Underestimation of the presence of breast carcinoma in papillary lesions initially diagnosed at core-needle biopsy

PURPOSE: To retrospectively determine the degree of underestimation of breast carcinoma diagnosis in papillary lesions initially diagnosed at core-needle biopsy. MATERIALS AND METHODS: Institutional review board approval and waiver of informed consent were obtained for this HIPAA-compliant study. Mammographic database review (1994-2003) revealed core biopsy diagnoses of benign papilloma (n=38), atypical papilloma (n=15), sclerotic papilloma (n=6), and micropapilloma (n=4) in 57 women (mean age, 57 years). Excisional or mammographic follow-up (>or=2 years) findings were available. Patients with in situ or invasive cancer in the same breast or patients without follow-up were excluded. Findings were collected from mammography, ultrasonography, core technique, core biopsy, excision, and subsequent mammography. Reference standard was excisional findings or follow-up mammogram with no change at 2 years. Associations were examined with regression methods. RESULTS: In 38 of 63 lesions, surgical excision was performed; in 25 additional lesions (considered benign), follow-up mammography (24-month minimum) was performed, with no interval change. In 15 lesions, 14-gauge core needle was used; in 48, vacuum assistance (mean cores per lesion, 8.7). Carcinoma was found at excision in 14 of 38 lesions. Core pathologic findings associated with malignancy were benign papilloma (n=1), sclerotic papilloma (n=1), micropapilloma (n=2), and atypical papilloma (n=10). Frequency of malignancy was one (3%) of 38 benign papillomas, 10 (67%) of 15 atypical papillomas, two (50%) of four micropapillomas, and one (17%) of six sclerotic papillomas. Excisional findings included lobular carcinoma in situ (n=2), ductal carcinoma in situ (n=7), papillary carcinoma (n=2), and invasive ductal carcinoma (n=3). Low-risk group (micropapillomas and sclerotic and benign papillomas) was compared with high-risk atypical papilloma group. Core findings were associated with malignancy at excision for atypical papilloma (P=.006). Lesion location, mammographic finding, core number, or needle type were not associated (P>.05) with underestimation of malignancy at excision. CONCLUSION: Benign papilloma diagnosed at core biopsy is infrequently (3%) associated with malignancy; mammographic follow-up is reasonable. Because of the high association with malignancy (67%), diagnosis of atypical papilloma at core biopsy should prompt excision for definitive diagnosis.     

Papillary lesions of the breast at percutaneous core-needle biopsy

PURPOSE: To retrospectively review the imaging and histologic findings in patients in whom a benign papillary lesion was diagnosed at core-needle breast biopsy. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board at each institution; patient consent was not required. The study was HIPAA compliant. The authors reviewed the findings from 42 patients (age range, 26-76 years; mean age, 54.3 years) with 43 benign papillary lesions diagnosed at core-needle biopsy. Thirty-six (84%) of the 43 lesions were surgically excised, and seven (16%) were followed up with long-term imaging. The authors assessed the radiographic findings, the histologic findings at core-needle biopsy, and the findings at subsequent surgical excision or imaging follow-up. Statistical analysis was performed on a per-patient basis and included the Blyth-Still-Casella procedure to construct exact 95% confidence intervals (CIs) and the Fisher exact test. RESULTS: At core-needle biopsy, lesions were diagnosed as papilloma (n = 29), sclerosing papilloma (n = 8), and benign papillary lesions not otherwise specified (n = 6). For the 36 lesions that were surgically excised, histologic follow-up showed no residual lesion in 10, intraductal papilloma in 14, intraductal papillomatosis in two, papilloma with adjacent foci of atypical ductal hyperplasia (ADH) in eight, and well-differentiated papillary ductal carcinoma in situ (DCIS) in two. Mammographic follow-up in the remaining seven lesions revealed stable calcifications in five (at 28-55 months) and no residual lesion in two (at 26-29 months). In nine of the 42 patients (21%), the diagnosis was upgraded to either ADH or DCIS (exact two-sided 95% CI = 11.4%, 36.4%). CONCLUSION: The results strongly suggest that papillary lesions diagnosed as benign at core-needle biopsy should be surgically excised because a substantial number of lesions were upgraded to ADH and DCIS at excision.     

Sonographically-Guided 14-Gauge Core Needle Biopsy for Papillary Lesions of the Breast

Objective

We wanted to assess the need for surgical excising papillary lesions of the breast that were diagnosed upon sonographically guided 14-gauge core needle biopsy.

Materials and Methods

Sixty-nine women (age range: 25-74 years, mean age: 51.7 years) with 69 papillary lesions (4.9%) were diagnosed and followed after performing sonographically guided 14-gauge core needle biopsies. Surgical excision was performed for 44 (64%) of 69 papillary lesions, and 25 lesions were followed with imaging studies (range: 6-46 months, mean: 17.9 months). The histologic findings upon core biopsy were compared with the surgical, imaging and follow-up findings.

Results

Core needle biopsies of 69 lesions yielded tissue that was classified as benign for 43 lesions, atypical for 18 lesions and malignant for eight lesions. Of the 43 lesions that yielded benign papilloma upon core needle biopsy, one had intraductal papillary carcinoma found upon surgery. An immediate surgical biopsy was recommended for this lesion because of the imaging-histologic discordance. No additional carcinoma was found during the imaging follow-up. Surgical excision was performed for 17 atypical papillary lesions, and this revealed intraductal (n = 6) or invasive (n = 2) papillary carcinoma in 8 (47%) lesions. Of the seven intraductal papillary carcinomas, surgery revealed invasive papillary carcinoma in one (14%).

Conclusion

Our results suggest that papillary lesions of the breast that are diagnosed as benign upon sonographically guided 14-gauge core needle biopsy can be followed when the results are concordant with the imaging findings.     

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.     

Atypical ductal hyperplasia and ductal carcinoma in situ as revealed by large-core needle breast biopsy: results of surgical excision

OBJECTIVE: This investigation compares the frequency of histologic underestimation of breast carcinoma that occurs when a large-core needle biopsy reveals atypical ductal hyperplasia or ductal carcinoma in situ with the automated 14-gauge needle, the 14-gauge directional vacuum-assisted biopsy device, and the 11-gauge directional vacuum-assisted biopsy device. SUBJECTS AND METHODS: Evaluation of 428 large-core needle biopsies yielding atypical ductal hyperplasia (139 lesions) or ductal carcinoma in situ (289 lesions) was performed. The results of subsequent surgical excision were retrospectively compared with the needle biopsy results. RESULTS: For lesions initially diagnosed as ductal carcinoma in situ, underestimation of invasive ductal carcinoma was significantly less frequent using the 11-gauge directional vacuum-assisted biopsy device when compared with the automated 14-gauge needle (10% versus 21%, p < 0.05) but was not significantly less frequent when compared with the 14-gauge directional vacuum-assisted device (10% versus 17%, p > 0.1). For lesions diagnosed initially as atypical ductal hyperplasia, underestimation of ductal carcinoma in situ and invasive ductal carcinoma was significantly less frequent using the 11-gauge directional vacuum-assisted biopsy device compared with the 14-gauge directional vacuum-assisted device (19% versus 39%, p = 0. 025) and with the automated 14-gauge needle (19% versus 44%, p = 0. 01). CONCLUSION: The frequency of histologic underestimation of breast carcinoma in lesions initially diagnosed as atypical ductal hyperplasia or ductal carcinoma in situ using large-core needle biopsy is substantially lower with the 11-gauge directional vacuum-assisted device than with the automated 14-gauge needle and with the 14-gauge directional vacuum-assisted device.     

乳腺高危病变的乳腺X线诊断及技术进展

乳腺高危病变包括良性病变及原位癌,具有发生乳腺癌的风险。高危病变首诊主要依赖于穿刺活检,但首诊后存在一定的病变升级率。对于不同的高危病变,如不典型导管增生（ADH）、乳头状瘤伴不典型增生、放射状瘢痕、小叶原位癌（LCIS）、不典型小叶增生（ALH）、黏液囊肿样病变、平坦上皮非典型增生等,乳腺X线检查的诊断及处理原则并不完全相同。就乳腺X线检查对高危病变的诊断、处理、预后评估的研究进展予以综述。     

Papillary lesions of the breast: evaluation with stereotactic directional vacuum-assisted biopsy.

PURPOSE: To evaluate the use of stereotactic directional vacuum-assisted biopsy (SDVAB) in diagnosing and managing papillary lesions of the breast. MATERIALS AND METHODS: The authors retrospectively reviewed the mammographic and histopathologic findings of 26 cases in which papillary lesions were diagnosed at SDVAB. In all cases, subsequent surgical excision (n = 20) or long-term imaging follow-up (n = 6) was performed and correlated with findings at SDVAB. RESULTS: SDVAB of 26 lesions yielded tissue that was classified as benign in 12, atypical in six, and malignant in eight. Of the 12 lesions that were diagnosed as histologically benign at SDVAB, six were surgically excised. Of these six lesions, five yielded benign correlative results. The sixth lesion was thought to be discordant with the imaging findings, and was surgically excised and determined to be malignant. Of the six benign lesions that were not surgically sampled for biopsy, five decreased in size and one was not seen at radiographic follow-up. Of the six lesions diagnosed as atypical at SDVAB that were surgically excised, one was benign and five were atypical. None proved to be malignant. Of the eight lesions diagnosed as malignant at SDVAB, surgical excision demonstrated ductal carcinoma in situ in all eight; two also had foci of invasive carcinoma. CONCLUSION: Benign and malignant papillary lesions of the breast can be reliably diagnosed at SDVAB when the SDVAB results correlate with the imaging findings. However, the extent of malignant papillary disease may be underestimated at SDVAB; in our study, invasive carcinoma was later discovered in 25% of patients with this diagnosis.     

Ductal enhancement on MR imaging of the breast

OBJECTIVE: The purpose of this study was to determine the prevalence and positive predictive value of ductal enhancement among MR imaging-detected breast lesions that had biopsy and to assess the histologic findings associated with ductal enhancement. MATERIALS AND METHODS: Retrospective review was performed of 427 nonpalpable, mammographically occult lesions that had MR imaging-guided needle localization and surgical biopsy. Lesions were reviewed by one radiologist who was unaware of the histologic outcomes and were classified according to a standardized lexicon. MR imaging and histologic findings of ductal enhancing lesions were reviewed. RESULTS: Ductal enhancement accounted for 88 (21%) of 427 lesions and 88 (59%) of 150 nonmass lesions. Histologic finding in these 88 lesions were ductal carcinoma in situ (DCIS) in 18 (20%); infiltrating carcinoma in five (6%), including three with DCIS; lobular carcinoma in situ (LCIS) in nine (10%); atypical ductal hyperplasia in eight (9%); and benign in 48 (55%). Among the 48 benign lesions, the dominant histologic findings were fibrocystic change (n = 16); ductal hyperplasia (n = 8); fibrosis (n = 8); postbiopsy change (n = 5); benign breast tissue (n = 3); sclerosing adenosis (n = 2); and single cases of fibroadenoma, fibroadenomatoid change, lymph node, mastitis, papilloma, and radial scar. Factors associated with a trend toward a higher frequency of carcinoma included clumped enhancement (p = 0.05) and synchronous ipsilateral cancer (p = 0.07). CONCLUSION: Ductal enhancement accounted for 21% of MR imaging-detected lesions that had biopsy and had a positive predictive value of 26%. Differential diagnosis of ductal enhancement includes carcinoma (usually DCIS); atypical ductal hyperplasia; LCIS; and benign findings such as fibrocystic change, ductal hyperplasia, and fibrosis.     

Management of non malignant papillary lesions diagnosed on percutaneous biopsy

PURPOSE: To assess the reliability of percutaneous breast biopsies in diagnosing and managing non malignant papillary lesions and determine if subsequent excision must be systematic. MATERIALS AND METHODS. Retrospective review of 2233 breast biopsies over a 43 months period (September 2001 to March 2005): sonographically guided core biopsies (n = 836), ultrasound (n = 346) or stereotactic (n:1051) guided vacuum biopsies. 86 non malignant papillary tumors were diagnosed (core biopsy:28, US:38 and stereotactic guided vacuum biopsy:20). A larger sample was systematic after core biopsy: lumpectomy (n = 19) or vacuum biopsy (n = 9). Surgical excision followed vacuum biopsy (n = 18) in case of atypia or sampling excision. Alternatively, yearly follow-up was advised (n = 40). Correlation with surgical findings (n = 37) or mammographic follow-up (n = 49) is presented. The influence of various factors on the risk of underestimation was analysed. RESULTS: Surgical resection revealed an underestimation of 5/37 (13.5%): 4/19 with core- and 1/18 with vacuum-assisted biopsy corresponding to 4 low grade ductal carcinoma in situ and a microinvasive ductal carcinoma in situ. It was higher for core biopsies and related to age and size: higher when women<50 years and when radiological image>1 cm. The influence of the other factors was not significant. Of the 9 non operated papillomas after core biopsy, vacuum biopsy revealed an additional underestimation (low-grade ductal carcinoma in situ). Of the 49 papillary lesions that were not surgically biopsied, 40 were monitored at 2-42 months (average: 19 months). No carcinoma was detected during this follow-up. CONCLUSION: Percutaneous biopsy is an accurate technique in managing papillary tumors. A larger histologic specimen is necessary after core biopsy. Vacuum biopsy is an attractive alternative to surgery for smaller papillomas (<1 cm), but in spite of nonsignificant results we advise subsequent excision in case of multiple papillomas, atypia or residual tumor.     

Stereotactic, automated, large-core needle biopsy of nonpalpable breast lesions: false-negative and histologic underestimation rates after long-term follow-up

PURPOSE: To determine the rate and causes of false-negative findings and histologic underestimates at stereotactic biopsy of nonpalpable breast lesions. MATERIALS AND METHODS: Stereotactic, 14-gauge, automated, large-core needle biopsy (LCNB) was performed in 483 consecutive nonpalpable breast lesions. Excision was advised for the 143 carcinomas, 25 atypical ductal hyperplasia (ADH) lesions, and five radial scars. Mammographic follow-up was advised for the benign lesions without a repeat biopsy. RESULTS: Of the 310 benign lesions, 259 underwent mammographic follow-up at 6-85 months (median, 55 months) without repeat biopsy, 48 underwent repeat biopsy and three were lost to follow-up. On the basis of the histologic diagnosis of carcinoma at surgical biopsy, diagnosis with LCNB was not correct (i.e., disease was underestimated at histologic examination) in 14 (58%) of 24 ADH lesions and two (40%) of five radial scars. Two (1.2%) of 161 lesions with a final diagnosis of carcinoma were benign at LCNB but malignant at repeat biopsy (i.e., false-negative findings at LCNB). Repeat biopsy was prompted by mammographic progression at 6 and 18 months after LCNB. CONCLUSION: The false-negative rate with LCNB was 1.2% in this study and 4.0% in the literature. The presence of carcinoma in ADH and radial scar lesions was often underestimated.     

Proliferative high-risk lesions of the breast: contribution and limits of US-guided core biopsy

PURPOSE: To retrospectively correlate high-risk proliferative breast lesions (radial scar, atypical lobular hyperplasia, lobular carcinoma in situ and papillary lesions) diagnosed on core biopsy with the definitive histopathological diagnosis obtained after surgical excision or with the follow-up, in order to assess the role of core biopsy in such lesions. To discuss the management of the patient after a core biopsy diagnosis of high-risk proliferative breast lesion. MATERIAL AND METHODS: We evaluated 74 out of 1776 core biopsies consecutively performed on 67 patients. The histopathologic findings were as follows: 11 radial scars (RS), 3 atypical lobular hyperplasias (ALH), 3 lobular carcinomas in situ (LCIS), 57 benign papillary lesions. All patients underwent bilateral mammography, whole-breast ultrasound with a linear-array broadband transducer, and core biopsy with a 14 Gauge needle and a mean number of samples of 5 (range 4-7). Sixty-two of 67 patients, for a total of 69/74 lesions, underwent surgical biopsy despite benign histopathologic findings, mostly because of highly suspicious imaging for malignancy (BIRADS 4-5), whereas 5 patients refused surgery and have been followed up for a least 18 months and are still being followed up (2 with RS, 1 with ADH and 2 with papillary lesions). RESULTS: Among the core biopsied lesions with a diagnosis of RS (n = 11) pathology revealed one ductal carcinoma in situ (DCIS) (this case was characterized by granular microcalcifications on mammography and by a mass with irregular margins on ultrasound). Also in the group of ADH (n = 3) pathology revealed one DCIS (lesion not visible on mammography but depicted as a suspicious mass on US). In the group of LCIS (n = 3) pathologists found an invasive lobular carcinoma (ILC). Among the benign papillary lesions (n = 57) histopathologic analysis of the surgical specimen revealed 7 malignant lesions (4 papillary carcinomas and 3 DCIS), whose mammographic and ultrasound findings were indistinguishable from benign lesions. Altogether there were 10 false negative results (underestimation) out of 74 core biopsies with a diagnosis of high-risk proliferative breast lesions. CONCLUSION: The high rate of histological underestimation after core biopsy (10/74) (13.5%) demands a very careful management of patents with a core biopsy diagnosis of high-risk proliferative breast lesions, especially in the case of RS, lobular neoplasia and papillary lesions. However, the high imaging suspicion for malignancy prompts surgery. It is possible to assume that, when there is a low imaging suspicion for malignancy, when enough tissue has been sampled for pathology and no atypia is found within the lesions, surgery is not mandatory but a very careful follow-up is recommended. We must underline that there is no agreement regarding the quantity of tissue to sample. Vacuum-assisted biopsy may lead to better results, although there is as yet no proof that it can actually replace surgery in this group of lesions, since it seems only to reduce but not abolish the histological underestimation.     

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.     

Stereotactic core needle biopsy of nonpalpable breast lesions using a conventional mammography unit with an add-on device

OBJECTIVE: The purpose of this prospective study was to assess the accuracy of an add-on stereotactic unit for core needle biopsy of mammographic lesions. SUBJECTS AND METHODS. Between September 1994 and February 2001, 506 stereotactic core needle biopsies of mammographic lesions in 492 patients were performed in our center on a mammography unit with add-on stereotactic equipment. Of the initial 92 patients, 80 underwent stereotactic core needle biopsy and surgical excision simultaneously. In subsequent cases, surgical biopsy was performed after core biopsy in patients who had malignant or atypical histologic results or discordance between mammographic and pathologic findings. Follow-up mammography was advised for all patients whose core biopsy results were diagnosed as benign lesions. RESULTS: Histologic results for 506 lesions undergoing stereotactic core needle biopsy were as follows: 113 (22.3%) were malignant; 369 (72.9%), benign; and 24 (4.7%), atypical. Of 113 malignant lesions identified at stereotactic core needle biopsy, 111 were confirmed as malignant, whereas two showed no evidence of malignancy at surgical excision. Of 369 lesions diagnosed as benign at stereotactic core needle biopsy, 172 (46.6%) showed no change on follow-up mammography, 114 (30.9%) were lost to follow-up, and 83 (22%) underwent surgical excision. Of 24 lesions with atypical histology, 23 had surgical follow-up, six were malignant, nine were benign, and eight were confirmed as showing atypical histology. Stereotactic core needle biopsy of the 506 lesions was complicated by five (1.0%) cases of vasovagal attack and four (0.8%) cases of bleeding. The resulting sensitivity, specificity, and positive and negative predictive values were 98.3%, 93.0%, 86.0%, and 99.2% respectively. CONCLUSION: Biopsy with an add-on unit is safe, reliable, accurate, and cost-effective with results comparable to those reported for dedicated prone biopsy devices.     

Variability in the Management Recommendations Given for High-risk Breast Lesions Detected on Image-guided Core Needle Biopsy at U.S. Academic Institutions

The purpose of this study was to describe and compare the management recommendations provided in the setting of a high-risk lesion diagnosed on core needle biopsy of the breast at academic institutions across the United States. We contacted breast imagers at U.S. academic institutions via email and asked them to complete a voluntary online survey. The survey consisted of eight questions regarding the management recommendations given when core biopsy yields various high-risk lesions. We received survey responses from 41 of the 59 institutions contacted (69% response rate). Surgical excision was the most frequently reported recommendation given for all high-risk lesions; however, the proportion varied from 95% for atypical ductal hyperplasia and papilloma with associated atypia, 76% for flat epithelial atypia, 73% for radial scar/complex sclerosing lesion, 71% for lobular carcinoma in-situ, 61% for atypical lobular hyperplasia, to 39% for intraductal papilloma without atypia. Our study demonstrates inconsistency in the management recommendations given for high-risk lesions detected on core needle biopsy at academic institutions nationally. This outcome suggests that patients may benefit from the creation of consensus recommendations for the management of high-risk lesions detected on core needle biopsy.     

Clinical management issues in percutaneous core breast biopsy

Percutaneous imaging-guided core biopsy is a less invasive and less expensive alternative to surgical biopsy for the evaluation of breast lesions. Percutaneous core biopsy is most often used for evaluation of BI-RADS category 4 lesions, but may also be helpful in the evaluation of some BI-RADS category 5 lesions. Stereotactic guidance is particularly useful for calcifications; for masses that can be seen with ultrasound, ultrasound guidance may be preferable because of the absence of radiation and lower cost. The automated core biopsy needle is excellent for mass lesions, but directional vacuum-assisted biopsy is superior for calcifications. Directional vacuum-assisted biopsy may also be preferable for small lesions that may require placement of a localizing clip and lesions that are superficial or in thin breasts. The more expensive ABBI device has substantial limitations, and its role in percutaneous breast biopsy has not been demonstrated. Complete removal of the mammographic target can occur at percutaneous biopsy, and is a more frequent event when the larger tissue acquisition devices are used. Complete removal of the mammographic target does not ensure complete excision of the histologic process. Further investigation is necessary to determine in which lesions, if any, complete removal of the target is advantageous. Epithelial displacement can occur during all breast needling procedures, but may be less frequent at directional vacuum-assisted biopsy than at fine-needle aspiration or automated core biopsy. There is no evidence that displaced cells are of biologic significance, but displaced DCIS can mimic infiltrating carcinoma. The pathologist should be aware of the findings of epithelial displacement, to avoid misdiagnosing DCIS as infiltrating ductal carcinoma. Some lesions warrant repeat biopsy or surgical excision after percutaneous core biopsy. Repeat biopsy is warranted if histologic findings and imaging findings are discordant. Surgical excision is warranted for lesions yielding a percutaneous diagnosis of ADH or possible phyllodes tumor. Controversy exists regarding the need for surgical excision after percutaneous diagnosis of radial scar, papillary lesion, ALH, or LCIS. Follow-up is necessary if percutaneous biopsy yields benign findings concordant with imaging characteristics. Follow-up protocols vary, but all require substantial commitment of time and resources. We have an embarassment of riches for performing percutaneous core biopsy of the breast. It can be estimated that approximately 1 million breast biopsies will be performed this year to diagnose approximately 200,000 breast cancers. Percutaneous core biopsy may spare many of these women the need for a more deforming, invasive, and expensive surgical biopsy. Further work is necessary to optimize criteria for patient selection, develop and define the role of new technologies for tissue acquisition, refine protocols for management after percutaneous breast biopsy, and assess long-term outcome, so that more women can benefit from this minimally invasive approach to breast diagnosis.     

Lobular carcinoma in situ at percutaneous breast biopsy: surgical biopsy findings.

OBJECTIVE: The purpose of this study was to review surgical histologic findings in women with lobular carcinoma in situ (LCIS) at percutaneous breast biopsy. MATERIALS AND METHODS: Retrospective review was performed of 1315 consecutive lesions that underwent percutaneous breast biopsy. Percutaneous biopsy yielded LCIS in 16 (1.2%) lesions. Subsequent surgical biopsy was performed in 14 lesions in 13 women. Histologic findings were reviewed. RESULTS: In five of the 14 lesions, percutaneous biopsy yielded LCIS and a high-risk lesion (radial scar in three and atypical ductal hyperplasia in two); in one (20%) of these five lesions, surgery revealed ductal carcinoma in situ (DCIS). In four of the 14 lesions, the LCIS in the percutaneous biopsy had features that overlapped with those of DCIS; in two (50%) of these four lesions, surgery revealed DCIS (n = 1) or infiltrating lobular carcinoma (n = 1). In the remaining five of the 14 lesions, surgery revealed no DCIS or infiltrating carcinoma. Five (38%) of 13 women with LCIS lesions had synchronous or metachronous infiltrating carcinoma (three ductal, one lobular, one mixed) in the ipsilateral (n = 1) or contralateral (n = 4) breast. CONCLUSION: Surgical excision was warranted in lesions in which LCIS was found at percutaneous breast biopsy when the percutaneous biopsy histologic features overlapped with those of DCIS, when a high-risk lesion was present, or when there was imaging-histologic discordance. LCIS without these factors was not shown to require surgical excision in our small series, but a larger study is needed. Diagnosis of LCIS at percutaneous biopsy is a marker for women who are at increased risk of ductal or lobular carcinoma in either breast.     

Uncommon high-risk lesions of the breast diagnosed at stereotactic core-needle biopsy: clinical importance

PURPOSE: To assess the outcome of papillary lesions, radial scars, or lobular carcinoma in situ (LCIS) diagnosed at stereotactic core-needle biopsy (SCNB). MATERIALS AND METHODS: Retrospective review of 1,236 lesions sampled with SCNB yielded 22 papillary lesions, nine radial scars, and five LCIS lesions. Diffuse lesions such as papillomatosis, papillary ductal hyperplasia, papillary ductal carcinoma in situ (DCIS), and atypical lobular hyperplasia were not included. The mammographic findings, associated histologic features, and outcome were assessed for each case. RESULTS: Sixteen papillary lesions were diagnosed as benign at SCNB. Of these, five were benign at excision, and 10 were unremarkable at mammographic follow-up. At excision of an unusual lesion containing a microscopic papillary lesion, DCIS was found. Three of four papillary lesions suspicious at SCNB proved to be papillary carcinomas; the fourth had no residual carcinoma at excision. Eight of nine radial scars were excised, which revealed atypical hyperplasia in four scars but no malignancies. One LCIS lesion was found at excision to contain DCIS. CONCLUSION: Benign or malignant papillary lesions were accurately diagnosed with SCNB in the majority of cases. Cases diagnosed as suspicious for malignancy or with atypia or unusual associated histologic findings should be excised. No malignancies were found at excision of radial scars diagnosed at SCNB. Surgical removal of these lesions following SCNB may not be routinely necessary. DCIS was found in one lesion diagnosed as LCIS at SCNB, which suggests that removal of these lesions may be prudent.     

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.     

MRI-guided breast biopsy: clinical experience with 14-gauge stainless steel core biopsy needle

OBJECTIVE: Core needle biopsy has proven advantages for wire localization and excision; however, MRI-guided core biopsy has been limited by less satisfactory sampling efficiency and less availability of MRI-compatible biopsy needles. We evaluated the feasibility and diagnostic yield of MRI-guided biopsy using 14-gauge stainless steel core biopsy needles and MRI-compatible coaxial sheaths in a closed 1.5-T scanner. MATERIALS AND METHODS: Thirty-five consecutive breast biopsies performed in 29 women between March 2001 and August 2002 were retrospectively reviewed. For each procedure, an MRI-compatible sheath was placed under MRI guidance using a dedicated breast coil and biopsy guidance system. With the patient out of the magnet, a 14-gauge steel core biopsy needle was used to obtain multiple samples. Lesion characteristics, including size, morphology, and enhancement, were recorded. Histology of all the lesions was obtained; and surgical, imaging, or clinical follow-up was performed. RESULTS: Targeted masses and enhancing foci ranged from 3 to 17 mm. Regional enhancement ranged from 14 to 70 mm. Thirty-four of the 35 biopsies were technically successful. Histology revealed malignancy in eight lesions (23%), atypical ductal hyperplasia in five lesions (14%), and benign entities in 21 lesions (60%). Surgery confirmed all eight core biopsies with malignant findings. Two of five lesions with atypical ductal hyperplasia were upgraded to malignancy after surgery. CONCLUSION: This new method of MRI-guided breast biopsy with a 14-gauge stainless steel core biopsy needle and a closed 1.5-T MRI scanner is feasible, safe, and effective and produces satisfactory diagnostic yield. This method offers an alternative to MRI-guided wire localization and to MRI-guided core biopsy with nonferrous needles.     

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.