Epithelial displacement after stereotactic 11-gauge directional vacuum-assisted breast biopsy

Comparative Evaluation of USG-Guided Single Tissue Marker Versus Multiple Tissue Marker Placements in Breast Malignancy Patients Undergoing Neoadjuvant Chemotherapy for Tumor Localization

Background Breast cancer remains one of the most common malignancies affecting women globally, contributing significantly to the disease burden. The advent of neoadjuvant chemotherapy (NAC) has revolutionized the treatment for locally advanced breast cancer, allowing tumors to be downstaged and making breast-conserving surgery (BCS) feasible. Accurate localization of the tumor bed post-NAC is crucial for successful surgical removal of residual disease. While traditional single tissue marker placement has been effective, recent advances suggest multiple markers might provide superior localization by comprehensively delineating the entire tumor area. This study aims to compare the effectiveness of single versus multiple tissue marker placements in breast malignancy patients undergoing NAC. Materials and methods A prospective study was conducted in the Department of Radio-diagnosis at Saveetha Medical College over 18 months, including 10 patients diagnosed with breast carcinoma, selected through convenience sampling. Inclusion criteria involved patients diagnosed with breast cancer via mammography, sonography, and histological confirmation, referred for clip placement before NAC. Exclusion criteria were patients unwilling to participate. The procedure involved placing one to two surgical clips within the tumor using a 14/16-gauge coaxial guiding needle under USG guidance, with additional clips for larger or multiple tumors. Data collection included pre-procedural USG, post-procedural mammography (MG1), pre-operative mammography (MG2)/USG, and gross specimen histopathological examination/specimen mammography. Statistical analysis Demographic data, clipping distribution, receptor status, localization methods, surgical outcomes, operation diagnoses, and correlation analysis were statistically analyzed. Mean age, standard deviation, and p-values were calculated to determine the significance of differences between single and multiple clip groups. Results The study included 10 patients with a mean age of 52.5 years. Of these, five (50%) had a single clip, and two (20%) had four clips. The average time from clipping to the second mammogram (MG2) was 106.3 days, and from clipping to operation was 111.0 days, with longer follow-up times for multiple clip patients. Six (60%) of the patients were estrogen receptor (ER) positive, and six (60%) were human epidermal growth factor receptor 2 (HER2) negative. Localization methods were similar between single and multiple clip groups. However, multiple clip patients tended to undergo more extensive surgeries like modified radical mastectomy (MRM). Imaging responses showed no preoperative ultrasound lesions in single clip patients, while multiple clip patients had higher inconsistent diagnoses (10 (100%)) suggesting that multiple clips provide better tumor localization but are linked to increased complexity and longer follow-up times. Conclusion Patients with multiple clips experienced significantly longer follow-up times, reflecting more complex clinical scenarios. Despite no significant differences in receptor status distributions, multiple clip patients required more extensive surgeries, emphasizing the need for tailored surgical planning. The study underscores the importance of considering the number of clips in clinical decision-making. Future research should focus on larger, prospective studies to validate these findings and explore underlying mechanisms.

Reducing the Risk of Needle Tract Seeding or Tumor Cell Dissemination during Needle Biopsy Procedures

PURPOSE

Many women fear that breast needle biopsies increase the risk of cancer spread. The purpose of this review article is to discuss the breast cancer literature regarding the risk of needle-biopsy-induced cancer cell displacement and its impact on local and regional recurrence and breast cancer survival.

METHODS

A literature review is performed to discuss the risks and mitigation of needle-biopsy-induced cancer cell displacement.

RESULTS

Needle-biopsy-induced cancer cell displacement is a common event. The risk is influenced by the biopsy technique and the breast cancer type. Evidence suggests that the risk of needle-biopsy-induced cancer cell displacement may potentially increase the odds of local recurrence but has no impact on regional recurrence and long-term survival.

CONCLUSIONS

Technical modifications of needle biopsy procedures can reduce the risk of breast needle-biopsy-induced cancer cell displacement and potentially reduce the risk of local recurrence, especially in patients for whom whole breast radiation is to be omitted.

Updates on Lymphovascular Invasion in Breast Cancer

Traditionally, lymphovascular invasion (LVI) has represented one of the foremost pathological features of malignancy and has been associated with a worse prognosis in different cancers, including breast carcinoma. According to the most updated reporting protocols, the assessment of LVI is required in the pathology report of breast cancer surgical specimens. Importantly, strict histological criteria should be followed for LVI assessment, which nevertheless is encumbered by inconsistency in interpretation among pathologists, leading to significant interobserver variability and scarce reproducibility. Current guidelines for breast cancer indicate biological factors as the main determinants of oncological and radiation therapy, together with TNM staging and age. In clinical practice, the widespread use of genomic assays as a decision-making tool for hormone receptor-positive, HER2-negative breast cancer and the subsequent availability of a reliable prognostic predictor have likely scaled back interest in LVI's predictive value. However, in selected cases, the presence of LVI impacts adjuvant therapy. This review summarizes current knowledge on LVI in breast cancer with regard to definition, histopathological assessment, its biological understanding, clinicopathological association, and therapeutic implications.

Artifactual Displacement of Ductal Carcinoma In Situ (ADDCIS) (Toothpaste Effect): A Mimicker of Invasive Ductal Carcinoma

Needle tract displacement is a recognized mimicker of invasive ductal carcinoma (IDC). Artifactual displacement of ductal carcinoma in situ (ADDCIS) unassociated with needle tracts may occur secondary to mechanical compression of breast specimens but has not been systematically studied. We identified 16 cases of ADDCIS unassociated with needle tract changes; the majority (75%) were internal referrals to the breast pathology service to rule out IDC, 19% were received as external diagnostic consultations to rule out IDC, and 6% were routine second review cases originally diagnosed as IDC at an outside hospital. The majority (62.5%) of ADDCIS occurred in lumpectomies, whereas 25% occurred in mastectomies and 12.5% in core biopsies. ADDCIS foci ranged from <1 to 5 mm; however, all ADDCIS spanning >4 mm demonstrated a linear pattern of displacement. In all cases, ADDCIS involved mammary stroma in a nonlobular distribution; in half, ADDCIS extended between benign lobules. Immunohistochemistry revealed no myoepithelial cells around the ADDCIS (n=7), adding to the concern for IDC. However, in contrast to most IDC, ADDCIS lacked stromal reaction and showed degenerative, smudged chromatin. None of the 9 patients with significant follow-up (mean, 7 y) developed metastasis. All received further local therapy for DCIS (5 radiation, 4 completion mastectomy); 1 received adjuvant systemic therapy (hormone therapy for contralateral IDC). In conclusion, ADDCIS mimics IDC, particularly given its permeative pattern and absence of myoepithelial cells. ADDCIS is most common in lumpectomies but can occur in mastectomies or core biopsies. Diagnostic clues include smudged nuclear chromatin, lack of stromal response, and linear pattern of displacement in larger lesions. The benign follow-up without systemic therapy supports our view that ADDCIS does not represent true IDC.

Breast cancer neoplastic seeding in the setting of image-guided needle biopsies of the breast

PURPOSE

To identify clinicopathologic, technical, and imaging features associated with neoplastic seeding (NS) following image-guided needle breast biopsy.

METHODS

We performed an institutional review board-approved retrospective review of patients presenting with a new diagnosis of breast cancer or suspicious breast findings requiring biopsy with subsequent diagnosis of NS. The time from biopsy to NS diagnosis was calculated. Histology, grade, estrogen receptor (ER) status, progesterone receptor (PR) status, HER2 status, T category, and N category were recorded. Biopsy guidance method, needle gauge, and number of passes were reviewed in addition to the mammographic and sonographic features of the primary tumors and the NS.

RESULTS

Eight cases of NS were identified in 4010 patients. The mean time from biopsy to NS diagnosis was 60.8 days. The most frequent histology was invasive ductal carcinoma (7/8). Six cases were grade 3 (75.0%). Five primary breast cancers were ER, PR, and HER2 negative (62.5%). Seven patients underwent biopsy with ultrasound guidance. Multiple-insertion, non-coaxial ultrasound-guided core-needle biopsy was done in 6 cases. Mammographic presentation of NS was focal asymmetry (3/7 cases), mass (1/7), calcifications only (1/7), or occult (2/7). Sonographic presentation of NS was most often a mass (7/8) with irregular shape (5/7) and without circumscribed margins (6/7) and was occult in 1 case (1/8). NS distribution was subdermal and intradermal.

CONCLUSION

High-grade, triple-negative breast cancers and multiple-insertion, non-coaxial biopsies may be risk factors for NS. NS should be suspected on the basis of the superficial and linear pattern of disease progression in these patients.

Benign breast lesions that mimic malignancy

Many benign and reactive lesions of the breast show morphological overlap with malignant lesions. These benign mimics of malignancy often present diagnostic challenges to even the most experienced pathologists. This review focuses on several benign lesions of the breast that mimic malignant entities. For each of these lesions, we describe the key morphological and immunohistochemical features, potential diagnostic pitfalls, and our approach to arriving at the correct diagnosis.

Is Sentinel Lymph Node Dissection Warranted for Patients with a Diagnosis of Ductal Carcinoma In Situ?

BACKGROUND

Positive sentinel lymph node (SLN) findings in ductal carcinoma in situ (DCIS) range from 1 to 22 % but have unknown biologic significance. This study sought to identify predictors of positive SLNs and to assess their clinical significance for patients with an initial diagnosis of DCIS.

METHODS

The study identified 1234 patients with an initial diagnosis of DCIS who underwent SLN dissection (SLND) at our institution from 1997 through 2011. Positive SLN findings were categorized as isolated tumor cells (ITCs) (≤0.2 mm), micrometastases (>0.2-2 mm), or macrometastases (>2 mm). Predictors of positive SLNs were analyzed, and survival outcomes were examined.

RESULTS

Positive SLN findings were identified in 132 patients (10.7 %): 66 patients with ITCs (5.4 %), 36 patients with micrometastases (2.9 %), and 30 patients with macrometastases (2.4 %). Upstaging to microinvasive (n = 68, 5.5 %) or invasive (n = 259, 21.0 %) cancer occurred for 327 patients (26.5 %). Factors predicting positive SLNs included diagnosis by excisional biopsy (odds ratio [OR] 1.90; P = 0.007), papillary histology (OR 1.77; P = 0.006), DCIS larger than 2 cm (OR 1.55; P = 0.030), more than three interventions before SLND (4 interventions: OR 2.04; P = 0.022; ≥5 interventions: OR 3.87; P < 0.001), and occult invasion (microinvasive: OR 3.44; P = 0.001; invasive: OR 6.21; P < 0.001). The median follow-up period was 61.7 months. Patients who had pure DCIS with and without positive SLNs had equivalent survival rates (100.0 vs 99.7 %; P = 0.679). Patients with occult invasion and positive SLNs had the worst survival rate (91.7 %; P < 0.001).

CONCLUSIONS

Occult invasion and more than three total interventions were the strongest predictors of positive SLN findings in patients with an initial diagnosis of DCIS. This supports the theory of benign mechanical transport of breast epithelial cells. Except for patients at high risk for invasive disease, routine use of SLND in DCIS is not warranted.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The current role of vacuum assisted breast biopsy system in breast disease

The gold standard for breast biopsy procedures is currently an open excision of the suspected lesion. However, an excisional biopsy inevitably makes a scar. The cost and morbidity associated with this procedure has prompted many physicians to evaluate less invasive, alternative procedures. More recently, image-guided percutaneous core-needle biopsy has become a frequently used method for diagnosing palpable and non-palpable breast lesions. Although sensitivity rates for core-needle biopsy are high, it has the disadvantage of histological underestimation, which renders the management of atypical ductal hyperplasia, papillary lesions, and fibroepithelial lesions somewhat difficult. Vacuum assisted breast biopsy (VABB) was developed to overcome some of these negative aspects of core-needle biopsy. VABB allows for a sufficient specimen to be obtained with a single insertion and can provide a more accurate diagnosis and completely remove the lesion under real-time ultrasonic guidance. The advantage of complete lesion removal with VABB is to reduce or eliminate sampling error, to decrease the likelihood of a histological underestimation, to decrease imaging-histological discordance, to decrease the re-biopsy rate, and to diminish the likelihood of subsequent growth on follow-up. In recent years, with the advancement of VABB instruments and techniques, many outcome studies have reported on the use of VABB for resecting benign breast lesions with a curative intent. VABB is highly accurate for diagnosing suspicious breast lesions and is highly successful at treating presumed benign breast lesions. Thus, in the near future, VABB will be routinely offered to all appropriately selected patients.

Local control of ductal carcinoma in situ based on tumor and patient characteristics: the surgeon's perspective

Ductal carcinoma in situ (DCIS) is a disease whose manifestations are largely confined to in-breast pathology. Management strategies therefore focus on various combinations of local therapy: mastectomy, lumpectomy alone, and lumpectomy followed by breast irradiation. Although DCIS does not carry an inherent risk of distant organ metastasis, optimal local control is essential because any in-breast or chest wall recurrence may occur as an invasive lesion. Local recurrence has been reported following breast-conserving surgery as well as mastectomy. Breast radiation is therefore generally recommended following breast-conserving surgery, and in selected circumstances, mastectomy may be the preferred treatment strategy. This article reviews the surgical and associated clinicopathologic issues related to initial biopsy and perioperative planning that should be considered for all DCIS cases to optimize local control.

Stereotactically guided breast biopsy: a review

The aims of this review are to compare and contrast the available stereotactic equipment, and to describe the variety of needle types used and their affect on pathological results and subsequent patient management. Initial stereotactic devices were "added-on" to analogue mammography units and have been replaced by prone or ducubitus equipment using digital image acquisition. Biopsies use either 14-G core biopsy (CB) needles or vacuum-assisted biopsies (VAB). Vacuum-assisted biopsy systems consistently out-perform 14-G CB with reduced need for diagnostic or multi-treatment surgery. The false-negative rate is 8% for 14-G CB compared with 0.7% for VAB. There is a risk of underestimating the disease present for lesions of uncertain malignant potential (Cat B3) and suspicious of malignancy (Cat B4) results with 25% of patients with a B3 biopsy found to have cancer at subsequent surgery and 66% of those with a B4 biopsy. A CB diagnosis of in situ malignancy is upgraded to invasive disease at surgery in 15-36% of patients undergoing CB and of the order of 10% with VAB. A high degree of diagnostic accuracy and hence safe patient care can only be achieved by meticulous attention to technique and multi-disciplinary cooperation.

Comparison of core needle biopsy (CNB) and surgical specimens for accurate preoperative evaluation of ER, PgR and HER2 status of breast cancer patients

The roles of core needle biopsy (CNB) have become well established as an important preoperative diagnostic method for breast lesions. We examined the concordance of histological types, nuclear grades, hormone receptors, and human epidermal growth factor receptor 2 (HER2) status between CNB and surgical specimens in 353 cases. In addition, we analyzed the correlation between the number of CNB specimens obtained and accuracy of histological factors in order to explore the optimal number of CNB specimens. Between CNB and surgical specimens, concordance rates of histological type, nuclear grade, estrogen receptor (ER), and progesterone receptor (PgR) status (cut-off 0-<1%, 1-10%, and 10%<), and HER2 were 84.4%, 81.3%, 92.9%, and 89.3%, respectively. In 52 of 353 patients who were histopathologically diagnosed as ductal carcinoma in situ (DCIS) by CNB, final diagnosis was changed in to invasive ductal carcinoma (IDC) in surgical specimens. Statistically significant differences were detected in the discrepancy of the following factors between CNB and subsequent surgical specimens: histological types, nuclear grade, and PgR, between patients who received four or more cores and those who had received three or less cores. In addition, a similar tendency was also detected in estrogen receptor (ER) and HER2 as in the above, and the cases that received four cores reached to 100% concordance in diagnosis between CNB and surgical specimens. Therefore, the optimal numbers of CNB were considered four at least in assessing the histological type, invasion, nuclear grade, hormone receptor status, and HER2 status of individual patients in the preoperative setting.

Two-year follow-up of stereotactically guided 9-G breast biopsy: a multicenter evaluation of a self-contained vacuum-assisted device

PURPOSE

To evaluate the performance of a self-contained, battery-driven, vacuum-assisted breast biopsy (VABB) system for the sampling of clustered breast microcalcifications and masses under stereotactic guidance.

METHODS AND MATERIALS

A total of 144 patients (median age: 56 years; range: 21-87 years) in four European breast centers underwent percutaneous 9-gauge (G), stereotactic-guided VABB. The median lesion size was 11 mm (range 2-60 mm). Patients were biopsied in the prone (n=125) or upright position (n=19). All patients were followed up for at least 24 months.

RESULTS

The stereotactic procedure was successful in 142 (98.6%) of 144 cases, with two cases cancelled due to either severe patient motion (one case) or failure to detect faint calcifications (one case). A median of 12 specimens per procedure was obtained. In 39 cases (27.5%), the suspicious lesion could no longer be detected mammographically after the biopsy procedure. The histological diagnosis was malignancy in 45 (31.7%) cases. One case of atypical ductal hyperplasia diagnosed preoperatively was upgraded to ductal carcinoma in situ (DCIS) at operation, giving an overall sensitivity of 97.7% for the vacuum-assisted biopsy procedure. In two cases where DCIS was diagnosed at vacuum-assisted biopsy, the malignant tissue was apparently completely removed and could no longer be found at operation. No serious complications occurred. During the follow-up period, no breast cancers appeared at the location of biopsy. Six patients dropped out during the follow-up period.

CONCLUSION

The self-contained, vacuum-assisted biopsy device is well suited for stereotactically guided breast biopsies, having demonstrated excellent sensitivity and specificity in the preoperative workup of mammographically detected breast lesions after 2 years of follow-up.

The use of positive core wash cytology to estimate potential risk of needle tract seeding of breast cancer: directional vacuum-assisted biopsy versus automated core needle biopsy

BACKGROUND

A disadvantage of the image-guided core needle biopsy is that needle tract seeding may occur and affect the local recurrence and overall survival rates of patients after breast-conserving surgery, although the chance is small. The purpose of this study was to compare the potential risk of needle tract seeding of breast cancer from ultrasonographically guided needle biopsies that were performed with a directional vacuum-assisted device and an automated core needle gun.

METHODS

The study compared the biopsies of 148 breast cancers performed using ultrasonographically guided core needle biopsy with the biopsies of 105 breast cancers performed using the vacuum suction probe. The potential risk of needle tract seeding of the breast cancer was defined by the cytological results derived from the needle wash material. The atypical/indeterminate, suspicious/probably malignant, and malignant categories were considered to represent positive cases.

RESULTS

There were significantly fewer positive cytological findings derived from the needle wash material with the directional vacuum-assisted device (33%) than with the automated core needle gun (69%) (P < 0.0001).

CONCLUSION

The use of the directional vacuum-assisted device significantly decreases the potential risk of needle tract seeding of breast cancer after an ultrasonographically guided needle biopsy.

Ultrasound-guided, vacuum-assisted excision in the diagnosis and treatment of clinically benign breast lesions

INTRODUCTION

Ultrasound-guided, vacuum-assisted biopsy has a definitive role in the diagnosis of breast lesions. Its role in the treatment of benign breast lesions like fibroadenomas has not been established.

PATIENTS AND METHODS

This is a retrospective review of patients undergoing ultrasound-guided, vacuum-assisted biopsy for clinically benign breast lesions. The procedures were performed in all cases by two consultant radiologists with special interest in breast radiology between February 2002 and January 2004. Patients were followed up in the clinic 6 weeks after the procedure.

RESULTS

Seventy-six patients had ultrasound-guided, vacuum-assisted excision of clinically benign breast lesions during this 2-year period. Mean age of the patients was 31 years. Altogether, 86 procedures were performed. Six patients with larger lesions (> 2 cm) had two procedures on separate sitting and 4 patients had separate lesions excised on a later date. Fifty-six patients were identified to have fibroadenomas and had complete excisions as evidenced on scan. Three out of nine patients identified with equivocal disease on fine needle aspiration cytology (FNAC) were found to have cancer following ultrasound-guided, vacuum-assisted excision. One patient who was diagnosed with cancer on FNAC, proved to be fibroadenoma on final histopathology. Four patients developed haematomas following ultrasound-guided, vacuum-assisted excision and all were managed conservatively.

CONCLUSIONS

Our study shows that ultrasound-guided, vacuum-assisted excision can play an efficient role in the diagnosis of benign breast lesions and is a safe and successful alternative in treatment of fibroadenomas.

Risk of needle tract seeding of breast cancer: cytological results derived from core wash material

Needle track seeding has been recognized as a possible, albeit rare, complication of breast core needle biopsy. The purpose of this study was to assess the risk of needle tract seeding of breast cancer from cytological results derived from core needle wash material. The study included biopsies of 207 breast cancers performed using ultrasonographically guided 18-gauge core needles. Each core needle without exposed sample notch was washed in saline solution immediately after removing the needles. Cytology derived from core wash material was performed by saline solution lavage of the fragments using a cytocentrifuge. The cytological diagnoses were divided into five categories: benign, atypical/indeterminate, suspicious/probably malignant, malignant and unsatisfactory. Atypical/indeterminate, suspicious/probably malignant and malignant categories were considered to represent positive cases of needle track seeding of breast cancer, whereas benign and unsatisfactory categories were counted as negative cases. Cytological diagnoses of the 207 lesions were as follows: 26 lesions (12%) were benign, 18 lesions (9%) were atypical/indeterminate, 37 lesions (18%) were suspicious/probably malignant, 79 lesions (38%) were malignant, and 47 lesions (23%) were unsatisfactory. The incidence of positive cases of cytology derived from core wash material was 65% (134/207). The 25% frequency of positive cases of invasive lobular carcinoma was significantly lower than the frequencies of DCIS (74%) and invasive ductal carcinoma (69%) (P = 0.001 and P < 0.01). The frequency of positive cases in the multiple passes group was 75%, which was slightly, although not significantly, higher than the 66% frequency in the single pass group (P = 0.3). In conclusion, the incidence of positive cases of cytology derived from ultrasonographically guided breast core needles' wash material was 65%. The clinical significance is debatable; however, there may be a theoretical risk of local recurrence if the tract is not excised or radiotherapy not given.

Predictors of Residual Invasive Disease after Core Needle Biopsy Diagnosis of Ductal Carcinoma In Situ

Core needle biopsy (CNB) is used to sample both mammographically and ultrasound detected breast lesions. A diagnosis of ductal carcinoma in situ (DCIS) by CNB does not ensure the absence of invasive cancer upon surgical excision and as a result an upstaged patient may need to undergo additional surgery for axillary nodal evaluation. This study evaluates the accuracy of CNB in excluding invasive disease and the preoperative features that predict upstaging of DCIS to invasive breast cancer. Two hundred fifty-four patients over an 8-year period from 1994 to 2002 with a diagnosis of DCIS alone by CNB were retrospectively reviewed. Underestimation of invasive cancer by CNB was determined. Radiographic, pathologic, and surgical features of the cohort were compared using univariate and multivariate analysis. The mean age was 55 years (range 27-84) and mean follow-up was 25 months with one patient unavailable for follow-up. There were a total of six patient deaths, all of which were not disease-specific. A total of 21 out of 254 patients (8%) with DCIS by CNB were upstaged to invasive cancer following surgical excision. There was a significant inverse relationship between the number of core biopsies and the incidence of upstaging (p < 0.006) in that patients with fewer core samples were more likely to be upstaged at surgical pathology. No relationship was noted between the size of the core samples and the likelihood of upstaging (p > 0.4). Of 21 patients with invasion, all but two had comedonecrosis by CNB. Comedonecrosis by CNB significantly increased the likelihood of upstaging (p < 0.001). Of the 21 patients who were upstaged, 12 required subsequent surgery for nodal evaluation while nine had sentinel node biopsy at initial operation. Finally, upstaged patients were significantly more likely to have a positive margin (p < 0.008). Ductal carcinoma in situ with comedonecrosis on CNB can help to predict the possibility of invasion. Increasing the number of core biopsies reduced the likelihood of sampling error.

Underestimation of malignancy of breast core-needle biopsy

BACKGROUND

A review of the literature indicated variable underestimation rates for breast core-needle biopsy (CNB) based on generally small series. In this article, the authors present precise estimates for overall underestimation and for categories of histologic underestimates (including categories that reflect contemporary classification) and examine the effect of lesion and sampling variables.

METHODS

Among 4035 consecutive CNBs, the authors examined women whose CNB outcome represented a potential underestimate of malignancy (benign but of uncertain biologic or malignant potential or B3 and ductal carcinoma in situ [DCIS]). From 889 eligible women, all 758 women who had excision histology available were included.

RESULTS

Overall underestimation of CNB was 27.7% (95% confidence interval [95% CI], 24.5-30.9%). The following category-specific rates were used: B3 underestimates, 36.2% (95% CI, 30.6-41.8%); B3 underestimates (excluding atypical proliferations), 17.9% (95% CI, 10.8-24.9%); atypical ductal hyperplasia underestimates, 29.0% (95% CI, 21.4-36.6%; upgraded to DCIS) and 44.2% (95% CI, 36.0-52.5%; upgraded to DCIS or invasive cancer); and DCIS underestimates, 22.8% (95% CI, 19.0-26.5%). There was a significant trend toward greater underestimation of malignancy with increasing lesion size on imaging studies for overall underestimates (P = .00008), B3 underestimates (P = .009), and DCIS underestimates (P = .0007). Underestimation rates did not differ between masses (27.9%) and microcalcifications (27.6%; chi-square statistic with 1 degree of freedom = 3.02; P = .98) and were significantly lower for vacuum-assisted CNB (11-gauge) than for automated CNB (14-gauge; P = .001). Underestimation rates, when sampling microcalcifications, decreased with increasing number of cores collected, but this was mainly for DCIS underestimates.

CONCLUSIONS

CNB results that were not definitely negative or were not positive for invasive cancer were associated with high rates of underestimation of disease and with target lesion size. Identifying imaging or sampling factors that affect underestimation rates of CNB may assist in reducing their occurrence and better predicting excision histology outcomes.

Guidelines from the European Society of Breast Imaging for diagnostic interventional breast procedures

The aim of the breast team is to obtain a definitive, nonoperative diagnosis of all potential breast abnormalities in a timely and cost-effective way. Percutaneous needle biopsy with its high sensitivity and specificity should now be standard practice, removing the need for open surgical biopsy or frozen section. For patients with cancer, needle biopsy provides a cost-effective and rapid way of providing not only a definitive diagnosis but prognostic information, allowing prompt discussion of treatment options, be they surgical or medical. Early removal of uncertainty also allows better psychosocial adjustment to the disease. Patients with benign conditions found either by themselves or as a result of population or opportunistic screening can be promptly reassured and discharged, removing the health care and psychological costs of surgical biopsy or repeated follow-up. Radiologists involved in breast imaging should ensure that they have the necessary skills to carry out core biopsy and/or fine-needle aspiration (FNA) under all forms of image guidance. This paper provides guidelines on best practice for diagnostic interventional breast procedures and standards, against which all practitioners should audit themselves, from the European Society of Breast Imaging.

Axillary sentinel lymph nodes can be falsely positive due to iatrogenic displacement and transport of benign epithelial cells in patients with breast carcinoma

PURPOSE

Immunohistochemical (IHC) staining for cytokeratins (CK) is common practice in evaluating sentinel lymph nodes (SLNs) in patients with breast carcinoma. IHC positivity typically indicates metastasis. SLN procedures are increasingly common in patients with pure intraductal carcinoma (DCIS). Iatrogenic epithelial cell displacement and benign transport of breast epithelial cells into axillary lymph nodes are recently described phenomena. We report 25 cases in which these factors probably resulted in benign epithelial cells in axillary SLNs (ie, false positivity).

METHODS

We reviewed 25 cases of CK-positive SLNs in which the epithelial cells had histologic and IHC characteristics different from their respective patients' underlying breast carcinomas.

RESULTS

In all cases, the cytologic features of the epithelial cells in the SLNs were benign, and 22 matched those of corresponding intraductal papillomas that were involved by or were separate from the DCIS in the original cores or surgical biopsies. Fifteen cases were pure DCIS; most invasive tumors were smaller than 1.0 cm. In six carcinomas (DCIS) showing strong Her-2/neu staining, the corresponding epithelial cells in the SLNs were negative. In 13 tumors that were strongly and uniformly positive for estrogen receptor (ER), the cytokeratin-positive cells in the SLNs were negative for ER. Nineteen cases showed benign epithelial cell displacement at the biopsy site.

CONCLUSION

Epithelial cells in SLNs may result from transport of displaced cells, usually originating in intraductal papillomas. Positive immunohistochemical results in SLNs should be interpreted with extreme caution to avoid automatically concluding that such cells represent metastasis. Sentinel lymph nodes in breast carcinoma can be falsely positive.

[Value of vacuum assisted biopsies under sonography guidance: results from a multicentric study of 650 lesions]

OBJECTIVE

With this retrospective, multi-centric study, the authors are showing the technique of Vacuum assisted biopsies under ultrasound guidance and comparing it with the other widely used diagnostic techniques. Material and method. Six hundred and fifty biopsies were performed between May 2000 and December 2004, on 644 patients, in 3 centres, following a unique protocol. Lesions were categorized, using the classification from Stavros, between "probably benign", "indeterminate", "probably malignant" and "malignant" Histology was validated only after review of the clinical and radiological data, as well as surgical data when available. All benign cases were included in an on-going follow-up protocol.

RESULTS

We have identified 471 benign lesions and 179 malignant lesions. The mean size of the lesions was 9 mm. Three cancers were diagnosed in the cases of "probably benign lesions" and in the cases of "probably malignant lesions" 18 (27%) were inflammatory disorders. In 5 cases vacuum biopsy underestimated the pathology with regard to surgery: 2 cases of atypical duct hyperplasia (HCA) were in situ ductal carcinoma (DCIS) at surgery and 3 cases of DCIS were infiltrative ductal carcinoma (DCI) at surgery. With this technique we have avoided surgery for 71% of all women who presented an "indeterminate" or "probably malignant" condition. Specificity is excellent with no cancer detected so far among the patients with benign findings, under follow-up.

CONCLUSION

Ultrasound guided Vacuum assisted biopsy is a fairly recent minimally invasive technique, with short learning curve. The ability to collect a larger volume of tissue overcomes the targeting issues on small lesions and avoids underestimation of heterogeneous and larger abnormalities and some specific at-risk lesions such as papilloma. This technique thus appears indicated in such cases because it overcomes some of the limitations of core needle biopsy and should be considered as an alternative to surgical biopsy.

Mammotome biopsy: impact on preoperative diagnosis rate

AIM

To assess the impact of mammotome biopsy on preoperative diagnosis rate.

METHODS

A prospective study was undertaken to examine the referral patterns, radiological abnormalities, sensitivity, specificity and outcome of the first 150 patients undergoing mammotome biopsy at our institution. Most of the referrals were from the NHS Breast Screening Programme (85/100).

RESULTS

The commonest radiological abnormality was microcalcification (87%). The accuracy of this biopsy technique for the target lesion was over 99%. Post-biopsy, 11 patients needed to proceed to a diagnostic surgical biopsy (7%). Forty-two malignancies were identified at final histology; 41 were diagnosed preoperatively. The positive predictive of mammotome biopsy was 98% for the present study. The present results for mammotome biopsy with regard to predicting invasion were: sensitivity 71.4% (10/14); specificity 100% (0/0); positive predictive value 100% (10/10); and negative predictive value 87% (27/31).

CONCLUSION

Prone mammotome biopsy has proven to be highly accurate, considerably improving the preoperative diagnosis within our unit, and obviating the majority of diagnostic excision biopsies.

Biopsy type does not influence sentinel lymph node status

BACKGROUND

This study sought to determine whether the type of biopsy examination independently affects sentinel lymph node (SLN) status in breast cancer patients.

METHODS

A prospective multicenter study of patients who had SLN biopsy examination followed by axillary node dissection was analyzed to determine whether the type of biopsy examination influenced SLN status.

RESULTS

Of the 3853 patients studied, 32% had a positive SLN. Patients were diagnosed by fine-needle (N = 293), core-needle (N = 2154), excisional (N = 1386), or incisional (N = 20) biopsy procedures. The rates of SLN positivity for these groups were 45%, 32%, 29%, and 65%, respectively (P < .001). Other factors predictive of SLN status included: patient age (P < .001), tumor size (P < .001), tumor palpability (P < .001), number of SLN removed (P < .001), type of surgery (mastectomy vs. lumpectomy) (P < .001), histologic subtype (P = .048), and the use of immunohistochemistry (P < .001). All of these factors remained significant in the multivariate model except for histologic subtype and biopsy examination type.

CONCLUSIONS

Biopsy examination type does not independently influence the risk for nodal metastasis.

Benign mechanical transport of breast epithelial cells to sentinel lymph nodes

The evaluation of sentinel lymph nodes (SLNs) for the presence of malignant epithelial cells is essential to the staging of breast cancer patients. Recently, increased attention has focused on the possibility that epithelial cells may reach SLNs by benign mechanical means, rather than by metastasis. The purpose of this study was to test the hypothesis that pre-SLN biopsy breast massage, which we currently use to facilitate the localization of SLNs, might represent a mode of benign mechanical transport. We studied 56 patients with invasive and/or in situ ductal carcinoma and axillary SLNs with only epithelial cells and/or cell clusters (< or =0.2 mm in diameter and not associated with features of established metastases) detected predominantly in subcapsular sinuses of SLNs on hematoxylin and eosin- and/or anti-cytokeratin-stained sections. No patient had an SLN involved by either micro- or macro-metastatic carcinoma. Epithelial cells and cell clusters, < or =0.2 mm in size and without features of established metastases, occurred more frequently in the SLNs of patients who underwent pre-SLN biopsy breast massage (P < 0.001, chi2 test). The latter finding supports the hypothesis that pre-SLN biopsy breast massage is a mode of benign mechanical transport of epithelial cells to SLNs.

Tumour cell displacement after 14G breast biopsy

INTRODUCTION

Seeding of biopsy needle tracks with viable malignant cells was an initial concern with all diagnostic breast needle procedures, including 14G automated needle biopsy. In an attempt to further evaluate this phenomenon, we have addressed the following questions: (1) are the tracks left by the needle biopsy procedure detectable in the surgical excision specimen? (2) Are displaced tumour cells visible along the needle tracks? (3) Is it possible to identify and excise the entire needle track for thorough histopathologic evaluation?

METHODS

Surgical biopsy specimens of patients previously diagnosed with cancer on stereotactic 14G-needle biopsy were studied to find needle tracks. These are characterised by hemosiderin, scar tissue, foreign body giant cell reaction, fat necrosis, or organizing haemorrhage. Occurrence of displaced tumour cells or groups of cells along the tracks was registered.

RESULTS

Needle tracks were found in 22/64 excision specimens of patients who underwent 14G-needle biopsy and surgery on the same day. Tumour-cell displacement along the needle track was seen in 11/22 cases (50%). In a prospective study, an attempt was made to excise the entire needle track in 13 consecutive cancer cases after 14G biopsy. Median time interval between core biopsy and first surgical excision was 21 days (range 7-35). Needle tracks could be visualised in 11/13 cases; displaced cells were seen in seven.

CONCLUSION

Needle tracks can be found in the excision specimens of patients who previously underwent 14G biopsy, and displaced tumour cells can be recognised. Excision of the entire needle track is neither feasible, nor advisable as a routine measure, since radiotherapy is advised for both in situ and invasive carcinoma after conservative surgery.

Stereotactic 11-gauge vacuum-assisted breast biopsy: influence of number of specimens on diagnostic accuracy

PURPOSE

To determine whether number of specimens obtained at stereotactic 11-gauge vacuum-assisted breast biopsy with the patient prone influences diagnostic accuracy and to determine whether this number varies depending on mammographic appearance of lesions as masses or microcalcifications.

MATERIALS AND METHODS

Biopsy was prospectively performed in 100 patients (median age, 55 years; range, 31-81 years) with 100 lesions that were mammographically evident as masses (n = 50) and microcalcifications (n = 50) with standardized protocol to acquire 20 specimens per lesion in three 360 degrees probe rotations at one skin entry site. Specimens were histologically evaluated sequentially, and findings were compared with results of surgical excision or of mammographic follow-up for at least 24 months. Differences in diagnostic yield after each probe rotation and differences in diagnostic yield between masses and microcalcifications were determined with chi(2) test.

RESULTS

Up to 12 specimens harvested within two 360 degrees probe rotations were necessary to yield correct diagnosis in 96% of patients with masses and 92% of patients with microcalcifications. Diagnostic yield was not improved with more than 12 specimens for masses or microcalcifications. In two (4%) of 47 patients with lesions that were eventually diagnosed as cancer, results at stereotactic biopsy indicated they were benign. Underestimation of diagnosis of lesions as atypical ductal hyperplasia and ductal carcinoma in situ occurred in two (50%) of four and two (17%) of 12 lesions, respectively. With 20 specimens harvested during three probe rotations, there was no statistically significant difference in diagnostic yield between patients with masses and those with microcalcifications (P =.68).

CONCLUSION

At 11-gauge vacuum-assisted biopsy, highest diagnostic yield was achieved with 12 specimens per lesion, independent of mammographic appearance of the lesion. Even with standardized retrieval of 20 specimens per lesion, underestimation of disease still occurs.

Morphologic changes in breast biopsies after duct endoscopy

Duct endoscopy is a recent technique used for a direct view of the breast ductal system. The aim of this study is to determine any morphological changes in breast tissue attributable to low-pressure irrigation with saline solution that the technique requires. A total of 26 breast biopsies from patients who underwent ductal endoscopy before surgery were compared with 26 breast specimens from the retroareolar region. Breast specimens from duct endoscopy showed more frequent epithelial detachment (73%), epithelial loss (35%), periductal clefts (77%), stromal disaggregation (46%) and displacement of epithelial cells into the stroma (27%) than the control group in which epithelial detachment was seen in 4% of patients, periductal clefts in 15%, and stromal disaggregation in 15%. Epithelial loss and epithelial displacement where not seen in the control group. Although low-pressure fluid perfusion used for duct endoscopy induced morphological changes in breast tissue, these can easily be distinguished from malignancy, and are most likely to occur as the result of duct rupture.

Issues in the interpretation of breast core biopsies

Core biopsies are now widely used for the nonoperative diagnosis of breast masses and microcalcifications and have replaced fine-needle aspiration (FNA) cytology for most lesions in many centers. In the United Kingdom, a scoring system of 5 reporting categories, B1-B5, has been adopted, which is to some extent similar to that used in the interpretation of breast FNA. This article is based on the practice at Charing Cross Hospital, London, which is a major regional breast screening and treatment center covering the West of London area; as well as on a thorough review of the contemporary literature. It begins by discussing issues related to the adoption of the technique and to handling core biopsies, followed by a brief presentation of the reporting categories. The article then deals with some commonly encountered diagnostic problems.

Local recurrence of breast cancer after breast conservation therapy in patients examined by means of stereotactic core-needle biopsy

PURPOSE

To evaluate the incidence of locally recurrent breast cancer in patients treated with breast conservation surgery and radiation therapy to determine if increased local recurrence is observed in women examined by means of stereotactic core-needle biopsy (SCNB).

MATERIALS AND METHODS

Records of 551 consecutive patients with breast cancer who were treated with conservation surgery and radiation therapy were reviewed retrospectively. The 551 cases were divided into three groups: those examined by means of SCNB (n = 86), those examined by means of excisional biopsy preceded by needle localization (n = 242), and those in which the masses were palpable and who underwent biopsy without imaging guidance (n = 223). The local recurrence rate and the Mantel-Haenszel statistic for survival curves were calculated for each group. To test for statistical significance, chi(2) analysis was performed for categorical variables and a t test or analysis of variance was performed for calculation of continuous variables.

RESULTS

With a mean follow-up of 4.9 years (range, 2.0-8.9 years), tumor recurrence rate in the SCNB group was 2.3% (two of 86), resulting in a 5-year actuarial recurrence-free rate of 0.96 +/- 0.03. For the needle-localized biopsy group, recurrence rate was 5.4% (13 of 242), with a 5-year actuarial tumor recurrence-free rate of 0.88 +/- 0.03. For the non-image-guided biopsy group, the recurrence rate was 10.3% (23 of 223), with a 5-year actuarial recurrence-free rate of 0.84 +/- 0.03. These rates were not significantly different when the SCNB group was compared with the needle-localized biopsy group. However, the recurrence-free rate was significantly greater for the SCNB group than that for the non-image-guided biopsy group (P =.03).

CONCLUSION

In the present series to date, cancers diagnosed by means of SCNB were not associated with an increased incidence of local recurrence after breast conservation surgery and radiation therapy.

To excise or to sample the mammographic target: what is the goal of stereotactic 11-gauge vacuum-assisted breast biopsy?

OBJECTIVE

This study was undertaken to determine whether complete percutaneous excision rather than sampling of the mammographic target conveys any significant advantage or disadvantage at stereotactic 11-gauge vacuum-assisted biopsy.

MATERIALS AND METHODS

A retrospective review was performed of 788 consecutive solitary lesions in which the mammographic target was excised (n = 466) or sampled (n = 322) at stereotactic 11-gauge vacuum-assisted biopsy. Medical records and histologic findings were reviewed to determine the frequency of sparing surgery, discordance, histologic underestimation, rebiopsy, complete histologic removal of cancer, and complications. Statistical comparisons were made using the Fisher's exact test.

RESULTS

Complete excision rather than sampling of the mammographic target was associated with a significantly lower frequency of discordance (1/466, 0.2% vs 8/322, 2.5%; p = 0.004) and a trend toward fewer ductal carcinoma in situ underestimates (4/59, 6.8% vs 12/60, 20.0%; p = 0.07). Complete histologic removal of cancer was significantly more likely if the mammographic target was excised rather than sampled (19/91, 20.9% vs 7/106, 6.6%; p = 0.006); however, among 91 cancers in which the mammographic target was excised, surgery revealed residual cancer in 72 (79.1%). Complete excision rather than sampling of the mammographic target yielded no significant differences in the frequency of sparing surgery, atypical ductal hyperplasia underestimates, rebiopsy, or complications.

CONCLUSION

Complete excision rather than sampling of the mammographic target was associated with lower frequencies of discordance and ductal carcinoma in situ underestimation but had no other advantage or disadvantage. Among cancers in which the mammographic target was excised, surgery revealed residual cancer in almost 80%.

Percutaneous image-guided core breast biopsy

Percutaneous image-guided core biopsy is an accurate, fast, minimally invasive, and less expensive alternative to surgery for the diagnosis of breast lesions. Percutaneous core biopsy is usually performed under stereotactic or ultrasound guidance, using an automated needle or vacuum-assisted biopsy probe. Use of percutaneous core biopsy spares the need for surgery in most women with benign disease and expedites treatment in women with breast cancer. This article reviews advantages, limitations, controversies, and future directions in percutaneous image-guided core breast biopsy.