Breast masses: US-guided fine-needle aspiration biopsy

Real-time ultrasonography (US) was used to guide fine-needle aspiration biopsy of 111 breast masses and three axillary lymph nodes. The masses included 51 (45%) nonpalpable lesions. Two different guidance techniques were used, with satisfactory results. Lesions less than 1 cm in diameter could be accurately aspirated, and the method allowed quick and accurate cytologic characterization of solid breast masses. The sensitivity of the cytologic diagnosis of malignancy was 92%, and the specificity was 93%. US-guided fine-needle aspiration biopsy of breast masses should be routinely performed, since it can lead to earlier and cost-effective diagnosis of breast carcinoma at virtually no risk. Because of the accuracy of real-time US guidance, negative cytologic findings (i.e., satisfactory smears with benign cells) should be considered highly reliable in ruling out malignancy.     

Fine-needle aspiration biopsy of nonpalpable breast lesions in a multicenter clinical trial: results from the radiologic diagnostic oncology group V

PURPOSE: To determine the diagnostic accuracy of ultrasonographically (US) and stereotactically guided fine-needle aspiration biopsy (FNAB) in the diagnosis of nonpalpable breast lesions. MATERIALS AND METHODS: At 18 institutions, 442 women who underwent 22-25-gauge imaging-guided FNAB were enrolled. Definitive surgical, core-needle biopsy, and/or follow-up information was available for 423 (95.7%) of these women. The reference standard was established from additional clinical and imaging information for an additional six (1.4%) women who did not undergo further histopathologic evaluation. The FNAB protocol was standardized at all institutions, and all specimens were reread by one of two expert cytopathologists. RESULTS: When insufficient samples were included in the analysis and classified as positive, the sensitivity and specificity of FNAB were 85%-88% and 55.6%-90.5%, respectively; accuracy ranged from 62.2% to 89.2%. The diagnostic accuracy of FNAB was significantly better for detection of masses than for detection of calcifications (67.3% vs. 53.8%, P =.006) and with US guidance than with stereotactic guidance (77.2% vs. 58.9%; P =.002). CONCLUSION: FNAB of nonpalpable breast lesions has limited value given the high insufficient sample rate and greater diagnostic accuracy of other interventions, including core-needle biopsy and needle-localized open surgical biopsy.     

Malignant seeding of the needle track during stereotaxic core needle breast biopsy.

Early reports demonstrated the diagnostic advantage of large-core (14-gauge) biopsy over fine-needle aspiration biopsy of nonpalpable lesions of the breast without apparent significant increase in morbidity. A case of malignant seeding of the needle track after a large-core biopsy of a mucinous carcinoma of the breast is documented. The potential for increased risk of tract seeding of malignancy must be considered.     

Nonpalpable breast tumors: diagnosis with stereotaxic localization and fine-needle aspiration

Modern mammography is the most effective means of detecting nonpalpable breast cancers, but correct diagnosis for malignancy is made in only 20%-30% of the cases. The conventional method of lesion localization usually results in approximate placement of the hookwire in the breast. The authors report the results of stereotaxic localization, combined with fine-needle aspiration and cytologic study, performed in 528 cases. Clinically occult breast lesions were localized precisely (within 2 mm 96% of the time), sampled by means of a 23-gauge needle, and marked with either methylene blue or a hookwire for subsequent open excisional biopsy. The results indicate a sensitivity of 95%, specificity of 91%, and accuracy of 92% for the fine-needle aspiration procedure. This technique offers a significantly improved preoperative method of diagnosing small breast lesions with minimal pain, no complications, reduced cost, and no disfigurement or scar interfering with subsequent mammographic follow-up.     

Stereotaxic needle-core biopsy and fine-needle aspiration biopsy in the diagnosis of nonpalpable breast lesions: controversies and future prospects

Objective: To determine the advantages and limitations of a combined stereotaxic fine-needle aspiration biopsy and needle-core biopsy in the diagnosis of 353 nonpalpable breast lesions with special attention given to the collection of follow-up data. Methods and material: 353 nonpalpable breast lesions underwent ‘one pass’ stereotaxic fine-needle aspiration (21 gauge needle) and needle-core biopsy (18 gauge needle) at our institution from January 1990 to October 1993. Stereotaxic biopsies were carried out by means of an ‘add-on unit’. Surgical biopsy was usually recommended for highly suspicious radiologic patterns and/or needle biopsy reports classified as atypical or malignant. In all other cases mammographic follow-up was advised at 6 months and then annually for 3 years. The data were collected retrospectively during September 1995 (theoretical average follow-up of greater than 3 years). Results: Following the combined needle biopsy technique procedure, surgery was recommended for 83 lesions. Fifty-four cancers were associated to these suspicious lesions. Because of changing radiological or clinical pattern during follow-up (mean follow-up: 22 months), 11 cancers were detected among the 270 lesions initially considered not to need surgery. Forty-three percent of the 65 malignant lesions were initially read as having less than highly suspicious mammographic features. There was no significant difference between the sensitivity and the specificity of one pass fine-needle aspiration biopsy (57% and 96% respectively) and needle-core biopsy (60% and 97% respectively), but noncontributive samples were not included in the false negative diagnoses and atypical samples were included in the true positive diagnoses. Of the 11 missed cancers, nine were manifested initially by clusters of calcifications. Our diagnostic approach was significantly less sensitive (P = 0.006) and less specific (P = 0.032) in cases of clusters of calcifications (31% false negative diagnoses) than in cases of soft-tissue masses (5.5% false negative diagnoses). In this study, an average delay in diagnosis of 22 months was responsible for a significantly increased percentage of axillary node positive invasive cancer (P < 0.001) and six of the 11 missed cancers were palpable at the time of the delayed diagnosis. For the nine cancers initially manifested by calcifications, the 22 months delay in diagnosis was responsible for a nonsignificant increase of microinvasive type at the expense of carcinoma in situ. Conclusion: Our enthusiasm with the sensitivity of this double stereotaxic needle sampling has been tempered by the results of this reanalysis in the light of a mean theoretical follow-up of three years. Our diagnostic approach was adequate in the presence of soft-tissue masses but not valid in the presence of clustered calcifications. When dealing with calcifications, multiple samplings must be done in order to improve the sensitivity of the diagnosis. Furthermore, this study does not favour the theory that the majority of mammographically detected cancers are indolent and highlights the poor sensitivity of the mammographic follow-up of nonpalpable lesions.     

New sonographic criteria for recommending fine-needle aspiration biopsy of nonpalpable solid nodules of the thyroid

OBJECTIVE: The purpose of our study was to provide new sonographic criteria for fine-needle aspiration biopsy of nonpalpable solid thyroid nodules. MATERIALS AND METHODS: Sonographic scans of 155 nonpalpable thyroid nodules in 132 patients were prospectively classified as having positive or negative findings. Sonographic findings that suggested malignancy included microcalcifications, an irregular or microlobulated margin, marked hypoechogenicity, and a shape that was more tall than it was wide. If even one of these sonographic features was present, the nodule was classified as positive (malignant). If a nodule had none of the features described, it was classified as negative (benign). The final diagnosis of a lesion as benign (n = 106) or malignant (n = 49) was confirmed by fine-needle aspiration biopsy and follow-up (>6 months) in 83 benign nodules, by fine-needle aspiration biopsy and surgery in 44 malignant and 15 benign lesions, and by surgery alone in five malignant and eight benign lesions. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated on the basis of our proposed classification method. RESULTS: Of 82 lesions classified as positive, 46 were malignant. Of 73 lesions classified as negative, three were malignant. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy based on our sonographic classification method were 93.8%, 66%, 56.1%, 95.9%, and 74.8%, respectively. CONCLUSION: Considering the high level of sensitivity of our proposed sonographic classification, fine-needle aspiration biopsy should be performed on thyroid nodules classified as positive, regardless of palpability.     

乳腺钼靶X线立体定位穿刺活检和手术

1992年7月～1993年9月间,对56例乳腺疾病患者进行钼靶摄片,发现56例57处病灶,对其中54例55处病灶进行了立体定位细针穿刺细胞学检查。结果显示其敏感性为92.5％,特异性为100％,诊断符合率为96.3％。若将细胞学检查结果与钼靶摄片相结合,联合敏感性与特异性均可达100％。上述病灶中有12处为临床所不能扪及的隐匿性病灶,6处在立体定位引导下完成了切除术。     

Sonographically guided fine-needle aspiration biopsy of adrenal masses

Percutaneous fine-needle aspiration biopsy of solid adrenal masses was performed under real-time sonographic guidance in 18 patients. Cellular material was aspirated in all cases. Cytologic examinations were correct in 11 metastatic deposits, three primary adrenal adenocarcinomas, and one pheochromocytoma. One subsequently proven primary adenocarcinoma was not diagnosed. In two cases of adenoma, normal adrenal cells were aspirated. Percutaneous aspiration of adrenal masses is recommended when the precise nature of the lesions is clinically required. The simplicity and speed of fine-needle aspiration biopsy under sonographic control and its high diagnostic accuracy and safety suggest its use as a routine procedure in the management of patients with adrenal masses well depicted by sonography.     

The impact of stereotactic large-core needle biopsy in the treatment of patients with nonpalpable breast lesions: a study of diagnostic accuracy in 510 consecutive cases

The objective of this study was to assess the usefulness of stereotactic large-core needle biopsy (LCNB) in the management of nonpalpable breast lesions (NBL) and compare it with stereotactic fine-needle aspiration biopsy (SFNA) performed simultaneously in a significant number of cases. From November 1993 through June 1997, 510 consecutive patients with NBL underwent 14-gauge LCNB with 354 women undergoing simultaneous 21-gauge SFNA in the same lesion. Mammographic findings, lesion size, number of core biopsy specimens, complications and diagnoses of both techniques were analysed. Surgical biopsy, tumorectomy or mastectomy was indicated for malignancy or poor correlation between SFNA or LCNB results and clinical or radiological findings. Values of diagnostic accuracy of both LCNB and SFNA were determined. The ratio benign surgical biopsies/malignant surgical biopsies (BB/CB) of the series was calculated. A total of 171 patients underwent surgical treatment; in 31 (18.1 %) a benign process or atypical ductal hyperplasia was the final diagnosis. The ratio BB/CB was 0.22. Sensitivity and specificity were 93.2 and 100 %, respectively, for LCNB, and 77.2 and 92.3 %, respectively, for SFNA with cytological analysis. Large-core needle biopsy provides more accurate diagnosis than SFNA in the management of nonpalpable breast lesions and obviates a surgical diagnostic procedure in a significant number of cases. Received 17 November 1997; Revision received 4 February 1998; Accepted 16 March 1998     

The clinical utility of stereotaxic x-ray guided cytological biopsy in nonpalpable neoplastic pathology of the breast

The authors report the initial results of the combined use of stereotaxic X-rays and fine-needle aspiration biopsy in 83 patients with nonpalpable breast lesions. The stereotaxic system employed is a simple accessory of conventional mammographic equipment. Cytologic diagnosis (94 biopsies) had 90% sensitivity and 97% specificity; the percentage of acellular/insufficient cytologic samples was 10.8%. To assess the clinical value of this technique, the obtained results were compared with both mammographic findings and US-guided aspiration biopsy data.     

Nonpalpable breast lesions: evaluation by means of fine-needle aspiration cytology

A prospective study was undertaken to assess the utility of fine-needle aspiration (FNA) cytology in women with nonpalpable suspicious microcalcifications or masses detected at mammography. Ninety-six breast lesions were aspirated during wire localization with standard mammographic technique. Cytologic results were compared with surgical pathology results. Sixty-one of the 96 aspirates were adequate for diagnosis. Nine were positive for malignant cells; seven, suspicious; 12, atypical; and 33, negative. All lesions demonstrating positive or suspicious cytologic findings were found to be malignant at biopsy; five of the 12 with atypical cytologic findings were malignant. Of 33 lesions deemed negative by means of cytology, two were biopsy-proved carcinomas. Cytologic examination permitted accurate diagnosis of 21 of the 23 (91%) carcinomas in which an adequate sample was obtained. Insufficient cellular material was obtained from 35 lesions, 16 of which showed marked fibrosis at histologic examination. The authors conclude that FNA cytology can aid in establishing a diagnosis in many cases in which nonpalpable breast lesions are detected at mammography.     

Sonographically occult screen detected breast masses: a retrospective analysis of cases undergoing biopsy

OBJECTIVE: The purpose of this study was to evaluate nonpalpable breast masses identified on mammograms that are sonographically occult. METHODS: The pathology data base at the Woman's Place for Breast Care of the Woman's Hospital of Texas was searched to identify patients who had undergone biopsy for a nonpalpable breast mass identified on mammograms in which a mass was not visible at sonography. RESULTS: There were 32 of 231 such nonpalpable masses that were sonographically occult. Twenty-eight of the masses were histologically benign; four were malignant. CONCLUSION: A small percentage of mammographically visible nonpalpable breast masses are sonographically occult; a majority of these masses are benign. However, biopsy of such masses should be considered and the decision to biopsy based on mammographic features and interval change.     

Incidental findings on sonography of the breast: clinical significance and diagnostic workup.

OBJECTIVE: The purpose of this study was to determine how often physician-performed high-resolution sonography can detect nonpalpable breast lesions not revealed by mammography. A sonographic classification scheme was tested for its accuracy in predicting malignancy of incidentally detected breast lesions. SUBJECTS AND METHODS: Six thousand one hundred thirteen asymptomatic women with breast density grades 2-4 and 687 patients with palpable or mammographically detected breast masses underwent sonography as an adjunct to mammography. All sonographically detected, clinically and mammographically occult breast lesions that were not simple cysts were prospectively classified into benign, indeterminate, or malignant categories. Diagnoses were confirmed by sonographically guided fine-needle aspiration or core needle biopsy. RESULTS: In 6113 asymptomatic women, 23 malignancies in 21 patients were detected with sonography only (prevalence, 0.31%). Five additional malignant lesions were found in patients with a malignant (n = 3) or a benign (n = 2) palpable or mammographically detected index lesion. The mean size of invasive malignancies detected only by sonography was 9.1 mm, which was not significantly different from the mean size of invasive cancers detected by mammography (p = .07). The sensitivity of the prospective sonographic classification for malignancy was 100%, and the specificity was 33.5%. CONCLUSION: The use of high-resolution sonography as an adjunct to mammography in women with dense breasts may lead to detection of a significant number of otherwise occult malignancies that are no different in size from nonpalpable mammographically detected lesions. Prospective classification of these lesions based on sonographic characteristics results in a significant reduction in number of unnecessary biopsies performed.     

Patient compliance with recommended follow-up after fine-needle aspiration biopsy of solid breast masses.

OBJECTIVE: Any needle biopsy procedure is associated with a false-negative rate; therefore, masses diagnosed as benign by needle biopsy should be followed to confirm their stability. This study determines patient compliance with recommended 6-month follow-up of breast masses that have had benign cytology. MATERIALS AND METHODS: This study consists of a retrospective 5-year chart review from August 1994 to August 1999. The study includes patients who had an ultrasound-guided fine-needle aspiration biopsy of a solid breast mass diagnosed as benign and were told to return in 6 months for follow-up. Patients who had the masses surgically removed were excluded. Patients who did not follow-up within a 1-year period were sent a letter of reminder. RESULTS: Over the 5-year period, a total of 462 patients had an ultrasound-guided fine-needle aspiration biopsy of a solid breast mass diagnosed as benign and were instructed to return at 6 months for follow-up. Two hundred ninety-six (64%) of these patients returned for follow-up within 1 year. The remaining 166 patients were sent a letter of reminder. Of these 166 patients, 71 (43%) responded to the letter; 5 patients were lost to follow-up because they had moved. Of all 462 patients, 367 (79%) eventually returned for follow-up, at an average of 9.2 months after biopsy. CONCLUSIONS: Over a 5-year period, 296 out of 462 (64%) patients were compliant with recommendations for follow-up, and an additional 71 patients responded to a letter of reminder. Noncompliance with recommended follow-up could lead to a delay in diagnosis of false-negative lesions. This study demonstrates the need for radiologists to have a system to track compliance.     

Nonpalpable breast lesions: stereotaxic fine-needle aspiration cytology

The authors reviewed the accuracy of stereotaxic fine-needle aspiration cytology in prediction of the presence of cancer. Seventy-four nonpalpable breast cancers and 144 benign lesions were studied. The rate of obtaining an inadequate sample was 8.1% for cancers and 20.8% for benign lesions. None of the cytology reports were false-positive, whereas the accuracy of cytologic atypia in prediction of cancer was 72%. Sensitivity and specificity after 1 year of follow-up were 83.8% and 96.6%, respectively, with atypia reports being assumed positive. In patients strongly suspected of having cancer at mammography, the decision to perform biopsy must be independent of the cytologic report, as false-negative cytologic findings are expected. In patients with a low suspicion at mammography, abnormal cytologic findings were the determining factor for a request for biopsy of six cancers and of two benign lesions. Negative cytologic results contributed to the recommendation of follow-up of two lesions that turned out to be malignant. At the authors' institution, the benign-to-malignant biopsy ratio of nonpalpable lesions was greatly reduced after stereotaxic cytologic study became available; the rate of detection of subclinical cancer remained almost unaffected.     

Transthoracic percutaneous lung biopsy

Percutaneous fine-needle aspiration biopsy of the lung is a relatively simple invasive procedure with good patient acceptance, low morbidity, and almost negligible mortality. It provides a diagnosis of pulmonary, hilar, and mediastinal masses quickly and accurately, eliminating many laboratory tests and saving hospital days, thereby saving time and money. Percutaneous fine-needle aspiration biopsy should be performed early in the investigation of many types of intrathoracic lesions.     

Interventional breast procedures

The capability to provide histologic diagnoses of nonpalpable lesions by performance of percutaneous needle biopsy has revolutionized breast imaging in the past decade. The radiologist who performs percutaneous breast biopsies assumes an increased level of responsibility for the patient regarding patient selection, lesion selection, performance of the biopsy procedure, interpretation of results, and patient follow-up. With variable and increasingly numerous options for the biopsy of breast lesions, careful attention must be paid to the selection of patients and types of lesions for different procedures. Critical technical considerations affect whether biopsy of a lesion can be optimally performed percutaneously, and these considerations must be factored into the recommendations for patient treatment. In addition, a limited preprocedural clinical assessment of the patient will allow a safer procedure to be performed expeditiously. Most breast abnormalities classified by using the ACR Lexicon as 4 (suggestive) or 5 (highly suggestive, likely malignant) are suitable for either percutaneous breast needle biopsy or needle localization and excisional biopsy. In general, those lesions classified as 3 (probably benign) carry a recommendation for early follow-up and not biopsy, because the likelihood of malignancy is small. A particular advantage of percutaneous biopsy is in the diagnosis of multicentric breast cancer. Core biopsy is less invasive and less costly than surgical biopsy, and it can be used to demonstrate multicentric disease, saving the patient a two-step surgery. However, several lesions are better treated by excision than by percutaneous biopsy. Among these are architectural distortion or loosely arranged, segmental or regional microcalcifications. For nonpalpable breast lesions visualized on mammography, sonography, or both, imaging-guided localization is required for precise needle placement either for wire localization or for percutaneous breast biopsy. The selection of which modality to use for guidance depends on (1) the adequacy of visualization of the lesion by the modality used, (2) the position of the lesion, (3) the ease of positioning the patient, (4) the skill of the operator, (5) the need to reduce radiation exposure, (6) the overall patient condition, and (7) size of the lesion. Fine-needle aspiration biopsy (FNAB) has a high sensitivity and specificity in the diagnosis of palpable breast lesions when the procedure is properly performed and interpreted. Variable results have been achieved with FNAB of nonpalpable breast lesions under imaging guidance. Three critical components are necessary to achieve reliable results by using FNAB. These include the following: (1) accuracy in needle placement, (2) skill in performance of FNAB, and (3) expert cytopathologic analysis. Accurate preoperative needle localization of nonpalpable breast lesions allows the radiologist to guide the surgeon performing an open biopsy and helps to ensure that the surgical procedure can be performed quickly and can be accomplished with the best possible cosmetic result for the patient. Lesions selected for needle localization and biopsy should undergo a complete tailored imaging evaluation before the needle localization is scheduled. Specimen radiography should be performed for all nonpalpable lesions. Once the lesion has been identified on specimen radiography, the radiologist can assist the pathologist in identifying the lesion microscopically by marking the lesion within the surgical specimen. We cover the technical and interpretative aspects of percutaneous breast biopsy and needle localization for surgical biopsy.     

Fine-needle aspiration of breast biopsy specimens: correlation of histologic and cytologic findings.

The accuracy of fine-needle aspiration (FNA) cytologic diagnosis of nonpalpable breast lesions and the prevalence of neoplasm occurring in areas unrelated to the radiologic abnormality were studied. Template-guided FNA cytologic examination was performed in 101 surgically excised breast specimens. The exact area of the mammographic abnormality was aspirated with radiographic control. Despite accurate placement of the needle for aspiration, seven of 101 aspirates (7%) yielded insufficient cytologic material. Ninety-four of the 101 aspirates (93%) were adequate for diagnosis. The cytologic diagnosis was benign in 58 (62%), atypical in seven (7%), suspicious for malignancy in four (4%), and malignant in 25 (27%). All cases diagnosed as suspicious or malignant and five of 58 cases diagnosed as benign at cytologic examination proved to be malignant at histologic examination. In three of these five the malignancy was in the area of the radiologic abnormality; in two it was not. FNA cytologic examination can be helpful in evaluating nonpalpable breast lesions, but it is not as accurate as histologic examination of surgically excised lesions.     

CT导向经皮肺活检的临床应用

31例肺部肿块病人在CT导向下作了经皮针吸肺活检术,其中肺癌16例,肺穿刺活检准确率87.5%;良性病变15例,肺穿刺活检准确率93%、术后气胸3例(9.7%),小量出血1例(3.2%).CT扫描图像清晰.病灶定位准确.因此CT导向经皮肺活检术安全、准确、成功率高,在肺部肿块的诊断中有重要作用.     

Palpable prostatic nodules: comparison of US and digital guidance for fine-needle aspiration biopsy

This study was undertaken to evaluate the use of transrectal sonographically guided fine-needle aspiration biopsy and to compare sonographic with digital guidance for biopsy. In 62 patients in whom prostatic carcinoma was suspected at digital rectal examination, fine-needle aspiration biopsies were performed transperineally under sonographic guidance and transrectally under digital guidance. These patients had 89 nodules, 73 of which were sampled with both techniques. Malignant cells were obtained under digital guidance in 17 of 73 nodules (23%) and under sonographic guidance in 16 (22%). An additional seven nodules, which were not seen sonographically, were sampled under digital guidance and proved to be negative. In nine other nodules that were nonpalpable and evident only with sonography, malignant cells were obtained under sonographic guidance in three. These findings indicate that sonographic guidance for fine-needle aspiration biopsy is as good as digital guidance for palpable lesions.