[Stereotactic vacuum core biopsy of clustered microcalcifications classified as B1-RADS 3]

Ultrasound-guided vacuum-assisted breast biopsy: Use at the European Institute of Oncology in 2010

Vacuum-assisted breast biopsy (VABB), which plays a fundamental role in the preoperative assessment of microcalcifications, can also be used (with ultrasound guidance) to obtain histology samples of breast lesions that are visible on ultrasonography. It is particularly useful when the lesion diameter is less than 1 cm. This technique has been used in our institute since 1998, and in this report we analyze our experience with it in 2010. This analysis shows that VABB is a safe, effective procedure that can markedly reduce the need for surgical biopsy.

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.

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.

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.

[Presentation of the French translation of the Breast Imaging Reporting System and Data System (BI-RADS)]

BI-RADS is a system of assistance to the drafting of the reports more and more used in the world and soon directly implemented on mammography and ultrasound units. The categories of evaluation of the BI-RADS allow a clear synthesis of the descriptive data resulting from the use of the lexicon and invite the radiologist to a reasoned, objective and less intuitive step. They give an action to be taken and responsibility to the radiologist and the referring physicians in the assumption of the patients. The 4th edition of the BI-RADS mammography appeared in 2003, and is now associated with the first editions of the BI-RADS ultrasound and MRI.

Applications and literature review of the BI-RADS classification

The Breast Imaging Reporting and Data System (BI-RADS) of the American College of Radiology (ACR) is a tool created to reduce variability in the terminology used in mammographic reports. An illustration of mammographic examples from our institution interpreted according to the BI-RADS lexicon of the American College of Radiology (ACR) is presented. A literature review concerning the usefulness and limitations of the BI-RADS lexicon is given.

Mammographic features and correlation with biopsy findings using 11-gauge stereotactic vacuum-assisted breast biopsy (SVABB)

BACKGROUND

Mammograms are assigned a BI-RADS (Breast Imaging Reporting and Data System) category, which indicates the level of suspicion for cancer.

OBJECTIVES

(i) To evaluate the use of BI-RADS categories in a non-academic radiology practice based in a community hospital compared with local radiology private offices; (ii) to determine positive predictive value (PPV), sensitivity and specificity of mammograms; and (iii) to explore the correlation of BI-RAD 3-5 and lesion description with diagnosis of cancer.

PATIENTS AND METHODS

We performed 947 SVABBs (stereotactic vacuum-assisted breast biopsies) on 911 patients with BI-RADS 3-5. Lesions were classified as: 1=microcalcifications; 2=asymmetric density; 3=circumscribed mass; and 4=spiculated mass.

RESULTS

BI-RADS category correlated with diagnosis of breast cancer (atypia excluded): category 3=4%; category 4=15%; and category 5=79%. The PPV of BI-RADS 4 and 5 for breast cancer or atypia was 20%, in contrast to 5% for BI-RADS 3. Sensitivity and specificity were 95% and 19%, respectively. For BI-RADS 3 without microcalcifications only 3% were positive, in contrast to 8% for remainder.

CONCLUSIONS

First, there is a stepwise increase in cancer for each of the BI-RADS categories 3-5. Secondly, in BI-RADS 3 with microcalcifications, a biopsy is indicated according to our findings. Finally, the sensitivity of mammograms is 95% but the specificity is 19%.

Evaluation of Breast Imaging Reporting and Data System Category 3 mammograms and the use of stereotactic vacuum-assisted breast biopsy in a nonacademic community practice

BACKGROUND

Breast Imaging Reporting and Data System (BI-RADS) Category 3 represents 'probably benign' mammographic abnormalities requiring close follow-up, but biopsies sometimes are performed on Category 3 abnormalities. Controversy exists as to when these biopsies are justified. The goals of the current study were to evaluate the use of stereotactic vacuum-assisted breast biopsy (SVABB) for BI-RADS 3 lesions in a nonacademic community hospital-based practice, to evaluate the false- negative rate of Category 3 mammograms, and to determine whether any specific lesions misinterpreted as BI-RADS 3 abnormalities might commonly be associated with malignant disease.

METHODS

From August 2000 to December 2002, the authors performed 947 SVABB procedures on 911 patients. They focused on 156 SVABBs of BI-RADS 3 abnormalities.

RESULTS

Of 634 SVABB procedures requested by outside sources, 114 (18%) were performed for BI-RADS 3 abnormalities, compared with 42 (13%) of 313 SVABB procedures that were performed based on mammographic findings at the authors' practice (P = 0.075). After SVABB, 7 of 156 patients with BI-RADS 3 lesions were diagnosed with breast carcinoma and 1 was diagnosed with atypical ductal hyperplasia. Therefore, the false-negative rate of BI-RADS 3 mammograms was 4.5% (i.e., 7 of 156 patients). Patients with linear microcalcifications had the highest rate of cancer (4 of 14 [29%]) compared with patients without microcalcifications (1 of 64 [1.5%]) and patients with nonlinear microcalcifications (2 of 69 [2.9%]).

CONCLUSIONS

The use of SVABB for BI-RADS 3 lesions reflected uncertainty regarding the potential for a diagnosis of malignant disease rather than the financial incentive of performing a biopsy. SVABB was not necessary for patients with BI-RADS 3 lesions without microcalcifications or for patients with nonlinear microcalcifications. Lesions with linear (casting or branching) microcalcifications should not be considered BI-RADS 3 abnormalities.