Stereotactic breast biopsy of nonpalpable lesions: determinants of ductal carcinoma in situ underestimation rates

PURPOSE: To measure the effect of biopsy device, probe size, mammographic lesion type, lesion size, and number of samples obtained per lesion on the ductal carcinoma in situ (DCIS) underestimation rate. MATERIALS AND METHODS: Nonpalpable breast lesions at 16 institutions received a histologic diagnosis of DCIS after 14-gauge automated large-core biopsy in 373 lesions and after 14- or 11-gauge directional vacuum-assisted biopsy in 953 lesions. The presence of histopathologic invasive carcinoma was noted at subsequent surgical biopsy. RESULTS: By performing the chi(2) test, independent significant DCIS underestimation rates by biopsy device were 20.4% (76 of 373) of lesions diagnosed at large-core biopsy and 11.2% (107 of 953) of lesions diagnosed at vacuum-assisted biopsy (P <.001); by lesion type, 24.3% (35 of 144) of masses and 12.5% (148 of 1,182) of microcalcifications (P <.001); and by number of specimens per lesion, 17.5% (88 of 502) with 10 or fewer specimens and 11.5% (92 of 799) with greater than 10 (P <.02). DCIS underestimations increased with lesion size. CONCLUSION: DCIS underestimations were 1.9 times more frequent with masses than with calcifications, 1.8 times more frequent with large-core biopsy than with vacuum-assisted biopsy, and 1.5 times more frequent with 10 or fewer specimens per lesion than with more than 10 specimens per lesion.     

Stereotactic biopsy of ductal carcinoma in situ of the breast using an 11-gauge vacuum-assisted device: persistent underestimation of disease.

OBJECTIVE: The purpose of this study was to compare the diagnostic accuracy of 14-gauge automated gun and 11-gauge directional vacuum-assisted biopsy techniques in the diagnosis of ductal carcinoma in situ of the breast. MATERIALS AND METHODS: We retrospectively reviewed 41 consecutive lesions that had been diagnosed as ductal carcinoma in situ using stereotactic needle biopsy. The first 21 lesions had been biopsied using a 14-gauge automated gun; the remaining 20 lesions, using an 11-gauge vacuum-assisted device. Surgical histopathologic results at lumpectomy were compared with the findings at needle biopsy and defined as either concordant, when only ductal carcinoma in situ (i.e., no evidence of invasive carcinoma) was evident at surgery, or discordant, when invasive carcinoma was found. One patient from the automated gun group was lost to follow-up and was not included in the analysis. RESULTS: Invasive carcinoma was found at surgery in seven (35%) of the 20 cases diagnosed using the automated gun compared with three (15%) of the 20 cases diagnosed using the vacuum-assisted device (p = .13). In all three of these discordant vacuum-assisted cases, only microinvasive disease was found at surgery. However, in only two of the seven discordant automated gun cases was only microinvasive disease found at surgery. CONCLUSION: The 11-gauge directional vacuum-assisted biopsy technique may improve the accuracy of ductal carcinoma in situ diagnosis. Underestimation of disease still occurs, however.     

Sonographically Guided Core Biopsy of the Breast: Comparison of 14-Gauge Automated Gun and 11-Gauge Directional Vacuum-Assisted Biopsy Methods

Objective

To compare the outcomes of 14-gauge automated biopsy and 11-gauge vacuum-assisted biopsy for the sonographically guided core biopsies of breast lesions.

Materials and Methods

We retrospectively reviewed all sonographically guided core biopsies performed from January 2002 to February 2004. The sonographically guided core biopsies were performed with using a 14-gauge automated gun on 562 breast lesions or with using an 11-gauge vacuum-assisted device on 417 lesions. The histologic findings were compared with the surgical, imaging and follow-up findings. The histologic underestimation rate, the repeat biopsy rate and the false negative rates were compared between the two groups.

Results

A repeat biopsy was performed on 49 benign lesions because of the core biopsy results of the high-risk lesions (n = 24), the imaging-histologic discordance (n = 5), and the imaging findings showing disease progression (n = 20). The total underestimation rates, according to the biopsy device, were 55% (12/22) for the 14-gauge automated gun biopsies and 36% (8/22) for the 11-gauge vacuum-assisted device (p = 0.226). The atypical ductal hyperplasia (ADH) underestimation (i.e., atypical ductal hyperplasia at core biopsy and carcinoma at surgery) was 58% (7/12) for the 14-gauge automated gun biopsies and 20% (1/5) for the 11-gauge vacuum-assisted biopsies. The ductal carcinoma in situ (DCIS) underestimation rate (i.e., ductal carcinoma in situ upon core biopsy and invasive carcinoma found at surgery) was 50% (5/10) for the 14-gauge automated gun biopsies and 41% (7/17) for the 11-gauge vacuum-assisted biopsies. The repeat biopsy rates were 6% (33/562) for the 14-gauge automated gun biopsies and 3.5% (16/417) for the 11-gauge vacuum-assisted biopsies. Only 5 (0.5%) of the 979 core biopsies were believed to have missed the malignant lesions. The false-negative rate was 3% (4 of 128 cancers) for the 14-gauge automated gun biopsies and 1% (1 of 69 cancers) for the 11-gauge vacuum-assisted biopsies.

Conclusion

The outcomes of the sonographically guided core biopsies performed with the 11-gauge vacuum-assisted device were better than those outcomes of the biopsies performed with the 14-gauge automated gun in terms of underestimation, rebiopsy and the false negative rate, although these differences were not statistically significant.     

Atypical ductal hyperplasia: histologic underestimation of carcinoma in tissue harvested from impalpable breast lesions using 11-gauge stereotactically guided directional vacuum-assisted biopsy

OBJECTIVE: This review was undertaken to determine the reliability of the histologic diagnosis of atypical ductal hyperplasia (ADH) made from tissue obtained by 11-gauge stereotactically guided directional vacuum-assisted biopsy of impalpable breast lesions. MATERIALS AND METHODS: Four hundred twenty-two 11-gauge stereotactically guided vacuum-assisted breast biopsies were performed at our institution between November 5, 1996, and June 30, 1998. Biopsies were performed with the patient prone on a dedicated stereotactic biopsy table. A directional vacuum-assisted biopsy device was used. Eight to 24 cores (mean, 13.4) were harvested from each lesion. Radiography of core specimens was performed in cases in which the target lesion contained microcalcifications. Twenty (4.7%) of the 422 biopsies yielded a histopathologic diagnosis of ADH. Surgical excision of 16 of the 20 lesions was subsequently performed. We compared the histopathologic results of the core extracted and the corresponding surgically excised tissue. RESULTS: Of the 16 surgically excised lesions, four (25.0%) retained the diagnosis of ADH. Four (25%) were upgraded to carcinoma: Two (12.5%) were ductal carcinoma in situ without comedonecrosis, one (6.3%) was invasive carcinoma, and one (6.3%) was tubular carcinoma. Of the remaining eight surgically excised lesions, six (37.5%) were interpreted as benign fibrocystic changes with ductal hyperplasia without atypia, and two (12.5%) were interpreted as lobular carcinoma in situ. CONCLUSION: Because ADH was underdiagnosed in 25% of the lesions, we recommend that surgical excision be performed whenever ADH is found in tissue obtained from 11-gauge directional vacuum-assisted breast biopsy.     

Underestimation of breast cancer with II-gauge vacuum suction biopsy

OBJECTIVE. The purpose of this study was to determine the mammographic and histologic features of cancerous lesions underestimated using 11-gauge vacuum suction biopsy. MATERIALS AND METHODS. Retrospective review of 11-gauge vacuum suction biopsy was performed to identify lesions diagnosed as atypical ductal hyperplasia or carcinoma. The histology of the core and surgical specimens was compared. Of 158 cases of cancer, underestimation occurred in 15 (9.5%). The mammographic and histologic features were assessed. RESULTS. Of 15 underestimated cases, six were atypical ductal hyperplasia that proved to be cancer (5 ductal carcinoma in situ and 1 invasive) and nine were ductal carcinoma in situ that proved to have invasion. The underestimation rate for calcifications was 16.3% (14/86) and for masses was 1.6% (1/64) (p = 0.007). Most (5/6) underestimated atypical ductal hyperplasia cases were reported as "markedly atypical," and four of nine underestimated ductal carcinoma in situ cases were reported as "possible invasion." No significant difference was seen in the number of core specimens obtained or the sizes of the lesions for underestimated cases versus accurately diagnosed cases. The percentage of calcifications retrieved was significantly different (p = 0.017). No underestimations were found among cases in which the entire mammographic lesion was removed at vacuum suction biopsy. CONCLUSION. The cancer underestimation rate with vacuum suction biopsy was 9.5%. The underestimation rate for calcifications (16.3%) was significantly higher than that for masses (1.6%) (p = 0.007). The percentage of the lesion removed was an important factor in reducing underestimation, as reflected by the percentage of calcifications retrieved and the instances of complete resolution of the lesion seen on mammography.     

Comparison of automated versus vacuum-assisted biopsy methods for sonographically guided core biopsy of the breast

OBJECTIVE: The purpose of this study was to compare the outcome of sonographically guided core biopsies performed with the 14-gauge automated gun with the outcome of those performed with the 11-gauge vacuum-assisted device. Outcome was defined in terms of missed tumors, the need (both immediate and delayed) for a second biopsy, histologic underestimation, and complication rates. MATERIALS AND METHODS: We retrospectively reviewed all sonographically guided core biopsies performed between January 1997 and August 2001. Before February 2000, biopsies were performed using the 14-gauge automated gun and after that time, with either the 14-gauge automated gun or the 11-gauge vacuum-assisted device. During the study period, 181 biopsies were performed with the 14-gauge automated gun and 100 with the 11-gauge vacuum-assisted device. RESULTS: The histologic results of the core biopsies were similar for the group who underwent biopsy with the 14-gauge automated gun and the group who underwent biopsy with the 11-gauge vacuum-assisted device: malignant, 19% versus 19%; benign, 78% versus 79%; and high-risk lesion or other, 3% versus 2%, respectively (p > 0.7). Complications were rare and similar for both methods: 2% for the 14-gauge automated gun and 3% for the 11-gauge vacuum-assisted device (p = 0.46). A second biopsy was recommended immediately after the first in 14% of the patients who underwent biopsy with the 14-gauge automated gun versus 17% of those who underwent biopsy with the 11-gauge vacuum-assisted device (p = 0.47). Recommendation for delayed rebiopsy due to interval change occurred in 2.5% of the patients who underwent biopsy with the 14-gauge automated gun method and 3% of those who underwent biopsy with the 11-gauge vacuum-assisted device (p = 0.94). CONCLUSION: No significant differences were found in the outcomes of sonographically guided core biopsies performed with the automated gun compared with those performed with the vacuum-assisted device in terms of missed cancers, underestimation, complications, or the need (immediate or delayed) for a second biopsy.     

Sonographically guided directional vacuum-assisted breast biopsy using a handheld device.

OBJECTIVE: The goal of this study was to show that one can safely remove all sonographic evidence of masses in the breast less than or equal to 1.5 cm in greatest dimension using the 11-gauge handheld Mammotome, thereby reducing the possibility of a false-negative diagnosis and other shortcomings of the automated core biopsy device. SUBJECTS AND METHODS: Over a 12-week period (May 3--July 31, 2000), 124 sonographically guided breast biopsies were performed in 113 patients, using a new handheld directional vacuum-assisted biopsy device. All lesions that were less than or equal to 1.5 cm were biopsied using a handheld Mammotome; an attempt was made to continue the biopsy until no sonographic evidence of the lesion remained. RESULTS: Of these 124 lesions, 14 had infiltrating ductal carcinomas, four had infiltrating ductal carcinomas with associated ductal carcinoma in situ, one had infiltrating lobular carcinoma, one had ductal carcinoma in situ, three had atypical ductal hyperplasias, one had atypical lobular hyperplasia, and one had phyllodes tumor. Only one infiltrating ductal carcinoma was entirely removed histologically at Mammotome biopsy. There were no underestimates of disease. No cases of epithelial displacement were observed in any of the surgical excisions of malignancies. The remaining 99 lesions were benign. CONCLUSION: The handheld Mammotome diminishes the shortcomings of the automated core biopsy device. It reduces the possibility of false-negatives and underestimation of disease. It eliminates the need for multiple insertions and reduces the likelihood of epithelial displacement. As a result, we now use this device for all sonographically guided biopsies of breast masses smaller than 1.5 cm and recommend that others consider it for such use.     

Mammographic abnormalities caused by percutaneous stereotactic biopsy of histologically benign lesions evident on follow-up mammograms

OBJECTIVE: The purpose of our study was to evaluate how often a mammographic abnormality thought to be produced by the biopsy procedure was evident on the initial follow-up mammogram after percutaneous biopsy of impalpable histologically benign lesions. We compared three stereotactic percutaneous biopsy methods. CONCLUSION: A mammographic density seen well only in the projection parallel to the biopsy needle tract was evident in 2% (5/226) of the lesions for which 11-gauge directional vacuum-assisted biopsy was used, 0% (0/96) of the lesions for which 14-gauge directional vacuum-assisted biopsy was used, and 0% (0/422) of the lesions for which 14-gauge automated large-core biopsy was used. No mammographic abnormalities assessed as BI-RADS categories 3, 4, or 5 (according to the American College of Radiology's Breast Imaging Reporting and Data System) and thought to be produced by the biopsy procedure were evident after any of the biopsy methods.     

Imaging-guided core needle biopsy of papillary lesions of the breast

OBJECTIVE: Our objective was to assess the incidence of papillary lesions of the breast diagnosed at imaging-guided core needle biopsy and the need for surgical excision after a benign diagnosis. MATERIALS AND METHODS: This retrospective study included 1374 patients with consecutive suspicious breast lesions that underwent either mammography or sonographically guided large-core needle breast biopsy. Fifty-seven lesions (4%) were classified as papillary lesions. Eleven of the 57 cases were lost to follow-up (n = 6) or had not yet shown 2 years of stability (n = 5) and were excluded from this study. The remaining 46 papillary lesions constitute our study population. RESULTS: Surgical excision was performed in 17 (37%) of 46 papillary lesions. In the group of patients whose lesions were recommended for excision because carcinoma was identified at core biopsy, surgical excision revealed one false-positive and two true-positive diagnoses. In four cases, histologic diagnoses of the excisional biopsy and the core needle biopsy were discordant. One false-positive finding at core needle biopsy initially was interpreted as invasive ductal carcinoma on the basis of core needle biopsy specimens. In three false-negative findings, the initial diagnosis at core needle biopsy was upgraded after surgical excision. Two cases of papilloma with adjacent atypical ductal hyperplasia and one of atypical papilloma were upgraded to ductal carcinoma in situ after surgical excision. Imaging follow-up was performed in the remaining 29 patients. All lesions were stable or had decreased in size during the 2-year follow-up period. The negative predictive value of core needle biopsy for excluding malignancy among the papillary lesions diagnosed in our study was 93%. CONCLUSION: When the histologic diagnosis is benign, our data suggest that papillary lesions may be safely managed with imaging follow-up rather than with surgical excision. However, atypical papillary lesions or those associated with atypia require surgical excision because histologic underestimation occurs at a frequency similar to that in other atypical lesions undergoing core needle biopsy.     

Breast lesions with imaging-histologic discordance during US-guided 14G automated core biopsy: can the directional vacuum-assisted removal replace the surgical excision? Initial findings

The purpose of this study was to determine the frequency of carcinoma at percutaneous directional vacuum-assisted removal (DVAR) in women with imaging-histologic discordance during ultrasound (US)-guided automated core needle biopsy, and to determine the role of DVAR in breast lesions with imaging-histologic discordance. A US-guided 14-gauge automated core needle biopsy was performed on 837 consecutive lesions. Imaging-histologic discordance was prospectively considered in 33 of 634 benign biopsies. DVAR was recommended in those lesions. Among the 33 lesions, 26 lesions that underwent subsequent DVAR or surgical excision made up our study population. Medical records, imaging studies, and histologic findings were reviewed. Among the 26 lesions, 18 lesions underwent subsequent US–guided DVAR, with 8-gauge probes for 15 of the lesions, and 11-gauge for three of the lesions. Two lesions were diagnosed as having carcinoma (2/18, 11.1% of upgrade rate; 3.1–32.8% CI). The remaining eight lesions underwent subsequent surgical excision, and carcinoma was diagnosed in one case (12.5% of upgrade rate; 2.2–47.1% CI). A US-guided DVAR of the breast mass with imaging-histologic discordance during US-guided 14-gauge automated core needle biopsy is a valuable alternative to surgery as a means of obtaining a definitive histological diagnosis. An erratum to this article can be found at     

Cost-effectiveness of stereotactic 11-gauge directional vacuum-assisted breast biopsy

OBJECTIVE: The purpose of our study was to determine the frequency with which stereotactic 11-gauge directional vacuum-assisted breast biopsy obviated a surgical procedure and to calculate cost savings attributable to that biopsy method. MATERIALS AND METHODS: We retrospectively reviewed 200 consecutive solitary nonpalpable lesions on which stereotactic 11-gauge directional vacuum-assisted breast biopsy was performed. Cost savings were calculated using Medicare reimbursements. Mammograms, histologic findings, and medical records were reviewed. RESULTS: Stereotactic 11-gauge directional vacuum-assisted biopsy obviated a surgical procedure in 151 (76%) of 200 lesions, including 112 (73%) of 154 calcific lesions and 39 (85%) of 46 masses. Reasons for not obviating a surgical procedure in 49 lesions (25%) included recommendation for surgical biopsy in 35 lesions (18%), small carcinomas treated by excision in 10 lesions (5%), and histologic underestimation in four lesions (2%). Stereotactic 11-gauge directional vacuum-assisted biopsy decreased the cost of diagnosis by S264 per case, a 20% ($264/$1289) decrease in the cost of diagnosis compared with surgical biopsy. Of 200 lesions that had stereotactic 11-gauge directional vacuum-assisted biopsy, 106 (53%) would not have been amenable to 14-gauge automated core biopsy because of their small size, their superficial location, or inadequate breast thickness. CONCLUSION: Stereotactic 11-gauge directional vacuum-assisted breast biopsy obviated a surgical procedure in 76% of lesions, yielding a 20% decrease in cost of diagnosis compared with surgical biopsy. Although savings per case are modest, 11-gauge directional vacuum-assisted biopsy expands the spectrum of lesions amenable to stereotactic biopsy, increasing cost savings in the population.     

Complete percutaneous excision of infiltrating carcinoma at stereotactic breast biopsy: how can tumor size be assessed?

OBJECTIVE: The purpose of this study was to determine the frequency of complete excision of infiltrating carcinoma at stereotactic 11-gauge directional vacuum-assisted breast biopsy and to evaluate the feasibility of measuring tumor size in stereotactic biopsy specimens in infiltrating carcinomas that were percutaneously excised. MATERIALS AND METHODS: We performed retrospective review of 51 infiltrating carcinomas diagnosed using stereotactic 11-gauge directional vacuum-assisted biopsy that underwent subsequent surgery. For lesions yielding no residual infiltrating carcinoma at surgery, the maximal dimension of the tumor was measured in stereotactic biopsy specimens using ocular micrometry. RESULTS: In 10 (20%) (95% confidence intervals, 9.8-33.1%) of 51 infiltrating carcinomas diagnosed at stereotactic biopsy, surgery revealed no residual infiltrating carcinoma. Complete excision of infiltrating carcinoma was more frequent if 14 or more specimens were obtained (32% versus 0%, p < .004), if the mammographic lesion was removed (35% versus 7%, p < .03), and if the mammographic lesion size measured 0.7 cm or less (50% versus 16%, p = .08). Tumor size in stereotactic biopsy specimens was within 3 mm of mammographic lesion size in six (60%) of 10 lesions, including five (71%) of seven masses and one (33%) of three calcification lesions, but was smaller than the mammographic lesion size in eight (80%) of 10 lesions. CONCLUSION: Surgery revealed no residual infiltrating carcinoma in 10 (20%) of 51 infiltrating carcinomas diagnosed at stereotactic 11-gauge biopsy. Although tumor size can be assessed in stereotactic biopsy specimens in these lesions, such measurements may underestimate the maximal dimension of the tumor. Further study is needed to evaluate the usefulness of these measurements in guiding treatment decisions.     

Comparison of rebiopsy rates after stereotactic core needle biopsy of the breast with 11-gauge vacuum suction probe versus 14-gauge needle and automatic gun

OBJECTIVE: The 11-gauge vacuum suction probe is an alternative to the 14-gauge needle and automatic gun for performing stereotactic core needle biopsies. This study compares rebiopsy rates after stereotactic core needle biopsies that were performed with the two methods. The study also assesses the outcomes of those repeat biopsies. MATERIALS AND METHODS: Five hundred ninety-two stereotactic core needle biopsies using a 14-gauge needle and automatic gun and 354 using an 11-gauge vacuum suction probe were performed consecutively. Excluding malignancies, the number of cases requiring rebiopsy and the reasons for rebiopsy were determined for each group. The histologic diagnoses of the repeat biopsies were assessed. RESULTS: The rebiopsy rate was significantly lower with the 11-gauge vacuum suction probe (9.0%) than with the 14-gauge needle and automatic gun (14.9%) (p = .013). Significant reductions were found in cases of insufficient sampling (probe, 1.7%; needle, 4.4%; p = .042) and mammographic-pathologic discrepancy (probe, 0.8%; needle, 3.4%; p = .026). The rebiopsy rate for masses was 6.1% with the vacuum probe versus 10.7% with the 14-gauge needle (p = .12) and for calcifications was 11.6% with the vacuum probe versus 23.7% with the 14-gauge needle (p = .003). After rebiopsy, the percentage of cases in which malignancy was found was 18.5% with the vacuum probe versus 13.7% with the 14-gauge needle. On rebiopsy, the percentage of malignancies found in each category were atypical hyperplasia: probe 26.7%, needle 20.0%; insufficient sample: probe 0%, needle 9.5%; pathologist recommendation: probe 50.0%, needle 12.5%; and lobular carcinoma in situ: probe 0%, needle 100%. CONCLUSION: Use of the 11-gauge vacuum-assisted device significantly decreases but does not eliminate the need for rebiopsy after stereotactic core needle biopsy. The rebiopsy rate for calcifications was significantly reduced by using the vacuum suction probe rather than the 14-gauge needle; however, the rate for masses was reduced only slightly. On rebiopsy, malignancies were found in both groups.     

乳腺立体定位核芯针活检的病理组织学低估原因分析

目的 分析乳腺立体定位核芯针活检的病理组织学低估的原因,以期引起临床多学科的重视及客观对待.方法 2000年9月至2005年9月,对146例乳腺病变患者(179个病变)进行立体定位核芯针病变部位穿刺活检,发生病理组织学低估21个.病变均不可触及(NPBL),根据乳腺影像报告和数据系统(BI.RADS),活检前诊断BI-RADS m类6个,Ⅳ类12个,V类3个,影像表现为钙化16个,肿块2个,不对称性致密1个,星芒征2个.结果 活检为纤维囊性乳腺病并导管上皮不典型增生11个,手术诊断为导管原位癌7个,伴早期浸润4个;活检为重度乳腺导管不典型增生3个,手术诊断为原位癌1个,原位癌伴早期浸润2个;活检为乳腺导管原位癌3个,手术证实均为浸润性癌;活检为乳头状病变4个,手术证实为原位癌及伴早期浸润各1个、浸润性导管癌及乳腺导管内乳头状腺癌各1个.结论 乳腺核芯针活检的病理组织学低估与立体定位技术、病变本身及医师的认识有关,放射科医师应熟练掌握活检技术并力求全面取材,当穿刺活检结果与影像表现不符时,应重新评价病变的实际病理诊断.     

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

OBJECTIVE: This study was undertaken to determine whether complete percutaneous excision rather than sampling of the mammographic target conveys any significant advantage or disadvantage at stereotactic 11-gauge vacuum-assisted biopsy. MATERIALS AND METHODS: A retrospective review was performed of 788 consecutive solitary lesions in which the mammographic target was excised (n = 466) or sampled (n = 322) at stereotactic 11-gauge vacuum-assisted biopsy. Medical records and histologic findings were reviewed to determine the frequency of sparing surgery, discordance, histologic underestimation, rebiopsy, complete histologic removal of cancer, and complications. Statistical comparisons were made using the Fisher's exact test. RESULTS: Complete excision rather than sampling of the mammographic target was associated with a significantly lower frequency of discordance (1/466, 0.2% vs 8/322, 2.5%; p = 0.004) and a trend toward fewer ductal carcinoma in situ underestimates (4/59, 6.8% vs 12/60, 20.0%; p = 0.07). Complete histologic removal of cancer was significantly more likely if the mammographic target was excised rather than sampled (19/91, 20.9% vs 7/106, 6.6%; p = 0.006); however, among 91 cancers in which the mammographic target was excised, surgery revealed residual cancer in 72 (79.1%). Complete excision rather than sampling of the mammographic target yielded no significant differences in the frequency of sparing surgery, atypical ductal hyperplasia underestimates, rebiopsy, or complications. CONCLUSION: Complete excision rather than sampling of the mammographic target was associated with lower frequencies of discordance and ductal carcinoma in situ underestimation but had no other advantage or disadvantage. Among cancers in which the mammographic target was excised, surgery revealed residual cancer in almost 80%.     

MR imaging-guided 10-gauge vacuum-assisted breast biopsy: histological characterisation

Purpose

The aim of this study was to evaluate a handheld vacuum-assisted device for magnetic resonance imaging (MRI)-guided breast biopsy.

Materials and methods

In 47 patients, a total of 47 suspicious breast lesions (mean maximum diameter 9 mm) seen with MRI (no suspicious changes on breast ultrasound or mammography) were sampled using a 10-gauge vacuum-assisted breast biopsy (VAB) device under MRI guidance. Histology of biopsy specimens was compared with final histology after surgery or with follow-up in benign lesions.

Results

Technical success was achieved in all biopsies. Histological results from VAB revealed malignancy in 15 lesions (32%), atypical ductal hyperplasia in four lesions (8%) and benign findings in 28 lesions (60%). One of four lesions with atypical ductal hyperplasia was upgraded to ductal carcinoma in situ after surgery. One of seven lesions showing ductal carcinoma was upgraded to invasive carcinoma after surgery. Two lesions diagnosed as infiltrating carcinoma by VAB were not validated at excisional biopsy due to complete removal of the lesion during the procedure. During the follow-up (mean 18 months) of histologically benign lesions, we observed no cases of breast cancer development. Because of morphological changes on follow-up MRI scans, two lesions underwent surgical excision, which confirmed their benign nature. Besides minor complications (massive bleeding, n=1) requiring no further therapeutic intervention, no complications occurred.

Conclusions

MRI-guided biopsy of breast lesions using a handheld vacuum-assisted device is a safe and effective method for the workup of suspicious lesions seen on breast MRI alone.     

MR imaging-guided 9-gauge vacuum-assisted core-needle breast biopsy: initial experience

PURPOSE: To perform magnetic resonance (MR) imaging-compatible vacuum-assisted 9-gauge core-needle biopsy of suspicious enhancing breast lesions identified at MR imaging. MATERIALS AND METHODS: The institutional review board granted exempt status for this HIPAA-compliant study and waived the requirement for informed consent. The MR imaging-guided 9-gauge vacuum-assisted core-needle biopsy findings of 85 lesions in 75 patients aged 31-89 years were retrospectively reviewed. The biopsies were performed as part of the patients' clinical care with a Food and Drug Administration-approved biopsy system and not within a research protocol. All included patients had received a diagnosis of malignant, benign, or high-risk (for cancer) breast tissue at core-needle biopsy and had undergone subsequent surgery or follow-up imaging. MR imaging-guided biopsy results were compared with final histopathologic or follow-up imaging findings. RESULTS: At MR imaging-guided core-needle biopsy, malignancy was identified in 52 (61%) lesions: 35 invasive cancers and 17 ductal carcinoma in situ (DCIS) lesions. Four (24%) of the 17 DCIS lesions were upgraded to invasive cancer at excisional biopsy or mastectomy. A high-risk lesion (ie, atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ, or radial scar) was identified in 18 (21%) cases. Two (25%) of eight atypical ductal hyperplasia lesions were upgraded to DCIS at excision. No malignancy was found in the atypical lobular hyperplasia (n = 2), lobular carcinoma in situ (n = 5), or radial scar (n = 3) lesions. Fifteen (18%) lesions were found to be benign lesions of unknown type at excision or mastectomy. For 13 of these 15 lesions, the benign results were concordant with the imaging findings. Both (two of 86, 2%) discordant cases represented false-negative lesions. The remaining 13 benign lesions were validated at excisional biopsy (n = 9) or follow-up imaging (n = 4). CONCLUSION: Initial experience revealed MR imaging-guided 9-gauge vacuum-assisted core-needle breast biopsy to be a reasonable alternative to MR imaging-guided wire localization of suspicious lesions identified at MR imaging only, on the basis of published information regarding the latter.     

Calcifications highly suggestive of malignancy: comparison of breast biopsy methods.

OBJECTIVE: The purpose of this study was to compare the usefulness of, and cost of diagnosing with, different breast biopsy methods for women with calcifications highly suggestive of malignancy. MATERIALS AND METHODS: One hundred thirty-nine women with calcifications highly suggestive of malignancy underwent diagnostic biopsy. Of these, 89 women had stereotactic biopsy with a 14-gauge automated needle (n = 25), 14-gauge vacuum-assisted probe (n = 17), or 11-gauge vacuum-assisted probe (n = 47); and 50 women had diagnostic surgical biopsy. Medical records were reviewed. Cost savings for stereotactic biopsy were calculated using Medicare data. RESULTS: The median number of operations was one for women who had stereotactic biopsy versus two for women who had diagnostic surgical biopsy. The likelihood of undergoing a single operation was significantly greater for women who had stereotactic rather than surgical biopsy, among all women (61/89 [68.5%] vs. 19/50 [38.0%], p < 0.001) and among women treated for breast cancer (55/77 [71.4%] vs. 6/37 [16.2%], p = 0.0000001). Stereotactic 11-gauge vacuum-assisted biopsy, as compared with 14-gauge automated core or 14-gauge vacuum-assisted biopsy, was significantly more likely to spare a surgical procedure (36/47 [76.6%] vs. 16/42 [38.1%], p = 0.0005). Stereotactic 11-gauge vacuum-assisted biopsy resulted in the greatest cost reduction, yielding savings of $315 per case compared with diagnostic surgical biopsy; for women with solitary lesions, stereotactic 11-gauge biopsy decreased the cost of diagnosis by 22.2% ($334/$1502). CONCLUSION: For women with calcifications highly suggestive of malignancy, the use of stereotactic rather than surgical biopsy decreases the number of operations. Stereotactic 11-gauge vacuum-assisted biopsy, as compared with 14-gauge automated core or 14-gauge vacuum-assisted biopsy, is significantly more likely to spare a surgical procedure and has the highest cost savings.     

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

OBJECTIVE: Displaced epithelial fragments at percutaneous biopsy of ductal carcinoma in situ (DCIS) may mimic stromal invasion. This study was undertaken to determine the frequency of epithelial displacement in DCIS lesions of patients who underwent stereotactic 11-gauge directional vacuum-assisted breast biopsy. MATERIALS AND METHODS: We retrospectively reviewed 28 consecutive DCIS lesions in patients who underwent stereotactic 11-gauge directional vacuum-assisted breast biopsy followed by surgery. Surgical specimens were examined for histologic evidence of epithelial displacement, consisting of fragments of epithelium in artifactual spaces in breast parenchyma or in lymphovascular channels, accompanied by hemorrhage, fat necrosis, inflammation, hemosiderin-laden macrophages, or granulation tissue. RESULTS: The median number of specimens obtained per lesion was 14 (range, seven to 45). The median interval from stereotactic biopsy to surgery was 27 days (range, 10-59 days). Surgery revealed DCIS in 19 (68%) of 28 lesions, DCIS and infiltrating carcinoma in four lesions (14%), and no residual carcinoma in five lesions (18%). Reactive changes at the biopsy site were identified in all cases. Displacement of benign epithelium into granulation tissue at the stereotactic biopsy site was identified in two cases (7%). We found no evidence of displacement of malignant epithelium. CONCLUSION: Epithelial displacement is uncommon after stereotactic 11-gauge directional vacuum-assisted biopsy of the breast. We observed displacement of benign epithelium in two (7%) of 28 DCIS lesions and no displacement of malignant epithelium.     

Radial scars diagnosed at stereotactic core-needle biopsy: surgical biopsy findings

We retrospectively reviewed surgical biopsy findings of lesions diagnosed as radial scars (RS) at stereotactic core-needle biopsy (SCNB). RS was diagnosed in 52 of 1415 (3.7%) consecutive mammographically detected lesions that underwent 14-gauge automated SCNB. Subsequent surgical biopsy findings were available for 43 lesions in 41 women constituting the study group. Of these 43 lesions, histopathological analysis of the surgical specimen yielded RS in 27 (63%), RS plus atypical ductal hyperplasia (ADH) in 8 (18%), RS plus carcinoma in five (12%), and only carcinoma in three (7%). Carcinomas underestimated at SCNB (n=8) were two in situ carcinomas, two invasive ductal carcinomas not otherwise specified, and four tubular carcinomas. A statistically significant difference (P=0.02) was found between the mean pathologic size of RS without carcinoma and of RS containing carcinoma. Mammographic features could not be used reliably to predict the presence of carcinoma at excision of lesions diagnosed as RS at SCNB. The results suggest that the diagnosis of RS at 14-gauge SCNB of mammographically detected lesions is an indication for surgical biopsy because of the high prevalence of carcinoma in these lesions.