Digital imaging improves upright stereotactic core biopsy of mammographic microcalcifications

AIM: This comparative study was carried out to assess the effect of using digital images compared to conventional film-screen mammography on the accuracy of core biopsy of microcalcifications using upright stereotactic equipment. MATERIALS AND METHODS: The biopsy results from a consecutive series of 104 upright stereotactic 14-gauge core biopsies performed with conventional X-ray (Group A) were compared with 40 biopsies carried out using stereotaxis with digital imaging (Group B). In all cases specimen radiography was performed and analysed for the presence of calcifications. Pathological correlation was then carried out with needle and surgical histology. RESULTS: The use of digital add-on equipment increased the radiographic calcification retrieval rate from 55 to 85% (P < 0.005). The absolute sensitivity of core biopsy in pure ductal carcinoma in situ (DCIS) cases rose from 34 to 69% (P < 0.03), with the complete sensitivity increasing from 52 to 94% (P < 0.005). For DCIS with or without an invasive component the absolute sensitivity rose from 41 to 67% (P = 0.052), while the complete sensitivity was 59% before and 86% after the introduction of digital imaging (P < 0.04). CONCLUSION: Digital equipment improves the performance of upright stereotactic core biopsy of microcalcifications, giving a significantly increased success rate in accurately obtaining calcifications. This leads to an improvement in absolute and complete sensitivity of core biopsy when diagnosing DCIS.     

Predicting invasion in mammographically detected microcalcification

AIM: To identify pre-operative factors which predict presence of invasive disease within mammographically detected malignant microcalcification. MATERIALS AND METHODS: A retrospective analysis was undertaken of 116 serial stereotactic core needle biopsies (SCNBs) performed on malignant mammographic calcification. Final surgical pathology was correlated with pre-operative features (clinical, radiological and core histology) in an attempt to predict the presence of an invasive component. RESULTS: Thirty-eight clusters contained invasive carcinoma. The sensitivity of SCNB for invasion was 55%. Clinical features, calcium morphology and cluster size were not shown to be predictive of invasive disease. Ductal carcinoma in situ (DCIS) of high grade on core histology and increasing number of calcifications were predictive of increased risk of invasion (high grade core biopsy DCIS and > 40 calcifications 48% invasive at surgical histology; high grade core biopsy DCIS and < 40 calcifications 15% invasive; non-high grade core biopsy DCIS 0% invasive). CONCLUSIONS: Identification of those clusters diagnosed as DCIS by percutaneous biopsy which are likely to harbour an invasive component is possible. It would seem reasonable to consider staging the axilla at therapeutic surgery in these patients.     

Ultrasound guided core biopsy of suspicious mammographic calcifications using high frequency and power Doppler ultrasound

AIM: The pre-operative diagnosis of suspicious mammographic microcalcifications usually requires stereotactic needle biopsy. The aim of this study was to evaluate if high frequency 13 MHz ultrasound (HFUS) and power Doppler (PD) can aid visualization and biopsy of microcalcifications. MATERIALS AND METHODS: Forty-four consecutive patients presenting with microcalcifications without associated mammographic or palpable masses were examined with HFUS and PD. Ultrasound-guided core biopsy (USCB) was performed where possible. Stereotactic biopsy was carried out when US-guided biopsy was unsuccessful. Surgery was performed if a diagnosis of malignancy was made on core biopsy or if the repeat core biopsy was non-diagnostic. RESULTS: Forty-one patients (93%) had ultrasound abnormalities corresponding to mammographic calcification. USCB was performed on 37 patients. In 29/37, USCB obtained a definitive result (78.4%). USCB was non-diagnostic in 4/9 benign (44.4%) and 4/28 (14.3%) malignant lesions biopsied. The complete and absolute sensitivities for malignancy using USCB were 85.7% (24/28) and 81% (23/28), respectively. USCB correctly identified invasive disease in 12/23 (52.2%) cases. There was no significant difference in the presence of abnormal flow on PD between benign and malignant lesions. However, abnormal PD vascularity was present in 43.5% of invasive cancer and was useful in directing successful biopsy in eight cases. CONCLUSION: The combination of high frequency US with PD is useful in the detection and guidance of successful needle biopsy of microcalcifications particularly where there is an invasive focus within larger areas of DCIS.     

When have mammographic calcifications been adequately sampled at needle core biopsy?

AIMS: To determine if the number of flecks of calcification retrieved at stereotaxic core needle biopsy or the number of core samples obtained containing calcification are related to biopsy sensitivity, and to determine how many calcifications or cores containing calcification the radiologist should aim to retrieve when sampling mammographic microcalcification. MATERIALS AND METHODS: A retrospective review was performed of core specimen radiographs from 57 consecutive patients who had stereotaxic core needle biopsies of impalpable malignant microcalcifications without an associated mammographic mass. The total number of calcifications retrieved and the numbers of cores containing calcification were correlated with findings at core and surgical histology. RESULTS: Increasing retrieval of calcification elements visible on specimen radiography was associated with increasing sensitivity of the biopsy. Five or more flecks of calcium gave an absolute sensitivity of 100%. Increasing numbers of core samples obtained containing radiographically demonstrable calcification was also associated with increasing sensitivity. Three or more cores containing calcium resulted in a 100% absolute sensitivity for malignancy. CONCLUSION: To ensure adequate sampling of calcification at core biopsy, an optimum of either three or more cores containing calcium or five or more flecks of calcium in total is required. Achieving this target ensures a high pre-operative diagnosis rate for malignant microcalcifications.Bagnall, M. J. C. (2000). Clinical Radiology 55, 548-553.     

Stereotactic breast biopsy: an audit of 18 months at BreastScreen Auckland

Stereotactic biopsy has become a widely used technique for marnmographically detected lesions that are clinically and sonographically occult. Vacuum-assisted (mammotome) biopsy on a dedicated prone stereotactic unit has further increased ease of biopsy and utility of the technique. Results of an 18-month audit in the national breast screening programme (BreastScreen Auckland and North) in the Auckland region demonstrates results comparable with those achieved elsewhere. Of a total of 399 stereotactic biopsies, 23 were excluded as they were 14-G core biopsies rather than 11-G mammotome biopsies. Of 376 mammotome biopsies, 10 (2%) failed, 266 (70.7%) were benign, 39 (10.3%) were atypical ductal hyperplasia (ADH) and 70 (18.6%) were malignant. Of these, 14.6% were ductal carcinoma in situ (DCIS) and 4% were invasive carcinomas. All cases diagnosed as ADH underwent formal excision biopsy. Of the 39 cases, 33 demonstrated benign disease or residual ADH only on excision (84.6%) and six (15.4%) patients were upgraded: five to DCIS and one to invasive carcinoma. The significant complication rate was 0.5%. Indications for biopsy were calcification in 89% of cases, mass lesions in 10.6% of cases and architectural distortion in 0.2% of cases. The failure rate of 2% compares with hookwire biopsy series. Practical issues and protocols have been presented.     

Retrieval Rate and Accuracy of Ultrasound-Guided 14-G Semi-Automated Core Needle Biopsy of Breast Microcalcifications

Objective

To evaluate the retrieval rate and accuracy of ultrasound (US)-guided 14-G semi-automated core needle biopsy (CNB) for microcalcifications in the breast.

Materials and Methods

US-guided 14-G semi-automated CNB procedures and specimen radiography were performed for 33 cases of suspicious microcalcifications apparent on sonography. The accuracy of 14-G semi-automated CNB and radiology-pathology concordance were analyzed and the microcalcification characteristics between groups with successful and failed retrieval were compared.

Results

Thirty lesions were successfully retrieved and the microcalcification retrieval rate was 90.9% (30/33). Thirty lesions were successfully retrieved. Twenty five were finally diagnosed as malignant (10 invasive ductal carcinoma, 15 ductal carcinoma in situ [DCIS]) and five as benign. After surgery and mammographic follow-up, the 25 malignant lesions comprised 12 invasive ductal carcinoma and 13 DCIS. Three lesions in the failed retrieval group (one DCIS and two benign) were finally diagnosed as two DCIS and one benign after surgery. The accuracy of 14-G semi-automated CNB was 90.9% (30/33) because of two DCIS underestimates and one false-negative diagnosis. The discordance rate was significantly higher in the failed retrieval group than in the successful retrieval group (66.7% vs. 6.7%; p < 0.05). Punctate calcifications were significantly more common in the failed retrieval group than in the successful retrieval group (66.7% vs. 3.7%; p < 0.05).

Conclusion

US-guided 14-G semi-automated CNB could be a useful procedure for suspicious microcalcifications in the breast those are apparent on sonography.     

Comparison of preoperative simultaneous stereotactic fine needle aspiration biopsy and stereotactic core needle biopsy in ductal carcinoma in situ of the breast

PURPOSE: To compare the preoperative results of stereotactic fine needle aspiration biopsy (S-FNAB) with stereotactic core needle biopsy (S-CNB) performed simultaneously in breast lesions with the postoperative histopathological diagnosis of ductal carcinoma in situ (DCIS) of all histological grades. MATERIAL AND METHODS: 733 consecutive stereotactic biopsies were performed between May 1993 and June 1999. In 72 patients with mammographic findings suspicious of malignancy who were subjected to breast surgery, postoperative histopathology showed DCIS. Preoperatively, S-FNAB and S-CNB had been done simultaneously in all patients, S-FNAB with spinal needle 0.7 or 0.9 mm and S-CNB was performed with an automated 2.1-mm biopsy gun. An average of 3 S-FNABs and 3 S-CNBs were performed in each patient. RESULTS: In 56 (78%) of the 72 patients S-CNB showed DCIS. In 3 patients (4%) the S-CNB revealed "probable carcinoma", in 7 patients (10%) "atypia" and in 6, the lesions were benign. In 34 (47%) of the 72 women S-FNABs showed carcinoma, not otherwise specified. In 6 cases (8%) the S-FNABs showed "probable carcinoma" and in 12 patients (17%) "atypia"; 8 lesions were benign and 12 not diagnostic. CONCLUSION: S-CNB was superior to S-FNAB in diagnosing DCIS. Only 6 patients (8%) received a benign or non-diagnostic preoperative diagnosis with S-CNB compared to 20 patients (28%) with S-FNAB. S-CNB was superior to S-FNAB for preoperative diagnosis of DCIS, but S-FNAB could further increase the sensitivity of the biopsy since it diagnosed cancer in 4 cases where S-CNB showed benign material.     

Contrast-enhanced MR imaging in patients with BI-RADS 3-5 microcalcifications

PURPOSE: The aim of this study was to evaluate the role of magnetic resonance imaging (MRI) in patients with microcalcifications classed as Breast Imaging Reporting and Data Systems (BI-RADS) 3-5. MATERIALS AND METHODS: Fifty-five patients with mammographic microcalcifications classified as BI-RADS categories 3, 4 or 5 underwent MRI and biopsy with stereotactic vacuum-assisted biopsy (VAB). Our gold standard was microhistology in all cases and histology with histological grading in patients who underwent surgery. Patients with a microhistological diagnosis of benign lesions underwent mammographic follow-up for at least 12 months. MRI was performed with a 1.5-Tesla (T) unit, and T1 coronal three-dimensional (3D) fast low-angle shot sequences were acquired before and after injection of paramagnetic contrast agent (0.1 mmol/kg). MRI findings, according to the Fisher score, were classified into BI-RADS classes. In patients with cancer who underwent surgery, we retrospectively compared the extension of the mammographic and MRI findings with histological extension. RESULTS: Histology revealed 26 ductal in situ cancers (DCIS) and ductal microinvasive cancers (DCmic), three atypical ductal hyperplasias (ADH) and 26 benign conditions. Histological grading of the 26 patients with cancer revealed four cases of G1, 11 cases of G2 and 11 cases of G3. If we consider mammographic BI-RADS category 3 as benign and BI-RADS 4 and 5 as malignant, mammography had 77% sensitivity, 59% specificity, 63% positive predictive value (PPV), 74% negative predictive value (NPV) and 67.2% diagnostic accuracy. If we consider MRI BI-RADS categories 1, 2 and 3 as benign and 4 and 5 as malignant, MRI had 73% sensitivity, 76% specificity, 73% PPV, 76% NPV and 74.5% diagnostic accuracy. As regards disease extension, mammography had 45% sensitivity and MRI had 84.6% sensitivity. CONCLUSION: Mammography and stereotactic biopsy still remain the only techniques for characterising microcalcifications. MRI cannot be considered a diagnostic tool for evaluating microcalcifications. It is, however, useful for identifying DCIS with more aggressive histological grades. An important application of MRI in patients with DCIS associated with suspicious microcalcifications could be to evaluate disease extension after a microhistological diagnosis of malignancy, as it allows a more accurate presurgical planning.     

Evaluation of the stereotactic 8G vacuum-assisted breast biopsy in the histologic evaluation of suspicious mammography findings (BI-RADS IV)

PURPOSE: The purpose of this study was to evaluate the potential of the new 8G stereotactic vacuum-assisted breast biopsy (ST-driver, Mammotome; Ethicon Endosurgery) in the histologic evaluation of BI-RADS IV microcalcifications. MATERIALS AND METHODS: Fifty-eight patients with 61 mammographic BI-RADS IV microcalcifications underwent stereotactic vacuum-assisted breast biopsy (SVAB). The new 8G system was mounted on the ST driver, which was formerly used only with the hand-held version under sonographic guidance. The evaluation criteria for each biopsy were minimally invasive and operative histologies, the time needed for biopsy, the amount of bleeding, number of rotations and specimen, the degree of resection, and the complications. RESULTS: Fifty-eight of 61 biopsies were technically successful because > or = 50% were resected (29 x 100%, 8 x 90%, 5 x 80%, 6 x 70%, 3 x 50%, 3 x 0%). In 7 cases with representative biopsies of segmental suspicious microcalcifications, the degree of resection could not be exactly measured. All but 2 biopsies were performed without clinically relevant complications and after gaining enough specimens (? 12.6 specimen, 1.85 rotations). Those 2 patients showed evidence of severe bleeding into the breast tissue and operative revision had to be performed (3.5%). The size of intramammary hematoma was measurable in 27 biopsies and showed a range from 0.5 to 5 cm (? 2.7 cm). The average external bleeding was still low with 16 mL (5-80 mL). In 3 of 61 lesions, it was not possible to gain representative tissue as a result of displacement of the lesion after introducing or shooting the needle. The average time needed for all biopsies was 28.2 minutes for all but 5 very complicated biopsies, which took 16.1 minutes. The histologic findings with further operative workup were: 10 ductal carcinomas in situ (DCIS), 4 atypical ductal hyperplasias, 1 atypical lobular hyperplasias (ALH), 3 lobular carcinomas in situ (LCIS), and 6 invasive ductal carcinomas. In 7 of 12 of the initial DCIS histologies, the operative histology was also DCIS, whereas in 4 of 12, no residual malignant tumor was found. In 1 of 12 patients with an initial DCIS histology, operative histology revealed invasive ductal cancer (8.3%). The cases with lobular lesions (ALH, LCIS) did not show any evidence for residual tissue in the operative workup. Most frequent benign histologies were mastopathy (13), ductal hyperplasia (9), fibroadenoma (8), and sclerosing adenosis (5). The control examinations (maximum 1 year) did not show any signs for a false-negative biopsy. CONCLUSION: The 11-G SVAB has proven to be a perfect adjunct to the existing breast biopsy methods. The new 8G SVAB speeds up the method when used for the same size of lesions and enables the user to representatively biopsy lesions up to 3 cm in diameter. The method is still minimally invasive; however, the amount of hematomas as well as clinically relevant complications is increased.     

Role of ultrasound and sonographically guided core biopsy in the diagnostic evaluation of ductal carcinoma in situ (DCIS) of the breast

PURPOSE: The aim of this study was to evaluate the role of ultrasound (US)-guided core biopsy in the diagnosis of ductal carcinoma in situ (DCIS) and to correlate the histological results on percutaneous biopsy and surgical excision. MATERIALS AND METHODS: Out of 2,423 consecutive core biopsies performed under US guidance, we evaluated 65 lesions with a histological diagnosis of DCIS. All patients underwent mammography, high-frequency broadband US and percutaneous breast biopsy with a 14-gauge needle and a mean number of five samples (range 4-7 passes). Surgical excision was performed in all cases, and the histological results on the surgical specimen were correlated with those on core biopsy samples. The sonographic features of DCIS lesions were described, comparing pure DCIS (those confirmed by definitive histology) and DCIS with invasive component at surgical excision. RESULTS: Twenty-seven out of 65 DCIS at core biopsy were found to have an invasive or microinvasive component at surgical excision, leading to rate of histological underestimation of core biopsy of 41.5%. The most frequent sonographic appearances were: (a) mass without microcalcifications (47.4% of pure DCIS, 63% of DCIS with invasive component); (b) mass with microcalcifications (23.7% of pure DCIS, 22% of DCIS with invasive component); (c) isolated microcalcifications (10.5% of pure DCIS); (d) ductal abnormalities (18.4% of pure DCIS, 15% of DCIS with invasive component). CONCLUSIONS: Due to the high underestimation rate of core biopsy, caution is mandatory in the case of DCIS diagnosis on core biopsy. Although some histological features (such as stromal fibrosis, periductal inflammatory infiltrate, high nuclear grade) can suggest the presence of an invasive component, the sonographic appearance of DCIS cannot be used to predict the cases that are underestimated on US-guided core biopsy. Nevertheless, a sonographically detectable solid component, either inside dilatated ducts or associated with microcalcifications, and a size greater than 20 mm are frequently associated with the presence of an invasive component.     

Atypical ductal hyperplasia of the breast. Its diagnostic imaging and the role of percutaneous needle biopsy with a 14-gauge needle

PURPOSE: To investigate the yield of core biopsy in the histologic characterization of atypical ductal hyperplasia (ADH) and to assess the radiological patterns, if any, of this condition. MATERIAL AND METHODS: January 1993 to October 1997 we studied 553 lesions, 8 of them with a diagnosis of ADH made on microhistologic samples obtained with 14G needles. Biopsy was performed under US guidance in 81.7% of cases and under mammographic guidance in 18.3%. The breast lesions were studied with mammography, US and MRI, the latter in one case. ADH was diagnosed by strict application of Page's and lesion extent criteria. RESULTS: Seven of 8 lesions with a core biopsy diagnosis of ADH were submitted to surgical biopsy. The diagnosis was changed in as many as 6 of 8 cases, into typical ductal hyperplasia (1 case) and carcinoma (1 papilliferous, 3 ductal infiltrating and 1 in situ lesions). ADH was confirmed in one case only. DISCUSSION: In agreement with other authors, we found no specific radiological patterns of ADH. Moreover, the core biopsy diagnosis of ADH requires a surgical biopsy, because ADH is often associated with carcinoma. CONCLUSIONS: Surgical biopsy is needed to diagnose ADH and therefore it is useless to perform more invasive procedures than 14G core biopsy.     

Predictive factors for invasive cancer in surgical specimens following an initial diagnosis of ductal carcinoma in situ after stereotactic vacuum-assisted breast biopsy in microcalcification-only lesions

PURPOSE

The aim of this study was to determine the incidence of invasive breast carcinoma in patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) by stereotactic vacuum-assisted biopsy (SVAB) performed for microcalcification-only lesions, and to identify the predictive factors of invasion.

METHODS

From 2000 to 2010, the records of 353 DCIS patients presenting with microcalcification-only lesions who underwent SVAB were retrospectively reviewed. The mammographic size of microcalcification cluster, presence of microinvasion within the cores, the total number of calcium specks, and the number of calcium specks within the retrieved core biopsy specimen were recorded. Patients were grouped as those with or without invasion in the final pathologic report, and variables were compared between the two groups.

RESULTS

The median age was 58 years (range, 34–88 years). At histopathologic examination of the surgical specimen, 63 of 353 patients (17.8%) were found to have an invasive component, although SVAB cores had only shown DCIS preoperatively. The rate of underestimation was significantly higher in patients with microcalcification covering an area of 40 mm or more, in the presence of microinvasion at biopsy, and in cases where less than 40% of the calcium specks were removed from the lesion.

CONCLUSION

Invasion might be underestimated in DCIS cases diagnosed with SVAB performed for microcalcification-only lesions, especially when the mammographic size of calcification is equal to or more than 40 mm or if microinvasion is found within the biopsy specimen and less than 40% of the calcifications are removed. At least 40% of microcalcification specks should be removed from the lesion to decrease the rate of underestimation with SVAB.Because of the widespread use of breast screening mammography, the number of women diagnosed with ductal carcinoma in situ (DCIS) has increased dramatically in recent years. DCIS is a noninvasive form of breast cancer, accounting for up to 30% of breast cancers in screening populations and approximately 5% of breast carcinomas in symptomatic patients (1–3). DCIS has a variety of mammographic presentations, but the most common mammographic feature is microcalcification (4). Indeed 80%–90% of DCIS lesions present with microcalcifications only, without any accompanying mass lesions (4). Other findings such as masses, nodular abnormalities, dilated retroareolar ducts, architectural distortions, and developing densities have also been reported (5).Ultrasound-guided biopsy is often the method of choice for sonographically visible breast lesions as it provides easy access for biopsy. However, in cases when the abnormality seen on mammography is not visible on ultrasonography, stereotactic biopsy is the recommended sampling method. For microcalcification-only lesions with no accompanying mass, ultrasonography often fails to identify the site of the lesion; hence, stereotactic biopsy is used more frequently.In most breast units, stereotactic 14-gauge automated core biopsy has been replaced by stereotactic vacuum-assisted biopsy (SVAB) using 8- to 11-gauge needles (6). Large core SVAB allows larger samples to be obtained in a shorter period of time compared with samples obtained using automated core biopsy devices (7). Moreover, this technique has the advantage of a single insertion in the area of interest compared with automated core biopsy devices, which require repeated insertions. Several published articles have shown that SVAB decreased the rate of cancer underestimation and the rate of failure to retrieve breast microcalcifications (8).The management of noninvasive and invasive breast cancers is different and therefore, an accurate preoperative diagnosis is crucial for adequate surgical planning. Underestimation of DCIS lesions occurs when an invasive component is found after surgery, which had been missed at the initial preoperative sampling. The underestimation rate of stereotactic 14-gauge automated core biopsy in DCIS was reported as 16%–35% (9–11), while that of SVAB was 5%–29% (6, 9, 11–13).The purpose of this study was to determine the rate, causes, and predictive factors of underestimation of invasive carcinoma in patients diagnosed with DCIS following SVAB of microcalcification-only lesions.     

Ductal carcinoma in situ diagnosed with stereotactic core needle biopsy: can invasion be predicted?

PURPOSE: To determine whether mammographic or histologic features can be used to predict which cases diagnosed as ductal carcinoma in situ (DCIS) without invasion by means of stereotactic core needle biopsy (SCNB) will have invasive disease at surgery. MATERIALS AND METHODS: From July 1992 to March 1999, DCIS without invasion was diagnosed by means of SCNB in 59 patients. Seventeen (29%) were found to have invasive disease after surgery. The underestimation rate for SCNB was compared with that obtained by means of open surgical biopsy. Mammographic and histologic features of cases with and those without invasion were compared. RESULTS: All patients had calcifications on mammograms. There was no significant difference (P: =.26) between the underestimation rate for SCNB with the 11-gauge vacuum-assisted device and that for open surgical biopsy. No statistically significant differences between cases with and those without invasion were seen in patient age, mean number of core specimens, level of suspicion, size of lesion, distribution and morphology of the calcifications, presence of an associated mass or density, subtype of DCIS, nuclear grade, or presence of necrosis or desmoplasia. CONCLUSION: Mammographic and histologic features cannot be used reliably to predict cases that are underestimated with SCNB. However, SCNB with the 11-gauge vacuum-assisted device was as reliable as open surgical biopsy for diagnosing DCIS without invasion.     

Stereotactic and sonographic large-core biopsy of nonpalpable breast lesions: results of the Radiologic Diagnostic Oncology Group V study

RATIONALE AND OBJECTIVES: To determine the diagnostic accuracy of stereotactically and sonographically guided core biopsy (CB) for the diagnosis of nonpalpable breast lesions. MATERIALS AND METHODS: Twenty-two institutions enrolled 2,403 women who underwent imaging-guided fine needle aspiration followed by imaging-guided large-CB of nonpalpable breast abnormalities. All mammograms were reviewed for study eligibility by one of two breast imaging radiologists. The protocol for image-guided biopsy, using either ultrasound (USCB) or stereotactic (SCB) guidance, was standardized at all institutions and all biopsy specimens were over-read by one of three expert pathologists. Patients with atypical ductal hyperplasia (ADH), atypical lobular hyperplasia, or lobular neoplasia on CB underwent surgical excision. Those with negative CB but suspicious ("discordant") pre-biopsy mammography also underwent surgical excision. Patients having a negative CB that was concordant with the pre-biopsy mammography suspicion were assigned to follow-up mammography at 6, 12, and 24 months following CB. RESULTS: A gold standard diagnosis based on definitive histopathologic diagnosis, mammography follow-up, or an imputed gold standard diagnosis was established for 1,681 patients. Of 310 cases with a gold standard diagnosis of invasive breast carcinoma, 261 (84.2%) were invasive carcinoma, 31 (10%) were ductal carcinoma in situ (DCIS), four (1.3%) were ADH, one (0.3%) was a non-breast cancer, and 13 (4.2%) were benign on CB. For 138 cases with a gold standard diagnosis of DCIS, 113 (81.9%) were DCIS, 20 (14.5%) were ADH, and five (3.6%) were benign on CB. For 57 cases (13 masses, 44 calcifications) with an initial CB diagnosis of ADH, atypical lobular hyperplasia or lobular neoplasia, 20 (35.1%) had a gold standard diagnosis of DCIS (4 masses, 16 calcifications) and four (7.0%) had a gold standard diagnosis of invasive cancer (4 calcifications). Of 144 cases (22 masses, 122 calcifications) with an initial CB diagnosis of DCIS, 31 (21.5%) had a gold standard diagnosis of invasive cancer (10 masses, 21 calcifications). The sensitivity, specificity and accuracy for CB by either imaging guidance method in this trial were .91, 1.00, and .98, respectively. The sensitivity, predictive value negative, and accuracy of CB for diagnosing masses (.96, .99, and .99, respectively) were significantly greater (P < .001) than for calcifications (.84, .94, and .96, respectively). The sensitivity (.89) of SCB for diagnosing all lesions was significantly lower (P = 0.029) than that of USCB (.97) because of the preponderance of calcifications biopsied by SCB versus USCB. There was no difference between USCB and SCB in sensitivity, predictive value negative, or accuracy for the diagnosis of masses (97.3, 98.9, and 99.2, respectively for USCB; 95.6, 98.5, and 98.9 respectively for SCB). CONCLUSION: Percutaneous, imaged-guided core breast biopsy is an accurate diagnostic alternative to surgical biopsy in women with mammographically detected suspicious breast lesions.     

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.     

Mammographic bi-dimensional product: a powerful predictor of successful excision of ductal carcinoma in situ

BACKGROUND: The aim of this analysis was to ascertain whether uni-dimensional measurement of mammographic microcalcification, the product of bi-dimensional measurement, calcification morphology, and pathological grade are helpful in predicting successful single therapeutic wide local excision (WLE) of ductal carcinoma in situ (DCIS). METHODS: The study group comprised 505 patients whose mammograms showed the DCIS as calcification, and in whom a non-operative diagnosis had been obtained and WLE attempted. The extents of mammographic calcifications was measured in two planes at 90 degrees on the oblique view, the appearances classified as comedo, granular, or punctate. DCIS was graded using cyto-nuclear characteristics. RESULTS: Three hundred and forty-two patients had a successful first WLE and 163 patients had further surgery. A uni-dimensional measurement of <35 mm and a bi-dimensional product of <800 mm(2) were associated with successful excision (69 versus 54%, p=0.02 and 70 versus 27%, p=0.0001, respectively). Mammographic calcification morphology and histological grade did not influence the likelihood of a successful first WLE. For high-grade DCIS, the upper limit of the bi-dimensional product associated with successful WLE was 800 mm(2) (69 versus 24%, p=0.0003). In contrast, for non-high-grade DCIS, the cut-off was 400 mm(2) (73 versus 33%, p=0.01). Analyses based on mammographic calcification morphology gave similar findings. CONCLUSION: The mammographic bi-dimensional product is a powerful predictor of successful WLE of DCIS when combined with histological grade and/or calcification morphology.     

Lobular carcinoma in situ or atypical lobular hyperplasia at core-needle biopsy: is excisional biopsy necessary?

PURPOSE: To retrospectively determine frequency of invasive cancer or ductal carcinoma in situ (DCIS) at excisional biopsy in women with atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) at percutaneous core-needle biopsy (CNB). MATERIALS AND METHODS: Review of results in 6,081 consecutive patients who underwent CNB at two institutions revealed that in 35 (0.58%), LCIS (n = 15) or ALH (n = 20) was the pathologic finding with highest risk. Patient age range was 41-84 years (mean, 59 years). Of 35 patients, 26 (74%) underwent excisional biopsy and nine (26%) underwent mammographic follow-up for longer than 2 years. Lesions with a pathologic upgrade were noted when invasive cancer or DCIS occurred at the CNB site. CNB results in patients with a diagnosis of atypical ductal hyperplasia (ADH) (75 of 6,081 [1.2%]) were reviewed; these patients underwent subsequent excisional biopsy. Statistical comparison of frequency of upgrading of lesions in patients with a diagnosis of LCIS or ALH at CNB and in those with a diagnosis of ADH at CNB was performed (Pearson chi(2) test). RESULTS: In six (17%) of 35 (95% CI: 4.7%, 29.6%) patients, lesions were upgraded to DCIS (n = 4) or invasive cancer (n = 2). In 15 patients with LCIS diagnosed at CNB, lesions in four (27%) were upgraded to either DCIS or invasive cancer. In 20 patients with ALH diagnosed at CNB, lesions were upgraded to DCIS in two (10%). Lesions in nine patients who underwent mammographic follow-up were stable. No mammographic or technical findings distinguished patients with upgraded lesions from those whose lesions were not upgraded. In 12 (16%) of 75 (95% CI: 7.7%, 24.3%) patients with ADH, lesions were upgraded. Difference between the upgrade rate in patients with LCIS or ALH and that in those with ADH was not significant (P =.88). CONCLUSION: Lesions in 17% of patients with LCIS or ALH at CNB were upgraded to invasive cancer or DCIS; this rate was similar to the upgrade rate in patients with ADH. Excisional biopsy is supported when LCIS, ALH, or ADH is diagnosed at CNB.     

MR-guided stereotactic breast biopsy: technical aspects and preliminary results

AIM: To assess the feasibility and accuracy of cytologic and microhistologic breast biopsy using a MR imaging-guided stereotactic system with MR-compatible non-magnetic needles. MATERIALS AND METHODS: Between December 2001 and September 2002, cytologic and microhistologic sampling of 14 lesions (12 patients) was performed in our radiology department using a commercially available MR-guided stereotactic device. MR-compatible non-magnetic needles or mixed kit (non-magnetic coaxial needle + conventional ferromagnetic needle) were used. Of the 12 patients examined, 2 were undergoing MR examination because of genetic/familial risk, 4 during post-operative follow-up and the remaining 6 for contradictory mammographic and sonographic findings. Ten of the 14 lesions were visible on MR alone. The mean lesion diameter was 12 mm (range 5-30 mm). RESULTS: The procedure was relatively simple and feasible. The procedure took 45 minutes on average. The cytologic samples were adequate in 4/14 cases (29%). The diagnosis was absence of malignant cells in one case, ductal carcinoma in one case and suspected carcinoma in two cases. The cytologic diagnosis was confirmed by core biopsy, and by post-operative histology in the malignant lesions. The remaining 10/14 (71%) cytologic samples were inadequate for diagnosis. All the microhistologic samples (100%) were considered sufficient for diagnosis and yielded diagnosis of benignity in 9/14 (60%) lesions and malignancy in 5/14 (40%). Two patients with benign diagnosis underwent surgery, which confirmed the diagnosis. The remaining seven patients were evaluated by follow-up MRI; the first follow-up at 3 months showed no significant changes. Post-operative histology of the 5 lesions with malignant microhistologic diagnosis confirmed the nature of the lesions. CONCLUSIONS: MR-guided stereotactic biopsy is a simple, fast and safe procedure comparable to the interventional breast procedures performed under mammography and ultrasound guidance. The stereotactic device used ensures correct positioning of the needle into the lesion. The new dedicated non-magnetic needles and the mixed kit provide quantitatively and qualitatively adequate tissue for the histologic analysis. On the basis of our initial experience, we conclude that the procedure is feasible and accurate and can therefore be recommended for routine clinical use.     

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.     

Multiple 14G stereotactic core biopsies in the diagnosis of mammographically detected stellate lesions of the breast

AIM: The aim of this retrospective study was to measure the accuracy of stereotactic guided 14 gauge core biopsy in distinguishing between benign and malignant causes of a mammographically detected stellate breast lesion and to assess the impact of the number of core samples taken on the sensitivity for detection of malignancy. MATERIALS AND METHODS: Seventy-two patients with mammographically detected stellate lesions of the breast formed the study group. All patients in the study group underwent multiple 14 gauge core biopsies using prone stereotactic breast biopsy equipment. The diagnostic accuracy of the technique was measured by retrospectively comparing the outcome with the core biopsy results. The result of each core sample was separately recorded to allow analysis of the effect of increasing the number of samples on accuracy. RESULTS: Nine of 72 (12%) did not have surgery. Forty of 72 (56%) had a benign surgical outcome and 23/72 (32%) a malignant surgical outcome [7/72 (10%) non-invasive, 16/72 (22%) invasive carcinoma]. The absolute sensitivity for multiple stereotactic guided core biopsies of stellate lesions for the detection of malignancy was 78% with a complete sensitivity of 100%. The sensitivity for the detection of invasive carcinoma was 94% (15 out of 16 patients). No statistically significant improvement in sensitivity was shown for multiple samples vs one sample, but in two patients, malignant tissue was only found in core samples 6-9, the first five cores showing atypia only. CONCLUSION: Multiple stereotactic guided 14 gauge core biopsies accurately distinguish malignant from benign causes of stellate breast lesions. When core biopsy histology is malignant, therapeutic surgery can be planned. When the core biopsy shows typical features of a benign radial scar, diagnostic surgical excision may not be required to confirm the diagnosis.Kirwan, S. E., (2000). Clinical Radiology55, 763-766.