Percutaneous imaging-guided core breast biopsy: 5 years' experience in a community hospital

An audit of the results of ultrasound-guided core needle biopsy of mammography versus ultrasound screen-detected breast lesions

PURPOSE

To analyze the malignancy rate of ultrasound-guided core needle biopsy (US-CNB) for screen-detected breast lesions and to evaluate the results according to the mode of detection of the target lesions.

METHODS

This is a retrospective review of 703 consecutive women who underwent US-CNB for screen-detected breast lesions at a single tertiary hospital. Breast Imaging Reporting and Data System (BI-RADS) categories and histopathological results of the target lesions were assessed. The cases were divided into two groups: the mammography-based detected lesions (M-group) and the US-based detected lesions (U-group). The biopsy performances of the two groups were compared using the χ² test.

RESULTS

The malignancy rate in the entire population was 22.0%: 0.8%, 12.3%, 65.2%, 89.3%, and 94.6% in BI-RADS categories 3, 4A, 4B, 4C, and 5, respectively. The malignancy rate was significantly higher in the M-group (54.1% [79/146]) than in the U-group (13.6% [76/557]) (p < 0.001). BI-RADS category 3 was the most common assessment overall that led to a US-CNB (362/703, 51.5%) and the rate of BI-RADS category 3 diagnoses that led to US-CNB was significantly higher in the U-group (p < 0.001).

CONCLUSIONS

The malignancy rate associated with US-CNB for screen-detected breast lesions was 22.0%. The breast lesions detected by mammography have a higher malignancy rate than those detected by US. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:261-266, 2017.

Can strain elastography combined with ultrasound breast imaging reporting and data system be a more effective method in the differentiation of benign and malignant breast lesions?

PURPOSE

To investigate whether a novel method that combines breast imaging reporting and data system (BI-RADS) with strain elastography contributes to diagnostic performance in differentiation of malignant and benign breast lesions.

METHODS

In 81 patients, 81 breast lesions were prospectively investigated. Breast lesions were separately evaluated with ultrasonography and strain elastography. While evaluations with ultrasonography were based on 2003 BI-RADS-US, strain elastography evaluations were based on a 5-point scale and strain ratio. Diagnostic performances of ultrasonography, strain elastography, and the combined method were compared.

RESULTS

Among 81 lesions, 43 (53.1%) were benign and 38 (46.9%) were malignant. When a cutoff point of category 3 was used, sensitivity, specificity, positive and negative predictive values, and accuracy for BI-RADS were 100, 11.6, 50, 100, and 53%, respectively. When BI-RADS and strain ratio were combined, sensitivity, specificity, positive and negative predictive values, and accuracy were 89.5, 93, 91.9, 90.9, and 91.3%, respectively. When BI-RADS and elastography scores were combined, sensitivity, specificity, positive and negative predictive values, and accuracy were 86.8, 97.7, 97.1, 89.4, and 92.5%, respectively.

CONCLUSIONS

The combination of strain elastography and BI-RADS was found to have better diagnostic performances to diagnose breast lesions than BI-RADS alone.

Comparing cancer detection rates of patients undergoing short term follow-up vs routine follow-up after benign breast biopsies, is follow-up needed?

PURPOSE

To compare cancer rates after benign breast biopsies between patients with short term imaging follow-up (STFU) and those with routine follow-up (RFU).

MATERIALS & METHODS

Retrospective review of benign stereotactic, US or DCE-MRI breast biopsies.

RESULTS

Of 580 lesions, 192 (33%) had STFU, and 388 (67%) had RFU. For US and mammographic detected lesions, there is no difference in cancer rates between the STFU (1 cancer, n=148) and the RFU group (0 cancer, n=365) (p=0.29). There were 2 cancers in the STFU group versus 0 in the RFU DCE-MRI group (p=0.54).

CONCLUSION

Our results support RFU after benign ultrasound and stereotactic breast biopsies.

Comparison of the accuracy of US-guided biopsy of breast masses performed with 14-gauge, 16-gauge and 18-gauge automated cutting needle biopsy devices, and review of the literature

OBJECTIVE

To compare the diagnostic accuracy of ultrasound (US)-guided core needle biopsy (CNB) of breast masses performed with 14-gauge, 16-gauge and 18-gauge needles.

METHODS

We retrospectively reviewed the charts of 1,112 patients who underwent US-guided breast CNB with 14-gauge, 16-gauge and 18-gauge needles. Cases with surgical excision or a minimum of 2 years of imaging follow-up were included. Rates of sample inadequacy, discordance with surgical or imaging findings and upgrade of DCIS to invasive cancer or high-risk lesion to in situ or invasive cancer were computed for each needle size.

RESULTS

The study included 703 CNBs: 203 performed with 14-gauge, 235 with 16-gauge and 265 with 18-gauge needles. There were no significant differences between 14-gauge, 16-gauge and 18-gauge needles in rates of specimen inadequacy (0 %, 0.4 % and 1.9 %, respectively) (p = 0.084); surgical discordance (2.6 %, 2.9 % and 3.8 %) (p = 0.76); imaging discordance (0 %, 0 % and 2 %) (p = 1.0); DCIS upgrade (43 %, 43 % and 36 %) (p = 1.00) or high-risk lesion upgrade (38 %, 25 % and 55 %) (p = 0.49).

CONCLUSION

There was no statistically significant difference in diagnostic accuracy of US-guided CNB of breast masses performed with 14-gauge, 16-gauge and 18-gauge needles.

KEY POINTS

• Percutaneous image-guided breast core needle biopsy (CNB) is the standard of care. • Breast CNB with 14-gauge, 16-gauge and 18-gauge needles has similar diagnostic accuracy. • Smaller gauge needles can be confidently used for ultrasound-guided breast CNB.

Six-Month Short-Interval Imaging Follow-Up for Benign Concordant Core Needle Biopsy of the Breast: Outcomes in 1444 Cases With Long-Term Follow-Up

OBJECTIVE

The purpose of this study is to assess whether 6-month imaging follow-up after benign core needle breast biopsy is important for patient outcomes and whether it depends on nonspecific versus definitive benign biopsy results.

MATERIALS AND METHODS

Consecutive breast biopsies from 2003 to 2010 were analyzed. Benign concordant lesions with at least 2 years of follow-up were assessed. Pathologic abnormalities were further characterized as having definitive or nonspecific features. A two-tailed Fisher exact test was used to assess the difference in pathologic features among lesions that had progressed.

RESULTS

Of 3256 cases, 1705 biopsies in 1602 women were benign concordant and were recommended for 6-month imaging follow-up; the compliance rate was 94.9%. Of these, 1444 biopsies were confirmed as benign with long-term follow-up or excision. At pathologic analysis, 805 (55.7%) benign lesions had definitive features and 639 (44.3%) had nonspecific features. Thirty-four (2.4%) lesions progressed; this was similar for the lesions with definitive (2.6%) and nonspecific (2.0%) features (p = 0.60). The false-negative rate was 0.18%, with a mean of 5.0 cores sampled per lesion.

CONCLUSION

For lesions with benign concordant biopsy results, selection of the follow-up interval should not be dictated by whether the pathologic features are definitive or nonspecific. The number of lesions that progress at imaging follow-up is low. The false-negative rate is low, regardless of modality or lesion type. A low false-negative rate is achievable with a reasonable number of core samples. The 6-month follow-up interval benefits only a small number of patients. Our results suggest that routine imaging after core needle biopsy is safe.

Improving Patient Care by Incorporation of Multidisciplinary Breast Radiology-Pathology Correlation Conference

PURPOSE

It is well known that radiologic-pathologic correlation is critical in managing patients with breast disease. Although regular multidisciplinary conferences addressing radiologic-pathologic correlation are common at most major academic institutions, this approach is not universal in community-based settings or even some of the smaller academic practices. This study was performed to assess the impact of a weekly multidisciplinary conference on patient care to determine whether all breast practices should adopt this approach as a means to streamline and improve the quality of patient care.

METHODS

We reviewed cases of percutaneous breast core biopsies presented at our weekly breast radiology-pathology correlation conference from July 1, 2008, to June 30, 2012. Each reviewed case was assigned to 1 of 4 categories (concordant → concordant, concordant → discordant, discordant → discordant, and discordant → concordant) based on the "initial" and "final" impressions of concordance between radiology and pathology. Changes in concordance, histopathological diagnosis, or management that occurred during the conference were recorded prospectively and analysed. Changes in management that were considered significant included changes in recommendations for surgery, repeat core biopsy, or follow-up imaging.

RESULTS

Of 1387 presented at the conference, 1313 (94.7%) had no change during the meeting, confirming 1279 (92.2%) concordant and 34 (2.4%) discordant cases. A total of 74 (5.3%) cases had a change during the conference: 22 of 74 (29.7%) were changed from discordant to concordant, avoiding surgical excision in 15 and short interval imaging in 7; 23 of 74 (31.1%) were changed from concordant to discordant; on excision 3 were cancer, 3 atypia, 10 benign, 2 stable on follow-up imaging, and 5 lost to follow-up; the remaining 29 of 74 (39.2%) stayed concordant after review, but had a change in management, avoiding surgery in 14 and short interval imaging in 15. Overall, as a result of this conference, repeat biopsy or excision was recommended in 23, surgery was avoided in 29, short interval imaging avoided in 22, and cancer detected in 3 cases.

CONCLUSIONS

Our weekly breast radiology-pathology correlation conference impacted patient management in up to 5.3% of cases. These results support the need to incorporate a weekly multidisciplinary case review of breast core biopsies into all breast care practices. Such a conference maximizes cancer detection, identifies discordant cases in a timely manner, decreases follow-up imaging, and avoids unnecessary surgical intervention.

Short-term follow-up in 6 months is unnecessary for asymptomatic breast lesions with benign concordant results obtained at ultrasonography-guided 14-gauge core needle biopsy

BACKGROUND

We investigated whether short-term follow-up in 6 months was appropriate for asymptomatic benign concordant lesions on ultrasonography-guided core needle biopsy (ultrasonography-guided CNB).

METHODS

Of 1,111 lesions, 944 underwent follow-up within 4 to 9 months after CNB, and 359 of 944 underwent a 2nd follow-up within 9 to 15 months. One hundred sixty-seven underwent a 1st follow-up within 9 to 15 months. Follow-up intervals were classified according to an interval of 6 and 12 months with 2 different methods. First, 944 and 167 lesions were classified into the 6- and 12-month groups. Second, 944 and 526 lesions (sum of 167 and 359 lesions) were classified into the 6- and 12-month groups. Clinicopathologic factors were compared between the 2 groups.

RESULTS

None of the benign concordant lesions were malignant; 1.4% of the lesions showed progression in the 6-month group, not significantly different from 1.2% and .8% of the 12-month group. Mean age, mean lesion size, final assessments, and specific or nonspecific pathologies were not different between the 2 groups.

CONCLUSIONS

Short-term follow-up in 6 months is unnecessary for asymptomatic benign concordant breast lesions at ultrasonography-guided CNB.

Breast cancer detection with short-interval follow-up compared with return to annual screening in patients with benign stereotactic or US-guided breast biopsy results

PURPOSE

To compare the cancer detection rate and stage after benign stereotactic or ultrasonography (US)-guided core breast biopsy between patients with short-interval follow-up (SIFU) and those who return to annual screening.

MATERIALS AND METHODS

The Breast Cancer Surveillance Consortium (BCSC) registry and the BCSC Statistical Coordinating Center received institutional review board approval for active and passive consent processes and a waiver of consent. All procedures were HIPAA compliant. BCSC data for 1994-2010 were used to compare ipsilateral breast cancer detection rates and tumor characteristics for diagnoses within 3 months after SIFU (3-8 months) versus return to annual screening (RTAS) mammography (9-18 months) after receiving a benign pathology result from image-guided breast biopsy.

RESULTS

In total, 17 631 biopsies with benign findings were identified with SIFU or RTAS imaging. In the SIFU group, 27 ipsilateral breast cancers were diagnosed in 10 715 mammographic examinations (2.5 cancers per 1000 examinations) compared with 16 cancers in 6916 mammographic examinations in the RTAS group (2.3 cancers per 1000 examinations) (P = .88). Sixteen cancers after SIFU (59%; 95% confidence interval [CI]: 39%, 78%) were invasive versus 12 after RTAS (75%; 95% CI: 48%, 93%). The invasive cancer rate was 1.5 per 1000 examinations after SIFU (95% CI: 0.9, 2.4) and 1.7 per 1000 examinations (95% CI: 0.9, 3.0) after RTAS (P = .70). Among invasive cancers, 25% were late stage (stage 2B, 3, or 4) in the SIFU group (95% CI: 7%, 52%) versus 27% in the RTAS group (95% CI: 6%, 61%). Positive lymph nodes were found in seven (44%; 95% CI: 20%, 70%) invasive cancers after SIFU and in three (25%; 95% CI: 5%, 57%) invasive cancers after RTAS.

CONCLUSION

Similar rates of cancer detection were found between SIFU and RTAS after benign breast biopsy with no significant differences in stage, tumor size, or nodal status, although the present study was limited by sample size. These findings suggest that patients with benign radiologic-pathologic-concordant percutaneous breast biopsy results could return to annual screening.

Could ultrasonic elastography help the diagnosis of small (≤2 cm) breast cancer with the usage of sonographic BI-RADS classification?

OBJECTIVES

To evaluate the additive value of ultrasound strain elastography (USE) to BI-RADS for the differentiation of benign and malignant breast small lesions.

METHODS

Breast masses (≤2 cm) with histological diagnosis examined by ultrasonography and USE in our department from April 2004 to December 2009 were reviewed. Conventional B-mode ultrasound findings were classified according to the BI-RADS classification. USE findings were classified according to the 5-point scale. Histological diagnosis was used as the reference standard.

RESULTS

401 (246 benign (61.3%), 155 malignant (38.7%)) from 370 consecutive patients were included in the study. Sensitivity and specificity were 90.3%, 68.3% for BI-RADS; 72.3%, 91.9% for USE. The sensitivity of BI-RADS was better than that of USE (P<0.05), while the specificity of USE was better than that of BI-RADS (P<0.05). A revised BI-RADS combined with USE results was proposed in this study. Sensitivity and specificity were 83.9% and 87.8% for revised BI-RADS. The diagnostic performance of revised BI-RADS was better than BI-RADS (P<0.05).

CONCLUSIONS

USE could give BI-RADS some help in the differentiation of benign and malignant breast small lesions. The addition of elastography to BI-RADS could improve the diagnostic performance in <2 cm lesions.

Utility of 6-month follow-up imaging after a concordant benign breast biopsy result

PURPOSE

To determine the utility of 6-month follow-up imaging after benign concordant image-guided percutaneous breast biopsy results.

MATERIALS AND METHODS

The institutional review board approved this retrospective, HIPAA-compliant study; informed consent was waived. Findings from consecutive stereotactic and ultrasonographically guided core breast biopsies performed from 2001 to 2005 were analyzed and included lesions with benign pathologic findings without atypia found to be concordant with imaging at a consensus conference. Rebiopsy recommendation rates and positive predictive values (PPVs) for detecting malignancy at each follow-up interval were measured and compared by using a two-tailed Fisher exact test.

RESULTS

In 2244 biopsies, lesions in 1465 were benign, concordant, and not excised. In 1057 of 1465 (72.2%) biopsies with imaging follow-up (average, 26.4 months; range, 4.0-49.9 months), recommended rebiopsy rates were 0.8% (four of 526), 0.5% (three of 588), and 1.0% (eight of 802) at 6-month, 12-month, and long-term follow-up intervals, respectively. When the initial follow-up did not occur until 12 months, the recommended rebiopsy rate was 0.9% (three of 322), compared with 0.8% (four of 526) at 6 months (P > .99), and no malignancies were found in either group. One malignancy was detected at the long-term follow-up interval (PPV for excision recommended, 12% [one of eight]; PPV for excision performed, 20% [one of five]).

CONCLUSION

Because rebiopsy recommendation rates and PPVs did not differ in the 6- and 12-month groups, a 6-month follow-up imaging examination, in the context of a formal concordancy consensus conference, may not contribute to improved breast cancer diagnosis.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10091824/-/DC1.

Valor preditivo positivo das categorias 3, 4 e 5 do Breast Imaging Reporting and Data System (BI-RADS®)

OBJETIVO: O objetivo deste trabalho foi avaliar o BI-RADS® como fator preditivo de suspeição de malignidade em lesões mamárias não palpáveis nas categorias 3, 4 e 5, correlacionando as mamografias com os resultados histopatológicos através do cálculo do valor preditivo positivo do exame mamográfico. MATERIAIS E MÉTODOS: Trezentas e setenta e uma pacientes encaminhadas a um serviço de referência em tratamento de câncer em Teresina, PI, para realização de exames histopatológicos em mama no período de julho de 2005 a março de 2008, por terem mamografia de categorias 3, 4 ou 5, tiveram seus exames revisados. Das 371 pacientes, 265 foram submetidas a biópsia por agulha grossa e 106, a marcação pré-cirúrgica. RESULTADOS: Em relação às mamografias, 11,32% foram classificadas como categoria 3, 76,28% como categoria 4 e 12,4% como categoria 5. Os resultados histológicos demonstraram 24% de exames positivos para malignidade. Os valores preditivos positivos das categorias 3, 4 e 5 foram, respectivamente, de 7,14%, 16,96% e 82,61%. Foram calculados os valores preditivos positivos, separadamente, para as biópsias percutâneas (7,14%, 15,76%, 76,47%) e para as marcações pré-cirúrgicas (7,14%, 20%, 100%). CONCLUSÃO: Achados malignos foram subestimados pelo laudo radiológico e houve superestimação de achados benignos, o que resultou na realização desnecessária de alguns procedimentos invasivos.

Breast Imaging Reporting and Data System - BI-RADS®: valor preditivo positivo das categorias 3, 4 e 5. revisão sistemática da literatura

OBJETIVO: Avaliar artigos, na literatura, que verificam o valor preditivo positivo das categorias 3, 4 e 5 do Breast Imaging Reporting and Data System (BI-RADS®). MATERIAIS E MÉTODOS: Foi realizada pesquisa na base de dados Medline utilizando os termos "predictive value" e "BI-RADS". Foram incluídos 11 artigos nesta revisão. RESULTADOS: O valor preditivo positivo das categorias 3, 4 e 5 variou entre 0% e 8%, 4% e 62%, 54% e 100%, respectivamente. Três artigos avaliaram, concomitantemente, os critérios morfológicos das lesões que apresentaram maior valor preditivo positivo na mamografia, sendo nódulo espiculado o critério com maior valor preditivo positivo. CONCLUSÃO: Houve grande variabilidade do valor preditivo positivo das categorias 3, 4 e 5 do BI-RADS® em todos os estudos, porém foram identificadas diferenças metodológicas que limitaram a comparação desses estudos.

Performance Parameters for Screening and Diagnostic Mammography in a Community Practice: Are There Differences Between Specialists and General Radiologists?

OBJECTIVE

The purpose of this study was to compare the performance of general radiologists in interpretation of mammograms with that of breast imaging specialists in a high-volume community hospital-based private practice.

MATERIALS AND METHODS

A retrospective observational study was conducted with data prospectively collected over a 5-year period in a community hospital-based practice in which 106,405 screening and 52,149 diagnostic mammograms were performed. The performance of three radiologists specializing in breast imaging was compared with that of six general radiologists. The following data were extracted and analyzed: recall rate, biopsy recommendation rate, and cancer detection rate. Statistical analysis was performed with a chi-square test and two-tailed calculation of p values.

RESULTS

The recall rates of the specialists and generalists were nearly the same at 6.5% and 6.7%, respectively. The biopsy recommendation rate at recall from screening examinations was nearly the same for generalists and specialists (1.2% and 1.1%, respectively; p = 0.4504). This rate also was similar for diagnostic examinations (8.5% for generalists; 8.4% for specialists; p = 0.4086). The cancer detection rate in the screening setting was slightly higher for specialists than for generalists: 2.5 and 2.0 cancers per 1,000 cases, respectively (p = 0.0614). The cancer detection rate in the diagnostic setting was 24.2% higher among specialists (20.0 cancers per 1,000 cases) compared with generalists (16.1 cancers per 1,000 cases) (p = 0.0177).

CONCLUSION

The only statistically significant difference between generalists and specialists was in cancer detection rate among patients undergoing diagnostic mammography. No statistically significant difference was identified between the two groups in terms of recall rate, biopsy recommendation rate, or percentage of favorable-prognosis cases of cancer detected. There was a trend toward greater cancer detection by specialists in the screening setting.

Personal experience of ultrasound-guided 14-gauge core biopsy of breast tumor

AIM

This study was aimed to examine the efficacy of ultrasound-guided core needle biopsy of breast tumor and compared with the results of previous publications.

METHODS

From January 2001 to September 2003, 546 lesions in 513 consecutive patients with the identification of a tumor on ultrasound examination categorized belong and above C3 according to BIRADS (Breast Image Reporting and Data Systems). A minimum of three samples was taken during the biopsy process.

RESULTS

The patients' ages ranged from 17 to 89 years (mean, 43 years); tumors were from 5.7 to 41.6 mm in diameter (mean, 20.3 mm). There were 341 lesions with benign findings, 202 lesions with malignancy and 3 lesions with atypical ductal hyperplasia (ADH). Underestimates were found in five patients. Two patients were "ADH-DCIS (ductal carcinoma in situ) underestimate", and three patients were "DCIS-IDC (invasive ductal carcinoma) underestimate". The ADH underestimation rate was 40% (2/5) and DCIS underestimation rate was 43% (3/7). No false-positive results were observed. According to this study, the accuracy rate was 99%, sensitivity rate 97.6%, specificity rate 100%, and false-negative rate 2.4%.

CONCLUSIONS

Both palpable and impalpable breast lesions should be examined under image guidance and automated core biopsy is the technique of first choice. Fourteen-gauge core biopsy can provide a definitive diagnosis in 99% of solid tumors in this series.

Validity of needle core biopsy in the histological characterisation of mammary lesions

Over the last few years, there has been an enormous increase in the use of needle core biopsy (CB) for the histopathological characterisation of suspect lesions of the breast. The aim of this study was to verify the diagnostic reliability of CB by comparing the histological results obtained with the use of this technique with those obtained from the whole of the surgically resected specimen. We studied 198 out of 426 patients with clinically and/or radiologically suspect breast lesions. We found correspondence between the histological examination of the whole of the excised specimen and that of the CB in 94.9% of the cases of infiltrating carcinoma and in 71.4% of those involving ductal carcinomas in situ. The predictive value of CB was 98.9%, sensitivity was 96.1% and specificity 93.3%. These results confirmed that CB is an extremely reliable diagnostic tool in the definition of breast lesions.

Ultrasound-guided core needle biopsy of non-palpable breast lesions: a prospective analysis in 204 cases

PURPOSE

To assess the diagnostic value of ultrasound (US)-guided 14 G core needle breast biopsy in non-palpable suspicious breast lesions.

MATERIAL AND METHODS

From August 1997 to April 2001, 198 patients with 204 suspicious non-palpable breast lesions underwent US-guided large core needle biopsy. Biopsies were performed with a free-hand technique using US equipment with a 7.5 MHz linear-array transducer; a minimum of three cores were obtained from each lesion. Pathological findings in US-guided core biopsy were correlated to findings in subsequent surgery or long-term (more than 2 years) imaging follow-up.

RESULTS

Among the 204 non-palpable breast lesions for which histopathological findings were obtained by US-guided core biopsy, 118 were malignant (114 carcinoma, 2 metastasis, 1 lymphoma, and 1 malignant phyllodes tumor) and 86 were benign (4 carcinoma and 82 benign lesions confirmed at surgery or after at least 2 years of follow-up). Sensitivity, specificity, positive predictive value, and negative predictive value for diagnosis of malignancy in our series were 97%, 100%, 100%, and 95%, respectively. Diagnostic yield with 1, 2, 3, and 4 specimens per lesion was 73.5%, 88%, 94%, and 97.5%, respectively.

CONCLUSION

US-guided core needle biopsy is a sensitive percutaneous biopsy method for diagnosing non-palpable breast lesions. To achieve a high diagnostic yield, a minimum number of three cores per lesion is advisable.

Accuracy of sonographically guided 14-gauge core-needle biopsy: results of 715 consecutive breast biopsies with at least two-year follow-up of benign lesions

PURPOSE

The objective of this study was to examine the diagnostic accuracy of sonographically guided 14-gauge core-needle biopsy (CNB).

METHODS

Sonographically guided 14-gauge CNBs of 715 breast lesions were performed in 652 patients. Histopathologic results were correlated with imaging findings, and repeat biopsy was recommended in the cases of discordance between the radiologic and pathologic results. Long-term follow-up was used for patients with CNB findings of a benign lesion.

RESULTS

Sonographically guided CNB revealed malignancy in 311 lesions (43%). Thirty-one lesions with CNB findings indicating benign conditions underwent additional image-guided or excisional biopsy because of indeterminate pathologic features, disagreement between radiologic and pathologic results, surgeon preference, or patient request. Within these 31 cases, 9 malignancies were diagnosed. The duration of follow-up for the remaining 373 benign lesions varied from 27 to 60 months. In 3 of these 373 cases, carcinoma was diagnosed at the site of CNB. The false-negative rate of 14-gauge sonographically guided CNB was 3.7%, and the sensitivity of sonographically guided CNB for the diagnosis of breast cancer was 96.3%.

CONCLUSIONS

Sonographically guided 14-gauge CNB is a safe and accurate method for evaluating breast lesions that require tissue sampling. Radiologic-pathologic correlation and follow-up of benign lesions are essential for a successful breast biopsy program.

Diagnosis of Palpable Breast Masses: Ultrasound-Guided Large Core Biopsy in a Multidisciplinary Setting

Cytologic diagnosis of palpable breast masses is an accepted method for diagnosis. However, the high nondiagnostic rate causes repeat biopsy, unnecessary delays, and increased costs. Our purpose is to evaluate the use of ultrasound (US)-guided large-core needle biopsy as part of the minimally invasive multidisciplinary diagnosis of palpable breast masses. We studied 502 consecutive patients with 510 palpable solid breast masses seen and evaluated by a multidisciplinary team. Patients had US-guided core biopsy. Clinical–imaging–pathologic correlation (CIPC) was done in all cases. Core biopsy was deemed conclusive if CIPC was congruent and was used to guide definitive management. The median age of our patients was 39 years. Median tumor size was 2.2 cm. Of these cases, 463 (91%) had a conclusive diagnosis on CIPC. Core needle findings on 47 masses were nondefinitive to guide therapy (fibroepithelial lesion, atypical ductal hyperplasia, intraductal papilloma, CIPC). Three cancers were detected in this group on excisional biopsy. In conclusion, US-guided large-core needle biopsy is a sensitive method for diagnosis of palpable breast masses. Multidisciplinary correlation of clinical findings, imaging, and pathology is essential for success. This approach improves use of operating room resources and maximizes patient participation in the decision-making process.

Image-guided breast biopsy and management of high-risk lesions

Across several series, the sensitivity of sonographically guided 14-gauge core biopsy is 95%, and the repeat biopsy rate averages 11%. Success of stereotactic biopsy requires obtaining larger volumes of tissue when sampling calcifications; use of vacuum-assisted devices results in comparable sensitivities. For MR imaging-guided percutaneous biopsy,success rates of 95% to 99% have been achieved. Independent of guidance method or the amounts of tissue acquired, the following diagnoses on percutaneous biopsy should generally prompt excision: atypical ductal hyperplasia, lobular neoplasia, radial sclerosing lesions, benign and atypical papillary lesions, and possible phyllodes tumor. Mucocele-like lesions may merit excision. Columnar alteration without atypia probably does not require excision, although further study is needed.

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

BACKGROUND

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Is Stereotactic Large-Core Needle Biopsy Beneficial Prior to Surgical Treatment in BI-RADS 5 Lesions?

INTRODUCTION

Due to screening mammography, more nonpalpable mammographic lesions warrant histological evaluation. Stereotactic large-core needle biopsy (SLCNB) has been shown to be as effective in diagnosing these lesions as diagnostic surgical excision, and has become the preferred diagnostic procedure for most mammographic lesions. Since radiologically malignant BI-RADS 5 lesions are almost always carcinoma, some centers advocate prompt diagnostic surgical excision for these lesions instead of SLCNB. For some patients this diagnostic surgical intervention may serve as definitive treatment. We set out to find a subgroup of mammographic BI-RADS 5 lesions for which surgical biopsy might be preferable.

METHODS

Of 1644 consecutive nonpalpable lesions referred for SLCNB between April 1997 and May 2002, 238 were classified as BI-RADS 5. We assessed the number of carcinomas and the surgical interventions performed. Outcomes were compared between various types of mammographic lesions: density with calcifications, density without calcifications, and calcifications only. Different theoretical strategies for diagnostic work-up of BI-RADS 5 lesions were explored.

RESULTS

Carcinoma was found in 229/238 lesions (96%). Most mammographic densities were invasive cancer (97%), while calcifications only showed the highest risk for DCIS (51%). In our study (current practice) all lesions were scheduled to first undergo SLCNB. A scenario was proposed where all lesions with only a density would be scheduled directly for sentinel node biopsy (SNB) and tumour excision (n = 154; 65%), while other lesions would still be scheduled for SLCNB. When we compared this scenario to current practice, four out of 238 patients (< 2%) would be 'overtreated' with SNB.

CONCLUSIONS

Our findings confirm a high predictive value of malignancy for BI-RADS 5 lesions (96%). Surgical excision is therefore imperative for all BI-RADS 5 lesions, irrespective of SLCNB results. For BI-RADS 5 lesions presenting as mammographic densities only, we propose to consider surgical excision with SNB to be the first diagnostic and therapeutic procedure. SLCNB is preferred in all other cases.

Patient perceptions of breast biopsy procedures for screen-detected lesions

OBJECTIVE

This study was undertaken to compare patient perceptions of 2 common image-guided breast biopsy procedures on 3 main outcomes: decision making about which procedure to undergo, its convenience, and its side effects.

METHODS

Women who had either an excisional or ultrasound-guided core needle breast biopsy in 1997 for a screen-detected lesion had telephone interviews 1 to 3 months after the biopsy. Bivariate associations were tested by using chi(2) and t test statistics. Mulitvariate analyses were used to control for effects of demographic characteristics.

RESULTS

Most women (66%) could not remember being offered a choice of procedures, and of those who did have a choice, a higher proportion had an excisional biopsy. Only 2% reported being told the cost of the biopsy procedure. Women who had an excisional biopsy compared with those who had undergone a core needle biopsy reported statistically more hours and days off from work and reported more side effects 1 to 3 days after the biopsy (P<.05). Associations between side effects and type of biopsy procedure were unchanged when adjustment was made for demographic characteristics.

CONCLUSION

Women who had the ultrasound-guided needle biopsy reported significantly fewer side effects and needed less time off from work. When a suspicious lesion is noticed on a screening mammogram, it is important that women and their physicians discuss the benefits and risks of the various biopsy procedures before deciding how to proceed, allowing for informed choice.

The continued utility of needle localised biopsy for non-palpable breast lesions

AIM

To analyse the results of needle localised biopsy (NLB) for non-palpable breast lesions in our hospital and to compare them with data on stereotactic large-core biopsy (SCB), which has been recently introduced as a new less invasive method for evaluating mammographic abnormalities.

METHODS

We evaluated the results of all consecutive NLB procedures in our hospital in the period 1998-2000 and compared them with data from literature. Clinical, mammographic and pathological data were reviewed.

RESULTS

In the present study 314 patients with 319 non-palpable mammographic abnormalities were included. Seventy percent of patients were referred to us from the national screening program. In all but one patient the NLB procedure was successful. The mean duration of hospital stay was 3 (1-10) days. Histological diagnosis was invasive carcinoma in 31%, invasive carcinoma with DCIS in 32%, DCIS alone in 13% and benign in 24%. The invasive carcinoma group scored tumour-free margins after the first operation in 77% of patients, for both the DCIS with invasive carcinoma group and DCIS alone group the tumour-free margin rate was 47%. Patients with invasive carcinoma and/or DCIS were re-operated in 88%. Of all procedures, 91% was performed without complications.

CONCLUSION

NLB is a safe, relatively simple procedure with a high diagnostic accuracy combined with a lower failure and false-negative rate compared to SCB.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Optimal management of ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) represents a breast lesion that is diagnosed with increasing frequency, mainly due to the wide use of screening mammography. Today, DCIS comprises 15-25% of all breast cancers detected at population screening programs. Consequently, the concepts of properly managing such patients assume a greater importance in everyday practice. Mammographically detected microcalcifications are the most common presentation of DCIS. Despite recent technological advances (including Stereotactic-guided directional vacuum-assisted biopsy), mammographically guided wire biopsy remains the "gold-standard" for obtaining a histological diagnosis in patients with non-palpable, mammographically detected DCIS. Management options include mastectomy, local excision combined with radiation therapy, and local excision alone. Given that DCIS is a heterogeneous group of lesions rather than a single entity, and because patients have a wide variety of personal needs that must be addressed during treatment selection, it is obvious that no single approach will be appropriate for all forms of DCIS or for all patients. Careful patient selection is of key importance in order to achieve the best results in the management of the individual patient with DCIS. Axillary lymph node dissection is unnecessary in the treatment of pure DCIS, but it is indicated when microinvasion is present. In these cases, sentinel lymph node biopsy may be an excellent alternative. In the NSABP B-24 trial, tamoxifen reduced both the invasive and non-invasive breast cancer events in either breast by 37%. Nearly all patients who develop a non-invasive recurrence following breast-sparing surgery are cured with mastectomy, and approximately 75% of those with an invasive recurrence are salvaged. Selected patients initially treated by lumpectomy alone may also undergo breast-conservation therapy at the time of relapse according to the same strict guidelines of tumor margin clearance required for the primary lesion; radiation therapy should be given following local excision. The use of systemic therapy in patients with invasive recurrence should be based on standard criteria for invasive breast cancer.

Does core needle breast biopsy accurately reflect breast pathology?

BACKGROUND

Core needle breast biopsy (CB) has replaced excisional biopsy as the initial diagnostic biopsy procedure for many suspicious breast lesions; however, CB remains a sampling procedure. The purpose of this study was to determine the degree of agreement between histology obtained at CB and that obtained at a subsequent excisional procedure (EP). We hypothesized a high degree of agreement.

METHODS

Data were collected prospectively for 3035 CBs performed by breast radiologists using either ultrasound or stereotactic guidance between January 1995 and July 2002, 1410 (46%) of which had a subsequent EP within 1 year. Histologic categories were defined as invasive breast cancer, duct carcinoma in-situ, atypia/lobular carcinoma in-situ, and benign. The principal histology (PH) from CB and EP was identified and compared.

RESULTS

Overall, there was moderate agreement (kappa=0.669) between CB and EP histology. Complete agreement occurred in 1168 (83%) procedures. For the remaining 242, the PH was identified only at CB for 78 (5%) procedures, and only after EP for 164 (12%) procedures.

CONCLUSIONS

Although the majority (83%) of CB and EP demonstrated exact histologic agreement, CB was diagnostic for 1246 (88%) procedures.

Clip placement after sonographically guided percutaneous breast biopsy

A simple and inexpensive technique for deployment of a metallic marker at the site of an ultrasound guided core breast biopsy is described. An illustrative case in which this technique was employed to mark the location of three biopsied lesions is presented.

Stereotactic histologic biopsy with patients prone: technical feasibility in 98% of mammographically detected lesions

OBJECTIVE

The purpose of this retrospective study was to determine which mammographically detected lesions in need of imaging-guided biopsy could undergo prone, stereotactic biopsy.

MATERIALS AND METHODS

From July 1991 through June 2001, 1687 consecutive patients (age range, 29-94 years; median age, 58 years) with 1894 lesions were referred by clinicians in a multispecialty clinic. The patients underwent stereotactic, prone, histologic biopsy of 1851 lesions (98%) and needle-localized breast biopsy of 43 lesions (2%). We performed stereotactic biopsies successively with 14-gauge automated large-core devices and 14- or 11-gauge vacuum-assisted devices. We evaluated lesions by patient, breast, lesion, and procedural variables to determine why stereotactic biopsy was not performed.

RESULTS

Of 1851 lesions referred for stereotactic biopsy, biopsies were canceled in 42 lesions (2%) not considered suspicious enough to warrant biopsy. Of 1809 lesions in which stereotactic biopsy was considered to be warranted, stereotactic biopsy was canceled for technical reasons in 29 lesions (2%). Of 43 lesions referred for surgical biopsy, stereotactic biopsy was thought to be technically problematic in five (12%). Inability to accomplish a stereotactic biopsy in 34 (2%) of 1852 lesions needing a biopsy was due to proximity to the chest wall (n = 10, 29%), inadequate lesion visualization unrelated to lesion depth (n = 19, 56%), and patient factors (n = 5, 15%).

CONCLUSION

Stereotactic biopsy had a technical success rate of 98% (1780/1809) and was used for histologic diagnosis in 96% (1780/1852) of mammographically detected lesions. Inadequate lesion visualization accounted for 85% (29/34) of stereotactic biopsy failures.

[Breast biopsies: stereotactic vacuum-assisted core biopsy and stereotactic surgical breast biopsy]

Stereotactically-guided procedures for diagnosis of breast lesions can avoid a lot of surgical biopsies. Stereotactic guidance is used for vacuum-assisted core biopsies and for stereotactic breast biopsies. Technical details of the procedures are described, and the benefits and the limits of these methods are discussed. Indications for breast sampling are proposed according to the Breast Imaging Reporting and Data System (BI-RADS) assessment categories.