Stereotaxic breast biopsy techniques have become the standard of care for mammographically suspicious lesions

An optimal technique for the evaluation of nonpalpable, suspicious mammographic lesions should have a low technical failure rate, no false-negative results and should remove the lesion completely. Since most of these lesions are benign, the procedure should be carried out in an outpatient setting without general anesthesia. Cancer is missed in 2.6% of cases with excisional biopsy following needle localization. Furthermore, 50-83% of these patients undergo a second surgical intervention for definitive surgical treatment. In contrast, the rate of missed cancers is less than 0.7% following stereotaxic core or large-core biopsies. However, using these techniques, discordant results and histologic high-risk lesions need to be recognized and reexcized. The cost-effectiveness of stereotaxic vacuum-assisted core biopsy has been demonstrated. Stereotaxic breast biopsy techniques such as vacuum-assisted core biopsy and large-core biopsy for suspicious mammographic lesions have low false-negative rates and result in few histologic underestimations.     

Radioguided occult lesion localisation in combination with detection of the sentinel lymph node in non-palpable breast cancer tumours

PURPOSE OF THE INVESTIGATION: The aim of study was to determine the efficacy of radioguided occult lesion localisation (ROLL) for non-palpable invasive breast cancer combined with sentinel lymph node biopsy (SLNB) and to compare the amount of tissue excised by radioguided navigation versus the hook-wire technique. METHODS: We injected 45 MBq of radiolabelled technetium intratumourally and 15 MBq subdermally 18 hours before surgery in 21 women with bioptically verified non-palpable breast cancer. We identified by gamma probe non-palpable tumours, which were excised, followed by identification and excision of the sentinel lymph node. We compared our results with a group of 12 women with non-palpable lesions marked by hook-wire localisation. RESULTS: ROLL combined with SLNB was successful in 100%; volume of excised tissue was smaller in the hook-wire group but expressed higher variability in volume than in the ROLL group although the difference was not statistically significant. CONCLUSION: The method of ROLL combined with SLNB is technically possible and safe, resulting in minimisation of the surgical intervention and a decrease in postoperative morbidity. ROLL was more precise than the hook-wire procedure even though the amount of tissue excised was the same in both groups.     

Comparative estimation of the limitations of mammography and echography in senologic practice

Mammography and breast ultrasonography are complementary examinations. The combination of the two examinations can provide an accurate diagnosis, which mammography alone is unable to do. Ultrasonography is particularly important in the examination of dense breasts, especially for the visualization of sonolucent or hypoechogenic formations. However, ultrasonography should not be performed alone, as it is unable to visualize microcalcifications. It can not be used as a screening test and it would be a professional error to perform only a clinical examination and ultrasonography, as a large number of diagnoses would be missed. Two essential points should be stressed: 30% of carcinomas have microcalcifications; amongst these 30%, many lesions are small and impalpable and they may not be seen on ultrasonography in a fatty breast. 40% of occult cancers are detected by the microcalcifications identified on mammography, which remains the key to breast investigations. Ultrasonography compensates for some of the deficiencies of radiography and can be very useful in dense breasts, in cystic or hypoechogenic structures. It can also be used to guide aspiration biopsy of non palpable lesions and for the pre-operative localization of impalpable lesions with abnormal echostructure, which are not visible on mammography.     

Minimally invasive biopsy and preoperative marking of suspect mammary lesions

Image-guided minimally invasive needle biopsy is an established method in the diagnosis of breast cancer, which - when indicated correctly and carried out with quality control - equals or even surpasses open diagnostic surgery. Therefore, an open diagnostic biopsy should only be performed as well-founded exception. Depending on the visibility in the various diagnostic techniques of the condition to be clarified histologically, needle biopsy has to be carried out with the image-guided procedure which can identify the mammary lesion most reliably. If a lesion is detectable mammographically as well as sonographically, a high-speed large-core biopsy is preferred, taking the strain on the patient and the costs into account, too. In the case of suspect microcalcifications, the needle biopsy has to be controlled stereotactically. Here, vacuum-assisted procedures [Mammotome, VacuFlash (BIP)/Vacora (Bard)] yield markedly better results when compared with large-core biopsy and are also preferred for lesions which are only visible on magnetic resonance tomography. Without exception, preoperative wire marking should be used in cases of suspect nonpalpable lesions in imaging diagnostics or even more so of lesions which have already been classified histologically as malignant by minimally invasive procedures before surgery. This is the only way to safely find the suspect and nonpalpable lesion during the operation and to excise it with a sufficient safety margin while preserving as much healthy issue as possible. Quality-controlled diagnostics and therapy of breast cancer constitute an interdisciplinary challenge and yield optimal results only when all concerned specialties collaborate in the best possible way.     

Mammographic wire localization in diagnosis and treatment of occult carcinoma of breast

The use of screening mammography has increased dramatically, leading to the discovery of suspicious, nonpalpable mammary lesions. Mammographic wire localization (MWL) is currently being used to facilitate the biopsy of these lesions. We reviewed 104 patients undergoing 106 biopsies after MWL during a 14 month period to determine the usefulness of MWL. The average age of the patients was 58 +/- 14 years, with a range of 38 to 83 years. Abnormal mammographic findings consisted of microcalcifications (48 per cent) or mass and density (43 per cent), or both (9 per cent). Lesions of the right side (55 per cent) and upper and outer quadrant (49 per cent) were predominant. An average of 1.4 (range of one to four) specimens taken at biopsy per patient were required to remove the lesion. The mean duration of the biopsy was 34 minutes, with a range of ten to 75 minutes, and the mean total time in the operating room was 63 (range 31 to 115) minutes. The average cost of the procedure did not differ significantly between local and general anesthesia ($1,030 versus $1,142, respectively). Pathologic findings included fibrocystic disease (77 per cent), carcinoma (12 per cent) and fibroadenoma (7 per cent). Normal mammary tissue was found in 4 per cent of the biopsies. Five of the 13 carcinomas were in situ and seven were either in situ (five) or microinvasive only (two); only six lesions were frankly invasive. Ten patients were treated with modified radical mastectomy while three had segmental resection. All patients had in situ or Stage I carcinoma. MWL effectively localized nonpalpable mammary lesions and allowed accurate diagnosis and treatment of early stage carcinoma of the breast.     

Needle localization and biopsy of nonpalpable lesions of the breast

Two hundred and three consecutive needle hookwire guided biopsies for nonpalpable lesions of the breast were performed upon 174 patients over a three year period. Patients ranged in age from 25 to 83 years (a mean of 55.4 years). Malignant growths of the breast were found in 44 of 203 specimens taken for biopsy. Sixty-six per cent of malignant lesions were in situ and 34 per cent were invasive carcinoma. The chance of a biopsy containing a malignant lesion was 17.5 per cent if the biopsy was done because of a discrete density on mammography, 22.1 per cent for microcalcifications and 29.6 per cent if both were present. The incidence of Stage I disease in 24 patients undergoing dissection of the axillary lymph node was 79.2 per cent. Specimen roentgenography was done in 165 biopsies. Anesthesia time was increased an average of 5.8 minutes by specimen roentgenography. In 198 instances, the mammographic lesion was present in the specimen taken for biopsy intended to remove it. Minor complications of needle hookwire insertion occurred in two patients. The mortality rate was nil.     

Non-palpable breast lesions: radio-pathologic correlations on open excisional biopsies. Significance of the choice of technique for minimal excisional biopsy

OBJECTIVE: To decrease the number of open excisional breast biopsies, percutaneous breast biopsies have been developed to perform the histologic diagnosis of non-palpable breast lesions. Some techniques allow a complete removal of small radiologic lesions. To evaluate the accuracy of a pathologic analysis performed only on the radiologic findings, we studied the radiologic and histologic correlation on open excisional biopsy (OEB) specimens. The aim of our study was to determine how many carcinomas were found distant from the radiologic findings. MATERIAL AND METHODS: Non-palpable breast lesions have been excised after preoperative localization. The radiologic findings were classified in microcalcifications, masses, architectural distortion and in sonographic masses. The correlation between the radiologic and pathologic findings was studied and all the lesions incidentally discovered on histology with no correlation with the imaging findings or distant from the radiologic findings were described. One hundred and twenty-nine lesions have been evaluated in 99 patients. Radiologic findings included 79 clusters of microcalcifications, 30 masses, six architectural distortions and 14 sonographic lesions. RESULTS: The histopathological results were benign in 41.9%, malignant in 49.6% and atypical hyperplasia lesions were discovered in 8.5%. All benign lesions were correlated to radiologic findings. No malignant lesion was found at a distance. In three cases atypical hyperplasia lesions were coexistent with the radiologic findings correlated with benign lesions and in three cases they were found at a distance. All but two malignant lesions were correlated with radiologic findings. In two cases a microinvasive carcinoma and foci of labular carcinoma in situ were found coexistent with benign lesions. The subgroup of small lesions lesser than 10 mm included 31 benign lesions. A complete removal of these lesions should be obtained with percutaneous biopsies. CONCLUSION: A pathologic analysis targeted on radiologic findings is accurate. Numerous open excisional biopsies performed for benign pathology should be avoided.     

Stereotactic vacuum-assisted breast biopsy - analysis of 166 cases

OBJECTIVE: Screening mammography (as planned in Germany) will lead to an increasing number of breast biopsies. The purpose of this study was to determine the promise of directional large core biopsy as a patient-protecting therapeutic method. MATERIAL AND METHODS: 166 vacuum assisted, X-ray-guided biopsy procedures were analysed. RESULTS: Histopathologic examination resulted in 75.8 % benign lesions. Atypical proliferation and noninvasive neoplasia was found in 18.6 %, invasive carcinoma in 5.4 % of the biopsies. Complications were few. Neither skin- or chestwall injuries, nor pain or intraoperative bleeding caused an abortion. Postoperative we found four cases of bleeding, further on in 28.3 % a superficial, in 3 % a larger and deep hematoma, but in total without any operative revision. No infection was diagnosed. In the average 17.2 (8-31) specimens were removed. After excision of 18 probes the definitive histopathologic diagnosis was clear in all cases, also, the microcalcifications were found. The underestimation rate amounted to 3 of 35 cases. CONCLUSIONS: This clinical study proves stereotactic vacuum-assisted biopsy as a relieable method for analysing indeterminate mammographically detected breast lesions, which shows lower rates of complications than conventional surgical procedures.     

Mammographic and histopathologic correlation of nonpalpable lesions of the breast and the reliability of frozen section diagnosis

During a period of ten years, 118 (32.9 per cent) instances of carcinoma were found in 359 specimens taken at biopsy for nonpalpable mammographic lesions. In recent years, the positive predictive value has increased from 68 per cent due to the development of magnification mammography and the use of a mammographic grid. Correlating mammographic and histopathologic data, the rate of malignant disease was 12.7 per cent for instances of a circumscribed or nodular mass, 32.4 per cent for clustered microcalcifications as the only suspect finding, 28.6 per cent when a mass with microcalcifications was present and 66.7 per cent when a stellate-shaped mass was found. Of 188 instances of carcinoma, 40 were noninvasive: 32 instances of ductal carcinoma (27.1 per cent) and eight of lobular carcinoma in situ (6.8 per cent). The possibility of frozen section diagnosis was studied retrospectively by comparison with the paraffin section reports. A correct diagnosis, whether benign or malignant, was achieved in 68 per cent. No frozen section examination was done in 17.3 per cent and the diagnosis was deferred to results of paraffin section in 12.2 per cent. False-negative results were encountered in seven patients (1.9 per cent) and false-positive results in two (0.6 per cent). Both of these patients had florid sclerosing adenosis. Although frozen section diagnosis is feasible in nonpalpable lesions of the breast, it is recommended that this method not be used in instances of pure microcalcifications and tiny solid masses of 5 millimeters or less.     

Limitations of mammography in the identification of noninfiltrating carcinoma of the breast

A retrospective study of 321 patients who underwent localizing mammography and excisional biopsy of the breast from 1984 to 1985 was performed. The study was undertaken to refine selection criteria for biopsy in women with nonpalpable mammographic abnormalities by comparing mammographic features and impression with histologic findings. Twenty-eight of 36 (78 per cent) noninfiltrating carcinomas presented with microcalcifications alone; in contrast, 27 of 39 (69 per cent) infiltrating carcinomas presented with a mass alone. As the number of microcalcifications increased, so did the incidence of carcinoma. The size of the mass was not a guide for predicting carcinoma. Although only 11 of 75 carcinomas presented as a mass with microcalcifications, 11 of 21 calcified masses were carcinoma. There were no significant differences in the mammographic presentation between ductal and lobular carcinoma. The sensitivity of the mammographic impression was 48/75 (0.64), and the specificity was 221/246 (0.898). The false-positive rate was 25/73 (0.34), and the false-negative rate was 10/141 (0.07). From this study, we concluded 1, the incidence of noninfiltrating carcinoma was significantly higher and the incidence of positive nodes was significantly lower in nonpalpable abnormalities than in palpable masses; 2, noninfiltrating carcinomas were generally associated with microcalcifications alone, but infiltrating carcinomas were generally associated with a mass alone, and 3, the diagnostic accuracy of mammography was limited by under-interpretation of the subtler signs of noninfiltrating carcinoma and by over-interpretation of mammographic findings generally accepted as criteria for carcinoma.     

Detection of localized breast cancer by prospective mammographic screening criteria

From 1983 to 1986, 1110 gynecology office patients met our prospective mammographic screening criteria. Ninety-eight mammographically guided, needle-localized breast biopsies were performed on 89 patients (8.0%). Twenty-one nonpalpable breast cancers (22.0%) were diagnosed in 18 patients with these methods. Treatment alternatives chosen in patients with positive biopsy specimens are presented. The importance of establishing consistent criteria for mammography and breast biopsy in the early diagnosis of localized breast cancer is discussed. The unique opportunity of the gynecologist to change the morality rate of breast cancer is emphasized.     

Localization and management of occult breast lesions

Mammography is an effective method for finding lesions of the breast which are occult at clinical examination. For occult lesions biopsy, including as little surrounding tissue as possible, it is necessary that they be located before surgery in order to improve the pathological process and the cosmetic outcome for the patients. Among the clinically occult lesions shown only by mammography, the frequency of breast cancers ranges from 10% to 47%. There are several different techniques for locating hidden lesions of the breast. We have employed the insertion of a single rigid needle into the breast, with X-ray confirmation of correct positioning. Forty-nine patients underwent this technique in our Institution and in all cases we were able to achieve a correct insertion of the needle at the X-ray check (the tip of the needle was less than 1 cm from the lesion). The target lesion was removed (as confirmed by X-ray of the surgical specimen) in all cases at the first attempt. In our study we found 11 invasive and 7 in situ tumours (36%). No complications delaying the surgical biopsy or the recovery of the patients were observed.     

Technique and interpretation of breast aspiration cytology

FNA biopsy as a diagnostic modality in breast lesions (palpable and nonpalpable) is a safe, rapid, cost-effective, and accurate method of diagnosis of breast pathology, which is beneficial to the patient, clinician, and cytopathologist. This diagnostic service has become an integral part in the workup of breast lesions in the practice of medicine today.     

The predictive value of needle localization mammographically assisted biopsy of the breast

This study was done to review critically the experience at the University of California at San Diego in needle localization mammographic biopsy of the breast with regard to use and accuracy in identifying early carcinoma of the breast. Ninety-seven patients underwent needle localization mammographic biopsy of the breast between 1985 and 1987. Indications for this procedure included the presence of microcalcifications or a mass shown on mammographic examination, or both, in conjunction with physical examination which did not define a discrete abnormality in the area. Mammographic, demographic, pathologic, hormone receptor data and staging information were recorded and processed on the MicroVax II computer (Digital Equipment Corporation). Twenty-four per cent of lesions with needle localization mammographic assisted biopsy proved to be malignant. Sixteen lesions were diagnosed as an infiltrating ductal carcinoma and ten of these had an accompanying intraductal carcinoma. Over-all, intraductal carcinoma was present in 16 of the 23 specimens diagnosed as malignant. At biopsy, the margins were clear in 17 of 23, and vascular invasion was present in only one patient with an infiltrating lobular carcinoma. Five were tumor in situ, 12 were stage 1 and five were stage 2 (staging information was not available in one instance). Hormone receptor data were available in 17 of 23 specimens. Estrogen receptors were positive in 13 and progesterone receptors were positive in six. The smallest preinvasive malignant lesion was 4 millimeters, as seen on the mammogram, and the smallest free-standing invasive lesion was 8 millimeters. Preinvasive lesions (intraductal) presented as microcalcifications in 80 per cent. Invasive lesions presented as either a mass (n = 9) or as a mass and microcalcifications (n = 5) in 81 per cent. All five lesions presenting as both a mass and microcalcifications on mammogram proved to be malignant. Multifocal lesions on mammographic examination which proved to be malignant were multifocal pathologically in only 50 per cent. Needle localization mammographic biopsy is useful in detecting early carcinoma of the breast. Biopsy should be done on lesions presenting on mammogram as both a mass and microcalcifications and not observed. Focality of lesions on mammogram does not correlate with focality on biopsy and may be misleading as criteria for operative planning.     

Una forma factible y precisa de ubicar las microcalcificaciones de mama: dando una oportunidad a la técnica SNOLL

ObjectivesTo evaluate the feasibility and accuracy of the ROLL technique to localize malignant mammary microcalcifications and the risk of local recurrence, we performed a multicentre prospective observational study to assess the application of the technique and progress of patients with a 10year follow-up.Materials and methodsBetween 2007 and 2010, 64 patients were recruited. All the patients had been diagnosed with breast neoplasm due to microcalcifications on mammography and were treated with conservative surgery and sentinel lymph node biopsy. A technetium-99m injection was performed preoperatively, with a single or several punctures (> 3.5 cm lesions), guided by mammography or by ultrasound. In all cases, we performed a preoperative lymphoscintigraphy, to assess contrast migration, and intraoperative mammogram to assess correct removal of the lesion.ResultsIn the 64 patients, contrast injection could be confirmed, and lymphoscintigraphy proved correct migration of the contrast to the sentinel node, allowing excision of the mammary lesion and of the sentinel lymph node in 100%.The intraoperative mammogram showed complete lesion excision in 100% cases. The pathology showed radicality in the first surgery of 84.4% and showed a disease-free survival of 84% at 10 years.ConclusiónThe SNOLL technique (ROLL + SNB) is a feasible and accurate technique for the localization and surgical treatment of malignant microcalcifications with disease-free survival and a relapse rate comparable to the rest of the techniques. Likewise, we propose systematic cavity shave to reduce the need for reinterventions.     

Mammography in the detection, diagnosis and management of carcinoma of the breast

Mammography is a major advance and essential in the earlier detection, diagnosis and management of carcinoma of the breast and should be more widely applied. Although mammography is at least as important as palpation and the only means of detecting nonpalpable lesions, both examinations are most effective as complementary procedures. A breast operation for suspected carcinoma should never be done without preoperative mammography. Mammographic needle localization and biopsy roentgenography are extremely useful, if not essential, in the surgical management of nonpalpable lesions.     

New and old procedures in the diagnosis of dubious breast lesions

In the last years the detection of early breast cancers (lesions less than one centimetre in diameter, with good prognosis) has consistently increased for the wide application of mammary screening programs. At the same time, an increasing number of radiographically detected unexpected lesions (nonpalpable breast lesions) has been evidenced. In those cases, often both mammography and ultrasound evaluation are dubious and a multidisciplinary diagnostic approach is mandatory. Fine-needle aspiration (FNA) and core biopsy (CB) are well established diagnostic methods but, in recent years, new microinvasive bioptic procedures (as the Mammotome and the ABBI systems) have been introduced. In this review the limits and the possibilities of the classical and new cytohistological techniques are evaluated. A possible multistep diagnostic approach is described on a cost-benefit basis and in consideration of the various procedures.     

Surgical management of breast disease in an obstetrics and gynecology group

The surgical management of breast disease from 1978 through 1988 by the Women's Health Center of Logansport is reviewed. Three hundred twelve biopsy procedures resulted in the diagnosis of 59 cancers. Biopsy and mastectomy procedures were performed by the authors (obstetrician-gynecologists). There were no significant complications and all patients had an adequate surgical result. Preoperative needle localization techniques proved to be a safe and effective method to identify and remove nonpalpable mammographic abnormalities. Because women depend on their gynecologist for advice regarding reproductive organs including the breasts, it is logical for the gynecologic surgeon to become involved in the surgical management of breast disease.     

Supraconservative breast surgery

Currently, 30% of the breast biopsies are performed for patients with nonpalpable lesions. The surgical management of these lesions had to evolve to a better three-dimensional targeting and a reduction of the tissue traumatism. The ABBI procedure allows the percutaneous one bloc excision of suspicious mammographically detected lesions with a diameter of less than 2cm. We prospectively evaluated this procedure as a therapeutic tool. Of the 10 malignant lesions with a pathologic size <10mm, 9 (90%) were completely resected with the ABBI device (no residual disease at re-excision of the biopsy site). The results of this preliminary study suggest a potential therapeutic role of the ABBI procedure in the therapeutic arsenal against mammary lesions.     

Surgical management of breast microclacifications

The breast infraclinic lesions, as microcalcifications, are images found very often within the framework of the tracking of the breast cancer. The majority of them correspond to benign lesions. The therapeutic strategy of these microcalcifications depends on the evaluation of the degree of suspicion of the image which classification BI-RADS makes it possible to make more precise and more reproducible. In certain cases where a histological diagnosis is necessary, the macrobiopsies make it possible to limit the surgery to the only cases where the antomo-pathological analysis impose it. Thus, the percutaneous procedure performed under local anaesthesia give the possibility of avoiding an useless intervention for a benign lesion, or of avoiding, for a malignant lesion, an operational time with aiming diagnoses followed by a therapeutic surgical recovery. The stereotaxic percutaneous procedures, by confirming a invasive malignant lesion, also follow to perform sentinel lymph node biopsy, or to program an axillary dissection. It also can in the event of large infraclinic lesion, confirmed by two macrobiopsies spaced of more than 3 cm, to perform a mastectomy associated to immediate breast surgical reconstruction.