Stereotactic core biopsy reduces the reexcision rate and the cost of mammographically detected cancer

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.

Gradual adoption of needle biopsy for breast lesions in a rural state

Background

Minimally invasive breast biopsy (MIBB) is the standard of care for the diagnosis of breast cancer, with consensus guidelines suggesting MIBB goals of 90% of total biopsies. In a previous study of patients in the rural state of Vermont, USA (population size of 640,000), rural breast cancer patients had open biopsies 42% of the time compared to 29% of urban breast cancer patients. The aim of this study was to assess overall population‐based biopsy trends in Vermont.

Methods

The Vermont Breast Cancer Surveillance System (VBCSS) was used to identify women receiving MIBB and excisional breast biopsies in Vermont. Patient zip code at the time of initial biopsy was used to determine the patient residence rurality by rural–urban commuting area codes (RUCA 2.0™).

Results

There were 9122 diagnostic episodes from 1999 to 2018. MIBB was the initial biopsy method in 7524 (82.5%) cases, while surgical excision was the initial biopsy method in 1598 (17.5%) cases. A linear trend fit estimated an increase of 1.3% per year (p < 0.001, 95% CI 1.1%–1.5%) in the fraction of patients undergoing MIBB. Patients living in rural areas were less likely to receive MIBB (78.5%) than those living in urban areas (94.9%), p < 0.001. Multivariate analysis showed that urban patients and those patients in the years 2014–2018 were more likely to receive MIBB (OR 5.00, 95% CI 4.13–6.05 [p < 0.05] and OR 4.41, 95%CI 3.68–5.28 [p < 0.05], respectively). The rate of MIBB for rural patients increased and met the 90% quality standard in 2013 and ultimately matched urban patient rates of MIBB in 2018.

Conclusions

For the first time, we show that MIBB usage is above 90% in the state of Vermont and that there no longer exist disparities in breast biopsies between urban and rural patients or rural/urban facilities in the state, overall.

Improving Quality Metric Adherence to Minimally Invasive Breast Biopsy among Surgeons Within a Multihospital Health Care System

BACKGROUND

Minimally invasive breast biopsy (MIBB) is the procedure of choice for diagnosing breast lesions indeterminate for malignancy. Multihospital health care systems face challenges achieving systemwide adherence to standardized guidelines among surgeons with varying practice patterns. This study tested whether providing individual feedback about surgeons' use of MIBB to diagnose breast malignancies improved quality metric adherence across a large health care organization.

STUDY DESIGN

We conducted a prospective matched-pairs study to test differences (or lack of agreement) between periods before and after intervention. All analytical cases of primary breast cancer diagnosed during 2011 (period 1) and from July 2012 to June 2013 (period 2) across a multihospital health care system were reviewed for initial diagnosis by MIBB or open surgical biopsy. Open surgical biopsy was considered appropriate care only if MIBB could not be performed for reasons listed in the American Society of Breast Surgeons' quality measure for preoperative diagnosis of breast cancer. Individual and systemwide results of adherence to the MIBB metric during period 1 were sent to each surgeon in June 2012 and were later compared with period 2 results using McNemar's test of marginal homogeneity for matched binary responses.

RESULTS

Forty-six surgeons were evaluated on use of MIBB to diagnose breast cancer. In period 1, metric adherence for 100% of cases was achieved by 37 surgeons, for a systemwide 100% compliance rate of 80.4%. After notification of individual performance, 44 of 46 surgeons used MIBB solely or otherwise appropriate care to diagnose breast cancer, which improved systemwide compliance to 95.7%.

CONCLUSIONS

Providing individual and systemwide performance results to surgeons can increase self-awareness of practice patterns when diagnosing breast cancer, leading to standardized best-practice care across a large health care organization.

Effectiveness of core biopsy for screen-detected breast lesions under 10 mm: implications for surgical management

BACKGROUND

Technical advances have improved the detection of small mammographic lesions. In the context of mammographic screening, accurate sampling of these lesions by percutaneous biopsy is crucial in limiting diagnostic surgical biopsies, many of which show benign results.

METHODS

Women undergoing core biopsy between January 1997 and December 2007 for <10-mm lesions are included. Patient demographics, imaging features and final histology were tabulated. Performance indices were evaluated.

RESULTS

This audit includes 803 lesions <10 mm. Based on core histology, 345 women (43.0%) were immediately cleared of malignancy and 300 (37.4%) were referred for definitive cancer treatment. A further 157 women (19.6%) required diagnostic surgical biopsy because of indefinite or inadequate core results or radiological-pathological discordance, and one woman (0.1%) needed further imaging in 12 months. The open biopsies were malignant in 46 (29.3%) cases. The positive predictive value of malignant core biopsy was 100%. The negative predictive value for benign core results was 97.7%, and the false-negative rate was 2.6%. The lesion could not be visualized after core biopsy in 5.1% of women and in 4.0% of women with malignant core biopsies excision specimens did not contain residual malignancy. Excessive delays in surgery because of complications of core biopsy were not reported.

CONCLUSION

Even at this small size range, core biopsy evaluation of screen-detected breast lesions is highly effective and accurate. A lesion miss rate of 3.1% and under-representation of lesions on core samples highlight the continued need for multidisciplinary collaboration and selective use of diagnostic surgical biopsy.

Phase I trial of intraoperative detection of tumor margins in patients with HER2-positive carcinoma of the breast following administration of 111In-DTPA-trastuzumab Fab fragments

INTRODUCTION

Our aim was to conduct a Phase I clinical trial to determine the feasibility of intraoperative detection of tumor margins in HER2 positive breast carcinoma using a hand-held γ-probe following administration of (111)In-DTPA-trastuzumab Fab fragments. Accurate delineation of tumor margins is important for preventing local recurrence.

METHODS

Six patients with HER2-positive in situ or invasive ductal carcinoma were administered 74MBq (0.5mg) of (111)In-DTPA-trastuzumab Fab fragments and counts in the tumor, surgical cavity wall and en face margins were measured intraoperatively at 72h post-injection using the Navigator or C-Trak γ-probes. Margins were evaluated histologically. Quantitative whole body planar imaging was performed to estimate radiation absorbed doses using OLINDA/EXM software. SPECT imaging of the thorax was performed to evaluate tumor uptake. The pharmacokinetics of elimination from the blood and plasma were determined over 72h.

RESULTS

There were no acute adverse reactions from (111)In-DTPA-trastuzumab Fab fragments and no changes in hematological or biochemical indices were found over a 3month period. (111)In-DTPA-trastuzumab Fab fragments exhibited a biphasic elimination from the blood and plasma with t1/2α=11.9h and 7.5h, respectively, and t1/2β=26.6 and 20.7h, respectively. The radiopharmaceutical accumulated in the liver, spleen and kidneys. SPECT imaging did not reveal tumor in any patient. The mean effective dose was 0.146mSv/MBq (10.8mSv for 74MBq). Counts in excised tumors were low but were higher than in margins. Margins in two patients harboured tumor but this was not correlated with counts obtained using the γ-probes. Surgical cavity counts were high and likely due to detection of γ-photons outside the surgical field.

CONCLUSION

We conclude that it was not feasible, at least at the administered amount of radioactivity used in this study, to reliably detect the margins of disease in patients with in situ or invasive ductal carcinoma intraoperatively using a hand-held γ-probe and (111)In-DTPA-trastuzumab Fab fragments due to low uptake in the tumor and involved margins.

Time trends and geographic variation in use of minimally invasive breast biopsy

BACKGROUND

Current guidelines recommend minimally invasive breast biopsy (MIBB) as the gold standard for the diagnosis of breast lesions. The purpose of this study was to describe geographic patterns and time trends in the use of MIBB in Texas.

METHODS

We used 100% Texas Medicare claims data (2000-2008) to identify women older than 66 years of age who underwent breast biopsy. Biopsies were classified as open or MIBB. Time trends, racial/ethnic variation, and geographic variation in the use of biopsy techniques were examined.

RESULTS

A total of 87,165 breast biopsies were performed on 75,518 breast masses in 67,582 women; 65.8% of the initial biopsies were MIBB. Radiologists performed 70.3% and surgeons performed 26.2% of MIBB. Surgeons performed 94.2% of open biopsies. Hispanic women were less likely to undergo MIBB (55.9%) compared with white (66.6%) and black (68.9%) women (p < 0.0001). Women undergoing MIBB were also more likely to live in metropolitan areas and have higher income and educational levels (p < 0.0001). The rate of MIBB increased from 44.4% in 2001 to 79.1% in 2008 (p < 0.0001). There are clear geographic patterns in MIBB use, with highest use near major cities. Although rates are increasing overall, rates of improvement in the use of MIBB vary considerably across geographic regions and remain persistently low in more rural areas.

CONCLUSIONS

Despite an increase in the use of MIBB over time, MIBB use was consistently lower than recommended. We must identify specific barriers in rural areas to effectively change practice and achieve the statewide goal of 90% MIBB.

Comparison of costs and benefits of breast cancer screening with mammography, ultrasonography, and MRI

Screening mammography performed annually on all women beginning at age 40 years has reduced breast cancer deaths by 30% to 50%. The cost per year of life saved is well within the range for other commonly accepted medical interventions. Various studies have estimated that reduction in treatment costs through early screening detection may be 30% to 100% or more of the cost of screening. Magnetic resonance imaging (MRI) screening is also cost-effective for very high-risk women, such as BRCA carriers, and others at 20% or greater lifetime risk. Further studies are needed to determine whether MRI is cost-effective for those at moderately high (15%-20%) lifetime risk. Future technical advances could make MRI more cost-effective than it is today. Automated whole-breast ultrasonography will probably prove cost-effective as a supplement to mammography for women with dense breasts.

Utilization of minimally invasive breast biopsy for the evaluation of suspicious breast lesions

BACKGROUND

Percutaneous needle biopsy, also known as minimally invasive breast biopsy (MIBB), has become the gold standard for the initial assessment of suspicious breast lesions. The purpose of this study is to determine modern rates of MIBB and open breast biopsy.

METHODS

The Florida Agency for Health Care Administration outpatient surgery and procedure database was queried for patients undergoing open surgical biopsy and MIBB between 2003 and 2008.

RESULTS

Although there was an increase in the use of MIBB, the overall rate of open surgical biopsy remained high (∼30%). A reduction in the open biopsy rate from 30% to 10% could be associated with a charge reduction of >$37.2 million per year.

CONCLUSIONS

The current rate of open surgical breast biopsy remains high. Interventions and quality initiatives are warranted, which could lead to a reduction in unnecessary operations for women, improved patient care, and a reduction in breast health care costs.

Percutaneous needle biopsy for breast diagnosis: how do surgeons decide?

BACKGROUND

Despite the advent of guidelines recommending core needle biopsy (CNB) for diagnosis of breast abnormalities, it is underused in some jurisdictions. We sought to determine those factors influencing surgeons' choices of breast biopsy techniques.

METHODS

We surveyed 385 general surgeons in Ontario to first determine factors influencing the choice of fine-needle aspiration biopsy (FNAB), CNB, both or neither for diagnosis of breast abnormalities in six clinical scenarios with varying risk of malignancy. Second, respondents were asked to rate 15 patient, organizational, and system factors for their impact on choice of biopsy technique. Third, surgeons were asked to describe their three greatest barriers to provision of cancer care.

RESULTS

Response rate was 44%, and 126 provided answers to the survey questions. When there was a high risk of malignancy, CNB and/or FNAB were favored over surgical biopsy (83% to 97% compared with 41% for presumed benign lesions), and CNB was preferred for percutaneous biopsy over FNAB (58% to 79% compared with 1% to 18%). Patient and clinical factors (46% FNAB, 42% CNB), patient preference for biopsy technique (34%, 31%), and delayed access to CNB, rather than lack of equipment (11% FNAB, 8% CNB) or expertise for CNB or FNAB (15%, 12%), had the greatest reported impact on choice of biopsy technique.

CONCLUSIONS

Surgeon preference for CNB is higher than actual use. Further research is needed to establish whether or how CNB use could be improved by support for shared decision making or facilitating access.

Intraoperative ultrasound versus mammographic needle localization for ductal carcinoma in situ

BACKGROUND

Ductal carcinoma in situ (DCIS) often requires some method of localization to achieve breast-conserving therapy. The purpose of this study was to compare the efficacy of intraoperative ultrasound versus mammographic needle localization (MNL) for partial mastectomy in DCIS.

MATERIALS AND METHODS

Data were collected from a Breast Cancer Surgery Database. All DCIS cases undergoing partial mastectomy (PM) were identified. Margin status, re-excision rates, and cost were determined for both groups.

RESULTS

A total of 155 patients undergoing PM for DCIS were identified from the database. In the 96 patients undergoing ultrasound-guided PM (Group 1), the positive margin rate was 10.4%, and close margins (<1 mm) were observed in 22.9% after initial surgery. There were 59 patients who underwent MNL (Group 2); the positive margin rate was 11.9%, and close margins were observed in 27.1%. The difference between positive and close margins in Group 1 versus Group 2 was not statistically significant. The rate of re-excision was 20.8% for Group 1 and 30.5% for Group 2, resulting in 1.23 and 1.37 operations per patient, respectively. The average cost of an intraoperative ultrasound at our institution was $933 and $1858 for MNL (excluding cost of radiologic interpretation), a difference of $925 per case.

CONCLUSION

Our study showed equivalent rates of positive margins and re-excision between intraoperative ultrasound and MNL when performing PM for nonpalpable DCIS. Considering the more invasive nature and increased cost of MNL, we consider surgeon-performed intraoperative ultrasound, when possible, the more cost-effective and practical procedure for patients with DCIS.

Factors associated with one step surgery in case of non-palpable breast cancer

PURPOSE

To examine factors associated with one step surgery in case of non-palpable breast cancer.

MATERIALS AND METHODS

Clinical data of 152 consecutively diagnosed patients with breast cancer were analyzed retrospectively. Preoperative diagnostic findings were divided in subgroups: mammographically visible mass/microcalcifications/sonographically visible mass/sonographically visible architectural distortion. Correlation between tumor-size, radiologic tumor morphology, quality of localization and number of operation was evulated. For localization exact wire position was defined less than 3mm apart from the lesion.

RESULTS

One hundred and thirty-six patients attempted breast conservation and underwent preoperative tumor localization. Fourteen of 16 patients had mastectomy without preoperative localization. Average tumor size was 12mm for one-operation, and 17mm for re-operation. Significant correlation (p<0.001) was found between one operation and masses visible in mammograms (55/62 (89%) patients) or sonography (53/64 (83%) patients). Significant correlation was found (p<0.001) between more re-operation and microcalcifications in mammograms (33/89 (37% patients). In 123/138 (89%) cases wire position was central, in 15/138 (11%) cases distance was maximally 10mm. No significant correlation was found between number of operation and wire position. Re-operation was required in 38 cases.

CONCLUSION

Mammographically or sonographically visible mass, small size of tumors, preoperative percutaneous biopsy and exact preoperative localization are important for a single step procedure for definite surgical treatment, that we found in 74% of the patients.

Stereotactic breast biopsy: comparison of histologic underestimation rates with 11- and 9-gauge vacuum-assisted breast biopsy

OBJECTIVE

The purpose of this study was to compare histologic underestimations at stereotactic 11- and 9-gauge vacuum-assisted breast biopsy.

MATERIALS AND METHODS

The reports of 1,223 consecutive stereotactic vacuum-assisted breast biopsies were retrospectively reviewed. An 11-gauge device was used to perform 828 and a 9-gauge device to perform 395 biopsies. The pathologic results were reviewed for all cases. Biopsy results of atypical ductal hyperplasia and ductal carcinoma in situ were compared with the pathologic results after surgical excision. Underestimation was defined as the need to upgrade atypical ductal hyperplasia to ductal carcinoma in situ or invasive carcinoma at surgery and to upgrade ductal carcinoma in situ to invasive carcinoma. Statistical significance was determined with the chi-square test and 95% CI.

RESULTS

In the 11-gauge group, 12 (26%) of 46 cases of atypical ductal hyperplasia were upgraded to ductal carcinoma in situ and one (2%) of the cases to invasive carcinoma. In the 9-gauge group, six (22%) of 27 cases of atypical ductal hyperplasia were upgraded to ductal carcinoma in situ and two (7%) of the cases to invasive carcinoma. In the 11-gauge group, 35 (28.7%) of 122 cases of ductal carcinoma in situ were upgraded to invasive carcinoma. In the 9-gauge group, 10 (23%) of 44 cases of ductal carcinoma in situ were upgraded to invasive carcinoma.

CONCLUSION

There was no statistically significant difference between 11-gauge biopsy and 9-gauge biopsy in underestimation of atypical ductal hyperplasia and ductal carcinoma in situ.

Variation in the use of percutaneous biopsy for diagnosis of breast abnormalities in Ontario

BACKGROUND

Preoperative diagnosis of breast abnormalities is currently the standard of care. A population-based study to determine the use of percutaneous needle biopsy for breast diagnosis in Ontario was performed.

METHODS

A total of 17,068 women undergoing breast tissue sampling (percutaneous needle biopsy or surgical excision) for diagnosis between April 1, 2002, and December 31, 2002, and without a previous cancer diagnosis were identified. Univariate and multivariate analyses examined the association of age, residence in a particular local health integration network (LHIN), income quintile, urban or rural residence, primary care provider, any prior mammogram, and prior regular screening mammography, as well as whether the biopsy was initiated by a screening mammogram with different methods of tissue diagnosis.

RESULTS

A total of 10,459 women (61%) underwent percutaneous biopsy for diagnosis. A total of 10,131 women underwent surgery, of whom 6,637 received a benign diagnosis and 3,494 had cancer, for a benign-to-malignant ratio of 1.9:1. Women with cancer were slightly more likely to undergo percutaneous biopsy than women without (64.7% vs. 60.3%). There was variation among LHINs in the use of percutaneous biopsy (range, 24%-72%). Women with the highest incomes, urban residence, a primary care provider, or history of any prior mammography were more likely to receive percutaneous biopsy. On multivariate analysis, age 50 to 69 years, LHIN, urban residence, primary care provider, and screen-initiated evaluation were associated with percutaneous biopsy.

CONCLUSIONS

Variation in the use of percutaneous biopsy by factors unrelated to indications for biopsy indicate that strategies to identify and overcome barriers to its use are needed.

Image-guided procedures for breast masses

Breast cancer is a disease affecting millions of women worldwide. In the United States, the institution of screening mammography protocols has increased the number of suspicious breast abnormalities requiring diagnostic intervention. Up to 80% of these lesions are benign, forcing the medical community to devise minimally invasive techniques for tissue sampling. A reduction in the number of needle-localized open breast biopsies reduces the morbidity and cost associated with image-detected breast masses. Ultrasound, stereotaxis, and MRI are excellent modalities for detection of breast cancers. Image-guided, large-core biopsy systems have been developed for each of these imaging modalities, enabling successful and accurate tissue sampling and, ultimately, diagnosis of a suspicious lesion. Care must be taken to ensure correlation between imaging findings and pathologic diagnosis; if the two are discordant, further investigation is mandatory. There remains a role for needle-localized open breast biopsy, although is has been reduced significantly. Some patients prefer this method of diagnosis, and in others further investigation in required because of discordant findings. When the documented pathology of the breast abnormality is ADH, ALH, or LCIS, the patient should undergo surgical excision because of the possibility of DCIS or invasive disease in the same area. Some lesions are inaccessible with the current imaging modalities and biopsy systems available. Minimally invasive, image-guided biopsy for breast masses promises to continue to evolve, enabling physicians to diagnose breast cancer with a high degree of accuracy without significant morbidity.

Breast surgery: minimally invasive diagnosis and treatment

The increasingly large proportion of elderly women in the United States population carries a disproportionate burden of breast cancer. The advent of minimally invasive surgical techniques applicable to breast disease has brought new opportunities to diagnose and treat breast cancer in the older population. This article reviews issues important to the evolving field of breast cancer management in older women: cancer risk and screening considerations, diagnosis and biopsy approaches, and surgical treatment options based on current studies and recommendations.

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.

Accuracy of typing and grading invasive mammary carcinomas on core needle biopsy compared with the excisional specimen

INTRODUCTION

Breast core needle biopsy (CNB) allows evaluation of histological, prognostic, and predictive factors in invasive mammary carcinomas (IMC). We tested the CNB accuracy on typing and grading of invasive breast carcinomas.

MATERIALS AND METHODS

A histological review of 120 CNBs and their related surgical specimens was carried out in a double-blind fashion. Tumor type and grade were assigned according to the World Health Organization classification and the Nottingham grading system.

RESULTS

The sum of CNB fragment lengths varied from 4 mm to 38 mm (mean 16.7 mm), and tumor sample size varied from 1 mm to 26 mm (mean 11.1 mm). Histological type matched surgical specimen evaluation in 80 of 120 cases (66.6%). Of the cases, 17 (14.2%) were changed to a different prognostic category. Histological grade comparison was accurate in 56 of 95 cases (59.0%, kappa=0.35). Histological grade components (tubule formation, nuclear grade, and mitotic index) agreed, respectively, in 54.7%, 58.9%, and 62.1% (kappa index 0.30, 0.36, and 0.28).

DISCUSSION

Typing IMC on CNB can be routinely assessed based on good correlation with surgical specimens, especially considering prognostic categories for IMC. Grading IMC based on CNB is not as accurate, and its evaluation should be delayed until the surgical specimen examination. Tumor heterogeneity seems to be the most important factor for disagreement.

Breast Cancer Care: Changing Community Standards

A community hospital-based program was developed to improve breast cancer care in the community. A consensus was developed for what should be optimal care; a database was established to document the care being delivered in the community; and the data were analyzed to document changes in practice patterns over time. The major clinical benefits to patients included a significant improvement in needle biopsy rates, decreased utilization of second operative procedures, increased breast conservation surgery, conformity to guidelines for adjuvant chemotherapy administration, and a sizable increase in discovery of small breast cancers by screening mammography.

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.

Implementation of a minimally invasive breast biopsy program in countries with limited resources

Minimally invasive breast biopsy techniques, such as core needle biopsy (CNB) and fine-needle aspiration biopsy (FNAB), offer several advantages over surgical biopsy. Patients in whom minimally invasive biopsy techniques are used may undergo biopsy more quickly, are more likely to have only one surgery for treatment of the breast tumor and axillary staging, and are less likely to need reoperation after breast-conserving surgery because of positive margins. Knowledge of a diagnosis of cancer before surgery allows patients to participate in treatment decisions, and compared with surgical biopsy, minimally invasive biopsy has lower costs, produces less scarring, has nearly equivalent diagnostic accuracy, and does not require general anesthesia or sedation. Minimally invasive biopsy can permit accurate diagnosis and prompt intervention in a cost-effective manner, particularly in countries with limited resources, where patients often present with advanced-stage breast cancer. Several events characterize the implementation of a successful program in minimally invasive breast biopsy: public education about the less invasive nature of these techniques, which may encourage women to seek care at earlier stages; a change in the philosophy of medical personnel that favors involving patients in treatment decisions and acceptance of less extensive but accurate methods of diagnosis; education of medical personnel in the selection of patients for minimally invasive biopsy, performance of the biopsy, and interpretation of histologic and/or cytologic samples; quality assessment and use of the triple test (i.e., correlation of clinical, radiologic, and pathologic findings); and economical use of resources, which results from the lower costs of minimally invasive procedures and the avoidance of unnecessary surgery for benign conditions.

Ultrasound-guided lumpectomy of nonpalpable breast cancer versus wire-guided resection: a randomized clinical trial

BACKGROUND

The wire-guided excision of nonpalpable breast cancer often results in tumor resections with inadequate margins. This prospective, randomized trial was undertaken to investigate whether intraoperative ultrasound (US) guidance enables a better margin clearance than the wire-guided technique in the breast-conserving treatment of nonpalpable breast cancers.

METHODS

Patients with a preoperative histological diagnosis of nonpalpable breast cancer that could be visualized both with US and mammography were included. Patients were randomized to undergo either a wire-guided or a US-guided excision. Adequate margins were defined as >or=1 mm.

RESULTS

Of 49 included patients, 23 were assigned to undergo wire-guided excision and 26 to undergo US-guided excision. One patient crossed over to US-guided excision after inadvertent wire displacement. Mean tumor diameter, specimen weight, and operating time were similar in both groups. The excision was adequate in 24 (89%) of 27 US-guided excisions and 12 (55%) of 22 wire-guide excisions (P =.007).

CONCLUSIONS

US-guided excision seems to be superior to wire-guided excision with respect to margin clearance of mammographically detected and US-visible nonpalpable breast cancers. Patients do not have to undergo the unpleasant wire placement before surgery.

A prospective, randomized, multicenter clinical trial to evaluate the safety and effectiveness of a new lesion localization device

BACKGROUND

The objective was to compare the safety and effectiveness of a new localization device to traditional flexible wires. Safety variables included blood loss, procedure time, pain and complications. Effectiveness variables included placement accuracy, lesion retrieval, histological diagnosis, procedural enhancements, and margin status.

METHODS

Twelve sites enrolled 120 patients between June 2000 and June 2001, with 58 randomized to treatment and 62 to control.

RESULTS

The two groups were equivalent in device placement accuracy, lesion retrieval, histological diagnosis, blood loss, pain, and complications. There was a significant difference favoring the treatment group for procedural enhancements, (ie, use as a palpable guide and retractor) and operating time. There were significantly fewer positive margins in the treatment group.

CONCLUSIONS

This multicenter trial demonstrated equivalent safety and improved effectiveness for the treatment group. The new device demonstrated greater surgeon utility, reduced operative time, and fewer positive margins than the current wires.

A prospective review of the decline of excisional breast biopsy

BACKGROUND

Although excisional breast biopsy has long been considered the standard for breast cancer diagnosis, core biopsies are now used more frequently. Whether core biopsy can eventually replace excisional biopsy remains unknown. The purpose of this study was to evaluate the relationship between diagnostic excisional and core biopsies relative to surgical treatment procedures.

METHODS

We analyzed our data collected prospectively from 1995 through 2000, which included inpatient and outpatient surgical data, office visits, and radiology biopsy data including stereotactic, mammotome, and ultrasound core biopsies. The Cochran-Armitage trend test was used to assess the shift in diagnostic technique.

RESULTS

From 1995 through 2000 there were 2,631 core biopsies performed, 2,685 excisional biopsies, 2,881 surgical procedures for breast cancer, and 51,109 office visits. Although the percentage of core biopsies relative to excisional biopsies increased from 31% to 68% (P <0.001), the percentage of biopsies relative to the number of office visits remained stable at 10% to 11%. The percentage of breast cancer procedures relative to office visits also remained stable at 5% to 6%.

CONCLUSIONS

Our data indicate that core biopsies are being performed more often than excisional biopsies. Nevertheless, one in three biopsies done at our institution is excisional.

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.

One operation after percutaneous diagnosis of nonpalpable breast cancer: frequency and associated factors

OBJECTIVE

The purpose of this study was to determine the frequency of and factors associated with performing one therapeutic operation after percutaneous diagnosis of nonpalpable breast cancer.

MATERIALS AND METHODS

Retrospective review was performed of records of 350 consecutive women who had therapeutic surgery after percutaneous imaging-guided core biopsy diagnosis of nonpalpable breast cancer. Records were reviewed to determine the frequency of performing one operation and associated factors. Statistical analysis was performed.

RESULTS

One operation was performed in 283 (80.9%) of 350 women, including 106 (95.5%) of 111 women who had mastectomy and 177 (74.1%) of 239 women who had breast conserving surgery. At bivariate analysis, one operation was significantly more likely in women who had no underestimation (p < 0.001), mastectomy rather than breast conservation (p < 0.001), axillary dissection during the first operation (p < 0.001), percutaneous diagnosis of infiltrating carcinoma (p = 0.001), or mammographic mass (p = 0.006). At multivariate analysis, one operation was significantly more likely if underestimation was absent (odds ratio [OR] = 10.1, 95% confidence interval [CI] = 4.2-24.7) or if mastectomy was performed (OR = 8.7, 95% CI = 3.2-23.5); for women who had breast-conserving surgery, one operation was significantly more likely if underestimation was absent (OR = 11.4, 95% CI = 3.9-33.2) or if a mammographic mass was present (OR = 2.4, 95% CI = 1.3-4.6).

CONCLUSION

One operation was performed in 80.9% of women with percutaneously proven nonpalpable breast cancer, including 74.1% of women who had breast-conserving surgery and 95.5% of women who had mastectomy. Among women who had breast conservation, one operation was significantly more likely if histologic underestimation was absent or if a mammographic mass was present.

Diagnosis of non-palpable breast cancer: a review

The literature on several methods of diagnosing non-palpable breast carcinoma has been reviewed. Skin projection and dye are methods not frequently used. Several aspects of FNA biopsy/cytology, ultrasound-directed methods, frozen section and MRI localization procedures are highlighted and comparisons are made. Much attention is being payed to needle localization breast biopsy and stereotactic core needle breast biopsy. The management of patients with mammographic abnormalities is shifting from needle localization to breast biopsy stereotactic core needle biopsy. Items of comparison between the two mentioned methods are accuracy, indications, complications and costs. The role of the ABBI system in the management of breast cancer has not yet been defined. A cooperative effort between the mammographer, surgeon and pathologist is critical to a successful image-guided breast biopsy programme.

Can expression of apoptosis genes, bcl-2 and bax, predict survival and responsiveness to chemotherapy in node-negative breast cancer patients?

BACKGROUND

Although the status of the axillary lymph nodes is widely accepted to be associated with prognosis in breast cancer patients, there is a need for biomarkers to be analyzed as indicators of responsiveness to treatment. The objective of this study was to test the hypothesis that the expression of apoptosis genes, bcl-2 and bax, predicts survival and responsiveness to chemotherapy in node-negative breast cancer patients.

METHODS

One hundred thirty premenopausal women with primary breast carcinoma were studied for the expression of bcl-2 and bax genes. The relationship between the expression of bcl-2 and bax proteins and a series of markers of known prognostic value [such as tumor size, nuclear grade, receptors of the steroid hormones estrogen (ER) and progesterone (PgR)]. The association of these proteins with survival and responsiveness to chemotherapy was also examined.

RESULTS

Sixty (46%) and sixty-four (49%) breast cancer cases were found positive for bcl-2 and bax, respectively, as indicated by immunohistochemistry. A statistically significant association was found between expression of bcl-2 and tumor size (P = 0.001), low grade (grade I) (P = 0.002), positivity of ER (P = 0.001), positivity of PR (P = 0.03), and superior disease-free survival (DFS) (P = 0.04), and superior overall survival (OS) (P = 0.03). In contrast, no similar associations were observed for the bax gene. Overall, there was a trend toward an association between adjuvant chemotherapy and DFS (P = 0.08) and OS (P = 0.07). This trend became statistically significant when the patients were analyzed by individual gene expression. In bax-positive patients, chemotherapy improves 6-year DFS (P = 0.01) and OS (P = 0.03) while similar effects were not observed in the other subgroups of patients.

CONCLUSION

Our results indicated that bcl-2 expression is associated with a number of favorable prognostic factors and better clinical outcome, while bax expression seems to have positive predictive value for responsiveness to chemotherapy in lymph node-negative breast cancer patients.

Impact of stereotactic large-core needle biopsy on diagnosis and surgical treatment of nonpalpable breast cancer

INTRODUCTION

Stereotactic large-core needle biopsy is increasingly replacing needle-localized breast biopsy for the diagnosis of nonpalpable breast disease. In this prospective study, the impact of the introduction of this technique on diagnosis and surgical treatment of nonpalpable breast cancer was assessed in two hospitals in The Netherlands.

PATIENTS AND METHODS

A total of 84 patients with nonpalpable breast cancer, diagnosed by means of stereotactic large-core needle biopsy (needle biopsy group) were compared with 80 patients diagnosed with nonpalpable breast cancer before the introduction of large-core needle biopsy. These patients were diagnosed by means of needle-localized open breast biopsy (control group). Clinical outcome measures evaluated included: duration of diagnostic and therapeutic intervals and number of surgical procedures required for complete surgical treatment. Subgroup analysis was performed for the category of microcalcifications without tissue distortion.

RESULTS

For the needle biopsy group, the median interval between initial referral to the surgeon and the availability of histological diagnosis was 9 days and the interval between initial referral and complete surgical treatment was 31 days. These intervals were significantly longer for the control group (19 days and 44 days respectively); 75% of patients in the needle biopsy group were treated in a single step surgical procedure compared to 16% of the patients in the control group (67 vs 25% respectively for the subgroup). The mean number of surgical procedures required to complete surgical treatment was 1.31 for needle biopsy group vs 1.91 for the open biopsy group (1.46 vs 1.84 for the subgroup).

CONCLUSION

Introduction of stereotactic large-core needle biopsy leads to a reduction of the time to diagnosis and the time to complete surgical treatment of nonpalpable breast cancer. It also reduces the number of surgical procedures required for complete surgical treatment of nonpalpable breast cancer. The benefits of large-core needle biopsy may also be anticipated for patients with microcalcifications without tissue distortion.

Long-Term Outcomes of Stereotactic Breast Biopsies

Stereotactic core needle biopsies (SCNBs) are accurate and relatively convenient for the patient; however, the long-term follow-up of benign results has not been reported. All patients between 1993 and 1998 undergoing SCNB at a community-based hospital were entered into a registry. Follow-up was obtained by a retrospective analysis of the charts. Biopsies were performed on 865 lesions. One hundred thirty-one (15%) were malignant, 42 (5%) were suspicious for malignancy, 687 (79%) were benign, and five (1%) were lobular carcinoma in situ. Of the 42 patients with suspicious findings 38 underwent biopsy. Ten were malignant and 28 benign. Of the 687 patients with benign pathology, 377 had follow-up available with a mean length of 1.7 years. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of SCNB for benign lesions in our study are all 100 per cent. Eight lesions were worrisome and await final analysis. Of 687 patients with benign lesions 310 were lost to follow-up. This study suggests that patients with a benign diagnosis should be returned to routine mammography. These data also extend the reported follow-up to 1.7 years and establish an acceptable level of accuracy for SCNB. The lost patients remind us that follow-up is essential despite a benign diagnosis.

Minimal access breast surgery

Minimal access procedures have great potential for providing patients with equal, if not superior, forms of breast cancer diagnosis and treatment. Many of these procedures are in a process of evolution. The reliability of each method probably depends heavily on the training, ability, and experience of the operator. Surgeons should be aware of the advantages and pitfalls of these techniques and exercise caution during the initial phases of their learning experience.

The incidence of positive margins with breast conserving therapy following mammotome biopsy for microcalcification

BACKGROUND AND OBJECTIVES

The ability to achieve clean margins with breast conserving therapy varies greatly even when the diagnosis of carcinoma is known beforehand. Although several reports reveal that the incidence of positive margins decreases after stereotaxic core biopsy of nonpalpable lesions and fine-needle aspiration biopsy of palpable lesions, the data on the results following mammotome biopsy (mmbx) is scanty.

METHODS

Two hundred and ninety-eight biopsy specimens for mammographically indeterminate microcalcification from 1/97 through 3/30/98 were reviewed. Biopsies were performed using the biopsys method utilizing an 11-gauge multidirectional, vacuum-directed device.

RESULTS

Ten percent (n = 31) of the mammotome biopsies were atypical and 9% (n = 27) were malignant. These 58 cases (19%) were recommended for surgical excision. The incidence of positive margins in this subset was determined. Of patients who underwent lumpectomy as their initial surgical procedure 69% had negative surgical margins. Seventy-seven percent of patients with carcinoma diagnosed by mammotome biopsy had definitive initial surgery with a single surgical procedure.

CONCLUSIONS

Mmbx facilitates fewer surgical procedures to achieve negative margins, and thus provides a better cosmetic result.

An introduction to economic issues in breast imaging

Marked increases in national health care costs, along with governmental coverage of health care costs for the elderly under Medicare, have resulted in increased government regulation of medical reimbursement rates. Private insurers and HMOs now provide reimbursements that are frequently the same or lower than those from Medicare. Reimbursement rates for mammography have been particularly restricted. Although screening mammography appears to be as cost-effective as other commonly accepted medical interventions, some third-party payors have been reluctant to reimburse screening mammography because of its perceived effect on overall health care costs. An objective analysis shows that inclusion of coverage for screening mammography, however, even beginning at age 40 years, has only a slight effect on total health care costs. Adequate reimbursement for screening mammography supports an effort that provides substantial reduction in deaths from breast cancer.

Changing Patterns of Care for Occult Breast Lesions in a Community Teaching Hospital

We performed a retrospective analysis of 384 consecutive stereotactic breast biopsies (SBBs) from March 1995 through January 1999 and compared it with our historical breast biopsy experience. Two hundred forty-four patients underwent biopsies for microcalcifications and 135 patients for abnormal mammographic densities. Pathology diagnoses included 302 patients with benign disease, 35 patients with atypical ductal hyperplasia, 4 patients with lobular carcinoma in situ, 29 patients with ductal carcinoma in situ, and 9 patients with invasive breast cancer. These diagnostic rates were compared with our prior needle-localized pathology findings. For the study period, the number of mammograms, open biopsies, and needle-localized biopsies remained stable. The number of SBBs, however, increased progressively in every year. Medicare reimbursement for SBB was $921.19, and for breast biopsy after needle localization, $1566.22. Our study strongly suggests that the availability of SBB has significantly lowered the threshold for recommending biopsy of abnormal mammograms. The increased utilization of SBB almost certainly indicates an increase in the overall cost of breast care. This cost must be balanced against substantial potential benefits of this minimally invasive technique: possible earlier diagnosis of atypical and precancerous lesions, patient reassurance in cases of uncertain mammographic interpretation, and a reduced need for follow-up of indeterminate mammograms.

Comparison of mammographically guided breast biopsy techniques

OBJECTIVE

To determine which mammographically guided breast biopsy technique is the most efficient in making a diagnosis in women with suspicious mammograms.

SUMMARY BACKGROUND DATA

Mammographically guided biopsy techniques include stereotactic 14-gauge core-needle biopsy (SC bx), stereotactic 11-gauge suction-assisted core biopsy (Mammotome [Mbx]), stereotactic coring excisional biopsy (Advanced Breast Biopsy Instrument [ABBI]), and wire-localized biopsy (WL bx). Controversy exists over which technique is best.

METHODS

All patients undergoing any one of these biopsy methods over a 15-month period were reviewed, totaling 245 SC bx, 107 Mbx, 104 ABBI, and 520 WL bx. Information obtained included technical success, pathology, discordant pathology, and need for open biopsy.

RESULTS

Technical success was achieved in 94.3% of SC bx, 96.4% of Mbx, 92.5% of ABBI, and 98.7% of WL bx. The sensitivity and specificity were 87.5% and 98.6% for SC bx, 87.5% and 100% for Mbx, and 100% and 100% for ABBI. Discordant results or need for a repeat biopsy occurred in 25.7% of SC bx, 23.2% of Mbx, and 7.5% of ABBI biopsies. In 63.6% of ABBI and 50.9% of WL bx, positive margins required reexcision; of the cases with positive margins, 71.4% of ABBI and 70.4% of WL bx had residual tumor in the definitive treatment specimen.

CONCLUSION

Although sensitivities and specificities of SC bx and Mbx are good, 20% to 25% of patients will require an open biopsy because a definitive diagnosis could not be reached. This does not occur with the ABBI excisional biopsy specimen. The positive margin rates and residual tumor rates are comparable between the ABBI and WL bx. The ABBI avoids operating room and reexcision costs; therefore, in appropriately selected patients, this appears to be the most efficient method of biopsy.