The significance of atypical lobular hyperplasia at percutaneous breast biopsy

Atypical lobular hyperplasia (ALH) is occasionally found in specimens obtained by percutaneous stereotactic vacuum-assisted breast biopsy for microcalcifications. Since malignancy is often found at surgical excision when atypical ductal hyperplasia is found at percutaneous biopsy, we reviewed our pathologic findings from surgery for ALH at percutaneous biopsy. This was a retrospective review of all percutaneous breast biopsy specimens for mammographic microcalcifications obtained from a single institution over a 30-month period. The pathologic findings from percutaneous biopsy were correlated with the radiologic appearance and the pathology from surgical excision. ALH was found in 13 of 766 (1.7%) stereotactic vacuum-assisted core needle biopsies performed for mammographic microcalcifications. Subsequent surgery in six patients revealed ductal carcinoma in situ (DCIS) in two patients and one case of invasive ductal carcinoma. Surgical excision is indicated for areas with ALH discovered by percutaneous biopsy for mammographic microcalcifications.     

Supplemental ultrasound screening in patients with a history of lobular neoplasia

To investigate the role of ultrasound (US) screening as an adjunct to annual mammography (M) in breast cancer detection in women with a history of lobular neoplasia (LN) diagnosed following core needle or excisional biopsy. A retrospective review of our database was performed between 11/2006 and 11/2011 to identify patients diagnosed with LN, and underwent annual screening. Patients with a lifetime risk >20% per risk modeling were excluded. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and cancer detection rate (CDR) of each screening test were identified. Cancer type and detection modality were recorded. A total of 100 patients who had M and/or US screening were included. Mean patient age was 54.7 years (range 33‐83). All 100 patients underwent a mean of 3.9 rounds of screening M and 93 (93%) received US screening (mean 3.3 rounds). Of 93 patients who received both M and US screening, 12 (13%) were diagnosed with breast cancer. Mammographic CDR was 4%. Incremental US CDR was 6.5%. The sensitivity, specificity, and NPV for M screening alone was 33% (10%, 65%), 77% (67%, 85%), and 89% (80%, 95%), respectively. US and mammography screening had a combined sensitivity: 83% (52%, 98%), Specificity: 72% (62%, 81%), NPV: 97% (89%, 100%). Supplemental US screening resulted in a significant increase in sensitivity, yielding 6.5% incremental CDR in this high‐risk patient subgroup that does not fulfill ACS high‐risk MRI screening criteria.     

Surgical excision of pure flat epithelial atypia identified on core needle breast biopsy

The biology of flat epithelial atypia (FEA) is still being investigated as its presence becomes more frequent on biopsy specimens. FEA is more commonly associated with malignancy when found in association with ADH, ALH or LCIS. Pure FEA is only upgraded to cancer in 3.2% of patients. Surgical excision of pure FEA found on core needle biopsy results in overtreatment in the vast majority of breast patients and may not be necessary.     

Outcomes of patients with lobular in situ neoplasia of the breast: The role of vacuum-assisted biopsy

ObjectivesTo audit the outcomes of patients with non-pleomorphic lobular in situ neoplasia (LISN) of the breast and clarify the role of vacuum-assisted biopsy (VAB), surgical biopsy and conservative management for this condition.Materials and methodA single-centre retrospective review of hospital databases covering a 14-year period was performed. Patients with LISN as the most pertinent diagnosis on core needle biopsy (CNB), vacuum-assisted biopsy (VABs) or surgical biopsy were identified. The radiological features, histopathological findings and outcome of subsequent annual mammography were recorded.ResultsBetween 1998 and 2012 there were 70 patients with LISN as the most pertinent diagnosis at CNB, VAB or surgery. 52 underwent VAB, typically 18 11-gauge samples. The pathology was upgraded from the preceding 14-gauge CNB in 7 cases. Of 11 patients who underwent surgery after VAB, one (who had undergone a low tissue yield VAB) was upgraded. There were no new breast cancers during a mean annual mammographic follow-up period of 53 months in 40 patients who had VAB with complete radiological-histopathological concordance.ConclusionProvided there is adequate tissue sampling and radiological-pathological concordance, VAB is a safe alternative to open biopsy in the management of non-pleomorphic LISN.     

Stereotactic core needle biopsy of mammographic breast lesions as a viable alternative to surgical biopsy

Background: Stereotactic needle biopsy technique has received considerable attention as a possible alternative to surgical biopsy of nonpalpable breast lesions. The exact role of this procedure in the management of mammographic breast lesions has not yet been accurately defined. Methods: Data have been collected prospectively on 416 patients over an 8-month period (January 1992 through August 1992). Of 416, 356 patients underwent only stereotactic breast biopsy with a 14-gauge needle. Sixty patients underwent stereotactic breast biopsy followed by surgical biopsy. Based on mammographic findings before biopsy, lesions were classified as benign (24%), likely benign (49%), malignant (2%), likely malignant (6%), and indeterminate (19%). The number of core biopsy specimens obtained from each patient ranged from one to six. Results: The specimen was considered adequate in 98% of cases. Complications were minimal. The tissue diagnosis was benign in 92% and malignant in 8% of patients. In those patients undergoing surgical and stereotactic biopsy, 57 of 60 had matching histopathological results, representing an agreement rate of 95% (p<0.001). The three patients whose histopathological results did not match had malignant diagnoses on stereotactic biopsy that were subsequently not identified in the modified radical mastectomy specimen because the entire focus of malignancy was removed by the several passes made by the core needle during biopsy. No patient had a negative stereotactic biopsy result in whom malignancy was later detected by surgical biopsy. Conclusions: This study indicates excellent agreement between surgical and stereotactic needle biopsy findings. Stereotactic biopsy with a 14-gauge needle could obviate the need for surgical biopsy in certain women with radiologically benign, likely benign, and indeterminate lesions. The results of this study were presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

骨肿瘤122例经皮芯针活检病理诊断率分析

目的：探讨经皮芯针活检诊断骨肿瘤诊断价值及安全性。方法：回顾性分析2007年3月至2011年2月间共122例骨肿瘤病例,所有病例均进行经皮芯针穿刺活检,6例患者在芯针活检病理诊断不明确或可疑的情况下进行切开活检,根据病灶的组成成分（硬化性、实质非硬化性、囊性）以及良性、恶性等分类计算诊断阳性率及准确率,砰检验分析评估其诊断效果。结果：所有病灶总的诊断阳性率89％（109／122）、准确率82％（100／122）。硬化性（100％）与实质性病灶（85％）准确率之间无显著差别（P=0．165）,囊性病灶准确率最低（58％）（P=0．016）,三者诊断阳性率无差别（P=0．572）。恶性病灶（89％）与良性病灶（82％）准确率之间无显著差别（P=-0．299）,恶性（100％）与良性（90％）诊断阳性率差别显著（P=0．025）。经皮芯针穿刺活检鉴别良恶性肿瘤的准确率为97％（118／122）,经皮芯针活检的并发症发生率为0．82％。结论：经皮芯针穿刺活检是诊断骨与软组织肿瘤的一种安全、准确、快捷、可靠的重要检查方法,并发症少,骨骼系统病变的正确诊断仍需依靠临床、病理及影像三结合的模式。     

Lobular neoplasia: core needle breast biopsy underestimation of malignancy in relation to radiologic and pathologic features

The purpose of this study is to assess the positive predictive value (PPV) for malignancy of core needle biopsy (CNB) demonstrating lobular neoplasia (LN). From 3920 CNBs, 35 (0.89%) LNs (14 atypical lobular hyperplasia – ALH – and 21 lobular carcinoma in situ – LCIS) were identified. Twenty-eight patients underwent surgical excision and seven radiologic follow-up. We describe the imaging findings and excision histology outcomes. We report the PPV for malignancy based on excision histology (n = 28) and on excision or follow-up (n = 35), and according to the histologic type, biopsy probe and guidance, lesion diameter, and BI-RADS category. PPV for malignancy (based on excision histology) was 46.4% (13/28) and PPV (based on excision or follow-up) was 37.1% (13/35). The overall rate of malignancy for LN was 37.1% (13/35), with a PPV for malignancy of ALH and LCIS of 7.1% (1/14) and 57.1% (12/21), respectively (p = 0.003). Estimates of the PPV for malignancy were: stereotactic-guided vacuum-assisted biopsy (22.7%) versus ultrasound-guided automated CNB (61.5%), p = 0.053; lesions < 20 mm (31.2%) versus lesions > 20 mm (100%), p = 0.043; lesions classified as BI-RADS 3 (16.7%) versus BI-RADS 4 or 5 (41.4%), p = 0.377. Underestimation of malignancy was therefore more likely in cases of LCIS, US-guided CNB, and lesions that were large and suspicious on imaging. Nevertheless, the absence of these features does not spare the need for surgical excision in lobular neoplasia diagnosed on CNB.     

The clinical significance of lobular neoplasia on breast core biopsy

A core biopsy diagnosis of atypical ductal epithelial hyperplasia is upstaged on follow-up excisional biopsy (FUEB) to in situ or invasive carcinoma in about 20% of cases, thus prompting a FUEB. In contrast, upstaging information for a core biopsy diagnosis of pure lobular neoplasia (LN), without mass lesions or other risk-associated lesions is less clear. In this retrospective study, we report the largest consecutive series of patients who had a breast core biopsy diagnosis of LN and a FUEB. Core needle breast biopsies with a diagnosis of LN were retrieved from our files for the period 1999 to 2005, yielding 110 patients. One hundred and one patients had a follow-up surgical excision. Cases of LN with coexisting high-risk lesions (n=9, 10%) were excluded from the study. Patients with associated mass lesions all had benign findings (n=15, 16%) and had no impact on the study results. The remaining 77 core biopsies had no masses or risk lesions and were mammographically Breast Imaging Reporting and Data System 4 (BIRADS) for microcalcifications. Overall, 8/77 (10%) of patients with a radiographic BIRADS 4 image with calcifications and a core biopsy diagnosis of LN on core biopsy were upstaged on FUEB to ductal carcinoma in situ or invasive carcinoma. The numbers upstaged from core biopsies were as follows: atypical lobular hyperplasia (ALH) 4/52 (8%), mixed ALH/lobular carcinoma in situ (LCIS) 1/9 (10%), and pure LCIS 3/16 (19%). A core biopsy of LCIS with neoplastic epithelial calcifications was nearly 3 times more likely to be upstaged on FUEB compared with ALH. We conclude that a finding of LN on breast core biopsy in a patient with a BIRADS 4 image and calcifications is associated with a risk of 8% to 19% of upstaging to a treatable disease on FUEB.     

A case report of pseudoaneurysm after a core needle biopsy of breast cancer

Breast pseudoaneurysms after a core needle biopsy are a rare complication with a low incidence. However, it is important to be aware of the possibility of complications that require treatment.     

Comparison of histologic diagnosis between stereotactic core needle biopsy and open surgical biopsy

Background: This study correlates the histologic findings of stereotactic core needle biopsy (SCNB) with open surgical biopsy (OSB) and identifies which lesions can be treated definitively based only on the SCNB histology. Methods: Women who underwent SCNB between July 1, 1993, and January 1, 1969, were identified by retrospective chart review. Mammographic (MGM) lesions found by SCNB to be ductal or lobular hyperplasia with atypia, or carcinoma underwent OSB. When the histologic findings by SCNB were inconsistent with the MGM findings, the lesion also underwent OSB. Results: 799 women underwent SCNB with 96 (12%) of these going on to OSB. MGM findings in the 92 who presented without a palpable mass included microcalcifications (MCS) in 39, mass in 47, MCS and mass in 7, and tissue distortion in 3. One hundred one breast lesions biopsied first by SCNB, then by OSB were correlated histologically. Sensitivity of SCNB is 89%, with a specificity of 94%. Eight-four women (88%) were able to have definitive treatment at time of OSB because of prior SCNB, and 703/799 (88%) of women were spared OSB entirely. Conclusion: SCNB accurately identifies benign breast histology and invasive cancers in women with MGM abnormalities, a distinct advantage over fine needle aspiration cytology. SCNB does not reliably identify women with DCIS and invasion. All women with SCNB diagnosis of ductal or lobular atypia should also undergo OSB.     

Risk of needle-track seeding after diagnostic image-guided core needle biopsy in breast cancer.

OBJECTIVE: Image-guided core needle biopsy (IGCNB) is an accepted technique for sampling nonpalpable mammographically detected suspicious breast lesions. However, the concern for needle-track seeding in malignant lesions remains. An alternative to IGCNB is needle-localization breast biopsy (NLBB). No study has been done to compare the local recurrence rate of breast cancer after IGCNB versus NLBB. METHODS: We have retrospectively reviewed the local recurrence of breast cancer in patients diagnosed by either IGCNB or NLBB who underwent breast-preserving treatment for their cancer between May 1990 and June 1995. The length of follow-up averaged 29.7 months. RESULTS: Three hundred ninety-eight patients were diagnosed with breast cancer by IGCNB (297 patients) or NLBB (101 patients). All patients underwent breast-conserving surgery. Fifteen (3.77%) patients had a local recurrence: 11(3.70%) in the IGCNB group and 4 (3.96%) in the NLBB group. These recurrence rates are not statistically different. CONCLUSION: Concerns for seeding of the needle track with cancer cells have made some surgeons wary of IGCNB. However, we did not find an increased rate of recurrence due to needle-track seeding, and IGCNB remains our procedure of choice for diagnosing mammographically detected suspicious breast lesions.     

Clinical and radiologic data and core needle biopsy findings should dictate management of cellular fibroepithelial tumors of the breast

Fibroepithelial lesions with cellular stroma identified on core needle biopsy (CNB) may prove to be either fibroadenoma or phyllodes tumor at excision; therefore, management of these rare lesions is highly controversial. We aim to assess the management and the outcome of 101 cellular fibroepithelial lesions diagnosed on CNB over a 6-year period in one institution. Consensus on clinical management in each individual patient was reached during multi-disciplinary conferences, based on careful correlation of clinical data with results of imaging studies and pathology of CNB samples. Radiologic findings (mammogram and sonogram) and multiple histologic parameters on CNB specimen were blindly re-evaluated by one experienced breast radiologist and two breast pathologists, respectively, and results were correlated with final diagnosis at excision. Cellular fibroepithelial lesions with indeterminate or suspect imaging findings, with larger size, and with an equivocal comment such as "cannot rule out phyllodes tumor" in the pathology report were excised more frequently (p = 0.05, p = 0.034, and p = 0.01, respectively). Of 43 excised lesions, 13 were classified as benign phyllodes tumors, 23 as fibroadenoma and seven as benign cellular fibroepithelial lesion. The final diagnosis at excision did not significantly correlate with any clinical data, or with retrospective evaluation of imaging findings or comprehensive evaluation of multiple histologic parameters. In 58 patients who had clinical and radiologic follow-up (mean ± SD: 30 ± 21 months) there was no evidence of disease progression. No clinical and radiologic findings and/or comprehensive evaluation of multiple histologic parameters on CNB specimen are distinctive enough to predict final classification of equivocal cellular fibroepithelial lesions. However, careful clinico-pathologic and radiologic correlation may help to select the most clinically significant lesions for proper immediate surgical management. Follow-up alone may be an appropriate alternative for a subset of patients, given a good clinical, pathologic, and radiologic correlation.     

Imaging and management of fibroepithelial breast lesions on percutaneous core needle biopsy

The purpose of this study is to review the clinical presentation, multi‐modality appearance, and management of the most common benign and malignant fibroepithelial lesions of the breast. Fibroepithelial lesions of the breast may exhibit characteristic features on mammography, ultrasound, and MRI, although definitive diagnosis most often requires biopsy and at times, surgical excision. Knowledge of the imaging features can assist in refining the differential diagnosis and guiding appropriate management.     

Distinguishing papillary endothelial hyperplasia and angiosarcoma on core needle biopsy of the breast: The importance of clinical and radiologic correlation

Papillary endothelial hyperplasia (PEH) is a rare non‐neoplastic exuberant organizing hematoma that can closely mimic angiosarcoma due to a resemblance to malignant anastomosing blood vessels. It could be particularly difficult to distinguish PEH from angiosarcoma in breast core needle biopsies. We identified all cases of these lesions diagnosed on core needle biopsy in order to identify clinical, radiologic, and pathologic features that could prove helpful to arrive at the correct diagnosis. Four cases of PEH and 4 cases of angiosarcoma were identified. The mean age at diagnosis was 62 for PEH and 33 for primary angiosarcoma. All cases of PEH formed small masses with circumscribed or lobulated margins by imaging (mean size 0.9 cm). In 3 cases, the masses were difficult or impossible to identify after the biopsy. Angiosarcomas presented as larger masses with ill‐defined margins (mean size 2.8 cm) that were unchanged in size after biopsy. PEH was surrounded by adipose tissue, whereas angiosarcoma invaded into fibrous stroma and involved lobules. The pseudopapillary structures of PEH were composed mainly of collagen, and thus, additional histologic stains for fibrin were not helpful for diagnosis. The 4 patients with PEH received no further treatment and are alive and disease‐free at 2‐11 years of follow‐up. In contrast, the patients with angiosarcoma underwent mastectomy and chemotherapy or radiation therapy. Two of the patients with angiosarcoma died 3 years after diagnosis and the other 2 patients are alive without disease at 5 and 6 years. Therefore, distinguishing PEH and angiosarcoma is essential for appropriate management. This is the first series to compare these lesions on core needle biopsy and the first to note important clinical, imaging, and histologic differences that aid in making a diagnosis of PEH with confidence on breast core needle biopsy.     

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.     

超声联合空芯针穿刺活检在原发性乳腺癌腋窝淋巴结转移中的诊断价值

目的研究术前超声引导下淋巴结空芯针穿刺(US-CNB)在检测乳腺癌患者腋窝淋巴结转移中的诊断价值。方法回顾性研究2016年1月至2017年7月在我院行超声检查及超声引导下空芯针穿刺活检,并有腋窝淋巴结术后病理诊断的所有乳腺癌病人。计算US-CNB的敏感性、特异性、阳性预测值(PPV)、阴性预测值(NPV)、准确性,同时统计Kappa值以明确一致性情况。分析US-CNB结果与N和T分期的关系。结果以术后病理结果为金标准,US-CNB诊断淋巴结转移的敏感性为91.8%(90/98),特异性为58.3%(21/36),PPV为85.7%(90/105),NPV为72.4%(21/29),误诊率为41.7%(15/36),漏诊率为8.2%(8/98),约登指数为50.1%,准确性82.8%(111/134),ROC曲线下面积为0.751。比较US-CNB与术后病理的一致性,Kappa=0.535。排除新辅助化疗患者14例,特异性、PPV和误诊率分别为95.5%(21/22)、98.9%(90/91)以及4.5%,约登指数87.3%,准确性92.5%(111/120),ROC曲线下面积为0.936(P0.0001),比较排除后US-CNB与术后病理的一致性,Kappa=0.777。随着T和N分期的增加,US-CNB的敏感性增加。结论乳腺癌患者术前腋窝淋巴结空芯针穿刺可作为诊断腋窝淋巴结转移的可靠方法,与术后病理有较高的一致性。淋巴结穿刺结果阳性可能与乳腺癌较高肿瘤负荷相关。     

原发性乳腺癌经皮病灶穿刺组织病理学检查临床应用研究

目的评价超声影像与徒手引导方式对原发性乳腺癌经皮病灶穿刺组织病理学检查结果可靠性的影响,探讨病灶穿刺组织病理学检查在目前原发性乳腺癌治疗中的应用价值。方法回顾性分析697例原发性乳腺癌经皮乳腺病灶穿刺组织病理学检查结果以及临床资料。结果本研究中病灶穿刺组织病理学阳性率90．5％、假阴性率8．9％、可疑癌占0．6％。超声影像引导368例,徒手引导329例;2组中T0期与T1期病灶所占比例分别为17．9％和18．2％（P〉0．05）,超声影像引导与徒手引导的确诊率分别为92．7％和88．2％（P〈0．05）,假阴性率分别为7．1％和10．9％（P〉0．05）。结论对可触及的乳腺癌病灶进行经皮病灶穿刺组织病理学检查,超声影像引导或徒手引导都为可靠的方式。超声影像引导方式的叮靠性优于徒手引导方式。     

Breast hormonal receptors test should be repeated on excisional biopsy after negative core needle biopsy

Therapeutic decision-making for women diagnosed with breast cancer requires accurate determination of the estrogen receptor (ER) and progesterone receptor (PR). Decisions about adjuvant therapy are often based on the immunohistochemical (IHC) profile of the core needle biopsy sample (CNB) because the staining is not repeated on the final excisional biopsy (EB). The purpose of this study was to assess the concordance of breast cancer IHC receptor assays on CNB and EB. We identified 176 patients with matching breast CNB and EB that had available ER and PR. While the CNBs were processed and stained in different laboratories, the EB were processed and stained in our institution. The following antibodies were used 1D5, 6F11 and SP1 for ER, and PgR636, 16 and 1E2 for PR, from Dako, Leica and Ventana respectively. Correlation of scores of CNBs with matching EB was analyzed using Spearman correlation coefficients. Sensitivity, specificity, overall agreement and the kappa statistic were used to measure the concordance between CNB and EB. For CNB, there were 141 (80.1%) cases positive for ER and 118 (67%) cases positive for PR. For EB, there were 143 (81.3%) cases positive for ER and 130 (73.9%) cases positive for PR. Overall agreement for ER and PR was seen in 93% (95% CI = 0.88, 0.96) and 90% (95% CI = 0.84, 0.94) respectively. Overall, ER- CNB/ER+ EB was seen in seven (4%) cases and PR- CNB/PR+ EB in 15 (8.5%) cases. ER+ CNB/ER- EB was seen in five (2.8%) cases and PR+ CNB/PR- EB in three (1.7%) cases. To avoid erroneous omission of life-saving endocrine therapy ER and PR should be repeated on the EB for patients whose CNB has negative hormonal receptors.