Comparison of the underestimation rate in cases with ductal carcinoma in situ at ultrasound-guided core biopsy: 14-gauge automated core-needle biopsy vs 8- or 11-gauge vacuum-assisted biopsy

Could breast multiparametric MRI discriminate between pure ductal carcinoma in situ and microinvasive carcinoma?

BACKGROUND

Ductal carcinoma in situ (DCIS) is often reclassified as invasive cancer in the final pathology report of the surgical specimen. It is of significant clinical relevance to acknowledge the possibility of underestimating invasive disease when utilizing preoperative biopsies for a DCIS diagnosis. In cases where such histologic upgrades occur, it is imperative to consider them in the preoperative planning process, including the potential inclusion of sentinel lymph node biopsy due to the risk of axillary lymph node metastasis.

PURPOSE

To assess the capability of breast multiparametric magnetic resonance imaging (MP-MRI) in differentiating between pure DCIS and microinvasive carcinoma (MIC).

MATERIAL AND METHODS

Between January 2018 and November 2022, this retrospective study enrolled patients with biopsy-proven DCIS who had undergone preoperative breast MP-MRI. We assessed various MP-MRI features, including size, morphology, margins, internal enhancement pattern, extent of disease, presence of peritumoral edema, time-intensity curve value, diffusion restriction, and ADC value. Subsequently, a logistic regression analysis was conducted to explore the association of these features with the pathological outcome.

RESULTS

Of 129 patients with biopsy-proven DCIS, 36 had foci of micro-infiltration on surgical specimens and eight were diagnosed with invasive ductal carcinoma (IDC). The presence of micro-infiltration foci was significantly associated with several MP-MRI features, including tumor size (P <0.001), clustered ring enhancement (P <0.001), segmental distribution (P <0.001), diffusion restriction (P = 0.005), and ADC values <1.3 × 10-3 mm2/s (P = 0.004).

CONCLUSION

Breast MP-MRI has the potential to predict the presence of micro-infiltration foci in biopsy-proven DCIS and may serve as a valuable tool for guiding therapeutic planning.

Update on Lobular Neoplasia

Lobular neoplasia (LN) is a histopathologic entity that encompasses both lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH). Management of LN is known to be variable and institutionally dependent. The variability in approach after a diagnosis of LN at percutaneous breast biopsy derives in part from heterogeneity in the literature, resulting in a range of reported upgrade rates to malignancy after initial identification at percutaneous biopsy, and also from historical shifts in understanding of the natural history of LN. It has become increasingly recognized that not all LN is the same and that distinct variants of LN such as pleomorphic LCIS and florid LCIS have distinct natural histories and distinct likelihoods of upgrade to malignancy. In addition, it is also increasingly understood that appropriate management of LN relies on scrupulous radiologic-pathologic correlation. This review details the imaging features and histopathologic nature of ALH, classic-type LCIS, and the LCIS variants; addresses changes in the historical understanding of this entity contributing to confusion regarding its management; and discusses the importance of performing radiologic-pathologic correlation after percutaneous biopsy to help guide appropriate management steps when LN is encountered. In addition to the short-term implications of an LN diagnosis in terms of upgrade and surgical outcomes, the long-term implications of an LN diagnosis regarding risk of developing a later breast cancer are examined. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Frozen Sections in Decision-Making Regarding the Axillary Procedures in Breast Conserving Surgery for Intraductal Carcinoma at Preoperative Diagnosis

BACKGROUND

Axillary evaluation is unnecessary for pure ductal carcinoma in situ (DCIS); however, it is performed because of the risk of upstaging to invasive cancer. We assessed the role of intraoperative frozen section (IOF) biopsy in reducing invasive cancer upstaging and axillary evaluation in preoperative DCIS patients.

METHODS

We reviewed patients with preoperative DCIS who underwent breast-conserving surgery (BCS) with IOF biopsy. Positive IOF biopsy findings were defined as the presence of invasive or micro-invasive cancer. The IOF biopsy and permanent pathology findings were compared.

RESULTS

Seventy-eight patients underwent BCS with IOF biopsy. Six patients showed positive IOF biopsy findings; five of these patients showed concordant permanent pathology findings. Sentinel lymph node biopsy (SLNB) was positive in one patient. Thirteen patients with invasive breast cancer were missed by IOF biopsy; they underwent SLNB during the second surgery. None of them had metastatic lymph nodes. The sensitivity and specificity of IOF biopsy were 27.7% and 98.3%, respectively, with 82.1% accuracy. None of the other factors showed statistically significant relationships with the permanent pathology findings, except for the IOF biopsy findings.

CONCLUSION

IOF evaluation can aid in detecting the invasiveness of tumors in patients with preoperative DCIS.

The comparison of efficacy and safety evaluation of vacuum-assisted Elite 10-G system and the traditional BARD 14-G core needle in breast diagnosis: an open-label, parallel, randomized controlled trial

BACKGROUND

Vacuum-assisted biopsy (VAB) and core needle biopsy (CNB) are both widely used methods in diagnosing breast lesions. We aimed to determine whether the Elite 10-gauge VAB achieves higher accuracy than the BARD spring-actuated 14-gauge CNB.

MATERIALS AND METHODS

This was a phase 3, open-label, parallel, randomized controlled trial (NCT04612439). In total, 1470 patients with ultrasound (US)-visible breast lesions requiring breast biopsy were enrolled from April to July 2021 and randomized at a 1 : 1 ratio to undergo VAB or CNB. All patients underwent surgical excision after needle biopsy. The primary outcome was accuracy, defined as the proportion of patients who had a consistent qualitative diagnosis between the biopsy and surgical pathology results. The underestimation rate, false-negative rate and safety evaluations were the secondary endpoints.

RESULTS

A total of 730 and 732 patients were evaluable for endpoints in the VAB and CNB groups, respectively. The accuracy of VAB surpassed that of CNB in the whole population (94.8 vs. 91.1%, P =0.009). The overall malignant underestimation rate was significantly lower in the VAB group than in the CNB group (21.4 vs. 30.9%, P =0.035). Additionally, significantly more false-negative events were noted in the CNB group (4.9 vs. 7.8%, P =0.037). In patients who presented with accompanying calcification, the accuracy of VAB surpassed that of CNB (93.2 vs. 88.3%, P =0.022). The potential superiority of VAB was indicated in patients with heterogeneous echo on US.

CONCLUSIONS

In general, the 10-G VAB procedure is a reasonable alternative to the 14-G CNB procedure with higher accuracy. We recommend the use of VAB for lesions with accompanying calcification or heterogeneous echo on US.

[Ultrasound-Guided Intervention for Breast Lesions]

The role of ultrasound-guided interventions in the diagnosis and treatment of breast lesions is gaining importance and prevalence, particularly as the instances of non-palpable breast lesion detection, breast-conserving surgery, and neoadjuvant chemotherapy are increasing. This review attempts to summarize the types and techniques of breast ultrasound-guided interventional procedures, such as biopsy, tissue marker insertion, and preoperative localization, and their indications. Furthermore, we highlight the pro and cons of the most commonly used procedures with the intention of promoting their use in clinical practice.

High rate of postoperative upstaging of ductal carcinoma in situ when prioritizing ultrasound evaluation of mammography-detected lesions: a single-center retrospective cohort study

BACKGROUND

The initial diagnosis of ductal carcinoma in situ (DCIS) can be upstaged to invasive cancer after definitive surgery. This study aimed to identify risk factors for DCIS upstaging using routine breast ultrasonography and mammography (MG) and to propose a prediction model.

METHODS

In this single-center retrospective study, patients initially diagnosed with DCIS (January 2016-December 2017) were enrolled (final sample size = 272 lesions). Diagnostic modalities included ultrasound-guided core needle biopsy (US-CNB), MG-guided vacuum-assisted breast biopsy, and wire-localized surgical biopsy. Breast ultrasonography was routinely performed for all patients. US-CNB was prioritized for lesions visible on ultrasound. Lesions initially diagnosed as DCIS on biopsy with a final diagnosis of invasive cancer at definitive surgery were defined as "upstaged."

RESULTS

The postoperative upstaging rates were 70.5%, 9.7%, and 4.8% in the US-CNB, MG-guided vacuum-assisted breast biopsy, and wire-localized surgical biopsy groups, respectively. US-CNB, ultrasonographic lesion size, and high-grade DCIS were independent predictive factors for postoperative upstaging, which were used to construct a logistic regression model. Receiver operating characteristic analysis showed good internal validation (area under the curve = 0.88).

CONCLUSIONS

Supplemental screening breast ultrasonography possibly contributes to lesion stratification. The low upstaging rate for ultrasound-invisible DCIS diagnosed by MG-guided procedures suggests that it is unnecessary to perform sentinel lymph node biopsy for lesions invisible on ultrasound. Case-by-case evaluation of DCIS detected by US-CNB can help surgeons determine if repeating biopsy with vacuum-assisted breast biopsy is necessary or if sentinel lymph node biopsy should accompany breast-preserving surgery.

TRIAL REGISTRATION

This single-center retrospective cohort study was conducted with the approval of the institutional review board of our hospital (approval number 201610005RIND). As this was a retrospective review of clinical data, it was not registered prospectively.

Comparison of the clinical and pathological characteristics of ultrasound-guided biopsy for breast masses and non-mass lesions between 16-gauge spring-loaded core needle biopsy and 12-gauge spring-loaded vacuum-assisted biopsy

PURPOSE

To retrospectively compare the clinical and pathological characteristics of breast masses and non-mass lesions that underwent ultrasound (US)-guided 16-gauge spring-loaded core needle biopsy (CNB) or 12-gauge spring-loaded vacuum-assisted biopsy (VAB).

METHODS

We retrospectively compared the results from US-guided diagnostic breast biopsy performed with a 16-gauge CNB (Magnum™) or a 12-gauge VAB (Celero^®). The patients' backgrounds and pathological features for each device were examined.

RESULTS

In 453 patients with 500 lesions, 373 lesions underwent CNB and 127 underwent VAB. The positive biopsy rate (positive predictive value 3) was significantly higher for VAB (92/127; 72.4%) than for CNB (231/373; 61.9%) (P = 0.032). Non-mass lesions were biopsied more frequently with VAB (57/127; 47.4%) than with CNB (27/378; 7.14%) (P = 0.000). The upgrade rate from high-risk to malignant lesions was significantly higher for CNB (5/19; 26.3%) than for VAB (1/8; 12.5%) (P = 0.043). There were five (1.34%) specimen failures with CNB and one (0.78%) with VAB, 18 (4.82%) re-biopsies with CNB and three (2.36%) with VAB, and 11/21 (52.4%) upgrades from ductal carcinoma in situ (DCIS) to invasive ductal carcinoma (IDC) with CNB and 11/30 (36.7%) with VAB. Although these rates tended to be higher with CNB than with VAB, the difference was not significant.

CONCLUSION

Although VAB had a significantly higher rate of non-mass lesion biopsies, the upgrade rate from high-risk to malignant lesions was significantly lower for VAB than for CNB. US-guided 12-gauge spring-loaded VAB may be more appropriate for biopsy of non-mass lesions.

Pathological underestimation and biomarkers concordance rates in breast cancer patients diagnosed with ductal carcinoma in situ at preoperative biopsy

Ductal carcinoma in situ (DCIS) often upgrade to invasive breast cancer at surgery. The current study aimed to identify factors associated with pathological underestimation and evaluate concordance rates of biomarkers between biopsy and surgery. Patients diagnosed with DCIS at needle biopsy from 2009 to 2020 were retrospectively reviewed. Univariate and multivariate analyses were performed to identify factors associated with pathological underestimation. Concordance rates between paired biopsy samples and surgical specimens were evaluated. A total of 735 patients with pure DCIS at biopsy were included, and 392 patients (53.3%) underwent pathological underestimation at surgery. Multivariate analysis demonstrated that tumor size > 5.0 cm [odds ratio (OR) 1.79], MRI BI-RADS ≥ 5 categories (OR 2.03), and high nuclear grade (OR 2.01) were significantly associated with pathological underestimation. Concordance rates of ER, PR, HER2 status and Ki-67 between biopsy and surgery were 89.6%, 91.9%, 94.8%, and 76.4% in lesions without pathological underestimation, and were 86.4%, 93.2%, 98.2% and 76.3% for in situ components in lesions with pathological underestimation. Meanwhile, in situ components and invasive components at surgery had concordance rates of 92.9%, 93.8%, 97.4%, and 86.5% for those biomarkers, respectively. In conclusion, lesions diagnosed as DCIS at biopsy have a high rate of pathological underestimation, which was associated with larger tumor size, higher MRI BI-RADS category, and higher nuclear grade. High concordances were found in terms of ER, PR, and HER2 status evaluation between biopsy and surgery, regardless of the pathological underestimation.

Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters

BACKGROUND

The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered.

MATERIALS AND METHODS

One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumours were analyzed to investigate its association with underestimation of IBC on final pathology.

RESULTS

Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%).

CONCLUSIONS

SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbour an IBC.

Prediction of Underestimation Using Contrast-Enhanced Spectral Mammography in Patients Diagnosed as Ductal Carcinoma In Situ on Preoperative Core Biopsy

BACKGROUND

To assess the performance of contrast-enhanced spectral mammography (CESM) for the prediction of DCIS underestimation in comparison with mammography, breast US, and breast MRI.

PATIENTS AND METHODS

We prospectively enrolled patients diagnosed with DCIS on preoperative core biopsy. Visibility, lesion type, and extent on each imaging modality, CESM gray values (CGV) were evaluated. Pathologic features of core biopsy and surgery were recorded. Chi-square or Fisher's exact test were used for univariate analysis. Multivariate logistic regression analysis was used to find independent predictors for DCIS underestimation and receiver operating characteristic (ROC) curve analysis was performed.

RESULTS

A total of 113 lesions in 108 patients were analyzed (50 pure DCIS; 63 underestimated DCIS). Visibility on mammography, breast US, CESM, and breast MRI were 44%, 76%, 58%, and 80% for pure DCIS, and 73%, 81%, 86%, and 92% for underestimated DCIS. Tumor extents on surgical pathology of pure and underestimated DCIS were 1.11 ± 1.35 cm and 2.61 ± 2.09 cm. On multivariate analysis, nuclear grade and suspected invasion on core biopsy, visibility on mammography, and extent on breast MRI were independent factors for the model 1, whereas nuclear grade on core biopsy, extent on CESM, and mean CGV on MLO-recombined image were independent factors for the model 2. Area under ROC curve (AUC) was 0.843 for model 1 including breast MRI, whereas AUC was 0.823 for model 2 including CESM, which didn't show a significant difference (P = .968).

CONCLUSION

For detecting underestimated DCIS, CESM was superior to mammography and breast US, and comparable to breast MRI.

Does Mammotome biopsy affect surgery option and margin status of breast conserving surgery in breast cancer?

Background

The Mammotome, an image-guided, usually ultrasound-guided vacuum-assisted breast biopsy (US-VABB) system, has been widely used in the early diagnosis of breast disease and the complete excision of benign lesions. However, in some malignant lesions underestimated by U.S., whether Mammotome biopsy would affect the surgery option, especially the margin status in breast-conserving surgery (BCS), has never been studied.

Methods

Between 2015 and 2019, 198 patients with 200 lesions who have been diagnosed with breast cancer by Mammotome elsewhere received surgery by pathological confirmation in our center. The clinicopathological characteristics, surgery options, therapies, and the details of the specimen, such as margin status of BCS, tumor residual after VABB, and hematoma were reviewed.

Results

Among 200 lesions, 90% were evaluated below US-BIRADS 4b before Mammotome biopsy and 94.5% with a tumor size ≤3 cm. 131 patients received mastectomy (66.2%) and 67 received BCS (33.8%). Hematoma and tumor residual were observed in 37.5% and 71.5% of all lesions, respectively. There is a higher incidence of hematoma in the mastectomy group than in the BCS group (44.4% vs. 23.9%, P=0.005). In BCS group, the positive margin was found in 7 patients at first examination including four focals with re-excision, two extensive with mastectomy and one focal but refusing further surgery. The ultimate success rate of BCS was 95.5%. Margin positivity correlated with tumor residual (P=0.044) but not with hematoma.

Conclusions

Mammotome biopsy might lead to hematoma and tumor residual; however, it is not the determinant factor for a surgery option, and BCS is feasible through a complete excision of tumor residual to acquire negative margin.

Touching Tumor-Infiltrating Lymphocytes in Low Risk Ductal Carcinoma in Situ Correlates with Upgrade to High Grade DCIS

AIMS

To examine our hypothesis that higher number of touching TILs in a low risk DCIS detected in a setting like active surveillance clinical trial correlates with upgrade to HG-DCIS in the subsequent excisional biopsy.

METHODS AND RESULTS

The clinical inclusion criteria of the COMET clinical trial were applied on women who were mammographically screened between 2007 and 2017. In the core needle biopsy, touching TILs were assessed by counting the number of TILs touching the ductal basement membrane or away from it by one lymphocyte thickness. The highest number of TILs around a single involved duct and the average number among involved ducts were recorded. DCIS was graded as low or intermediate. Twenty-six of 129 (20.2%) cases had upgrade [14 (10.9%) to pure HG-DCIS, and 12 (9.3%) to invasive carcinoma, 2 of which with concurrent HG-DCIS]. Increased average touching TILs and intermediate grade DCIS correlated with upgrade to HG-DCIS in 11 of 16 (68.8%) cases and decreased average touching TILs and low-grade DCIS correlated with no upgrade in 89 of 113 (78.8%) [accuracy 0.775; AUC 0.746]. Increased highest touching TILs and intermediate-grade DCIS correlated with upgrade to HG-DCIS in 12 of 16 (75%) cases and decreased highest touching TILs and low-grade DCIS correlated with no upgrade in 82 of 113 (72.6%) [accuracy 0.7287; AUC 0.734]. Highest touching TILs ≥ 10 cells correlated with upgrade to invasive carcinoma and/or HG-DCIS (p=0.018).

CONCLUSIONS

Intermediate-grade and touching TILs may be good variables to examine in the COMET clinical trial and correlate with the risk of upgrade.

Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters

INTRODUCTION

The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered.

METHODS

One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumors were analyzed to investigate its association with underestimation of IBC on final pathology.

RESULTS

Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%).

CONCLUSIONS

SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbor an IBC.

An Updated Nomogram for Predicting Invasiveness in Preoperative Ductal Carcinoma In Situ of the Breast

PURPOSE

To validate and update a nomogram for predicting ductal carcinoma in situ (DCIS) upstaging in preoperative biopsy.

MATERIALS AND METHODS

Medical records of 444 preoperative DCIS patients were evaluated and used to validate a previous version of the Severance nomogram for predicting DCIS upstaging in preoperative biopsy. Patients were divided into two groups according to the final postoperative pathology. Univariate and multivariate analyses with the chi-square test, Student's t-test, and binary logistic regression method identified new significant variables. The updated nomogram was evaluated with the C-index and Hosmer-Lemeshow goodness of fit test.

RESULTS

The area under a receiver operating characteristic curve for comparison with the previous nomogram was 0.48. In postoperative pathology, the pure DCIS and invasive cancer groups comprised 345 and 99 cases, respectively. Approximately 22.3% of patients preoperatively diagnosed with DCIS were upstaged to invasive cancer. Significant variables in the univariate analysis were operation type, human epidermal growth factor receptor 2 overexpression, comedo necrosis, sonographic mass, mammographic mass, preoperative biopsy method, and suspicious microinvasion in preoperative biopsy. In multivariate analysis, operation type, sonographic mass, mammographic mass, and suspicious microinvasion were risk factors for upstaging. The updated model with these variables showed moderate discrimination and was appropriate in the calibration test.

CONCLUSION

The previous nomogram did not effectively discriminate upstaging of preoperative DCIS in an independent cohort. An updated version of the nomogram appears to provide more accurate information for predicting preoperative DCIS upstaging.

The Evolving Role of Vacuum Assisted Biopsy of the Breast: A Progression from Fine-Needle Aspiration Biopsy

BACKGROUND

The management of breast disease has been greatly facilitated by the technology of needle biopsy interventions, and over the past 30 years, this has evolved from the use of fine-needle aspiration biopsy (FNAB) to the current methodology of vacuum assisted biopsy (VAB).

METHODS

This article provides an historical review of the application of needle interventions of the breast in the diagnosis and management of breast conditions, and discusses current indications for the use of vacuum assisted biopsies and vacuum assisted excisions.

RESULTS

Whilst FNAB continues to have a limited role in breast disease diagnosis, the necessity of achieving an histological diagnosis has preferentially seen the development and wider application of automated core needle biopsies (CNB) and VAB in the assessment and management of breast lesions. The advantages of CNB and VAB include the ability to distinguish in situ and invasive disease pre-operatively, and the ability to achieve prior knowledge of immunohistochemical tumour markers particularly in the setting of neoadjuvant drug treatments.

CONCLUSION

Due to its ability to obtain larger tissue samples, VAB does have diagnostic advantages over CNB and indications for the utilization of VAB are discussed. VAB additionally has an expanding role as a tool for breast lesion excision.

Ultrasound-guided vacuum-assisted breast biopsy with a small-caliber device: A multicenter consecutive study of 162 biopsied lesions

Objective:

In this study, we aimed to analyze technical and diagnostic potential, and safety of the small-caliber vacuum-assisted biopsy (SCVAB) device in a multicenter consecutive study taking into consideration the type and location of breast lesion.

Methods:

We collected data from 5 breast imaging centers where radiologists used the SCVAB device for biopsies in 162 patients. We analyzed the conditions for using the SCVAB device according to the characteristics of the lesions, the volume of excision, and the analyzability obtained by biopsy samples.

Results:

The biopsies of 80 circumscribed masses, 61 complex lesions, and 24 microcalcification foci were included in the study. The reasons for choosing SCVAB as an initial technique were identified. A total of 47 lesions were removed with SCVAB; among them, 24 lesions were initially chosen for total excision. SCVAB was used as a second-choice biopsy method after core-needle biopsy failure in 20 cases. If SCVAB had not been available, vacuum-assisted biopsy would have been the most frequently used technique (106 under ultrasound, and 18 under stereotactical guidance).

Conclusions:

The SCVAB system is an alternative to classical vacuum biopsy, enabling representative samples to be obtained from lesions that are difficult to access, complex, small, or in cases of unsuccessful previous biopsy. The SCVAB system was determined as the chosen technique by the radiologists in this study due to feasibility, ergonomics and absence of side effects detected in this study.

Analysis of Efficacy and Accuracy of 2 Vacuum-Assisted Breast Biopsy Devices: Mammotome and Elite

BACKGROUND

Ultrasound-guided vacuum-assisted breast biopsy (US-VABB) has recently replaced surgical biopsy as a result of its high diagnostic accuracy and low patient discomfort, and at present it relies mainly on 2 devices, Mammotome and, more recently, Mammotome Elite (Elite). Our purpose was to compare the efficacy of these 2 bioptical devices.

PATIENTS AND METHODS

We performed US-VABB on 195 patients with Mammotome 8G or 11G in 130 patients and Elite 13G in 65 patients. Of these 195 patients, 95 were submitted to surgery for lumpectomy or mastectomy in case of malignant lesions or of lesions of uncertain malignant potential (B5 and B3), while the remaining 100 were strictly monitored clinically and radiologically for 12 to 24 months.

RESULTS

Both the devices showed high absolute sensitivity (96.2% for Mammotome and 83.3% for Elite), complete sensitivity (98.1% for Mammotome and 90.0% for Elite), specificity (92.3% for Mammotome and 94.3% for Elite), and diagnostic accuracy (99.1% for Mammotome and 95% for Elite), thus fulfilling criteria suggested by the European guidelines. Total underestimation rate seemed to be higher in the Elite cohort (14.2%) than in the Mammotome cohort (3.4%) (P = .02). However, none of the patients with a benign diagnosis (B2) presented any event during the follow-up period.

CONCLUSION

US-VABB is an accurate method for sampling breast lesions. Our study did not show large, statistically significant differences in diagnostic accuracy between the Elite and Mammotome systems, except for a slight increase in diagnostic underestimation of benign pathologies when using the Elite.

Ultrasonography-guided 14-gauge core biopsy of the breast: results of 7 years of experience

PURPOSE

This study assessed the outcomes of ultrasound (US)-guided core needle biopsies (CNBs) of breast lesions with at least 2 years of follow-up to determine the false-negative rate and to evaluate the diagnostic accuracy of CNB.

METHODS

We retrospectively analyzed 13,254 consecutive US-guided 14-gauge CNBs for breast lesions. We excluded biopsies if non-malignant biopsy result was not confirmed by surgical excision or US-guided vacuum-assisted biopsy, or fewer than 2 years of follow-up data were available. A total of 4,186 biopsies were excluded, and 9,068 breast masses from 7,039 women were included. The pathologic findings from each CNB were assessed using the standard diagnostic reference, defined based on the results of surgical excision, vacuum-assisted biopsy, or at least 2 years of long-term imaging follow-up. The false-negative rate and underestimation rate were calculated.

RESULTS

Of the 9,068 CNBs, benign pathology was found in 64.2%, high-risk results in 3.5%, and malignant results in 32.3%. Of the 5,821 benign CNBs, an additional malignancy was found at excision in 63 lesions, leading to a false-negative rate of 2.0% (63 of 3,067). The underestimation rate was 33.6% (111 of 330) for ductal carcinoma in situ and 24.5% (79 of 322) for high-risk results at surgical excision. Most false-negative diagnoses (84.1%, 53 of 63) were recognized through imaging-histology correlations, and immediate rebiopsies were performed. Ten malignancies (15.9%, 10 of 63) had delayed diagnoses and showed progression in follow-up US imaging.

CONCLUSION

US-guided 14-gauge CNB provided optimal diagnostic information. Imaging-histology correlations and appropriate imaging follow-up should be performed to avoid delayed diagnoses.

Ultrasound-guided cable-free 13-gauge vacuum-assisted biopsy of non-mass breast lesions

PURPOSE

To compare the outcomes of ultrasound-guided core biopsy for non-mass breast lesions by the novel 13-gauge cable-free vacuum-assisted biopsy (VAB) and by the conventional 14-gauge semi-automated core needle biopsy (CCNB).

MATERIALS AND METHODS

Our institutional review board approved this prospective study, and all patients provided written informed consent. Among 1840 ultrasound-guided percutaneous biopsies performed from August 2013 to December 2014, 145 non-mass breast lesions with suspicious microcalcifications on mammography or corresponding magnetic resonance imaging finding were subjected to 13-gauge VAB or 14-gauge CCNB. We evaluated the technical success rates, average specimen numbers, and tissue sampling time. We also compared the results of percutaneous biopsy and final surgical pathologic diagnosis to analyze the rates of diagnostic upgrade or downgrade.

RESULTS

Ultrasound-guided VAB successfully targeted and sampled all lesions, whereas CCNB failed to demonstrate calcification in four (10.3%) breast lesions with microcalcification on specimen mammography. The mean sampling time were 238.6 and 170.6 seconds for VAB and CCNB, respectively. No major complications were observed with either method. Ductal carcinoma in situ (DCIS) and atypical ductal hyperplasia (ADH) lesions were more frequently upgraded after CCNB (8/23 and 3/5, respectively) than after VAB (2/26 and 0/4, respectively P = 0.028).

CONCLUSION

Non-mass breast lesions were successfully and accurately biopsied using cable-free VAB. The underestimation rate of ultrasound-detected non-mass lesion was significantly lower with VAB than with CCNB.

TRIAL REGISTRATION

CRiS KCT0002267.

Ductal carcinoma in situ diagnosed by breast needle biopsy: Predictors of invasion in the excision specimen

BACKGROUND

A substantial proportion of women with a pre-operative diagnosis of pure ductal carcinoma in situ (DCIS) has a final diagnosis of invasive breast cancer (IBC) after surgical excision and, consequently, a potential indication for lymph node staging. The aim of our study was to identify novel predictors of invasion in patients with a needle-biopsy diagnosis of DCIS that would help us to select patients that may benefit from a sentinel node biopsy (SNB).

PATIENTS AND METHODS

We included 153 patients with a needle-biopsy diagnosis of DCIS between 2000 and 2014, which was followed by surgical excision. Several pre-operative clinical, radiological and pathological features were assessed and correlated with the presence of invasion in the excision specimen. Features that were significantly associated with upstaging in the univariable analysis were combined to calculate upstaging risks.

RESULTS

Overall, 22% (34/155) of the patients were upstaged to IBC. The following risk factors were significantly associated with upstaging: palpability, age ≤40 years, mammographic mass lesion, moderate to severe periductal inflammation and periductal loss of decorin expression. The upstaging-risk correlated with the number of risk factors present: e.g. 9% for patients without risk factors, 29% for patients with 1 risk factor, 37% for patients with 2 risk factors and 54% for patients with ≥3 risk factors.

CONCLUSION

The identified risk factors may be helpful to predict the upstaging-risk for patients with a needle-biopsy diagnosis of pure DCIS, which facilitates the performance of a selective SNB for high-risk patients and avoid this procedure in low-risk patients.

The Role of Sentinel Lymph Node Biopsy and Factors Associated with Invasion in Extensive DCIS of the Breast Treated by Mastectomy: The Cinnamome Prospective Multicenter Study

Background

When invasive components are discovered at mastectomy for vacuum-assisted biopsy (VAB)-diagnosed ductal carcinoma in situ (DCIS), the only option available is axillary lymph node dissection (ALND). The primary aim of this prospective multicenter trial was to determine the benefit of performing upfront sentinel lymph node (SLN) biopsy for these patients. The secondary aim was to determine DCIS factors associated with microinvasion or invasion.

Methods

The SLN procedure was performed during mastectomy, and for positive SLN an ALND was performed during the same intervention. A tissue microarray containing DCIS lesions from the mastectomy specimens was subsequently performed.

Results

From May 2008 to December 2010, 228 patients were enrolled from 14 French cancer centers, including 192 eligible patients with pure DCIS on VAB and successful SLN procedures. ALND was avoided for 51 [67 %; 95 % confidence interval (CI), 56–77 %] of all the patients who had microinvasive DCIS or DCIS associated with invasive carcinoma at mastectomy and a negative SLN. Of the 192 patients, 76 (39 %) with VAB-diagnosed DCIS were upgraded after mastectomy to micro (n = 20) or invasive disease (n = 56). The rate of positive SLN for patients with DCIS on VAB was 14 %. High nuclear grade of DCIS was associated with greater risk of microinvasion and invasion, and HER2-amplified DCIS was associated with greater risk of invasion.

Conclusions

Underestimation of invasive components is high when DCIS is diagnosed by VAB in patients undergoing mastectomy. Upfront SLN for patients with VAB-diagnosed extensive DCIS avoids unnecessary ALND for two-thirds of patients with micro or invasive disease on mastectomy.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-015-4476-5) contains supplementary material, which is available to authorized users.

Non-mass-like lesions on breast ultrasound: classification and correlation with histology

PURPOSE

Owing to advances in ultrasound (US) technology, optimal US techniques with a high-frequency transducer can identify more and more breast lesions. However, some lesions show up as non-mass-like lesions, which are difficult to be correctly identified and often result in missed diagnosis and misdiagnosis. The purpose of the present study was to develop a classification of the US features of non-mass-like breast lesions correlated with pathology, so as to improve the diagnostic accuracy of US in non-mass-like breast lesions.

MATERIALS AND METHODS

A total of 854 breast lesions in 836 consecutive women scheduled for US-guided core-needle biopsy or US-guided vacuum-assisted biopsy between May 2008 and October 2011 were initially included in this study. Finally, 80 breast lesions in 78 women were classified as non-mass-like lesion and included in this study. The US features of the 80 non-mass-like breast lesions were classified and their correlation with pathology was analysed.

RESULTS

Of the 80 non-mass-like breast lesions, 43 cases (53.8 %) were malignant and 37 cases (46.2 %) were benign. Fifty-two cases (73.7 %) appeared as a hypoechoic area, 22 cases (21.1 %) appeared as a hypoechoic area with sporadic or clustered microcalcification, four cases appeared as architectural distortion, and two cases appeared as solid echogenicity within a duct. The diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value of US for non-mass-like breast lesions were 71.25, 95.35, 43.24, 66.13 and 88.89 %, respectively. The finding of a hypoechoic area with microcalcification showed a statistically significant association with malignant lesions and its positive predictive value for carcinoma was 78.26 %.

CONCLUSION

Non-mass-like breast lesions usually appeared as a hypoechoic area or a hypoechoic area with microcalcification. The finding of a hypoechoic area with microcalcification had a close correlation with malignant lesions. US had a high sensitivity but a low specificity in the diagnosis of non-mass-like breast lesions and a definitive diagnosis requires a US-guided biopsy.

Upgrade of ductal carcinoma in situ on core biopsies to invasive disease at final surgery: a retrospective review across the Scottish Breast Screening Programme

AIM

To identify factors affecting upgrade rates from B5a (non-invasive) preoperative core biopsies to invasive disease at surgery and ways to improve screening performance.

MATERIAL AND METHODS

This was a retrospective analysis of 1252 cases of B5a biopsies across all six Scottish Breast Screening Programmes (BSPs), ranging between 2004 and 2012. Final surgical histopathology was correlated with radiological and biopsy factors. Data were analysed using basic Microsoft Excel and standard Chi-squared test used for evaluating statistical significance.

RESULTS

B5a upgrade rates for the units ranged from 19.2% to 29.2%, with an average of 23.6%. Mean sizes of invasive tumours were small (3-11 mm). The upgrade rate was significantly higher for cases where the main mammographic abnormality was mass, distortion, or asymmetry, compared with micro-calcification alone (33.2% versus 21.7%, p = 0.0004). The upgrade rate was significantly lower with the use of large-volume vacuum-assisted biopsy (VAB) devices than 14 G core needles (19.9% versus 26%, p = 0.013); in stereotactic than ultrasound-guided biopsies (21.2% versus 36.1%, p < 0.001). Heterogeneity of data from different centres limited evaluation of other potential factors.

CONCLUSION

Upgrade rates are lower for cases with micro-calcification as the sole mammographic feature with the use of VAB devices. Nevertheless, there is variation in practice across Scottish BSPs, including first-line biopsy technique and/or device; and it is of interest that a few centres maintain low upgrade rates despite not using VAB routinely for biopsy of micro-calcification.

Percutaneous ultrasound-guided vacuum-assisted removal versus surgery for breast lesions showing imaging-histology discordance after ultrasound-guided core-needle biopsy

Objective

To evaluate the upgrade rate and delayed false-negative results of percutaneous vacuum-assisted removal (VAR) and surgical excision in women with imaging-histologic discordance during ultrasound (US)-guided automated core needle biopsy (CNB) of the breast and to validate the role of VAR as a rebiopsy method for these discordant lesions.

Materials and Methods

Percutaneous US-guided 14-gauge CNB was performed on 7470 patients between August 2005 and December 2010. Our study population included 161 lesions in 152 patients who underwent subsequent rebiopsy due to imaging-histologic discordance. Rebiopsy was performed using VAR (n = 88) or surgical excision (n = 73). We investigated the upgrade rate immediately after rebiopsy and delayed false-negative results during at least 24 months of follow-up after rebiopsy. We also evaluated the clinicoradiological differences between VAR and surgical excision.

Results

Total upgrade to malignancy occurred in 13.7% (22/161) of lesions at rebiopsy including both VAR and surgical excision: 4.6% (4/88) of VAR cases (4/88) and 24.7% (18/73) of surgical excision cases (p < 0.001). Surgical excision was performed significantly more frequently in older patients and for larger-sized lesions than that of VAR, and a significant difference was detected between VAR and surgical excision in the Breast Imaging and Reporting and Data System category (p < 0.007). No delayed false-negative results were observed after VAR or surgical excision during the follow-up period.

Conclusion

Long-term follow-up data showed no delayed cancer diagnoses after US-guided VAR in imaging-histologic discordant lesions of the breast, suggesting that VAR might be a rebiopsy method for these lesions.

Ductal carcinoma in situ diagnosed at US-guided 14-gauge core-needle biopsy for breast mass: preoperative predictors of invasive breast cancer

OBJECTIVES

To identify preoperative features that could be used to predict invasive breast cancer in women with a diagnosis of ductal carcinoma in situ (DCIS) at ultrasound (US)-guided 14-gauge core needle biopsy (CNB).

METHODS

A total of 86 DCIS lesions that were diagnosed at US-guided 14-gauge CNB and excised surgically in 84 women were assessed. We retrospectively reviewed the patients' medical records, mammography, US, and MR imaging. We compared underestimation rates of DCIS for the collected clinical and radiologic variables and determined the preoperative predictive factors for upstaging to invasive cancer.

RESULTS

Twenty-seven (31.4%) of 86 DCIS lesions were upgraded to invasive cancer. Preoperative features that showed a significantly higher underestimation of DCIS were palpability or nipple discharge (p=0.040), number of core specimens less than 5 (p=0.011), mammographic maximum lesion size of 25 mm or larger (p=0.022), mammographic mass size of 40 mm or larger (p=0.046), sonographic mass size of 32 mm or larger (p=0.009), lesion size of 30 mm on MR (p=0.004), lower signal intensity (SI) on fat-saturated T2-weighted MR images (FS-T2WI) (p=0.005), heterogeneous or rim enhancement on MR images (p=0.009), and apparent diffusion coefficient (ADC) values lower than 1.04 × 10(-3)mm(2)/s on diffusion-weighted MR imaging (DWI) (p<0.001).

CONCLUSION

Clinical symptom of palpability or nipple discharge, number of core specimen, mammographic maximum lesion or mass size, SI on FS-T2WI, heterogeneous or rim enhancement on MR, and ADC value may be helpful in predicting the upgrade to invasive breast cancer for DCIS diagnosed at US-guided 14-gauge CNB.

Risk predictors of underestimation and the need for sentinel node biopsy in patients diagnosed with ductal carcinoma in situ by preoperative needle biopsy

BACKGROUND

Diagnosis of ductal carcinoma in situ (DCIS) by core needle biopsy showed a high rate of underestimation of invasiveness, and performing sentinel lymph node biopsy (SLNB) in DCIS patients was controversial.

METHODS

We analyzed 340 DCIS patients who were diagnosed by needle biopsies. Final pathology and clinicopathological features were reviewed. Predictors were accessed using the Chi-square test and a binary logistic regression model.

RESULTS

The overall DCIS underestimation rate was 42.6%. The underestimation was significantly related to the palpability, mass or calcification by ultrasonography, grade, suspicious microinvasion, and biopsy method in univariate analysis. In multivariate analysis, palpability, ultrasonographic calcification or mass, suspicious microinvasion, and core needle biopsy were independent predictors of underestimation of invasive cancer. In cases with one or no risk predictors, the underestimation rate was 14.3%, whereas, in those with five predictors, it increased to 90.9%. Among 144 invasive cancer patients who underwent axillary staging, 15.4% had node metastasis.

CONCLUSIONS

DCIS diagnosed by preoperative needle biopsy has a high probability of underestimation, and 15% of invasive cancer patients have node metastasis. SLNB may be justified in DCIS patients undergoing needle biopsies, and caution should be exercised in omitting SLNB in patients with one or no risk predictors.