Coaxial technique: approach to breast core biopsies

A new risk stratification score for the management of ultrasound-detected B3 breast lesions

To develop a predictive scoring system for ultrasound-detected B3 lesions at ultrasound-guided core needle biopsy (US-CNB). A total of 2724 consecutive US-CNBs performed in our Institution (January 2011 to December 2014) were retrospectively reviewed. Inclusion criteria were as follows: (a) histopathological examination of the entire lesion or (b) availability of radiologic follow-up (FUP) ≥24 months. Patient- and lesion-related variables-patients' age, lesion consistency, lesion size, vascularization, BI-RADS category, and US-CNB result-were analyzed. Positive predictive values (PPVs) for malignancy were calculated correlating US-CNB results with excision histology or FUP. A scoring system for underlying malignancy was developed using risk factors weighting. A total of 102 B3 lesions were included: 27 atypical ductal hyperplasia (26.5%), 5 lobular intraepithelial neoplasia (4.9%), 32 radial scar (31.4%), 37 papillary lesions (36.3%), and 1 fibroepithelial lesion (0.9%). Surgery was performed on 71/102 (69.6%) lesions, and 22/71 were malignant; the remaining 31/102 lesions (30.4%) were unchanged at FUP. The overall PPV for malignancy was 21.6%. Patients' age (odds ratio [OR] = 3.63, P = 0.008), lesion consistency (OR = 5.96, P = 0.001), BI-RADS category (OR = 17.52, P < 0.001), and CNB result (OR = 3.6, P = 0.008) were associated with a higher risk of malignancy underestimation and selected as risk factors in the score definition. Two risk groups were identified: low (0-2 points) and high risk (3-5 points), with significantly different risk of malignancy underestimation (8.0% vs 59.3%, P < 0.001). The proposed score helps to predict the risk of malignancy underestimation and choose the management of B3 lesions at US-CNB.

Initial Experience with a Wireless Ultrasound-Guided Vacuum-Assisted Breast Biopsy Device

Objective

To determine the imaging characteristic of frequent target lesions of wireless ultrasound (US)-guided, vacuum-assisted breast biopsy (Wi-UVAB) and to evaluate diagnostic yield, accuracy and complication of the device in indeterminate breast lesions.

Materials and Methods

From March 2013 to October 2014, 114 women (age range, 29–76 years; mean age, 50.0 years) underwent Wi-UVAB using a 13-gauge needle (Mammotome Elite^®; Devicor Medical Products, Cincinnati, OH, USA). In 103 lesions of 96 women with surgical (n = 81) or follow-up (n = 22) data, complications, biopsy procedure, imaging findings of biopsy targets and histologic results were reviewed.

Results

Mean number of biopsy cores was 10 (range 4–25). Nine patients developed moderate bleeding. All lesions were suspicious on US, and included non-mass lesions (67.0%) and mass lesions (33.0%). Visible calcifications on US were evident in 57.3% of the target lesions. Most of the lesions (93.2%) were nonpalpable. Sixty-six (64.1%) were malignant [ductal carcinoma in situ (DCIS) rate, 61%] and 12 were high-risk lesions (11.7%). Histologic underestimation was identified in 11 of 40 (27.5%). DCIS cases and in 3 of 9 (33.3%) high-risk lesions necessitating surgery. There was no false-negative case.

Conclusion

Wi-UVAB is very handy and advantageous for US-unapparent non-mass lesions to diagnose DCIS, especially for calcification cases. Histologic underestimation is unavoidable; still, Wi-UVAB is safe and accurate to diagnose a malignancy.

Image-guided breast biopsy: state-of-the-art

Percutaneous image-guided breast biopsy is widely practised to evaluate predominantly non-palpable breast lesions. There has been steady development in percutaneous biopsy techniques. Fine-needle aspiration cytology was the original method of sampling, followed in the early 1990s by large core needle biopsy. The accuracy of both has been improved by ultrasound and stereotactic guidance. Larger bore vacuum-assisted biopsy devices became available in the late 1990s and are now commonplace in most breast units. We review the different types of breast biopsy devices currently available together with various localization techniques used, focusing on their advantages, limitations and current controversial clinical management issues.

Halfpipe coaxial cannula for self-contained vacuum-assisted biopsy systems: feasibility in a pig breast model

OBJECTIVE

The purpose of this article is to discuss the development of a dedicated halfpipe coaxial cannula for stereotactic vacuum-assisted biopsy. We evaluated the system by retrieving 18 copper targets from a pig breast model in the upright position via vertical and lateral approaches.

CONCLUSION

Sampling was successful in 15 of 18 cases. Errors occurred only in superficial lesions biopsied via the vertical approach. The halfpipe coaxial cannula shows promise for improving positioning accuracy, avoiding target dislocation, and obviating repeated needle repositioning.

Impact of stereotactic 11-g vacuum-assisted breast biopsy on cost of diagnosis in Austria

PURPOSE

To determine the frequency with which stereotactic 11-g vacuum-assisted breast biopsy (11-g SVAB) obviates an open surgical biopsy (OSB), to compare the costs of these two biopsy methods, and to estimate the potential cost savings attributable to 11-g SVAB in the diagnosis of suspicious breast lesions in patients in Austria.

MATERIALS AND METHODS

We retrospectively reviewed 318 consecutive breast lesions of BI-RADS categories IV and V (microcalcifications n=166; masses n=152) on which 11-g SVAB and OSB were performed. Cost savings were calculated using nationally allowed flat rates and patient charges. Costs were measured from a hospital and a socioeconomic perspective. Common clinical scenarios and sensitivity analyses assessed the extent of achievable cost savings.

RESULTS

11-g SVAB obviated the need for an OSB in 93 (29%) of 318 women. Overall cost savings per 11-g SVAB over OSB were € 242 per case from a hospital perspective, and € 422 per case from a socioeconomic perspective. The use of 11-g SVAB decreased the cost of diagnosis by 7% from a hospital perspective, and by 10% from a socioeconomic perspective.

CONCLUSION

In Austria, annual national savings of over 5 million Euro could be realized with the use of 11-g SVAB for the diagnosis of suspicious breast lesions. Although savings per case are modest, the national health care system realizes significant cost reduction as women benefit from a faster and less invasive approach to diagnosis.

Cost comparison between ultrasound-guided 14-g large core breast biopsy and open surgical biopsy: an analysis for Austria

PURPOSE

To examine the budget impact of ultrasound-guided 14-g large core breast biopsy (US-guided LCBB) by comparing the costs of US-guided LCBB and open surgical biopsy (OSB); to calculate the cost savings attributable to US-guided LCBB; and to assess the frequency with which US-guided LCBB obviates the need for an OSB.

MATERIALS AND METHODS

In a retrospective study, we reviewed 399 suspicious breast lesions on which US-guided LCBB and OSB or, in cases of benign histology, clinical follow-up, were performed. Cost savings were calculated using nationally allowed flat rates (A-drg) and patient charges. Costs were measured from both, a hospital and a socioeconomic perspective. Deterministic sensitivity analyses were simulated to assess the extent of achievable cost savings.

RESULTS

Overall cost savings for US-guided LCBB over OSB were euro 977 (euro 2,337/euro 3,314) per case from a hospital perspective, resulting in a total cost decrease of 30% for the diagnosis of suspicious breast lesions. From a socioeconomic perspective, cost savings were euro 1,542 (euro 2,600/euro 4,142) per case, resulting in a 37% reduction in biopsy cost. US-guided LCBB obviated the need for a surgical procedure in 240 (60%) of 399 women. In all four sensitivity analyses, costs of US-guided LCBB remained lower than that of OSB.

CONCLUSION

From an economic perspective, US-guided LCBB is highly recommended for the diagnosis of suspicious breast lesions, as this procedure reduces the cost of diagnosis substantially. In Austria, annual cost savings would be euro 18.5 million.

Fluorescence spectroscopy: an adjunct diagnostic tool to image-guided core needle biopsy of the breast

We explored the use of a fiber-optic probe for in vivo fluorescence spectroscopy of breast tissues during percutaneous image-guided breast biopsy. A total of 121 biopsy samples with accompanying histological diagnosis were obtained clinically and investigated in this study. The tissue spectra were analyzed using partial least-squares analysis and represented using a set of principal components (PCs) with dramatically reduced data dimension. For nonmalignant tissue samples, a set of PCs that account for the largest amount of variance in the spectra displayed correlation with the percent tissue composition. For all tissue samples, a set of PCs was identified using a Wilcoxon rank-sum test as showing statistically significant differences between: 1) malignant and fibrous/benign; 2) malignant and adipose; and 3) malignant and nonmalignant breast samples. These PCs were used to distinguish malignant from other nonmalignant tissue types using a binary classification scheme based on both linear and nonlinear support vector machine (SVM) and logistic regression (LR). For the sample set investigated in this study, the SVM classifier provided a cross-validated sensitivity and specificity of up to 81% and 87%, respectively, for discrimination between malignant and fibrous/benign samples, and up to 81% and 81%, respectively, for discriminating between malignant and adipose samples. Classification based on LR was used to generate receiver operator curves with an area under the curve (AUC) of 0.87 for discriminating malignant versus fibrous/benign tissues, and an AUC of 0.84 for discriminating malignant from adipose tissue samples. This study demonstrates the feasibility of performing fluorescence spectroscopy during clinical core needle breast biopsy, and the potential of this technique for identifying breast malignancy in vivo.

Accuracy of ultrasound-guided, large-core needle breast biopsy

Ultrasound-guided, large-core needle biopsy (US-LCNB) of suspicious breast lesions is acknowledged as less invasive and less expensive and less time consuming than surgical biopsy, and provides a histologic diagnosis with a comparable high degree. US-LCNB has been proven to help reduce the number of unnecessary surgeries for benign disease. Its limitations, however, are false-negative results and underestimation of disease. Thus, the demand for breast teams is to carefully adhere to the principles of triple assessment and imaging-histologic correlation, and follow-up of lesions with a specific benign histology after biopsy. Also, the acceptance of guidelines and rigorous quality controls help to reliably minimize the delay in the diagnosis of breast cancer in patients with false-negative biopsies. This paper aims to summarize the equipment and methods as well as the benefits and limitations of US-LCNB. Also, guidelines of quality assessment are suggested. Finally, recent developments which may help to overcome the limitations of US-LCNB will be discussed, i.e., directional vacuum-assisted biopsy (VAB), three-dimensional (3D) US-guided biopsy, as well as the use of tissue harmonic imaging (THI) and compound imaging (CI) during biopsy.

MRI-Guided percutaneous biopsy of breast lesions: materials, techniques, success rates, and management in patients with suspected radiologic-pathologic mismatch

MR imaging of the breast allows the detection of suspicious breast lesions that are occult at mammography and ultrasound. For the histologic verification of such lesions, percutaneous MR imaging-guided biopsy techniques can now be offered as an alternative to open breast biopsy. This review focuses on the currently available devices and techniques for MR imaging-guided percutaneous breast biopsy and reports their achievable diagnostic accuracy. Technical success rates and strategies for patient management are also outlined. In addition, new developments in MR imaging-guided minimally invasive therapeutic interventions are discussed, as well as the potential for research opportunities and directions.

Missed Breast Cancers at US-guided Core Needle Biopsy: How to Reduce Them

Ultrasonographically (US) guided core needle biopsy is currently recognized as a reliable alternative to surgical biopsy for the histopathologic diagnosis of breast lesions. However, despite advances in biopsy devices and techniques, false-negative diagnoses are unavoidable and may delay the diagnosis and treatment of breast cancer. The most common reasons for false-negative diagnosis are (a) technical or sampling errors, (b) failure to recognize or act on radiologic-histologic discordance, and (c) lack of imaging follow-up after a benign biopsy result. Technical difficulties (eg, poor lesion or needle visualization, deeply located lesions, dense fibrotic tissue) cause inaccurate sampling but can be reduced by using modified standard techniques. Radiologic-histologic correlation is also of critical importance in US-guided core needle biopsy. Radiologic-histologic discordance occurs when the histologic results do not provide a sufficient explanation for the imaging features and indicates that the lesion may not have been sampled adequately, so that repeat biopsy is warranted. Appropriate follow-up imaging is invaluable; even patients with concordant benign findings after US-guided core needle biopsy are directed to undergo follow-up imaging because there may be delays in the recognition of false-negative findings. Optimization of technique, radiologic-histologic correlation, and postbiopsy follow-up protocols are recommended to reduce the occurrence of false-negative diagnosis at US-guided core needle biopsy performed by radiologists.

Stereotactic 11-gauge vacuum-assisted breast biopsy: a validation study

OBJECTIVE

The aim of our study was to determine the false-negative rate of stereotactic 11-gauge vacuum-assisted biopsy in a validation study of lesions that had subsequent surgical excision.

MATERIALS AND METHODS

Retrospective review was performed of 318 lesions that underwent stereotactic 11-gauge vacuum-assisted biopsy and subsequent surgical excision. A false-negative case was defined as a pathologically proven cancer in which stereotactic biopsy yielded benign results without atypia. Medical records, imaging studies, and histologic findings were reviewed.

RESULTS

False-negative findings were encountered at stereotactic 11-gauge vacuum-assisted biopsy in 3.3% (7/214) of pathologically proven cancers. False-negative findings occurred in 3.5% (4/115) of malignant calcification lesions versus 3.0% (3/99) of malignant masses (p = 1.0). The seven false-negative findings included five Breast Imaging Reporting and Data System (BI-RADS) category 5 lesions that yielded benign results at biopsy, one BI-RADS category 4 mass that benign breast tissue, and one BI-RADS category 4 cluster of calcifications in which no calcifications were retrieved. The false-negative rate was 10.0% (6/60) for radiologists who performed 15 or fewer previous stereotactic vacuum-assisted biopsy procedures versus 0.6% (1/154) for radiologists who performed more than 15 previous stereotactic vacuum-assisted biopsy procedures (p = 0.002).

CONCLUSION

Stereotactic 11-gauge vacuum-assisted biopsy had a false-negative rate of 3.3% that diminished to 0.6% with experience. All false-negative findings could be prospectively identified because of failure to sample calcifications or imaging-histologic discordance.

Comparison of core needle breast biopsy techniques: freehand versus three-dimensional US guidance

RATIONALE AND OBJECTIVES

No single method is generally accepted for evaluating the accuracy of breast biopsy techniques before their clinical implementation. The purpose of this study was to test a new process for evaluating biopsy techniques by using it in the evaluation of a prototype three-dimensional ultrasound (US)-guided biopsy device.

MATERIALS AND METHODS

The biopsy accuracy of a new three-dimensional US-guided breast biopsy device was compared to that of the accepted clinical practice of biopsy by expert radiologists with two-dimensional freehand US guidance. Biopsies were performed in chicken tissue phantoms containing 3.2-mm lesions made of poly(vinyl alcohol) cryogel. The criterion for a successful biopsy was the presence of lesion in the sample. The equivalence limit difference tested was 10% by using a power of 90% and a two-sided test significance level, a, of 10%.

RESULTS

The biopsy success rate of the three-dimensional US-guided system (96%) was equivalent to that of expert radiologists using two-dimensional freehand US guidance (94.5%) in tissue phantoms containing poly(vinyl alcohol) cryogel lesions.

CONCLUSION

This evaluation procedure is a valuable precursor to clinical trials in the assessment of biopsy techniques. The three-dimensional US-guided breast biopsy system provides a suitable alternative to two-dimensional freehand US guidance for biopsy of breast cancer.

Comparison of sitting versus prone position for stereotactic large-core breast biopsy in surgically proven lesions

OBJECTIVE

Our purpose was to compare the two different body positions for stereotactic large-core breast biopsy with regard to sensitivity, specificity, and accuracy, as well as complication rate.

SUBJECTS AND METHODS

Two hundred patients had large-core breast biopsy performed either in the prone (n = 100) or in the sitting (n = 100) position and subsequently underwent surgical resection. The histopathologic findings of large-core breast biopsy and surgery of all 200 patients were compared; sensitivity, specificity, and accuracy were calculated for both groups. Biopsy-associated complications were prospectively recorded for immediate and delayed events and for technical failures in both groups.

RESULTS

Sensitivity (96%), specificity (100%), and accuracy (98%) were the same for both groups with two false-negative findings in each group. The two false-negative results in the sitting group were caused by vasovagal reactions, whereas those in the prone group were caused by technical failure and uncomfortable biopsy position. More statistically significant complications (seven vs four, p < 0.001) and vasovagal reactions (seven vs two, p < 0.0001) were seen in the sitting group.

CONCLUSION

For performance of large-core breast biopsy, both the prone and sitting positions are reliable and accurate methods. However, vasovagal reactions that could potentially complicate biopsy were seen significantly more often in the sitting position.

Localization and biopsy of breast lesions by magnetic resonance imaging guidance

Contrast-enhanced MRI of the breast has proved to be a valuable tool in the detection and work-up of breast lesions. Most of these lesions are small and not visible by other imaging modalities, such as mammography or US. Thus, only MR-guided preoperative localization techniques or MR-guided percutaneous biopsy can provide a histologic work-up of such lesions. MR-guided preoperative localization seems to be a well-established procedure. However, MR-guided biopsy is still problematic. Although prototypical biopsy systems have been developed, considerable progress is still required. Problems exist with MR-guided biopsy due to severe needle artifacts and tissue shift during the intervention. Thus, needle biopsy currently is not recommended for lesions smaller than 10 mm. This work reviews current techniques for MR-guided preoperative localization and percutaneous biopsy in breast lesions. The diagnostic accuracy achievable with these techniques will be discussed, as well as the potential for new research opportunities and directions. J. Magn. Reson. Imaging 2001;13:903-911.

Role of high magnification specimen radiography in surgical and core biopsies of the breast

The clinical relevance of a high magnification specimen radiography (HMSR) system in breast biopsies was evaluated and compared with conventional specimen radiography with a mammography system (SRM). 100 surgical biopsies of 72 patients and 248 core biopsies of 30 patients were examined in (a) maximal 20-fold HMSR in combination with storage phosphors and (b) 1.8-fold SRM using a film-screen system. Detection of calcifications/soft tissue lesions and the impact on management were evaluated. In surgical biopsies, SRM could detect only 22% of individual microcalcifications, 39% of calcified lesions and 67% of soft tissue lesions identified with HMSR. Calcifications down to 10 microns were identified with HMSR. In five biopsies, peripheral calcifications leading to additional resection were recognized only with HMSR; in three of these they were indicative of malignant tissue. In core biopsies, only 12% of individual microcalcifications seen with HMSR were identified with SRM. 52% and 16% of all cores were calcified on HMSR and SRM, respectively. Microcalcifications within cores were found only with HMSR in 41% of patients with calcified lesions. In conclusion, the better detectability of microcalcifications with HMSR led to justified additional tissue resections in surgical patients and reduced the number of core biopsies required in interventional patients.

Technique and pitfalls of ultrasound-guided core-needle biopsy of the breast

When using ultrasound guidance to perform core-needle biopsy, the curvature of the breast can be used to advantage. By entering the breast from the periphery, chest wall injury is avoided and needle visualization is improved. Visualization of the needle is expedited by bringing the needle to the lesion by using a gentle sweeping motion while keeping the transducer relatively fixed in position. Standard techniques can be modified for difficult lesions, such as those that are mobile, deep, small, or in a large breast. Careful correlation with the mammogram will insure biopsy of the corresponding sonographic lesion. Although complications are uncommon, hematoma or infection may occur after the procedure. With practice, application of standard and modified techniques can result in efficient and accurate ultrasound-guided percutaneous core-needle biopsy of the breast.

Contrast-enhanced magnetic resonance imaging of the breast

Contrast-enhanced magnetic resonance (MR) imaging is increasingly used as a complementary diagnostic modality in breast imaging. The sensitivity of MR imaging of the breast for malignancy has consistently been reported to be excellent. The specificity has been rather variable. Study methods and imaging techniques are not standardized and there is still a great deal of uncertainty about MR imaging's place in clinical practice. Nevertheless, radiologists should be familiar with the current technique and the varying MR appearance of breast tumors to improve the accuracy of this method. This paper reviews the techniques for breast MR imaging, the pathopysiologic basis of contrast enhancement in breast tumors, and the current knowledge about detection and differentiation of breast tumors. In addition, future directions for breast MR imaging are discussed.

Sonographically guided needle biopsy of nonpalpable breast lesions

This article describes the techniques of sonographically guided fine-needle aspiration (FNA) and core-needle biopsy (CNB) of nonpalpable breast lesions. Virtually any nonpalpable breast lesion that is clearly demonstrated on sonograms can be sampled with a needle under ultrasound guidance. Advantages of ultrasound-guided FNA include its pinpoint accuracy, the excellent tolerance by patients, and the ability to aspirate or inject fluid or air. Advantages of ultrasound-guided CNB include a near 100% tissue recovery rate even in fibrous masses, the ability to assess the invasiveness of a cancer, and the fact that tissue cores are readily interpreted by any pathologist. In institutions in which an expert cytopathologist is available, FNA is often used as a first-line biopsy technique, with CNB being reserved for situations in which FNA cannot provide a definitive answer to the question asked. In most institutions, however, CNB has become the standard for percutaneous needle biopsy of breast masses, and sonography has replaced stereotaxy as the standard guidance technique for nonpalpable masses.

Randomized in vitro and in vivo evaluation of different biopsy needles and devices for breast biopsy

In an experimental study (in vitro and in vivo) we evaluated the efficacy of various biopsy needles/devices for breast biopsy. In vitro, biopsies of five human cadaveric breast specimens were performed using 33 different needles/devices ranging from 14 to 20-gauge. Of these 33 needles/devices, 22 optimally performing needles were selected for the in vivo study. In the clinical part of the study, 44 breast lesions were randomly biopsied with each of the 22 needles/devices under stereotactic guidance. Tissue specimens were analysed quantitatively and qualitatively. Several automatic long-throw guns (Acecut, Asap, Biopty, Magnum) obtained greater tissue areas and had a better histopathologic score than the conventional type of a side-notch needle like Trucut, an aspiration needle like Surecut, or an end-cut needle like Autovac. The automatic long-throw guns performed better than the short-throw Monopty gun. Regardless of needle size (14-20-gauge), breast biopsies should be routinely performed with automated long-throw side-notch guns (Acecut, Asap, Biopty, Magnum).

Evaluation of needle size for breast biopsy: comparison of 14-, 16-, and 18-gauge biopsy needles

OBJECTIVE

The purpose of our study was to compare the quantity and quality of tissue harvested from breast biopsy when using 14-, 16-, and 18-gauge "long-throw" needles.

SUBJECTS AND METHODS

We performed a prospective randomized study in 64 patients with 66 breast lesions. Under stereotactic guidance, passes were made in random order with each of the three biopsy needles in each lesion. Samples were measured for tissue area and scored for their quality. All lesions, including benign and malignant lesions and lesions with and without microcalcifications, were analyzed. Findings of the biopsy samples were compared with the final diagnoses made at surgical excision.

RESULTS

In all 66 lesions, 14-gauge biopsy needles obtained significantly larger specimens (14-gauge, 13.14 mm2; 16-gauge, 9.6 mm2; 18-gauge, 6.41 mm2; p < .05) and scored significantly better (14-gauge, 8.37; 16-gauge, 7.56; 18-gauge, 7.14; p < .016) than either of the smaller needles. The results for malignant and benign lesions and for lesions with and without microcalcifications were similar but not equal to the overall results. However, benign lesions and areas with microcalcifications seem to be more problematic for both smaller needles than for 14-gauge needles.

CONCLUSION

Our results indicate that the quantity and quality of breast biopsy specimens depend on the needle size. Of the three needle sizes tested, only 14-gauge long-throw biopsy needles can be recommended for breast biopsy.