Definitive Diagnosis for High-Risk Breast Lesions Without Open Surgical Excision: The Intact Percutaneous Excision Trial (IPET)

Background  

Open surgical excision (OSE) is generally recommended when image-guided core-needle breast biopsy demonstrates a high-risk lesion (HRL). We evaluated intact percutaneous excision (IPEX) with standard radiologic and histologic criteria for definitive diagnosis of HRL, particularly atypical ductal hyperplasia (ADH). The primary aim is to confirm criteria associated with <2% risk for upgrade to carcinoma, equivalent to risk associated with Breast Imaging Reporting and Data System (BI-RADS) 3 lesions, for which imaging surveillance is considered sufficient.     

Intraoperative Ultrasound-Guided Excision of Nonpalpable Breast Lesions

The methods commonly used to guide surgical excision of impalpable breast lesions include preoperative placement of hookwires, carbon injections, and, more recently, radioisotope injections. However, all of these techniques have disadvantages, not the least of which is subjecting the patient to an additional stressful and often traumatic procedure preoperatively. The use of intraoperative ultrasound to guide the excision of sonographically visible impalpable lesions is a new technique that avoids the need for a preoperative localization procedure. This report describes one of the authors (I.B.) personal series of ultrasound-guided breast excisions, collating data collected prospectively, and reviews the efficacy of this technique. Data in relation to 115 ultrasound guided breast excisions performed in 103 patients were reviewed. The technique of using a high-frequency real-time ultrasound probe intraoperatively to localize and guide excision of breast abnormalities is described. There were no failed excisions, as confirmed by specimen sonography, pathology findings, and/or follow-up ultrasound. Breast malignancies comprised 42% of all excised lesions, and of these, adequate margins of excision were achieved at the first operation in 93% of cases. Direct ultrasound localization of the lesion at the time of surgery allowed optimal placement of the incision and eliminated delays in operating time because specimens did not have to be sent to the Radiology Department for confirmation of excision. Intraoperative ultrasound-guided excision is a safe and efficient technique in the management of impalpable, sonographically visible breast lesions, and early reports in the world literature support the findings of this series, which show it to have significant advantages over other current methods, particularly with respect to a reduction in patient anxiety and improved surgical resection margins.     

Intraoperative Ultrasonography-Guided Excision of Nonpalpable Breast Lesions

Background  

The use of intraoperative ultrasonography (US) to localize and guide excision of nonpalpable breast lesions has advantages over other techniques. It avoids the need for additional resources and minimizes patient morbidity.     

Intraoperative Ultrasound-Guided Excision of Nonpalpable Breast Lesions

In order to determine if intraoperative ultrasound (US)-guided excision is a feasible procedure, we prospectively studied 15 female patients between July 1996 and December 1998 for US-detected nonpalpable breast lesions. Intraoperative US was used by the operating surgeon to identify the lesion, guide its excision, and evaluate the specimen to document complete removal. A control group of 15 female patients with mammographically detected nonpalpable lesions was used for comparison. These patients underwent preoperative needle localization, excision of the lesions, and specimen radiographs. Age, size of the lesion, total excised tissue volume, and operative time were documented in all cases. Fifteen patients aged 20-83 years (mean 51) underwent US-guided excision, which adequately localized all lesions, and excision was successful in all patients. Specimen US documented the lesion in all cases. Lesion size ranged from 0.7 to 2 cm (mean 1.1) and the total excised tissue volume averaged 30 cc. Mean operative time was 53 minutes (range 30-75 minutes). The 15 patients of the control group ranged in age from 32 to 82 years (mean 61). Excision was successful in all cases. Lesion size ranged from 1 to 2.5 cm (average 1.5) and the average excised tissue volume was 35 cc. Mean operative time was 50 minutes (range 30-75 minutes). There were no statistically significant differences between the two groups with regard to age (p = 0.2), operative time (p = 0.5), and total excised tissue volume (p = 0.5). The size of the lesions did have a statistically significant difference (p = 0.01). There were no perioperative complications. In conclusion, US-guided excision of nonpalpable breast lesions is a feasible and effective technique. US documents results immediately, is of minimal discomfort to the patient, avoids the need for preoperative localization, allows the entire procedure to be performed in the operating room, does not require radiation, and provides the surgeon with a useful alternative in selected cases.     

Differential Diagnosis of Proliferative Breast Lesions

The correct diagnosis of proliferations within the mammary terminal duct-lobular unit has paramount prognostic and therapeutic implications. Occasionally, the differential diagnosis of compact florid hyperplasia, atypical ductal hyperplasia, and low-grade ductal carcinoma in situ can be quite challenging, with seeming morphologic overlap. This article presents s conceptual and practical understanding of these processes and their impact on subsequent cancer risk, with the intention of assisting the practicing pathologist render accurate and clinically relevant diagnoses for this frequently encountered set of mammary epithelial lesions.     

Significance of Papillary Lesions at Percutaneous Breast Biopsy

Background The management of nonpalpable papillary lesions found in specimens obtained by percutaneous breast biopsy is controversial. We reviewed the treatment of patients found to have papillary lesions by stereotactic, sonographic, or fine-needle aspiration breast biopsy to identify indications for surgical excision. Methods Consecutive patients with intraductal papilloma, atypical papilloma/papilloma with atypical ductal hyperplasia, papillary neoplasm, and papillomatosis according to percutaneous breast biopsy were identified from radiology records. The charts were reviewed to identify patients who had subsequent surgical excision, and the pathologic findings were correlated with the biopsy method and indications for surgery. Results Papillary lesions were found in 120 biopsy samples from 109 patients. Malignancy was found at operation in 19 (24%) of 80 lesions that underwent surgical excision: 12 (63%) were ductal carcinoma-in-situ, 4 (21%) were infiltrating ductal carcinoma, 2 (11%) were infiltrating papillary carcinoma, and 1 (5%) was intracystic papillary carcinoma. Malignancy was found in 9 (30%) of 30 fine-needle biopsy papillary lesions, 6 (35%) of 17 core biopsy papillary lesions, and 4 (12%) of 33 stereotactic biopsy papillary lesions. Malignancy was missed significantly less frequently with stereotactic biopsy (P < .05). Conclusions Malignancy is frequently found at surgical excision for papillary lesions found on percutaneous breast biopsy. Malignancy is missed significantly less frequently with stereotactic biopsy.     

Cytomorphology of Fibrocystic Change, High-Risk, and Premalignant Breast Lesions

Abstract: Fine-needle aspiration biopsy has proven to be an accurate and well-tolerated procedure with a reported specificity of 99% and sensitivity of 70–99%. Similarly, nonpalpable breast lesions can be effectively sampled by needle biopsies under radiologic guidance. Breast aspirates have also been extensively utilized for assessment of nuclear grade, hormone receptor status, ploidy status, and proliferation rate, and have proven to be an attractive alternative to surgical biopsy. Using strict cytologic criteria, it may also be possible to recognize the cytomorphologic changes in breast lesions that are associated with increased risk for subsequent development of breast cancer. Presence of myoepithelial cells within the clusters of atypical epithelial cells recognized morphologically and/or detected by immunostaining for muscle specific actin is an important diagnostic feature of proliferative breast disease with atypia (atypical hyperplasia). This recognition has significant clinical implications and is important in the design of chemoprevention trials. The cytologic distinction between carcinoma in situ and invasive breast cancer remains difficult.     

Risk Factors Associated with Conversion from Nonmalignant to Malignant Diagnosis After Surgical Excision of Breast Papillary Lesions

Purpose  

Management of papillary lesions of the breast identified during preoperative tissue diagnosis remains controversial. This study was designed to analyze the clinical factors associated with under-diagnosis of malignancy in breast papillary lesions.     

定位针引导下的乳管内隆起样病变切除术

目的评价乳管镜和乳腺定位针对乳管内隆起样病变的诊断和指导微创手术的价值。方法对103例不伴有乳腺肿块的乳头溢液病人行乳管镜检查,其中63例乳管内隆起样病变行乳腺定位针定位,乳晕弧形切口手术切除定位针及周围1cm腺体组织一并送术中冰冻,导管内单发乳头状瘤者结束手术,乳管内乳头状瘤病行单纯乳房切除术,导管内癌行单纯乳房切除联合一期腹壁下动脉穿支皮瓣(DIEP)自体再造术。结果冰冻及术后病理诊断导管内单发乳头状瘤59例(93.6%),乳管内乳头状瘤病2例(3.2%),导管内癌2例(3.2%)。59例导管内乳头状瘤术后3个月复查,无溢液症状及明显不适。结论定位针引导下的乳管内隆起样病变手术切除范围小,创伤小,乳房外形基本无改变,手术切除率和病理标本检出率高,误诊和漏诊少。     

乳癌术前细针针吸细胞学替代术中切除活检的指征探讨

为探讨乳癌术前细针针吸细胞学选择性替代术中切除活检的可能性，对１９９５年９月～１９９６年５月间住院手术治疗的１１８例“乳房肿块”病人均行了术前临床触诊及细针针吸细胞学检查。结果显示：１１８例病人病理证实为乳癌者６９例。细针针吸细胞学检查诊断乳癌灵敏度为９５．７％，阳性预测值为９７．１％。当触诊与细针针吸均阳性时，其联合诊断乳癌的灵敏度仅为４７．８％，但联合阳性预测值却达到１００％。提示：对于住院接受手术的乳腺肿块病人，如果术前触诊能基本肯定为乳癌，则应行细针针吸细胞学检查；若针吸涂片查到癌细胞，则可免除术中切除活检而直接行根治性手术     

Feasibility of Percutaneous Excision Followed by Ablation for Local Control in Breast Cancer

Purpose  

Percutaneous ablation of breast cancer has shown promise as a treatment alternative to open lumpectomy. We hypothesized that percutaneous removal of breast cancer followed by percutaneous ablation to sterilize and widen the margins would not only provide fresh naive tissue for tumor marker and research investigation, but also better achieve negative margins after ablation.     

优化乳腺病变的诊断流程

传统的乳腺病变诊断流程是对临床可触及病变进行术中切开活检和快速冰冻检查一步法的诊断流程,随着乳腺癌的早期发现、保乳手术、前哨淋巴结活检及新辅助治疗的开展,传统的乳腺病变诊断流程已经远远不能满足临床需要,需要优化乳腺病变的诊断流程。     

Diagnostic Utility of ABBI(R) (Advanced Breast Biopsy Instrumentation) for Nonpalpable Breast Lesions in Korea

Abstract: Introduction of mammography along with particular attention for the diagnosis and treatment of nonpalpable breast lesions has led to the development of nonresectional biopsies such as mammography-guided core needle biopsy, ultrasound-guided fine needle aspiration cytology, and localization and excisional biopsy. The Advanced Breast Biopsy Instrumentation (ABBI®) system, a recently developed device, has made it possible to remove a lesion completely under local anesthesia, thus providing a more reliable and rapid evaluation on an outpatient basis. We studied 159 patients with nonpalpable breast lesions from December 1996 to August 1998. Fifty-nine patients received core needle biopsies and 100 patients received excision with the ABBI system. The ABBI system patients had postexcisional mammography and specimen radiographs to confirm complete excision of the lesions. Pathologists examined permanent section specimens. In cases of malignancy, total mastectomy or reexcision was performed to secure a tumor-free margin. We collected malignant lesions in 23 of 159 patients, of whom 17 had ductal carcinoma in situ (DCIS). Postoperative histopathologic reports showed DCIS in 11 and infiltrating ductal carcinoma (IDC) in 2 among the 13 malignancies proven by stereotactic core biopsy. Among 10 malignancies proven by the ABBI system, there were 6 DCIS, 1 lobular carcinoma in situ (LCIS), and 3 IDC. In seven patients in whom mammography suggested malignancy but core biopsy showed benign lesion, localization and excisional biopsy confirmed DCIS in four of seven patients. The ABBI system is a more reliable and rapid method of evaluating breast lesions compared with stereotactic core biopsy. It is usually done under local anesthesia, minimizing the deformity of the breast. Therefore the ABBI system can be used as a preferred technique over conventional localization and excisional biopsy.     

Role of Wire-guided Breast Biopsy for Diagnosis of Malignant Nonpalpable Mammographic Lesions

Biopsies of mammographically detected nonpalpable lesions have resulted in increased numbers of diagnosed early breast malignancies. From June 1992 to September 1996 a total of 433 consecutive patients underwent 438 biopsies. The mean age was 55.7 years (range 30–82 years); 150 patients were younger than 50 years. Mammographic findings were classified as microcalcifications (C), masses (M), masses with microcalcifications (MC), architectural distortions (A), and stellate lesions (S). In 30 women two needles were placed to localize a lesion in the ipsilateral side and in 5 on the contralateral side. There were 182 (41.6%) biopsies performed for M, 144 (32.9%) for C, 78 (17.8%) for A, 25 (5.7%) for MC, and 9 (2.1%) for S. The overall malignancy rate was 34% (149/438). Thirty-four women (23%) who presented malignancy were younger than 50 years of age. From year to year, it increased from 27% during the first year to 51% during the fourth year. Altogether 100 (67%) patients had invasive carcinoma, 40 (27%) ductal carcinoma in situ (DCIS), 6 (4%) lobular carcinoma in situ, and 3 (2%) tubular carcinoma. Four patients had simultaneous bilateral palpable and nonpalpable carcinoma. Among the patients, 9 of 20 with previously operated breast carcinoma and 9 of 19 with other previous malignancies were found to have early breast carcinoma. The mammographic finding with high rates of malignancy were S 67%, MC 40%, M 34%, C 33%, and A 28%. A group of 11 of 110 (10%) patients had histologically proven axillary lymph node metastasis. Results from this large retrospective study of wire-guided localization biopsies showed a relatively high rate of malignancy (34%) and DCIS (27%).     

Localizing High-Risk Lesions for Excisional Breast Biopsy: A Comparison Between Radioactive Seed Localization and Wire Localization

Background

Improved resolution and utilization of screening breast imaging has increased identification of nonpalpable high-risk lesions (HRL) and subsequent excisional breast biopsies (EBBs). Wire localization (WL), used most commonly for EBBs, may have shortcomings, including wire displacement, patient discomfort, limitations with incision planning and scheduling logistics. Radioactive seed localization (RSL) may overcome these drawbacks. The purpose of this study was to compare WL and RSL for EBBs for HRLs.

Methods

All single-site EBBs for HRL performed by four breast surgeons were retrospectively reviewed over two consecutive 1-year periods. Patients with cancer on percutaneous core biopsy (CB) were excluded. Clinicopathologic information, operative time, targeted lesion retrieval rate, and upstage rate were collected.

Results

A total of 324 EBBs for HRL were performed: 196 using WL and 128 using RSL. CB pathology was atypical hyperplasia in 56 % of WLs and 62 % of RSLs. The remaining pathologies were radial scar, papilloma, atypical papilloma or lobular carcinoma in situ. Mean age was 54 years. OR time was 27 ± 8 min for WL and 27 ± 7 min for RSL (p = 0.9). Upstage rate was 6 and 5 % for WLs and RSLs, respectively (p = 0.5). Targeted lesions were retrieved in 98 % of WL and 99 % of RSL (p = 0.5). SV was 37.2 ± 32.8 cm³ and 25.7 ± 22.3 cm³ for WL and RSL, respectively (p = 0.001).

Conclusions

RSL is comparable to WL for EBB of HRLs with similar OR times and upstage rates. SV is significantly decreased with RSL and may translate into improved cosmetic outcomes without sacrificing the diagnostic accuracy of the EBB.