performed in 78 patients and I-125 GL in 91 patients. The groups did not differ with respect to age, size of DCIS or type of imaging used. Patients in the I-125 GL group had a significantly lower risk of extensively involved resection margins than those in the WGL group (4 versus 13 per cent respectively; P = 0·048).

Conclusion

In patients treated with breast-conserving surgery for non-palpable DCIS, localization with iodine-125 seeds is superior to the WGL technique in reducing the risk of extensively involved resection margins.

Additional diagnostic value of MRI in patients with suspicious breast lesions based on ultrasound

OBJECTIVE

Biopsy has long been the standard approach in Breast Imaging Reporting and Data System® (BI-RADS) 4 or BI-RADS 5 (American College of Radiology, Reston, VA) lesions despite a wide variation in reported incidence of malignancy in BI-RADS 4 lesions. This study examined the diagnostic value of breast MRI as well as its ability to decrease unnecessary biopsies in patients with solid breast lesions who had an indication for biopsy.

METHODS

In this retrospective study, 277 breast lesions with a documented histological diagnosis as established by ultrasound-guided biopsy were included. All patients were female, and biopsy was performed owing to a BI-RADS score of 4 or 5 on ultrasonography. In addition, all patients had undergone MRI before biopsy. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of MRI in predicting malignancy were calculated.

RESULTS

When all lesions were analysed, sensitivity, specificity, NPV and PPV of MRI in detecting malignancy were 94.2%, 56.1%, 90.7% and 68.1%, respectively. When only ultrasonographic BI-RADS 4 lesions are considered, the corresponding figures were as follows: 90.9%, 56.7%, 93.8% and 46.4%, respectively. False-negative rate of MRI for the latter group of lesions was 2.6%. 42% of unnecessary biopsies were avoided in sonographic BI-RADS 4 lesions.

CONCLUSION

Despite promising results obtained in this study, dynamic MRI currently does not seem to be effective in ruling out the need for biopsy in the assessment of sonographic BI-RADS 4 lesions. However, advanced MRI techniques may assist in improving possible benefits of MRI in this patient group.

Histological grade concordance between diagnostic core biopsy and corresponding surgical specimen in HR-positive/HER2-negative breast carcinoma

Background:

The identification and validation of suitable predictive and prognostic factors are a challenge to improve the treatment scheme selection. Discordances in histological grade can be established between core biopsy and surgical specimens. This is important in HR-positive/HER2-negative subgroup where histological grade identifies patients at high risk and is a strong determinant for treatment scheme.

Methods:

A total of 350 consecutive invasive breast carcinoma biopsies were assessed and compared with surgical specimens in Institut Curie, Paris, France. Clinical, radiological and pathological data were recorded.

Results:

Histological grade concordance rate in the HR+/HER2− group was 75%. A grade underestimation was mainly due to mitotic index misgrading (23%). Large tumours (P<0.05), premenopausal patients (P=0.005) and non-ultrasound-guided biopsies (P=0.04) were risk factors for misgrading. The highest discordance was found in tumours that required chemotherapy (39%, P<0.05), and it was related to an underestimation of histological grade on core biopsies (94%).

Conclusions:

Histological grade in HR+/HER2− group is important to identify patients with poor prognosis and start a systemic therapy. Histological grade discordance was correlated with an underestimation of mitotic index and factors probably associated with intratumor heterogeneity (premenopausal status, tumour size and the type of core biopsy performed). But such discordance did not appear to modify the therapeutic decision, because systemic treatment decision-making also integrates other variables. Determining histological grade in core biopsy can be especially important in HR-positive/HER2-negative subgroup where it identifies patients at high risk and is a strong determinant of the treatment scheme.

Accuracy of 16/18G core needle biopsy for ultrasound-visible breast lesions

Background

To assess the accuracy of ultrasound-guided 16G or 18G core needle biopsy (CNB) for ultrasound-visible breast lesions, and to analyze the effects of lesion features.

Methods

Between July 2005 and July 2012, 4,453 ultrasound-detected breast lesions underwent ultrasound-guided CNB and were retrospectively reviewed. Surgical excision was performed for 955 lesions (566 with 16G CNB and 389 with 18G CNB) which constitute the basis of the study. Histological findings were compared between the ultrasound-guided CNB and the surgical excision to determine sensitivity, false-negative rate, agreement rate, and underestimation rate, according to different lesion features.

Results

Final pathological results were malignant in 84.1% (invasive carcinoma, ductal carcinoma in situ, lymphoma, and metastases), high-risk in 8.4% (atypical lesions, papillary lesions, and phyllodes tumors), and benign in 7.5%. False-negative rates were 1.4% for 16G and 18G CNB. Agreement rates between histological findings of CNB and surgery were 92.4% for 16G and 92.8% for 18G CNB. Overall underestimate rates (high-risk CNB becoming malignant on surgery and ductal carcinoma in situ becoming invasive carcinoma) were 47.4% for 16G and 48.9% for 18G CNB. Agreements were better for mass lesions (16G: 92.7%; 18G: 93.7%) than for non-mass lesions (16G, 85.7%; 18G, 78.3%) (P <0.01). For mass lesions with a diameter ≤10 mm, the agreement rates (16G, 83.3%; 18G, 86.7%) were lower (P <0.01).

Conclusions

Ultrasound-guided 16G and 18G CNB are accurate for evaluating ultrasound-visible breast mass lesions with a diameter >10 mm.

Extensive pure ductal carcinoma in situ of the breast: identification of predictors of associated infiltrating carcinoma and lymph node metastasis before immediate reconstructive surgery

AIM

To identify predictors for infiltrating carcinoma and lymph node involvement, before immediate breast reconstructive surgery, in patients with an initial diagnosis of extensive pure ductal carcinoma in situ of the breast (DCIS).

PATIENTS AND METHODS

Between January 2000 and December 2009, 241 patients with pure extensive DCIS in preoperative biopsy had underwent mastectomy. Axillary staging (sentinel node and/or axillary dissection) was performed in 92% (n = 221) of patients. Patients with micro-invasive lesions at initial diagnosis, recurrence or contralateral breast cancer were excluded.

RESULTS

Respectively 14% and 21% of patients had a final diagnosis of micro-invasive carcinoma (MIC) and invasive ductal carcinoma (IDC). Univariate analysis showed that the following variables at diagnosis were significantly correlated with the presence of either MIC or IDC in the mastectomy specimen: palpable tumor (p = 0.002), high grade DCIS (p = 0.002) and detection of an opacity by mammography (p = 0.019). Axillary lymph node (ALN) involvement was reported in 9% of patients. Univariate analysis suggested that a body mass index higher than 25 (p = 0.007), a palpable tumor (p = 0.012) and the detection of an opacity by mammography (p = 0.044) were associated with an increased rate of ALN involvement.

CONCLUSION

Skin-sparing mastectomy and immediate breast reconstruction (IBRS) has become increasingly popular, especially for patients with extended DCIS of the breast. This study confirmed that extended DCIS is associated with a substantial risk of finding MIC or IDC on the surgical specimen but also ALN involvement. Adjuvant systemic treatment and/or radiotherapy could be indicated for some of these patients after the surgery. Patients should be informed of the rate of 1) complications associated to IBRS that will potentially delay the introduction of systemic or local therapy 2) complications associated to radiotherapy after IBRS.

Step-by-step of ultrasound-guided core-needle biopsy of the breast: review and technique

Ultrasound-guided core-needle biopsy has high sensitivity in the diagnosis of breast cancer. The present study is aimed at detailing the main steps of such procedure, including indications, advantages, limitations, follow-up and description of the technique, besides presenting a checklist including the critical steps required for an appropriate practice of the technique. In the recent years, an increasing number of patients have required breast biopsy, indicating the necessity of a proportional increase in the number of skilled professionals to carry out the procedures and histological diagnoses. A multidisciplinary approach involving the tripod clinical practice-radiology-pathology is responsible for the highest rate of accuracy of the technique and must always be adopted.

Evaluation of the diagnostic power of thermography in breast cancer using Bayesian network classifiers

Breast cancer is one of the leading causes of death among women worldwide. There are a number of techniques used for diagnosing this disease: mammography, ultrasound, and biopsy, among others. Each of these has well-known advantages and disadvantages. A relatively new method, based on the temperature a tumor may produce, has recently been explored: thermography. In this paper, we will evaluate the diagnostic power of thermography in breast cancer using Bayesian network classifiers. We will show how the information provided by the thermal image can be used in order to characterize patients suspected of having cancer. Our main contribution is the proposal of a score, based on the aforementioned information, that could help distinguish sick patients from healthy ones. Our main results suggest the potential of this technique in such a goal but also show its main limitations that have to be overcome to consider it as an effective diagnosis complementary tool.

Cost-effectiveness of radioguided occult lesion localization (ROLL) versus wire-guided localization (WGL) in breast conserving surgery for nonpalpable breast cancer: results from a randomized controlled multicenter trial

BACKGROUND

Accurate preoperative localization of nonpalpable breast cancer is essential to achieve complete resection. Radioguided occult lesion localization (ROLL) has been introduced as an alternative for wire-guided localization (WGL). Although efficacy of ROLL has been established in a randomized controlled trial, cost-effectiveness of ROLL compared with WGL is not yet known. The objective of this study was to determine whether ROLL has acceptable cost-effectiveness compared with WGL.

METHODS

An economic evaluation was performed along with a randomized controlled trial (ClinicalTrials.gov, No. NCT00539474). Women (>18 years) with histologically proven nonpalpable breast cancer and eligible for breast conserving treatment with sentinel node procedure were randomized to ROLL (n = 162) or WGL (n = 152). Empirical data on direct medical costs were collected, and changes in quality of life were measured over a 6-month period. Bootstrapping was used to assess uncertainty in cost-effectiveness estimates, and sensitivity of the results to the missing data approach was investigated.

RESULTS

In total, 314 patients with 316 invasive breast cancers were enrolled. On average ROLL required the same time as WGL for the surgical procedure (119 vs 118 min), resulted in a 7 % higher reinterventions risk, and 13 % more complications. Quality of life effects were similar (difference 0.00 QALYs 95 % CI (-0.04-0.05). Total costs were also similar for ROLL and WGL (+<euro>26 per patient 95 % CI <euro>-250-311).

CONCLUSION

ROLL is comparable to WGL with respect to both costs and quality of life effects as measured with the EQ5D and will therefore not lead to more cost-effective medical care.

Does breast tumor heterogeneity necessitate further immunohistochemical staining on surgical specimens?

BACKGROUND

Prognostic and predictive tumor markers in breast cancer are most commonly performed on core needle biopsies (CNB) of the primary tumor. Because treatment recommendations are influenced by these markers, it is imperative to verify strong concordance between tumor markers on CNB specimens and the corresponding surgical specimens (SS).

STUDY DESIGN

A prospective study was performed on 165 women (205 samples) with breast cancer diagnosed from January 2009 to July 2011. Tumor type, grade, estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor 2 (HER2), and Ki67 expression by immunohistochemical (IHC) testing were retrospectively analyzed in the CNB and SS. Contingency tables and agreement modeling were performed.

RESULTS

There was substantial agreement between the CNB and SS for PR% and HER2; moderate agreement for tumor type, grade, and ER%; and fair agreement for Ki67%. In 8% of patients (n = 13), tumor heterogeneity was seen. In heterogeneous tumors the overall concordance between the CNB and SS was worse, especially for HER2. Six of these patients had areas of tumor that were positive for HER2, which were not detected in their CNBs. Nine patients had multiple distinct molecular subtypes within their tumor(s).

CONCLUSIONS

The heterogeneous distribution of antigens in breast cancer tumors raises concern that the CNB may not adequately represent the true biologic profile in all patients. There is strong concordance for tumor type, ER, and PR between CNB and SS (although a quantitative decline was noted from CNB to SS); however, HER2 activity does not appear to be adequately detected on CNB in patients with heterogeneous tumors. These data suggest that IHC testing on the CNB alone may not be adequate to tailor targeted therapy in all patients.

Efficacy of 'radioguided occult lesion localisation' (ROLL) versus 'wire-guided localisation' (WGL) in breast conserving surgery for non-palpable breast cancer: a randomised controlled multicentre trial

For the management of non-palpable breast cancer, accurate pre-operative localisation is essential to achieve complete resection with optimal cosmetic results. Radioguided occult lesions localisation (ROLL) uses the radiotracer, injected intra-tumourally for sentinel lymph node identification to guide surgical excision of the primary tumour. In a multicentre randomised controlled trial, we determined if ROLL is superior to the standard of care (i.e. wire-guided localisation, WGL) for preoperative tumour localisation. Women (>18 years.) with histologically proven non-palpable breast cancer and eligible for breast conserving treatment with sentinel node procedure were randomised to ROLL or WGL. Patients allocated to ROLL received an intra-tumoural dose of 120 Mbq technetium-99 m nanocolloid. The tumour was surgically removed, guided by gamma probe detection. In the WGL group, ultrasound- or mammography-guided insertion of a hooked wire provided surgical guidance for excision of the primary tumour. Primary outcome measures were the proportion of complete tumour excisions (i.e. with negative margins), the proportion of patients requiring re-excision and the volume of tissue removed. Data were analysed according to intention-to-treat principle. This study is registered at ClinincalTrials.gov, number NCT00539474. In total, 314 patients with 316 invasive breast cancers were enrolled. Complete tumour removal with negative margins was achieved in 140/162 (86 %) patients in the ROLL group versus 134/152 (88 %) patients in the WGL group (P = 0.644). Re-excision was required in 19/162 (12 %) patients in the ROLL group versus 15/152 (10 %) (P = 0.587) in the WGL group. Specimen volumes in the ROLL arm were significantly larger than those in the WGL arm (71 vs. 64 cm(3), P = 0.017). No significant differences were seen in the duration and difficulty of the radiological and surgical procedures, the success rate of the sentinel node procedure, and cosmetic outcomes. In this first multicentre randomised controlled comparison of ROLL versus WGL in patients with histologically proven breast cancer, ROLL is comparable to WGL in terms of complete tumour excision and re-excision rates. ROLL, however, leads to excision of larger tissue volumes. Therefore, ROLL cannot replace WGL as the standard of care.

Assessment accuracy of core needle biopsy for hormone receptors in breast cancer: a meta-analysis

The concordance of hormone receptors (HR) status identified by core needle biopsy (CNB) compared with excisional biopsy (EB) has been widely reported, but results were extremely variable and underpowered. To derive a more precise estimation of assessment accuracy of CNB for HR in breast cancer, we conducted a meta-analysis of all eligible studies comparing concordance or disconcordance between CNB and EB for HR status. Eligible articles were identified by search of databases including PubMed, Web of Science, EMBASE, and Chinese Biomedical Literature database for the period up to November 2011, and the reference lists of identified studies, relevant reviews, meta-analyses, and abstracts from recent conference proceedings were reviewed as a augmented searching. Finally, a total of 21 articles involving 2,450 patients for estrogen receptor (ER) and 2,448 patients for progesterone receptor (PR) were included and analyzed in this analysis. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies checklist. The overall aggrement between CNB and EB were 92.8 % for ER (κ = 0.78) and 85.2 % for PR (κ = 0.66), indicating a good agreement in PR and a better result in ER. The pooled sensitivity and specificity were 97.3 % (95 % CI 96.0-98.2) and 82.0 % (95 % CI 68.2-90.6) for ER, and the corresponding values for PR were 92.3 % (95 % CI 88.2-95.1) and 76.5 % (95 % CI 64.6-85.3), respectively. The pooled positive likelihood ratios was 5.39 % (95 % CI 2.92-9.97) and the negative likelihood ratios was 0.03 % (95 % CI 0.02-0.05) for ER, the corresponding values for PR were 3.93 % (95 % CI 2.53-6.11) and 0.10 % (95 % CI 0.07-0.16), respectively. In summary, although a good agreement was observed between CNB and EB for both ER and PR, we still suggest that negative HR testing results should be interpreted with caution or repeated on EB.

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

RATIONALE AND OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluation of the clinical efficacy of minimally invasive procedures for breast cancer screening at a teaching hospital

AIMS

To assess the clinical efficacy of diagnostic procedures for breast cancer at a teaching hospital using internal auditing tools and quality control measures.

METHODS

A retrospective assessment of 500 patients who underwent core needle biopsy (wide-bore needle biopsy; WBN) of palpable or non-palpable breast nodes that were submitted for at least one cytological examination (fine needle aspiration (FNA) cytology and/or imprint of a WBN specimen). For statistical analysis the auditing tool and quality control proposed by the National Health Service breast screening programme was utilised.

RESULTS

For FNA, full specificity, positive predictive value, inadequate rates and suspicious rates were satisfactory while absolute sensitivity, complete sensitivity, false negatives and false positives were unsatisfactory. For imprint, absolute sensitivity, complete sensitivity, inadequate rate from cancers and suspicious rates were satisfactory, and the remaining indicators were unsatisfactory. WBN displayed the best performance with absolute sensitivity, complete sensitivity, false negative, suspicious rates, full specificity and predictive value showing satisfactory results and only one unsatisfactory result (false positive).

CONCLUSIONS

Based on an overall analysis, WBN displayed the highest clinical efficacy compared with FNA and imprint, and demonstrated adequate safety for confirming the appropriate diagnosis and management of patients, ensuring the efficacy of the service.

Needle versus excisional biopsy for noninvasive and invasive breast cancer: report from the National Cancer Data Base, 2003-2008

BACKGROUND

Needle biopsy to diagnose breast cancer may soon become a quality measure for which hospitals are held accountable. This study examines the utilization of needle versus excisional biopsy in a contemporary cohort of patients and identifies factors associated with biopsy type.

METHODS

Women with nonmetastatic, clinical Tis-T3 breast cancers diagnosed between 2003 and 2008 were selected from the National Cancer Data Base, which captures information from ~79% of breast cancers in the United States. Patients whose cancer was diagnosed by needle biopsy (fine-needle aspiration or core) were compared with patients diagnosed via excision, analyzing patient, hospital, and tumor characteristics. Logistic regression was used to identify important predictors of biopsy type.

RESULTS

Of 373,837 patients, 303,677 (81.2%) underwent needle biopsy while 70,160 (18.8%) had excisional biopsy to diagnose their cancer. The needle biopsy rate increased from 73.8 to 86.7% whereas excisional biopsy declined from 26.2 to 13.3% over the study period (P < 0.001). In 2008, patients were statistically significantly more likely to undergo excisional biopsy if they had stage 0 disease; were treated at low-volume (<25 cases/year), community, or Atlantic census region hospitals; were <40 years old at diagnosis; were less educated; or were Asian/Pacific Islander (P < 0.001). The median rate of needle biopsy at high-volume hospitals (≥140 cases/year) was 89.6%.

CONCLUSION

The use of needle biopsy is increasing. Tumor stage, hospital volume, and hospital location were the most statistically significant predictors of biopsy type. Rates of needle biopsy at high-volume hospitals suggest that appropriate utilization of this preferred diagnostic method should approach 90%.

Accuracy and Upgrade Rates of Percutaneous Breast Biopsy: The Surgeon's Role

We sought to evaluate the impact of needle core size and number of core samples on diagnostic accuracy and upgrade rates for image-guided core needle biopsies of the breast. A total of 234 patients underwent image-guided percutaneous needle biopsies and subsequent surgical excision. Large-core needles (9 gauge or less) were used in 14.5 per cent of cases and the remainder were performed with smaller core needles. More than four core samples were taken in 78.9 per cent of patients. In 71.8 per cent of cases, needle biopsy pathology matched surgical excision pathology. After surgical excision, upgraded pathology was revealed in 10.7 per cent of cases. Of 11 patients (52.4%) with benign needle core pathology who had upgraded final pathology on surgical excision, 10 had a Breast Imaging Recording and Data System score 4 or 5 imaging study. Lesions smaller than 10 mm were more likely to be misdiagnosed ( P = 0.01) or have upgraded pathology ( P = 0.009). Other predictors of upgraded pathology were patient age 50 years or older ( P = 0.03) and taking four or fewer core samples ( P = 0.003). Needle core size did not impact accuracy or upgrade rates. Surgeons should exercise caution when interpreting needle biopsy results with older patients, smaller lesions, and limited sampling. Discordant pathology and imaging still mandate surgical confirmation.

Analysis of false-negative results after US-guided 14-gauge core needle breast biopsy

OBJECTIVES

To determine the false-negative rate and to evaluate the clinical, radiologic or histologic features of false-negative results at ultrasound (US)-guided 14-gauge core needle biopsy (CNB).

METHODS

A total of 3,724 masses from 3,308 women who had undergone US-guided 14-gauge CNB and who had a rebiopsy or at least 2 years' follow-up were included. The histology of CNB was correlated with the rebiopsy or long-term imaging follow-up. In cases of missed cancer, the time interval between CNB and rebiopsy, the reasons for rebiopsy, and the procedural or lesion characteristics were analysed.

RESULTS

Of 1,706 benign CNBs, 50 additional malignancies were found at excision (false-negative rate, 2.5% of 1,982 with a final diagnosis of malignancy). Of 50 false negatives, 41 were found immediately of which 28 had rebiopsy because of imaging-histological discordance. Regarding the frequency of malignancy according to the reasons for rebiopsy, suspicious imaging finding (24%) showed significantly higher frequency than suspicious clinical findings or request (1%). Regarding the characteristics except invasiveness, no significant differences in false-negative rates were found.

CONCLUSIONS

Most false negatives were found immediately and imaging-histological discordance was the most important clue. Careful correlation of clinical, radiological and histological results as well as appropriate follow-up is essential.

Can galactography-guided stereotactic, 11-gauge, vacuum-assisted breast biopsy of intraductal lesions serve as an alternative to surgical biopsy?

The purpose of this study was to determine the value of galactography-guided, stereotactic, vacuum-assisted breast biopsy (VABB) for the assessment of intraductal breast lesions and its potential as a therapeutic tool that could eliminate the need for surgical excision. Eighteen patients (median age 64 years, range 37-80) with nipple discharge and galactography-verified intraductal lesions underwent galactography-guided, stereotactic, 11-gauge VABB followed by surgery. Histopathology findings from VABB and subsequent surgery were compared. Underestimation and false-negative rates were assessed. After VABB, histopathology revealed invasive ductal carcinoma (IDC) in three (17%), ductal carcinoma in situ (DCIS) in six (33%), high-risk lesions in six (33%) and benign lesions in three (17%) cases. After surgical biopsy, histopathology confirmed the previously established diagnosis in 11 lesions (61%). The underestimation rate for high-risk lesions and DCIS was 50% (6/12). The false-negative rate was 7% (1/14). Histopathology examination after surgery showed that not a single lesion had been completely removed at VABB. Galactography-guided VABB is a feasible diagnostic tool. However, its value as a therapeutic procedure is limited because of the high number of underestimated and missed lesions and because of the histopathological detection of lesions' remnants in every case. Surgical excision should be the therapeutic gold standard in cases of pathological nipple discharge and galactography abnormalities.

False-negative diagnoses at stereotactic vacuum-assisted needle breast biopsy: long-term follow-up of 1,280 lesions and review of the literature

OBJECTIVE

The purpose of this study was to determine retrospectively the frequency and causes of false-negative diagnoses of lesions evaluated with percutaneous stereotactic biopsy performed with vacuum-assisted probes with the patient prone on a biopsy table.

MATERIALS AND METHODS

The records of 1,152 women (median age, 55 years; range, 31-94 years) with 1,280 lesions consecutively biopsied with 14-gauge (n = 159) or 11-gauge (n = 1,121) vacuum probes were reviewed retrospectively. The histologic diagnoses were malignant (n = 489), high-risk (n = 117), and benign (n = 674) lesions. Benign lesions were evaluated with repeated biopsy (n = 46) or mammographic follow-up for 24 months or longer (n = 506) or less than 24 months (n = 57). In 65 cases (10% of all benign lesions), follow-up was not performed. Fisher's exact tests were used to correlate patient, mammographic, and biopsy variables with false-negative diagnoses.

RESULTS

Of 508 lesions with a final diagnosis of malignancy, the initial needle biopsy diagnosis was malignant (n = 489), high-risk (n = 14), or benign (n = 5) lesion. The five false-negative diagnoses were related to gauge of the biopsy probe and specimen radiographic findings regarding calcifications but were not related to lesion type. False-negative diagnoses were made in 4.4% (three of 68) of cases in which 14-gauge vacuum biopsy was performed and in 0.45% (two of 440) of cases in which 11-gauge vacuum biopsy was performed (p = 0.019). False-negative diagnoses were made in 25% (one of four) of cases in which specimen radiographs showed no calcifications and 0.67% (two of 300) of cases in which they did show calcifications (p = 0.0390). False-negative diagnoses were made in 1.2% (three of 248) of cases of calcification lesions and 0.8% (two of 260) of cases of mass lesions (p = 0.679).

CONCLUSION

False-negative findings at stereotactic biopsy were least common with 11-gauge probes and were similar in frequency for calcifications and masses.

Diagnostic Accuracy and Prognostic Value of Core Biopsy in the Management of Breast Cancer: A Series of 542 Patients

Purpose. Core biopsy is considered to be a highly accurate method for gaining preoperative diagnosis of breast cancer. The purpose of this study is to compare the results of core biopsy with those of the surgical excision specimen. Experimental design. A total of 567 core biopsies with subsequent surgical excision were performed. Results. In 488 patients, invasive breast cancer was diagnosed in the preoperative biopsy and in 486 patients (99.6%) the surgical specimen showed identical results. In 160 of the 502 patients (32%) with invasive breast cancer, DCIS was found in the surgical specimen but was not diagnosed in the biopsy. Estrogen and progesterone receptor demonstrated a high rate of agreement, Her2/neu analysis showed a complete concordance in 54% of patients. Conclusions. Core biopsies allow diagnosis of invasive breast cancer with high accuracy. Levels of agreement have to be improved for the detection of DCIS and Her2/neu status.